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Unal TC, Aydoseli A, Ozgen U, Dolas I, Sabanci PA, Aras Y, Ozturk M, Ozata MS, Gul N, Kubat Uzum A, Mutlu U, Bilgic B, Saka E, Yarman S, Sencer A. A single-center experience of transsphenoidal endoscopic surgery for acromegaly in 73 patients: results and predictive factors for remission. Br J Neurosurg 2024; 38:648-653. [PMID: 34241568 DOI: 10.1080/02688697.2021.1947977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 05/29/2021] [Accepted: 06/22/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Transsphenoidal endoscopic surgery is the first-line treatment for growth hormone-secreting adenomas. OBJECTIVE To analyse the results of the transsphenoidal endoscopic approach for acromegaly and to determine the predictive factors of remission. METHODS A single-centre retrospective review was performed in patients who underwent endoscopic transsphenoidal surgery for acromegaly between January 2009 and January 2019. Demographic features, clinical presentation, histopathology records, complications and pre- and postoperative radiologic and endocrinological assessments were evaluated. The factors that influenced the remission rates were investigated. RESULTS A total of 73 patients underwent surgery via the transsphenoidal endoscopic approach. Cavernous sinus invasion was detected in 32 patients (43.8%); and macroadenoma, in 57 (78%). The pathology specimens of the 27 patients (36.9%) showed dual-staining adenomas with prolactin. A total of 51 patients (69.8%) attained biochemical remission 1 year after surgery. A second operation was performed in 10 patients (13.6%) with residual tumours without biochemical remission in the first year. Six (60%) of the patients attained remission at the last follow-up. Transient diabetes insipidus was observed in 18 patients (24.6%); and rhinorrhoea, which was resolved with conservative treatment, in 4 (5.4%). None of the patients developed panhypopituitarism. The presence of cavernous sinus invasion and preoperative IGF-1, immediate postoperative GH and third-month IGF-1 levels were predictive of remission. CONCLUSION Transsphenoidal endoscopic surgery is a safe and effective treatment for acromegaly. Reoperation should be considered in patients with residual tumours without remission.
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Affiliation(s)
- Tugrul Cem Unal
- Department of Neurosurgery, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Aydin Aydoseli
- Department of Neurosurgery, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Utku Ozgen
- Department of Neurosurgery, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Ilyas Dolas
- Department of Neurosurgery, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Pulat Akin Sabanci
- Department of Neurosurgery, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Yavuz Aras
- Department of Neurosurgery, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Metehan Ozturk
- Department of Neurosurgery, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Musa Samet Ozata
- Department of Neurosurgery, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Nurdan Gul
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Ayse Kubat Uzum
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Ummu Mutlu
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Bilge Bilgic
- Department of Pathology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Esra Saka
- Department of Anesthesiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Sema Yarman
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Altay Sencer
- Department of Neurosurgery, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
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Cremaschi A, Sala E, Lavezzi E, Carosi G, Del Sindaco G, Mangone A, Mungari R, Pagnano A, Indirli R, Ferrante E, Mazziotti G, Locatelli M, Lasio G, Arosio M, Lania AG, Mantovani G. Recurrence in acromegaly: two tertiary centers experience and review of the literature. J Endocrinol Invest 2024:10.1007/s40618-024-02321-6. [PMID: 38502285 DOI: 10.1007/s40618-024-02321-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 01/26/2024] [Indexed: 03/21/2024]
Abstract
BACKGROUND Recurrence of acromegaly after successful surgery is a rare event, but no clear data are reported in the literature about its recurrence rates. This study aimed to evaluate the recurrence rate in a series of acromegalic patients treated by transsphenoidal surgery (TSS) with a long follow-up. METHODS We retrospectively analyzed data from 283 acromegalic patients who underwent TSS at two pituitary units in Milan (Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico and IRCCS Humanitas Research Hospital). The diagnosis and recurrence of acromegaly were defined by both elevated IGF-1 levels and a lack of GH suppression based on appropriate criteria for the assay used at the time of diagnosis. RESULTS After surgery, 143 patients (50%) were defined as not cured, 132 (47%) as cured and 8 (3%) as partially cured because of normalization of only one parameter, either IGF1 or GH. In the cured group, at the last follow-up (median time 86.8 months after surgery), only 1 patient (0.7%) showed full recurrence (IGF-1 + 5.61 SDS, GH nadir 1.27 µg/l), while 4 patients (3%) showed only increased IGF1. In the partially cured group at the last follow-up, 2/8 (25%) patients showed active acromegaly (IGF-1 SDS + 2.75 and + 3.62; GH nadir 0.6 and 0.5 µg/l, respectively). CONCLUSIONS In the literature, recurrence rates range widely, from 0 to 18%. In our series, recurrence occurred in 3.7% of patients, and in fewer than 1%, recurrence occurred with elevation of both IGF-1 and the GH nadir. More frequently (25%), recurrence came in the form of incomplete normalization of either IGF-1 or GH after surgery.
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Affiliation(s)
- A Cremaschi
- Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
- Department of Medical Sciences and Community Health, University of Milan, Milan, Italy.
| | - E Sala
- Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - E Lavezzi
- Endocrinology and Diabetology Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - G Carosi
- Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - G Del Sindaco
- Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Medical Sciences and Community Health, University of Milan, Milan, Italy
| | - A Mangone
- Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Medical Sciences and Community Health, University of Milan, Milan, Italy
| | - R Mungari
- Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - A Pagnano
- Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Medical Sciences and Community Health, University of Milan, Milan, Italy
| | - R Indirli
- Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Medical Sciences and Community Health, University of Milan, Milan, Italy
| | - E Ferrante
- Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - G Mazziotti
- Endocrinology and Diabetology Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - M Locatelli
- Neurosurgery Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - G Lasio
- Neurosurgery Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - M Arosio
- Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Medical Sciences and Community Health, University of Milan, Milan, Italy
| | - A G Lania
- Endocrinology and Diabetology Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - G Mantovani
- Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Medical Sciences and Community Health, University of Milan, Milan, Italy
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Clemmons DR, Bidlingmaier M. Interpreting growth hormone and IGF-I results using modern assays and reference ranges for the monitoring of treatment effectiveness in acromegaly. Front Endocrinol (Lausanne) 2023; 14:1266339. [PMID: 38027199 PMCID: PMC10656675 DOI: 10.3389/fendo.2023.1266339] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 10/06/2023] [Indexed: 12/01/2023] Open
Abstract
Standard treatment for acromegaly focuses on the achievement of target absolute levels of growth hormone (GH) and insulin-like growth factor (IGF-I). The appropriateness of these targets when measured using modern assay methods is not well defined. This paper reviews biochemical status assessed using methods available at the time and associated clinical outcomes. GH measurements were shown to provide an indication of changes in tumor size, and failure of GH suppression after glucose stimulation is associated with tumor recurrence. IGF-I levels were more closely associated with changes in symptoms and signs. Reduced GH and IGF-I concentrations were shown to be associated with increased longevity, although the degree of increase has only been analyzed for GH. Lowering of GH and IGF-I has consistently been associated with improved outcomes; however, absolute levels reported in previous studies were based on results from methods and reference ranges that are now obsolete. Applying previously described absolute thresholds as targets (e.g. "normal" IGF-I level) when using current methods is best applied to those with active acromegaly symptoms who could benefit from further lowering of biochemical markers. In asymptomatic individuals with mild IGF-I or GH elevations, targeting biochemical "normalization" would result in the need for combination pharmacotherapy in many patients without proven benefit. Measurement of both GH and IGF-I remains an essential component of diagnosis and monitoring the effectiveness of treatment in acromegaly; however, treatment goals based only on previously identified absolute thresholds are not appropriate without taking into account the assay and reference ranges being employed. Treatment goals should be individualized considering biochemical improvement from an untreated baseline, symptoms of disease, risks, burdens and costs of complex treatment regimens, comorbidities, and quality of life.
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Affiliation(s)
- David R. Clemmons
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Martin Bidlingmaier
- Neuroendocrine Unit, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany
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4
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Carosi G, Mangone A, Sala E, Del Sindaco G, Mungari R, Cremaschi A, Ferrante E, Arosio M, Mantovani G. Clinical and hormonal findings in patients presenting with high IGF-1 and growth hormone suppression after oral glucose load: a retrospective cohort study. Eur J Endocrinol 2021; 185:289-297. [PMID: 34081617 PMCID: PMC8284905 DOI: 10.1530/eje-21-0024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 06/03/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVE High insulin-like growth factor 1 (IGF-1) and unsuppressed growth hormone (GH) levels after glucose load confirm the diagnosis of acromegaly. Management of patients with conflicting results could be challenging. Our aim was to evaluate the clinical and hormonal evolution over a long follow-up in patients with high IGF-1 but normal GH nadir (GHn < 0.4 μg/L according to the latest guidelines). DESIGN Retrospective cohort study. METHODS We enrolled 53 patients presenting high IGF-1 and GHn < 0.4 μg/L, assessed because of clinical suspicion of acromegaly or in other endocrinological contexts (e.g. pituitary incidentaloma). Clinical and hormonal data collected at the first and last visit were analyzed. RESULTS At the first evaluation, the mean age was 54.1 ± 15.4 years, 34/53 were females, median IGF-1 and GHn were +3.1 SDS and 0.06 μg/L, respectively. In the whole group, over a median time of 6 years, IGF-1 and GHn levels did not significantly change (IGF-1 mean of differences: -0.58, P = 0.15; GHn +0.03, P = 0.29). In patients with clinical features of acromegaly, the prevalence of acromegalic comorbidities was higher than in the others (median of 3 vs 1 comorbidities per patient, P = 0.005), especially malignancies (36% vs 6%, P = 0.03), and the clinical worsening overtime was more pronounced (4 vs 1 comorbidities at the last visit). CONCLUSIONS In patients presenting high IGF-1 but GHn < 0.4 μg/L, a hormonal progression is improbable, likely excluding classical acromegaly in its early stage. However, despite persistently low GH nadir values, patients with acromegalic features present more acromegalic comorbidities whose rate increases over time. Close clinical surveillance of this group is advised.
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Affiliation(s)
- Giulia Carosi
- Endocrinology Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Alessandra Mangone
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Elisa Sala
- Endocrinology Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giulia Del Sindaco
- Endocrinology Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Roberta Mungari
- Endocrinology Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Arianna Cremaschi
- Endocrinology Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Emanuele Ferrante
- Endocrinology Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Maura Arosio
- Endocrinology Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Giovanna Mantovani
- Endocrinology Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Correspondence should be addressed to G Mantovani;
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Akirov A, Masri-Iraqi H, Dotan I, Shimon I. The Biochemical Diagnosis of Acromegaly. J Clin Med 2021; 10:jcm10051147. [PMID: 33803429 PMCID: PMC7967116 DOI: 10.3390/jcm10051147] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 03/03/2021] [Accepted: 03/05/2021] [Indexed: 12/20/2022] Open
Abstract
Background: The diagnosis of acromegaly still poses a clinical challenge, and prolonged diagnostic delay is common. The most important assays for the biochemical diagnosis and management of acromegaly are growth hormone (GH) and insulin-like growth factor-1 (IGF-1). Objective: Discuss the role of IGF-1, basal serum GH, and nadir GH after oral glucose tolerance test (OGTT) for the diagnosis, management, and treatment of patients with acromegaly. Methods: We performed a narrative review of the published data on the biochemical diagnosis and monitoring of acromegaly. An English-language search for relevant studies was conducted on PubMed from inception to 1 January 2021. The reference lists of relevant studies were also reviewed. Results: Serum IGF-1 levels, basal GH values, and nadir GH after OGTT play a major role in the diagnosis, management, and treatment of patients with acromegaly. Measurement of IGF-1 levels is the key factor in the diagnosis and monitoring of acromegaly, but basal and nadir GH following OGTT are also important. However, several factors may significantly influence the concentrations of these hormones, including assay methods, physiologic and pathologic factors. In some cases, discordant GH and IGF-1 levels may be challenging and usually requires additional data and monitoring. Conclusion: New GH and IGF-1 standards are much more precise and provide more accurate tools to diagnose and monitor patients with acromegaly. However, all these biochemical tools have their limitations, and these should be taken under consideration, along with the history, clinical features and imaging studies, when assessing patients for acromegaly.
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Affiliation(s)
- Amit Akirov
- Institute of Endocrinology, Beilinson Hospital, 49100 Petach Tikva, Israel; (H.M.-I.); (I.D.); (I.S.)
- Correspondence: ; Tel.: +972-524650760
| | - Hiba Masri-Iraqi
- Institute of Endocrinology, Beilinson Hospital, 49100 Petach Tikva, Israel; (H.M.-I.); (I.D.); (I.S.)
- Sackler School of Medicine, Tel Aviv University, 39040 Tel Aviv, Israel
| | - Idit Dotan
- Institute of Endocrinology, Beilinson Hospital, 49100 Petach Tikva, Israel; (H.M.-I.); (I.D.); (I.S.)
- Sackler School of Medicine, Tel Aviv University, 39040 Tel Aviv, Israel
| | - Ilan Shimon
- Institute of Endocrinology, Beilinson Hospital, 49100 Petach Tikva, Israel; (H.M.-I.); (I.D.); (I.S.)
- Sackler School of Medicine, Tel Aviv University, 39040 Tel Aviv, Israel
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Karahan M, Demirtaş AA, Erdem S, Ava S, Pekkolay Z, Keklikçi U. Evaluation of Ocular Hypoperfusion in Patients with Acromegaly by Using Optical Coherence Tomography Angiography. Curr Eye Res 2021; 46:1209-1213. [PMID: 33445974 DOI: 10.1080/02713683.2021.1877311] [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] [Indexed: 10/22/2022]
Abstract
PURPOSE This study aimed to evaluate the retinal blood vessel parameters and the foveal avascular zone (FAZ) area using optical coherence tomography angiography (OCTA) in patients with acromegaly in comparison with healthy controls. METHODS A total of 45 patients with acromegaly and 45 healthy controls were included in this study. In all patients, the vessel density (VD) of the deep and superficial macular vascular networks and the foveal avascular zone (FAZ) were measured using OCTA. The correlation of insulin-like growth factor 1 (IGF-1) level and disease duration with deep macular VD and FAZ values was analyzed. All parameters were registered. Results were assessed and compared between the two groups. RESULTS Deep macular plexus VD values were lower in patients with acromegaly compared to the control group. No significant differences in VD values in the superficial segment, except for that in the inferior parafovea (P = .01) were found between the two groups. Furthermore, patients with acromegaly showed enlargement in the superficial (P = .30) and deep FAZ areas (P < .001). IGF-1 level and disease duration showed a significant negative correlation with the deep whole image (R = -0.216, P = .041, R = -0.339, P = .001, respectively), deep parafovea (R = -0.271, P = .01; R = -0.372, P < .001, respectively), deep parafovea superior hemi (R = -0.342, P = .001; R = -0.350, P = .001, respectively), deep parafovea temporal (R = -0.224, P = .034; R = -0.234, P = .026, respectively), deep parafovea nasal (R = -0.320, P = .002; R = -0.361, P < .001, respectively), and deep parafovea superior VD values (R = -0.293, P = .005; R = -0.307, P = .003, respectively) and a significant positive correlation with the deep FAZ area values (R = 0.244, P = .02; R = 0.329, P = .002, respectively). CONCLUSION VD values in the deep macular capillary plexus were lower in patients with acromegaly, and the superficial and deep FAZ area enlarged. Patients with acromegaly may have an increased risk of developing ocular vascular complications. OCTA can be used to evaluate retinal blood VD in patients with acromegaly.
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Affiliation(s)
- Mine Karahan
- Department of Ophthalmology, Dicle University Faculty of Medicine, Diyarbakır, Turkey
| | - Atılım Armağan Demirtaş
- Department of Ophthalmology, Health Sciences University, Izmir Tepecik Training and Research Hospital, Izmir, Turkey
| | - Seyfettin Erdem
- Department of Ophthalmology, Dicle University Faculty of Medicine, Diyarbakır, Turkey
| | - Sedat Ava
- Department of Ophthalmology, Dicle University Faculty of Medicine, Diyarbakır, Turkey
| | - Zafer Pekkolay
- Department of Endocrinology and Metabolism, Dicle University Faculty of Medicine, Diyarbakır, Turkey
| | - Uğur Keklikçi
- Department of Ophthalmology, Dicle University Faculty of Medicine, Diyarbakır, Turkey
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Ishikawa M, Toyomura J, Yagi T, Kuboki K, Morita T, Sugihara H, Hirose T, Minami S, Yoshino G. Role of growth hormone signaling pathways in the development of atherosclerosis. Growth Horm IGF Res 2020; 53-54:101334. [PMID: 32721858 DOI: 10.1016/j.ghir.2020.101334] [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: 01/26/2020] [Revised: 06/07/2020] [Accepted: 06/12/2020] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The direct actions of growth hormone (GH) in the development of atherosclerosis are unclear. The goal of this study was to characterize GH-induced changes in expression of signaling pathway elements and other proteins that may be related to atherosclerosis. METHODS Human umbilical vein endothelial cells (HUVEC) and THP-1, a human acute monocytic leukemia cell line, were stimulated by exposure to 10-9 M or 10-8 M human GH with or without pretreatment with a mitogen-activated protein kinase kinase (MEK) 1 inhibitor. Levels of transcripts encoding vascular cell adhesion molecule (VCAM) -1, E-selectin, monocyte chemotactic protein (MCP-1), interleukin (IL) -6, and IL-8 were investigated by reverse transcription (RT) -PCR. For the quantitative adhesion assay, THP-1 cells or human primary monocytes were fluorescently labeled with 3'-O-acetyl-2',7'-bis(carboxyethyl) -4 diacetoxymethyl ester (BCECF/AM). HUVEC treated with human GH were co-incubated with BCECF-labeled THP-1 cells. One hour later, the number of BCECF-labeled THP-1 cells was assessed. An equivalent experiment was performed using BCECF-labeled primary monocytes, and the number of monocytes adhering to HUVEC was counted. RESULTS Treatment with hGH increased the levels of E-selectin- and VCAM-1-encoding mRNAs in HUVEC. This effect was attenuated by pretreatment with a MEK1 inhibitor. Furthermore, hGH treatment increased adhesion of BCECF-labeled THP-1 cells or primary monocytes to HUVEC, and this effect was attenuated by pretreatment with a MEK1 inhibitor. CONCLUSIONS VCAM-1 and E-selectin expression was stimulated by GH via the mitogen-activated protein kinase pathway, resulting in augmented adhesion of THP-1 cells and monocytes to HUVEC. These data suggested that GH directly stimulates the development of atherosclerosis.
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Affiliation(s)
- Mayumi Ishikawa
- Center of Endocrinology, Diabetes and Arteriosclerosis, Nippon Medical School Musashikosugi Hospital, 1-396, Kosugi-cho, Nakahara-ku, Kawasaki 211-8533, Japan.
| | - Junko Toyomura
- Laboratory of Clinical Regenerative Medicine, Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, 1-1-1, Tennodai, Tsukuba-City, Ibaraki 305-8575, Japan
| | - Takashi Yagi
- Center of Endocrinology, Diabetes and Arteriosclerosis, Nippon Medical School Musashikosugi Hospital, 1-396, Kosugi-cho, Nakahara-ku, Kawasaki 211-8533, Japan
| | - Koji Kuboki
- The Division of Diabetes, Metabolism and Endocrinology, Department of Internal Medicine, Toho University, 6-11-1, Omorinishi, Ota-ku, Tokyo 143-8541, Japan
| | - Toshisuke Morita
- Department of Laboratory Medicine, Toho University, 6-11-1, Omorinishi, Ota-ku, Tokyo 143-8541, Japan
| | - Hitoshi Sugihara
- Department of Endocrinology, Diabetes and Metabolism, Graduate School of Medicine, Nippon Medical School, 1-1-5, Sendagi, Bunkyo-ku, Tokyo 113-8603, Japan
| | - Takahisa Hirose
- The Division of Diabetes, Metabolism and Endocrinology, Department of Internal Medicine, Toho University, 6-11-1, Omorinishi, Ota-ku, Tokyo 143-8541, Japan
| | - Shiro Minami
- Center of Endocrinology, Diabetes and Arteriosclerosis, Nippon Medical School Musashikosugi Hospital, 1-396, Kosugi-cho, Nakahara-ku, Kawasaki 211-8533, Japan
| | - Gen Yoshino
- The Division of Diabetes, Metabolism and Endocrinology, Department of Internal Medicine, Toho University, 6-11-1, Omorinishi, Ota-ku, Tokyo 143-8541, Japan
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8
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Fahlbusch R, Kleinberg D, Biller B, Bonert V, Buchfelder M, Cappabianca P, Carmichael J, Chandler W, Colao A, George A, Klibanski A, Knopp E, Kreutzer J, Kundurti N, Lesser M, Mamelak A, Pivonello R, Post K, Swearingen B, Vance ML, Barkan A. Surgical debulking of pituitary adenomas improves responsiveness to octreotide lar in the treatment of acromegaly. Pituitary 2017; 20:668-675. [PMID: 28825168 DOI: 10.1007/s11102-017-0832-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Studies comparing primary medical treatment of acromegaly with surgery are often non-randomized, and not stratified by illness severity. We prospectively compared primary medical therapy with pituitary surgery in patients with acromegaly. All patients had macroadenomas, at least one random human growth hormone (GH) level ≥12.5 ng/mL, elevated IGF-I levels and failure to suppress GH to <1 ng/mL during an oral glucose tolerance test (oGTT). METHODS Forty-one patients from seven centers were randomized to primary treatment with octreotide LAR, 30 mg every 4 weeks × 3 months (ARM A, N = 15), or pituitary surgery (ARM B, N = 26) using a 1:2 randomization design. Patients cured by surgery (defined as nadir GH during oGTT <1 ng/mL and normal IGF-I) received no subsequent treatment. Those not cured surgically were then treated with octreotide LAR (SubArm B1) for 3 months. RESULTS Only one of the 15 patients in ARM A (6.7%) had normalization of both GH and IGF-I. In contrast, 13/26 patients had normalization of both GH and IGF-I after surgery alone (50%). Of the remaining 13 patients who did not normalize with surgery alone, treatment with octreotide LAR resulted in a normal nadir GH and normal serum IGF-I in 7 (53.9%). In total, 20/26 in ARM B (76.9%) experienced normalization of defined biochemical acromegaly parameters. CONCLUSIONS Pituitary surgery alone was more effective than primary medical treatment (p = 0.006), and the combination of surgery followed by medical therapy was even more effective (p < 0.0001). Subjects treated with medical therapy after surgical debulking had a significant improvement in response rate compared to matched subjects treated with primary medical therapy.
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Affiliation(s)
| | | | | | | | | | | | | | - William Chandler
- Division of MEND, University of Michigan, 24 Frank Lloyd Wright, G-1500, Ann Arbor, MI, 48106, USA
| | | | | | | | | | | | | | - Martin Lesser
- Feinstein Institute for Medical Research, Manhasset, USA
| | | | | | | | | | | | - Ariel Barkan
- Division of MEND, University of Michigan, 24 Frank Lloyd Wright, G-1500, Ann Arbor, MI, 48106, USA.
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Yu M, Bruns DE, Jane JA, Nass RM, Oldfield EH, Vance ML, Thorner MO. Decrease of Serum IGF-I following Transsphenoidal Pituitary Surgery for Acromegaly. Clin Chem 2017; 63:486-494. [DOI: 10.1373/clinchem.2016.262592] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 10/12/2016] [Indexed: 01/09/2023]
Abstract
Abstract
BACKGROUND
In the immediate postoperative period following resection of growth hormone (GH)-secreting pituitary tumors, serum concentrations of GH have limited ability to predict remission of acromegaly. Since many actions of GH actions are mediated by insulin-like growth factor-1 (IGF-I), we aimed to determine the rates of fall of IGF-I during 72 h after surgical resection of pituitary tumors.
METHODS
We studied patients who were undergoing pituitary surgery for acromegaly. IGF-I was measured by LC-MS and GH by immunoassay. Remission was defined by the combination of serum GH <0.4 ng/mL during oral glucose tolerance testing performed 8 weeks after the surgical procedure and normal IGF-I at ≥8 weeks.
RESULTS
During the first 72 h after surgery, the mean (SD) rate of decline of IGF-I was 185 (61) ng/mL per 24 h in those who achieved remission (n = 23), with a mean (SD) apparent half-life of 55 (19) h. IGF-I had decreased to <65% of the preoperative IGF-I on postoperative day 2 in 20 of 23 remission patients (87%) vs none of 5 patients who did not achieve remission. GH was <2.7 ng/mL on day 2 in 21 of 23 remission patients (91%), but in none of the nonremission patients. The combination of IGF-I and GH on day 2 separated the remission and nonremission groups of patients.
CONCLUSIONS
Rapid decline of serum IGF-I during the immediate postoperative period warrants further study as an analytically independent adjunct to GH measurement for early prediction of biochemical remission of acromegaly.
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Affiliation(s)
- Min Yu
- Division of Laboratory Medicine, Department of Pathology
| | - David E Bruns
- Division of Laboratory Medicine, Department of Pathology
| | | | - Ralf M Nass
- Division of Endocrinology and Metabolism, Department of Medicine, University of Virginia School of Medicine and Health System, Charlottesville, VA
| | | | - Mary Lee Vance
- Division of Endocrinology and Metabolism, Department of Medicine, University of Virginia School of Medicine and Health System, Charlottesville, VA
| | - Michael O Thorner
- Division of Endocrinology and Metabolism, Department of Medicine, University of Virginia School of Medicine and Health System, Charlottesville, VA
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Retina ganglion cell/inner plexiform layer and peripapillary nerve fiber layer thickness in patients with acromegaly. Int Ophthalmol 2016; 37:591-598. [PMID: 27492731 DOI: 10.1007/s10792-016-0310-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 07/28/2016] [Indexed: 10/21/2022]
Abstract
Increased secretion of growth hormone and insulin-like growth factor-1 in acromegaly has various effects on multiple organs. However, the ocular effects of acromegaly have yet to be investigated in detail. The aim of the present study was to compare retina ganglion cell/inner plexiform layer (GCIPL) and peripapillary nerve fiber layer thickness (pRNFL) between patients with acromegaly and healthy control subjects using spectral domain optical coherence tomography (SD-OCT). This cross-sectional, comparative study included 18 patients with acromegaly and 20 control subjects. All participants underwent SD-OCT to measure pRNFL (in the seven peripapillary areas), GCIPL (in the nine ETDRS areas), and central macular thickness (CMT). Visual field (VF) examinations were performed using a Humphrey field analyzer in acromegalic patients. Measurements were compared between patients with acromegaly and control subjects. A total of 33 eyes of 18 patients with acromegaly and 40 eyes of 20 control subjects met the inclusion criteria of the present study. The overall calculated average pRNFL thickness was significantly lower in patients with acromegaly than in control subjects (P = 0.01), with pRNFL thickness significantly lower in the temporal superior and temporal inferior quadrants. Contrary to our expectations, pRNFL thickness in the nasal quadrant was similar between acromegalic and control subjects. The mean overall pRNFL thickness and superonasal, nasal, inferonasal, and inferotemporal quadrant pRNFL thicknesses were found to correlate with the mean deviation (MD) according to Spearman's correlation. However, other quadrants were not correlated with VF sensitivity. No significant difference in CMT values was observed (P = 0.6). GCIPL thickness was significantly lower in all quadrants of the inner and outer macula, except for central and inferior outer quadrants, in the acromegaly group than that in the control group (P < 0.05). GCIPL thicknesses of the inferior inner and outer macula quadrants were found to correlate with MD, whereas no correlation was observed between other quadrants and VF sensitivity. We demonstrated that GCIPL thickness decreased in patients with acromegaly compared with that in control subjects. However, the nasal quadrant pRNFL thickness was similar in acromegaly, in contrast to our expectations. SD-OCT may have utility in the assessment of the effects of acromegaly on retinal structures.
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11
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Suda K, Matsumoto R, Fukuoka H, Iguchi G, Hirota Y, Nishizawa H, Bando H, Yoshida K, Odake Y, Takahashi M, Sakaguchi K, Ogawa W, Takahashi Y. The influence of type 2 diabetes on serum GH and IGF-I levels in hospitalized Japanese patients. Growth Horm IGF Res 2016; 29:4-10. [PMID: 27060213 DOI: 10.1016/j.ghir.2016.03.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Revised: 03/15/2016] [Accepted: 03/18/2016] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Although serum insulin like growth factor type 1 (IGF-I) levels are negatively correlated with hemoglobin A1c (HbA1c) in patients with type 1 diabetes, this correlation is controversial in patients with type 2 diabetes mellitus (T2DM) because of the influence of multiple factors including insulin secretion and obesity. The aim of this study was to evaluate the influence of T2DM on serum growth hormone (GH) and IGF-I levels in Japanese patients, who exhibited relatively low BMI compared with white patients in the previous studies. DESIGN We retrospectively analysed 315 consecutive Japanese hospitalized patients with T2DM. We analysed factors correlated with changes in serum IGF-I levels and those related to diabetes. RESULTS The median HbA1c was 8.7% (7.4-10.2) and the median body mass index (BMI) was 26.2kg/m(2) (23.1-29.7), which was relatively low compared with the previous studies. Overall, no correlations was found between serum GH or IGF-I levels and fasting plasma glucose (FPG) or HbA1c; however, when stratified by FPG and HbA1c levels, serum IGF-I levels were significantly lower in patients with FPG≥200mg/dL than in those with FPG<200mg/dL (p=0.039). In addition, serum IGF-I levels were significantly lower in patients with HbA1c≥12% than in those with HbA1c<12% (p=0.046). Multiple linear regression analysis revealed a positive correlation between fasting C-peptide levels and serum IGF-I levels (p=0.040), whereas no correlations was found for BMI, duration of T2DM, FPG levels, or HbA1c. Moreover, patients with improved HbA1c levels during the follow up period showed a significant increase in serum IGF-I levels. CONCLUSIONS Serum IGF-I levels were significantly decreased in Japanese patients with uncontrolled T2DM, and impaired insulin secretion may be a mechanism underlying this effect. When diagnosing acromegaly in patients with uncontrolled diabetes, these factors should be taken into account.
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Affiliation(s)
- Kentaro Suda
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Ryusaku Matsumoto
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Hidenori Fukuoka
- Division of Diabetes and Endocrinology, Kobe University Hospital, Japan
| | - Genzo Iguchi
- Division of Diabetes and Endocrinology, Kobe University Hospital, Japan
| | - Yushi Hirota
- Division of Diabetes and Endocrinology, Kobe University Hospital, Japan
| | - Hitoshi Nishizawa
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Hironori Bando
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Kenichi Yoshida
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Yukiko Odake
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | | | | | - Wataru Ogawa
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Yutaka Takahashi
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan.
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12
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Mooney MA, Simon ED, Little AS. Advancing Treatment of Pituitary Adenomas through Targeted Molecular Therapies: The Acromegaly and Cushing Disease Paradigms. Front Surg 2016; 3:45. [PMID: 27517036 PMCID: PMC4963385 DOI: 10.3389/fsurg.2016.00045] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 07/12/2016] [Indexed: 11/14/2022] Open
Abstract
The current treatment of pituitary adenomas requires a balance of conservative management, surgical resection, and in select tumor types, molecular therapy. Acromegaly treatment is an evolving field where our understanding of molecular targets and drug therapies has improved treatment options for patients with excess growth hormone levels. We highlight the use of molecular therapies in this disease process and advances in this field, which may represent a paradigm shift for the future of pituitary adenoma treatment.
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Affiliation(s)
- Michael A Mooney
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center , Phoenix, AZ , USA
| | - Elias D Simon
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center , Phoenix, AZ , USA
| | - Andrew S Little
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center , Phoenix, AZ , USA
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13
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Fletcher JM, Scudder CJ, Kiupel M, Pipe-Martin HN, Kenny PJ, Mantis P, Fenn J, Smith K, Blair RV, Granger LA, Niessen SJM. Hypersomatotropism in 3 Cats without Concurrent Diabetes Mellitus. J Vet Intern Med 2016; 30:1216-21. [PMID: 27255700 PMCID: PMC5089606 DOI: 10.1111/jvim.14360] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 05/12/2016] [Accepted: 05/16/2016] [Indexed: 11/30/2022] Open
Affiliation(s)
- J M Fletcher
- Department of Veterinary Clinical Sciences, School of Veterinary Medicine, Louisiana State University, Baton Rouge, LA, 70810
| | - C J Scudder
- Department of Clinical Science and Services, The Royal Veterinary College, University of London, North Mymms, AL9 7TA, Herts, UK
| | - M Kiupel
- Department of Pathobiology and Diagnostic Investigation, Diagnostic Center for Population and Animal Health, Michigan State University, Lansing, MI, 48910
| | - H N Pipe-Martin
- Department of Veterinary Clinical Sciences, School of Veterinary Medicine, Louisiana State University, Baton Rouge, LA, 70810
| | - P J Kenny
- Department of Clinical Science and Services, The Royal Veterinary College, University of London, North Mymms, AL9 7TA, Herts, UK
| | - P Mantis
- Department of Clinical Science and Services, The Royal Veterinary College, University of London, North Mymms, AL9 7TA, Herts, UK
| | - J Fenn
- Department of Clinical Science and Services, The Royal Veterinary College, University of London, North Mymms, AL9 7TA, Herts, UK
| | - K Smith
- Department of Pathology and Pathogen Biology, The Royal Veterinary College, University of London, North Mymms, AL9 7TA, Herts, UK
| | - R V Blair
- Department of Pathobiological Sciences, School of Veterinary Medicine, Louisiana State University, Baton Rouge, LA, 70810
| | - L A Granger
- Department of Veterinary Clinical Sciences, School of Veterinary Medicine, Louisiana State University, Baton Rouge, LA, 70810
| | - S J M Niessen
- Department of Clinical Science and Services, The Royal Veterinary College, University of London, North Mymms, AL9 7TA, Herts, UK
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14
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Colao A, Auriemma RS, Pivonello R, Kasuki L, Gadelha MR. Interpreting biochemical control response rates with first-generation somatostatin analogues in acromegaly. Pituitary 2016; 19:235-47. [PMID: 26519143 PMCID: PMC4858561 DOI: 10.1007/s11102-015-0684-z] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
CONTEXT The somatostatin analogues octreotide LAR and lanreotide Autogel have been evaluated for the treatment of acromegaly in numerous clinical trials, with considerable heterogeneity in reported biochemical response rates. This review examines and attempts to account for these differences in response rates reported in the literature. EVIDENCE ACQUISITION PubMed was searched for English-language studies of a minimum duration of 24 weeks that evaluated ≥10 patients with acromegaly treated with octreotide LAR or lanreotide Autogel from 1990 to March 2015 and reported GH and/or IGF-1 data as the primary objective of the study. EVIDENCE SYNTHESIS Of the 190 clinical trials found, 18 octreotide LAR and 15 lanreotide Autogel studies fulfilled the criteria for analysis. It is evident from the protocols of these studies that multiple factors are capable of impacting on reported response rates. Prospective studies reporting an intention-to-treat analysis that evaluated medically naïve patients and used the composite endpoint of both GH and IGF-1 control were associated with lower response rates. The use of non-composite biochemical control endpoints, heterogeneous patient populations, analyses that exclude treatment non-responders, assay variability and prior responsiveness to medical therapy are just a few of the factors identified that likely contribute to higher success rates. CONCLUSIONS The wide range of reported response rates with somatostatin analogues may be confusing and could lead to misinterpretation by both the patient and the physician in certain situations. Understanding the factors that potentially drive the variation in response rates should allow clinicians to better gauge treatment expectations in specific patients.
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Affiliation(s)
- Annamaria Colao
- Dipartimento di Medicina Clinica e Chirurgia, Università Federico II di Napoli, Via S Pansini 5, 80131, Naples, Italy.
| | - Renata S Auriemma
- Dipartimento di Medicina Clinica e Chirurgia, Università Federico II di Napoli, Via S Pansini 5, 80131, Naples, Italy
| | - Rosario Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Università Federico II di Napoli, Via S Pansini 5, 80131, Naples, Italy
| | - Leandro Kasuki
- Endocrine Unit, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Mônica R Gadelha
- Endocrine Unit, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
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15
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Park HY, Hwang IR, Seo JB, Kim SW, Seo HA, Lee IK, Kim JG. Association between the Growth Hormone Receptor Exon 3 Polymorphism and Metabolic Factors in Korean Patients with Acromegaly. Endocrinol Metab (Seoul) 2015; 30:312-7. [PMID: 25559716 PMCID: PMC4595356 DOI: 10.3803/enm.2015.30.3.312] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Revised: 09/22/2014] [Accepted: 10/17/2014] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND This study investigated the association between the frequency of growth hormone receptor (GHR) exon 3 polymorphism (exon 3 deletion; d3-GHR) and metabolic factors in patients with acromegaly in Korea. METHODS DNA was extracted from the peripheral blood of 30 unrelated patients with acromegaly. GHR genotypes were evaluated by polymerase chain reaction and correlated with demographic data and laboratory parameters. RESULTS No patient had the d3/d3 genotype, while four (13.3%) had the d3/fl genotype, and 26 (86.7%) had the fl/fl genotype. Body mass index (BMI) in patients with the d3/fl genotype was significantly higher than in those with the fl/fl genotype (P=0.001). Age, gender, blood pressure, insulin-like growth factor-1, growth hormone, fasting plasma glucose, triglycerides, high density lipoprotein cholesterol, and low density lipoprotein cholesterol levels showed no significant differences between the two genotypes. CONCLUSION The d3-GHR polymorphism may be associated with high BMI but not with other demographic characteristics or laboratory parameters.
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Affiliation(s)
- Hye Yoon Park
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - In Ryang Hwang
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Jung Bum Seo
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Su Won Kim
- Department of Biomedical Laboratory Science, Kyungwon University, Gumi, Korea
| | - Hyun Ae Seo
- Department of Internal Medicine, Daegu Fatima Hospital, Daegu, Korea
| | - In Kyu Lee
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Jung Guk Kim
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea.
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16
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Abstract
Acromegaly (ACM) is a chronic, progressive disorder caused by the persistent hypersecretion of GH, in the vast majority of cases secreted by a pituitary adenoma. The consequent increase in IGF1 (a GH-induced liver protein) is responsible for most clinical features and for the systemic complications associated with increased mortality. The clinical diagnosis, based on symptoms related to GH excess or the presence of a pituitary mass, is often delayed many years because of the slow progression of the disease. Initial testing relies on measuring the serum IGF1 concentration. The oral glucose tolerance test with concomitant GH measurement is the gold-standard diagnostic test. The therapeutic options for ACM are surgery, medical treatment, and radiotherapy (RT). The outcome of surgery is very good for microadenomas (80-90% cure rate), but at least half of the macroadenomas (most frequently encountered in ACM patients) are not cured surgically. Somatostatin analogs are mainly indicated after surgical failure. Currently their routine use as primary therapy is not recommended. Dopamine agonists are useful in a minority of cases. Pegvisomant is indicated for patients refractory to surgery and other medical treatments. RT is employed sparingly, in cases of persistent disease activity despite other treatments, due to its long-term side effects. With complex, combined treatment, at least three-quarters of the cases are controlled according to current criteria. With proper control of the disease, the specific complications are partially improved and the mortality rate is close to that of the background population.
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Affiliation(s)
- Cristina Capatina
- Department of EndocrinologyCarol Davila University of Medicine and Pharmacy, Bucharest, RomaniaCI Parhon National Institute of EndocrinologyBucharest, RomaniaDepartment of EndocrinologyOxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Old Road, Headington, Oxford OX3 7LE, UK Department of EndocrinologyCarol Davila University of Medicine and Pharmacy, Bucharest, RomaniaCI Parhon National Institute of EndocrinologyBucharest, RomaniaDepartment of EndocrinologyOxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Old Road, Headington, Oxford OX3 7LE, UK
| | - John A H Wass
- Department of EndocrinologyCarol Davila University of Medicine and Pharmacy, Bucharest, RomaniaCI Parhon National Institute of EndocrinologyBucharest, RomaniaDepartment of EndocrinologyOxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Old Road, Headington, Oxford OX3 7LE, UK
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17
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Zeinalizadeh M, Habibi Z, Fernandez-Miranda JC, Gardner PA, Hodak SP, Challinor SM. Discordance between growth hormone and insulin-like growth factor-1 after pituitary surgery for acromegaly: a stepwise approach and management. Pituitary 2015; 18:48-59. [PMID: 24496953 DOI: 10.1007/s11102-014-0556-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Follow-up management of patients with acromegaly after pituitary surgery is performed by conducting biochemical assays of growth hormone (GH) and insulin-like growth factor-1 (IGF1). Despite concordant results of these two tests in the majority of cases, there is increasing recognition of patients who show persistent or intermittent discordance between GH and IGF1 (normal GH and elevated IGF1 or vice versa). METHOD In this narrative review, the last three decades materials on the issue of discrepancy between GH and IGF1 were thoroughly assessed. RESULTS Various studies have obtained different discordance rates, ranging from 5.4 to 39.5%. At present, despite the use of current sensitive assays and more stringent criteria to define remission, the rate of discordance still remains high. A number of mechanisms have been proposed to explain the postoperative discordance of GH and IGF1 including; altered dynamics of the GH secretion after surgery, early postoperative hormone assay, inaccurate or less sensitive tests and laboratory errors, too high cut-off point for GH suppression in the GH assays, GH nadir values not adjusted to age, sex, and body mass index, the influence of concomitant medication, co-existing physiologic and pathologic conditions, and many other proposed reasons. Nevertheless, the underlying mechanisms are still far from clear, and the solution continues to evade complete elucidation. Similarly, the impacts of such a discrepancy over mortality and morbidity and the risk of biochemical and/or clinical recurrence are unclear. CONCLUSION As a challenging clinical problem, a stepwise evaluation and management of these patients appears to be more rational.
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Affiliation(s)
- Mehdi Zeinalizadeh
- Department of Neurological Surgery, Imam Khomeini Hospital, Tehran University of Medical Sciences, 1419733141, Tehran, Iran,
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18
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Suda K, Fukuoka H, Iguchi G, Hirota Y, Nishizawa H, Bando H, Matsumoto R, Takahashi M, Sakaguchi K, Takahashi Y. The prevalence of acromegaly in hospitalized patients with type 2 diabetes. Endocr J 2015; 62:53-9. [PMID: 25284247 DOI: 10.1507/endocrj.ej14-0254] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The prevalence of acromegaly is estimated to be 8-24/100,000, but several recent studies suggest it is underestimated. In particular, acromegaly is considered more prevalent in patients with type 2 diabetes mellitus (T2DM) than in the normal population. This study aimed to evaluate the prevalence of acromegaly in hospitalized patients with T2DM. A total of 327 hospitalized patients with T2DM were recruited as subjects. If serum insulin-like growth factor 1 (IGF-1) levels were found to be elevated, random GH level was measured or oral glucose tolerance test (OGTT) was performed. Five patients with elevated serum IGF-1 levels and random GH level or inadequate suppression of GH in the OGTT underwent pituitary magnetic resonance imaging. Of those patients, pituitary adenoma was detected in 2 patients. These 2 patients were diagnosed with acromegaly, as they also exhibited mild acromegalic features. Intriguingly, both these patients exhibited severe macroangiopathy and an absence of microangiopathy. The prevalence of acromegaly in the hospitalized patients with T2DM in this study was therefore 0.6%, suggesting a higher prevalence than that predicted. Although a large-scale prospective study is required to clarify the precise prevalence of acromegaly in hospitalized patients with T2DM, the present study shows that it is useful to screen hospitalized patients with T2DM for acromegaly by measuring their serum IGF-1 level.
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Affiliation(s)
- Kentaro Suda
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
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19
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Chorio-retinal thickness measurements in patients with acromegaly. Eye (Lond) 2014; 28:1350-4. [PMID: 25233822 DOI: 10.1038/eye.2014.216] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2014] [Accepted: 08/09/2014] [Indexed: 01/26/2023] Open
Abstract
PURPOSE To compare choroidal, foveal, and peripapillary retinal thickness between patients with acromegaly and healthy adults. METHODS This prospective, cross-sectional, and comparative study included 30 patients with acromegaly (study group) and 30 healthy subjects (control group). The subfoveal choroidal thickness (SFCT), foveal thickness, and peripapillary retinal nerve fibre layer thickness were measured with spectral domain optical coherence tomography. RESULTS The mean SFCT in the study group and in the control eyes was 374.4±98.1 and 308.6±77.3 μm, respectively (P<0.001). The mean thinnest foveal thickness value was 233.2±22.4 μm in the acromegaly group and 222.8±13.9 μm in the control group (P=0.003). The mean peripapillary retinal nerve fibre layer thickness did not differ significantly between the groups (P=0.34). CONCLUSION The SFCT and foveal thickness were significantly higher in patients with acromegaly, whereas peripapillary retinal nerve fibre layer thickness was similar between the groups.
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20
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Shin MS, Yu JH, Choi JH, Jung CH, Hwang JY, Cho YH, Kim CJ, Kim MS. Long-term changes in serum IGF-1 levels after successful surgical treatment of growth hormone-secreting pituitary adenoma. Neurosurgery 2014; 73:473-9; quiz 479. [PMID: 23728452 DOI: 10.1227/01.neu.0000431480.87160.84] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Successful treatment of acromegaly is known to normalize serum insulin-like growth factor 1 (IGF-1) levels within days after surgery. However, our clinical observations indicate that many cases of acromegaly show delayed normalization of serum IGF-1 levels after complete tumor resection. OBJECTIVE To study long-term changes of the serum IGF-1 levels in acromegalic patients for whom surgical treatment was thought to be successful. METHODS A retrospective observational study was performed with 46 acromegalic patients with no residual tumor on sellar magnetic resonance imaging, and a nadir growth hormone of less than 0.4 μg/L on a postoperative oral glucose tolerance test. RESULTS In all patients, serum IGF-1 levels returned to the normal reference values for age and sex during the observational period (12-132 months). The mean duration from the time of surgery until IGF-1 normalization was 10 months (range, 3 days-57 months). Twenty-seven patients (59%) reached normal IGF-1 ranges within 3 months of surgery, whereas 19 patients (41%) experienced delayed (>3 months) IGF-1 normalization. Eleven patients (24%) recovered normal IGF-1 levels 12 to 57 months after surgery. The possibility of delayed IGF-1 cure was increased 8.8-fold with an immediate postoperative IGF-1 level increase of 100 μg/L. CONCLUSION Satisfactory remission of acromegaly by IGF-1 criteria was delayed in a large proportion of acromegalic patients, especially those with high postoperative IGF-1 levels. Hence, additional treatment can be delayed in clinically stable acromegalic patients who show no evidence of residual tumors on postoperative magnetic resonance imaging and a normal growth hormone suppressive response to a glucose load.
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Affiliation(s)
- Mi-Seon Shin
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Asan Medical Center University of Ulsan College of Medicine, Seoul, Korea.
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Verrua E, Ferrante E, Filopanti M, Malchiodi E, Sala E, Giavoli C, Arosio M, Lania AG, Ronchi CL, Mantovani G, Beck-Peccoz P, Spada A. Reevaluation of Acromegalic Patients in Long-Term Remission according to Newly Proposed Consensus Criteria for Control of Disease. Int J Endocrinol 2014; 2014:581594. [PMID: 25587273 PMCID: PMC4283389 DOI: 10.1155/2014/581594] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Accepted: 11/24/2014] [Indexed: 11/18/2022] Open
Abstract
Acromegaly guidelines updated in 2010 revisited criteria of disease control: if applied, it is likely that a percentage of patients previously considered as cured might present postglucose GH nadir levels not adequately suppressed, with potential implications on management. This study explored GH secretion, as well as hormonal, clinical, neuroradiological, metabolic, and comorbid profile in a cohort of 40 acromegalic patients considered cured on the basis of the previous guidelines after a mean follow-up period of 17.2 years from remission, in order to assess the impact of the current criteria. At the last follow-up visit, in the presence of normal IGF-I concentrations, postglucose GH nadir was over 0.4 μg/L in 11 patients (Group A) and below 0.4 μg/L in 29 patients (Group B); moreover, Group A showed higher basal GH levels than Group B, whereas a significant decline of both GH and postglucose GH nadir levels during the follow-up was observed in Group B only. No differences in other evaluated parameters were found. These results seem to suggest that acromegalic patients considered cured on the basis of previous guidelines do not need a more intensive monitoring than patients who met the current criteria of disease control, supporting instead that the cut-off of 0.4 mcg/L might be too low for the currently used GH assay.
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Affiliation(s)
- Elisa Verrua
- Endocrinology and Diabetology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Padiglione Granelli, Via F. Sforza 35, 20122 Milan, Italy
- *Elisa Verrua:
| | - Emanuele Ferrante
- Endocrinology and Diabetology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Padiglione Granelli, Via F. Sforza 35, 20122 Milan, Italy
| | - Marcello Filopanti
- Endocrinology and Diabetology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Padiglione Granelli, Via F. Sforza 35, 20122 Milan, Italy
| | - Elena Malchiodi
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy
| | - Elisa Sala
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy
| | - Claudia Giavoli
- Endocrinology and Diabetology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Padiglione Granelli, Via F. Sforza 35, 20122 Milan, Italy
| | - Maura Arosio
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy
- Unit of Endocrine Diseases and Diabetology, Ospedale San Giuseppe Multimedica, 20123 Milan, Italy
| | - Andrea Gerardo Lania
- Endocrine Unit, IRCCS Humanitas Clinical Institute, 20089 Rozzano, Italy
- Department of Medicine Biotechnology and Translational Medicine, University of Milan, 20122 Milan, Italy
| | - Cristina Lucia Ronchi
- Endocrine and Diabetes Unit, Department of Internal Medicine I, University Hospital of Würzburg, 97070 Würzburg, Germany
| | - Giovanna Mantovani
- Endocrinology and Diabetology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Padiglione Granelli, Via F. Sforza 35, 20122 Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy
| | - Paolo Beck-Peccoz
- Endocrinology and Diabetology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Padiglione Granelli, Via F. Sforza 35, 20122 Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy
| | - Anna Spada
- Endocrinology and Diabetology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Padiglione Granelli, Via F. Sforza 35, 20122 Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy
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Hazer DB, Işık S, Berker D, Güler S, Gürlek A, Yücel T, Berker M. Treatment of acromegaly by endoscopic transsphenoidal surgery: surgical experience in 214 cases and cure rates according to current consensus criteria. J Neurosurg 2013; 119:1467-77. [DOI: 10.3171/2013.8.jns13224] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Acromegaly is a disease that has significant morbidity and mortality related to high levels of growth hormone (GH) and insulin-like growth factor–I (IGF-I), and is usually caused by pituitary adenomas. The goal in this study was to investigate the role of endoscopic transsphenoidal surgery and surgical experience in the treatment of GH adenoma cases in relation to surgical results and hormonal cure rates, and to perform a review of the literature.
Methods
The authors present a retrospective analysis of 214 GH adenoma cases. Restoration of IGF-I levels to normal for age and sex, suppression of GH levels below 0.4 μg/L on the oral glucose tolerance test, and demonstration of the total removal of the tumor on MRI studies obtained after administration of contrast material at the 3-month postoperative follow-up visit were the criteria for cure.
Results
In total 214 patients with a mean age of 41.9 ± 12 years (range 17–75 years) and a male/female ratio of 106/108 were enrolled in the study. Cure was achieved in 134 (62.6%) of 214 patients. One hundred sixty-nine patients were primary cases, and of these 109 (64.5%) were cured, whereas 61 patients were previously operated cases and of these 25 (41%) were cured. With a 51.1% decrease in the 1st month postoperatively, IGF-I levels were found to be predictive of cure (74.4% sensitivity and 73.7% specificity). Cut-off values for GH levels in predicting cure for the 1st day, 1st week, and 1st month postoperatively were 2.33, 2.05, and 2.25 μg/L, respectively.
The cut-off value for surgical experience was 57 for primary surgeries (58.5% cure rate before this cut-off value compared with 72.6% after it; p = 0.025) and 108 for all operations (45.8% vs 79.4%, p = 0.037). Although 28 patients were found to be in remission according to the criteria in 2000, they were not in remission according to the new consensus criteria. Nine of these cases (32.1%) had random GH levels < 1 μg/L at the 1-year follow-up. The 1-year IGF-I and GH levels in these 28 patients showed no significant difference when compared with the cases defined as cured according to the current criteria.
Conclusions
In acromegaly treatment, transsphenoidal endoscopic surgery performed by an expert senior surgeon and increased surgical experience are important for higher cure rates. Random GH levels < 2.33 μg/L after the 1st day postoperatively and a > 50% decrease in IGF-I levels after the 1st month postoperatively are predictive of cure. Moreover, there is no urgency for additional therapy in patients with GH levels of 0.4–1 μg/L and MRI sequences showing no tumor at the 3-month follow-up, because for these cases remission can be achieved at the 1-year follow-up.
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Affiliation(s)
- Derya Burcu Hazer
- 1Department of Neurosurgery, Muğla Sıtkı Koçman University Faculty of Medicine, Muğla
| | - Serhat Işık
- 2Department of Endocrinology and Metabolism, Ministry of Health, Ankara Numune Research and Training Hospital, Ankara; and
| | - Dilek Berker
- 2Department of Endocrinology and Metabolism, Ministry of Health, Ankara Numune Research and Training Hospital, Ankara; and
| | - Serdar Güler
- 3Department of Endocrinology, Faculty of Medicine, Hitit University, Çorum
| | | | | | - Mustafa Berker
- 6Neurosurgery, Hacettepe University Faculty of Medicine, Ankara, Turkey
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Turgut S, Akın F, Ayada C, Topsakal S, Yerlikaya E, Turgut G. The growth hormone receptor polymorphism in patients with acromegaly: relationship to BMI and glucose metabolism. Pituitary 2012; 15:374-9. [PMID: 21744231 DOI: 10.1007/s11102-011-0329-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The aim of this study was to investigate association between the frequencies of Growth Hormone receptor (d3GHR) gene polymorphisms and some clinical parameters of acromegalic patients. Total of 35 acromegalic patients were enrolled to study. The d3GHR polymorphism was identified by using polymerase chain reaction from peripheral blood samples. The levels of systolic and diastolic blood pressure, BMI, fasting plasma glucose (FPG), Fasting insulin, HOMA-IR, IGF-I, GH, IGFBP3, triglyceride, HDL and LDL cholesterol concentrations were evaluated. The frequencies of d3GHR genotypes were found as follows; 5 (14.3%) subjects had d3/d3, 11 (31.4%) had d3/fl and 19 (54.3%) had fl/fl in patients. The prevalence of the d3 and fl alleles was 30 and 70%, respectively. Systolic blood pressure, fasting insulin and HOMA-IR was found significantly increased in homozygote d3GHR genotype group compared to d3/fl subjects (P < 0.05). In addition, BMI was observed significantly different among three genotypes (P = 0.007) and in the subjects with d3/d3 genotype, BMI was found significantly higher than d3/fl and fl/fl genotypes groups. As well as, no significant difference was found between the d3 and fl alleles group in terms of the clinical parameters except for BMI (P = 0.002). It can be said that the d3GHR gene polymorphism may affect BMI, systolic blood pressure and insulin regulation. At the same time we can say homozygote d3GHR genotype and d3 allele carriers may have more risk than other genotypes for high BMI.
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Affiliation(s)
- Sebahat Turgut
- Faculty of Medicine, Department of Physiology, University of Pamukkale, Denizli, 20070, Turkey.
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Manolopoulou J, Alami Y, Petersenn S, Schopohl J, Wu Z, Strasburger CJ, Bidlingmaier M. Automated 22-kD growth hormone-specific assay without interference from Pegvisomant. Clin Chem 2012; 58:1446-56. [PMID: 22908135 DOI: 10.1373/clinchem.2012.188128] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Large variability exists among different growth hormone (GH) assays owing to differences in calibration, antibody specificity, isoform recognition, and interference from GH binding protein (GHBP). The GH receptor antagonist Pegvisomant presents a new challenge because Pegvisomant interferes with many GH assays. A recent consensus conference established criteria for standardization and evaluation of GH assays. Following consensus recommendations, we developed a new GH assay on an automated analyzer (IDS-iSYS, Immunodiagnostic Systems). METHODS A monoclonal antibody not cross-reacting with Pegvisomant was combined with a monoclonal antibody specific for 22-kD GH. Isoform specificity and interference from GHBP was tested and compared to that seen in 2 existing automated GH assays (Siemens Immulite, Diasorin Liaison). We also compared GH concentrations measured by the 3 assays for healthy volunteers and patients with acromegaly receiving different treatments. Using the iSYS assay, we also established nadir GH values during oral glucose load and analyzed changes in endogenous GH during Pegvisomant treatment. RESULTS Analytical and functional sensitivities were 0.01 μg/L and 0.04 μg/L, with a dynamic range from 0.04 to 100 μg/L. Intraassay CVs were 2%-4%, whereas interassay CVs were 5%-7% at GH concentrations between 1.7 and 27.5 μg/L. The assay was specific for 22-kD GH and not affected by GHBP. The presence of Pegvisomant, which leads to a negative bias on the Immulite and dramatic overestimation of GH on the Liaison, had no impact on the iSYS GH assay. CONCLUSIONS The new assay fulfils recent consensus recommendations and presents a useful new tool for reliable measurement of GH.
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Affiliation(s)
- Jenny Manolopoulou
- Endocrine Research Laboratories, Medizinische Klinik und Poliklinik IV, Ludwig Maximilians University, Munich, Germany
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25
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Plöckinger U. Medical therapy of acromegaly. Int J Endocrinol 2012; 2012:268957. [PMID: 22550484 PMCID: PMC3328958 DOI: 10.1155/2012/268957] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2011] [Revised: 12/20/2011] [Accepted: 01/09/2012] [Indexed: 12/18/2022] Open
Abstract
This paper outlines the present status of medical therapy of acromegaly. Indications for permanent postoperative treatment, postirradiation treamtent to bridge the interval until remission as well as primary medical therapy are elaborated. Therapeutic efficacy of the different available drugs-somatostatin receptor ligands (SRLs), dopamine agonists, and the GH antagonist Pegvisomant-is discussed, as are the indications for and efficacy of their respective combinations. Information on their mechanism of action, and some pharmakokinetic data are included. Special emphasis is given to the difficulties to define remission criteria of acromegaly due to technical assay problems. An algorithm for medical therapy in acromegaly is provided.
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Affiliation(s)
- U. Plöckinger
- Interdisziplinäres Stoffwechsel-Centrum, Charité-Universitätsmedizin Berlin, Campus Virchow-Klinikum, 13353 Berlin, Germany
- *U. Plöckinger:
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26
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Arafat AM, Müller L, Möhlig M, Mayr B, Kremenevskaya N, Pfeiffer AFH, Buchfelder M, Schöfl C. Comparison of oral glucose tolerance test (OGTT) 100 g with OGTT 75 g for evaluation of acromegalic patients and the impact of gender on test reproducibility. Clin Endocrinol (Oxf) 2011; 75:685-91. [PMID: 21575028 DOI: 10.1111/j.1365-2265.2011.04108.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
CONTEXT Growth hormone (GH) measurements during an oral glucose tolerance test (OGTT) are essential for the diagnosis and follow-up management of acromegaly. However, both 100 g glucose (OGTT(100) ) and 75 g glucose (OGTT(75) ) test variants are in clinical use. Whether the tests are interchangeable concerning GH nadir and test interpretation is unclear. Furthermore, information on test reproducibility and the impact of gender is scarce. OBJECTIVE To compare both tests in acromegalic patients and to evaluate test reproducibility with respect to gender. DESIGN, SUBJECTS AND METHODS OGTT(100) and OGTT(75) were performed on two consecutive days in 54 acromegalic patients (46·9 ± 1·8 years, 30 women). OGTT(75) was repeated on three different occasions in 11 healthy men and 13 healthy women at different phases of the menstrual cycle. RESULTS GH nadirs were comparable between tests [2·40 ± 0·52 (OGTT(100) ) and 2·46 ± 0·54 μg/l (OGTT(75) ); P = 0·356]. There were no differences at any time point in the mean values of GH, serum glucose or insulin between the two test variants. Test interpretation was highly consistent between the OGTT(100) and OGTT(75) [area under the receiver operated curve (ROC) = 0·995]. In men, GH, insulin and glucose measurements during OGTT(75) were highly reproducible. In women, however, basal and GH nadirs were significantly higher midcycle (P < 0·05). CONCLUSIONS In acromegalic patients, there is no difference in GH nadirs and test interpretation after the ingestion of 100 g or 75 g glucose. The OGTT(75) is highly reproducible in men, but in women, it should be performed preferably in the early follicular phase.
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Affiliation(s)
- A M Arafat
- Department of Endocrinology, Diabetes and Nutrition, Charité-University Medicine Berlin, Campus Benjamin Franklin, Berlin, Germany
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Vieira Neto L, Abucham J, Araujo LAD, Boguszewski CL, Bronstein MD, Czepielewski M, Jallad RS, Musolino NRDC, Naves LA, Ribeiro-Oliveira Júnior A, Vilar L, Faria MDS, Gadelha MR. Recomendações do Departamento de Neuroendocrinologia da Sociedade Brasileira de Endocrinologia e Metabologia para o diagnóstico e tratamento da acromegalia no Brasil. ACTA ACUST UNITED AC 2011; 55:91-105. [DOI: 10.1590/s0004-27302011000200001] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2010] [Accepted: 02/06/2011] [Indexed: 12/27/2022]
Abstract
A acromegalia é uma doença associada à elevada morbidade e à redução da expectativa de vida. Em virtude do seu caráter insidioso e do seu não reconhecimento, o diagnóstico é frequentemente realizado com atraso, o que, associado às complicações relacionadas ao excesso do GH/IGF-I, determina elevada morbimortalidade. No entanto, um diagnóstico precoce e um tratamento efetivo minimizam a morbidade e normalizam a taxa de mortalidade. Nesta publicação, o objetivo do Departamento de Neuroendocrinologia da Sociedade Brasileira de Endocrinologia e Metabologia é divulgar quando suspeitar clinicamente da acromegalia e como diagnosticá-la. Além disso, discute-se a maneira mais eficaz e segura de realizar o tratamento da acromegalia, enfatizando que este deve ser realizado em centros de referência. Assim, com base em dados publicados em periódicos de nível científico reconhecido e na experiência dos autores, são apresentadas as recomendações para o diagnóstico e tratamento da doença.
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Affiliation(s)
- Leonardo Vieira Neto
- Hospital Universitário Clementino Fraga Filho, Brasil; Hospital da Lagoa, Brasil
| | | | | | | | | | | | | | | | | | | | | | | | - Mônica R. Gadelha
- Hospital Universitário Clementino Fraga Filho, Brasil; Instituto Estadual de Diabetes e Endocrinologia Luiz Capriglione, Brasil
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Fukuda I, Kurimoto M, Tanaka S, Yamakado Y, Muraoka T, Takano K, Hizuka N. Effects of GH assay standardization on evaluation of treatment outcomes for acromegaly in Japan. Endocr J 2011; 58:777-82. [PMID: 21720049 DOI: 10.1507/endocrj.k11e-099] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
In Japan, the growth hormone (GH) assay has been standardized since April 2005 through use of a uniform recombinant human GH (rhGH) standard. Since then, GH values measured using the rhGH standard have been approximately 40% lower than previous values measured using kit standards based on the WHO standards for hGH of pituitary origin. However, the Japanese criteria for evaluating treatment outcomes for acromegaly have remained the same: a nadir GH during a 75 g OGTT <1 µg/L is considered cured, 1≤GH<2.5µg/L is considered inadequately controlled, and ≥2.5 µg/L is considered poorly controlled, instead of these levels were lowered to 60%, i.e. from 1 to 0.6 µg/L for cured and from 2.5 to 1.5µg/L for inadequately controlled (termed as "newly proposed criteria" in this study). We investigated the effects of standardization of the GH assay on the evaluation of post-surgical disease activity in 50 patients with acromegaly (M/F 19/31, 21-72 yr.). Post-surgical nadir GH levels during OGTT were positively correlated with the IGF-I SD score 3 months after TSS. Five of 6 patients whose post-surgical nadir GH levels ranged between 0.6 and 1 µg/L had normal serum IGF-I levels 3 months after TSS. Rates of improvement in glucose metabolism did not differ when patients were classified based on the present criteria vs. the newly proposed criteria. In conclusion, the current Japanese remission criteria for acromegaly still accurately reflect post-surgical disease activity in most patients, though long-term observation is still required.
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Affiliation(s)
- Izumi Fukuda
- Department of Medicine II, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, Japan.
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29
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Akin F, Turgut S, Cirak B, Kursunluoglu R. IGF(CA)19 and IGFBP-3-202A/C gene polymorphism in patients with acromegaly. Growth Horm IGF Res 2010; 20:399-403. [PMID: 20920870 DOI: 10.1016/j.ghir.2010.09.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2009] [Revised: 06/15/2010] [Accepted: 09/06/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVE We aimed to investigate IGF-1 and IGFBP-3 gene polymorphisms in patients with acromegaly. DESIGN We included 34 patients with acromegaly and 37 healthy subjects to study. At baseline examinations, antropometric measurements were done. Genomic DNA from the patients and controls were prepared. Serum, glucose, insulin, total cholesterol, triglyceride, HDL cholesterol, LDL cholesterol, growth hormone (GH), Insulin-like growth factor I (IGF-I) and IGFBP-3 levels of subjects were analyzed. RESULTS The frequency of genotype IGF-1(CA)19 and IGFBP3-202 A/C gene was significantly different between control and patients. In acromegalic patients, a significant difference in the serum IGF-1 levels and LDL cholesterol levels among the three IGF(CA)19 genotype. LDL levels were positively correlated with IGF-1. Subjects having >194 bp genotype had higher IGF-1 and LDL cholesterol levels. We observed that the patients with 194 bp genotype have more invasive and bigger tumors and they require adjunctive therapies. Clinical characteristics among the three IGFBP3-202 A/C genotype, AA, AC and CC, did not display any significant difference. CONCLUSIONS In our study, 194 bp allele (20 CA repeats) of the IGF-I promoter have higher circulating IGF-I levels than others. We have found that the patients with 194 bp genotype are the resistant patients with active disease and they required high dose medication. We think this study may help to define the patients, who are resistant to drug therapy, and possible cardiovascular disease.
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Affiliation(s)
- Fulya Akin
- Pamukkale University, Department of Endocrinology and Metabolism, Kınıklı Kampusü, 20070, Denizli, Turkey.
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Rubeck KZ, Madsen M, Andreasen CM, Fisker S, Frystyk J, Jørgensen JOL. Conventional and novel biomarkers of treatment outcome in patients with acromegaly: discordant results after somatostatin analog treatment compared with surgery. Eur J Endocrinol 2010; 163:717-26. [PMID: 20813787 DOI: 10.1530/eje-10-0640] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
CONTEXT Control of disease activity in acromegaly is critical, but the biochemical definitions remain controversial. OBJECTIVE To compare traditional and novel biomarkers and health status in patients with acromegaly treated with either surgery alone or somatostatin analog (SA). DESIGN AND METHODS Sixty-three patients in long-term remission based on normalized total IGF1 levels after surgery alone (n=36) or SA (n=27) were studied in a cross-sectional manner. The groups were comparable at diagnosis regarding demographic and biochemical variables. Each subject underwent 3 h of serum sampling including a 2-h oral glucose tolerance test (OGTT). Health status was measured by two questionnaires: EuroQoL and Acrostudy (Patient-assessed-Acromegaly symptom questionnaire (PASQ)). RESULTS Total and bioactive IGF1 (μg/l) levels were similar (total: 185 ± 10 (SA) versus 171 ± 8 (surgery) (P=0.28); bioactive: 1.9 ± 0.2 vs 1.9 ± 0.1 (P=0.70)). Suppression of total and free GH (μg/l) during OGTT was blunted in the SA group (total GH(nadir): 0.59 ± 0.08 (SA) versus 0.34 ± 0.06 (surgery) (P=0.01); free GH(nadir): 0.43 ± 0.06 vs 0.19 ± 0.04 (P<0.01)). The insulin response to OGTT was delayed, and the 2-h glucose level was elevated during SA treatment (P=0.02). Disease-specific health status was better in patients after surgery (P=0.02). CONCLUSIONS i) Despite similar and normalized IGF1 levels, SA treatment compared with surgery alone was associated with less suppressed GH levels and less symptom relief; ii) this discordance may be due to specific suppression of hepatic IGF1 production by SA; iii) we suggest that biochemical assessment during SA treatment should include both GH and IGF1.
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Affiliation(s)
- Kristine Z Rubeck
- The Medical Research Laboratories, Department of Endocrinology and Internal Medicine, Clinical Institute, Aarhus University Hospital, Nørrebrogade 44, DK-8000 Aarhus C, Denmark.
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31
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Angiotensin converting enzyme I/D, angiotensinogen M235T and AT1-R A/C1166 gene polymorphisms in patients with acromegaly. Mol Biol Rep 2010; 38:569-76. [PMID: 20361261 DOI: 10.1007/s11033-010-0142-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2010] [Accepted: 03/23/2010] [Indexed: 10/19/2022]
Abstract
Acromegaly is associated with increased morbidity and mortality related to cardiovascular disease. Hypertension is one of the most common cardiovascular risk factors in acromegalic patients. The aim of this study was to investigate association between the frequencies of angiotensin converting enzyme (ACE) I/D, angiotensinogen (AGT) M235T and the angiotensin II type 1 receptor (AT1-R) A/C1166 gene polymorphisms and some clinical parameters of acromegalic patients. Total of 33 acromegalic patients and 63 controls were enrolled to study. We determined the ACE I/D, AGT M235T and AT1-R A/C1166 gene polymorphisms. Serum insulin, glucose, triglyceride, HDL-cholesterol, LDL-cholesterol, growth hormone and Insulin-like growth factor I (IGF-I) levels of subjects were analyzed. The frequencies of ACE and M235T AGT genotype were not significantly different between control and patients. The distribution of AT1R A/C1166 genotypes was significantly different between patients and control subjects (P=0.016). None of the three ACE genotypes, DD, ID and II displayed significant difference in acromegalic patients. A significant difference in systolic blood pressure and the serum IGF-I levels among the three AGT genotype, MM, MT and TT genotypes was found in patient group. Individuals with MT genotypes had significantly higher serum IGF-I levels and systolic blood pressure than MM and TT genotype subjects, P<0.05. In addition, serum triglyceride and HDL levels differed significantly between MM and MT genotypes, P<0.05. However, systolic blood pressure of patients with CC genotypes was found to be significantly higher than AA genotypes individuals in acromegaly group, P<0.05. It can be said that the angiotensinogen MT and AT1R CC1166 genotype carriers may have more risk than other genotypes in the development of hypertension in acromegaly.
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Bidlingmaier M, Freda PU. Measurement of human growth hormone by immunoassays: current status, unsolved problems and clinical consequences. Growth Horm IGF Res 2010; 20:19-25. [PMID: 19818659 PMCID: PMC7748084 DOI: 10.1016/j.ghir.2009.09.005] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2009] [Accepted: 09/17/2009] [Indexed: 01/28/2023]
Abstract
Measuring the concentration of growth hormone (GH) in blood samples taken during dynamic tests represents the basis for diagnosis of growth hormone related disorders, namely growth hormone deficiency and growth hormone excess. Today, a wide spectrum of immunoassays are in use, enabling rapid and sensitive determination of growth hormone concentrations in routine diagnostics. From a clinical point of view several difficulties exist with the use and interpretation of GH assay results in the assessment of GH related disorders: Many physiological factors such as fat mass, age and gender influence the outcome of dynamic tests, overall leading to significant inter-individual differences in GH responses. However, in addition to the physiological variability, considerable variability exists in GH assay results obtained by different immunoassays. Unfortunately, all the new technical advances in the field of GH measurement techniques have not reduced this methodological variability. To a large extent, the actual values reported for the GH concentration in a sample depend on the method used by the respective laboratory. Obviously, such discrepancies limit the applicability of consensus guidelines on diagnosis and treatment in clinical practice. This review summarizes current practices for GH measurement with respect to the methods used, their limitations and the clinical consequences of the existing heterogeneity in GH immunoassay results.
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Affiliation(s)
- Martin Bidlingmaier
- Endocrine Research Laboratories, Medizinische Klinik - Innenstadt, Ludwig-Maximilians University, Munich, Germany.
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Reid TJ, Post KD, Bruce JN, Nabi Kanibir M, Reyes-Vidal CM, Freda PU. Features at diagnosis of 324 patients with acromegaly did not change from 1981 to 2006: acromegaly remains under-recognized and under-diagnosed. Clin Endocrinol (Oxf) 2010; 72:203-8. [PMID: 19473180 PMCID: PMC2866138 DOI: 10.1111/j.1365-2265.2009.03626.x] [Citation(s) in RCA: 134] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Traditionally, acromegaly evaded diagnosis until in its clinically obvious later stages when treatment is more difficult. Over the last 25 years diagnostic tests have improved, but whether clinical disease detection also improved was unknown, so we tested if disease severity at diagnosis had changed from 1981 to 2006. METHODS Data on 324 consecutive acromegaly patients presenting from 1981 to 2006 at two New York City hospitals were collected by retrospective review (n = 324) and by interview (n = 200). The main complaint, acromegaly associated comorbidities, signs, symptoms, healthcare providers visited, preoperative GH and IGF-I levels and pituitary tumour size at diagnosis were compared in patients presenting in the earlier vs. later halves of the time period. RESULTS Times from symptom onset to diagnosis were 5.9 year (early) vs. 5.2 year (late; P = NS). At diagnosis, 96% of early and late groups had facial feature changes and/or hand/foot enlargement. Comorbidities included hypertension 37% (early) vs. 36% (late), carpal tunnel syndrome (24%vs. 24%), sleep apnoea (13%vs. 29%; P < 0.01), osteoarthritis (25%vs. 23%) and diabetes mellitus (18%vs. 15%); each patient had 1.2 (early) vs. 1.3 (late; P = 0.53) comorbidities. Groups were similar in signs, symptoms, tumour size, GH and IGF-I. CONCLUSIONS Clinical, biochemical and tumour size characteristics at diagnosis of acromegaly patients were unchanged from 1981 to 2006. Most patients still have marked manifestations of acromegaly at diagnosis, suggesting that acromegaly remains clinically under-recognized. Healthcare professionals should more commonly consider acromegaly, which can lead to earlier diagnosis and better treatment outcome.
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Affiliation(s)
- Tirissa J Reid
- Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, NY 10032, USA
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Feelders RA, Hofland LJ, van Aken MO, Neggers SJ, Lamberts SWJ, de Herder WW, van der Lely AJ. Medical therapy of acromegaly: efficacy and safety of somatostatin analogues. Drugs 2009; 69:2207-26. [PMID: 19852525 DOI: 10.2165/11318510-000000000-00000] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Acromegaly is a chronic disease with signs and symptoms due to growth hormone (GH) excess. The most frequent cause of acromegaly is a GH-producing pituitary adenoma. Chronic GH excess is accompanied by long-term complications of the locomotor (arthrosis) and cardiovascular (atherosclerosis, cardiomyopathy) systems and is, when untreated, associated with an increased mortality. The aim of treatment of acromegaly is to improve symptoms, to achieve local tumour mass control, and to decrease morbidity and mortality. Treatment options include surgery, medical therapy and radiotherapy. Transsphenoidal surgery is the first choice of treatment when a definitive cure can be achieved, particularly in the case of microadenomas and when decompression of surrounding structures (optic chiasm, ophthalmic motor nerves) is indicated. Primary medical therapy has been increasingly applied in recent years, especially when a priori chances of surgical cure are low (because of adenoma size and localization) and in patients with advanced age and/or serious co-morbidity. In addition, preoperative primary medical therapy may result in tumour shrinkage, facilitating tumour resection, and may reduce perioperative complications due to GH excess. Within the spectrum of medical therapy, long-acting somatostatin analogues (somatostatins) are considered as first-line treatment. Treatment with somatostatin analogues results in GH control in approximately 60% of patients. In addition, somatostatin analogues induce tumour shrinkage in 30-50% of patients, particularly when applied as primary therapy. Prolonged treatment with somatostatin analogues appears to be safe and is usually well tolerated. The currently available somatostatin analogues, octreotide and lanreotide, seem to be equally effective; however, this should still be evaluated in prospective, randomized trials evaluating efficacy with respect to GH control and tumour shrinkage. In patients with an insufficient clinical and biochemical response to somatostatin analogues, combination therapy with dopamine receptor agonists or the GH receptor antagonist pegvisomant usually leads to disease control. New developments in the medical therapy of acromegaly include the universal somatostatin receptor agonist pasireotide, which has a broader affinity for all somatostatin receptor (sst) subtypes compared with the currently available somatostatin analogues with preferential affinity for the sst2 receptor, and chimeric compounds that interact with both somatostatin and dopamine receptors with synergizing effects on GH secretion.
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Affiliation(s)
- Richard A Feelders
- Department of Internal Medicine, Section of Endocrinology, Erasmus Medical Center, Rotterdam, The Netherlands.
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Abstract
Monitoring of a patient with acromegaly requires periodic evaluation of levels of GH and IGF-1, the biochemical markers of this disease. Although the results of these two tests are usually concordant, they can be discrepant and how to proceed when they are can be a challenging clinical problem. In some cases, IGF-1 levels are normal yet GH suppression after oral glucose is abnormal; this pattern may be due to persistent GH dysregulation despite remission. In other cases, IGF-1 levels are elevated yet GH suppression appears to be normal; this pattern may be observed if the cutoff for GH suppression is inappropriately high for the GH assay being used. Various conditions known to alter GH and IGF-1 including malnutrition, thyroid disease and oestrogen use as well as the potential for methodological or normative data issues with the GH and IGF-1 assays should be considered in the interpretation of discrepant results. When a known cause of the discrepancy other than acromegaly is not identified, a clinical decision about the patient's therapy needs to be made. We adjust treatment in most patients whose results are discrepant based on the IGF-1 level, continuing current treatment if it is persistently normal or modifying this if it is elevated. The clinical picture of the patient, however, also needs to be incorporated into this decision. All patients should have continued periodic surveillance of both GH and IGF-1 levels.
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Affiliation(s)
- Pamela U Freda
- College of Physicians and Surgeons, Columbia University, New York, NY 10032, USA.
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Sherlock M, Aragon Alonso A, Reulen RC, Ayuk J, Clayton RN, Holder G, Sheppard MC, Bates A, Stewart PM. Monitoring disease activity using GH and IGF-I in the follow-up of 501 patients with acromegaly. Clin Endocrinol (Oxf) 2009; 71:74-81. [PMID: 19178529 DOI: 10.1111/j.1365-2265.2008.03461.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
CONTEXT The aims of treatment in patients with acromegaly are to achieve serum GH/IGF-I concentrations associated with cure or normalization of mortality and alleviation of symptoms. OBJECTIVE AND METHODS Using the West Midlands Acromegaly database (n = 501) we investigated the reliability of basal fasting GH in predicting nadir or mean GH during oral glucose tolerance test (OGTT) or GH day curve (GHDC), respectively, the degree of discordance between disease activity measured by GH and IGF-I values and the effect of radiotherapy on the above relationships. In total 773 OGTT and 507 GHDC were performed. RESULTS Basal fasting GH was strongly correlated with nadir/mean GH on OGTT/GHDC (r = +0.87, P < 0.0001, r = +0.93, P < 0.0001, respectively). A basal GH < 2.5 microg/l was associated with a nadir/mean GH during OGTT/GHDC < 2.5 microg/l in 98.6% and 88.2% of cases, respectively. Elevated IGF-I was seen in 32.4% and 46.4% of patients with GH nadir values during OGTT < 1 and < 2.5 microg/l, respectively, and in 21.2% and 45.9% of GHDC with mean GH < 1 and < 2.5 microg/l, respectively. Radiotherapy increased the discordance in GH and IGF-I as markers of disease activity at GH < 2.5 microg/l (elevated IGF-I-values when OGTT nadir GH < 2.5 microg/l: radiotherapy 55.5%vs. no radiotherapy 36.9%, P = 0.002). CONCLUSIONS There is a close relationship between a basal fasting GH < 2.5 microg/l and nadir/mean GH < 2.5 microg/l during OGTT/GHDC. There is a large discordance between disease activity when assessed by GH and IGF-I which is further increased by radiotherapy. These observations illustrate the challenge of defining appropriate biochemical end-points to achieve control of disease and normalization of mortality in acromegaly.
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Affiliation(s)
- M Sherlock
- Division of Medical Sciences, Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham, Birmingham, UK
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Roelfsema F, Biermasz NR, Pereira AM, Romijn JA. The role of pegvisomant in the treatment of acromegaly. Expert Opin Biol Ther 2008; 8:691-704. [DOI: 10.1517/14712598.8.5.691] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Abstract
While most transsphenoidal pituitary surgery is accomplished without complication, monitoring is required postoperatively for a set of disorders that are specific to this surgery. Postoperative assessments are tailored to the early and later postoperative periods. In the early period, which spans the first few weeks after surgery, both monitoring of anterior and posterior pituitary function and managing neurosurgical issues are the focus of care. Potential disruption of pituitary-adrenal function is covered with perioperative glucocorticoids. Various strategies exist for ensuring the integrity of this axis, but typically this is done by measuring a morning cortisol on the 2nd or 3rd postoperative days. Patients with levels <10 microg/l should continue therapy with reassessment in the later postoperative period. Monitoring for water imbalances, which are due to deficiency or excess of ADH (DI or SIADH, respectively), is accomplished by continuous accounting of fluid intake, urine output and specific gravities coupled with daily serum electrolyte measurements. DI is characterized by excess volumes of inappropriately dilute urine, which can lead to hypernatremia. Most patients maintain adequate fluid intake and euvolemia, but desmopressin therapy is required for some. SIADH, which peaks in incidence on 7th postoperative day, presents with hyponatremia that can be severe and symptomatic. Management consists of fluid restriction. Neurosurgical monitoring is primarily for disturbances in vision or neurological function, and although uncommon, for CSF leak and infections such as meningitis. In the later postoperative period, the adrenal, thyroid and gonadal axes are assessed. New persistent hypopituitarism is rare when transsphenoidal surgery is performed by an experienced surgeon. Various strategies are available for assessing each axis and for providing replacement therapy in patients with deficiencies. Long term monitoring with assessments of visual, neurological and pituitary function coupled with pituitary imaging is necessary for all patients who have undergone surgery, irrespective of the hormone status of their tumors.
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Affiliation(s)
- John C Ausiello
- Department of Medicine, Columbia University, College of Physicians & Surgeons, New York, NY 10032, USA
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Jayasena CN, Wujanto C, Donaldson M, Todd JF, Meeran K. Measurement of basal growth hormone (GH) is a useful test of disease activity in treated acromegalic patients. Clin Endocrinol (Oxf) 2008; 68:36-41. [PMID: 18088288 DOI: 10.1111/j.1365-2265.2007.02996.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Nadir GH during oral glucose tolerance test (OGTT) is the gold-standard test of GH secretion in treated acromegaly. However, it was recently reported that variability in GH is reduced postradiotherapy, making basal GH a potential surrogate marker for nadir GH in such patients. OBJECTIVE We aimed to investigate how predictive basal GH is of nadir GH and IGF-I, and whether radiotherapy influenced these relationships. DESIGN A total of 226 pairs of basal and nadir GH values from 76 treated acromegalic patients were analysed. Basal GH was defined as the fasting serum GH immediately prior to OGTT. RESULTS A highly positive linear correlation (Pearson correlation = 0.955, P < 0.01) between basal and nadir GH was found. Negative predictive value for basal GH < 1 microg/l with respect to nadir GH > 1 microg/l was 100% (53/53 in radiotherapy group, 15/15 in nonradiotherapy group). Positive predictive values for basal GH > 2 microg/l with respect to nadir GH > 1 microg/l for patients treated and not treated with radiotherapy were 96.7% (88/91) and 95.2% (20/21), respectively. No significant difference between concordance of basal and nadir GH with IGF-I in assessment of disease activity was found. Discordance between IGF-I and nadir or basal GH < 1 microg/l was lower in the radiotherapy group than nonradiotherapy group, but this was nonsignificant. CONCLUSIONS Basal GH < 1 microg/l and > 2 microg/l are highly predictive of nadir GH < 1 microg/l and > 1 microg/l, respectively, regardless of previous radiotherapy. Basal GH is as good as nadir GH in concordance with IGF-I. We therefore suggest basal GH is a useful test of disease activity in treated acromegaly, and can reliably replace OGTT unless basal GH is between 1 microg/l and 2 microg/l.
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Affiliation(s)
- C N Jayasena
- Department of Endocrinology, Imperial College Faculty of Medicine, Hammersmith Hospital, Du Cane Road, London, UK
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Cazabat L, Souberbielle JC, Chanson P. Dynamic tests for the diagnosis and assessment of treatment efficacy in acromegaly. Pituitary 2008; 11:129-39. [PMID: 18418712 DOI: 10.1007/s11102-008-0113-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
In the vast majority of cases, basal serum GH and IGF-1 levels are markedly increased in patients with obvious clinical signs and symptoms of acromegaly. The oral glucose tolerance test (OGTT) is useful for diagnosis in the minority of patients who have weak GH hypersecretion. The cutoff for a "normal" GH nadir in the OGTT remains to be agreed. The type of GH assay, its sensitivity, the type of standard used by the manufacturer, the patient's age and especially gender, must all be taken into account. Recent studies using new highly sensitive assays suggest an upper normal GH nadir of 0.71 microg/l for female healthy patients, but no "universal" cut-off has yet been defined for healthy males (from 0.057 to 0.25 microg/l). The 1 microg/l cutoff proposed for the diagnosis of acromegaly in a 2000 consensus should be abandoned in favor of a 0.30 microg/l cutoff. Clinicians should know which assay is used, together with its sensitivity and the standard, before making therapeutic decisions. A more pragmatic view should probably be adopted when assessing the treatment response. Indeed, if "cure" is defined not with the <1 microg/l GH nadir but on the basis of healthy control values, many patients will not be considered controlled. However, the clinical relevance of such goal (e.g. achieving GH nadir <0.4 microg/l rather than <1 microg/l) in terms of prognosis and prediction of outcome on long term is not firmly established. Thus, from a pragmatic point of view, achieving a normal age-adjusted IGF-1 level and a GH nadir below 1 microg/l during OGTT will probably remain relevant for defining remission and good disease control in terms of morbidity and mortality in acromegaly.
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Affiliation(s)
- Laure Cazabat
- Service d'Endocrinologie et Maladies de la Reproduction, Hôpital de Bicêtre, Le-Kremlin-Bicetre, France
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Misra M, Cord J, Prabhakaran R, Miller KK, Klibanski A. Growth hormone suppression after an oral glucose load in children. J Clin Endocrinol Metab 2007; 92:4623-9. [PMID: 17878248 DOI: 10.1210/jc.2007-1244] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND GH nonsuppression after oral glucose is diagnostic for GH excess, but normative data are lacking in children. Adult data cannot be extrapolated to children given the pubertal increase in GH concentration. In addition, because GH levels are higher in pubertal girls than boys, nadir GH may differ across gender. OBJECTIVE Our objective was to determine whether nadir GH during an oral glucose tolerance test (OGTT) is gender and pubertal stage specific. We hypothesized that nadir GH would be higher in girls, and at the pubertal stage known to correspond with peak height velocity (Tanner 2-3 in girls and Tanner 3-4 in boys) and maximal GH concentrations. SUBJECTS/ METHODS: A 2-h OGTT using 2.35 g/kg oral glucose (maximum 100 g) was performed in 64 girls and 43 boys, 9-17 yr (10th-90th percentiles for body mass index). Girls were grouped as group 1 (Tanner 1), group 2 (Tanner 2-3), and group 3 (Tanner 4-5), and boys as group 1 (Tanner 1-2), group 2 (Tanner 3-4), and group 3 (Tanner 5). RESULTS Nadir GH was higher in girls than boys, and in group 2 girls and boys than the other two groups. The upper limit for nadir GH was highest in group 2 girls (1.57 ng/ml), and lower for the other two groups of girls (0.64 ng/ml), and for boys (0.50 ng/ml). All but one girl, and all boys suppressed to less than 1.0 ng/ml. There were 16 girls and five boys who had a nadir GH of more than 0.3 ng/ml. CONCLUSION GH suppression after oral glucose is gender and pubertal stage specific.
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Affiliation(s)
- Madhusmita Misra
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, Massachusetts 02114, USA.
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Ronchi CL, Arosio M, Rizzo E, Lania AG, Beck-Peccoz P, Spada A. Adequacy of current postglucose GH nadir limit (< 1 microg/l) to define long-lasting remission of acromegalic disease. Clin Endocrinol (Oxf) 2007; 66:538-42. [PMID: 17371472 DOI: 10.1111/j.1365-2265.2007.02769.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Some authors proposed to lower the present postglucose GH nadir cut-off (i.e. < 1 microg/l) to that obtained in healthy subjects to establish remission of acromegaly. The aim of the study was to correlate GH nadir with hormonal and metabolic parameters and to confirm the adequacy of the current limit to define disease remission. DESIGN AND PATIENTS Retrospective study of 40 acromegalic patients cured by surgery, followed by radiotherapy when appropriate, studied at the time of disease remission (Phase 1) and re-evaluated after at least 3 years' follow-up (median 6.5 year, Phase 2). GH nadir was evaluated in 44 sex- and age-matched controls. MEASUREMENTS Symptom score, pituitary function, neuroradiological imaging, metabolic parameters (BMI, glucose metabolism, insulin sensitivity, lipid profile, blood pressure). RESULTS The upper limit of the 'normal' GH nadir was fixed at 0.26 microg/l (mean + 2SD of controls). In Phase 1, GH nadir was < 0.26 microg/l in 16 patients (Group A) and > 0.26 microg/l in 24 patients (Group B). Group B had only slightly higher IGF-1 SDS (0.4 +/- 1.0 vs.- 0.1 +/- 1.0, P = ns) and lower body mass index (BMI) than Group A (26.2 +/- 2.4 vs. 30.6 +/- 4.5 kg/m(2), P < 0.005). GH nadir positively correlated with IGF-1 (P < 0.05, r = 0.32) and negatively with BMI (P < 0.05, r = 0.42). In Phase 2, all patients had IGF-1 levels in the normal range and GH nadir < 1 microg/l, both parameters being even lower than those found at the time of remission. No patient had either clinical or neuroradiological evidence of disease recurrence. CONCLUSIONS The current GH nadir limit is still adequate to define both short- and long-lasting remission of acromegaly, independently of the type of definitive treatment. Patients with the lowest GH nadir should probably be monitored long-term for adequacy of their GH secretion.
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Affiliation(s)
- Cristina L Ronchi
- Department of Medical Sciences, Institute of Endocrine Sciences, University of Milan, Milan, Italy.
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Lavis VR, Picolos MK, Willerson JT. Endocrine Disorders and the Heart. CARDIOVASCULAR MEDICINE 2007. [DOI: 10.1007/978-1-84628-715-2_111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Abstract
Before the availability of immunoassays for IGF-I, growth hormone (GH) measurement was the sole method used in the biochemical assessment of acromegaly. IGF-I has since been established as the most reliable biochemical indicator of acromegaly. The last 25 years has seen important advances in the understanding of the neuroregulation and in the characterization of GH secretion in acromegaly. The availability of supersensitive GH has changed many aspects of the interpretation of GH-value in the management of acromegaly. Hypersecretion and abnormal neuroregulation characterize GH secretion in acromegaly. GH can be measured in many ways: as a single random sample, as multiple samples, either spontaneously or as an integral part of a dynamic test. These approaches give useful information on diagnosis, therapy, and prognosis. There is a place for measuring GH in the management of acromegaly although it complements that of IGF-I.
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Affiliation(s)
- Akira Sata
- Department of Endocrinology, St Vincent's Hospital and the Garvan Institute of Medical Research, 384 Victoria Street, Darlinghurst, Sydney, NSW 2010, Australia
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Bastemir M, Akin F, Yaylali GF. The PPAR-gamma activator rosiglitazone fails to lower plasma growth hormone and insulin-like growth factor-1 levels in patients with acromegaly. Neuroendocrinology 2007; 86:119-23. [PMID: 17671378 DOI: 10.1159/000106830] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2007] [Accepted: 06/26/2007] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIM Despite combined therapy consisting of surgery, external X-ray, and medical therapy, a significant number of acromegaly patients continue to have uncontrolled growth hormone (GH) secretion and active disease. These patients, particularly those with large or invasive tumors, require additional therapy to decrease their GH levels. Our aim was to investigate whether patients with documented GH-secreting pituitary adenomas leading to acromegaly would respond with attenuation of GH and insulin-like growth factor-1 (IGF-1) levels after treatment with a peroxisome proliferator-activated receptor gamma (PPAR-gamma) agonist. METHODS We conducted prospective analyses in the Endocrinology Clinic of the Pamukkale University. Acromegaly patients who had active disease participated in two admissions: before and after 6 weeks of daily treatment with 8 mg of oral rosiglitazone. Four male and 3 female patients have completed the study. Basal and nadir GH levels during an oral glucose tolerance test were determined, and the IGF-1 and IGF-binding protein-3 levels were also measured both before and 6 weeks after the rosiglitazone treatment. RESULTS Treatment with rosigitazone did not reduce basal and nadir GH levels during the oral glucose tolerance test and the IGF-1 levels in the patient population as a whole (p > 0.05). CONCLUSIONS The PPAR-gamma activator rosiglitazone, used at maximum approved dosage, did not reduce plasma GH and IGF-1 levels in patients with acromegaly. Further studies with higher doses and longer duration of PPAR-gamma agonist administration would be required to determine its usefulness in the treatment in this group of patients.
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Affiliation(s)
- Mehmet Bastemir
- Department of Endocrinology and Metabolic Diseases, Pamukkale University School of Medicine, Denizli, Turkey.
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46
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Abstract
Insulin-Like Growth Factor-I (IGF-I) is a reliable marker of disease activity and growth hormone (GH) status in acromegaly, but its clinical utility has been hampered over the years by various issues including a lack of robust reference range data and variability in assay sensitivity and specificity. In acromegaly IGF-I correlates well with GH activity and nadir GH on oral glucose tolerance test (OGTT) and is the most sensitive and specific test in diagnosis, where serum IGF-I is persistently seen to be elevated to a range that is distinct from that in healthy individuals. However it should not be relied on exclusively for diagnosis or used as the sole indication of disease severity and GH burden. Successful medical or surgical treatment of acromegaly is usually associated with normalisation of serum IGF-I but there is discordance between GH and IGF-I in some patients. Patients with a normal IGF-I but an abnormal GH suppression to OGTT are at risk of relapse and therefore it should not be used alone to establish disease remission. In contrast to the diagnosis of acromegaly, there is also considerable overlap in serum IGF-I with normality after primary treatment of disease, even in the presence of persisting GH excess. Gender, age and prior radiotherapy alters the relationship between GH and IGF-I and reliance on one marker of disease activity such as IGF-I is particularly precarious in certain disease states. However an elevated serum IGF-I has been shown to be associated with excess mortality and normalising IGF-I normalises mortality making it a useful marker. The tightening up of the assays means that establishing absolute concentrations as well as standard deviation scores are essential to allow cross-study comparisons. This becomes especially important in the use of Pegvisomant, where IGF-I becomes the sole biochemical marker of disease activity.
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Affiliation(s)
- A M Brooke
- Department of Endo, Saint Bartholomew's Hospital, West Smithfield, London EC1A 7BE, UK
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Massart C, Poirier JY. Serum insulin-like growth factor-I measurement in the follow-up of treated acromegaly: Comparison of four immunoassays. Clin Chim Acta 2006; 373:176-9. [PMID: 16815351 DOI: 10.1016/j.cca.2006.05.027] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2006] [Revised: 05/16/2006] [Accepted: 05/16/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND Measurement of serum insulin-like growth factor I (IGF-I) is currently used for the diagnosis and for monitoring treated acromegaly. In this work, we have studied the performances of four IGF-1 immunoassays in the follow-up of acromegaly. METHODS The study was carried out on 52 sera from 40 patients with treated acromegaly. Serum IGF-I was measured with radioimmunoassays from Immunotech, DiaSorin and Schering Laboratories and by the chemiluminescent automated immunoassay (Advantage) from Nichols. Normal age- and gender-matched subjects constituted the reference population for two assays. RESULTS Deming regression and Bland-Altman analyses showed a high correlation with the four methods tested. The use of restricted number of age-adjusted controls with the Immunotech assay, the DiaSorin assay and the Schering assay induced discordance with the Nichols assay in the interpretation of results in treated acromegaly. When normal ranges of the Immunotech assay and the DiaSorin assay were defined from large number of controls, the frequency of normal IGF-I became similar as that obtained with the Nichols assay. CONCLUSION The four immunoassays display suitable analytical performance for serum IGF-I measurement in the follow-up of acromegaly. For correct interpretation, IGF-I normal ranges should be defined in a large number of age-adjusted healthy subjects.
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Affiliation(s)
- C Massart
- Laboratoire de Génétique Moléculaire et Hormonologie, CHU de Pontchaillou, rue H. Le Guilloux, 35043 Rennes Cedex, France.
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Colao A, Pivonello R, Cavallo LM, Gaccione M, Auriemma RS, Esposito F, Cappabianca P, Lombardi G. Age changes the diagnostic accuracy of mean profile and nadir growth hormone levels after oral glucose in postoperative patients with acromegaly. Clin Endocrinol (Oxf) 2006; 65:250-6. [PMID: 16886969 DOI: 10.1111/j.1365-2265.2006.02584.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND This analytical, retrospective study was designed to select cut-off thresholds of mean GH levels during a diurnal profile and nadir GH levels after oral glucose tolerance test (OGTT) according to age to diagnose surgical remission of acromegaly. METHODS One hundred forty-one patients (76 women, aged 44 +/- 15 years and 65 men, aged 43 +/- 13 years) were included in this study. For the purpose of this study, remission was based on insulin-like growth factor-I (IGF-I) levels in the normal range for age. Diagnostic accuracy was analysed by receiving-operator characteristics (ROC) curves in the entire series, and in young (20-40 years), middle-aged (41-60 years) and older patients (> 60 years), separately. RESULTS Sixty patients (42.6%) had normal IGF-I levels after surgery. In the entire series, in young and in middle-aged patients, the ROC analysis showed that optimum cut-off for mean GH levels was 2.3 microg/l (diagnostic accuracy range, 94-97%) whereas that for nadir GH after OGTT were, respectively, 0.85, 0.9 and 0.8 microg/l (diagnostic accuracy range, 90-95%). In the older patients, the optimum cut-off selected for mean GH levels was 1.4 microg/l and that for nadir GH after OGTT was 0.5 microg/l (diagnostic accuracy, 100% for both). The comparative analysis of the ROC curves did not show any significant difference between mean GH and nadir GH after OGTT (P = 0.21). CONCLUSIONS The criteria currently accepted for diagnosing post-surgical remission of acromegaly have high diagnostic accuracy only in the patients aged below 60 years. In older patients, lower cut-offs (i.e. = 1.4 microg/l for fasting GH and = 0.5 microg/l for nadir GH after OGTT) predict normal IGF-I levels. Mean GH levels during a diurnal profile have similar diagnostic accuracy of nadir GH levels after OGTT. This suggests that OGTT is not necessary to establish surgical cure.
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Affiliation(s)
- Annamaria Colao
- Department of Molecular and Clinical Endocrinology and Oncology, Section of Endocrinology, University Federico II of Naples, Naples, Italy.
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Abstract
Despite traditional, multimodality therapy that consisted of surgery, radiotherapy and medical therapies, many patients with acromegaly could not be adequately treated. Pegvisomant is a novel growth hormone receptor antagonist that became available for the treatment of acromegaly in 2003. This drug is a growth hormone variant that has nine mutations to human growth hormone. These give it high affinity for the growth hormone receptor as well as disrupting growth hormone receptor dimerization, with the net effect being antagonism of growth hormone at its receptor. Traditional methods of therapy for acromegaly treat the disease by reducing pituitary tumor secretion of growth hormone and, thus, lowering serum insulin-like growth factor-I levels. Pegvisomant, by contrast, blocks the actions of circulating growth hormone excess, but does not lower serum growth hormone levels. Its efficacy, therefore, is assessed by monitoring serum insulin-like growth factor-I levels. In clinical trials, pegvisomant has been shown to effectively normalize insulin-like growth factor-I levels in up to 97% of patients and to improve acromegaly-related signs and symptoms, and morbidities such as insulin resistance. As the action of pegvisomant does not rely on the tumor's receptor profile, it can be effective even in patients resistant to somatostatin analog therapy. Individually tailored therapy guided by serum insulin-like growth factor-I normalization goals and improvement in clinical signs and symptoms should be undertaken while growth hormone deficiency should be avoided. Pegvisomant is very well tolerated, but liver transaminase levels need to be monitored during therapy. As pegvisomant does not shrink pituitary tumors, the underlying rate of tumor growth may continue on this therapy and periodic pituitary imaging needs to be conducted during therapy.
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Affiliation(s)
- Pamela U Freda
- a Department of Medicine, Columbia College of Physicians and Surgeons, 630 West 168th Street, New York, NY 10032, USA.
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Biermasz NR, Romijn JA, Pereira AM, Roelfsema F. Current pharmacotherapy for acromegaly: a review. Expert Opin Pharmacother 2006; 6:2393-405. [PMID: 16259571 DOI: 10.1517/14656566.6.14.2393] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Acromegaly is associated with considerable morbidity and excess mortality; however, after effective treatment, both morbidity and mortality risks improve. Growth hormone excess in acromegaly can be controlled in many patients by pharmacotherapy alone, and with a combination of transsphenoidal surgery and pharmacotherapy in almost all patients. Since the clinical introduction of pegvisomant, a growth hormone-receptor antagonist, the role of radiotherapy is restricted. This review focuses on the treatment options for acromegaly (e.g., surgery, radiotherapy and pharmacotherapy with the depot preparations of the somatostatin analogues octreotide long-acting release formulation, lanreotide slow-release formulation and lanreotide Autogel, the growth hormone antagonist pegvisomant and the dopamine agonist cabergoline). Pharmacological characteristics of these drugs and the clinical and adverse effects are discussed individually and in relation to the other treatment modalities. The evidence for biochemical goals aimed at during medical treatment and the costs of pharmacotherapy are discussed. A new treatment algorithm is proposed, in which the choice between primary medical treatment and primary surgery is individualised, dependent on adenoma size and extension, patient factors (age, preference for therapy, contraindication for surgery), surgical experience of the centre and octreotide sensitivity of the adenoma. The high cost of lifelong medical treatment, especially of pegvisomant, must be weighed against the cost of a single surgical procedure.
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Affiliation(s)
- Nienke R Biermasz
- Department of Endocrinology and Metabolism, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands.
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