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Wang L, He X, Lu L, Chen L, Peng C, Shao C, Ge R. Clinicopathological Analysis of Densely and Sparsely Granulated Somatotroph Tumors of Pituitary. World Neurosurg 2024; 185:e713-e720. [PMID: 38408701 DOI: 10.1016/j.wneu.2024.02.115] [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: 02/01/2024] [Revised: 02/19/2024] [Accepted: 02/20/2024] [Indexed: 02/28/2024]
Abstract
OBJECTIVE Somatotroph tumors are the second most common type of pituitary neuroendocrine tumors, which can be further classified into 2 subtypes-densely granulated somatotroph tumors (DGSTs) and sparsely granulated somatotroph tumors (SGSTs). The aim of this study was to investigate the clinical significance of the 2 subtypes in a retrospective analysis. METHODS From the database of the Ningbo Clinical Pathology Diagnosis Center, we collected patients diagnosed with pituitary somatotroph tumors. We then compiled pertinent clinical and radiological data and proceeded with histopathological examination involving hematoxylin-eosin staining and immunohistochemical staining. Subsequent analysis compared the 2 subtypes using either χ2 test or Fisher exact test. RESULTS We analyzed 40 cases of somatotroph tumors, 18 cases DGSTs and 22 SGSTs. Male-to-female ratio was 5:4 for DGSTs and 4:7 for SGSTs. Mean age was 52.83 years for DGSTs and 47.18 years for SGSTs. Statistically significant differences were observed between the DGST and SGST groups in invasiveness (P = 0.0267) and postoperative remission (P = 0.007). Cells of both DGSTs and SGSTs exhibited coexpression of PIT1, growth hormone, and CAM5.2, although the patterns of CAM5.2 expression differed between the 2 subtypes. CONCLUSIONS The efficacy of CAM5.2 staining in distinguishing between DGSTs and SGSTs was demonstrated. SGSTs, with their increased invasiveness and lower remission rate, are a high-risk subtype. The histological subtype of somatotroph tumors plays a crucial role in guiding treatment decisions and prognostic evaluation in affected patients.
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Affiliation(s)
- Li Wang
- Department of Pathology, Ningbo Clinical Pathology Diagnosis Center, Ningbo, China
| | - Xiaoman He
- Department of Pathology, Ningbo Clinical Pathology Diagnosis Center, Ningbo, China
| | - Lixia Lu
- Department of Pathology, Ningbo Clinical Pathology Diagnosis Center, Ningbo, China
| | - Li Chen
- Department of Pathology, Ningbo Clinical Pathology Diagnosis Center, Ningbo, China
| | - Can Peng
- Department of Pathology, Ningbo Clinical Pathology Diagnosis Center, Ningbo, China
| | - Chenning Shao
- Department of Pathology, Ningbo Clinical Pathology Diagnosis Center, Ningbo, China
| | - Rong Ge
- Department of Pathology, Ningbo Clinical Pathology Diagnosis Center, Ningbo, China.
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McLaren DS, Seejore K, Lynch J, Murray RD. Oral Octreotide Capsules and Paltusotine in Management of Acromegaly. TOUCHREVIEWS IN ENDOCRINOLOGY 2024; 20:32-36. [PMID: 38812672 PMCID: PMC11132651 DOI: 10.17925/ee.2023.20.1.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 08/01/2023] [Indexed: 05/31/2024]
Abstract
Injectable somatostatin receptor ligands (iSRL) are the most frequently utilized medical therapy in patients with acromegaly; however, satisfaction rates are suboptimal. Injections can result in local erythema, discomfort and subcutaneous nodule formation, encompassed with the inconvenience of attending either primary or secondary care medical facilities for injections every 4 weeks. Some patients also note breakthrough of acromegaly-related symptoms towards the end of the injection cycle. To improve acceptance and ultimately improve wellbeing of these individuals, two oral SRLs, oral octreotide capsules (OOC) and paltusotine, have been developed. The OOC combines an enteric coating to allow delivery to the small intestines and a transient permeability enhancer to enable oral bioavailability. Comparable octreotide levels are obtained with twice-daily OOC and subcutaneous octreotide 100 µg. Phase III studies show OOC to maintain equivalent biochemical control in at least 60% of patients previously receiving a stable dose of iSRL. In longer-term studies, the response to OOC was durable up to 3 years. Paltusotine is a novel potent orally available non-peptidyl somatostatin receptor subtype-2 ligand. Studies in healthy volunteers show dose-dependent suppression of growth hormone-releasing hormone-induced growth hormone secretion and suppression of insulin-like growth factor-I (IGF-I) with repeat doses. In the recent phase II study, patients with acromegaly who were partial responders (IGF-I 1.0 - 2.5 x upper limit of normal) to monotherapy with iSRL when switched to once-daily paltusotine maintained control of IGF-I within 20% of baseline or lower in 87% after 13 weeks. Adverse events with both OOC and paltusotine were reflective of those recognized with iSRL and occurred at a similar frequency. OOC and paltusotine are well-received additions to the therapeutic armamentarium in medical therapy for the management of acromegaly; however, further data on efficacy, tumour control and shrinkage are required to allow positioning of this medication within the management algorithm for acromegaly.
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Affiliation(s)
- David S McLaren
- Department of Endocrinology, Leeds Centre for Diabetes & Endocrinology, Leeds Teaching Hospital NHS Trust, Leeds, UK
- Division of Cardiovascular and Diabetes Research, Leeds Institute of Cardiovascular and Metabolic Medicine (LICAMM), University of Leeds, Leeds, UK
| | - Khyatisha Seejore
- Department of Endocrinology, Leeds Centre for Diabetes & Endocrinology, Leeds Teaching Hospital NHS Trust, Leeds, UK
- Division of Cardiovascular and Diabetes Research, Leeds Institute of Cardiovascular and Metabolic Medicine (LICAMM), University of Leeds, Leeds, UK
| | - Julie Lynch
- Department of Endocrinology, Leeds Centre for Diabetes & Endocrinology, Leeds Teaching Hospital NHS Trust, Leeds, UK
| | - Robert D Murray
- Department of Endocrinology, Leeds Centre for Diabetes & Endocrinology, Leeds Teaching Hospital NHS Trust, Leeds, UK
- Division of Cardiovascular and Diabetes Research, Leeds Institute of Cardiovascular and Metabolic Medicine (LICAMM), University of Leeds, Leeds, UK
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3
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Guinto G, Guinto-Nishimura GY, Uribe-Pacheco R, Sangrador-Deitos MV, Villanueva-Castro E, García-Iturbide R, Gallardo D, Guinto P, Vargas A, Aréchiga N. Surgical outcomes in patients with acromegaly: Microscopic vs. endoscopic transsphenoidal surgery. Best Pract Res Clin Endocrinol Metab 2024:101879. [PMID: 38403492 DOI: 10.1016/j.beem.2024.101879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
Transsphenoidal resection of growth hormone-secreting pituitary neuroendocrine tumors remains the first-line treatment for acromegaly. This can be performed through microsurgery or endoscopic surgery. For the past decades, endoscopic surgery has become the preferred technique in an increasing number of centers worldwide. However, whether it offers superior clinical outcomes has yet to be determined. In this paper, we performed a narrative review of the literature comparing both techniques in the treatment of acromegaly. We critically assessed available comparative studies from an objective perspective to determine their suitability for defining superiority of either technique. Available evidence displays substantial methodological variations and reports conflicting findings. Although endoscopic surgery provides a wider exposure and enhanced visibility of the surgical field, this does not consistently translate into better clinical outcomes, as most tumors are equally accessible through both techniques. Postoperative outcomes such as remission and complication rates are similar between both techniques. The management of acromegaly should be performed by experienced pituitary neurosurgeons, regardless of the approach. The involvement of a multidisciplinary team in a dedicated pituitary center is critical to ensure optimal outcomes.
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Affiliation(s)
- Gerardo Guinto
- Centro Medico ABC, Carlos Graef Fernández #154, Santa Fe, Cuajimalpa, 05300 Mexico City, Mexico
| | - Gerardo Y Guinto-Nishimura
- Hospital de Especialidades Centro Médico Nacional SXXI, Instituto Mexicano del Seguro Social, Av. Cuauhtémoc 330, Cuauhtémoc, 06720 Mexico City, Mexico; Departamento de Neurocirugía, Instituto Nacional de Neurología y Neurocirugía, Av. Insurgentes Sur 3877, Tlalpan, 14269 Mexico City, Mexico
| | - Rodrigo Uribe-Pacheco
- Departamento de Neurocirugía, Instituto Nacional de Neurología y Neurocirugía, Av. Insurgentes Sur 3877, Tlalpan, 14269 Mexico City, Mexico
| | - Marcos V Sangrador-Deitos
- Departamento de Neurocirugía, Instituto Nacional de Neurología y Neurocirugía, Av. Insurgentes Sur 3877, Tlalpan, 14269 Mexico City, Mexico
| | - Eliezer Villanueva-Castro
- Departamento de Neurocirugía, Instituto Nacional de Neurología y Neurocirugía, Av. Insurgentes Sur 3877, Tlalpan, 14269 Mexico City, Mexico
| | - Ricardo García-Iturbide
- Hospital de Especialidades Centro Médico Nacional SXXI, Instituto Mexicano del Seguro Social, Av. Cuauhtémoc 330, Cuauhtémoc, 06720 Mexico City, Mexico
| | - David Gallardo
- Hospital Ángeles del Pedregal, Periférico Sur 3697, Colonia Héroes de Padierna, 10700 Mexico City, Mexico
| | - Patricia Guinto
- Hospital Ángeles Clínica Londres, Durango 64, 06700 Mexico City, Mexico
| | - Alejandro Vargas
- Centro Medico ABC, Carlos Graef Fernández #154, Santa Fe, Cuajimalpa, 05300 Mexico City, Mexico
| | - Norma Aréchiga
- Centro Medico ABC, Carlos Graef Fernández #154, Santa Fe, Cuajimalpa, 05300 Mexico City, Mexico
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4
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Guinto G, Guinto-Nishimura GY, Sangrador-Deitos MV, Uribe-Pacheco R, Soto-Martinez R, Gallardo D, Guinto P, Vargas A, Aréchiga N. Current and Future Perspectives of Microscopic and Endoscopic Transsphenoidal Surgery for Pituitary Adenomas: A Narrative Review. Arch Med Res 2023; 54:102872. [PMID: 37633807 DOI: 10.1016/j.arcmed.2023.102872] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 08/09/2023] [Indexed: 08/28/2023]
Abstract
Transsphenoidal resection remains the standard treatment for most pituitary adenomas. However, the ideal surgical approach to safely access these lesions, either microsurgical or endoscopic, continues to be debated. Since the introduction of endoscopic transsphenoidal surgery, centers around the world have increasingly adopted this technique, experiencing a shift away from the conventional microsurgical approach. Large series reporting the efficacy and safety of endoscopic surgery have fueled a growing interest in comparing clinical outcomes between both approaches. Still, proving superiority of either surgical approach remains an elusive task due to the inherent drawbacks of surgical observational studies, as we are still faced with a growing body of evidence reporting conflicting results. Thus, a comprehensive discussion regarding the reach and limitations of both techniques becomes necessary. In this narrative review, we perform a critical appraisal of the literature and provide an expert opinion on the state-of-the-art in transsphenoidal surgery for pituitary adenomas. The advantages and limitations of each approach are assessed and compared from a technical standpoint, and their reported outcomes evaluated in the framework of this transition phase. Available evidence should be interpreted in light of individual patient characteristics and within the context of each medical center, taking into consideration the known impact that surgical expertise and multidisciplinary management hold on clinical outcomes.
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Affiliation(s)
| | - Gerardo Y Guinto-Nishimura
- Hospital de Especialidades Centro Médico Nacional SXXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico; Departamento de Neurocirugía, Instituto Nacional de Neurología y Neurocirugía, Mexico City, Mexico
| | | | - Rodrigo Uribe-Pacheco
- Departamento de Neurocirugía, Instituto Nacional de Neurología y Neurocirugía, Mexico City, Mexico
| | - Rene Soto-Martinez
- Hospital de Especialidades Centro Médico Nacional SXXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
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5
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Nishioka H. Aggressive pituitary tumors (PitNETs). Endocr J 2023; 70:241-248. [PMID: 36858483 DOI: 10.1507/endocrj.ej23-0007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2023] Open
Abstract
The majority of anterior pituitary tumors behave benignly, that is, they grow slowly and do not metastasize, and were therefore called adenomas. However, they would frequently invade adjacent structures, leading to recurrence. One of the misleading assumptions in their previous classification was the simplistic distinction made between adenoma and carcinoma. In the upcoming WHO 2022 classification, a new terminology will be introduced: pituitary neuroendocrine tumor (PitNET) which is consistent with that used for other neuroendocrine neoplasms. In general, aggressive PitNETs are invasive and proliferative tumors with frequent recurrences, resistant to conventional treatments, and yet virtually without metastases. At present, no single morphological or histological marker has been shown as yet to reliably predict their aggressive behavior. In terms of treatment, temozolomide (TMZ) had been considered promising and the sole therapeutic option for aggressive and malignant PitNETs following failure of standard therapies. However, recent reports have disclosed that TMZ does not provide long-term control of many aggressive PitNETs. A further multidisciplinary approach is necessary for both reliable prediction and successful management of aggressive PitNETs.
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Affiliation(s)
- Hiroshi Nishioka
- Department of Hypothalamic and Pituitary Surgery, Toranomon Hospital, Tokyo 105-8470, Japan
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6
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Mamelak A. Surgery as a first-line option for prolactinomas. Expert Rev Endocrinol Metab 2022; 17:485-498. [PMID: 36200144 DOI: 10.1080/17446651.2022.2131531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 09/28/2022] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Treatment of prolactinomas with dopamine agonists has been the established first-line treatment option for many years, with surgery reserved for refractory cases or medication intolerance. This approach may not be the best option in many cases. AREAS COVERED Review of the epidemiology, biology, and treatment options available for prolactinomas, including best available data on outcomes, costs, and morbidities for each therapy. These data are then used to propose a 'surgery-first' treatment approach for a subset of prolactinomas as an alternative to primary medical management. EXPERT OPINION Based on the available data, there is a strong rationale that transsphenoidal surgery should be considered a first-line treatment option for both micro- and macro-prolactinomas that do not demonstrate high grade cavernous sinus invasion on MRI imaging, with dopamine agonists administered as a secondary therapy for tumors not in remission following surgery, and for giant tumors. This 'surgery-first' approach assumes the availability of skilled and experienced pituitary surgeons to ensure optimal outcomes. This approach should result in high cure rates and reduced DA requirements for patients not cured from initial surgery. Further, it will reduce medical costs over a patient's lifetime and the chronic morbidities associated with protracted dopamine agonist usage.
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Affiliation(s)
- Adam Mamelak
- Surgical Director, Pituitary Center & Center for Minimally Invasive Skull Base Surgery, Cedars-Sinai Medical Center, Los Angeles
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7
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Fleseriu M, Langlois F, Lim DST, Varlamov EV, Melmed S. Acromegaly: pathogenesis, diagnosis, and management. Lancet Diabetes Endocrinol 2022; 10:804-826. [PMID: 36209758 DOI: 10.1016/s2213-8587(22)00244-3] [Citation(s) in RCA: 56] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 08/01/2022] [Accepted: 08/09/2022] [Indexed: 11/23/2022]
Abstract
Growth hormone-secreting pituitary adenomas that cause acromegaly arise as monoclonal expansions of differentiated somatotroph cells and are usually sporadic. They are almost invariably benign, yet they can be locally invasive and show progressive growth despite treatment. Persistent excess of both growth hormone and its target hormone insulin-like growth factor 1 (IGF-1) results in a wide array of cardiovascular, respiratory, metabolic, musculoskeletal, neurological, and neoplastic comorbidities that might not be reversible with disease control. Normalisation of IGF-1 and growth hormone are the primary therapeutic aims; additional treatment goals include tumour shrinkage, relieving symptoms, managing complications, reducing excess morbidity, and improving quality of life. A multimodal approach with surgery, medical therapy, and (more rarely) radiation therapy is required to achieve these goals. In this Review, we examine the epidemiology, pathogenesis, diagnosis, complications, and treatment of acromegaly, with an emphasis on the importance of tailoring management strategies to each patient to optimise outcomes.
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Affiliation(s)
- Maria Fleseriu
- Department of Medicine (Division of Endocrinology, Diabetes and Clinical Nutrition) and Department of Neurological Surgery, and Pituitary Center, Oregon Health & Science University, Portland, OR, USA.
| | - Fabienne Langlois
- Division of Endocrinology, Department of Medicine, Centre Intégré Universitaire de Santé et de Services Sociaux de l'Estrie-Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | | | - Elena V Varlamov
- Department of Medicine (Division of Endocrinology, Diabetes and Clinical Nutrition) and Department of Neurological Surgery, and Pituitary Center, Oregon Health & Science University, Portland, OR, USA
| | - Shlomo Melmed
- Department of Medicine and Pituitary Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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8
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Sulu C, Bektaş AB, Şahin S, Durcan E, Kara Z, Demir AN, Özkaya HM, Tanrıöver N, Çomunoğlu N, Kızılkılıç O, Gazioğlu N, Gönen M, Kadıoğlu P. Machine learning as a clinical decision support tool for patients with acromegaly. Pituitary 2022; 25:486-495. [PMID: 35435565 DOI: 10.1007/s11102-022-01216-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/10/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To develop machine learning (ML) models that predict postoperative remission, remission at last visit, and resistance to somatostatin receptor ligands (SRL) in patients with acromegaly and to determine the clinical features associated with the prognosis. METHODS We studied outcomes using the area under the receiver operating characteristics (AUROC) values, which were reported as the performance metric. To determine the importance of each feature and easy interpretation, Shapley Additive explanations (SHAP) values, which help explain the outputs of ML models, are used. RESULTS One-hundred fifty-two patients with acromegaly were included in the final analysis. The mean AUROC values resulting from 100 independent replications were 0.728 for postoperative 3 months remission status classification, 0.879 for remission at last visit classification, and 0.753 for SRL resistance status classification. Extreme gradient boosting model demonstrated that preoperative growth hormone (GH) level, age at operation, and preoperative tumor size were the most important predictors for early remission; resistance to SRL and preoperative tumor size represented the most important predictors of remission at last visit, and postoperative 3-month insulin-like growth factor 1 (IGF1) and GH levels (random and nadir) together with the sparsely granulated somatotroph adenoma subtype served as the most important predictors of SRL resistance. CONCLUSIONS ML models may serve as valuable tools in the prediction of remission and SRL resistance.
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Affiliation(s)
- Cem Sulu
- Department of Internal Medicine, Division of Endocrinology, Metabolism, and Diabetes, Cerrahpasa Medical School, Istanbul University-Cerrahpaşa, Kocamustafapaşa Street No:53, 34098 Fatih, Istanbul, Turkey
| | - Ayyüce Begüm Bektaş
- Graduate School of Sciences and Engineering, Koç University, Istanbul, Turkey
| | - Serdar Şahin
- Department of Internal Medicine, Division of Endocrinology, Metabolism, and Diabetes, Cerrahpasa Medical School, Istanbul University-Cerrahpaşa, Kocamustafapaşa Street No:53, 34098 Fatih, Istanbul, Turkey
| | - Emre Durcan
- Department of Internal Medicine, Division of Endocrinology, Metabolism, and Diabetes, Cerrahpasa Medical School, Istanbul University-Cerrahpaşa, Kocamustafapaşa Street No:53, 34098 Fatih, Istanbul, Turkey
| | - Zehra Kara
- Department of Internal Medicine, Division of Endocrinology, Metabolism, and Diabetes, Cerrahpasa Medical School, Istanbul University-Cerrahpaşa, Kocamustafapaşa Street No:53, 34098 Fatih, Istanbul, Turkey
| | - Ahmet Numan Demir
- Department of Internal Medicine, Division of Endocrinology, Metabolism, and Diabetes, Cerrahpasa Medical School, Istanbul University-Cerrahpaşa, Kocamustafapaşa Street No:53, 34098 Fatih, Istanbul, Turkey
| | - Hande Mefkure Özkaya
- Department of Internal Medicine, Division of Endocrinology, Metabolism, and Diabetes, Cerrahpasa Medical School, Istanbul University-Cerrahpaşa, Kocamustafapaşa Street No:53, 34098 Fatih, Istanbul, Turkey
- Pituitary Center, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Necmettin Tanrıöver
- Pituitary Center, Istanbul University-Cerrahpasa, Istanbul, Turkey
- Department of Neurosurgery, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Nil Çomunoğlu
- Department of Medical Pathology, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Osman Kızılkılıç
- Pituitary Center, Istanbul University-Cerrahpasa, Istanbul, Turkey
- Department of Radiology, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Nurperi Gazioğlu
- Pituitary Center, Istanbul University-Cerrahpasa, Istanbul, Turkey
- Department of Neurosurgery, Istinye University, Istanbul, Turkey
| | - Mehmet Gönen
- Department of Industrial Engineering, College of Engineering, Koç University, Istanbul, Turkey
- School of Medicine, Koç University, Istanbul, Turkey
| | - Pınar Kadıoğlu
- Department of Internal Medicine, Division of Endocrinology, Metabolism, and Diabetes, Cerrahpasa Medical School, Istanbul University-Cerrahpaşa, Kocamustafapaşa Street No:53, 34098 Fatih, Istanbul, Turkey.
- Pituitary Center, Istanbul University-Cerrahpasa, Istanbul, Turkey.
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9
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Rass L, Rahvar AH, Matschke J, Saeger W, Renné T, Aberle J, Flitsch J, Rotermund R. Differences in somatostatin receptor subtype expression in patients with acromegaly: new directions for targeted therapy? Hormones (Athens) 2022; 21:79-89. [PMID: 34674191 PMCID: PMC8818633 DOI: 10.1007/s42000-021-00327-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 10/04/2021] [Indexed: 11/02/2022]
Abstract
PURPOSE To analyze the expression of somatostatin receptor (SSTR)2a and 5 by immunohistochemistry (IHC) in surgically resected somatotrophic pituitary adenomas and to associate expression rates with tumor size and clinical, biochemical, and histological parameters and response to somatostatin analog (SA) therapy. METHODS Forty-three microsurgically treated patients with histopathologically proven growth hormone (GH)-producing pituitary adenoma were included (WHO 2017). SSTR subtype expression was analyzed in adenoma tissues using monoclonal antibodies (Abcam, SSTR2a-UMB1, SSTR5-UMB4). Expression rates were classified as low (≤ 20% staining positivity), moderate (21-50%), and high (> 50%). Furthermore, biochemical parameters such as human growth hormone (hGH) and insulin-like growth factor-1 (IGF-1) levels were measured and clinical, biochemical, radiological, and histological data were evaluated. RESULTS Of the 43 patients included in this study, 28 were female and 15 were male. The median age was 52 years (range 17-72 years). The median tumor size was 1.2 cm (range: 0.13-3.93 cm). All resected tumors showed positivity for somatotrophic hormone (STH). In all tissue samples, SSTR2a signal expression was detectable in immunohistochemistry, while only 39 samples were positive for SSTR5. Thirty-six samples had a high expression of SSTR2a, while three had a moderate and four a low SSTR2a signal. In comparison, SSTR5 signal was high in 26 out of 43 samples, while seven adenomas showed a moderate and six cases a low expression rate of SSTR5. The median IGF-1 was 714.2 µg/l and the median GH 19.6 mU/l (= 6.53 µg/l). The present study indicates that there is no significant relationship between the expression rates of receptor subtypes and the parameters we analyzed. However, our study revealed that smaller adenomas have a lower baseline GH level (p = 0.015), CONCLUSION: IHC with monoclonal antibodies appears to be a suitable method to determine the expression rates of SSTR2a and 5 at protein levels, as it is not possible to draw conclusions regarding receptor subtypes solely on the basis of the parameters analyzed.
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Affiliation(s)
- Lena Rass
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Amir-Hossein Rahvar
- III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jakob Matschke
- Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Wolfgang Saeger
- Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Renné
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Aberle
- III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jörg Flitsch
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Roman Rotermund
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
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10
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Bray DP, Mannam S, Rindler RS, Quillin JW, Oyesiku NM. Surgery for acromegaly: Indications and goals. Front Endocrinol (Lausanne) 2022; 13:924589. [PMID: 35992136 PMCID: PMC9386525 DOI: 10.3389/fendo.2022.924589] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 06/29/2022] [Indexed: 12/02/2022] Open
Abstract
Acromegaly is a disease that occurs secondary to high levels of GH, most often from a hormone-secreting pituitary adenoma, with multisystem adverse effects. Diagnosis includes serum GH and IGF-1 levels, and obtaining an MRI pituitary protocol to assess for a functional pituitary adenoma. Attempted gross total resection of the GH-secreting adenoma is the gold standard in treatment for patients with acromegaly for a goal of biochemical remission. Medical and radiation therapies are available when patients do not achieve biochemical cure after surgical therapy.
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Affiliation(s)
- David P Bray
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, United States
| | - Sai Mannam
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, United States
| | - Rima S Rindler
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, United States
| | - Joseph W Quillin
- Department of Neurosurgery, Medical City Hospital, Dallas, TX, United States
| | - Nelson M Oyesiku
- Department of Neurosurgery, University of North Carolina School of Medicine, Chapel Hill, NC, United States
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11
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Gillett D, Bashari W, Senanayake R, Marsden D, Koulouri O, MacFarlane J, van der Meulen M, Powlson AS, Mendichovszky IA, Cheow H, Bird N, Kolias A, Mannion R, Gurnell M. Methods of 3D printing models of pituitary tumors. 3D Print Med 2021; 7:24. [PMID: 34462823 PMCID: PMC8406959 DOI: 10.1186/s41205-021-00118-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 08/15/2021] [Indexed: 12/21/2022] Open
Abstract
Background Pituitary adenomas can give rise to a variety of clinical disorders and surgery is often the primary treatment option. However, preoperative magnetic resonance imaging (MRI) does not always reliably identify the site of an adenoma. In this setting molecular (functional) imaging (e.g. 11C-methionine PET/CT) may help with tumor localisation, although interpretation of these 2D images can be challenging. 3D printing of anatomicalal models for other indications has been shown to aid surgical planning and improve patient understanding of the planned procedure. Here, we explore the potential utility of four types of 3D printing using PET/CT and co-registered MRI for visualising pituitary adenomas. Methods A 3D patient-specific model based on a challenging clinical case was created by segmenting the pituitary gland, pituitary adenoma, carotid arteries and bone using contemporary PET/CT and MR images. The 3D anatomical models were printed using VP, MEX, MJ and PBF 3D printing methods. Different anatomicalal structures were printed in color with the exception of the PBF anatomical model where a single color was used. The anatomical models were compared against the computer model to assess printing accuracy. Three groups of clinicians (endocrinologists, neurosurgeons and ENT surgeons) assessed the anatomical models for their potential clinical utility. Results All of the printing techniques produced anatomical models which were spatially accurate, with the commercial printing techniques (MJ and PBF) and the consumer printing techniques (VP and MEX) demonstrating comparable findings (all techniques had mean spatial differences from the computer model of < 0.6 mm). The MJ, VP and MEX printing techniques yielded multicolored anatomical models, which the clinicians unanimously agreed would be preferable to use when talking to a patient; in contrast, 50%, 40% and 0% of endocrinologists, neurosurgeons and ENT surgeons respectively would consider using the PBF model. Conclusion 3D anatomical models of pituitary tumors were successfully created from PET/CT and MRI using four different 3D printing techniques. However, the expert reviewers unanimously preferred the multicolor prints. Importantly, the consumer printers performed comparably to the commercial MJ printing technique, opening the possibility that these methods can be adopted into routine clinical practice with only a modest investment.
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Affiliation(s)
- Daniel Gillett
- Department of Nuclear Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge Biomedical Campus, Hills Road, Cambridge, CB2 0QQ, UK. .,Cambridge Endocrine Molecular Imaging Group, University of Cambridge, Addenbrooke's Hospital, Hills Road, Cambridge, Biomedical Campus, Hills Road, Cambridge, CB2 0QQ, UK.
| | - Waiel Bashari
- Cambridge Endocrine Molecular Imaging Group, University of Cambridge, Addenbrooke's Hospital, Hills Road, Cambridge, Biomedical Campus, Hills Road, Cambridge, CB2 0QQ, UK
| | - Russell Senanayake
- Cambridge Endocrine Molecular Imaging Group, University of Cambridge, Addenbrooke's Hospital, Hills Road, Cambridge, Biomedical Campus, Hills Road, Cambridge, CB2 0QQ, UK
| | - Daniel Marsden
- Clinical Engineering, Cambridge University Hospitals NHS Foundation Trust, Cambridge Biomedical Campus, Hills Road, Cambridge, CB2 0QQ, UK
| | - Olympia Koulouri
- Cambridge Endocrine Molecular Imaging Group, University of Cambridge, Addenbrooke's Hospital, Hills Road, Cambridge, Biomedical Campus, Hills Road, Cambridge, CB2 0QQ, UK
| | - James MacFarlane
- Cambridge Endocrine Molecular Imaging Group, University of Cambridge, Addenbrooke's Hospital, Hills Road, Cambridge, Biomedical Campus, Hills Road, Cambridge, CB2 0QQ, UK
| | - Merel van der Meulen
- Cambridge Endocrine Molecular Imaging Group, University of Cambridge, Addenbrooke's Hospital, Hills Road, Cambridge, Biomedical Campus, Hills Road, Cambridge, CB2 0QQ, UK
| | - Andrew S Powlson
- Cambridge Endocrine Molecular Imaging Group, University of Cambridge, Addenbrooke's Hospital, Hills Road, Cambridge, Biomedical Campus, Hills Road, Cambridge, CB2 0QQ, UK
| | - Iosif A Mendichovszky
- Department of Nuclear Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge Biomedical Campus, Hills Road, Cambridge, CB2 0QQ, UK.,Department of Radiology, University of Cambridge, Cambridge Biomedical Campus, Hills Road, Cambridge, CB2 0QQ, UK
| | - Heok Cheow
- Department of Nuclear Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge Biomedical Campus, Hills Road, Cambridge, CB2 0QQ, UK
| | - Nick Bird
- Department of Nuclear Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge Biomedical Campus, Hills Road, Cambridge, CB2 0QQ, UK
| | - Angelos Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge & Addenbrooke's Hospital, Cambridge, CB2 0QQ, UK
| | - Richard Mannion
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge & Addenbrooke's Hospital, Cambridge, CB2 0QQ, UK
| | - Mark Gurnell
- Cambridge Endocrine Molecular Imaging Group, University of Cambridge, Addenbrooke's Hospital, Hills Road, Cambridge, Biomedical Campus, Hills Road, Cambridge, CB2 0QQ, UK.,Metabolic Research Laboratories, Wellcome-MRC Institute of Metabolic Science, University of Cambridge, National Institute for Health Research, Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK
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12
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Torres A, Sanmillan JL, Lau R, Gabarros A. Final Outcome in Growth Hormone-Secreting Adenomas After Combination of Maximal Tumor Resection and Medical Treatment. World Neurosurg 2021; 154:e292-e301. [PMID: 34252630 DOI: 10.1016/j.wneu.2021.07.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 07/04/2021] [Accepted: 07/05/2021] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Gross total resection (GTR) is not always possible in acromegalic patients, especially in patients with invasive growth hormone-secreting adenomas. We analyzed the biochemical remission outcome in relation to extent of tumor resection and effectiveness of medical treatment in cases of remnant tumor. METHODS Retrospective analysis was performed of acromegalic patients operated on between 2002 and 2017. Preoperative imaging, tumor invasiveness, extent of resection, and biochemical remission were collected. Patients with tumor remnant not amenable to second surgery began medical treatment. The relationship between pituitary adenoma remnant volume and final biochemical outcome was analyzed. RESULTS Of 120 acromegalic patients operated on, 82 underwent transsphenoidal microsurgery and 38 underwent endonasal endoscopic approach. GTR was achieved in 72 cases (60%); subtotal resection (STR), 21 (17.5%) cases; and partial resection, 27 (22.5%) cases. There was a nonsignificant higher rate of GTR/STR in patients who underwent endonasal endoscopic approach. However, a significantly higher remission rate (89.45% vs. 67.1%) was achieved in these patients (P < 0.01). Greater tumor volume and invasiveness were associated with a lower remission (P < 0.05). Patients with tumor remnant who achieved biochemical remission with added medical therapy had a significantly smaller tumor volume (P < 0.001). CONCLUSIONS The more aggressive surgical resection is, the greater the chance of attaining final biochemical remission, whether or not GTR is achieved. Medical therapy effectiveness is enhanced in cases with STR. Invasive growth hormone-secreting macroadenomas that are not surgically amenable to total resection are best managed with a combination of safe STR and medical treatment.
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Affiliation(s)
- Alberto Torres
- Department of Neurological Surgery, Bellvitge University Hospital, Barcelona, Spain.
| | - Jose Luis Sanmillan
- Department of Neurological Surgery, Bellvitge University Hospital, Barcelona, Spain
| | - Ruth Lau
- Department of Neurological Surgery, Bellvitge University Hospital, Barcelona, Spain
| | - Andreu Gabarros
- Department of Neurological Surgery, Bellvitge University Hospital, Barcelona, Spain
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13
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Nie D, Fang Q, Li B, Cheng J, Li C, Gui S, Zhang Y, Zhao P. Research advances on the immune research and prospect of immunotherapy in pituitary adenomas. World J Surg Oncol 2021; 19:162. [PMID: 34090476 PMCID: PMC8180072 DOI: 10.1186/s12957-021-02272-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 05/20/2021] [Indexed: 12/16/2022] Open
Abstract
Background Pituitary adenomas are one type of intracranial tumor, which can be divided into microadenoma (≤ 1 cm), macroadenoma (> 1 cm), and giant adenoma (≥ 4 cm) according to their diametral sizes. They are benign, typically slow-progressing, whereas the biological behavior of some of them is invasive, which presents a major clinical challenge. Treatment of some pituitary adenomas is still difficult due to drug resistance or multiple relapses, usually after surgery, medication, and radiation. At present, no clear prediction and treatment biomarkers have been found in pituitary adenomas and some of them do not cause clinical symptoms, so patients are often found to be ill through physical examination, and some are even found through autopsy. With the development of research on pituitary adenomas, the immune response has become a hot spot and may serve as a novel disease marker and therapeutic target. The distribution and function of immune cells and their secreted molecules in pituitary adenomas are extremely complex. Researchers found that infiltration of immune cells may have a positive effect on the treatment and prognosis of pituitary adenomas. In this review, we summarized the advance of tumor immunity in pituitary adenomas, revealing the immunity molecules as potential biomarkers as well as therapeutic agents for pituitary adenomas. Conclusion The immune studies related to pituitary adenomas may help us find relevant immune markers. At the same time, the exploration of immunotherapy also provides new options for the treatment of pituitary adenomas.
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Affiliation(s)
- Ding Nie
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Qiuyue Fang
- Beijing Neurosurgical Institute, Beijing, China
| | - Bin Li
- Beijing Neurosurgical Institute, Beijing, China
| | - Jianhua Cheng
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chuzhong Li
- Beijing Neurosurgical Institute, Beijing, China
| | - Songbai Gui
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | | | - Peng Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
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14
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Niño MC, Mejía JA, Cohen D, Ruiz C, Oñate R, Díaz J, González M. In Reference to Other Factors That Alter Outcomes Following Skull Base Surgery. Laryngoscope 2021; 131:E2443. [PMID: 34060649 DOI: 10.1002/lary.29631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 04/20/2021] [Indexed: 11/07/2022]
Affiliation(s)
- Maria Claudia Niño
- Department of Anesthesiology, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - Juan Armando Mejía
- Department of Neurosurgery, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - Darwin Cohen
- Department of Anesthesiology, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - Cristian Ruiz
- Department of Anesthesiology, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - Rosangélica Oñate
- Department of Anesthesiology, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - Julieth Díaz
- Department of Anesthesiology, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - Mariana González
- Department of Anesthesiology, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia
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15
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Swanson AA, Erickson D, Donegan DM, Jenkins SM, Van Gompel JJ, Atkinson JLD, Erickson BJ, Giannini C. Clinical, biological, radiological, and pathological comparison of sparsely and densely granulated somatotroph adenomas: a single center experience from a cohort of 131 patients with acromegaly. Pituitary 2021; 24:192-206. [PMID: 33074402 DOI: 10.1007/s11102-020-01096-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/13/2020] [Indexed: 01/01/2023]
Abstract
PURPOSE Growth hormone-producing pituitary adenomas are divided into two clinically relevant histologic subtypes, densely (DG-A) and sparsely (SG-A) granulated. Histologic subtype was evaluated in a large cohort of patients with acromegaly, separating DG-A and SG-A, and correlated with clinicopathological characteristics. METHODS Patients with acromegaly undergoing surgery as initial therapy between 1995 and 2015 were identified. Histologic subtype was determined by keratin expression pattern with CAM5.2 and correlated with clinical and imaging parameters, somatostatin receptor subtype 2 (SST2) expression, post-surgical remission rate, and application of a prognostic scoring system incorporating proliferation and invasiveness. RESULTS One hundred thirty-one patients were included. Tumors were classified as DG-A (75, 57.3%), SG-A (29, 22.1%), intermediate (I-A) (9, 6.9%), and unclassified (18, 13.7%) when CAM5.2 was negative. DG-A and I-A were combined for analysis (DG/I-A) and compared to SG-A. Age, gender, proliferation, and post-surgical remission did not differ. SG-A were larger [2 vs. 1.5 cm (median), p = 0.03], more frequently invasive [65.5% vs. 32.9%, p = 0.004], associated with higher MRI T2-weighted signal ratio [1.01 vs. 0.82 (median), p = 0.01], showed lower SST2 expression (p < 0.0001), and scored higher in the prognostic classification (p = 0.004). Surgical remission occurred in 41.7% DG/I-A and 41.4% SG-A (p = 1.0). On multivariate analysis, absence of invasion (p = 0.009) and lower pre-operative IGF-1 index (p = 0.0002) were associated with post-surgical remission. CONCLUSION CAM5.2 allowed distinction between DG/I-A and SG-A in most but not all cases. Histologic subtype did not predict surgical outcome. Absence of invasion and lower pre-operative IGF-1 index were the only significant predictors of post-surgical remission in this cohort.
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Affiliation(s)
- Amy A Swanson
- Division of Anatomic Pathology, Mayo Clinic, Rochester, MN, USA
| | - Dana Erickson
- Division of Endocrinology, Diabetes and Metabolism, Mayo Clinic, Rochester, MN, USA
| | - Diane Mary Donegan
- Division of Endocrinology, Diabetes and Metabolism, Mayo Clinic, Rochester, MN, USA
- Division of Endocrinology, Diabetes and Metabolism, Indiana University, Indianapolis, IN, USA
| | - Sarah M Jenkins
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | | | | | | | - Caterina Giannini
- Division of Anatomic Pathology, Mayo Clinic, Rochester, MN, USA.
- Department of Laboratory Medicine and Pathology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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16
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Hadzhiyanev A, Popov D. Comparison of endoscopic and microscopic transsphenoidal pituitary surgery for managing growth hormone-secreting adenomas. BIOTECHNOL BIOTEC EQ 2021. [DOI: 10.1080/13102818.2021.1996273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Affiliation(s)
- Asen Hadzhiyanev
- Neurosurgery Department, University Hospital ‘St. Ivan Rilski’, Medical University of Sofia, Sofia, Bulgaria
| | - Deyan Popov
- Neurosurgery Department, University Hospital ‘St. Ivan Rilski’, Medical University of Sofia, Sofia, Bulgaria
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17
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Araujo-Castro M, Pascual-Corrales E, Martínez-Vaello V, Baonza Saiz G, Quiñones de Silva J, Acitores Cancela A, García Cano AM, Rodríguez Berrocal V. Predictive model of surgical remission in acromegaly: age, presurgical GH levels and Knosp grade as the best predictors of surgical remission. J Endocrinol Invest 2021; 44:183-193. [PMID: 32441006 DOI: 10.1007/s40618-020-01296-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 05/11/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE To identify presurgical clinical, hormonal and radiological variables associated with surgical remission in acromegaly and develop a predictive model for surgical remission. METHODS Ambispective study of acromegaly surgical patients followed in two Spanish tertiary hospitals. Patients operated by the same neurosurgeon by endonasal endoscopic transsphenoidal approach (n = 49) were included to develop the predictive model, and patients operated by other neurosurgeons (n = 37) were used for external validation of the predictive model. The predictive model was developed with a multivariate logistic regression model based on the 2000 criteria. RESULTS 86 acromegalic patients were included. 49 patients, 83.7% with macroadenomas and 32.7% with Knosp grade > 2, were included for the development of the predictive model. The overall rate of surgical remission with the 2000 criteria was 73.5% and 51.0% with the 2010 criteria. Using the 2000 criteria, variables associated with surgical remission were: older age (OR = 1.1, p = 0.001), lower basal presurgical GH levels (OR = 0.9, p = 0.003), Knosp 0-2 (OR = 34.1, p < 0.0001) and lower maximum pituitary adenoma diameter (OR = 0.9, p = 0.019). The model with the best diagnostic accuracy to predict surgical remission combined age, Knosp 0-2 and presurgical GH levels (AIC = 29.7, AUC = 0.95) with a sensitivity of 93.8% and a specificity of 75.0%. The estimated loss of prediction with the external validation (n = 37) was 4.2%. CONCLUSION The predictive model with the best diagnosis accuracy for surgical remission combined age, Knosp 0-2 and presurgical GH levels, with a sensitivity of 93.8% and a specificity of 75.0%. This model could be very useful to select candidates to preoperative medical treatment and planning the follow-up.
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Affiliation(s)
- M Araujo-Castro
- Neuroendocrinology Unit, Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, Madrid, Spain.
| | - E Pascual-Corrales
- Neuroendocrinology Unit, Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - V Martínez-Vaello
- Neuroendocrinology Unit, Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - G Baonza Saiz
- Neuroendocrinology Unit, Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - J Quiñones de Silva
- Neuroendocrinology Unit, Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - A Acitores Cancela
- Neuroendocrinology Unit, Department of Neurosurgery, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - A M García Cano
- Hormones and Tumors Markers Unit, Department of Biochemistry, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - V Rodríguez Berrocal
- Neuroendocrinology Unit, Department of Neurosurgery, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Endoscopic Skull Base Unit, Department of Neurosurgery, Hospital Universitario HM Puerta del Sur, Madrid, Spain
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18
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Diri H, Ozaslan E, Kurtsoy A, Bayram F. A single-center observational study assessing the predictive factors associated with the prognosis of acromegaly. Growth Horm IGF Res 2020; 55:101342. [PMID: 32916586 DOI: 10.1016/j.ghir.2020.101342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 07/27/2020] [Accepted: 07/28/2020] [Indexed: 10/23/2022]
Abstract
AIM The aim of this study was to clarify the prognostic values of various preoperative factors, including the surgeon's ability as well as the patient's age, gender, tumor size, cavernous sinus invasion, compression of the optic chiasm, hypopituitarism, immunohistochemical (IHC) staining pattern of the adenoma, and insulin-like growth factor-1 (IGF-1) level, in acromegalic patients who had undergone pituitary surgery. STUDY DESIGN This single-center, retrospective study assessed the medical records of 108 patients who had undergone pituitary surgery with the same neurosurgical team. RESULTS The mean total follow-up period after surgery was 44.8 (min: 24, max: 59) months. Remission was reported in 67 (62.0%) patients, and 57 (52.8%) patients did not experience recurrence. Initial tumor volume, IGF-1 level, and optic chiasm compression, but not patients' age, gender, cavernous sinus invasion, and IHC staining patterns of the adenoma, were prognostic of either remission or recurrence. An IGF-1 level of 860 ng/mLwas found to be a convenient cut-off point for determining remission. CONCLUSIONS The experience of the surgical team suggests that the initial tumor volume, IGF-1 level, and optic chiasm compression have high prognostic values in relation to pituitary surgery for patients with acromegaly.
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Affiliation(s)
- Halit Diri
- Erciyes University Medical School, Department of Endocrinology, Kayseri, Turkey.
| | - Ersin Ozaslan
- Erciyes University Medical School, Department of Medical Oncology, Kayseri, Turkey
| | - Ali Kurtsoy
- Erciyes University Medical School, Department of Neurosurgery, Kayseri, Turkey
| | - Fahri Bayram
- Erciyes University Medical School, Department of Endocrinology, Kayseri, Turkey
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19
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Wu Y, Wang M, Xu Y, Wen R, Liu X, Gao Y, Shi Y, Pan W, Deng H, Wang W. Comparing primary gamma knife radiosurgery and postoperative gamma knife radiosurgery for acromegaly: A monocenter retrospective study. Clin Neurol Neurosurg 2020; 200:106385. [PMID: 33290886 DOI: 10.1016/j.clineuro.2020.106385] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 11/13/2020] [Accepted: 11/22/2020] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To compare the efficacy and safety between primary GKS and postoperative GKS for acromegaly, and to elucidate predictors associated with endocrine remission, we performed a monocenter, retrospective study. METHOD Seventy-five patients with acromegaly who had received GKS in West China Hospital between March 2010 and December 2018 were included in this study. Endocrine remission was defined as age-sex matched IGF-I normalization and either nadir level of GH <1 ng/mL after OGTT or the random GH < 2.0 ng/mL. RESULTS We didn't find significant differences in endocrine remission, biochemical recurrence, imaging regression, imaging progression, radiation-induced complications between the primary GKS group and the postoperative GKS group(P > 0.05). Actuarial rates of durable endocrine remission at 3, 5, 8 year were 10.60 %, 33.80 % and 70.60 % in the primary GKS group and 6.70 %, 43.40 % and 78.80 % in the postoperative GKS group(P = 0.800). Only base nadir GH after OGTT (HR = 0.637,95 % CI:0.416-0.977; P = 0.039) was found to be a predictor of duration endocrine remission. CONCLUSION We find comparable efficacy and safety between primary GKS and postoperative GKS. Lower base nadir GH after OGTT was a positive predictor associated with endocrine remission. GKS should be considered for residual or recurrent tumor after surgery. For those who couldn't sustain surgery, GKS is an alternative treatment. Further studies are required to elucidate the efficacy and safety of GKS in acromegaly.
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Affiliation(s)
- Yang Wu
- Department of Neurosurgery, West China Hospital, Sichuan University, China.
| | - Mengqi Wang
- Department of Neurosurgery, West China Hospital, Sichuan University, China.
| | - Yangyang Xu
- Department of Neurosurgery, West China Hospital, Sichuan University, China.
| | - Rong Wen
- Department of Neurosurgery, West China Hospital, Sichuan University, China.
| | - Xiaowei Liu
- Department of Neurosurgery, West China Hospital, Sichuan University, China.
| | - Yuan Gao
- Department of Neurosurgery, West China Hospital, Sichuan University, China.
| | - Yifeng Shi
- Department of Neurosurgery, West China Hospital, Sichuan University, China.
| | - Wei Pan
- Department of Neurosurgery, West China Hospital, Sichuan University, China.
| | - Hao Deng
- Department of Neurosurgery, West China Hospital, Sichuan University, China.
| | - Wei Wang
- Department of Neurosurgery, West China Hospital, Sichuan University, China.
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20
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Giraldi EA, Veledar E, Oyesiku NM, Ioachimescu AG. Incidentally detected acromegaly: single-center study of surgically treated patients over 22 years. J Investig Med 2020; 69:351-357. [DOI: 10.1136/jim-2020-001605] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/14/2020] [Indexed: 12/14/2022]
Abstract
Acromegaly is a rare disease associated with comorbidities that are common in the general population. Most patients undergo screening for classic phenotypical (CP) or mass effect manifestations. By retrospective review of pituitary tumor surgeries performed between 1994 and 2016 (1836), we identified patients with acromegaly (112). Main presentations were: CP (43%), mass effect (26%), incidentally detected (ID) tumors (17%), and other (14%). We compared the ID and CP groups regarding prevalence, clinical, biochemical, radiological and histopathological characteristics, and postoperative outcomes. The prevalence of ID among all surgeries increased after 2011 from 0.6% to 1.9% (p=0.01), while prevalence of CP remained stable (2.8% and 2.33%, p=0.65). Almost half of ID (47.4%) presented with otolaryngological manifestations. The ID and CP groups were similar regarding age, gender, comorbidities (hypertension, diabetes, hypopituitarism), tumor diameter and cavernous sinus invasion. Median insulin-like growth factor (IGF-1) and growth hormone (GH) levels were lower in the ID than CP (p<0.05 and p=0.07). Patients younger than 40 had smaller tumors in the ID than CP, while the opposite was true for older patients. The 3-month biochemical remission rates were similar (68% ID and 58% CP). A similar number of patients had normal IGF-1 at last follow-up (89.5% ID and 81.25% CP) after surgery alone and multimodality treatment. In conclusion, an increased number of patients with GH-secreting adenomas were ID in recent years. Education of physicians other than endocrinologists regarding presentation and comorbidity clustering may lead to an earlier diagnosis of acromegaly and improved outcomes.
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Agrawal N, Ioachimescu AG. Prognostic factors of biochemical remission after transsphenoidal surgery for acromegaly: a structured review. Pituitary 2020; 23:582-594. [PMID: 32602066 DOI: 10.1007/s11102-020-01063-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
PURPOSE Biochemical control is the main determinant of survival, clinical manifestations and comorbidities in acromegaly. Transsphenoidal selective adenomectomy (TSA) is the initial treatment of choice with reported biochemical remission rates varying between 32 and 85%. Understanding the limiting factors is essential for identification of patients who require medical treatment. METHODS We reviewed the English literature published in Medline/Pubmed until Dec 31, 2019 to identify eligible studies that described outcomes of TSA as primary therapy and performed analyses to determine the main predictors of remission. RESULTS Most publications reported single-institution, retrospective studies. The following preoperative parameters were consistently associated with lower remission rates: cavernous sinus invasion by imaging, larger tumor size and higher GH levels. Young age and preoperative IGF-1 levels were predictive in some studies. When controlled for covariates, the best single preoperative predictor was cavernous sinus invasion, followed by preoperative GH levels. Conversely, low GH level in the first few days postoperatively was a robust predictor of durable remission. The influence of tumor histology (sparsely granular pattern, co-expression of prolactin and proliferation markers) on surgical remission remains to be established. Few studies developed predictive models that yielded much higher predictive values than individual parameters. CONCLUSION Surgical outcome prognostication systems could be further generated by machine learning algorithms in order to support development and implementation of personalized care in patients with acromegaly.
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Affiliation(s)
- Nidhi Agrawal
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, NYU School of Medicine, 550 First Avenue, New York City, NY, 10016, USA
| | - Adriana G Ioachimescu
- Department of Medicine and Neurosurgery, Emory University School of Medicine, 1365 B Clifton Road B-2200, Northeast, B6209, Atlanta, GA, 30322, USA.
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Kyriakakis N, Seejore K, Hanafy A, Murray RD. Management of persistent acromegaly following primary therapy: The current landscape in the UK. Endocrinol Diabetes Metab 2020; 3:e00158. [PMID: 32704572 PMCID: PMC7375072 DOI: 10.1002/edm2.158] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 03/30/2020] [Accepted: 05/02/2020] [Indexed: 11/12/2022] Open
Abstract
Acromegaly is the clinical consequence of chronic exposure of the tissues to excess GH and IGF-I. It is almost exclusively the result of a GH-secreting pituitary adenoma. In addition to the somatic features, uncontrolled acromegaly is associated with a number of complications and excess mortality. Management is aimed at control of the tumour; normalization of GH and IGF-I secretion and relief of symptoms. Initial management of GH-secreting pituitary adenoma is widely accepted as endonasal trans-sphenoidal surgery, with second-line therapy where disease is uncontrolled in most cases being somatostatin analogue therapy. With the combination of surgery and somatostatin analogue therapy, control is achieved in around 75% of patients; however, this leaves a significant proportion of patients requiring multimodality therapy to achieve remission. Within the UK, the health system has finite resources, and decisions for management require consideration of efficacy and cost-effectiveness. To add to the complexity, subtle differences exist in availability of high-cost medications used in the treatment of patients with acromegaly across the devolved nations of the UK. In this article, we discuss options for the management of persistent acromegaly following initial surgery and somatostatin analogue therapy, and explore earlier use of dopaminergics and conservative management.
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Affiliation(s)
- Nikolaos Kyriakakis
- Department of EndocrinologyLeeds Centre for Diabetes & EndocrinologyLeeds Teaching Hospitals NHS TrustLeedsUK
- Leeds Institute of Cardiovascular and Metabolic MedicineUniversity of LeedsLeedsUK
| | - Khyatisha Seejore
- Department of EndocrinologyLeeds Centre for Diabetes & EndocrinologyLeeds Teaching Hospitals NHS TrustLeedsUK
- Leeds Institute of Cardiovascular and Metabolic MedicineUniversity of LeedsLeedsUK
| | - Ahmed Hanafy
- Department of EndocrinologyLeeds Centre for Diabetes & EndocrinologyLeeds Teaching Hospitals NHS TrustLeedsUK
| | - Robert D. Murray
- Department of EndocrinologyLeeds Centre for Diabetes & EndocrinologyLeeds Teaching Hospitals NHS TrustLeedsUK
- Leeds Institute of Cardiovascular and Metabolic MedicineUniversity of LeedsLeedsUK
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Hanson M, Li H, Geer E, Karimi S, Tabar V, Cohen MA. Perioperative management of endoscopic transsphenoidal pituitary surgery. World J Otorhinolaryngol Head Neck Surg 2020; 6:84-93. [PMID: 32596652 PMCID: PMC7296486 DOI: 10.1016/j.wjorl.2020.01.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 01/19/2020] [Indexed: 11/12/2022] Open
Abstract
The contemporary embrace of endoscopic technology in the approach to the anterior skull base has altered the perioperative landscape for patients requiring pituitary surgery. Utility of a multi-disciplinary unit in management decisions facilitates the delivery of optimal care. Evolution of technology and surgical expertise in pituitary surgery mandates ongoing review of all components of the care central to these patients. The many areas of potential variability in the pre, intra and post-operative timeline of pituitary surgery are readily identifiable. Core undertakings and contemporary controversies in the peri-operative management of patients undergoing endoscopic transsphenoidal pituitary surgery are assessed against the available literature with a view to providing guidance for the best evidence-based practice.
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Affiliation(s)
- Martin Hanson
- Multidisciplinary Pituitary and Skull Base Tumour Program, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, USA
| | - Hao Li
- Multidisciplinary Pituitary and Skull Base Tumour Program, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, USA
| | - Eliza Geer
- Multidisciplinary Pituitary and Skull Base Tumour Program, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, USA
| | - Sasan Karimi
- Multidisciplinary Pituitary and Skull Base Tumour Program, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, USA
| | - Viviane Tabar
- Multidisciplinary Pituitary and Skull Base Tumour Program, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, USA
| | - Marc A Cohen
- Multidisciplinary Pituitary and Skull Base Tumour Program, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, USA
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Abstract
Pituitary adenomas are considered benign tumors, but approximately 10% of them can have an aggressive behavior and more rarely (0.2%) can present metastasis, being classified as pituitary carcinomas. Aggressive adenomas are generally large and invasive tumors that present unusually rapid growth and/or that grow irrespective of conventional treatment with surgery, medical therapy and radiotherapy. Nevertheless, large tumors, as well as invasive tumors are not always aggressive, with this definition being possible only after clinical follow-up of these tumors, with growth rate and response to therapies being key points to its diagnosis. The correct identification and diagnosis of aggressive adenomas is of great importance as they are associated with great morbidity and increased mortality.
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Affiliation(s)
- Leandro Kasuki
- Neuroendocrinology Research Center/ Endocrinology Division - Medical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
- Neuroendocrinology Division, Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
- Endocrinology Division, Hospital Federal de Bonsucesso, Rio de Janeiro, Brazil
| | - Gérald Raverot
- "Groupement Hospitalier Est" Hospices Civils de Lyon, Endocrinology Department, Reference Center for Rare Pituitary Diseases HYPO, 59 Pinel Boulevard, 69677, Bron, France.
- Université Lyon 1, 69100, Villeurbanne, France.
- INSERM U1052, CNRS, UMR5286, Cancer Research Center of Lyon, 69372, Lyon, France.
- Fédération d'Endocrinologie du Pôle Est, Groupement Hospitalier Est, 59 Bd Pinel, F-69677, Bron, France.
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Galm BP, Buckless C, Swearingen B, Torriani M, Klibanski A, Bredella MA, Tritos NA. MRI texture analysis in acromegaly and its role in predicting response to somatostatin receptor ligands. Pituitary 2020; 23:212-222. [PMID: 31897778 DOI: 10.1007/s11102-019-01023-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE Given the paucity of reliable predictors of tumor recurrence, progression, or response to somatostatin receptor ligand (SRL) therapy in acromegaly, we attempted to determine whether preoperative MR image texture was predictive of these clinical outcomes. We also determined whether image texture could differentiate somatotroph adenomas from non-functioning pituitary adenomas (NFPAs). METHODS We performed a retrospective study of patients with acromegaly due to a macroadenoma who underwent transsphenoidal surgery at our institution between 2007 and 2015. Clinical data were extracted from electronic medical records. MRI texture analysis was performed on preoperative non-enhanced T1-weighted images using ImageJ (NIH). Logistic and Cox models were used to determine if image texture parameters predicted outcomes. RESULTS Eighty-nine patients had texture parameters measured, which were compared to that of NFPAs, while 64 of these patients had follow-up and were included in the remainder of analyses. Minimum pixel intensity, skewness, and kurtosis were significantly different in somatotroph adenomas versus NFPAs (area under the receiver operating characteristic curve, 0.7771, for kurtosis). Furthermore, those with a maximum pixel intensity above the median had an increased odds of IGF-I normalization on SRL therapy (OR 5.96, 95% CI 1.33-26.66), which persisted after adjusting for several potential predictors of response. Image texture did not predict tumor recurrence or progression. CONCLUSION Our data suggest that MRI texture analysis can distinguish NFPAs from somatotroph macroadenomas with good diagnostic accuracy and can predict normalization of IGF-I with SRL therapy.
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Affiliation(s)
- Brandon P Galm
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, 100 Blossom Street, Suite 140, Boston, MA, 02114, USA.
| | - Colleen Buckless
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Brooke Swearingen
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Martin Torriani
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Anne Klibanski
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, 100 Blossom Street, Suite 140, Boston, MA, 02114, USA
| | - Miriam A Bredella
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Nicholas A Tritos
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, 100 Blossom Street, Suite 140, Boston, MA, 02114, USA
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Karsy M, Bowers CA, Scoville J, Kundu B, Azab MA, Gee JM, Guan J, Couldwell WT. Evaluation of Complications and Costs During Overlapping Transsphenoidal Surgery in the Treatment of Pituitary Adenoma. Neurosurgery 2020; 84:1104-1111. [PMID: 29897572 DOI: 10.1093/neuros/nyy269] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 05/21/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Pituitary adenomas are among the most common primary brain tumors. Recently, overlapping surgery has been curbed in many institutions because of the suggestion there might be more significant adverse events, despite several studies showing that complication rates are equivalent. OBJECTIVE To assess complications and costs associated with overlapping surgery during the transsphenoidal resection of pituitary adenomas. METHODS A single-center, retrospective cohort study was performed to evaluate the cases of patients who underwent a transsphenoidal approach for pituitary tumor resection. Patient, surgical, complication, and cost (value-driven outcome) variables were analyzed. RESULTS A total of 629 patients (302 nonoverlapping, 327 overlapping cases) were identified. No significant differences in age (P = .6), sex (P = .5), tumor type (P = .5), or prior rates of pituitary adenoma resection (P = .5) were seen. Similar presenting symptoms were observed in the 2 groups, and follow-up length was comparable (P = .3). No differences in tumor sizes (P = .5), operative time (P = .4), fat/fascia use (P = .4), or cerebrospinal fluid diversion (P = .8) were seen between groups. The gross total resection rate was not significantly different (P = .9), and no difference in recurrence rate was seen (P = .4). A comparable complication rate was seen between groups (P = .6). No differences in total or subtotal costs were seen either. CONCLUSION The results of this study offer additional evidence that overlapping surgery does not result in worsened complications, lengthened surgery, or increased patient cost for patients undergoing transsphenoidal resection of pituitary adenomas. Thus, studies and policy aiming to improve patient safety and cost should focus on optimizing other aspects of healthcare delivery.
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Affiliation(s)
- Michael Karsy
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Christian A Bowers
- Department of Neurosurgery, New York Medical College, Valhalla, New York
| | - Jonathan Scoville
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Bornali Kundu
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Mohammed A Azab
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - J Michael Gee
- Department of Radiology, University of Minnesota, Minneapolis, Minnesota
| | - Jian Guan
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - William T Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
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Micko A, Vila G, Höftberger R, Knosp E, Wolfsberger S. Endoscopic Transsphenoidal Surgery of Microprolactinomas: A Reappraisal of Cure Rate Based on Radiological Criteria. Neurosurgery 2020; 85:508-515. [PMID: 30169711 DOI: 10.1093/neuros/nyy385] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 08/15/2018] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Current standard treatment of microprolactinomas is dopamine agonist therapy. As this drug treatment is lifelong in up to 80% of cases, many patients consult pituitary surgeons regarding a surgical alternative. OBJECTIVE To identify prognostic criteria for surgical remission, we reviewed outcomes of our series of microprolactinomas treated with endoscopic transsphenoidal surgery, with a special emphasis on magnetic resonance adenoma delineation and position. METHODS Our study cohort comprises a single center series of 60 patients operated for histopathologically verified magnetic resonance imaging unequivocally identifiable endosellar microprolactinoma between 2003 and 2017. In 31 patients the adenoma was enclosed by pituitary gland (group ENC), in 29 patients the adenoma was located lateral to the gland adherent to the medial cavernous sinus wall (group LAT). RESULTS After a mean follow-up of 37 mo (range 4-143 mo), remission rate was significantly higher in adenomas enclosed by pituitary gland (group ENC) than adenomas located lateral to the gland (group LAT), with 87% vs 45%, P = .01. Intraoperatively, 4 patients showed signs of invasiveness. Preoperative prolactin levels did not differ between the groups (mean 155 and 187 ng/ml in group ENC and LAT, respectively).A binary logistic regression model revealed that only the radiological criteria applied showed a significant correlation (P = .003) with endocrine remission. CONCLUSION According to our results, remission rate is significantly higher in microprolactinomas enclosed by the pituitary gland. However, the decision for surgery should take into account surgeons experience and possibility of complications.
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Affiliation(s)
- Alexander Micko
- Department of Neurosurgery, Medical University Vienna, Vienna, Austria
| | - Greisa Vila
- Department of Internal Medicine III, Division of Endocrinology and Metabolism, Medical University Vienna, Vienna, Austria
| | | | - Engelbert Knosp
- Department of Neurosurgery, Medical University Vienna, Vienna, Austria
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Dai W, Zhuang Z, Ling H, Yang Y, Hang C. Systematic review and network meta-analysis assess the comparative efficacy and safety of transsphenoidal surgery for pituitary tumor. Neurosurg Rev 2020; 44:515-527. [PMID: 32036504 DOI: 10.1007/s10143-020-01240-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 01/03/2020] [Accepted: 01/08/2020] [Indexed: 12/27/2022]
Abstract
To quantitatively synthesize the comparative efficacy and safety of the most common surgical approaches including endonasal transsphenoidal endoscopic surgery (ETES), sublabial transsphenoidal microsurgery (STMS) and endonasal transsphenoidal microsurgery (ETMS) for all kinds of pituitary tumors. This systematic review and network meta-analysis was performed on randomized controlled trials (RCTs) and comparison studies from databases of Pubmed, EMBASE, and the Cochrane library. We selected the rate of gross complete resection as our primary outcome of efficacy. And the incidence of all complications, cerebrospinal fluid (CSF) leak, diabetes insipidus, nasal septal perforation, death, and bleeding were designed as our primary outcomes of safety. Twenty-seven studies with 2618 patients were included in this network meta-analysis. On efficacy, there was no statistical difference among the three methods including ETES, STMS, and ETMS. As for safety, results indicated that the incidence of total complications of STMS (OR = 4.74; 95% CI 1.03, 40.14) is significantly superior to ETES. And the incidence of diabetes insipidus of ETMS (OR = 2.21; 95% CI 1.31, 3.81) was significantly superior to that of ETES. Besides, there was no statistical difference in the other complications including CSF leak, nasal septal perforation, death, and bleeding. We clarified the overpraise of the efficacy of endoscopy especially the endonasal transsphenoidal approach, and verified that all the approaches owned similar efficacy. Moreover, we recommended the endoscopy to be the first choice for pituitary tumors, because it demonstrated the best safety.
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Affiliation(s)
- Wei Dai
- Department of Neurosurgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, No. 321 Zhongshan Road, Nanjing, 210000, China
| | - Zong Zhuang
- Department of Neurosurgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, No. 321 Zhongshan Road, Nanjing, 210000, China
| | - Haiping Ling
- Department of Neurosurgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, No. 321 Zhongshan Road, Nanjing, 210000, China
| | - Yongbo Yang
- Department of Neurosurgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, No. 321 Zhongshan Road, Nanjing, 210000, China
| | - Chunhua Hang
- Department of Neurosurgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, No. 321 Zhongshan Road, Nanjing, 210000, China.
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Cozzi R, Ambrosio MR, Attanasio R, Bozzao A, De Marinis L, De Menis E, Guastamacchia E, Lania A, Lasio G, Logoluso F, Maffei P, Poggi M, Toscano V, Zini M, Chanson P, Katznelson L. Italian Association of Clinical Endocrinologists (AME) and Italian AACE Chapter Position Statement for Clinical Practice: Acromegaly - Part 2: Therapeutic Issues. Endocr Metab Immune Disord Drug Targets 2020; 20:1144-1155. [PMID: 31995025 PMCID: PMC7579256 DOI: 10.2174/1871530320666200129113328] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 12/02/2019] [Accepted: 12/02/2019] [Indexed: 12/03/2022]
Abstract
Any newly diagnosed patient should be referred to a multidisciplinary team experienced in the treatment of pituitary adenomas. The therapeutic management of acromegaly always requires a personalized strategy. Normal age-matched IGF-I values are the treatment goal. Transsphenoidal surgery by an expert neurosurgeon is the primary treatment modality for most patients, especially if there are neurological complications. In patients with poor clinical conditions or who refuse surgery, primary medical treatment should be offered, firstly with somatostatin analogs (SSAs). In patients who do not reach hormonal targets with first-generation depot SSAs, a second pharmacological option with pasireotide LAR or pegvisomant (alone or combined with SSA) should be offered. Irradiation could be proposed to patients with surgical remnants who would like to be free from long-term medical therapies or those with persistent disease activity or tumor growth despite surgery or medical therapy. Since the therapeutic tools available enable therapeutic targets to be achieved in most cases, the challenge is to focus more on the quality of life.
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Affiliation(s)
- Renato Cozzi
- Address correspondence to this author at the Endocrinologia, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore 3, 20162 Milano, Italy; Tel: +39.347.5225490; E-mail:
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Faraj MK, Sagban WJ. Endoscopic transsphenoidal approach to skull base lesions. A clinical prospective study. ACTA ACUST UNITED AC 2019; 23:35-38. [PMID: 29455219 PMCID: PMC6751911 DOI: 10.17712/nsj.2018.1.20170229] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To review the patients operated by endoscopic transphenoidal approach for skull base lesions. All the clinical data including age, gender, type of pathology, surgical outcome and surgical complications were studied. METHODS A clinical prospective study was conducted on 94 cases with skull base lesion that were treated in Neuroscience Hospital in Baghdad, Iraq between October 2011 and December 2016. We followed each patient for an average of 2 years after surgery to determine most common lesion involving the skull base, age and gender distribution, surgical outcome, complications and hospital accommodation. Freeze system of Storz all the cases in the study. RESULTS The majority of our patients were between the ages of 20-29 years. Among the 94 patients, 67% had macro adenomas, followed by craniopharyngioma 11%. The mortality rate was 2.1%, Gross total removal was 57.4%. All patients show improvement of the headache after surgery, visual improvement was noticed in 73.4% and hospital accommodation was 2-5 days. Three patients developed cerebrospinal fluid leak, Infection meningitis developed in 3 patients 3.1%, and 2 patients (2.1%) suffered from hormonal disorders and were referred to endocrinologist for therapy. Diabetes insipidus developed as a temporary complication in 4 cases (4.2%). CONCLUSION Trassphenoidal surgery is relatively safe surgery for properly selected patients.
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Affiliation(s)
- Moneer K Faraj
- College of Medicine, Baghdad University, Baghdad, Iraq. E-mail:
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Asha MJ, Takami H, Velasquez C, Oswari S, Almeida JP, Zadeh G, Gentili F. Long-term outcomes of transsphenoidal surgery for management of growth hormone-secreting adenomas: single-center results. J Neurosurg 2019; 133:1360-1370. [PMID: 31604330 DOI: 10.3171/2019.6.jns191187] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Accepted: 06/18/2019] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Transsphenoidal surgery is advocated as the first-line management of growth hormone (GH)-secreting adenomas. Although disease control is defined by strict criteria for biochemical remission, the length of follow-up needed is not well defined in literature. In this report, the authors present their long-term remission rate and identify various predictive factors that might influence the clinical outcome. METHODS The authors conducted a single-institute retrospective analysis of all transsphenoidal procedures for GH-secreting adenomas performed from January 2000 to June 2016. The primary outcome was defined as biochemical remission according to the 2010 consensus criteria and measured at the 1-year postoperative mark as well as on the last recorded follow-up appointment.Secondary variables included recurrence rate, patterns of clinical presentation, and outcome of adjuvant therapy (including repeat surgery). Subgroup analysis was performed for patients who had biochemical or radiological "discordance"-patients who achieved biochemical remission but with incongruent insulin-like growth factor 1 (IGF-1)/GH or residual tumor on MRI. Recurrence-free survival analysis was conducted for patients who achieved remission at 1 year after surgery. RESULTS Eighty-one patients (45 female and 36 male) with confirmed acromegaly treated with transsphenoidal surgery were included. In 62 cases the patients were treated with a pure endoscopic approach and in 19 cases an endoscopically assisted microscopic approach was used.Primary biochemical remission after surgery was achieved in 59 cases (73%) at 1 year after surgery. However, only 41 patients (51%) remained in primary surgical remission (without any adjuvant treatment) at their last follow-up appointment, indicating a recurrence rate of 31% (18 of 59 patients) over the duration of follow-up (mean 100 ± 61 months). Long-term remission rates for pure endoscopic and endoscopically assisted cases were not significantly different (48% vs 52%, p = 0.6). Similarly, no significant difference in long-term remission was detected between primary surgery and repeat surgery (54% vs 33%, p = 0.22).Long-term remission was significantly influenced by extent of resection, cavernous sinus invasion (radiologically as well as surgically reported), and preoperative and early postoperative GH and IGF-1 levels (within 24-48 hours after surgery) as well as by clinical grade, with lower remission rates in patients with dysmorphic features and/or medical comorbidities (grade 2-3) compared to minimally symptomatic or silent cases (grade 1). CONCLUSIONS The long-term surgical remission rate appears to be significantly less than "early" remission rates and is highly dependent on the extent of tumor resection. The authors advocate a long-term follow-up regimen and propose a clinical grading system that may aid in predicting long-term outcome in addition to the previously reported anatomical factors. The role of repeat surgery is highlighted.
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Pappy AL, Savinkina A, Bicknese C, Neill S, Oyesiku NM, Ioachimescu AG. Predictive modeling for pituitary adenomas: single center experience in 501 consecutive patients. Pituitary 2019; 22:520-531. [PMID: 31432313 DOI: 10.1007/s11102-019-00982-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Personalized postoperative management of patients with pituitary adenomas requires an early risk stratification system. METHODS We reviewed 501 cases operated between 10/27/2011 and 5/5/2016 by a single neurosurgeon. We determined biochemical remission and tumor resection at 3 months, and biochemical recurrence, tumor recurrence, radiation and reoperation during follow-up. We considered age, gender, tumor diameter, cavernous sinus invasion (CSI) by MRI, diagnostic category (clinical, biochemical and immunohistochemical), and proliferation markers in a Cox proportional hazards model. We built predictive models with the significant parameters and used Kaplan-Meier survival curves for time-dependent analyses. RESULTS The 501 cases comprised 141 functional and 360 nonfunctional adenomas. Tumor diameter, CSI, and ki-67 index predicted long-term events. Model 1 (CSI, diameter ≥ 2.9 cm and ki-67 > 3%) identified 18 (3.6%) adenomas and predicted persistent hypersecretory syndrome and residual tumor with 98.7% specificity (OR 8.6; CI 3.0-24.7). Model 2 (ki-67 > 3% and CSI) identified 48 (9.6%) adenomas and had 93.1% specificity (OR 3.3; CI 1.8-6.0). Model 3 (ki-67 > 3%, mitoses and p53, former "atypical" adenoma) identified 26 (5.2%) adenomas and had 96.0% specificity (OR 2.3; CI 1.0-5.0). Model 1 best predicted the long-term event-free survival and was strengthened when Knosp 3-4 CSI grades were used. Model 2 better identified the smaller adenomas at risk. Among the WHO 2017 special PA subtypes, patients with silent corticotroph adenoma had a lower event-free survival than ACTH-negative nonfunctional adenomas. CONCLUSION Use of CSI, ki-67 and tumor diameter in prediction models facilitates tailored surveillance and management of patients with pituitary adenomas.
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Affiliation(s)
- A L Pappy
- Emory University School of Medicine, Atlanta, GA, USA
| | - A Savinkina
- Emory Rollins School of Public Health, Atlanta, GA, USA
| | - C Bicknese
- Emory University School of Medicine, Atlanta, GA, USA
| | - S Neill
- Department of Pathology, Emory University School of Medicine, Atlanta, GA, USA
| | - N M Oyesiku
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, 1364 Clifton Road NE, Atlanta, GA, 30322, USA
- Department of Neurosurgery, Emory University School of Medicine, 1365 B Clifton Rd NE, Atlanta, GA, USA
| | - A G Ioachimescu
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, 1364 Clifton Road NE, Atlanta, GA, 30322, USA.
- Department of Neurosurgery, Emory University School of Medicine, 1365 B Clifton Rd NE, Atlanta, GA, USA.
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Rutkowski M, Zada G. Management of Pituitary Adenomas Invading the Cavernous Sinus. Neurosurg Clin N Am 2019; 30:445-455. [DOI: 10.1016/j.nec.2019.05.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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34
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Porto LB, Zimmermann IR, Naves LA. Economics of Acromegaly Treatment in Brazil: A Budget Impact Analysis of Pituitary Surgery Compared with Long-Term Octreotide LAR. PHARMACOECONOMICS - OPEN 2019; 3:247-254. [PMID: 30390240 PMCID: PMC6533371 DOI: 10.1007/s41669-018-0103-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND Acromegaly is a rare, chronic and debilitating disease whose treatment places a high burden on health systems. In the reality of the Brazilian public health network, many patients are kept on drug treatment because of barriers to access to surgery. OBJECTIVE The aim of this study was to estimate the costs and budget impact of routine transsphenoidal endoscopic surgery in relation to those of long-term drug treatment with octreotide long-acting release (LAR) from a cohort of patients followed at the referral medical centre for acromegaly treatment in the Federal District, Brazil. METHODS Based on micro-costing data collected using mixed methods from a local perspective of the public health system, we performed a budget impact analysis (BIA) on a 3-year time horizon. Uncertainty was handled with deterministic (tornado and scenario) and probabilistic (Monte Carlo simulations) sensitivity analyses. RESULTS Compared with the continued use of octreotide LAR at a dose of 30 mg every 28 days, the incremental budget impact of conducting two surgeries per month, considering a cure rate of 55%, could bring savings of approximately US$879,362.18 (95% CI 860,176.29-898,548.08) over 3 years. Depending on the key variable values, the savings amplitude ranged from US$431,836.39 to US$1,519,132.04. CONCLUSIONS Improving access to surgery could result in significant cost reductions in acromegaly treatment. The present study stands out for being the first to estimate the costs of transsphenoidal surgery in the context of the public health system in Brazil.
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Affiliation(s)
- Lara Benigno Porto
- Faculty of Health Sciences, University of Brasilia, Brasília, Brazil.
- Unit of Endocrinology and Research Centre, Regional Hospital of Taguatinga, Secretariat of Health of the Federal District, Federal District, Brazil.
| | - Ivan Ricardo Zimmermann
- Department of Pharmaceutical Assistance and Strategic Inputs, Ministry of Health, Brasília, Brazil
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Shen M, Tang Y, Shou X, Wang M, Zhang Q, Qiao N, Ma Z, Ye Z, He W, Zhang Y, Chen Z, Zhang Z, Ye H, Li Y, Li S, Zhao Y, Zhou X, Wang Y. Surgical Results and Predictors of Initial and Delayed Remission for Growth Hormone-Secreting Pituitary Adenomas Using the 2010 Consensus Criteria in 162 Patients from a Single Center. World Neurosurg 2018; 124:S1878-8750(18)32738-4. [PMID: 30500578 DOI: 10.1016/j.wneu.2018.11.179] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 11/18/2018] [Accepted: 11/19/2018] [Indexed: 01/19/2023]
Abstract
BACKGROUND The factors associated with initial and delayed remission after growth hormone (GH)-secreting pituitary adenoma excision have not been completely elucidated. METHODS We recruited 185 consecutive patients who had undergone resection of GH-secreting pituitary adenomas from January 2013 to December 2014 and assessed their tumor characteristics and surgical outcomes. The criteria for initial or delayed remission (using the 2010 consensus criteria) were normalized insulin-like growth factor 1 (IGF-1) levels, GH levels <0.4 μg/L with an oral glucose tolerance test, and/or random GH levels <1.0 μg/L at or after the postoperative 3-month (PO3M) follow-up, without adjuvant therapy. RESULTS Remission was achieved in 92 of 162 patients (56.8%) after surgery alone and was associated with a lower Knosp grade of 0-2 and lower postoperative day 1 GH level on multivariate regression analysis. A baseline IGF-1 index (IGF-1 level/upper limit of normal) of <2.835 predicted for initial remission at the PO3M follow-up (positive predictive value, 95.3%; negative predictive value, 36.6%; P < 0.001). The PO3M IGF-1 index was significantly lower in the delayed remission group than in the nonremission group. Furthermore, the former had had fewer invasive tumors (1.23 ± 0.21 vs. 1.77 ± 0.37 [9.52% vs. 76.47%]; P < 0.001). A PO3M IGF-1 index of <1.485 predicted for delayed remission during subsequent follow-up (positive predictive value, 84.6%; negative predictive value, 92.3%; P < 0.001). CONCLUSIONS A lower Knosp grade of 0-2 and lower postoperative day 1 GH level were independent predictors of surgical remission. The baseline IGF-1 and PO3M IGF-1 indexes might predict for initial and delayed remission, respectively.
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Affiliation(s)
- Ming Shen
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Shanghai Pituitary Tumor Center, Shanghai, China
| | - Yifan Tang
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Shanghai Pituitary Tumor Center, Shanghai, China
| | - Xuefei Shou
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Shanghai Pituitary Tumor Center, Shanghai, China
| | - Meng Wang
- Department of Endocrinology and Metabolism, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Shanghai Pituitary Tumor Center, Shanghai, China
| | - Qilin Zhang
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Shanghai Pituitary Tumor Center, Shanghai, China
| | - Nidan Qiao
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Shanghai Pituitary Tumor Center, Shanghai, China
| | - Zengyi Ma
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Shanghai Pituitary Tumor Center, Shanghai, China
| | - Zhao Ye
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Shanghai Pituitary Tumor Center, Shanghai, China
| | - Wenqiang He
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Shanghai Pituitary Tumor Center, Shanghai, China
| | - Yichao Zhang
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Shanghai Pituitary Tumor Center, Shanghai, China
| | - Zhengyuan Chen
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Shanghai Pituitary Tumor Center, Shanghai, China
| | - Zhaoyun Zhang
- Department of Endocrinology and Metabolism, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Shanghai Pituitary Tumor Center, Shanghai, China
| | - Hongying Ye
- Department of Endocrinology and Metabolism, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Shanghai Pituitary Tumor Center, Shanghai, China
| | - Yiming Li
- Department of Endocrinology and Metabolism, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Shanghai Pituitary Tumor Center, Shanghai, China
| | - Shiqi Li
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Shanghai Pituitary Tumor Center, Shanghai, China
| | - Yao Zhao
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Shanghai Pituitary Tumor Center, Shanghai, China
| | - Xiang Zhou
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Shanghai Pituitary Tumor Center, Shanghai, China
| | - Yongfei Wang
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Shanghai Pituitary Tumor Center, Shanghai, China.
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Li Z, Yang C, Bao X, Yao Y, Feng M, Deng K, Liu X, Xing B, Wang R. Secondary pituitary abscess following transsphenoidal surgery with recurrent meningitis: A case report. Medicine (Baltimore) 2018; 97:e13458. [PMID: 30508969 PMCID: PMC6283055 DOI: 10.1097/md.0000000000013458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
RATIONALE The transsphenoidal surgical (TS) approach to sellar masses is the preferred surgical route in most cases. Secondary pituitary abscess (PA) following TS is an extremely rare but serious postoperative complication with potentially high disability and mortality. PATIENT CONCERNS We describe an uncommon case of secondary PA in a 42-year-old woman, who underwent uncomplicated transsphenoidal procedures without cerebrospinal fluid leak, to treat primary Rathke cleft cyst. Without obvious cause, the patient suffered recurrent meningitis with complaints of headache, hyperpyrexia, and chills from 1 month after the operation. DIAGNOSIS There were no significant imaging findings until a new rim-enhancement lesion was seen in the sellar region on magnetic resonance imaging during the 6th episode of meningitis 11 months after the initial surgery. A diagnosis of secondary PA was considered; INTERVENTIONS:: Therefore, she underwent a 2nd TS with pus evacuation and antibiotic treatment. OUTCOMES She improved remarkably and had no recurrence of symptoms during the 9-month follow-up. LESSONS Our aim was to present this rare case and discuss the most likely etiologies and preventive measures for this condition. In patients with recurrent meningitis but dormant imaging manifestations after TS, the possibility of secondary PA should considered. Adequate surgical drainage with microbiology-guided antibiotic therapy is the 1st choice for treatment.
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Affiliation(s)
| | - Chengxian Yang
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Xinjie Bao
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Yong Yao
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Ming Feng
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Kan Deng
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaohai Liu
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Bing Xing
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Renzhi Wang
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
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Trevisi G, Vigo V, Morena MG, Grieco DL, Rigante M, Anile C, Mangiola A. Comparison of Endoscopic Versus Microsurgical Resection of Pituitary Adenomas with Parasellar Extension and Evaluation of the Predictive Value of a Simple 4-Quadrant Radiologic Classification. World Neurosurg 2018; 121:e769-e774. [PMID: 30312824 DOI: 10.1016/j.wneu.2018.09.215] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Revised: 09/27/2018] [Accepted: 09/28/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND The amount of parasellar extension is a known limitation for gross total resection (GTR) of pituitary adenomas. Endoscopic technique seems to improve resection of adenomas extending laterally. Knosp classification is used to evaluate the extent of parasellar invasion: increasing Knosp grades correspond with lower rates of GTR. The 4-quadrant method could help to estimate the risk of partial resection in adenomas with parasellar extension. The objective of this study was to compare the rate of GTR between microsurgical and endoscopic techniques in pituitary adenomas with parasellar extension. The secondary aim was to compare the predictive value of Knosp classification and of the 4-quadrant classification regarding GTR. METHODS This was a retrospective comparison of GTR in different Knosp grades and per quadrant in 55 consecutive patients who underwent microsurgical (n = 28, 2001-2008) or endoscopic (n = 27, 2008-2016) resection of a pituitary adenoma with parasellar extension. RESULTS The endoscopic group (19/27 patients) had a significant higher rate of GTR than the microsurgical group (8/28 patients) (P = 0.005). This was evident in all patients but those with Knosp grade 4. Using the quadrant classification, the endoscopic group had a significantly higher rate of GTR than the microsurgical group in all but the inferolateral quadrant. The 2 classifications showed similar sensitivity in predicting subtotal resection (78% quadrant vs. 82% Knosp), with limited specificity (both 25%). CONCLUSIONS GTR of macroadenomas with parasellar extension is significantly enhanced by the endoscopic approach. The 4-quadrant classification appears as sensitive as the Knosp classification and could be a simple adjunct to predict surgical radicality, in particular in cases of inferolateral quadrant invasion.
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Affiliation(s)
- Gianluca Trevisi
- Department of Neurosurgery, Università Cattolica del Sacro Cuore, Rome, Italy; Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Vera Vigo
- Department of Neurosurgery, Università Cattolica del Sacro Cuore, Rome, Italy; Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
| | - Maria Grazia Morena
- Department of Neurosurgery, Università Cattolica del Sacro Cuore, Rome, Italy; Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Domenico Luca Grieco
- Department of Anesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy; Department of Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Mario Rigante
- Department of Otolaryngology, Università Cattolica del Sacro Cuore, Rome, Italy; Department of Otolaryngology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Carmelo Anile
- Department of Neurosurgery, Università Cattolica del Sacro Cuore, Rome, Italy; Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Annunziato Mangiola
- Department of Neurosurgery, Università degli Studi "G. D'Annunzio", Pescara, Italy
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Antunes X, Ventura N, Camilo GB, Wildemberg LE, Guasti A, Pereira PJM, Camacho AHS, Chimelli L, Niemeyer P, Gadelha MR, Kasuki L. Predictors of surgical outcome and early criteria of remission in acromegaly. Endocrine 2018; 60:415-422. [PMID: 29626274 DOI: 10.1007/s12020-018-1590-8] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 03/30/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Transsphenoidal surgery (TSS) is the cornerstone of acromegaly treatment, however there are no robust predictors of surgical outcome and remission can only be defined three months after surgery. PURPOSE To analyze if biochemical, demographical, radiological, and immunohistochemical characteristics are predictors of surgical remission and investigate if immediate postoperative GH and IGF-I levels can help defining remission earlier. METHODS Consecutive acromegaly patients submitted to TSS between 2013-2016 were evaluated. Remission criteria was defined as normal IGF-I and GH <1 mcg/L three months after surgery. Data of age, sex, GH and IGF-I levels, tumor volume, cavernous sinus invasion, T2-weighted signal, Ki-67, and granulation pattern were correlated with remission status. GH and IGF-I levels at 24, 48 h, and one week postoperative were evaluated as early criteria of remission. RESULTS Sixty-nine patients were included (84% macroadenomas) and surgical remission was achieved in 45%. No difference between cured and not cured patients concerning age, gender, preoperative GH or IGF-I levels, tumor volume, T2-weighted signal, Ki-67 and tumor granularity was observed. Remission was obtained in 20 of 36 (56%) of the non-invasive tumors, and in 3 of 16 (19%) of the invasive tumors (p = 0.017). A GH <1.57 mcg/L 48 h after surgery was able to predict remission with 93% sensitivity and 86% specificity and an IGF-I < 231% ULNR one week after surgery predicted remission with 86% sensitivity and 93% specificity. CONCLUSION Cavernous sinus invasion is the only preoperative predictor of surgical remission. GH at 48 h and IGF-I one week after surgery can define earlier not cured patients.
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Affiliation(s)
- Ximene Antunes
- Neuroendocrinology Research Center / Endocrinology Division - Medical School and Hospital Universitário Clementino Fraga Filho - Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Nina Ventura
- Radiology Division - Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | - Gustavo Bittencourt Camilo
- Radiology Division - Instituição Hospital e Maternidade Terezinha de Jesus -Juiz de Fora, Minas Gerais, Brazil
| | - Luiz Eduardo Wildemberg
- Neuroendocrinology Research Center / Endocrinology Division - Medical School and Hospital Universitário Clementino Fraga Filho - Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
- Neuroendocrinology Division - Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | - Andre Guasti
- Neurosurgery Division - Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | - Paulo José M Pereira
- Neurosurgery Division - Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | - Aline Helen Silva Camacho
- Neuropathology and Molecular Genetics Laboratory - Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
- Pathology Division - Instituto Nacional do Câncer, Rio de Janeiro, Brazil
| | - Leila Chimelli
- Neuropathology and Molecular Genetics Laboratory - Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | - Paulo Niemeyer
- Neurosurgery Division - Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | - Mônica R Gadelha
- Neuroendocrinology Research Center / Endocrinology Division - Medical School and Hospital Universitário Clementino Fraga Filho - Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
- Neuroendocrinology Division - Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | - Leandro Kasuki
- Neuroendocrinology Research Center / Endocrinology Division - Medical School and Hospital Universitário Clementino Fraga Filho - Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.
- Neuroendocrinology Division - Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil.
- Endocrinology Division - Hospital Federal de Bonsucesso, Rio de Janeiro, Brazil.
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Li Z, Yang C, Bao X, Yao Y, Feng M, Deng K, Liu X, Xing B, Wang R. Clinical Features and Treatment of Secondary Pituitary Abscess After Transsphenoidal Surgery: A Retrospective Study of 23 Cases. World Neurosurg 2018; 113:e138-e145. [DOI: 10.1016/j.wneu.2018.01.197] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Revised: 01/27/2018] [Accepted: 01/29/2018] [Indexed: 01/26/2023]
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Kasuki L, Wildemberg LE, Gadelha MR. MANAGEMENT OF ENDOCRINE DISEASE: Personalized medicine in the treatment of acromegaly. Eur J Endocrinol 2018; 178:R89-R100. [PMID: 29339530 DOI: 10.1530/eje-17-1006] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Accepted: 01/16/2018] [Indexed: 12/31/2022]
Abstract
Acromegaly is associated with high morbidity and elevated mortality when not adequately treated. Surgery is the first-line treatment for most patients as it is the only one that can lead to immediate cure. In patients who are not cured by surgery, treatment is currently based on a trial-and-error approach. First-generation somatostatin receptor ligands (fg-SRL) are initiated for most patients, although approximately 25% of patients present resistance to this drug class. Some biomarkers of treatment outcome are described in the literature, with the aim of categorizing patients into different groups to individualize their treatments using a personalized approach. In this review, we will discuss the current status of precision medicine for the treatment of acromegaly and future perspectives on the use of personalized medicine for this purpose.
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Affiliation(s)
- Leandro Kasuki
- Neuroendocrinology Research Center/Endocrine Section and Medical School, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
- Neuroendocrine Section, Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde do Rio de Janeiro, Rio de Janeiro, Brazil
- Endocrine Unit, Hospital Federal de Bonsucesso, Rio de Janeiro, Brazil
| | - Luiz Eduardo Wildemberg
- Neuroendocrinology Research Center/Endocrine Section and Medical School, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
- Neuroendocrine Section, Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Mônica R Gadelha
- Neuroendocrinology Research Center/Endocrine Section and Medical School, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
- Neuroendocrine Section, Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde do Rio de Janeiro, Rio de Janeiro, Brazil
- Neuropathology and Molecular Genetics Laboratory, Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
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Microsurgical versus endoscopic transsphenoidal resection for acromegaly: a systematic review of outcomes and complications. Acta Neurochir (Wien) 2017; 159:2193-2207. [PMID: 28913667 DOI: 10.1007/s00701-017-3318-6] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 08/28/2017] [Indexed: 12/16/2022]
Abstract
PURPOSE The aim of this systematic review is to evaluate the long-term endocrine outcomes and postoperative complications following endoscopic vs. microscopic transsphenoidal resection (TSR) for the treatment of acromegaly. METHODS A literature review was performed, and studies with at least five patients who underwent TSR for acromegaly, reporting biochemical remission criteria and long-term remission outcomes were included. Data extracted from each study included surgical technique, perioperative complications, biochemical remission criteria, and long-term remission outcomes. RESULTS Fifty-two case series from 1976 to 2016 met the inclusion criteria, comprising 4375 patients. Thirty-six reports were microsurgical (n = 3144) and 13 were endoscopic (n = 940). Three studies compared microsurgical (n = 111) to endoscopic TSR outcomes (n = 180). The overall initial and long-term remission rates were 58.2 vs. 57.4% and 69.2 vs. 70.2% for the microsurgical and endoscopic groups, respectively. For microadenomas, the initial and long-term remission rates were 77.6 vs. 82.2% and 76.9 vs. 73.5% for microsurgical and endoscopic approaches, respectively. For macroadenomas, the initial and long-term remission rates were 46.9 vs. 60.0% and 40.2 vs. 61.5% for microsurgical and endoscopic approaches, respectively. The rates of postoperative CSF leak were 3.0 vs. 2.3% for the microscopic and endoscopic groups, respectively. The rates of hypopituitarism and transient diabetes insipidus were 6.7 vs. 6.4% and 9.0 vs. 7.8% for the microscopic and endoscopic groups, respectively. CONCLUSIONS Both endoscopic and microsurgical approaches for TSR of growth hormone-secreting adenomas are viable treatment options for patients with acromegaly, and yield similarly high rates of remission under the most current consensus criteria.
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