Self image and quality of life in acromegaly

Acromegaly in humans and cats: Pathophysiological, clinical and management resemblances and differences

OBJECTIVE

Acromegaly is a disorder associated with excessive levels of growth hormone (GH) and insulin-like growth factor-1 (IGF-1). In general, GH/IGF-1 excess leads to morphologic craniofacial and acral changes as well as cardiometabolic complications, but the phenotypic changes and clinical presentation of acromegaly differ across species. Here, we review the pathophysiology, clinical presentation and management of acromegaly in humans and cats, and we provide a systematic comparison between this disease across these different species.

DESIGN

A comprehensive literature review of pathophysiology, clinical features, diagnosis and management of acromegaly in humans and in cats was performed.

RESULTS

Acromegaly is associated with prominent craniofacial changes in both species: frontal bossing, enlarged nose, ears and lips, and protuberant cheekbones are typically encountered in humans, whereas increased width of the head and skull enlargement are commonly found in cats. Malocclusion, prognathism, dental diastema and upper airway obstruction by soft tissue enlargement are reported in both species, as well as continuous growth and widening of extremities resulting in osteoarticular compromise. Increase of articular joint cartilage thickness, vertebral fractures and spine malalignment is more evident in humans, while arthropathy and spondylosis deformans may also occur in cats. Generalized organomegaly is equally observed in both species. Other similarities between humans and cats with acromegaly include heart failure, ventricular hypertrophy, diabetes mellitus, and an overall increased cardiometabolic risk. In GH-secreting pituitary tumours, local compressive effects and behavioral changes are mostly observed in humans, but also present in cats. Cutis verticis gyrata and skin tags are exclusively found in humans, while palmigrade/plantigrade stance may occur in some acromegalic cats. Serum IGF-1 is used for acromegaly diagnosis in both species, but an oral glucose tolerance test with GH measurement is only useful in humans, as glucose load does not inhibit GH secretion in cats. Imaging studies are regularly performed in both species after biochemical diagnosis of acromegaly. Hypophysectomy is the first line treatment for humans and cats, although not always available in veterinary medicine.

CONCLUSION

Acromegaly in humans and cats has substantial similarities, as a result of common pathophysiological mechanisms, however species-specific features may be found.

Psychological complications in patients with acromegaly: relationships with sex, arthropathy, and quality of life

PURPOSE

Current treatment of acromegaly restores a normal life expectancy in most cases. So, the study of persistent complications affecting patients' quality of life (QoL) is of paramount importance, especially motor disability and depression. In a large cohort of acromegalic patients we aimed at establishing the prevalence of depression, to look for clinical and sociodemographic factors associated with it, and to investigate the respective roles (and interactions) of depression and arthropathy in influencing QoL.

METHODS

One hundred and seventy-one acromegalic patients (95 women and 76 men, aged 20-85 years) among those recruited in a cross-sectional Italian multicentric study were investigated. Each patient filled in three validated questionnaires: AcroQoL, WOMAC (measuring articular pain, stiffness and functionality), and AIMS (evaluating articular symptoms and depression).

RESULTS

A very high (up to 28%) depression rate was detected in acromegalic subjects. Two patients showing pathological AIMS depression scores, committed suicide during the three years observational period. In our population poor psychological status was significantly associated with female sex. Furthermore, a significant strong correlation was found between AIMS depression score and WOMAC score. Both depression and arthropathy-related motor disability turned out to independently contribute with similar strength to the impairment of QoL.

CONCLUSIONS

We report a high prevalence of depression in acromegaly, which is associated with female sex and arthropathy. Both depression and arthropathy strongly and independently contribute to the impaired QoL of patients. Our study shows that assessment and monitoring of psychological status is mandatory in acromegaly, also suggesting an inexpensive tool for this assessment.

Cognitive behavioral therapy adapted for patients with acromegaly

In acromegaly, excess secretion of growth hormone and insulin-like growth factor 1 may result in coarse features and enlargement of the extremities. Its negative repercussion on self-esteem can impair quality of life. Ten patients with acromegaly participated in this study. The treatment covered nine weekly group sessions. Unhealthy behaviors, thoughts, and emotions were identified, and healthy behaviors and thoughts were constructed, along with positive reflections on their associated emotions. In Session 7, the “Think healthy and feel the difference” technique was adapted to help patients better deal with their physical appearance and improve their quality of life. Qualitative data was obtained from an analysis of the content of a collaborative exercise developed in Session 7. Factors, especially thoughts, emotions, and advantages and disadvantages associated with both healthy and unhealthy behaviors, were identified. The technique improved quality of life for patients with acromegaly in relation to their acceptance of their physical appearance. UTN U 1111–1220-9846 (September 24th, 2018).

Variables Associated With Body Image Concerns in Acromegaly Patients: A Cross-Sectional Study

Objective

Acromegaly is often characterized by altered physical (including facial) appearance. However, there is little medical or psychological research on body image concerns in patients with acromegaly. The aim of this study was to identify factors influencing the body image distress in patients with acromegaly and to explore the possible effects of stigma on body image concerns.

Design

Cross-sectional study.

Methods

A total of 68 individuals with acromegaly were enrolled in the study. A total of 70 persons with nonfunctional pituitary adenomas were randomly recruited as a healthy control group. Using structured questionnaires, we explored perceived body image using the Body Image Concern Inventory. We also used the Hamilton Anxiety Scale, the Stigma Scale for Chronic Illness, the Brief Illness Perception Questionnaire, and the 36-Item Short-Form Health Survey to evaluate health-associated variables and to analyze factors that affect body image concerns in patients with acromegaly.

Results

Of the 68 participants, 31 were men and 37 women (mean age ± standard deviation: 46.36 ± 12.47 years). The mean body image concern score was 47.49 ± 13.81 for patients with acromegaly and 21.10 ± 7.44 for patients with nonfunctional pituitary adenoma. The difference between the two groups was statistically significant. A multiple stepwise regression analysis showed that the related factors for body image distress were gender (P = 0.001), age at diagnosis (P = 0.01), and internalized stigma (P < 0.001, Adj. R² = 0.756).

Conclusions

People with acromegaly have substantial body image concerns, and these concerns are increased by the stigma associated with this disease; such concerns lead to poor quality of life (QoL). Physicians need to find better ways to control patients' hormone levels, and nurses should provide more information on how to improve body image or find ways to reduce patients' body image distress.

Quality of life after long-term biochemical control of acromegaly

PURPOSE

To assess long-term quality of life (QoL) in patients with sustained biochemical control of acromegaly, comparing those receiving vs not receiving pharmacotherapy (primary analysis); to assess change in QoL over time (secondary analysis).

METHODS

Cross-sectional study, with a secondary longitudinal component, of 58 patients with biochemically controlled acromegaly. All had participated in studies assessing QoL years previously, after having undergone surgery ± radiotherapy. One cohort received medical therapy [MED (n = 33)]; the other did not [NO-MED (n = 25)]. QoL was assessed by the 36-Item-Short-Form Health Survey (SF-36), Acromegaly Quality of Life Questionnaire (AcroQoL), Gastrointestinal Quality of Life Index (GIQLI), Symptom Questionnaire, and QoL-Assessment of Growth Hormone Deficiency in Adults (QoL-AGHDA).

RESULTS

Mean (± SD) duration of biochemical control was 15.0 ± 6.4 years for MED and 20.4 ± 8.2 years for NO-MED (p = 0.007). 58% of subjects scored < 25% of normal on ≥ 1 SF-36 domain and 32% scored < 25% of normal on ≥ 4 of 8 domains. Comparing MED vs NO-MED and controlling for duration of biochemical control, there were no significant differences in QoL by SF-36, AcroQOL, GIQLI, Symptom Questionnaire, or QoL-AGHDA. Growth hormone deficiency (GHD) but not radiotherapy predicted poorer QoL. In MED, QoL improved over time in three AcroQoL domains and two GIQLI domains. In NO-MED, QoL worsened in two SF-36 domains and two Symptom Questionnaire domains; QoL-AGHDA scores also worsened in subjects with GHD.

CONCLUSION

A history of acromegaly and development of GHD, but not pharmacologic or radiotherapy, are detrimental to QoL, which remains poor over the long-term despite biochemical control.

Oral Manifestations and Maxillo-Facial Features in the Acromegalic Patient: A Literature Review

Background: Acromegaly is a chronic disease caused by an abnormal secretion of growth hormone (GH) by a pituitary adenoma, resulting in an increased circulating concentration of insulin-like growth factor 1 (IGF-1). The main characteristics are a slow progression of signs and symptoms, with multisystemic involvement, leading to acral overgrowth, progressive somatic changes, and a complex range of comorbidities. Most of these comorbidities can be controlled with treatment. The literature reveals that the most evident and early signs are those related to soft tissue thickening and skeletal growth, especially in the head and neck region. Methods: The authors reviewed the available literature on the clinical oro-dental features of acromegaly, selecting articles from PubMed and Google Scholar. The aim of this review was to summarize all the reported clinical oro-dental features of acromegalic patients. Results: The most common facial dimorphisms involved the maxillo-facial district, with hypertrophy of the paranasal sinuses, thickening of the frontal bones, and protruding glabella, which may be associated with joint pain and clicks. Regarding the oro-dental signs, the most frequent are dental diastema (40–43%), mandibular overgrowth (22–24%), mandibular prognathism (20–22%), and macroglossia (54–58%). These signs of acromegaly can be significantly reduced with adequate treatment, which is more effective when initiated early. Conclusions: Increased awareness of acromegaly among dentists and maxillo-facial surgeons, along with the early identification of oro-facial changes, could lead to an earlier diagnosis and treatment, thereby improving patients’ quality of life and prognosis.

Left to themselves: Time to target chronic pain in childhood rare diseases

BACKGROUND

Chronic pain is prevalent among patients with rare diseases (RDs). However, little is understood about how biopsychosocial mechanisms may be integrated in the unique set of clinical features and therapeutic challenges inherent in their pain conditions.

METHODS

This review presents examples of major categories of RDs with particular pain conditions. In addition, we provide translational evidence on clinical and scientific rationale for psychosocially- and neurodevelopmentally-informed treatment of pain in RD patients.

RESULTS

Neurobiological and functional overlap between various RD syndromes and pain states suggests amalgamation and mutual modulation of the respective conditions. Emotional sequelae could be construed as an emotional homologue of physical pain mediated via overlapping brain circuitry. Given their clearly defined genetic and molecular etiologies, RDs may serve as heuristic models for unraveling pathophysiological processes inherent in chronic pain.

CONCLUSIONS

Systematic evaluation of chronic pain in patients with RD contributes to sophisticated insight into both pain and their psychosocial correlates, which could transform treatment.

Effects of growth hormone receptor antagonism and somatostatin analog administration on quality of life in acromegaly

OBJECTIVE

Acromegaly is associated with impaired quality of life (QoL). We investigated the effects of biochemical control of acromegaly by growth hormone receptor antagonism vs somatostatin analog therapy on QoL.

DESIGN

Cross-sectional.

PATIENTS

116 subjects: n = 55 receiving a somatostatin analog (SSA group); n = 29 receiving pegvisomant (PEG group); n = 32 active acromegaly on no medical therapy (ACTIVE group).

MEASUREMENTS

Acromegaly QoL Questionnaire (AcroQoL), Rand 36-Item Short Form Survey (SF-36) and Gastrointestinal QoL Index (GIQLI); fasting glucose, insulin and IGF-1 levels (LC/MS, Quest Diagnostics).

RESULTS

There were no group differences in mean age, BMI or sex [(whole cohort mean ± SD) age 52 ± 14 years, BMI 30 ± 6 kg/m² , and male sex 38%]. Mean IGF-1 Z-scores were higher in ACTIVE (3.9 ± 1.0) vs SSA and PEG, which did not differ from one another (0.5 ± 0.7 and 0.5 ± 0.7, P < .0001 vs ACTIVE). Eighty-three per cent of PEG previously received somatostatin analogs, which had been discontinued due to lack of efficacy (52%) or side effects (41%). There were no differences in the four QoL primary end-points (AcroQoL Global Score, SF-36 Physical Component Summary Score, SF-36 Mental Health Summary Score and GIQLI Global Score) between SSA and PEG. Higher HbA1c, BMI and IGF-1 Z-scores were associated with poorer QoL in several domains.

CONCLUSION

Our data support a comparable QoL in patients receiving pegvisomant vs somatostatin analogs, despite the fact that the vast majority receiving pegvisomant did not respond to or were not able to tolerate somatostatin analogs.

Assessment of Anthropometric and Physical Health Indicators before and after Pituitary Surgery in Patients with Nonfunctioning Pituitary Adenomas, Acromegaly, and Cushing Disease

INTRODUCTION

Individuals with pituitary adenomas may have organic consequences of their disease or therapy, and psychological changes can compromise their quality of life (QoL). This study aimed to determine the anthropometric profile and health indicators of patients with pituitary adenoma before and after pituitary surgery.

METHODS

Forty-four patients were included in this study. Out of these, 22 patients had nonfunctioning adenomas (50%), 17 acromegaly (38.6%), and 5 patients with Cushing's disease (11.4%). Anthropometric measurements included body mass index (BMI), waist circumference (WC), and waist-to-hip ratio (WHR). Health indicators included body fat percentage (BF%), basal metabolic rate (BMR), maximal oxygen uptake (VO₂ max), and hand grip strength. Physical activity level (the International Physical Activity Questionnaire [IPAQ]), subjective perception of health, body image (Body Shape Questionnaire), body satisfaction (Stunkard Figure Rating Scale) were used.

RESULTS

The mean patient age was 47.2 ± 14.6 years; of which 25 were women (56.8%). Before surgery, 75.0% were overweight or obese, 84.1% had WC with risk of metabolic complications, and 90.0% had WHR with cardiovascular risk. There was a high BF% in 56.4% of cases, low BMR in 65.1%, lower VO₂ max in 16.2%, and below-average grip strength in 88.6%. Hypopituitary patients had poorer cardiorespiratory fitness. The IPAQ showed reduction in physical activity, and 79.5% of patients were dissatisfied with their body image. Patients with nonfunctioning adenomas had better perception of their health while those with Cushing's disease had more distorted body image. Postoperatively, patients with acromegaly showed improvement in WHR and physical activity level, and patients with Cushing's disease showed improvement in anthropometric variables.

CONCLUSIONS

These findings emphasize the need for continuous monitoring of this population for anthropometric indicators associated with metabolic and cardiovascular comorbidities as well as body satisfaction.

Acromegaly

Acromegaly is characterized by increased release of growth hormone and, consequently, insulin-like growth factor I (IGF1), most often by a pituitary adenoma. Prolonged exposure to excess hormone leads to progressive somatic disfigurement and a wide range of systemic manifestations that are associated with increased mortality. Although considered a rare disease, recent studies have reported an increased incidence of acromegaly owing to better disease awareness, improved diagnostic tools and perhaps a real increase in prevalence. Acromegaly treatment approaches, which include surgery, radiotherapy and medical therapy, have changed considerably over time owing to improved surgical procedures, development of new radiotherapy techniques and availability of new medical therapies. The optimal use of these treatments will reduce mortality in patients with acromegaly to levels in the general population. Medical therapy is currently an important treatment option and can even be the first-line treatment in patients with acromegaly who will not benefit from or are not suitable for first-line neurosurgical treatment. Pharmacological treatments include somatostatin receptor ligands (such as octreotide, lanreotide and pasireotide), dopamine agonists and the growth hormone receptor antagonist pegvisomant. In this Primer, we review the main aspects of acromegaly, including scientific advances that underlie expanding knowledge of disease pathogenesis, improvements in disease management and new medical therapies that are available and in development to improve disease control.

Oro-dental pathologies in acromegaly

PURPOSE

Oro-dental pathologies (ODP) such as enlargement of the tongue, mandibular prognathism, and spaced teeth are characteristic features of acromegaly. Their frequency of occurrence during the course of the disease is largely unresolved. Purpose of this study was to assess ODP and oro-dental treatments in patients with acromegaly with regard to the length of the diagnostic process, tumor histology, and quality of life (QoL).

METHODS

Single-center retrospective survey study using questionnaires on dental symptoms, diagnostic process, and treatment in patients with acromegaly operated on a growth hormone-secreting pituitary adenoma. The association between ODP and QoL was assessed using the Short-Form 36 (SF-36) Health Survey.

RESULTS

145/314 patients completed the questionnaires. 80.7% were affected by any ODP, most frequently enlargement of the tongue (57.9%), spaced teeth (42.8%), mandibular growth (24.1%), and mandibular prognathism (22.1%). ODP were significantly more frequent in patients with sparsely vs. densely granulated adenomas (p = 0.045). Early diagnosis within 2 years was associated with significantly fewer ODP than later diagnosis (68.5 vs. 87.2%, p = 0.009). Treatments included dental crowns (16.6%), dental bridges (12.4%), dental implants (9.7%), dental prostheses (3.4%), orthodontal (i.e., braces, 6.9%), and surgical correction of the teeth (2.1%). Physical QoL was significantly lower in patients with ODP than in those without (p = 0.014).

CONCLUSION

In our large series of patients, four of five patients were affected by ODP at any time during the course of the disease. The results highlight the importance of early identification and treatment of oro-dental problems in patients with acromegaly as hallmarks of the disease.

Higher Income and Integration into the Workforce Are the Main Factors Associated with Quality of Life in Acromegalic Patients in Northeastern Brazil

OBJECTIVE

To identify the factors associated with quality of life in patients with acromegaly with follow-up at the referral service in neuroendocrinology of the state of Maranhão, northeast Brazil.

METHODS

The Acromegaly Quality of Life Questionnaire (Acro-QoL) was used. Factors independently associated with quality of life were identified using multivariate linear regression, with p values < 0.05 considered significant.

RESULTS

The multivariate linear regression analysis indicated a positive association between being integrated into the job market and quality of life scores in the overall domain (β = 0.288, p = 0.003), psychological domain (β = 0.291, p = 0.032), and personal relationship domain (β = 0.314, p = 0.019). We also observed a positive association with income and the quality of life scores in all domains as follows: overall domain (β = 0.037, p = 0.003), physical domain (β = 0.988, p = 0.001), psychological domain (β = 0.342, p = 0.008), physical appearance domain (β = 0.270, p = 0.049), and personal relationship domain (β = 0.315, p = 0.012).

CONCLUSION

For patients with acromegaly living in one of the least developed regions of Brazil, integration into the job market and a higher income were associated with a better quality of life.

Patient-centered assessment on disease burden, quality of life, and treatment satisfaction associated with acromegaly

The study aimed to assess the economic burden, health-related quality of life (HRQoL), and acromegaly treatment satisfaction in the USA. A web-based, cross-sectional survey was distributed to members of Acromegaly Community. Data related to comorbidities, treatment patterns, and treatment satisfaction were collected. The costs over the past 3 months included out-of-pocket cost, sick leave, leave of absence, direct loss of job due to acromegaly, unemployment, assistance to perform household chores, and family member loss of income. The HRQoL was assessed by Acromegaly Quality of Life (AcroQoL) and EQ-5D-3L questionnaires. Among 106 patients who completed the survey (mean age: 46 years, female: 76.4%), 44.3% presented with ≥5 comorbidities, and 90.6% reporting acromegaly-related symptoms. Compared with the low-symptom group 0-3 (n=41), the 4+ symptoms group (n=65) was more likely to have depression (OR=2.3, 95% CI 1.1 to 5.2) and cardiovascular disease (OR=5.8, 95% CI 2.0 to 16.7), and experienced higher costs (loss of job: $8874 vs $1717, P=0.02; unemployment disability: $17,102 vs $429, P=0.003; household chores: $2160 vs $932, P=0.0003; family members' income loss: $692 vs $122, P=0.03). The high-symptom group had lower HRQoL scores, compared with the low-symptom group (EQ-5D-3L: 0.53 vs 0.75, P<0.0001; AcroQoL: 27 vs 56, P<0.0001). Only 55.7% among patients requiring injections for acromegaly were satisfied. Patients with acromegaly who presented with multiple acromegaly-related symptoms were evidenced to have experienced higher economic burden and poorer quality of life than patients with the same diagnosis but fewer symptoms. The low rate of treatment satisfaction warrants need for further studies.

[Mental disorders in patients with acromegaly]

AIM

To study mental disorders in acromegaly due to somatotropinoma.

MATERIAL AND METHODS

The study included 115 consecutively recruited patients with acromegaly (95 female and 20 male, aged from 21 to 78 years). Acromegaly was diagnosed by endocrinologists according to current guidelines based on clinical, laboratory data and brain MRI. All patients underwent a clinical psychiatric interview based on ICD-10 criteria. The Mini-Mental State Examination scale and Hypomania-Checklist (HCL-32) were used.

RESULTS

Mental disorders were diagnosed in 79.1% of patients. Organic spectrum disorders were found in 46.1%, bipolar spectrum disorders in 35.7%, schizophrenia spectrum disorders in 4.3%. The patients with bipolar spectrum disorders had significantly lower serum insulin-like growth factor 1 (IGF-1) levels compared to patients with organic spectrum disorders (p=0.01). The presence of organic spectrum disorders was associated with older age and number of somatic comorbidities (р=0.0001 and 0.001).

CONCLUSION

The prevalence of bipolar, organic and schizophrenia spectrum disorders in patients with acromegaly exceeds that in the general population. Significantly lower IGF-1 levels in acromegalic patients with bipolar disorders, compared to those with organic disorders, can have some implications to their pathogenesis.

Challenges in the diagnosis and management of acromegaly: a focus on comorbidities

INTRODUCTION

Acromegaly is a rare, insidious disease resulting from the overproduction of growth hormone (GH) and insulin-like growth factor 1 (IGF-1), and is associated with a range of comorbidities. The extent of associated complications and mortality risk is related to length of exposure to the excess GH and IGF-1, thus early diagnosis and treatment is imperative. Unfortunately, acromegaly is often diagnosed late, when patients already have a wide range of comorbidities. The presence of comorbid conditions contributes significantly to patient morbidity/mortality and impaired quality of life.

METHODS

We conducted a retrospective literature review for information relating to the diagnosis of acromegaly, and its associated comorbidities using PubMed. The main aim of this review is to highlight the issues of comorbidities in acromegaly, and to reinforce the importance of early diagnosis and treatment.

FINDINGS AND CONCLUSIONS

Successful management of acromegaly goes beyond treating the disease itself, since many patients are diagnosed late in disease evolution, they present with a range of comorbid conditions, such as cardiovascular disease, diabetes, hypertension, and sleep apnea. It is important that patients are screened carefully at diagnosis (and thereafter), for common associated complications, and that biochemical control does not become the only treatment goal. Mortality and morbidities in acromegaly can be reduced successfully if patients are treated using a multimodal approach with comprehensive comorbidity management.

Endoscopic transphenoidal surgery for acromegaly improves quality of life

BACKGROUND

Acromegaly has important effects on quality of life (QOL). This is the first study to measure QOL in acromegalic patients after endoscopic transsphenoidal surgery (ETSS).

METHODS

We prospectively collected the RAND-36, Center for Epidemiologic Studies Depression (CES-D), and Pituitary QOL validated questionnaires and patients' demographics, clinical presentation, endocrine laboratory results, radiological studies, development of complications and remission rates from 20 consecutive acromegalic patients who had undergone endoscopic transphenoidal surgery.

RESULTS

The eleven females and nine males had an average age of 42 years; 90 percent had macroadenomas and 70% had cavernous sinus invasion on their preoperative imaging. Ninety percent had improved symptoms post-operatively and 80% stated that treatment improved their QOL. Biochemically, 35% were cured, 35% had discordant results and 30% were not cured, while pan-hypopituitarism occurred in 4 patients. Physical health subscales and pituitary-related symptoms were similar to norms. "Social," "emotional health," and "energy levels" were significantly lower than norms. Seventy percent stated that their relationship with their physician "very much so" affected their quality of life. Pan hypopituitarism and adjuvant therapy were the most significant predictors of lower QOL subscale scores.

CONCLUSION

Transsphenoidal surgery improves QOL in acromegaly. Attempts to achieve a cure, avoidance of surgically induced pan-hypotpituitarism and adjuvant therapy, will improve quality of life. Our study demonstrates the important role of the patient-physician relationship to QOL and the need to measure QOL in addition to the traditional measures of outcome.

Effects of lanreotide Autogel primary therapy on symptoms and quality-of-life in acromegaly: data from the PRIMARYS study

PURPOSE

To evaluate the effects of lanreotide Autogel on patient-reported outcomes and association with biochemical control, using PRIMARYS data.

METHODS

PRIMARYS was a 1-year, open-label study of lanreotide Autogel (Depot in USA) 120 mg every 4 weeks in 90 treatment-naïve patients with acromegaly. Symptoms were assessed using Patient-assessed Acromegaly Symptom Questionnaire (PASQ) and health-related quality of life (HRQoL) using the AcroQoL questionnaire. Correlations between PASQ and AcroQoL scores, and between PASQ/AcroQoL and growth hormone (GH)/insulin-like growth factor-1 (IGF-1) levels were also evaluated (post hoc).

RESULTS

Acromegaly symptoms and HRQoL significantly improved from week 12 to week 48, with modest correlations at week 48 between PASQ total score (R = -0.55, p < 0.0001) and AcroQoL global and physical scores (R = -0.67, p < 0.0001). Approximately 60% of patients achieved a minimal important difference (MID; improvement >50% of baseline standard deviation) in PASQ total score and >40% achieved a MID in AcroQoL global score (post hoc). Changes in PASQ scores were similar in biochemically controlled (GH levels ≤2.5 μg/L and normal IGF-1 levels) and uncontrolled groups, while changes in global and psychological AcroQoL scores were greater in the controlled group. There was no correlation between changes in PASQ or AcroQoL scores and changes in GH or IGF-1 levels.

CONCLUSIONS

Primary treatment with lanreotide Autogel over 1 year was associated with rapid and sustained improvements in clinical signs and symptoms and HRQoL in patients with acromegaly. Improvements in HRQoL, but not symptoms, were greater in those achieving biochemical control (ClinicalTrials.gov: NCT00690898; EudraCT: 2007-000155-34).

Pituitary Macroadenoma Presenting with Multiple Psychiatric Complications

We report a case of pituitary macroadenoma with multiple physical and psychiatric complications, which posed a significant diagnostic dilemma and management challenge for the treating teams of neurosurgery, endocrinology and psychiatry. A pragmatic approach comprising of interdisciplinary collaboration resulted in satisfactory management of the case.

60 YEARS OF NEUROENDOCRINOLOGY: Acromegaly

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.

Persistent self-consciousness about facial appearance, measured with the Derriford appearance scale 59, in patients after long-term biochemical remission of acromegaly

CONTEXT

Acromegaly is associated with impaired quality of life (QoL) and causes anatomical disproportions, which may contribute to the decreased QoL after successful treatment. The Derriford appearance scale 59 (DAS59) is a questionnaire measuring psychological distress and disruptions to everyday life associated with self-consciousness of appearance.

OBJECTIVE

Investigate the psychological distress and dysfunction related to self-consciousness about appearance and its effect on QoL in patients in long-term remission of acromegaly.

PATIENTS, DESIGN AND METHODS

Patients (>18 years old) treated for acromegaly at the Department of Endocrinology of the Radboud University Medical Center Nijmegen were invited to participate. A gender-, age- and body mass index matched control group was provided by the patients themselves. Participants were asked to complete the modified DAS59-, research and development 36- (RAND-36), acromegaly quality of life questionnaire (AcroQoL) and a sociodemographic questionnaire. Differences between patient- and control groups and correlations between questionnaire scores and clinical characteristics collected from medical records were analyzed.

MAIN OUTCOME MEASURES

Questionnaire scores.

RESULTS

Of the 120 respondents, 73 agreed to participate [all cured or under biochemical control, median remission time 10.5 years (range 2.3-43.6 years)]. Of these, 34 (46.6%) reported self-consciousness about their appearance. Twenty-nine of these patients (85.3%) pointed out their face to be a prominent source of self-consciousness. Fifty-seven matched control subjects were included as well. Significant correlations were found between the scores of the DAS59 and the AcroQoL, RAND-36 and VAS in patients.

CONCLUSIONS

Even after long-term remission of acromegaly, a large number of patients are self-conscious about their appearance, leading to psychological distress and disruptions to everyday life and decreased QoL. Facial features were the most important source of self-consciousness. This stresses the importance of addressing self-consciousness of appearance and the need for additional support in this regard during follow-up in these patients.

Body Image Disturbance in Acromegaly Patients Compared to Nonfunctioning Pituitary Adenoma Patients and Controls

Purpose. Excess growth hormone secretion in adults results in acromegaly, a condition in which multiple physical changes occur including bony and soft tissue overgrowth. Over time these changes can markedly alter a person's appearance. The aim of this study was to compare body image disturbance in patients with acromegaly to those with nonfunctioning pituitary adenomas (NFAs) and controls and assess the impact of obesity in these groups. Methods. A cross-sectional survey including quality of life, body image disturbance, anxiety and depression measures, growth hormone, and BMI measurement was carried out. Results. The groups did not differ with respect to body image disturbance. However separate analysis of obese participants demonstrated relationships between mood scales, body image disturbance, and pain issues, particularly for acromegaly patients. Conclusions. While the primary hypothesis that acromegaly might be associated with body image disturbance was not borne out, we have shown that obesity together with acromegaly and NFA can be associated with body image issues, suggesting that BMI rather than primary diagnosis might better indicate whether patients might experience body image disturbance problems.

Biochemical and quality of life responses to octreotide-LAR in acromegaly

OBJECTIVES

AcroQoL is a questionnaire developed to assess quality of life in patients with acromegaly, covering physical and psychological dimensions. This study was designed to determine AcroQoL score changes and concentrations of growth hormone (GH) and insulin-like growth factor 1 (IGF-1), before and after treatment with octreotide-LAR (oct-LAR) in acromegaly.

METHODS

Retrospective observational study of 28 acromegalic patients with a mean age of 45 years (range 28-64), evaluated over a 4-year period, before and during treatment with oct-LAR in clinical practice conditions.

RESULTS

Baseline AcroQoL score (53 ± 15) improved after oct-LAR treatment (70 ± 15) globally for the 28 patients (p < 0.001). Three patients in whom AcroQoL score did not improve over time had severe headaches, which did not disappear. In patients who normalized, both GH (<2.5 μg/L) and IGF-1, AcroQoL score increased on average by 22 points (p = 0.003); when GH and IGF-1 improved, but did not normalize, AcroQol score increased on average by 16 points (p = 0.008). In 6 patients with discordant results, AcroQol score tended to improve if IGF-1 normalized (n = 4, p = 0.066), but not if IGF-1 remained high.

CONCLUSION

Oct-LAR therapy in acromegaly improved quality of life scores in parallel to biochemical markers, except in patients with severe headaches. The AcroQoL questionnaire is an additional tool to establish therapeutic effectivity.

Octreotide for acromegaly treatment: a reappraisal

INTRODUCTION

Acromegaly is a rare disorder characterized by excess secretion of growth hormone (GH) generally caused by a pituitary macroadenoma and associated with reduced life expectancy if the disease is untreated. This article covers the recent available evidences published on octreotide , the first somatostatin analog introduced into clinical practice for the medical treatment of acromegaly.

AREAS COVERED

This article discusses i) pharmacology of somatostatin and octreotide; ii) biochemical effects of regular octreotide and long-acting repeatable formulation; iii) tumor shrinkage effects of octreotide in acromegaly; iv) impact of octreotide on acromegalic clinical manifestations and chronic complications; v) safety of octreotide and vi) place of octreotide in the guidelines for acromegaly treatment. Full-text articles in the English language were selected from a PubMed search spanning 1984 - 2013, for keywords including 'octreotide,' 'acromegaly,' 'GH,' 'IGF-I,' and 'tumor shrinkage.' Reference lists in selected papers were also used to broaden the search.

EXPERT OPINION

Octreotide is a mature drug with a consolidated favorable benefit versus risks profile in the treatment of acromegaly.

Assessment of balance performance and fear of falling in acromegalic patients: a comparative study

BACKGROUND

Acromegaly may lead to balance disturbances and fear of falling due to changes in body composition and co-morbidities.

AIM

The aim of this study was to evaluate balance and fear of falling in acromegalic patients and their relation with disease characteristics.

MATERIALS AND METHODS

Forty-eight acromegalic patients and 41 age- and gender-matched controls were enrolled in the study. The median ages of the patients and controls were 48 (25-75) and 50 (25-67) yr, respectively. Berg Balance Scale (BBS) and one-leg stance test (OLST) were used to compare dynamic and static balance respectively, 50 meters walking test was used to compare functional capacity and falls efficacy scale-international (FES-I) was used to compare fear of falling between the groups.

RESULTS

Balance tests (BBS and 50 meter walking test) and fear of falling (FES-I) were significantly disturbed in patients compared with controls. There was no significant difference in OLST. BBS and OLST were negatively and FES-I was positively correlated with age. FES-I was negatively correlated with BBS and OLST was positively correlated with 50 meters walking test. Only OLST was negatively correlated with disease duration. Logistic regression analysis revealed that balance was not affected by the presence of co-morbidities, postoperative vision loss and disease control.

CONCLUSIONS

This is the first study showing that balance is disturbed in acromegalic patients. This disturbance is not related to disease control and co-morbidities but somewhat to disease duration.

Health-related quality of life and psychiatric symptoms improve effectively within a short time in patients surgically treated for pituitary tumors--a longitudinal study of 106 patients

BACKGROUND

Reduced health-related quality of life (HRQoL) is a common complaint in patients suffering from pituitary tumors. Although successful tumor treatment has been reported to lead to an improvement in perceived HRQoL, the temporal gradient at which these improvements occur has not been fully addressed.

METHODS

Using three validated health-related questionnaires (SF-36, SCL-90-R, QLS-H), we assessed HRQoL in 106 adult patients harboring pituitary tumors (mean age 48.0 ± 16.0 years) before as well as 3 and 12 months after initiation of treatment. The AcroQoL questionnaire was additionally applied in acromegalic patients.

RESULTS

There was a significant improvement in all but one scale (role-physical) of the SF-36 questionnaire and all but two scales (interpersonal sensitivity, paranoid ideation) of the SCL-90-R, the QLS-H score and the AcroQoL subscales within 3 months after surgical treatment. The trend to amelioration continued at the 12 month re-assessment, but did not reach statistical significance. Linear regression analyses revealed that younger age and male gender favor a more distinct improvement of HRQoL after treatment.

CONCLUSIONS

HRQoL is considerably reduced before treatment for pituitary disease. Improvement is an early postoperative phenomenon and occurs within 3 months after treatment. Men and younger patients are more likely to improve within this time span.

Quality of life in female patients with acromegaly

AIM

The aim of the study was to assess the quality of life and depression status in female patients with acromegaly.

PATIENTS AND METHODS

Fifty-seven female patients with acromegaly (21 inactive, 36 active) who were being followed-up at the Cerrahpasa Medical School, Endocrinology and Metabolism out-patient clinic, were included in the study. Depression status and quality of life of the patients were evaluated according to disease activity using the Beck Depression Inventory (BDI) and the Acromegaly Quality of Life (AcroQoL) Questionnaire. Prolactin, luteinizing hormone (LH), follicle-stimulating hormone (FSH), estradiol (E2), total and free testosterone, dehydroepiandrosterone sulfate (DHEA-SO4), 17α-hydroxyprogesterone, androstenedione, free thyroxin (FT4), thyrotropin (TSH), cortisol, GH and IGF-I were studied in the groups.

RESULTS

The AcroQoL total score in female patients with controlled acromegaly and uncontrolled acromegaly were 45.5 [Interquartile range (IQR)= 32.9-57.4], 47.7 [(IQR)= 38.6-63.3], respectively (p=0.53). There was no difference in BDI scores in acromegalic patients according to disease activity (p=0.41). In the correlation analysis, a strong negative correlation was found between AcroQoL total score and BDI score (r=-0.72, p<0.0001), OSAS (r=-0.32, p=0.01).

CONCLUSION

This study showed that QoL was impaired in female patients with acromegaly even if they were in remission. Depressive mood and obstructive sleep apnea syndrome (OSAS) could affect QoL in female patients with acromegaly.

Acromegaly is associated with higher frequency of female sexual dysfunction: experience of a single center

The aim of the study was to assess female sexual dysfunction (FSD), quality of life and depression status in female patients with acromegaly. Fifty-seven sexually active female patients with acromegaly disease (21 controlled, 36 uncontrolled) monitored by Cerrahpasa Medical School, Endocrinology and Metabolism out-patient clinic and age and body mass index-matched 46 healthy female subjects were included in the study. Sexual functions and status of depression in both patient and control groups were evaluated by using the Female Sexual Function Index Form (FSFI) and the Beck Depression Inventory (BDI), respectively. Quality of life was evaluated by using the Acromegaly Quality of Life (AcroQoL) Scale. Hormone levels were studied in the groups. The FSFI total score and desire, arousal, orgasm, and satisfaction domains in patients with acromegaly were significantly lower than in the healthy controls (p ≤ 0.0001). There was no difference between biochemically controlled and uncontrolled patients with acromegaly with respect to FSFI scores (p = 0.7). AcroQoL total score in female patients with controlled acromegaly and uncontrolled acromegaly were 46.33 ± 16.5% and 50.13 ± 18.21%, respectively (p = 0.53). The difference in BDI scores between controlled and uncontrolled acromegaly patients was not significant but they were significantly higher in the control group (p ≤ 0.0001). In the correlation analysis, a negative correlation was found between FSFI total and BDI score (r = -0.69, p< 0.001), age (r = -0.45, p< 0.001), and IGF-I (r = -0.28, p = 0.006). This study showed that sexual dysfunction and depression rates in female patients with acromegaly are higher than in healthy females.

Comparative effectiveness review of treatment options for pituitary microadenomas in acromegaly

OBJECT

Acromegaly, a syndrome of excess growth hormone (GH) secretion typically caused by a GH-secreting pituitary adenoma, reduces life expectancy by approximately 10 years when left untreated. Treatment of acromegaly involves combinations of one or more discrete therapeutic modalities to achieve biochemical control. Unfortunately, data capable of informing decisions among alternate management strategies are presently lacking.

METHODS

The authors performed a comparative effectiveness research (CER) review integrating efficacy, cost, and quality of life (QOL) analysis for treatment strategies comprising various combinations of surgery, radiotherapy, stereotactic radiosurgery, and pharmacotherapy in patients with acromegaly caused by a pituitary microadenoma. A management decision tree was used to identify 5 treatment strategies, each with up to 4 potential treatment steps. Efficacy was assessed using recent literature reports of biochemical control rates for each modality. Cost estimations were derived from wholesale drug prices and from the Healthcare Cost and Utility Project. Quality of life data were obtained from studies utilizing the Acromegaly Quality of Life Questionnaire.

RESULTS

Individual treatment modalities were analyzed and ranked in each of 3 domains: highest rate of success, lowest cost, and highest QOL, and these scores were combined to facilitate comparison of overall effectiveness of each of the management strategies. These aggregate effectiveness scores were used to compare the 5 strategies from the decision tree, and a novel strategy was also proposed.

CONCLUSIONS

The choice of management strategy must be individualized for each patient with acromegaly. This CER analysis provides a comprehensive framework to inform clinical decisions among alternate management strategies in patients with GH-secreting pituitary microadenomas.

Increased prevalence of restless legs syndrome in patients with acromegaly and effects on quality of life assessed by Acro-QoL

Restless legs syndrome (RLS), a neurological sensory-motor disorder characterized by a compelling urge to move the limbs during the night, is a sleep disturbance that impairs quality of life. Prevalence of RLS and consequences on quality of life were investigated in acromegalic patients. Fifty-six patients (20 men, 55.0 ± 1.6 years), 22 with active acromegaly (group 1) and 34 with controlled disease (group 2), and 95 controls (35 men, 52.9 ± 1.1 years) were evaluated by a structured sleep interview concerning insomnia, circadian sleep disorders and excessive diurnal sleepiness (EDS). The Epworth Sleepiness Scale (ESS) questionnaire was administered to those reporting EDS. Patients were investigated by RLS diagnostic interview and International Restless Leg Syndrome-Rating Scale (IRLS-RS). Quality of life was investigated by AcroQoL questionnaire. RLS was diagnosed in 21% of acromegalics and in 4% of controls (P < 0.002). Prevalence of RLS and mean IRLS-RS was higher in group 1 than in group 2 (P < 0.05). Prevalence of insomnia (P < 0.0002) and of EDS (P < 0.05) and mean ESS score (P < 0.01) were higher in RLS-positive than in RLS-free acromegalics. Video-PSG showed that mean sleep latency (P < 0.01), micro-arousal index (P < 0.05) and wakefulness after sleep onset (P < 0.01) were higher, whereas sleep efficiency (P < 0.01) was lower, in RLS-positive than in RLS-free patients. Global and physical AcroQoL scores were significantly lower in RLS-positive than in RLS-free acromegalics (P < 0.01 and P < 0.001, respectively). Prevalence and severity of RLS is increased in patients with active acromegaly and impacts negatively on their physical performances, dramatically impairing quality of life.

Approach to the patient with persistent acromegaly after pituitary surgery

The approach to a patient with acromegaly and persistent disease after surgery requires a complex diagnostic assessment. Acromegaly is a chronic and insidious disease that is associated with multisystem comorbidities, including cardiovascular disease, hypertension, sleep apnea syndrome, colon polyposis, arthropathy, and metabolic complications including glucose intolerance and type 2 diabetes mellitus. Patients also have a variety of signs and symptoms, including headache, arthralgias, carpal tunnel syndrome, sweating, fatigue, and psychological issues that impact significantly on quality of life. The recommended approach to the evaluation of the postoperative patient includes a biochemical assessment, with measurement of serum IGF-I along with a glucose-suppressed GH value, radiological assessment to determine location of residual tumor and presence of mass effects, a physical examination for evidence of skeletal and soft tissue overgrowth and related signs of acromegaly, and a thorough clinical assessment for the presence of comorbidities. Repeat surgery is indicated if there is residual tumor that is surgically accessible and there may be a chance for surgical cure, or if there are persistent mass effects upon the optic chiasm. Otherwise, medical therapy is indicated, utilizing somatostatin analogs, dopamine agonists, and pegvisomant, a GH receptor antagonist. Radiation therapy is usually relegated to situations where medical therapy is ineffective or poorly tolerated or where patients would prefer not to sustain the cost of long-term medical therapy. The choice of therapy requires close dialog among endocrinologists, neurosurgeons, radiation therapists, and neuroophthalmologists for optimal care of patients.

Growth hormone deficiency is associated with decreased quality of life in patients with prior acromegaly

CONTEXT

Both GH deficiency (GHD) and GH excess are associated with a decreased quality of life. However, it is unknown whether patients with GHD after treatment for acromegaly have a poorer quality of life than those with normal GH levels after cure of acromegaly.

OBJECTIVE

The aim of the study was to determine whether patients with GHD and prior acromegaly have a poorer quality of life than those with GH sufficiency after cure of acromegaly.

DESIGN AND SETTING

We conducted a cross-sectional study in a General Clinical Research Center.

STUDY PARTICIPANTS

Forty-five patients with prior acromegaly participated: 26 with GHD and 19 with GH sufficiency.

INTERVENTION

There were no interventions.

MAIN OUTCOME MEASURES

We evaluated quality of life, as measured by 1) the Quality of Life Adult Growth Hormone Deficiency Assessment (QoL-AGHDA); 2) the Short-Form Health Survey (SF-36); and 3) the Symptom Questionnaire.

RESULTS

Mean scores on all subscales of all questionnaires, except for the anger/hostility and anxiety subscales of the Symptom Questionnaire, showed significantly impaired quality of life in the GH-deficient group compared with the GH-sufficient group. Peak GH levels after GHRH-arginine stimulation levels were inversely associated with QoL-AGHDA scale scores (R = -0.53; P = 0.0005) and the Symptom Questionnaire Depression subscale scores (R = -0.35; P = 0.031) and positively associated with most SF-36 subscale scores.

CONCLUSIONS

Our data are the first to demonstrate a reduced quality of life in patients who develop GHD after cure of acromegaly compared to those who are GH sufficient. Further studies are warranted to determine whether GH replacement would improve quality of life for patients with GHD after cure from acromegaly.

Assessment of quality of life in patients with uncontrolled vs. controlled acromegaly using the Acromegaly Quality of Life Questionnaire (AcroQoL)

OBJECTIVE

Acromegaly is a chronic disease with an important impact on quality of life. An acromegaly disease-generated quality of life questionnaire (AcroQoL) has recently been developed. We aimed to confirm reliability, construct validity and disease-specificity of the AcroQoL questionnaire. Second, we investigated the effect of remission status on health-related quality of life (HRQoL) in patients with acromegaly.

DESIGN AND PATIENTS

Using a prospective, cross-sectional design, 33 patients with treated acromegaly and 22 patients with treated hormone-inactive pituitary adenoma under stable replacement therapy completed the German version of the AcroQoL questionnaire.

MEASUREMENTS AND RESULTS

Cronbach's alpha analysis showed high reliability of the total score and the different scales and subscales in patients with acromegaly (alpha ranging from 0.83 to 0.93, item-total correlation 0.41-0.84). Patients with hormone-inactive pituitary adenoma showed lower reliability (alpha ranging from 0.17 to 0.75). Exploratory factor analysis in patients with acromegaly suggested a two-factorial solution with item distribution largely matching the scaling of the original Spanish questionnaire. Multiple regression analysis revealed significantly lower results of the total score and the different scales and subscales (indicating worse HRQoL) in patients with persistent acromegalic activity compared to patients with acromegaly in remission or discordant remission status. Consistently, IGF-I was an independent negative predictor of the different scores of the questionnaire.

CONCLUSIONS

The AcroQoL questionnaire represents a reliable, construct valid and disease-specific tool for assessing health-related quality of life in patients with acromegaly. Patients with biochemically uncontrolled acromegaly showed significantly lower HRQoL than patients with acromegaly in remission or discordant remission status.

Acromegaly Quality of Life Questionnaire (AcroQoL)

Acromegaly is a chronic disease with an important impact on patients, Health Related Quality of Life (HRQoL). The ability to effectively measure Health Related Quality of Life is central to describing the impacts of disease or treatment upon the patient, therefore the importance of having a disease specific questionnaire for acromegaly. For the development of the AcroQoL questionnaire different sources of information were used: first a literature search was performed to identify relevant papers describing the impact of acromegaly in HRQoL, second the main domains of impact on HRQoL were identified by 10 experts endocrinologists, and third ten in-depth semi-structured interviews were conducted in acromegalic patients to identify domains and items related to the self-perceived impact of acromegaly in patients' life. After a proper qualitative analysis a preliminary 38 item questionnaire was obtained. Rasch analysis concluded with a final 22 item questionnaire. The measurement properties (validity and reliability) of the resulting final questionnaire were tested and compared using standard procedures (Cronbach's Alpha and item-total correlation). The evaluation of the item parameters confirmed the construct validity of the new instrument. Responsiveness to change was assessed in a small sample of 32 acromegalic patients with active disease in Spain who were administered the AcroQoL and the generic questionnaire EuroQoL 5-D. The results showed a statistically significant relationship between all the dimensions of AcroQoL and the VAS (visual analogic scale) of EQ-5D. An improvement in the global score of AcroQoL was related to a global improvement in the VAS of the EQ-5D.

Following the current recommended standard methodology the Spanish questionnaire was translated into eleven other languages.