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Cetinalp NE, Akkus G, Seydaoglu G, Ozsoy KM, Akbaba M, Baykara O, Oktay K, Erman T. Early Predictors of Remission in Acromegaly Patients after Pure Endoscopic Endonasal Transsphenoidal Surgery. J Neurol Surg B Skull Base 2024. [DOI: 10.1055/a-2319-0344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/03/2024] Open
Abstract
Abstract
Objective Surgery is the first-line treatment in acromegaly but it takes months to confirm remission. It is crucial to determine remission early in order to inform the patient and plan further treatment options. We aimed to evaluate the predictors of remission at the early phase after endoscopic endonasal pituitary surgery in acromegaly patients.
Methods Fifty-four growth hormone (GH)-adenoma patients operated via pure endoscopic endonasal approach were analyzed in this observational study. We compared the basic clinical, radiological characteristics, and the preoperative and postoperative hormone levels in terms of remission according to current guidelines.
Results The surgical remission rate was 61.1%. When the patients were compared according to surgical remission, the age, gender, and immunohistochemical granulation type were found to be nonsignificant, while diabetes mellitus was more common (55.6 vs. 44.4%). The preoperative tumor volume (1.2 ± 0.9 vs. 4.1 ± 4.2 cm3) and postoperative GH and insulin-like growth factor-1 (IGF-1) levels were higher in the nonremission group (p < 0.05). We defined a number of cut-off values of both GH and IGF-1 levels to predict remission at the postoperative phase. Age standardized regression analyses showed that postoperative day 1 (POD-1) GH levels (odds ratio [OR]: 8.9; 95% confidence interval [CI]: 1.99–40.0, p = 0.004) and tumor volume (OR: 3.14; 95% CI: 1.09–9.0, p = 0.034) were found to be significant independent predictors for remission.
Conclusion We demonstrated that tumor volume and POD-1 GH levels are independent predictors of remission in acromegaly patients operated via the pure endoscopic endonasal technique and may be used as an early marker of remission, and this may lead to taking adjuvant medical therapies early into account to improve prognosis.
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Affiliation(s)
- Nuri Eralp Cetinalp
- Department of Neurosurgery, Cukurova University Faculty of Medicine, Balcali, Adana, Türkiye
| | - Gamze Akkus
- Division of Endocrinology, Department of Internal Medicine, Cukurova University Faculty of Medicine, Adana, Türkiye
| | - Gulsah Seydaoglu
- Department of Biostatistics, Cukurova University Faculty of Medicine, Adana, Türkiye
| | - Kerem Mazhar Ozsoy
- Department of Neurosurgery, Cukurova University Faculty of Medicine, Balcali, Adana, Türkiye
| | - Mevlana Akbaba
- Department of Neurosurgery, Cukurova University Faculty of Medicine, Balcali, Adana, Türkiye
| | - Okay Baykara
- Department of Neurosurgery, Cukurova University Faculty of Medicine, Balcali, Adana, Türkiye
| | - Kadir Oktay
- Department of Neurosurgery, Cukurova University Faculty of Medicine, Balcali, Adana, Türkiye
| | - Tahsin Erman
- Department of Neurosurgery, Cukurova University Faculty of Medicine, Balcali, Adana, Türkiye
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Maroufi SF, Assar M, Khorasanizadeh M, Sabet FM, Sabahi M, Dabecco R, Adada B, Zada G, Borghei-Razavi H. Assessment of multimodal treatment options in recurrent and persistent acromegaly: a systematic review and meta-analysis. J Neurooncol 2024; 168:13-25. [PMID: 38587609 DOI: 10.1007/s11060-024-04658-7] [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: 02/07/2024] [Accepted: 03/21/2024] [Indexed: 04/09/2024]
Abstract
PURPOSE In patients with acromegaly, secondary treatment options in cases of hormonal non-remission or tumor progression include repeat transsphenoidal surgery (TSS), radiation-based treatment (RT), or medical therapy (MT). In this study, we aim to evaluate the clinical effectiveness of various second-line treatment options for acromegaly. METHODS Using the PRISMA guideline, a systematic review was performed by searching MEDLINE (PubMed), Web of Science, Scopus, and Cochrane electronic bibliographic databases from conception to the end of 2022. Outcomes of interest included hormonal remission rate, complications, and mortality associated with each treatment modality for refractory acromegaly. RESULTS A total of 79 studies including 3,208 refractory acromegaly patients (44.90% males) were analyzed, with a mean patient age of 43.89 years. There was a statistically significant difference between various therapeutic modalities in terms of remission rate, with MT offering the highest remission rate (62.55%), followed by RT (50.15%) and TSS (37.39%). Subgroup analysis of radiotherapeutic and medical modalities did not show a significant difference in remission rate between different kinds of sub-modalities in each treatment approach. Recurrence following secondary treatment was not different in patients treated with reoperation TSS compared to other modalities. CONCLUSIONS The management of persistent and recurrent acromegaly optimally requires a multimodal approach. In different scenarios of refractory acromegaly based on previous treatment, secondary treatments may vary in terms of remission rate and complications. Medical agents provide considerable effectiveness as a second-line therapy for recurrent or persistent disease. In selected cases, however, reoperation still provides an opportunity for cure or freedom from medications. The findings of this study may help clinicians to prioritize varying options involved in this multifaceted decision-making process.
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Affiliation(s)
- Seyed Farzad Maroufi
- Neurosurgery Research Network (NRN), Universal Scientific Education and Research Network (USERN), Tehran, Iran
- Department of Neurosurgery, Tehran University of Medical Sciences, Tehran, Iran
| | - Manijeh Assar
- Department of Surgery, University of Florida, Jacksonville, FL, USA
| | - MirHojjat Khorasanizadeh
- Department of Neurosurgery, Mount Sinai Hospital, Icahn School of Medicine, New York City, NY, USA
| | - Fatemeh Mahdavi Sabet
- Neurosurgery Research Network (NRN), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Mohammadmahdi Sabahi
- Department of Neurological Surgery, Pauline Braathen Neurological Centre, Cleveland Clinic Florida, Weston, FL, USA
| | - Rocco Dabecco
- Department of Neurological Surgery, Pauline Braathen Neurological Centre, Cleveland Clinic Florida, Weston, FL, USA
| | - Badih Adada
- Department of Neurological Surgery, Pauline Braathen Neurological Centre, Cleveland Clinic Florida, Weston, FL, USA
| | - Gabriel Zada
- Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Hamid Borghei-Razavi
- Department of Neurological Surgery, Pauline Braathen Neurological Centre, Cleveland Clinic Florida, Weston, FL, USA.
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, 2950 Cleveland Clinic Blvd., 33331, Weston, FL, USA.
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Giustina A, Biermasz N, Casanueva FF, Fleseriu M, Mortini P, Strasburger C, van der Lely AJ, Wass J, Melmed S. Consensus on criteria for acromegaly diagnosis and remission. Pituitary 2024; 27:7-22. [PMID: 37923946 PMCID: PMC10837217 DOI: 10.1007/s11102-023-01360-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/17/2023] [Indexed: 11/06/2023]
Abstract
PURPOSE The 14th Acromegaly Consensus Conference was convened to consider biochemical criteria for acromegaly diagnosis and evaluation of therapeutic efficacy. METHODS Fifty-six acromegaly experts from 16 countries reviewed and discussed current evidence focused on biochemical assays; criteria for diagnosis and the role of imaging, pathology, and clinical assessments; consequences of diagnostic delay; criteria for remission and recommendations for follow up; and the value of assessment and monitoring in defining disease progression, selecting appropriate treatments, and maximizing patient outcomes. RESULTS In a patient with typical acromegaly features, insulin-like growth factor (IGF)-I > 1.3 times the upper limit of normal for age confirms the diagnosis. Random growth hormone (GH) measured after overnight fasting may be useful for informing prognosis, but is not required for diagnosis. For patients with equivocal results, IGF-I measurements using the same validated assay can be repeated, and oral glucose tolerance testing might also be useful. Although biochemical remission is the primary assessment of treatment outcome, biochemical findings should be interpreted within the clinical context of acromegaly. Follow up assessments should consider biochemical evaluation of treatment effectiveness, imaging studies evaluating residual/recurrent adenoma mass, and clinical signs and symptoms of acromegaly, its complications, and comorbidities. Referral to a multidisciplinary pituitary center should be considered for patients with equivocal biochemical, pathology, or imaging findings at diagnosis, and for patients insufficiently responsive to standard treatment approaches. CONCLUSION Consensus recommendations highlight new understandings of disordered GH and IGF-I in patients with acromegaly and the importance of expert management for this rare disease.
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Affiliation(s)
- Andrea Giustina
- San Raffaele Vita-Salute University and IRCCS Hospital, Milan, Italy
| | | | | | | | - Pietro Mortini
- San Raffaele Vita-Salute University and IRCCS Hospital, Milan, Italy
| | | | | | | | - Shlomo Melmed
- Cedars-Sinai Medical Center, 8700 Beverly Blvd, NT 2015, Los Angeles, CA, 90048, USA.
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Cohen-Cohen S, Rindler R, Botello Hernandez E, Donegan D, Erickson D, Meyer FB, Atkinson JL, Van Gompel JJ. A Novel Preoperative Score to Predict Long-Term Biochemical Remission in Patients with Growth-Hormone Secreting Pituitary Adenomas. World Neurosurg 2024; 182:e882-e890. [PMID: 38123128 DOI: 10.1016/j.wneu.2023.12.076] [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: 10/19/2023] [Revised: 12/12/2023] [Accepted: 12/13/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVE Transsphenoidal surgery (TSS) is considered the treatment of choice in most patients with growth hormone (GH)-secreting pituitary adenomas. Several preoperative factors have been studied to predict postsurgical remission. Our objective was to design a score that could be used in the preoperative setting to identify patients that will achieve long-term biochemical remission after TSS. METHODS A retrospective analysis of consecutive patients with GH-secreting pituitary adenomas that underwent TSS in our institution from 2000 to 2015 who fulfilled prespecified criteria were included. Logistic regression methods were used to evaluate independent preoperative variables predicting long-term remission. Beta coefficients were used to create a scoring system for clinical practice. RESULTS Sixty-eight patients were included, with a mean follow-up time of 87 months. Twenty (29%) patients had tumors with a Knosp grade ≥ 3A. Gross-total resection was achieved in 43 (63%) patients. Thirty-three (48%) patients had long-term biochemical remission after TSS. In a multivariate analysis, the following variables were statistically significantly associated with long-term biochemical remission: age, adenoma size (diameter), Knosp grade, GH level, and insulin growth-factor 1index 1 at diagnosis. A score of <3 out of 8 total points was identified as a cutoff associated with long-term remission, with a sensitivity of 91.4% and specificity of 72.7% (AUC 0.867, OR 28.44, 95% CI 6.94-116.47, P = < 0.001). CONCLUSIONS A novel, simple, easy-to-use scoring system was created to identify patients with the highest chances of long-term biochemical remission following TSS. This scale should be prospectively validated in a multicenter study before widespread adoption.
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Affiliation(s)
| | - Rima Rindler
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Diane Donegan
- Division of Endocrinology, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA; Division of Endocrinology, Diabetes and Metabolism, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Dana Erickson
- Division of Endocrinology, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Fredric B Meyer
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - John L Atkinson
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Jamie J Van Gompel
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA.
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Tomasik A, Stelmachowska-Banaś M, Maksymowicz M, Czajka-Oraniec I, Raczkiewicz D, Zieliński G, Kunicki J, Zgliczyński W. Pathologic Characteristics of Somatotroph Pituitary Tumors-An Observational Single-Center Study. Biomedicines 2023; 11:3315. [PMID: 38137536 PMCID: PMC10741635 DOI: 10.3390/biomedicines11123315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 11/26/2023] [Accepted: 12/04/2023] [Indexed: 12/24/2023] Open
Abstract
The pathologic evaluation of a tumor tissue is an essential part of an acromegaly patient's assessment. This study aimed to analyze the pathologic characteristics of pituitary tumors in patients with acromegaly. The demographic data, in addition to the hormonal, imaging, and pathologic results of 120 patients with acromegaly after pituitary surgery, were extracted from the Polish Acromegaly Registry. We compared sparsely and densely granulated tumors, GH(+), mixed GH(+)/PRL(+) and plurihormonal tumors, α-subunit-positive and α-subunit-negative tumors, and tumors of various Ki-67 indices in terms of the abovementioned features. Sparsely granulated tumors were more frequent in women than in men (p = 0.001) and in younger patients (p = 0.011), and they were larger (p < 0.001) compared to densely granulated tumors. Tumors with positive α-subunit were smaller (p = 0.013), showed extrasellar extension less often (p = 0.039), and were more often densely granulated (p < 0.001) compared to α-subunit-negative tumors. Patients with a higher Ki-67 index were younger (p < 0.001) and more often diagnosed with genetic syndromes (p = 0.02); they had higher GH concentrations (p = 0.007), larger tumors (p = 0.006), and cavernous sinus invasions more frequently (p = 0.022). Conclusions: The pathologic characteristics of somatotroph pituitary tumors are associated with patient's age, sex, hormonal results, tumor size, and the degree of extrasellar expansion.
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Affiliation(s)
- Agnieszka Tomasik
- Department of Endocrinology, Centre of Postgraduate Medical Education, 01-813 Warsaw, Poland
| | | | - Maria Maksymowicz
- Department of Cancer Pathomorphology, Maria Sklodowska-Curie National Research Institute of Oncology, 02-781 Warsaw, Poland
| | - Izabella Czajka-Oraniec
- Department of Endocrinology, Centre of Postgraduate Medical Education, 01-813 Warsaw, Poland
| | - Dorota Raczkiewicz
- Department of Medical Statistics, School of Public Health, Centre of Postgraduate Medical Education, 01-813 Warsaw, Poland
| | - Grzegorz Zieliński
- Department of Neurosurgery, Military Institute of Medicine, 04-141 Warsaw, Poland
| | - Jacek Kunicki
- Department of Neurosurgery, Maria Sklodowska-Curie National Research Institute of Oncology, 02-781 Warsaw, Poland
| | - Wojciech Zgliczyński
- Department of Endocrinology, Centre of Postgraduate Medical Education, 01-813 Warsaw, Poland
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6
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Falch CM, Dupont AK, Olarescu NC, Wiedmann M, Dahlberg D, Bollerslev J, Berg-Johnsen J, Heck A. Long-term control of acromegaly after pituitary surgery in South-Eastern Norway. Acta Neurochir (Wien) 2023; 165:3003-3010. [PMID: 37665404 PMCID: PMC10542199 DOI: 10.1007/s00701-023-05772-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 08/17/2023] [Indexed: 09/05/2023]
Abstract
PURPOSE Sustained cure of acromegaly can only be achieved by surgery. Most growth hormone (GH) secreting pituitary adenomas are macroadenomas (≥ 10 mm) at diagnosis, with reported surgical cure rates of approximately 50%. Long-term data on disease control rates after surgery are limited. Our aim was to estimate short- and long-term rates of biochemical control after pituitary surgery in acromegaly and identify predictive factors. METHODS Patients operated for GH-secreting pituitary adenomas between 2005-2020 were included from the local pituitary registry (n = 178). Disease activity and treatment data were recorded at one-year (short-term) and five-year (long-term) postoperative follow-up. Biochemical control was defined as insulin-like growth factor 1 (IGF-1) ≤ 1.2 × upper limit of normal value. Multivariate regression models were used to identify factors potentially predicting biochemical control. RESULTS A total of 178 patients with acromegaly (median age at diagnosis 49 (IQR: 38-59) years, 46% women) were operated for a pituitary adenoma. Biochemical control was achieved by surgery in 53% at short-term and 41% at long-term follow-up, without additional treatment for acromegaly. Biochemical control rates by surgery were of same magnitude in paired samples (45% vs. 41%, p = 0.213) for short- and long-term follow-up, respectively. At short-term, 62% of patients with microadenomas and 51% with macroadenomas, achieved biochemical control. At long-term, the biochemical control rate was 58% for microadenomas and 37% for macroadenomas (p = 0.058). With adjunctive treatment, 82% achieved biochemical control at long-term. Baseline IGF-1 levels significantly predicted biochemical control by surgery at short-term (OR: 0.98 (95% CI: 0.96-0.99), p = 0.011), but not at long-term (OR: 0.76 (95% CI: 0.57-1.00), p = 0.053). CONCLUSION In unselected patients with acromegaly, the long-term biochemical control rate remains modest. Our findings indicate a need to identify patients at an earlier stage and improve therapeutic methods and surgical outcomes.
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Affiliation(s)
- Camilla M. Falch
- Section of Specialized Endocrinology, Department of Endocrinology, Oslo University Hospital, Postboks 4950 Nydalen, 0424 Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Postboks 1171 Blindern, 0318 Oslo, Norway
| | - Anne K. Dupont
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Postboks 1171 Blindern, 0318 Oslo, Norway
| | - Nicoleta C. Olarescu
- Section of Specialized Endocrinology, Department of Endocrinology, Oslo University Hospital, Postboks 4950 Nydalen, 0424 Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Postboks 1171 Blindern, 0318 Oslo, Norway
| | - Markus Wiedmann
- Department of Neurosurgery, Oslo University Hospital, Postboks 4950 Nydalen, 0424 Oslo, Norway
| | - Daniel Dahlberg
- Department of Neurosurgery, Oslo University Hospital, Postboks 4950 Nydalen, 0424 Oslo, Norway
| | - Jens Bollerslev
- Section of Specialized Endocrinology, Department of Endocrinology, Oslo University Hospital, Postboks 4950 Nydalen, 0424 Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Postboks 1171 Blindern, 0318 Oslo, Norway
| | - Jon Berg-Johnsen
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Postboks 1171 Blindern, 0318 Oslo, Norway
- Department of Neurosurgery, Oslo University Hospital, Postboks 4950 Nydalen, 0424 Oslo, Norway
| | - Ansgar Heck
- Section of Specialized Endocrinology, Department of Endocrinology, Oslo University Hospital, Postboks 4950 Nydalen, 0424 Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Postboks 1171 Blindern, 0318 Oslo, Norway
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7
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Romanisio M, Pitino R, Ferrero A, Pizzolitto F, Costelli S, Antoniotti V, Marzullo P, Aimaretti G, Prodam F, Caputo M. Discordant biochemical parameters of acromegaly remission do not influence the prevalence or aggressiveness of metabolic comorbidities: a single-center study. Front Endocrinol (Lausanne) 2023; 14:1256975. [PMID: 37829686 PMCID: PMC10565344 DOI: 10.3389/fendo.2023.1256975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 09/06/2023] [Indexed: 10/14/2023] Open
Abstract
Purpose The discrepancy between the biomarkers of disease's activity in acromegalic patients (GH and IGF-1) is almost frequent representing a challenge for the development of comorbidities in the long term. The aim of this study was to evaluate the prevalence and severity of metabolic comorbidities (diabetes, hypertension, and dyslipidemia) in surgically treated acromegalic patients with disease control and discordant GH and/or IGF-1 levels compared with those with concordant values. Patients and methods Retrospective monocentric observational study on acromegalic surgically treated patients with biochemical remission (group A) or mild discordant GH or IGF-1 levels (group B). Metabolic complications and medical therapy were assessed at diagnosis and at the last follow-up visit. Severity of the disease was set for drug titration or shift to another molecule or more than before. Results There were 18 patients that met the inclusion criteria [group A: nine patients; group B: nine patients, follow-up 7 years (IQR 5.0;11.25)]. The prevalence of female patients was significantly higher in the remission group compared with the discordant group (p < 0.02). Considering metabolic complications, at the last follow-up, 61.1% was affected by hypertension, 33.3% by diabetes, and 61.1% by dyslipidemia, without differences between groups. Drug characteristics (dose, shift, number) during the follow-up did not differ significantly between groups. Conclusion Metabolic complications, mainly dyslipidemia, are frequent in cured acromegalic patients, but GH/IGF-1 discrepancy does not seem to represent a risk factor for their presence or persistence. More extended studies are needed to confirm our results in a long-term period.
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Affiliation(s)
- Martina Romanisio
- Endocrinology, Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Rosa Pitino
- Endocrinology, Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Alice Ferrero
- Endocrinology, Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Francesca Pizzolitto
- Endocrinology, Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Samuele Costelli
- Endocrinology, Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | | | - Paolo Marzullo
- Endocrinology, Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Gianluca Aimaretti
- Endocrinology, Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Flavia Prodam
- Endocrinology, Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
- Department of Health Sciences, Università del Piemonte Orientale, Novara, Italy
| | - Marina Caputo
- Endocrinology, Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
- Department of Health Sciences, Università del Piemonte Orientale, Novara, Italy
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8
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Dumitriu-Stan RI, Burcea IF, Salmen T, Poiana C. Prognostic Models in Growth-Hormone- and Prolactin-Secreting Pituitary Neuroendocrine Tumors: A Systematic Review. Diagnostics (Basel) 2023; 13:2118. [PMID: 37371013 DOI: 10.3390/diagnostics13122118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 06/02/2023] [Accepted: 06/09/2023] [Indexed: 06/29/2023] Open
Abstract
Growth-hormone (GH)- and prolactin (PRL)-secreting PitNETs (pituitary neuroendocrine tumors) are divided into multiple histological subtypes, which determine their clinical and biological variable behavior. Proliferation markers alone have a questionable degree of prediction, so we try to identify validated prognostic models as accurately as possible. (1) Background: The data available so far show that the use of staging and clinical-pathological classification of PitNETs, along with imaging, are useful in predicting the evolution of these tumors. So far, there is no consensus for certain markers that could predict tumor evolution. The application of the WHO (World Health Organisation) classification in practice needs to be further evaluated and validated. (2) Methods: We performed the CRD42023401959 protocol in Prospero with a systematic literature search in PubMed and Web of Science databases and included original full-text articles (randomized control trials and clinical trials) from the last 10 years, published in English, and the search used the following keywords: (i) pituitary adenoma AND (prognosis OR outcome OR prediction), (ii) growth hormone pituitary adenoma AND (prognosis OR outcome OR prediction), (iii) prolactin pituitary adenoma AND (prognosis OR outcome OR prediction); (iv) mammosomatotroph adenoma AND (prognosis OR outcome OR prediction). (3) Results: Two researchers extracted the articles of interest and if any disagreements occurred in the selection process, these were settled by a third reviewer. The articles were then assessed using the ROBIS bias assessment and 75 articles were included. (4) Conclusions: the clinical-pathological classification along with factors such as GH, IGF-1, prolactin levels both preoperatively and postoperatively offer valuable information.
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Affiliation(s)
- Roxana-Ioana Dumitriu-Stan
- Department of Endocrinology, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Doctoral School of 'Carol Davila' University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Iulia-Florentina Burcea
- Department of Endocrinology, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania
- 'C. I. Parhon' National Institute of Endocrinology, 011863 Bucharest, Romania
| | - Teodor Salmen
- Doctoral School of 'Carol Davila' University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Catalina Poiana
- Department of Endocrinology, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania
- 'C. I. Parhon' National Institute of Endocrinology, 011863 Bucharest, Romania
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9
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Zhang S, Chen J, Yao S, Akter F, Wang Z, Hu B, Zhu D, Duan C, Chen W, Zhu Y, Wang H, Mao Z. Predictors of postoperative biochemical remission in lower Knosp grade growth hormone-secreting pituitary adenomas: a large single center study. J Endocrinol Invest 2023; 46:465-476. [PMID: 36125731 DOI: 10.1007/s40618-022-01873-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 07/16/2022] [Indexed: 10/14/2022]
Abstract
PURPOSE Growth hormone-secreting pituitary adenomas (GH-PAs) with a low Knosp grade are typically associated with a good postoperative biochemical remission (BR) rate. However, a proportion of patients do not achieve remission. In this study, we aimed to investigate predictive factors of postoperative remission for lower Knosp GH-PAs. METHODS In this retrospective study, we enrolled 140 patients who were diagnosed with lower Knosp (0-2) GH-PAs and received trans-sphenoidal surgery between December 2016 and June 2021 from the largest pituitary tumor surgery center in southern China. The univariate, binary Logistic regression, and receiver operating characteristic curve (ROC) analyses were employed to determine independent predictors and cutoff values of remission. The postoperative outcome was defined as remission using the 2010 consensus criteria of acromegaly. RESULTS One hundred and thirty six patients (97.1%) achieved gross total resection. The postoperative long-term BR was 68.6%. Empty sella, tumor maximum diameter and postoperative GH levels were independent factors predicting remission. ROC revealed that postoperative 24 h GH ≤ 1.3 ng/mL and ≤ 1.23 ng/mL were valuable predictors for 3-month and long-term remission respectively, and that postoperative 3-month GH ≤ 1.6 ng/mL and tumor maximum diameter ≤ 17 mm were predictors for delayed remission. CONCLUSION Early postoperative GH levels can be used as predictors of remission. However, BR was not associated with preoperative somatostatin analogs therapy or Knosp grade (0-2). For patients without residual tumor or recurrence and whose GH levels are slightly elevated within 1 year after surgery, adjuvant treatments may not be necessary.
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Affiliation(s)
- S Zhang
- Department of Neurosurgery, Center for Pituitary Tumor Surgery, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - J Chen
- Department of Neurosurgery, Center for Pituitary Tumor Surgery, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - S Yao
- Department of Neurosurgery, Center for Pituitary Tumor Surgery, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - F Akter
- Faculty of Arts and Sciences, Harvard University, Cambridge, MA, USA
| | - Z Wang
- Department of Neurosurgery, Center for Pituitary Tumor Surgery, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - B Hu
- Department of Neurosurgery, Center for Pituitary Tumor Surgery, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - D Zhu
- Department of Neurosurgery, Center for Pituitary Tumor Surgery, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - C Duan
- Department of Neurosurgery, Center for Pituitary Tumor Surgery, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - W Chen
- Department of Neurosurgery, Center for Pituitary Tumor Surgery, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Y Zhu
- Department of Histology and Embryology, Zhongshan School of Medicine, Sun Yat-Sen University, Guangzhou, China.
| | - H Wang
- Department of Neurosurgery, Center for Pituitary Tumor Surgery, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.
| | - Z Mao
- Department of Neurosurgery, Center for Pituitary Tumor Surgery, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.
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10
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Hamblin R, Fountas A, Levy M, Karavitaki N. UK practice on incidentally detected non-functioning pituitary microadenomas: analysis of two national surveys during a 12-year interval. Pituitary 2023; 26:94-104. [PMID: 36434293 PMCID: PMC9908737 DOI: 10.1007/s11102-022-01290-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/06/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE The optimal management approach for presumed non-functioning pituitary microadenomas (microNFPAs) remains unclear. Our aim was to capture current UK practice and identify changes with time. METHODS Two online surveys investigating clinicians' approaches were performed in 2009-2010 and 2021-2022 (advertised through Society for Endocrinology UK). RESULTS 150 and 214 clinicians participated in the 2021 and 2009 survey, respectively (response rates 31.2% and 35.4%, respectively). At baseline, 2021 survey respondents were more likely to measure IGF-1 (96.0% vs 74.1%, p < 0.001) and morning cortisol (87.9% vs 62.6%, p < 0.001), and less likely GH (26.2% vs 42.6% p = 0.002), 24 h urine free cortisol (3.4% vs 23.2%, p < 0.0001) or dynamically assess adrenal reserve (11.4% vs 30.4%, p < 0.001). 47.2% of clinicians in 2021 would reassess pituitary function annually until discharge (in absence of tumour growth/symptoms). The 2021 survey respondents were more likely to stop imaging at or before 3 years (81.7% vs 44.3%, p < 0.001) and at or before 5 years (86.6.% vs 72.9%, p = 0.002), whilst 2009 survey respondents were more likely to continue imaging beyond 5 years (24% vs 7%, p < 0.001). Responses on imaging frequency/intervals showed notable variability in both surveys. CONCLUSIONS Diagnostic and management approaches for microNFPAs have evolved in the UK. Biochemical investigations are performed in accord with consensus guidelines, though many clinicians perform annual biochemical surveillance without tumour growth/symptoms. A small number of clinicians request imaging beyond 5 years, but the frequency of imaging intervals until discharge remains variable. Robust evidence on the long-term natural history of microNFPAs is necessary to unify clinician approach.
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Affiliation(s)
- Ross Hamblin
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, IBR Tower, Level 2, Birmingham, B15 2TT, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Athanasios Fountas
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, IBR Tower, Level 2, Birmingham, B15 2TT, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Miles Levy
- Department of Endocrinology, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Niki Karavitaki
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, IBR Tower, Level 2, Birmingham, B15 2TT, UK.
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK.
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
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11
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Zachariah MA, Bozer JJ, Cua S, Prevedello LM, Ghalib LM, Hardesty DA, Carrau RL, Kirschner LS, Prevedello DM. Intraoperative Prediction of Long-Term Remission in Acromegaly. Oper Neurosurg (Hagerstown) 2023; 24:74-79. [PMID: 36317950 DOI: 10.1227/ons.0000000000000421] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 07/14/2022] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND The features of long-term remission in acromegaly adenomectomy are incompletely understood. An intraoperative predictor for long-term outcome would be valuable for assessing resection of growth hormone (GH)-secreting tumors in real-time. OBJECTIVE To evaluate whether intraoperative GH measurement could predict long-term outcomes for acromegaly. METHODS In 47 patients, peripheral blood GH levels were measured thrice intraoperatively: once before tumor dissection, once during tumor dissection, and once after tumor dissection. Long-term remission was defined by age-appropriate, normalized insulin-like growth factor-1 at most recent follow-up and a random GH less than 1.0 ng/mL. Patients were only considered to be in long-term remission without the use of postoperative medical therapy for acromegaly or radiation therapy. RESULTS The median length of follow-up was 4.51 (range: 0.78-9.80) years. Long-term remission was achieved in 61.7% (29/47) of operations. Like previous studies, cavernous sinus invasion (odds ratio [OR]: 0.060; 95% CI: 0.014-0.260; P value < .01), suprasellar extension (OR: 0.191; 95% CI: 0.053-0.681; P value<.01), and tumor size greater than 1 cm (OR: 0.177; 95% CI: 0.003-0.917; P value = .03) were associated with not being in long-term remission. The minimum GH measured intraoperatively predicted long-term outcome (area under the curve: 0.7107; 95% CI: 0.537-0.884; P value < .01). The odds ratio of remission in patients with the lowest quartile minimum intraoperative GH compared with patients with the highest quartile minimum intraoperative GH was 27.0 (95% CI: 2.343-311.171; P value < .01). CONCLUSION Minimum intraoperative GH may predict long-term outcome for acromegaly, which in principle could provide the pituitary neurosurgeon with real-time feedback and inform intraoperative decision making.
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Affiliation(s)
- Marcus A Zachariah
- Department of Neurosurgery, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Jordan J Bozer
- College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Santino Cua
- College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Luciano M Prevedello
- Department of Neuroradiology, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Luma M Ghalib
- Department of Endocrinology, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Douglas A Hardesty
- Department of Neurosurgery, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Ricardo L Carrau
- Head and Neck Surgery, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Lawrence S Kirschner
- Department of Endocrinology, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Daniel M Prevedello
- Department of Neurosurgery, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
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12
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Yeom HG, Lee BD. McCune-Albright syndrome with acromegaly: A case report with characteristic radiographic features of fibrous dysplasia. Imaging Sci Dent 2022; 52:421-427. [PMID: 36605861 PMCID: PMC9807795 DOI: 10.5624/isd.20220825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 09/19/2022] [Accepted: 09/22/2022] [Indexed: 11/07/2022] Open
Abstract
McCune-Albright syndrome (MAS) is a rare multisystem disorder characterized by a clinical triad of polyostotic fibrous dysplasia (FD), skin pigmentation, and hyperfunctioning endocrinopathies. A 42-year-old man visited our medical hospital for the treatment of intermittent headaches and was diagnosed with MAS with acromegaly. This patient showed various clinical features of MAS, including pituitary adenoma, polyostotic FD, and hypogonadotropic hypogonadism. The FD lesions showed characteristic radiographic features, such as widespread, sclerotic bony lesions in the cranial bones, mixed radiolucent-radiopaque multilocular lesions in the mandible, and radiolucent lesions in the axial and appendicular skeleton. Over the years, the patient had been hospitalized multiple times due to accidental bony fractures associated with the fragile bony state of FD. This report presents a retrospective description of a case of MAS, with a review of the relevant literature.
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Affiliation(s)
- Han-Gyeol Yeom
- Department of Oral and Maxillofacial Radiology and Wonkwang Dental Research Institute, College of Dentistry, Wonkwang University, Iksan, Korea
| | - Byung-Do Lee
- Department of Oral and Maxillofacial Radiology and Wonkwang Dental Research Institute, College of Dentistry, Wonkwang University, Iksan, Korea
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13
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Луценко АС, Белая ЖЕ, Пржиялковская ЕГ, Лапшина АМ, Никитин АГ, Азизян ВН, Иващенко ОВ, Григорьев АЮ, Мельниченко ГА. [Short-term and long-term remission after endoscopic transnasal adenomectomy in patients with acromegaly]. PROBLEMY ENDOKRINOLOGII 2022; 68:67-75. [PMID: 36689713 PMCID: PMC9939963 DOI: 10.14341/probl13192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 12/05/2022] [Accepted: 12/05/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Neurosurgery is the most effective treatment for acromegaly. As most of the patients present with macroadenomas, surgical treatment is not always successful, even with the expert level of a neurosurgeon. Assessment of the postoperative remission rates in acromegaly preoperative predictors of treatment efficacy is an urgent task of modern research. AIM To assess the short-term and long-term remission of acromegaly after endoscopic transnasal adenomectomy in a tertiary medical center and assess preoperative predictors of the treatment effectiveness. MATERIALS AND METHODS A single-center, prospective, uncontrolled study was conducted. We included patients with active acromegaly who did not receive medical therapy with somatostatin analogues and were referred for endoscopic transsphenoidal adenomectomy. Plasma miRNA expression was assessed by quantitative reverse transcription PCR. Postoperative samples of adenomas were sent for study, with the determination of the immunohistochemical staining for somatostatin receptors 2 and 5 subtypes and morphology was performed on postoperative adenoma samples. RESULTS The study included 44 patients: 32.8% men, median age 47.0 [34.0; 55.0], IGF-1 744.75 ng/ml [548.83;889.85], growth hormone 9.5 ng/ml [4.94; 17.07]. Tumor volume 832 mm3 [419.25; 2532.38]. Early postoperative remission was achieved in 35 patients (79.5%). Patients who achieved short-term remission had higher IGF-1 and basal growth hormone levels. Median follow-up was 19.0 months [12.5;29.0]. Long-term remission was achieved in 61.4% (27 patients), no remission in 9 (20.5%), recurrency in 2 patients (4.5%), 6 patients were to follow-up (13.6%). In patients with long-term remission, we observed lower growth hormone and IGF-1 levels. No differences in miRNA expression was observesd. The predictive value of basal GH before surgery for long-term remission was assessed: area under the curve 0.811 (95% CI: 0.649; 0.973). A cut-off value of 15.55 ng/mL corresponded to a sensitivity of 70.0% (34.8%; 93.3%), a specificity of 85.7% (67.3%; 96.0%), an accuracy of 81.6% (65 .7%; 92.3%), PPV 63.6% (39.3%; 82.5%), NPV 88.9% (75.4%; 95.4%). CONCLUSION Rates of short-term and long-term remission after endoscopic transsphenoidal adenomectomy in our cohort is 79,5% и 61,4%, respectively, and is comparable with literature data for expert pituitary centers. Preoperative GH shows potential value in predicting the long-term remission of acromegaly, but further studies in a larger sample are needed to obtain more accurate cut-off values.
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Affiliation(s)
- А. С. Луценко
- Национальный медицинский исследовательский центр эндокринологии
| | - Ж. Е. Белая
- Национальный медицинский исследовательский центр эндокринологии
| | | | - А. М. Лапшина
- Национальный медицинский исследовательский центр эндокринологии
| | | | - В. Н. Азизян
- Национальный медицинский исследовательский центр эндокринологии
| | - О. В. Иващенко
- Национальный медицинский исследовательский центр эндокринологии
| | - А. Ю. Григорьев
- Национальный медицинский исследовательский центр эндокринологии
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14
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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: 57] [Impact Index Per Article: 28.5] [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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15
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Guo X, Zhang R, Zhang D, Wang Z, Gao L, Yao Y, Deng K, Bao X, Feng M, Xu Z, Yang Y, Lian W, Wang R, Ma W, Xing B. Determinants of immediate and long-term remission after initial transsphenoidal surgery for acromegaly and outcome patterns during follow-up: a longitudinal study on 659 patients. J Neurosurg 2022; 137:618-628. [PMID: 35171834 DOI: 10.3171/2021.11.jns212137] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 11/04/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Treatment outcomes following initial transsphenoidal surgery (TSS) for acromegaly are erratic. Identifying outcome patterns can assist in informing patients about possible treatment outcomes and planning for individualized adjuvant treatments in advance. In this study, the authors aimed to investigate the immediate and long-term endocrine remission rates following initial TSS for acromegaly, identify clinical determinants of treatment outcomes, and explore outcome patterns during a long-term follow-up and the pattern-specific patient features. METHODS This prospective, single-center, longitudinal cohort study enrolled patients with acromegaly who underwent TSS in the period from 2015 to 2018 at the authors' institution. Immediate remission, assessed on the 2nd postoperative morning, and long-term remission, assessed at least 18 months after TSS, were evaluated according to the strict 2010 consensus criteria (random growth hormone [GH] < 1 ng/ml or GH nadir < 0.4 ng/ml after oral glucose tolerance test, and age- and sex-normalized insulin-like growth factor 1). Univariate and bivariate regression analyses were used to identify determinants of remission. RESULTS A total of 659 patients with acromegaly (average age 42 years, 44% males) underwent TSS for pituitary adenomas (macroadenomas, 85%; invasive tumors, 35%) and were followed up during a median of 51 months. Immediate and long-term remission rates after initial TSS were 37% and 69%, respectively. Older age at diagnosis (OR 1.7), male sex (OR 1.6), smaller tumors (OR 2.0), noninvasive tumors (OR 4.8), and tumors positive for follicle-stimulating hormone/luteinizing hormone (OR 1.5) were predictors of immediate surgical remission. In addition to the above predictors, lower preoperative GH (OR 2.4), absence of preoperative central hypothyroidism (OR 2.6), and endoscopic TSS (OR 10.6) were predictors of long-term remission. Regression analyses revealed that endoscopic TSS (OR 2.8, 95% CI 1.524-5.291, p = 0.001), absence of cavernous sinus invasion (OR 4.1, 95% CI 2.522-6.613, p < 0.001), older age (OR 1.03, 95% CI 1.006-1.048, p = 0.013), and male sex (OR 2.0, 95% CI 1.224-3.247, p = 0.006) were independent determinants of long-term remission. Five outcome patterns were identified based on the changes in hormonal results during follow-up, including continuous remission (34%), refractory acromegaly (28%), delayed remission (21%), remission after adjuvant therapy (14%), and recurrence after initial remission (3%). The clinical characteristics of each subgroup were identified. CONCLUSIONS Cavernous sinus invasion, age at diagnosis, and sex are the best determinants of immediate and long-term remission after initial TSS for acromegaly. Endoscopic TSS predicts a higher long-term remission rate than that with microscopic TSS. The authors identified five outcome patterns in acromegaly and group-specific patient characteristics for clinical decision-making.
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Affiliation(s)
- Xiaopeng Guo
- 1Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing
- 2Key Laboratory of Endocrinology of Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing
- 3China Pituitary Disease Registry Center, Beijing
- 4China Pituitary Adenoma Specialist Council, Beijing; and
| | - Ruopeng Zhang
- 1Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing
- 2Key Laboratory of Endocrinology of Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing
- 5Peking Union Medical College, Tsinghua University, Beijing, China
| | - Duoxing Zhang
- 1Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing
- 2Key Laboratory of Endocrinology of Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing
- 5Peking Union Medical College, Tsinghua University, Beijing, China
| | - Zihao Wang
- 1Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing
- 2Key Laboratory of Endocrinology of Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing
- 3China Pituitary Disease Registry Center, Beijing
- 4China Pituitary Adenoma Specialist Council, Beijing; and
| | - Lu Gao
- 1Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing
- 2Key Laboratory of Endocrinology of Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing
- 3China Pituitary Disease Registry Center, Beijing
- 4China Pituitary Adenoma Specialist Council, Beijing; and
| | - Yong Yao
- 1Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing
- 2Key Laboratory of Endocrinology of Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing
- 3China Pituitary Disease Registry Center, Beijing
- 4China Pituitary Adenoma Specialist Council, Beijing; and
| | - Kan Deng
- 1Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing
- 2Key Laboratory of Endocrinology of Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing
- 3China Pituitary Disease Registry Center, Beijing
- 4China Pituitary Adenoma Specialist Council, Beijing; and
| | - Xinjie Bao
- 1Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing
- 2Key Laboratory of Endocrinology of Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing
- 3China Pituitary Disease Registry Center, Beijing
- 4China Pituitary Adenoma Specialist Council, Beijing; and
| | - Ming Feng
- 1Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing
- 2Key Laboratory of Endocrinology of Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing
- 3China Pituitary Disease Registry Center, Beijing
- 4China Pituitary Adenoma Specialist Council, Beijing; and
| | - Zhiqin Xu
- 1Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing
- 2Key Laboratory of Endocrinology of Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing
- 3China Pituitary Disease Registry Center, Beijing
- 4China Pituitary Adenoma Specialist Council, Beijing; and
| | - Yi Yang
- 1Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing
- 2Key Laboratory of Endocrinology of Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing
- 3China Pituitary Disease Registry Center, Beijing
- 4China Pituitary Adenoma Specialist Council, Beijing; and
| | - Wei Lian
- 1Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing
- 2Key Laboratory of Endocrinology of Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing
- 3China Pituitary Disease Registry Center, Beijing
- 4China Pituitary Adenoma Specialist Council, Beijing; and
| | - Renzhi Wang
- 1Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing
- 2Key Laboratory of Endocrinology of Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing
- 3China Pituitary Disease Registry Center, Beijing
- 4China Pituitary Adenoma Specialist Council, Beijing; and
| | - Wenbin Ma
- 1Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing
- 2Key Laboratory of Endocrinology of Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing
- 3China Pituitary Disease Registry Center, Beijing
- 4China Pituitary Adenoma Specialist Council, Beijing; and
| | - Bing Xing
- 1Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing
- 2Key Laboratory of Endocrinology of Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing
- 3China Pituitary Disease Registry Center, Beijing
- 4China Pituitary Adenoma Specialist Council, Beijing; and
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16
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Coopmans EC, van der Lely AJ, Neggers SJCMM. Approach to the Patient With Treatment-resistant Acromegaly. J Clin Endocrinol Metab 2022; 107:1759-1766. [PMID: 35090028 PMCID: PMC9315163 DOI: 10.1210/clinem/dgac037] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Indexed: 11/29/2022]
Abstract
Although most tumors in patients with acromegaly are benign and are cured or controlled by surgery and/or first-generation somatostatin receptor ligands therapy, some can behave more aggressively and are resistant to these standard therapies. Acromegaly, if left untreated, is a rare and chronic disorder, commonly caused by a GH-producing pituitary adenoma and is associated with significant comorbidities and an increased mortality. Transsphenoidal surgery is considered the mainstay of acromegaly management, but medical therapy has an increasingly important role. However, disease activity is not fully controlled in a significant number of patients treated with surgery and/or high-dose first-generation somatostatin receptor ligand monotherapy. In these circumstances, therefore, repeated surgery, second-line medical therapy, and radiotherapy, alone or combined as multimodal therapeutic strategies should be considered, in a patient-centered perspective.
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Affiliation(s)
- Eva C Coopmans
- Department of Medicine, Section Endocrinology, Pituitary Center Rotterdam, Erasmus University Medical Center, 3000 CA Rotterdam, the Netherlands
| | - Aart J van der Lely
- Department of Medicine, Section Endocrinology, Pituitary Center Rotterdam, Erasmus University Medical Center, 3000 CA Rotterdam, the Netherlands
| | - Sebastian J C M M Neggers
- Correspondence: S. Neggers, Erasmus University Medical Center Rotterdam, PO box 2040, 3000 CA Rotterdam, The Netherlands.
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17
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Ershadinia N, Tritos NA. Diagnosis and Treatment of Acromegaly: An Update. Mayo Clin Proc 2022; 97:333-346. [PMID: 35120696 DOI: 10.1016/j.mayocp.2021.11.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 10/16/2021] [Accepted: 11/04/2021] [Indexed: 01/01/2023]
Abstract
Acromegaly is typically caused by a growth hormone-secreting pituitary adenoma, driving excess secretion of insulin-like growth factor 1. Acromegaly may result in a variety of cardiovascular, respiratory, endocrine, metabolic, musculoskeletal, and neoplastic comorbidities. Early diagnosis and adequate treatment are essential to mitigate excess mortality associated with acromegaly. PubMed searches were conducted using the keywords growth hormone, acromegaly, pituitary adenoma, diagnosis, treatment, pituitary surgery, medical therapy, and radiation therapy (between 1981 and 2021). The diagnosis of acromegaly is confirmed on biochemical grounds, including elevated serum insulin-like growth factor 1 and lack of growth hormone suppression after glucose administration. Pituitary magnetic resonance imaging is advised in patients with acromegaly to identify an underlying pituitary adenoma. Transsphenoidal pituitary surgery is generally first-line therapy for patients with acromegaly. However, patients with larger and invasive tumors (macroadenomas) are often not in remission postoperatively. Medical therapies, including somatostatin receptor ligands, cabergoline, and pegvisomant, can be recommended to patients with persistent disease after surgery. Select patients may also be candidates for preoperative medical therapy. In addition, primary medical therapy has a role for patients without mass effect on the optic chiasm who are unlikely to be cured by surgery. Clinical, endocrine, imaging, histologic, and molecular markers may help predict the response to medical therapy; however, confirmation in prospective studies is needed. Radiation therapy is usually a third-line option and is increasingly administered by a variety of stereotactic techniques. An improved understanding of the pathogenesis of acromegaly may ultimately lead to the design of novel, efficacious therapies for this serious condition.
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Affiliation(s)
- Nazanin Ershadinia
- Neuroendocrine Unit and Neuroendocrine and Pituitary Tumor Clinical Center, Massachusetts General Hospital, Boston
| | - Nicholas A Tritos
- Neuroendocrine Unit and Neuroendocrine and Pituitary Tumor Clinical Center, Massachusetts General Hospital, Boston; Harvard Medical School, Boston, MA.
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Zanier O, Zoli M, Staartjes VE, Guaraldi F, Asioli S, Rustici A, Picciola VM, Pasquini E, Faustini-Fustini M, Erlic Z, Regli L, Mazzatenta D, Serra C. Machine learning-based clinical outcome prediction in surgery for acromegaly. Endocrine 2022; 75:508-515. [PMID: 34642894 PMCID: PMC8816764 DOI: 10.1007/s12020-021-02890-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Accepted: 09/08/2021] [Indexed: 11/13/2022]
Abstract
PURPOSE Biochemical remission (BR), gross total resection (GTR), and intraoperative cerebrospinal fluid (CSF) leaks are important metrics in transsphenoidal surgery for acromegaly, and prediction of their likelihood using machine learning would be clinically advantageous. We aim to develop and externally validate clinical prediction models for outcomes after transsphenoidal surgery for acromegaly. METHODS Using data from two registries, we develop and externally validate machine learning models for GTR, BR, and CSF leaks after endoscopic transsphenoidal surgery in acromegalic patients. For the model development a registry from Bologna, Italy was used. External validation was then performed using data from Zurich, Switzerland. Gender, age, prior surgery, as well as Hardy and Knosp classification were used as input features. Discrimination and calibration metrics were assessed. RESULTS The derivation cohort consisted of 307 patients (43.3% male; mean [SD] age, 47.2 [12.7] years). GTR was achieved in 226 (73.6%) and BR in 245 (79.8%) patients. In the external validation cohort with 46 patients, 31 (75.6%) achieved GTR and 31 (77.5%) achieved BR. Area under the curve (AUC) at external validation was 0.75 (95% confidence interval: 0.59-0.88) for GTR, 0.63 (0.40-0.82) for BR, as well as 0.77 (0.62-0.91) for intraoperative CSF leaks. While prior surgery was the most important variable for prediction of GTR, age, and Hardy grading contributed most to the predictions of BR and CSF leaks, respectively. CONCLUSIONS Gross total resection, biochemical remission, and CSF leaks remain hard to predict, but machine learning offers potential in helping to tailor surgical therapy. We demonstrate the feasibility of developing and externally validating clinical prediction models for these outcomes after surgery for acromegaly and lay the groundwork for development of a multicenter model with more robust generalization.
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Affiliation(s)
- Olivier Zanier
- Machine Intelligence in Clinical Neuroscience (MICN) Laboratory, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Matteo Zoli
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Programma Neurochirurgia Ipofisi-Pituitary Unit, Bologna, Italy
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
| | - Victor E Staartjes
- Machine Intelligence in Clinical Neuroscience (MICN) Laboratory, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Federica Guaraldi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Programma Neurochirurgia Ipofisi-Pituitary Unit, Bologna, Italy
| | - Sofia Asioli
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
- Azienda USL di Bologna, Anatomic Pathology Unit, Bologna, Italy
| | - Arianna Rustici
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), University of Bologna, Bologna, Italy
| | | | - Ernesto Pasquini
- Azienda USL di Bologna, Bellaria Hospital, ENT Unit, Bologna, Italy
| | - Marco Faustini-Fustini
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Programma Neurochirurgia Ipofisi-Pituitary Unit, Bologna, Italy
| | - Zoran Erlic
- Department of Endocrinology, Diabetology and Clinical Nutrition, University Hospital Zurich (USZ) and University of Zurich (UZH), Zurich, Switzerland
| | - Luca Regli
- Machine Intelligence in Clinical Neuroscience (MICN) Laboratory, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Diego Mazzatenta
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Programma Neurochirurgia Ipofisi-Pituitary Unit, Bologna, Italy
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
| | - Carlo Serra
- Machine Intelligence in Clinical Neuroscience (MICN) Laboratory, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland.
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Tomasik A, Stelmachowska-Banaś M, Maksymowicz M, Czajka-Oraniec I, Raczkiewicz D, Zieliński G, Kunicki J, Zgliczyński W. Clinical, hormonal and pathomorphological markers of somatotroph pituitary neuroendocrine tumors predicting the treatment outcome in acromegaly. Front Endocrinol (Lausanne) 2022; 13:957301. [PMID: 36187106 PMCID: PMC9523725 DOI: 10.3389/fendo.2022.957301] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 08/29/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Transsphenoidal adenomectomy (TSS) of somatotroph pituitary neuroendocrine tumor (PitNET) is the first-line treatment of acromegaly. Pharmacological treatment is recommended if surgery is contraindicated or did not lead to disease remission. The choice of treatment best fitting each patient should be based on thorough investigation of patients' characteristics. The current analysis attempts to create a tool for personalized treatment planning. AIM This study aimed to assess whether clinical, biochemical, imaging and pathological characteristics can predict surgical remission and response to first-generation somatostatin receptor ligands (SRLs) and pasireotide-LAR in acromegaly. PATIENTS AND METHODS A retrospective study of 153 acromegaly patients, treated in the Department of Endocrinology in Bielanski Hospital in Warsaw, Poland was performed. Data on demographics, hormonal and imaging results, pathological evaluation, and treatment outcome was extracted from the Polish Acromegaly Registry collecting information from 11 endocrinology centers in Poland and analyzed. RESULTS Patients with surgical remission had lower GH and IGF-1 concentrations at diagnosis (median GH 5.5 µg/L [IQR: 3.1-16.0] vs. 19.9 µg/L [IQR: 9.8-42.4], p=<0.001 and mean IGF-1 3.1xULN ± SD=1.2 vs. 3.7xULN ± SD=1.2, p=0.007, respectively) and smaller tumors (median 12.5mm [IQR: 9-19] vs. 23mm [IQR: 18-30], p<0.001). These tumors were more often densely granulated (DG) (73.2% vs. 40.0%, p=0.001) with positive staining for alpha-subunit (α-SU) (58.3% vs. 35.5%, p=0.021) and lower Ki-67 index (p=0.002). Patients responding well to SRLs were more often male (55.6% vs 44.4%, p=0.026), presented lower GH concentration (median GH 17.2 µg/L [IQR: 6.2-29.0] vs. 23.8 µg/L [IQR: 11.2-49.5], p=0.048) and had more often DG tumors (63.0% vs. 14.3%, p<0.001). No significant differences between good and poor-response to pasireotide-LAR groups were found. In multivariate logistic regression analysis fasting GH concentration <8.63 µg/L, maximal tumor diameter <15.5mm, normoprolactinemia and DG tumor turned out to be independent predictors of surgical remission (OR=0.92, p=0.026; OR=0.87, p=0.069, OR=3.86, p=0.096 and OR=3.05, p=0.181, respectively). Fasting GH concentration <36.6 µg/L and DG tumor turned out to be independent predictors of good response to first-generation SRLs (OR=0.96, p=0.06 and OR=10.68, p=0.002, respectively). CONCLUSIONS Younger age at diagnosis, male sex, lower GH, IGF-1 and PRL concentrations, smaller tumor size at diagnosis as well as positive α-SU staining, lower Ki-67 index and DG tumors predicted better treatment outcome in acromegaly patients.
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Affiliation(s)
- Agnieszka Tomasik
- Department of Endocrinology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Maria Stelmachowska-Banaś
- Department of Endocrinology, Centre of Postgraduate Medical Education, Warsaw, Poland
- *Correspondence: Maria Stelmachowska-Banaś,
| | - Maria Maksymowicz
- Department of Cancer Pathomorphology, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | | | - Dorota Raczkiewicz
- Department of Medical Statistics, School of Public Health, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Grzegorz Zieliński
- Department of Neurosurgery, Military Institute of Medicine, Warsaw, Poland
| | - Jacek Kunicki
- Department of Neurosurgery, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Wojciech Zgliczyński
- Department of Endocrinology, Centre of Postgraduate Medical Education, Warsaw, Poland
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20
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Biagetti B, Iglesias P, Villar-Taibo R, Moure MD, Paja M, Araujo-Castro M, Ares J, Álvarez-Escola C, Vicente A, Álvarez Guivernau È, Novoa-Testa I, Guerrero Perez F, Cámara R, Lecumberri B, García Gómez C, Bernabéu I, Manjón L, Gaztambide S, Cordido F, Webb SM, Menéndez-Torre EL, Díez JJ, Simó R, Puig-Domingo M. Factors associated with therapeutic response in acromegaly diagnosed in the elderly in Spain. Front Endocrinol (Lausanne) 2022; 13:984877. [PMID: 36187107 PMCID: PMC9523598 DOI: 10.3389/fendo.2022.984877] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 08/30/2022] [Indexed: 11/13/2022] Open
Abstract
CONTEXT Some reports suggest that acromegaly in elderly patients has a more benign clinical behavior and could have a better response to first-generation long-acting somatostatin receptor ligands (SRL). However, there is no specific therapeutic protocol for this special subgroup of patients. OBJECTIVE This study aimed at identifying predictors of response to SRL in elderly patients. DESIGN Multicentric retrospective nationwide study of patients diagnosed with acromegaly at or over the age of 65 years. RESULTS One-hundred and eighteen patients (34 men, 84 women, mean age at diagnosis 71.7 ± 5.4 years old) were included. Basal insulin-like growth factor type 1 (IGF-1) above the upper limit of normal (ULN) and growth hormone (GH) levels (mean ± SD) were 2.7 ± 1.4 and 11.0 ± 11.9 ng/ml, respectively. The mean maximal tumor diameter was 12.3 ± 6.4 mm, and up to 68.6% were macroadenoma. Seventy-two out of 118 patients (61.0%) underwent surgery as primary treatment. One-third of patients required first-line medical treatment due to a rejection of surgical treatment or non-suitability because of high surgical risk. After first-line surgery, 45/72 (63.9%) were in disease remission, and 16/34 (46.7%) of those treated with SRL had controlled disease. Patients with basal GH at diagnosis ≤6 ng/ml had lower IGF-1 levels and had smaller tumors, and more patients in this group reached control with SRL (72.7% vs. 33.3%; p < 0.04) [OR: 21.3, IC: 95% (2.4-91.1)], while male patients had a worse response [OR: 0.09, IC 95% (0.01-0.75)]. The predictive model curve obtained for SRL response showed an AUC of 0.82 CI (0.71-0.94). CONCLUSIONS The most frequent phenotype in newly diagnosed acromegaly in the elderly includes small adenomas and moderately high IGF-1 levels. GH at diagnosis ≤6 ng/ml and female gender, but not age per se, were associated with a greater chance of response to SRL.
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Affiliation(s)
- Betina Biagetti
- Endocrinology Department, Diabetes and Metabolism Research Unit, Vall d’Hebron University Hospital and Vall d’Hebron Research Institute (VHIR), Universidad Autónoma de Barcelona, Barcelona, Spain
- *Correspondence: Betina Biagetti, ; Manel Puig-Domingo,
| | - Pedro Iglesias
- Department of Endocrinology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
| | - Rocío Villar-Taibo
- Endocrinology Department, University Hospital of Santiago de Compostela, Neoplasia and Differentiation of Endocrine Cells Group, Instituto de Investigación Sanitaria-IDIS (Health Research Institute), Santiago de Compostela, Spain
| | - María-Dolores Moure
- Endocrinology Department, Cruces University Hospital, Biocruces Bizkaia, Endo-European Reference Networks (ERN), Barakaldo, Spain
- Neoplasia and Differentiation of Endocrine Cells Group, Instituto de Investigación Sanitaria-IDIS (Health Research Institute), Santiago de Compostela, Spain
| | - Miguel Paja
- Department of Endocrinology, Hospital Universitario Basurto, Bilbao, Spain
| | - Marta Araujo-Castro
- Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Jessica Ares
- Department of Endocrinology and Nutrition, Hospital Universitario Central de Asturias, Asturias, Spain
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Centro de Investigación Biomédica en Red Enfermedades Raras (CIBERER), Universidad de Oviedo, Oviedo, Spain
| | | | - Almudena Vicente
- Department of Endocrinology and Nutrition, Hospital Universitario de Toledo, Toledo, Spain
| | - Èlia Álvarez Guivernau
- Department of Endocrinology, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Hospital Sant Pau, Institut d’Investigacions Biomèdiques (IIB) SPau, Barcelona, Spain
- Department of Medicine, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Iria Novoa-Testa
- Endocrinology and Nutrition Department, A Coruña University Hospital and A Coruña University, A Coruña, Spain
| | - Fernando Guerrero Perez
- Department of Endocrinology, Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain
| | - Rosa Cámara
- Endocrinology and Nutrition Service, La Fe University Hospital, Valencia, Spain
| | - Beatriz Lecumberri
- Department of Endocrinology, Hospital Universitario La Paz, Madrid, Spain
| | - Carlos García Gómez
- Department of Endocrinology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
| | - Ignacio Bernabéu
- Endocrinology Department, University Hospital of Santiago de Compostela, Neoplasia and Differentiation of Endocrine Cells Group, Instituto de Investigación Sanitaria-IDIS (Health Research Institute), Santiago de Compostela, Spain
| | - Laura Manjón
- Department of Endocrinology and Nutrition, Hospital Universitario Central de Asturias, Asturias, Spain
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Centro de Investigación Biomédica en Red Enfermedades Raras (CIBERER), Universidad de Oviedo, Oviedo, Spain
| | - Sonia Gaztambide
- Endocrinology Department, Cruces University Hospital, Biocruces Bizkaia, Endo-European Reference Networks (ERN), Barakaldo, Spain
- Health Research Institute, Universidad País Vasco - Euskal Herriko Unibertsitatea (UPV-EHU), Centro de Investigación Biomédica en Red Enfermedades Raras (CIBERER), Centro de Investigación Biomédica en Red Diabetes y Enfermedades Metabólicas (CIBERDEM), Barakaldo, Spain
| | - Fernando Cordido
- Endocrinology and Nutrition Department, A Coruña University Hospital and A Coruña University, A Coruña, Spain
| | - Susan M. Webb
- Department of Endocrinology, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Hospital Sant Pau, Institut d’Investigacions Biomèdiques (IIB) SPau, Barcelona, Spain
- Department of Medicine, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Edelmiro Luis Menéndez-Torre
- Department of Endocrinology and Nutrition, Hospital Universitario Central de Asturias, Asturias, Spain
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Centro de Investigación Biomédica en Red Enfermedades Raras (CIBERER), Universidad de Oviedo, Oviedo, Spain
| | - Juan J. Díez
- Department of Endocrinology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
- Department of Medicine, Instituto de Investigación Sanitaria Puerta de Hierro Segovia de Arana, Universidad Autónoma de Madrid, Majadahonda, Spain
| | - Rafael Simó
- Endocrinology Department, Diabetes and Metabolism Research Unit, Vall d’Hebron University Hospital and Vall d’Hebron Research Institute (VHIR), Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Manel Puig-Domingo
- Endocrinology and Nutrition Service, Germans Trias Hospital and Research Institute, Autonomous University of Barcelona, Badalona, Spain
- *Correspondence: Betina Biagetti, ; Manel Puig-Domingo,
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21
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Goyal-Honavar A, Sarkar S, Asha HS, Kapoor N, Thomas R, Balakrishnan R, Chacko G, Chacko AG. Impact of Experience on Outcomes After Endoscopic Transsphenoidal Surgery for Acromegaly. World Neurosurg 2021; 151:e1007-e1015. [PMID: 34023462 DOI: 10.1016/j.wneu.2021.05.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 05/10/2021] [Accepted: 05/11/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Acromegaly is a syndrome of metabolic alterations secondary to increased growth hormone levels from a somatotroph pituitary adenoma. A multidisciplinary approach beginning with surgery, followed by adjuvant radiation or medical therapy for residual disease, is considered standard of care. Several factors affect the likelihood of remission after surgery, but the impact of surgical experience on remission rates has not been adequately assessed. METHODS Retrospective review of 203 patients, divided into 2 eras (era 1, 102 patients; era 2, 101 patients) of patients who underwent transsphenoidal surgery for acromegaly by a single surgeon over 11 years, was performed, determining the effect of surgical experience on rates of remission and various complications. Remission was defined according to the 2014 Endocrine Society Clinical Practice Guideline. RESULTS The rate of surgical remission was 40.6% (62.9% among noninvasive adenomas). Rates of surgical remission significantly improved in the latter half of this cohort (31.2% in the first half vs. 50% in the second half), despite other factors being comparable. On multivariate analysis, surgeon experience, cavernous sinus invasion, and preoperative growth hormone levels affected the rates of surgical remission. Rates of cerebrospinal fluid leak and hypopituitarism were lower in the second half, whereas resolution of acromegaly-associated comorbidities was increased. CONCLUSIONS We report, in this large single-surgeon review of endoscopically operated acromegaly cases, increased rates of surgical remission and reduced complications with increasing surgeon experience. The overall experience of the treating team in dealing with perioperative and intraoperative factors also contributes to improved outcomes.
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Affiliation(s)
| | - Sauradeep Sarkar
- Department of Neurosurgery, Christian Medical College, Vellore, Tamil Nadu, India
| | | | - Nitin Kapoor
- Department of Endocrinology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Regi Thomas
- Department of Otorhinolaryngology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Rajesh Balakrishnan
- Department of Radiation Oncology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Geeta Chacko
- Department of Pathology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Ari G Chacko
- Department of Neurosurgery, Christian Medical College, Vellore, Tamil Nadu, India. ]
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