1
|
Clemmons DR, Bidlingmaier M. IGF-I assay methods and biologic variability: evaluation of acromegaly treatment response. Eur J Endocrinol 2024; 191:R1-R8. [PMID: 38916798 DOI: 10.1093/ejendo/lvae065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 05/06/2024] [Accepted: 05/13/2024] [Indexed: 06/26/2024]
Abstract
Serum insulin-like growth factor (IGF-I) is the primary biochemical measure of disease activity in patients with acromegaly, and the 2014 Endocrine Society guidelines recommended normal age-adjusted serum IGF-I as the biochemical target of treatment. However, quantification and interpretation of IGF-I levels are subject to limitations that may affect therapeutic decisions. Techniques for measuring IGF-I have evolved greatly over the past 40 years and continue to do so. Results can vary substantially for different assays, procedures, and laboratories. For any assay, the interpretation of IGF-I values requires robust reference ranges. Using currently available large normative databases, the upper limit of normal (ULN) for IGF-I in middle-aged and elderly individuals is lower than historical reference ranges. Thus, the goal of achieving IGF-I < 1× ULN is more demanding than in the past, and some patients with acromegaly who were classified as "normal" (IGF-I < 1× ULN) in previous studies would be reclassified as above the ULN based on newer normative data. In addition, substantial intra-individual, week-to-week variation in serum IGF-I levels (unrelated to assay performance) has been observed. With changes over time in the measurement of IGF-I and the advent of updated reference ranges derived from large normative databases, it is difficult to justify rigid adherence to the goal of maintaining IGF-I below the ULN for all patients with acromegaly. Instead, symptoms, comorbidities, and quality of life should be considered, along with growth hormone and IGF-I levels, when evaluating the need for further treatment.
Collapse
Affiliation(s)
- David R Clemmons
- Department of Medicine, UNC School of Medicine, Chapel Hill, NC 27599, United States
| | - Martin Bidlingmaier
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich 81377, Germany
| |
Collapse
|
2
|
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: 20] [Impact Index Per Article: 20.0] [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.
Collapse
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.
| |
Collapse
|
3
|
Maroufi SF, Sabahi M, Aarabi SS, Samadian M, Dabecco R, Adada B, Arce KM, Borghei-Razavi H. Recurrent acromegaly: a systematic review on therapeutic approaches. BMC Endocr Disord 2024; 24:13. [PMID: 38279102 PMCID: PMC10811946 DOI: 10.1186/s12902-023-01533-w] [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: 05/01/2023] [Accepted: 12/15/2023] [Indexed: 01/28/2024] Open
Abstract
BACKGROUND AND OBJECTIVE Management of recurrent acromegaly is challenging for both neurosurgeons and endocrinologists. Several treatment options including repeat surgery, medical therapy, and radiation are offered for such patients. The efficacy of these modalities for the treatment of recurrence has not been studied previously in the literature. In this study, we aim to systematically review the existing cases of recurrence and come to a conclusion regarding the appropriate treatment in such cases. METHOD A systematic review was performed through PubMed, Scopus, Web of Science, and Cochrane database to identify studies reporting the treatment outcome of recurrent acromegaly patients. Using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, the included studies were reviewed for primary and secondary treatment, complications, and outcomes of the secondary treatment. RESULTS The systematic review retrieved 23 records with 95 cases of recurrent acromegaly. The mean time of recurrence was 4.16 years after the initial treatment. The most common primary treatment was surgery followed by radiotherapy. The remission rate was significantly higher in medical and radiotherapy compared to surgical treatment. CONCLUSION In cases of recurrent acromegaly, the patient may benefit more from radiotherapy and medical therapy compared to surgery. As the quality of evidence is low on this matter feature studies specifically designed for recurrent patients are needed.
Collapse
Affiliation(s)
- Seyed Farzad Maroufi
- Neurosurgery Research Network (NRN), Universal Scientific Education and Research Network (USERN), Tehran, Iran
- Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammadmahdi Sabahi
- Department of Neurological Surgery, Pauline Braathen Neurological Centre, Cleveland Clinic Florida, Weston, Florida, USA
| | - Seyed Sahab Aarabi
- Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Samadian
- Department of Neurosurgery, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Rocco Dabecco
- Department of Neurological Surgery, Pauline Braathen Neurological Centre, Cleveland Clinic Florida, Weston, Florida, USA
| | - Badih Adada
- Department of Neurological Surgery, Pauline Braathen Neurological Centre, Cleveland Clinic Florida, Weston, Florida, USA
| | - Karla M Arce
- Department of Endocrinology Diabetes and Metabolism, Cleveland Clinic Florida, Weston, Florida, USA
| | - Hamid Borghei-Razavi
- Department of Neurological Surgery, Pauline Braathen Neurological Centre, Cleveland Clinic Florida, Weston, Florida, USA.
- Department of Neurological Surgery, Pauline Braathen Neurological Centre, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA.
| |
Collapse
|
4
|
Araujo-Castro M, Rodríguez-Berrocal V, Dios E, Serramito R, Biagetti B, Bernabeu I. Executive summary of the expert consensus document from the Spanish Society of Neurosurgery and the Spanish Society of Endocrinology and Nutrition: Clinical recommendations on the perioperative management of pituitary tumors. ENDOCRINOL DIAB NUTR 2023; 70:592-608. [PMID: 37973522 DOI: 10.1016/j.endien.2023.11.001] [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: 04/19/2023] [Accepted: 06/28/2023] [Indexed: 11/19/2023]
Abstract
Pituitary tumors (PT) account for 15% of intracranial tumors affect 10.7%-14.4% of the population although the incidence of clinically relevant PT is 5.1 cases/100,000 inhabitants. Surgical treatment is indicated in PTs with hormone hypersecretion (except for prolactin-producing PTs) and those with local compressive or global neurological symptoms. Multidisciplinary care, is essential for patients with PTs, preferably delivered in a center of excellence and based on a well-defined care protocol. In order to facilitate and standardize the clinical procedures for this type of tumor, this document gathers the positioning of the Neuroendocrinology Knowledge Area of the Spanish Society of Endocrinology and Nutrition (SEEN) and the Spanish Society of Neurosurgery (SENEC) on the management of patients with PTs and their preoperative, surgical and postoperative follow-up.
Collapse
Affiliation(s)
- Marta Araujo-Castro
- Servicio de Endocrinología y Nutrición, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Universidad de Alcalá, Madrid, Spain
| | - Víctor Rodríguez-Berrocal
- Servicio de Neurocirugía, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Universidad de Alcalá, Madrid, Spain
| | - Elena Dios
- Unidad de Gestión Clínica de Endocrinología y Nutrición, Instituto de Biomedicina de Sevilla (IBIS), Hospital Virgen del Rocío, Consejo Superior de Investigaciones Científicas (CSIC), Universidad de Sevilla, Sevilla, Spain
| | - Ramon Serramito
- Servicio de Neurocirugía, Complejo Hospitalario Universitario de Santiago de Compostela, Instituto de Investigación Sanitaria, Santiago de Compostela, A Coruña, Spain
| | - Betina Biagetti
- Servicio de Endocrinología y Nutrición, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Ignacio Bernabeu
- Servicio de Endocrinología y Nutrición, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain.
| |
Collapse
|
5
|
Araujo-Castro M, Berrocal VR, Dios E, Serramito R, Biagetti B, Bernabeu I. Executive summary of the expert consensus document from the Spanish Society of Neurosurgery and the Spanish Society of Endocrinology and Nutrition: clinical recommendations on the perioperative management of pituitary tumors. NEUROCIRUGIA (ENGLISH EDITION) 2023; 34:292-307. [PMID: 37858619 DOI: 10.1016/j.neucie.2023.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 07/11/2023] [Indexed: 10/21/2023]
Abstract
Pituitary tumors (PT) account for 15% of intracranial tumors affect 10.7-14.4% of the population although the incidence of clinically relevant PT is 5.1 cases/100,000 inhabitants. Surgical treatment is indicated in PTs with hormone hypersecretion (except for prolactin-producing PTs) and those with local compressive or global neurological symptoms. Multidisciplinary care, is essential for patients with PTs, preferably delivered in a center of excellence and based on a well-defined care protocol. In order to facilitate and standardize the clinical procedures for this type of tumor, this document gathers the positioning of the Neuroendocrinology Knowledge Area of the Spanish Society of Endocrinology and Nutrition (SEEN) and the Spanish Society of Neurosurgery (SENEC) on the management of patients with PTs and their preoperative, surgical and postoperative follow-up.
Collapse
Affiliation(s)
- Marta Araujo-Castro
- Servicio de Endocrinología y Nutrición, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Universidad de Alcalá, Madrid, Spain
| | - Víctor Rodríguez- Berrocal
- Servicio de Neurocirugía, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Universidad de Alcalá, Madrid, Spain
| | - Elena Dios
- Unidad de Gestión Clínica de Endocrinología y Nutrición, Instituto de Biomedicina de Sevilla (IBIS), Hospital Virgen del Rocío, Consejo Superior de Investigaciones Científicas (CSIC), Universidad de Sevilla, Sevilla, Spain
| | - Ramon Serramito
- Servicio de Neurocirugía, Complejo Hospitalario Universitario de Santiago de Compostela, Instituto de Investigación Sanitaria, Santiago de Compostela, A Coruña, Spain
| | - Betina Biagetti
- Servicio de Endocrinología y Nutrición, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Ignacio Bernabeu
- Servicio de Endocrinología y Nutrición, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain.
| |
Collapse
|
6
|
Clemmons DR, Bidlingmaier M. Interpreting growth hormone and IGF-I results using modern assays and reference ranges for the monitoring of treatment effectiveness in acromegaly. Front Endocrinol (Lausanne) 2023; 14:1266339. [PMID: 38027199 PMCID: PMC10656675 DOI: 10.3389/fendo.2023.1266339] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 10/06/2023] [Indexed: 12/01/2023] Open
Abstract
Standard treatment for acromegaly focuses on the achievement of target absolute levels of growth hormone (GH) and insulin-like growth factor (IGF-I). The appropriateness of these targets when measured using modern assay methods is not well defined. This paper reviews biochemical status assessed using methods available at the time and associated clinical outcomes. GH measurements were shown to provide an indication of changes in tumor size, and failure of GH suppression after glucose stimulation is associated with tumor recurrence. IGF-I levels were more closely associated with changes in symptoms and signs. Reduced GH and IGF-I concentrations were shown to be associated with increased longevity, although the degree of increase has only been analyzed for GH. Lowering of GH and IGF-I has consistently been associated with improved outcomes; however, absolute levels reported in previous studies were based on results from methods and reference ranges that are now obsolete. Applying previously described absolute thresholds as targets (e.g. "normal" IGF-I level) when using current methods is best applied to those with active acromegaly symptoms who could benefit from further lowering of biochemical markers. In asymptomatic individuals with mild IGF-I or GH elevations, targeting biochemical "normalization" would result in the need for combination pharmacotherapy in many patients without proven benefit. Measurement of both GH and IGF-I remains an essential component of diagnosis and monitoring the effectiveness of treatment in acromegaly; however, treatment goals based only on previously identified absolute thresholds are not appropriate without taking into account the assay and reference ranges being employed. Treatment goals should be individualized considering biochemical improvement from an untreated baseline, symptoms of disease, risks, burdens and costs of complex treatment regimens, comorbidities, and quality of life.
Collapse
Affiliation(s)
- David R. Clemmons
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Martin Bidlingmaier
- Neuroendocrine Unit, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany
| |
Collapse
|
7
|
McKevitt C, Gabriel E, Marenco-Hillembrand L, Otamendi-Lopez A, Jeevaratnam S, Almeida JP, Samson S, Chaichana KL. Supervised machine learning to validate a novel scoring system for the prediction of disease remission of functional pituitary adenomas following transsphenoidal surgery. Sci Rep 2023; 13:15409. [PMID: 37717023 PMCID: PMC10505180 DOI: 10.1038/s41598-023-42157-3] [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: 06/05/2023] [Accepted: 09/06/2023] [Indexed: 09/18/2023] Open
Abstract
Functional pituitary adenomas (FPAs) are associated with hormonal hypersecretion resulting in systemic endocrinopathies and increased mortality. The heterogenous composition of the FPA population has made modeling predictive factors of postoperative disease remission a challenge. Here, we aim to define a novel scoring system predictive of disease remission following transsphenoidal surgery (TSS) for FPAs and validate our process using supervised machine learning (SML). 392 patients with FPAs treated at one of the three Mayo Clinic campuses were retrospectively reviewed. Variables found significant on multivariate analysis were incorporated into our novel Pit-SCHEME score. The Pit-SCHEME score with a cut-off value ≥ 6 achieved a sensitivity of 86% and positive likelihood ratio of 2.88. In SML models, without the Pit-SCHEME score, the k-nearest neighbor (KNN) model achieved the highest accuracy at 75.6%. An increase in model sensitivity was achieved with inclusion of the Pit-SCHEME score with the linear discriminant analysis (LDA) model achieving an accuracy of 86.9%, which suggests the Pit-SCHEME score is the variable of most importance for prediction of postoperative disease remission. Ultimately, these results support the potential clinical utility of the Pit-SCHEME score and its prospective future for aiding in the perioperative decision making in patients with FPAs.
Collapse
Affiliation(s)
- Chase McKevitt
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA.
| | - Ellie Gabriel
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Lina Marenco-Hillembrand
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Andrea Otamendi-Lopez
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Suren Jeevaratnam
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Joao Paulo Almeida
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Susan Samson
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Kaisorn L Chaichana
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| |
Collapse
|
8
|
Ul Huda Maria N, Sajjad F, Siddiq QA, Ul Ain Fatima N. Letter to the Editor. Remission of acromegaly after transsphenoidal surgery. J Neurosurg 2022; 137:901. [PMID: 35334456 DOI: 10.3171/2022.2.jns22291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
| | | | - Qurrat A Siddiq
- 3Postgraduate Medical Institute/Ameeruddin Medical College, Lahore, Pakistan
| | - Noor Ul Ain Fatima
- 4Institute of Developmental Sciences, University of Sussex, Brighton, United Kingdom
| |
Collapse
|
9
|
Maione L, Albrici C, Grunenwald S, Mouly C, Cimino V, Lecoq AL, Souberbielle JC, Caron P, Chanson P. IGF-I Variability Over Repeated Measures in Patients With Acromegaly Under Long-Acting Somatostatin Receptor Ligands. J Clin Endocrinol Metab 2022; 107:e3644-e3653. [PMID: 35772775 DOI: 10.1210/clinem/dgac385] [Citation(s) in RCA: 2] [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] [Received: 03/27/2022] [Indexed: 11/19/2022]
Abstract
CONTEXT In patients with acromegaly on long-term treatment with long-acting somatostatin receptor ligands (SRLs), the time of blood collection for IGF-I measurement after injection is not well defined. OBJECTIVE We aimed to assess serum IGF-I dynamics and variability in SRL-treated patients compared with surgically cured patients and healthy controls. METHODS Thirty patients under SRLs considered controlled based on a normal previous IGF-I level, 10 patients cured by pituitary surgery, and 7 healthy subjects underwent 4 weekly IGF-I determinations. RESULTS In SRL-treated patients, the IGF-I SDS (mean ± SD) was higher just before injection (0.34 ± 0.66) than at Day 7 (-0.33 ± 0.61; P = 0.0041) and Day 14 (-0.23 ± 0.60; P = 0.047) after injection, but it did not significantly vary in cured patients and healthy controls. The IGF-I CV was higher in SRL-treated patients than in cured patients or healthy controls (14.4 ± 7.6% vs 7.9 ± 4.4% and 8.3 ± 3.2%, respectively; P < 0.05 for both). Among SRL-treated patients, IGF-I CV was higher in "nonoptimally controlled patients"-i.e., patients with at least one elevated IGF-I value out of 4 (n = 9) compared with "optimally controlled" patients for whom all 4 IGF-I SDS values were < 2.0 (21.3 ± 9.3 vs 11.6 ± 6.0%; P = 0.0019). The latter did not differ from surgically cured patients and healthy controls. The measurement at the farthest distance from the SRL injection was the most predictive of patients with nonoptimally controlled disease. CONCLUSION In patients treated with long-acting SRLs, IGF-I sampling at the farthest distance from SRL injection is the most informative and best predictor of optimal disease control.
Collapse
Affiliation(s)
- Luigi Maione
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, 94275 Le Kremlin-Bicêtre, France
| | - Cristina Albrici
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, 94275 Le Kremlin-Bicêtre, France
| | - Solange Grunenwald
- Service d'Endocrinologie et Maladies métaboliques, Pôle Cardio-Vasculaire et Métabolique, CHU Larrey, 31059 Toulouse Cedex, France
| | - Céline Mouly
- Service d'Endocrinologie et Maladies métaboliques, Pôle Cardio-Vasculaire et Métabolique, CHU Larrey, 31059 Toulouse Cedex, France
| | - Vincenzo Cimino
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, 94275 Le Kremlin-Bicêtre, France
| | - Anne-Lise Lecoq
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, 94275 Le Kremlin-Bicêtre, France
| | - Jean Claude Souberbielle
- Assistance Publique-Hôpitaux de Paris Hôpital Necker-Enfants Malades, Département de Physiologie, 75015 Paris, France
| | - Philippe Caron
- Service d'Endocrinologie et Maladies métaboliques, Pôle Cardio-Vasculaire et Métabolique, CHU Larrey, 31059 Toulouse Cedex, France
| | - Philippe Chanson
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, 94275 Le Kremlin-Bicêtre, France
| |
Collapse
|
10
|
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.
Collapse
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.
| |
Collapse
|
11
|
Paragliola RM, Carrozza C, Corsello SM, Salvatori R. The biochemical diagnosis of acromegaly: revising the role of measurement of IGF-I and GH after glucose load in 5 questions. Expert Rev Endocrinol Metab 2022; 17:205-224. [PMID: 35485763 DOI: 10.1080/17446651.2022.2069558] [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: 12/13/2021] [Accepted: 04/20/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Acromegaly is a rare disorder characterized by the excessive secretion of growth hormone (GH), mostly caused by pituitary adenomas. While in full-blown cases the diagnosis is easy to establish, milder cases are more challenging. Additionally, establishing whether full cure after surgery is reached may be difficult. AREAS COVERED In this article, we will review the challenges posed by the variability in measurements of GH and its main effector insulin-like growth factor I (IGF-I) due to both biological changes, co-morbidities, and assays variability. EXPERT OPINION Interpretation of GH and IGF-I assays is important in establishing an early diagnosis of acromegaly, in avoiding misdiagnosis, and in establishing if cure is achieved by surgery. Physicians should be familiar with the variables that affect measurements of these 2 hormones, and with the performance of the assays available in their practice.
Collapse
Affiliation(s)
- Rosa Maria Paragliola
- Unit of Endocrinology, Department of Translational Medicine and Surgery - Universita' Cattolica del Sacro Cuore, Fondazione Policlinico "Gemelli", IRCCS, Rome, Italy
| | - Cinzia Carrozza
- Unit of Chemistry, Biochemistry and Clinical Molecular Biology - Università Cattolica Del Sacro Cuore, Fondazione Policlinico "Gemelli," IRCCS, Rome, Italy
| | - Salvatore M Corsello
- Unit of Endocrinology, Department of Translational Medicine and Surgery - Universita' Cattolica del Sacro Cuore, Fondazione Policlinico "Gemelli", IRCCS, Rome, Italy
- UniCamillus-Saint Camillus International University of Health Sciences, Rome, Italy
| | - Roberto Salvatori
- Division of Endocrinology Diabetes and Metabolism and Pituitary Center, Johns Hopkins University, Baltimore MD, USA
| |
Collapse
|
12
|
Donegan D, Algeciras-Schimnich A, Ashrafzadeh-Kian S, Erickson D. Insulin-Like Growth Factor 1 in the Early Postoperative Assessment of Acromegaly. Am J Clin Pathol 2022; 157:595-601. [PMID: 34665848 DOI: 10.1093/ajcp/aqab168] [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: 06/08/2021] [Accepted: 08/31/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Assessment of surgical outcome in acromegaly is typically recommended at 3 to 6 months following surgery. The purpose of this study was to determine if insulin-like growth factor 1 (IGF-1) concentrations at 6 weeks were equally predictive of surgical outcomes compared with IGF-1 concentrations at 3 to 6 months postoperatively applying newer IGF-1 assays. METHODS Retrospective review of patients with newly diagnosed acromegaly who had surgery between 2013 and 2020 and had postoperative IGF-1 measured by 6 weeks and 3 to 6 months. RESULTS At 6 weeks, 20 (35%) of the total 57 had normal IGF-1 and became abnormal in 1 at 3 to 6 months, whereas 37 (65%) of 57 had abnormal IGF-1 concentrations at 6 weeks, which normalized in 1 patient by 3 to 6 months. In patients who changed clinical status, IGF-1 at 6 weeks was within ±0.1-fold of normal. Although a difference was seen between median IGF-1 concentrations (286 vs 267 ng/mL, P = .009) at 6 weeks and 3 to 6 months, the mean reduction was small (-19.9 ng/mL). CONCLUSIONS Compared with 3 to 6 months, use of IGF-1 at 6 weeks was associated with a change in clinical status in 3.5% of patients. Therefore, in most patients, IGF-1 at 6 weeks can be used to assess clinical outcome via newer assays.
Collapse
Affiliation(s)
- Diane Donegan
- Department of Endocrinology Diabetes and Metabolism, Indiana University School of Medicine, Indianapolis, IN, USA
- Department of Endocrinology, Diabetes and Metabolism, Mayo College of Medicine, Rochester, MN, USA
| | | | | | - Dana Erickson
- Department of Endocrinology, Diabetes and Metabolism, Mayo College of Medicine, Rochester, MN, USA
| |
Collapse
|
13
|
Cambria V, Beccuti G, Prencipe N, Penner F, Gasco V, Gatti F, Romanisio M, Caputo M, Ghigo E, Zenga F, Grottoli S. First but not second postoperative day growth hormone assessments as early predictive tests for long-term acromegaly persistence. J Endocrinol Invest 2021; 44:2427-2433. [PMID: 33837920 PMCID: PMC8502138 DOI: 10.1007/s40618-021-01553-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 03/10/2021] [Indexed: 10/24/2022]
Abstract
PURPOSE Postoperative assessment of acromegaly activity is typically performed at least 3 months after neurosurgery (NS). Few studies have evaluated the use of early postoperative growth hormone (GH) levels as a test to predict short- and long-term remission of acromegaly. Our objective was to evaluate the diagnostic performance of serum random GH on a postoperative day one (D1-rGH) and two (D2-rGH), particularly in predicting long-term disease persistence. MATERIALS AND METHODS Forty-one subjects with acromegaly who were undergoing NS were enrolled (mean age ± SD 47.4 ± 13.1 years at diagnosis; women 54%; macroadenomas 71%). The final assessment of disease activity was performed one year after NS. ROC curves were used to evaluate the diagnostic performance of D1-rGH and D2-rGH. RESULTS After a 1-year follow-up, the overall remission rate was 55%. ROC analysis identified an optimal D1-rGH cut-off value of 2.1 ng/mL for diagnosing long-term disease persistence (55.6% SE; 90.9% SP). The cut-off point became 2.5 ng/mL after maximizing specificity for disease persistence (yielding a 100% positive predictive value) and 0.3 ng/mL after maximizing sensitivity for disease remission. The optimal D2-rGH cut-off value was 0.6 ng/mL (81.8% SE; 50% SP); the cut-off point became 2.9 ng/mL after maximizing specificity and 0.1 ng/mL after maximizing sensitivity, with no clinical utility. CONCLUSIONS D1-rGH could be a highly specific test for the early diagnosis of long-term acromegaly persistence, which is predicted by a value > 2.5 ng/mL with a great degree of certainty. The diagnostic performance of D2-rGH was insufficient. Further research is required to validate these preliminary results prior to modifying the postoperative management of acromegaly.
Collapse
Affiliation(s)
- V. Cambria
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126 Turin, Italy
| | - G. Beccuti
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126 Turin, Italy
| | - N. Prencipe
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126 Turin, Italy
| | - F. Penner
- Division of Neurosurgery, Department of Neurosciences “Rita Levi Montalcini”, University of Turin, Turin, Italy
| | - V. Gasco
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126 Turin, Italy
| | - F. Gatti
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126 Turin, Italy
| | - M. Romanisio
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126 Turin, Italy
| | - M. Caputo
- Division of Endocrinology, Department of Translational Medicine, University of Eastern Piedmont “Amedeo Avogadro”, Novara, Italy
| | - E. Ghigo
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126 Turin, Italy
| | - F. Zenga
- Division of Endocrinology, Department of Translational Medicine, University of Eastern Piedmont “Amedeo Avogadro”, Novara, Italy
| | - S. Grottoli
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126 Turin, Italy
| |
Collapse
|
14
|
Sakata K, Nagata Y, Takeshige N, Kikuchi J, Shikata M, Ashida K, Nomura M, Morioka M. Early postoperative prediction of both disease remission and long-term disease control in acromegaly using the oral glucose tolerance test. Hormones (Athens) 2021; 20:515-526. [PMID: 33738782 DOI: 10.1007/s42000-021-00281-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 03/07/2021] [Indexed: 12/18/2022]
Abstract
PURPOSE Transsphenoidal surgery (TSS) is the cornerstone of acromegaly treatment. Two biochemical parameters, growth hormone (GH) and insulin-like growth factor-1 (IGF-1) levels, sometimes diverge postoperatively; however, it is important to maintain disease control without further treatment, regardless of whether these parameters converge. This study investigated whether remission and long-term disease control could be predicted using early postoperative GH and IGF-1 levels. METHODS We reviewed 36 consecutive surgically treated patients with acromegaly. IGF-1 levels and minimum GH levels during an oral glucose tolerance test (OGTT) were evaluated at 2 weeks, as well as at 3 months postoperatively. After comparison between the remission and nonremission groups, we analyzed whether early postoperative parameters could predict remission and long-term disease control. RESULTS Twenty-five patients (69.4%, Group A) achieved remission within 1 year postoperatively. Of the remaining patients (median follow-up period, 53 months), seven (19.5%, Group B) maintained normal IGF-1 levels without treatment, whereas four (11.1%, Group C) required additional treatment. GH levels <1.5 ng/mL measured on the morning after surgery and nadir GH levels <0.7 ng/mL during the OGTT conducted at 2 weeks postoperatively were predictive of remission, with the latter demonstrating 95.2% sensitivity and 100% specificity. All group C patients had nadir GH levels ≥0.7 ng/mL during the OGTT and IGF-1 levels ≥SD +3 at 2 weeks postoperatively. CONCLUSION Early postoperative nadir GH levels during the OGTT and IGF-1 levels at 2 weeks postoperatively demonstrated excellent predictive value for both endocrinological remission and the necessity for additional treatment.
Collapse
Affiliation(s)
- Kiyohiko Sakata
- Department of Neurosurgery, Kurume University School of Medicine, Fukuoka, Japan.
| | - Yui Nagata
- Department of Neurosurgery, Kurume University School of Medicine, Fukuoka, Japan
| | - Nobuyuki Takeshige
- Department of Neurosurgery, Kurume University School of Medicine, Fukuoka, Japan
| | - Jin Kikuchi
- Department of Neurosurgery, Kurume University School of Medicine, Fukuoka, Japan
| | - Masato Shikata
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, Fukuoka, Japan
| | - Kenji Ashida
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, Fukuoka, Japan
| | - Masatoshi Nomura
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, Fukuoka, Japan
| | - Motohiro Morioka
- Department of Neurosurgery, Kurume University School of Medicine, Fukuoka, Japan
| |
Collapse
|
15
|
Jung IH, Choi S, Ku CR, Lee SG, Lee EJ, Kim SH, Kim EH. Revisiting the Role of Insulin-like Growth Factor-1 Measurement After Surgical Treatment of Acromegaly. J Clin Endocrinol Metab 2021; 106:e2589-e2599. [PMID: 33738470 DOI: 10.1210/clinem/dgab186] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Indexed: 11/19/2022]
Abstract
CONTEXT In the management of growth hormone (GH)-secreting pituitary adenomas, the oral glucose tolerance test (OGTT) has been the gold standard not only for diagnoses but also for the determination of biochemical remission. Insulin-like growth factor-1 (IGF-1) is an essential biomarker, although it should be adjusted for both age and sex. OBJECTIVE We evaluated whether IGF-1 levels could serve as a reliable alternative to an OGTT for disease monitoring after the surgical treatment of acromegaly. We retrospectively reviewed the medical records of 320 patients who underwent surgical resection of their GH-secreting pituitary tumors at the Severance hospital. Receiver operator characteristic (ROC) analyses were performed to validate the accuracy of IGF-1 levels for the assessment of remission. In addition, regression analyses were performed to identify factors associated with discrepancy between OGTT and IGF-1 levels. RESULTS Except for 1 week after surgery, ROC analyses showed an area under the curve of greater than 0.8 for IGF-1 at all time points. Of 320 patients, 270 achieved endocrine remission after surgery alone. Among these patients, IGF-1 levels were normalized in 250 patients. The mean duration from surgery to IGF-1 normalization was 4.7 months. Regression analyses demonstrated that risk of failed IGF-1 normalization was increased by 3.1-fold when the tumor invaded the cavernous sinus and increased by 9.0-fold in patients with incomplete tumor removal. CONCLUSION IGF-1 level is a reliable alternative to OGTT and plays a valuable role in monitoring acromegaly status.
Collapse
Affiliation(s)
- In-Ho Jung
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul,Republic of Korea
| | - Seonah Choi
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul,Republic of Korea
| | - Cheol Ryong Ku
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
- Pituitary Tumor Center, Severance Hospital, Seoul, Republic of Korea
- Yonsei Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sang-Guk Lee
- Department of Laboratory Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Eun Jig Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
- Pituitary Tumor Center, Severance Hospital, Seoul, Republic of Korea
- Yonsei Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sun Ho Kim
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul,Republic of Korea
- Department of Neurosurgery, Ewha Woman's University College of Medicine, Seoul, Republic of Korea
| | - Eui Hyun Kim
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul,Republic of Korea
- Pituitary Tumor Center, Severance Hospital, Seoul, Republic of Korea
- Yonsei Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| |
Collapse
|
16
|
Wang YY, Waqar M, Abou-Zeid A, Kearney T, Caputo C, Davis J, Trainer P, Higham C, Roncaroli F, Gnanalingham KK. Value of Early Post-Operative Growth Hormone Testing in Predicting Long-Term Remission and Residual Disease after Transsphenoidal Surgery for Acromegaly. Neuroendocrinology 2021; 112:345-357. [PMID: 34052822 DOI: 10.1159/000517476] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 05/18/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Surgical remission for acromegaly is dependent on a number of factors including tumour size, invasiveness, and surgical expertise. We studied the value of early post-operative growth hormone (GH) level as a predictor of outcome and to guide early surgical re-exploration for residual disease in patients with acromegaly. METHODS Patients with acromegaly undergoing first-time endoscopic transsphenoidal surgery between 2005 and 2015, in 2 regional neurosurgical centres, were studied. Insulin-like growth factor-1 (IGF-1), basal GH (i.e., sample before oral glucose), and GH nadir on oral glucose tolerance test (OGTT) were tested at various time points, including 2-5 days post-operatively. Definition of disease remission was according to the 2010 consensus statement (i.e., GH nadir <0.4 μg/L during an OGTT and normalized population-matched IGF-1). Forward stepwise logistic regression was used to determine factors associated with remission. RESULTS We investigated 81 consecutive patients with acromegaly, 67 (83%) of which had macroadenomas and 22 (27%) were noted to be invasive at surgery. Mean follow-up was 44 ± 25 months. Overall, surgical remission was achieved in 55 (68%) patients at final follow-up. On univariate analysis, the remission rates at the end of the study period for patients with early post-operative GH nadir on OGTT of <0.4 (N = 43), between 0.4 and 1 (N = 28), and >1 μg/L (N = 8) were 88, 54, and 20%, respectively. Similar results were seen with basal GH on early post-operative OGTT. On multivariate regression analysis, pre-operative IGF-1 (odds ratio of 13.1) and early post-operative basal GH (odds ratio of 5.0) and GH nadir on OGTT (odds ratio of 6.8) were significant predictors of residual disease. Based on a raised early GH nadir and post-operative MR findings, 10 patients underwent early surgical re-exploration. There was reduction in post-operative GH levels in 9 cases, of which 5 (50%) achieved long-term remission. There was an increased risk of new pituitary hormone deficiencies in patients having surgical re-exploration compared to those having a single operation (60 vs. 14%). CONCLUSIONS An early post-operative basal GH and GH nadir on OGTT are reliable predictors of long-term disease remission. It can be used to guide patients for early surgical re-exploration for residual disease, although there is increased risk of hypopituitarism.
Collapse
Affiliation(s)
- Yi Yuen Wang
- Departments of Neurosurgery, Greater Manchester Neurosciences Centre, Salford Royal Foundation Trust (SRFT), Manchester Academic Health Sciences Centre, Manchester, UK
- Department of Neurosurgery, The University of Melbourne, St Vincent's Hospital, Fitzroy, Victoria, Australia
| | - Mueez Waqar
- Departments of Neurosurgery, Greater Manchester Neurosciences Centre, Salford Royal Foundation Trust (SRFT), Manchester Academic Health Sciences Centre, Manchester, UK,
- Division of Neuroscience and Experimental Psychology, School of Biology, Faculty of Biology, Medicine and Health, Geoffrey Jefferson Brain Research Centre, University of Manchester, Manchester, UK,
| | - Ahmed Abou-Zeid
- Departments of Neurosurgery, Greater Manchester Neurosciences Centre, Salford Royal Foundation Trust (SRFT), Manchester Academic Health Sciences Centre, Manchester, UK
- Department of Neurosurgery, Ain Shams University, Cairo, Egypt
| | - Tara Kearney
- Department of Endocrinology, Greater Manchester Neurosciences Centre, Salford Royal Foundation Trust (SRFT), Manchester Academic Health Sciences Centre, Manchester, UK
| | - Carmela Caputo
- Department of Endocrinology, The University of Melbourne, St Vincent's Hospital, Fitzroy, Victoria, Australia
| | - Julian Davis
- Department of Endocrinology, Manchester University NHS Foundation Trust, and Faculty of Biology, Medicine & Health, Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
| | - Peter Trainer
- Department of Endocrinology, The Christie Hospital, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Claire Higham
- Department of Endocrinology, The Christie Hospital, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Federico Roncaroli
- Division of Neuroscience and Experimental Psychology, School of Biology, Faculty of Biology, Medicine and Health, Geoffrey Jefferson Brain Research Centre, University of Manchester, Manchester, UK
| | - Kanna K Gnanalingham
- Departments of Neurosurgery, Greater Manchester Neurosciences Centre, Salford Royal Foundation Trust (SRFT), Manchester Academic Health Sciences Centre, Manchester, UK
| |
Collapse
|
17
|
Freda PU, Bruce JN, Reyes-Vidal C, Singh S, DeLeon Y, Jin Z, Khandji AG, Cremers S, Post KD. Prognostic value of nadir GH levels for long-term biochemical remission or recurrence in surgically treated acromegaly. Pituitary 2021; 24:170-183. [PMID: 33124000 PMCID: PMC7969360 DOI: 10.1007/s11102-020-01094-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/08/2020] [Indexed: 11/25/2022]
Abstract
CONTEXT Outcome of acromegaly surgery is assessed by IGF-1 and glucose-suppressed GH, but whether the latter provides additional clinically relevant information when IGF-1 is normal is unclear. The role of GH suppression testing after surgery requires clarification. METHODS We studied 97 acromegaly patients with normal IGF-1 after surgery by measuring GH after oral glucose longitudinally, initially at ≥ 3 months after surgery and repeated one or more times ≥ 1 year later. Nadir GH was categorized as normal or abnormal relative to the 97.5th percentile of nadir GH in 100 healthy subjects, which were ≤ 0.14 µg/L (DSL IRMA) or ≤ 0.15 µg/L(IDS iSYS). Signs and symptoms scores and insulin resistance were followed longitudinally. RESULTS Of 68 patients with initial normal GH suppression 63 (93%) remained in remission and of 29 with initial abnormal GH suppression, 9 (31%) recurred. Recurrence was more common in patients with abnormal suppression (P < 0.001). A total of 14 patients recurred, including 5 with normal GH suppression progressing to abnormal and then recurrence. Overall, serial signs and symptoms and insulin resistance assessments did not identify patients with abnormal suppression or recurrence. CONCLUSION Risk of recurrence after surgery is increased for patients with a normal IGF-1 level, but abnormal GH suppression. We newly find, using both our and others' cut-offs, that while normal suppression predicts long-term remission in most patients, some can progress from normal to abnormal suppression and then recurrence after many years of follow up. Nadir GH levels are of prognostic value in acromegaly patients with normal IGF-1 levels after surgery.
Collapse
Affiliation(s)
- Pamela U Freda
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, 650 West 168th Street, Rm.1014, New York, NY, 10032, USA.
| | - Jeffrey N Bruce
- Department of Neurosurgery, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Carlos Reyes-Vidal
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, 650 West 168th Street, Rm.1014, New York, NY, 10032, USA
| | - Simran Singh
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, 650 West 168th Street, Rm.1014, New York, NY, 10032, USA
| | - Yessica DeLeon
- Department of Pathology and Cell Biology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Zhezhen Jin
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Alexander G Khandji
- Department of Radiology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Serge Cremers
- Department of Pathology and Cell Biology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Kalmon D Post
- Department of Neurosurgery, Mount Sinai School of Medicine, New York, NY, USA
| |
Collapse
|
18
|
Fleseriu M, Biller BMK, Freda PU, Gadelha MR, Giustina A, Katznelson L, Molitch ME, Samson SL, Strasburger CJ, van der Lely AJ, Melmed S. A Pituitary Society update to acromegaly management guidelines. Pituitary 2021; 24:1-13. [PMID: 33079318 PMCID: PMC7864830 DOI: 10.1007/s11102-020-01091-7] [Citation(s) in RCA: 139] [Impact Index Per Article: 46.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/28/2020] [Indexed: 02/06/2023]
Abstract
Guidelines and consensus statements ensure that physicians managing acromegaly patients have access to current information on evidence-based treatments to optimize outcomes. Given significant novel recent advances in understanding acromegaly natural history and individualized therapies, the Pituitary Society invited acromegaly experts to critically review the current literature in the context of Endocrine Society guidelines and Acromegaly Consensus Group statements. This update focuses on how recent key advances affect treatment decision-making and outcomes, and also highlights the likely role of recently FDA-approved therapies as well as novel combination therapies within the treatment armamentarium.
Collapse
Affiliation(s)
- Maria Fleseriu
- Pituitary Center, Departments of Medicine and Neurological Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Beverly M K Biller
- Neuroendocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Pamela U Freda
- Department of Medicine, Columbia University, Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Monica R Gadelha
- Neuroendocrinology Research Center/Endocrinology Section, Medical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal Do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Andrea Giustina
- Institute of Endocrine and Metabolic Sciences, San Raffaele Vita-Salute University and IRCCS San Raffaele Hospital, Milan, Italy
| | - Laurence Katznelson
- Departments of Medicine and Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Mark E Molitch
- Division of Endocrinology, Metabolism & Molecular Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Susan L Samson
- Pituitary Center, Departments of Medicine and Neurosurgery, Baylor College of Medicine, Houson, TX, USA
| | - Christian J Strasburger
- Department of Medicine for Endocrinology, Diabetes and Nutritional Medicine, Charité Universitätsmedizin, Berlin, Germany
| | - A J van der Lely
- Pituitary Center Rotterdam, Endocrinology Section, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Shlomo Melmed
- Pituitary Center, Cedars-Sinai Medical Center, 8700 Beverly Blvd., Room 2015, Los Angeles, CA, 90048, USA.
| |
Collapse
|
19
|
Cardinal T, Collet C, Wedemeyer M, Singer PA, Weiss M, Zada G, Carmichael JD. Postoperative GH and Degree of Reduction in IGF-1 Predicts Postoperative Hormonal Remission in Acromegaly. Front Endocrinol (Lausanne) 2021; 12:743052. [PMID: 34867787 PMCID: PMC8637049 DOI: 10.3389/fendo.2021.743052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 09/30/2021] [Indexed: 11/13/2022] Open
Abstract
PURPOSE Determine predictive factors for long-term remission of acromegaly after transsphenoidal resection of growth hormone (GH)-secreting pituitary adenomas. METHODS We identified 94 patients who had undergone transsphenoidal resection of GH-secreting pituitary adenomas for treatment of acromegaly at the USC Pituitary Center from 1999-2019 to determine the predictive value of postoperative endocrine lab values. RESULTS Patients underwent direct endoscopic endonasal (60%), microscopic transsphenoidal (38%), and extended endoscopic approaches (2%). The cohort was 63% female and 37% male, with average age of 48.9 years. Patients presented with acral enlargement (72, 77%), macroglossia (40, 43%), excessive sweating (39, 42%), prognathism (38, 40%) and frontal bossing (35, 37%). Seventy-five (80%) were macroadenomas and 19 (20%) were microadenomas. Cavernous sinus invasion was present in 45%. Available immunohistochemical data demonstrated GH staining in 88 (94%) and prolactin in 44 (47%). Available postoperative MRI demonstrated gross total resection in 63% of patients and subtotal resection in 37%. Most patients (66%) exhibited hormonal remission at 12 weeks postoperatively. Receiver operating characteristic (ROC) curves demonstrated postoperative day 1 (POD1) GH levels ≥1.55ng/mL predicted failure to remit from surgical resection alone (59% specificity, 75% sensitivity). A second ROC curve showed decrease in corrected insulin-like growth factor-1 (IGF-1) levels of at least 37% prognosticated biochemical control (90% sensitivity, 80% specificity). CONCLUSION POD1 GH and short-term postoperative IGF-1 levels can be used to successfully predict immediate and long-term hormonal remission respectively. A POD1 GH cutoff can identify patients likely to require adjuvant therapy to emphasize clinical follow-up.
Collapse
Affiliation(s)
- Tyler Cardinal
- University of Southern California (USC) Pituitary Center, Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, CA, United States
- *Correspondence: Tyler Cardinal,
| | - Casey Collet
- University of Southern California (USC) Pituitary Center, Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, CA, United States
| | - Michelle Wedemeyer
- University of Southern California (USC) Pituitary Center, Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, CA, United States
| | - Peter A. Singer
- University of Southern California (USC) Pituitary Center, Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, CA, United States
- Department of Medicine, Division of Endocrinology and Diabetes, Keck School of Medicine of University of Southern California, Los Angeles, CA, United States
| | | | - Gabriel Zada
- University of Southern California (USC) Pituitary Center, Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, CA, United States
| | - John D. Carmichael
- University of Southern California (USC) Pituitary Center, Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, CA, United States
- Department of Medicine, Division of Endocrinology and Diabetes, Keck School of Medicine of University of Southern California, Los Angeles, CA, United States
| |
Collapse
|
20
|
Giustina A, Barkhoudarian G, Beckers A, Ben-Shlomo A, Biermasz N, Biller B, Boguszewski C, Bolanowski M, Bollerslev J, Bonert V, Bronstein MD, Buchfelder M, Casanueva F, Chanson P, Clemmons D, Fleseriu M, Formenti AM, Freda P, Gadelha M, Geer E, Gurnell M, Heaney AP, Ho KKY, Ioachimescu AG, Lamberts S, Laws E, Losa M, Maffei P, Mamelak A, Mercado M, Molitch M, Mortini P, Pereira AM, Petersenn S, Post K, Puig-Domingo M, Salvatori R, Samson SL, Shimon I, Strasburger C, Swearingen B, Trainer P, Vance ML, Wass J, Wierman ME, Yuen KCJ, Zatelli MC, Melmed S. Multidisciplinary management of acromegaly: A consensus. Rev Endocr Metab Disord 2020; 21:667-678. [PMID: 32914330 PMCID: PMC7942783 DOI: 10.1007/s11154-020-09588-z] [Citation(s) in RCA: 176] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/01/2020] [Indexed: 12/18/2022]
Abstract
The 13th Acromegaly Consensus Conference was held in November 2019 in Fort Lauderdale, Florida, and comprised acromegaly experts including endocrinologists and neurosurgeons who considered optimal approaches for multidisciplinary acromegaly management. Focused discussions reviewed techniques, results, and side effects of surgery, radiotherapy, and medical therapy, and how advances in technology and novel techniques have changed the way these modalities are used alone or in combination. Effects of treatment on patient outcomes were considered, along with strategies for optimizing and personalizing therapeutic approaches. Expert consensus recommendations emphasize how best to implement available treatment options as part of a multidisciplinary approach at Pituitary Tumor Centers of Excellence.
Collapse
Affiliation(s)
- Andrea Giustina
- Institute of Endocrine and Metabolic Sciences, San Raffaele Vita-Salute University, IRCCS San Raffaele Hospital, Ospedale San Raffaele, Via Olgettina, 58, 20132, Milan, Italy.
| | - Garni Barkhoudarian
- Pacific Pituitary Disorders Center, Pacific Neuroscience Institute, Santa Monica, CA, USA
| | - Albert Beckers
- Department of Endocrinology, University of Liège, Liège, Belgium
| | - Anat Ben-Shlomo
- Pituitary Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Nienke Biermasz
- Division of Endocrinology and Center for Endocrine Tumors, Department of Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Beverly Biller
- Neuroendocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Cesar Boguszewski
- SEMPR, Endocrine Division, Department of Internal Medicine, Federal University of Parana, Curitiba, Brazil
| | - Marek Bolanowski
- Department of Endocrinology, Diabetes and Isotope Therapy, Wroclaw Medical University, Wroclaw, Poland
| | - Jens Bollerslev
- Section of Specialized Endocrinology, Department of Endocrinology, University of Oslo, Oslo, Norway
| | - Vivien Bonert
- Pituitary Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Marcello D Bronstein
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, Hospital das Clinicas, University of Sao Paulo, Sao Paulo, Brazil
| | - Michael Buchfelder
- Department of Neurosurgery, University Hospital Erlangen, Erlangen, Germany
| | - Felipe Casanueva
- Division of Endocrinology, Santiago de Compostela University and Ciber OBN, Santiago de Compostela, Spain
| | - Philippe Chanson
- Centre de Référence des Maladies Rares de l'Hypophyse and Université Paris-Saclay, Univ. Paris-Sud, Inserm, Signalisation Hormonale, Physiopathologie Endocrinienne et Métabolique, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Le Kremlin-Bicêtre, Paris, France
| | - David Clemmons
- Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Maria Fleseriu
- Departments of Medicine and Neurological Surgery, Pituitary Center, Oregon Health & Science University, Portland, Oregon, USA
| | - Anna Maria Formenti
- Institute of Endocrine and Metabolic Sciences, San Raffaele Vita-Salute University, IRCCS San Raffaele Hospital, Ospedale San Raffaele, Via Olgettina, 58, 20132, Milan, Italy
| | - Pamela Freda
- Department of Medicine, Columbia University, Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Monica Gadelha
- Neuroendocrinology Research Center/Endocrinology Section, Medical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Eliza Geer
- Multidisciplinary Pituitary and Skull Base Tumor Center, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Mark Gurnell
- Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge and NIHR Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge, UK
| | - Anthony P Heaney
- Division of Endocrinology, Diabetes and Hypertension, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Ken K Y Ho
- The Garvan Institute of Medical Research, St. Vincent's Hospital, University of New South Wales, Sydney, Australia
| | - Adriana G Ioachimescu
- Department of Neurosurgery and Medicine, Division of Endocrinology, Metabolism and Lipids, Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA
| | | | - Edward Laws
- Pituitary/Neuroendocrine Center, Brigham & Women's Hospital, Boston, MA, USA
| | - Marco Losa
- Department of Neurosurgery, San Raffaele University Health Institute Milan, Milan, Italy
| | - Pietro Maffei
- Department of Medicine, Padua University Hospital, Padua, Italy
| | - Adam Mamelak
- Pituitary Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Moises Mercado
- Medical Research Unit in Endcrine Diseases, Hospital de Especialidades, Centro Médico Nacional, Siglo XXI, IMSS, Facultad de Medicina, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - Mark Molitch
- Division of Endocrinology, Metabolism & Molecular Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Pietro Mortini
- Department of Neurosurgery, San Raffaele University Health Institute Milan, Milan, Italy
| | - Alberto M Pereira
- Division of Endocrinology and Center for Endocrine Tumors, Department of Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Kalmon Post
- Department of Neurosurgery, Medicine, Mount Sinai Health System, New York, NY, USA
| | - Manuel Puig-Domingo
- Germans Trias i Pujol Research Institute, Universitat Autònoma de Barcelona, Badalona, Barcelona, Spain
| | - Roberto Salvatori
- Division of Endocrinology, Diabetes, and Metabolism and Pituitary Center, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Susan L Samson
- Departments of Medicine and Neurosurgery, Baylor St. Luke's Pituitary Center, Baylor College of Medicine, Houson, TX, USA
| | - Ilan Shimon
- Endocrine Institute, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
| | - Christian Strasburger
- Department of Medicine for Endocrinology, Diabetes and Nutritional Medicine, Charité Universitätsmedizin, Berlin, Germany
| | - Brooke Swearingen
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA
| | - Peter Trainer
- Department of Endocrinology, The Christie NHS Foundation Trust, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Mary L Vance
- Department of Medicine, University of Virginia, Charlottesville, VA, USA
| | - John Wass
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, UK
| | - Margaret E Wierman
- Pituitary, Adrenal and Neuroendocrine Tumor Program, Department of Medicine, University of Colorado Anschutz Medical Center, Aurora, CO, USA
| | - Kevin C J Yuen
- Barrow Pituitary Center and Neuroendocrinology Clinic, Barrow Neurological Institute, University of Arizona College of Medicine, Creighton School of Medicine, Phoenix, AZ, USA
| | - Maria Chiara Zatelli
- Section of Endocrinology & Internal Medicine, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Shlomo Melmed
- Pituitary Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| |
Collapse
|
21
|
Tsiberkin AI, Tsoy UA, Cherebillo VY, Polezhaev AV, Kuritsyna NV, Paltsev AA, Alkhazishvili AV, Grineva EN. [Early postoperative measurement of growth hormone level for prognosis of surgical outcomes in acromegaly]. TERAPEVT ARKH 2020; 92:48-53. [PMID: 33346479 DOI: 10.26442/00403660.2020.10.000490] [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: 11/23/2020] [Accepted: 11/23/2020] [Indexed: 11/22/2022]
Abstract
AIM To investigate the value of 24 hours post-surgery measurement of growth hormone (GH) level for prognosis of surgical outcomes in acromegaly. MATERIALS AND METHODS A prospective cohort study included 45 patients with newly diagnosed acromegaly. The degree of parasellar extension was measured on the preoperative sellar magnetic resonance imaging according to the Knosps classification. All patients underwent a transsphenoid adenomectomy performed by one neurosurgeon. Basal GH level was measured at 24 hours after surgery. The efficacy of transsphenoidal adenomectomy evaluated at 12 months after surgery. RESULTS Acromegaly remission was achieved in 19 (42%) of 45 patients at 12 months after surgery. Pituitary microadenomas and the absence of paracellular invasion, corresponding to Knosp Grade 02, had low prognostic value for long-term remission due to low sensitivity (31.6%) and low specificity (38.5%), respectively. The highest prognostic value for acromegaly remission was showed for 24 hours post-surgery GH level with cut-off 1.30 ng/ml with sensitivity of 96.2% (95% confidence interval 81.199.8%) and specificity of 84.2% (95% confidence interval 62.494.4%). CONCLUSION The study demonstrated the possibility of using GH level at 24 after surgery as a predictor for acromegaly remission. GH level 1.30 ng/ml at 24 hours after surgery showed better predictive value for long-term remission compared with the presence of microadenomas and Knosp Grade 02. The absence of decrease of GH level on the first day after surgery may serve as a reason for more close monitoring of patients in the postoperative period. Further studies in a larger number of observers are required to confirm our findings.
Collapse
Affiliation(s)
| | - U A Tsoy
- Almazov National Medical Research Center
| | | | | | | | | | | | | |
Collapse
|
22
|
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.
Collapse
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.
| |
Collapse
|
23
|
Ishikawa M, Toyomura J, Yagi T, Kuboki K, Morita T, Sugihara H, Hirose T, Minami S, Yoshino G. Role of growth hormone signaling pathways in the development of atherosclerosis. Growth Horm IGF Res 2020; 53-54:101334. [PMID: 32721858 DOI: 10.1016/j.ghir.2020.101334] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Revised: 06/07/2020] [Accepted: 06/12/2020] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The direct actions of growth hormone (GH) in the development of atherosclerosis are unclear. The goal of this study was to characterize GH-induced changes in expression of signaling pathway elements and other proteins that may be related to atherosclerosis. METHODS Human umbilical vein endothelial cells (HUVEC) and THP-1, a human acute monocytic leukemia cell line, were stimulated by exposure to 10-9 M or 10-8 M human GH with or without pretreatment with a mitogen-activated protein kinase kinase (MEK) 1 inhibitor. Levels of transcripts encoding vascular cell adhesion molecule (VCAM) -1, E-selectin, monocyte chemotactic protein (MCP-1), interleukin (IL) -6, and IL-8 were investigated by reverse transcription (RT) -PCR. For the quantitative adhesion assay, THP-1 cells or human primary monocytes were fluorescently labeled with 3'-O-acetyl-2',7'-bis(carboxyethyl) -4 diacetoxymethyl ester (BCECF/AM). HUVEC treated with human GH were co-incubated with BCECF-labeled THP-1 cells. One hour later, the number of BCECF-labeled THP-1 cells was assessed. An equivalent experiment was performed using BCECF-labeled primary monocytes, and the number of monocytes adhering to HUVEC was counted. RESULTS Treatment with hGH increased the levels of E-selectin- and VCAM-1-encoding mRNAs in HUVEC. This effect was attenuated by pretreatment with a MEK1 inhibitor. Furthermore, hGH treatment increased adhesion of BCECF-labeled THP-1 cells or primary monocytes to HUVEC, and this effect was attenuated by pretreatment with a MEK1 inhibitor. CONCLUSIONS VCAM-1 and E-selectin expression was stimulated by GH via the mitogen-activated protein kinase pathway, resulting in augmented adhesion of THP-1 cells and monocytes to HUVEC. These data suggested that GH directly stimulates the development of atherosclerosis.
Collapse
Affiliation(s)
- Mayumi Ishikawa
- Center of Endocrinology, Diabetes and Arteriosclerosis, Nippon Medical School Musashikosugi Hospital, 1-396, Kosugi-cho, Nakahara-ku, Kawasaki 211-8533, Japan.
| | - Junko Toyomura
- Laboratory of Clinical Regenerative Medicine, Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, 1-1-1, Tennodai, Tsukuba-City, Ibaraki 305-8575, Japan
| | - Takashi Yagi
- Center of Endocrinology, Diabetes and Arteriosclerosis, Nippon Medical School Musashikosugi Hospital, 1-396, Kosugi-cho, Nakahara-ku, Kawasaki 211-8533, Japan
| | - Koji Kuboki
- The Division of Diabetes, Metabolism and Endocrinology, Department of Internal Medicine, Toho University, 6-11-1, Omorinishi, Ota-ku, Tokyo 143-8541, Japan
| | - Toshisuke Morita
- Department of Laboratory Medicine, Toho University, 6-11-1, Omorinishi, Ota-ku, Tokyo 143-8541, Japan
| | - Hitoshi Sugihara
- Department of Endocrinology, Diabetes and Metabolism, Graduate School of Medicine, Nippon Medical School, 1-1-5, Sendagi, Bunkyo-ku, Tokyo 113-8603, Japan
| | - Takahisa Hirose
- The Division of Diabetes, Metabolism and Endocrinology, Department of Internal Medicine, Toho University, 6-11-1, Omorinishi, Ota-ku, Tokyo 143-8541, Japan
| | - Shiro Minami
- Center of Endocrinology, Diabetes and Arteriosclerosis, Nippon Medical School Musashikosugi Hospital, 1-396, Kosugi-cho, Nakahara-ku, Kawasaki 211-8533, Japan
| | - Gen Yoshino
- The Division of Diabetes, Metabolism and Endocrinology, Department of Internal Medicine, Toho University, 6-11-1, Omorinishi, Ota-ku, Tokyo 143-8541, Japan
| |
Collapse
|
24
|
Lam-Chung CE, Rodríguez-Orihuela DL, Arízaga-Ramírez R, Almeda-Valdés P, Castillo-Valdez AK, Magaña-Pérez K, Ventura-Gallegos JL, Gamboa-Domínguez A, De Anda González J, Gómez-Pérez FJ, Cuevas-Ramos D. ACROMEGALY AND A GIANT RETROPERITONEAL LIPOSARCOMA PRODUCING IGF-1. AACE Clin Case Rep 2020; 6:e165-e169. [PMID: 32671218 DOI: 10.4158/accr-2020-0061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 03/03/2020] [Indexed: 11/15/2022] Open
Abstract
Objective Liposarcoma is the most common histotype of retroperitoneal sarcomas, representing up to 45% of all cases. We report a rare combination of acromegaly and liposarcoma in the same individual. Methods Laboratory and imaging studies including an oral glucose tolerance test, measurements of growth hormone (GH) and insulin-like growth factor-1 (IGF-1), and a computed tomography scan were performed. Results The patient was a 60-year-old male with a history of acromegaly diagnosed on the basis of elevated IGF-1 at 1,373 ng/mL (age-appropriate reference range is 87 to 225 ng/mL) and macroadenoma treated with transsphenoidal surgery. He presented 8 years later with a history of abdominal distension and weight loss. Physical examination was notable for a right-sided abdominal mass that was tense and non-fluctuant. Two years earlier, he had a post oral glucose tolerance test GH level <0.25 ng/mL and IGF-1 level of 256 ng/mL (age-appropriate reference range is 55 to 206 ng/mL). Pituitary magnetic resonance imaging reported a 3.7 × 2.0-mm left-sided parasagittal lesion. Computed tomography scan showed a 25.0 × 22.0 × 32.3-cm heterogeneous giant mass in the right abdomen corresponding to a liposarcoma causing displacement of kidney, liver, and bowel loops. The patient was treated with a complete en bloc resection of the liposarcoma with the right kidney (45 × 33 × 17 cm) and tumor (9,400 g). Immunohistochemical examination revealed positive IGF-1 and GH staining. The patient suffered postoperative gastrointestinal bleeding that resulted in hemorrhagic shock and died on the 29th postoperative day after a cardiorespiratory arrest. Conclusion Acromegalic patients are at increased risk of developing various types of neoplasms. This is the first documented coexistence of liposarcoma and history of acromegaly.
Collapse
|
25
|
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 1: Diagnostic and Clinical Issues. Endocr Metab Immune Disord Drug Targets 2020; 20:1133-1143. [PMID: 31985386 PMCID: PMC7579251 DOI: 10.2174/1871530320666200127103320] [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: 12/05/2019] [Accepted: 12/05/2019] [Indexed: 12/21/2022]
Abstract
Acromegaly is a rare disease. Improvements in lifespan in these patients have recently been reported due to transsphenoidal surgery (TSS), advances in medical therapy, and strict criteria for defining disease remission. This document reports the opinions of a group of Italian experts who have gathered together their prolonged clinical experience in the diagnostic and therapeutic challenges of acromegaly patients. Both GH and IGF-I (only IGF-I in those treated with Pegvisomant) are needed in the diagnosis and follow-up. Comorbidities (cardio-cerebrovascular disease, sleep apnea, metabolic derangement, neoplasms, and bone/joint disease) should be specifically addressed. Any newly diagnosed patient should be referred to a multidisciplinary team experienced in the treatment of pituitary adenomas.
Collapse
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:
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
26
|
Li YL, Zhang S, Guo XP, Gao L, Lian W, Yao Y, Deng K, Wang RZ, Xing B. Correlation analysis between short-term insulin-like growth factor-I and glucose intolerance status after transsphenoidal adenomectomy in acromegalic patients: a large retrospective study from a single center in China. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2019; 63:157-166. [PMID: 30916168 PMCID: PMC10522129 DOI: 10.20945/2359-3997000000118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 02/17/2017] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Our study aimed to investigate the associations of glucose tolerance status with insulin-like growth factor-I (IGF-I) and other clinical laboratory parameters of acromegalic patients before and after the patients underwent transsphenoidal adenomectomy (TSA) by conducting a single-center, retrospective study. SUBJECTS AND METHODS A total of 218 patients with acromegaly who had undergone TSA as the first treatment were retrospectively analyzed. Serum IGF-I, growth hormone (GH) and glucose levels were measured before and after surgery. RESULTS The follow-up levels for random GH, GH nadir, and the percentage of the upper limit of normal IGF-I (%ULN IGF-I) were decreased significantly. The percentages of normal (39.0%), early carbohydrate metabolism disorders (33.0%) and diabetes mellitus (28.0%) changed to 70.2%, 16.5% and 13.3%, respectively, after TSA. %ULN IGF-I at baseline was higher in the diabetes mellitus (DM) group than in the normal glucose tolerance group and impaired glucose tolerance (IGT) /impaired fasting glucose (IFG) groups before TSA, and the DM group exhibited a greater reduction in %ULN IGF-I value after surgery. The follow-up %ULN IGF-I value after surgery was significantly lower in the improved group, and Pearson's correlation analysis revealed that the reductions in %ULN IGF-I corresponded with the reductions in glucose level. CONCLUSION This study examined the largest reported sample with complete preoperative and follow-up data. The results suggest that the age- and sex-adjusted IGF-I level, which reflects altered glucose metabolism, and the change of it are associated with improved glucose tolerance in acromegalic patients both before and after TSA.
Collapse
Affiliation(s)
- Yi-Lin Li
- Peking Union Medical College HospitalDepartment of NeurosurgeryPekingChinaDepartment of Neurosurgery, Peking Union Medical College Hospital, Peking, China
- Chinese Academy of Medical SciencesPlastic Surgery HospitalDepartment No. 16BeijingChinaDepartment No. 16, Plastic Surgery Hospital, Chinese Academy of Medical Sciences, Beijing, China
- The Ministry of Health Key Laboratory of EndocrinologyPekingChinaThe Ministry of Health Key Laboratory of Endocrinology, Peking, China
| | - Shuo Zhang
- Peking Union Medical College HospitalDepartment of NeurosurgeryPekingChinaDepartment of Neurosurgery, Peking Union Medical College Hospital, Peking, China
- The Ministry of Health Key Laboratory of EndocrinologyPekingChinaThe Ministry of Health Key Laboratory of Endocrinology, Peking, China
| | - Xiao-Peng Guo
- Peking Union Medical College HospitalDepartment of NeurosurgeryPekingChinaDepartment of Neurosurgery, Peking Union Medical College Hospital, Peking, China
- The Ministry of Health Key Laboratory of EndocrinologyPekingChinaThe Ministry of Health Key Laboratory of Endocrinology, Peking, China
| | - Lu Gao
- Peking Union Medical College HospitalDepartment of NeurosurgeryPekingChinaDepartment of Neurosurgery, Peking Union Medical College Hospital, Peking, China
- The Ministry of Health Key Laboratory of EndocrinologyPekingChinaThe Ministry of Health Key Laboratory of Endocrinology, Peking, China
| | - Wei Lian
- Peking Union Medical College HospitalDepartment of NeurosurgeryPekingChinaDepartment of Neurosurgery, Peking Union Medical College Hospital, Peking, China
- The Ministry of Health Key Laboratory of EndocrinologyPekingChinaThe Ministry of Health Key Laboratory of Endocrinology, Peking, China
| | - Yong Yao
- Peking Union Medical College HospitalDepartment of NeurosurgeryPekingChinaDepartment of Neurosurgery, Peking Union Medical College Hospital, Peking, China
- The Ministry of Health Key Laboratory of EndocrinologyPekingChinaThe Ministry of Health Key Laboratory of Endocrinology, Peking, China
| | - Kan Deng
- Peking Union Medical College HospitalDepartment of NeurosurgeryPekingChinaDepartment of Neurosurgery, Peking Union Medical College Hospital, Peking, China
- The Ministry of Health Key Laboratory of EndocrinologyPekingChinaThe Ministry of Health Key Laboratory of Endocrinology, Peking, China
| | - Ren-Zhi Wang
- Peking Union Medical College HospitalDepartment of NeurosurgeryPekingChinaDepartment of Neurosurgery, Peking Union Medical College Hospital, Peking, China
- The Ministry of Health Key Laboratory of EndocrinologyPekingChinaThe Ministry of Health Key Laboratory of Endocrinology, Peking, China
| | - Bing Xing
- Peking Union Medical College HospitalDepartment of NeurosurgeryPekingChinaDepartment of Neurosurgery, Peking Union Medical College Hospital, Peking, China
- The Ministry of Health Key Laboratory of EndocrinologyPekingChinaThe Ministry of Health Key Laboratory of Endocrinology, Peking, China
| |
Collapse
|
27
|
Rotermund R, Burkhardt T, Rohani Z, Jung R, Aberle J, Flitsch J. Value of early postoperative random growth hormone levels and nadir growth hormone levels after oral glucose tolerance testing in acromegaly. Growth Horm IGF Res 2018; 41:64-70. [PMID: 29555234 DOI: 10.1016/j.ghir.2018.03.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Revised: 03/03/2018] [Accepted: 03/08/2018] [Indexed: 10/17/2022]
Abstract
OBJECTIVE There is no ideal marker to identify residual tumor tissue after surgery in patients with acromegaly. The purpose was to elucidate if early postoperative hormone testing gives reliable information regarding complete resection of a GH-producing pituitary adenoma. DESIGN Fourty-eight patients undergoing surgery for acromegaly from 04/2013-05/2014 were prospectively examined for random GH, IGF1, and GH levels after oral glucose tolerance testing (OGTT) in the early postoperative phase and on follow-up. Criterion for inclusion was a minimum follow-up of one year for each patient with respect to remission. RESULTS Thirty-three patients showed GH suppression below 1 μg/l after OGTT in the early postoperative phase. Follow-up GH, IGF1 and OGTT tests confirmed the initial findings in 30 patients. The three remaining patients showed biochemical signs of persisting acromegaly. In the remaining 15 patients early postoperative GH suppression was above 1 μg/l. Of those, six patients went into remission during follow-up, nine patients without postoperative GH suppression <1 μg/l remained acromegalic. CONCLUSIONS GH suppression to <1 μg/l as well as random GH levels below 1 μg/l in the early postoperative phase seem to be of good positive predictive value for long-term remission. However, several patients without suppression of GH to <1 μg/l in the early postoperative OGTT went into delayed remission. These results have to be taken into account prior to initiation of further therapy.
Collapse
Affiliation(s)
- Roman Rotermund
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany.
| | - Till Burkhardt
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Zaina Rohani
- Department of Endocrinology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Roman Jung
- Department of laboratory medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany.
| | - Jens Aberle
- Department of Endocrinology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany.
| | - Jörg Flitsch
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany.
| |
Collapse
|
28
|
van Esdonk MJ, van Zutphen EJM, Roelfsema F, Pereira AM, van der Graaf PH, Biermasz NR, Stevens J, Burggraaf J. How are growth hormone and insulin-like growth factor-1 reported as markers for drug effectiveness in clinical acromegaly research? A comprehensive methodologic review. Pituitary 2018; 21:310-322. [PMID: 29605877 PMCID: PMC5942341 DOI: 10.1007/s11102-018-0884-4] [Citation(s) in RCA: 18] [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] [Indexed: 12/19/2022]
Abstract
OBJECTIVE In rare disease research, most randomized prospective clinical trials can only use limited number of patients and are comprised of highly heterogeneous populations. Therefore, it is crucial to report the results in such a manner that it allows for comparison of treatment effectiveness and biochemical control between studies. The aim of this review was to investigate the current methods that are being applied to measure and report growth hormone (GH) and insulin-like growth factor-1 (IGF-1) as markers for drug effectiveness in clinical acromegaly research. SEARCH STRATEGY A systematic search of recent prospective and retrospective studies, published between 2012 and 2017, that studied the effects of somatostatin analogues or dopamine agonists in acromegaly patients was performed. The markers of interest were GH, IGF-1, and the suppression of GH after an oral glucose tolerance test (OGTT). Additionally, the use of pharmacokinetic (PK) measurements in these studies was analyzed. The sampling design, cut-off for biochemical control, reported units, and used summary statistics were summarized. RESULTS A total of 49 articles were selected out of the 263 screened abstracts. IGF-1 concentrations were measured in all 49 studies, GH in 45 studies, and an OGTT was performed in 11 studies. A wide range of different cut-off values and sampling designs were used to determine biochemical control in acromegaly patients. The summary statistics were reported in various ways, with the percentage of biochemical control most frequently used. Nine studies sampled the PK at one or more time points. Non-compartmental analyses were commonly performed on the available PK data. CONCLUSIONS The way GH and IGF-1 are measured and reported in acromegaly research varies considerably. A consensus on how to report study results would enable better comparisons between studies, thereby improving evidence based decision making to optimize treatment in acromegaly.
Collapse
Affiliation(s)
- Michiel J van Esdonk
- Division of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands.
- Centre for Human Drug Research, Leiden, The Netherlands.
| | - Eline J M van Zutphen
- Division of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
| | - Ferdinand Roelfsema
- Division of Endocrinology, Department of Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Alberto M Pereira
- Division of Endocrinology, Department of Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Piet H van der Graaf
- Division of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
- Certara QSP, Canterbury, UK
| | - Nienke R Biermasz
- Division of Endocrinology, Department of Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Jasper Stevens
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jacobus Burggraaf
- Division of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
- Centre for Human Drug Research, Leiden, The Netherlands
| |
Collapse
|
29
|
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.
Collapse
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.
| |
Collapse
|
30
|
Xia Z, Guo X, Zhou Q, Wu J, Lian W, Yao Y, Deng K, Feng M, Wang R, Xing B. Somatotrophic Adenoma in Children Younger than 14 Years: Clinical Features and Treatment of 22 Cases at a Large Pituitary Center. World Neurosurg 2018; 112:e561-e568. [DOI: 10.1016/j.wneu.2018.01.087] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 01/11/2018] [Accepted: 01/12/2018] [Indexed: 12/17/2022]
|
31
|
Zhang S, Li Y, Guo X, Gao L, Lian W, Yao Y, Feng M, Bao X, Wang R, Xing B. Body mass index and insulin-like growth factor 1 as risk factors for discordant growth hormone and insulin-like growth factor 1 levels following pituitary surgery in acromegaly. J Formos Med Assoc 2018; 117:34-41. [DOI: 10.1016/j.jfma.2017.02.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 01/21/2017] [Accepted: 02/16/2017] [Indexed: 10/19/2022] Open
|
32
|
Nishioka H, Fukuhara N, Yamaguchi-Okada M, Takeshita A, Takeuchi Y, Yamada S. Pitfalls in early biochemical evaluation after transsphenoidal surgery in patients with acromegaly. Endocr J 2017; 64:1073-1078. [PMID: 28835593 DOI: 10.1507/endocrj.ej17-0261] [Citation(s) in RCA: 7] [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] [Indexed: 11/23/2022] Open
Abstract
Although the current remission criteria for acromegaly are clear and concise, some pitfalls have been reported in early endocrinological evaluation after surgery. To evaluate the long-term (>4 year) outcome and to detect the pitfalls in early evaluation, we retrospectively reviewed 128 patients with acromegaly who underwent primary transsphenoidal surgery during 2011 and 2012. These included 66 men and 62 women, aged from 7 to 76 (mean 46) years old. 49 patients (38.3%) were preoperatively treated with somatostatin analog (SSA). Follow-up period ranged from 52 to 75 (63) months. Long-term remission using the current consensus criteria was achieved in 107 patients (83.6%), 105 of which patient had achieved remission in early evaluation. In 5 patients with preoperative SSA treatment, IGF-1 levels re-elevated more than one year after surgery. Five female patients without pretreatment with SSA showed delayed normalization of IGF-1 between 13 to 27 months postoperatively, two of which patients satisfied the remission criteria. In conclusion, the long-term results can be reliably predicted by the remission criteria early after surgery in most patients with acromegaly. For the accurate evaluation within a year after surgery, however, influence of preoperative treatment with SSA, delayed normalization of IGF-1, and poor GH suppression due to low insulin resistance must be considered, particularly in women.
Collapse
Affiliation(s)
- Hiroshi Nishioka
- Department of Hypothalamic and Pituitary Surgery, Toranomon Hospital, Tokyo, Japan
- Okinaka Memorial Institute for Medical Research, Tokyo, Japan
| | - Noriaki Fukuhara
- Department of Hypothalamic and Pituitary Surgery, Toranomon Hospital, Tokyo, Japan
| | | | - Akira Takeshita
- Department of Endocrinology, Toranomon Hospital, Tokyo, Japan
- Okinaka Memorial Institute for Medical Research, Tokyo, Japan
| | - Yasuhiro Takeuchi
- Department of Endocrinology, Toranomon Hospital, Tokyo, Japan
- Okinaka Memorial Institute for Medical Research, Tokyo, Japan
| | - Shozo Yamada
- Department of Hypothalamic and Pituitary Surgery, Toranomon Hospital, Tokyo, Japan
- Okinaka Memorial Institute for Medical Research, Tokyo, Japan
| |
Collapse
|
33
|
Abstract
Measurements of human growth hormone (GH) and insulin-like growth-factor I (IGF-I) are cornerstones in the diagnosis of acromegaly. Both hormones are also used as biochemical markers in the evaluation of disease activity during treatment. Management of acromegaly is particularly challenging in cases where discordant information is obtained from measurement of GH concentrations following oral glucose load and from measurement of IGF-I. While in some patients biological factors can explain the discrepancy, in many cases issues with the analytical methods seem to be responsible. Assays used by endocrine laboratories to determine concentrations of GH and IGF-I underwent significant changes during the last decades. While generally leading to more sensitive and reproducible methods, these changes also had considerable impact on absolute concentrations measured. This must be reflected by updated decision limits, cut-offs and reference intervals. Since different commercially available assays do not agree very well, method specific interpretation of GH and IGF-I concentrations is required. This complexity in the interpretation of hormone concentrations is not always appropriately reflected in laboratory reports, but also not in clinical guidelines reporting decision limits not related to a specific analytical method. The present review provides an overview about methodological and biological variables affecting the biochemical assessment of acromegaly in diagnosis and follow up.
Collapse
Affiliation(s)
- Katharina Schilbach
- Clinical Endocrinology and Endocrine Laboratory, Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität (LMU), Ziemssenstr. 1, 80336, Munich, Germany
| | - Christian J Strasburger
- Department of Endocrinology and Metabolic Diseases, Campus Charité Mitte, Charité Universitätsmedizin, Charitéplatz 1, 10117, Berlin, Germany
| | - Martin Bidlingmaier
- Endocrine Laboratory, Endocrine Research Unit, Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität (LMU), Ziemssenstr. 1, 80336, Munich, Germany.
| |
Collapse
|
34
|
Yu M, Bruns DE, Jane JA, Nass RM, Oldfield EH, Vance ML, Thorner MO. Decrease of Serum IGF-I following Transsphenoidal Pituitary Surgery for Acromegaly. Clin Chem 2017; 63:486-494. [DOI: 10.1373/clinchem.2016.262592] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 10/12/2016] [Indexed: 01/09/2023]
Abstract
Abstract
BACKGROUND
In the immediate postoperative period following resection of growth hormone (GH)-secreting pituitary tumors, serum concentrations of GH have limited ability to predict remission of acromegaly. Since many actions of GH actions are mediated by insulin-like growth factor-1 (IGF-I), we aimed to determine the rates of fall of IGF-I during 72 h after surgical resection of pituitary tumors.
METHODS
We studied patients who were undergoing pituitary surgery for acromegaly. IGF-I was measured by LC-MS and GH by immunoassay. Remission was defined by the combination of serum GH <0.4 ng/mL during oral glucose tolerance testing performed 8 weeks after the surgical procedure and normal IGF-I at ≥8 weeks.
RESULTS
During the first 72 h after surgery, the mean (SD) rate of decline of IGF-I was 185 (61) ng/mL per 24 h in those who achieved remission (n = 23), with a mean (SD) apparent half-life of 55 (19) h. IGF-I had decreased to <65% of the preoperative IGF-I on postoperative day 2 in 20 of 23 remission patients (87%) vs none of 5 patients who did not achieve remission. GH was <2.7 ng/mL on day 2 in 21 of 23 remission patients (91%), but in none of the nonremission patients. The combination of IGF-I and GH on day 2 separated the remission and nonremission groups of patients.
CONCLUSIONS
Rapid decline of serum IGF-I during the immediate postoperative period warrants further study as an analytically independent adjunct to GH measurement for early prediction of biochemical remission of acromegaly.
Collapse
Affiliation(s)
- Min Yu
- Division of Laboratory Medicine, Department of Pathology
| | - David E Bruns
- Division of Laboratory Medicine, Department of Pathology
| | | | - Ralf M Nass
- Division of Endocrinology and Metabolism, Department of Medicine, University of Virginia School of Medicine and Health System, Charlottesville, VA
| | | | - Mary Lee Vance
- Division of Endocrinology and Metabolism, Department of Medicine, University of Virginia School of Medicine and Health System, Charlottesville, VA
| | - Michael O Thorner
- Division of Endocrinology and Metabolism, Department of Medicine, University of Virginia School of Medicine and Health System, Charlottesville, VA
| |
Collapse
|
35
|
Starnoni D, Daniel RT, Marino L, Pitteloud N, Levivier M, Messerer M. Surgical treatment of acromegaly according to the 2010 remission criteria: systematic review and meta-analysis. Acta Neurochir (Wien) 2016; 158:2109-2121. [PMID: 27586125 DOI: 10.1007/s00701-016-2903-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Accepted: 07/19/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND In 2010, the Acromegaly Consensus Group revised the criteria for cure of acromegaly and thus rates of surgical remission need to be revised in light of these new thresholds. Two subgroups consisted of patients with discordant GH and IGF-1 levels and patients in remission according to the 2000 criteria, but not to the 2010 criteria, have been reported after adenomectomy and for these subgroups the precise incidence and management has not been established. The objective of the study was to update rates of surgical remission and complications and to evaluate the incidence, management, and long-term outcome of the two previously described subgroups of patients. METHODS Systematic review and meta-analysis of surgical series that defined remission according to the 2010 biochemical criteria. RESULTS We included 13 studies (1105 patients). The pooled rate of overall surgical remission was 54.8 % (95 % CI 44.4-65.2 %), and 72.2 % with previous criteria. Remission was achieved in 77.9 % (95 % CI 68.1-87.6 %) of microadenomas; 52.7 % (95 % CI 41-64.4 %) of macroadenomas; 29 % (95 % CI 20.1-37.8 %) of invasive and 68.8 % (95 % CI 60-77.6 %) of non-invasive adenomas. Complication rates were 1.2 % (95 % CI 0.6-1.9 %) for CSF leak, 1.3 % (95 % CI 0.6-2.1 %) for permanent diabetes insipidus, 8.7 % (95 % CI 4.8-12.5 %) for new anterior pituitary dysfunction and 0.6 % (95 % CI 0.1-1.1 %) for severe intraoperative hemorrhage. We identified an intermediate group of patients, defined as: (1) Remission according to one, but not the other biochemical criteria (GH or IGF-1) or 2010 criteria (14.3 % and 47.1 % cases), (2) Remission according to 2000, but not 2010 criteria (13.2-58.8 % cases). Two studies reported a remission rate of 56.5 % and 100 %, in the two subgroups respectively, in a long-term outcome without adjuvant therapy. CONCLUSIONS Overall remission with transsphenoidal surgery is achieved in ∼55 % of patients. For the intermediate group of patients, future prospective studies with long-term follow-up are required to determine the long-term biochemical remission rates and clinical implications.
Collapse
Affiliation(s)
- Daniele Starnoni
- Service de Neurochirurgie, Centre Hospitalier Universitaire Vaudois (CHUV) and University of Lausanne (Unil), Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Roy Thomas Daniel
- Service de Neurochirurgie, Centre Hospitalier Universitaire Vaudois (CHUV) and University of Lausanne (Unil), Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Laura Marino
- Service d'Endocrinologie, Centre Hospitalier Universitaire Vaudois (CHUV) and University of Lausanne (Unil), Lausanne, Switzerland
| | - Nelly Pitteloud
- Service d'Endocrinologie, Centre Hospitalier Universitaire Vaudois (CHUV) and University of Lausanne (Unil), Lausanne, Switzerland
| | - Marc Levivier
- Service de Neurochirurgie, Centre Hospitalier Universitaire Vaudois (CHUV) and University of Lausanne (Unil), Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Mahmoud Messerer
- Service de Neurochirurgie, Centre Hospitalier Universitaire Vaudois (CHUV) and University of Lausanne (Unil), Rue du Bugnon 46, 1011, Lausanne, Switzerland.
| |
Collapse
|
36
|
Kanakis GA, Chrisoulidou A, Bargiota A, Efstathiadou ZA, Papanastasiou L, Theodoropoulou A, Tigas SK, Vassiliadi DA, Tsagarakis S, Alevizaki M. The ongoing challenge of discrepant growth hormone and insulin-like growth factor I results in the evaluation of treated acromegalic patients: a systematic review and meta-analysis. Clin Endocrinol (Oxf) 2016; 85:681-688. [PMID: 27292418 DOI: 10.1111/cen.13129] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 06/05/2016] [Accepted: 06/09/2016] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Growth hormone (GH) and insulin-like growth factor I (IGF-I) are the principal biomarkers used to assess disease activity in acromegaly, and any discrepancy between them renders interpretation of results inconclusive. Purpose of this study was to assess the frequency of this discrepancy and identify parameters that might affect its occurrence. DESIGN A systematic review of MEDLINE and Scopus was performed (1987-2013) followed by a meta-analysis to address the frequency of discrepant results between GH and IGF-I levels. Meta-regression and subgroup analyses were performed assessing the effects of the year of publication, the different types of GH testing and GH assays used, as well as the impact of treatment with somatostatin analogues (SSAs) on the occurrence of this discrepancy. RESULTS The analysis retrieved 39 eligible studies totalling 7071 patients. The pooled discordance rate between GH and IGF-I was 25·7% (95% CI: 22·3-29·4), and the predominant format was that of elevated IGF-I with normal GH levels (15·3%, 95% CI: 12·5-18·7). No significant correlation between the discordance rate and the year of publication was shown; whereas, the use of ultrasensitive GH assays resulted in higher discordance rates (30·7%, 95% CI: 25·9-35·9 vs 19·8%, 95% CI: 14·1-27·2, P = 0·04) as did treatment with SSAs (32·5%, 95% CI: 27·8-37·4) vs (21·6%, 95% CI: 17·8-25·6, P = 0·001). CONCLUSIONS Discrepancy between GH and IGF-I results is encountered in a quarter of treated patients with acromegaly, especially when using ultrasensitive GH assays or in patients receiving SSAs, a fact that the clinician should take into consideration when making clinical decisions.
Collapse
Affiliation(s)
- G A Kanakis
- Department of Endocrinology, Athens Naval & VA Hospital, Athens, Greece.
| | - A Chrisoulidou
- Department of Endocrinology, Theagenio Cancer Hospital, Thessaloniki, Greece
| | - A Bargiota
- Department of Endocrinology and Metabolic Diseases, University of Thessaly, Larissa, Greece
| | - Z A Efstathiadou
- Department of Endocrinology, 'Hippokration' General Hospital of Thessaloniki, Thessaloniki, Greece
| | - L Papanastasiou
- Department of Endocrinology and Diabetes Center, Athens General Hospital 'G. Gennimatas', Athens, Greece
| | - A Theodoropoulou
- Division of Endocrinology, Department of Internal Medicine, University Hospital of Patras, Rio, Greece
| | - S K Tigas
- Department of Endocrinology, University of Ioannina, Ioannina, Greece
| | - D A Vassiliadi
- Endocrine Unit, 2nd Department of Internal Medicine - Propaedeutic, Research Institute and Diabetes Center, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - S Tsagarakis
- Department of Endocrinology, Evangelismos Hospital, Athens, Greece
| | - M Alevizaki
- Endocrine Unit, Department of Medical Therapeutics, Medical School, University of Athens, Athens, Greece
| |
Collapse
|
37
|
Clinical features and natural course of acromegaly in patients with discordance in the nadir GH level on the oral glucose test and the IGF-1 value at 3 months after adenomectomy. Neurosurg Rev 2016; 39:313-8; discussion 318-9. [DOI: 10.1007/s10143-015-0692-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2014] [Revised: 08/10/2015] [Accepted: 10/31/2015] [Indexed: 10/22/2022]
|
38
|
Schilbach K, Bidlingmaier M. Growth hormone binding protein - physiological and analytical aspects. Best Pract Res Clin Endocrinol Metab 2015; 29:671-83. [PMID: 26522453 DOI: 10.1016/j.beem.2015.06.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
A significant proportion of total circulating growth hormone (GH) is bound to a high affinity growth hormone binding protein (GHBP). Several low affinity binding proteins have also been described. Significant differences between species exist with respect to origin and regulation of GHBP, but generally it resembles the extracellular domain of the GH receptor. Concentrations are associated with GH status, body composition and other factors. Although the clinical relevance of GHBP is not fully understood it is suggested that concentrations indirectly reflect GH receptor status. This is supported by cases of Laron's syndrome where a molecular defect in the extracellular domain of the GH receptor is associated with low or unmeasurable GHBP concentrations. Methods to measure GHBP have evolved from chromatographic, activity based procedures to direct immunoassays. In clinical practice, measurement of GHBP can be helpful to differentiate between GH deficiency and GH insensitivity, particularly if GHBP is absent.
Collapse
Affiliation(s)
- Katharina Schilbach
- Endocrine Laboratory, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ziemssenstr. 1, 80336, Munich, Germany.
| | - Martin Bidlingmaier
- Endocrine Laboratory, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ziemssenstr. 1, 80336, Munich, Germany.
| |
Collapse
|
39
|
Abstract
Acromegaly (ACM) is a chronic, progressive disorder caused by the persistent hypersecretion of GH, in the vast majority of cases secreted by a pituitary adenoma. The consequent increase in IGF1 (a GH-induced liver protein) is responsible for most clinical features and for the systemic complications associated with increased mortality. The clinical diagnosis, based on symptoms related to GH excess or the presence of a pituitary mass, is often delayed many years because of the slow progression of the disease. Initial testing relies on measuring the serum IGF1 concentration. The oral glucose tolerance test with concomitant GH measurement is the gold-standard diagnostic test. The therapeutic options for ACM are surgery, medical treatment, and radiotherapy (RT). The outcome of surgery is very good for microadenomas (80-90% cure rate), but at least half of the macroadenomas (most frequently encountered in ACM patients) are not cured surgically. Somatostatin analogs are mainly indicated after surgical failure. Currently their routine use as primary therapy is not recommended. Dopamine agonists are useful in a minority of cases. Pegvisomant is indicated for patients refractory to surgery and other medical treatments. RT is employed sparingly, in cases of persistent disease activity despite other treatments, due to its long-term side effects. With complex, combined treatment, at least three-quarters of the cases are controlled according to current criteria. With proper control of the disease, the specific complications are partially improved and the mortality rate is close to that of the background population.
Collapse
Affiliation(s)
- Cristina Capatina
- Department of EndocrinologyCarol Davila University of Medicine and Pharmacy, Bucharest, RomaniaCI Parhon National Institute of EndocrinologyBucharest, RomaniaDepartment of EndocrinologyOxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Old Road, Headington, Oxford OX3 7LE, UK Department of EndocrinologyCarol Davila University of Medicine and Pharmacy, Bucharest, RomaniaCI Parhon National Institute of EndocrinologyBucharest, RomaniaDepartment of EndocrinologyOxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Old Road, Headington, Oxford OX3 7LE, UK
| | - John A H Wass
- Department of EndocrinologyCarol Davila University of Medicine and Pharmacy, Bucharest, RomaniaCI Parhon National Institute of EndocrinologyBucharest, RomaniaDepartment of EndocrinologyOxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Old Road, Headington, Oxford OX3 7LE, UK
| |
Collapse
|
40
|
Zeinalizadeh M, Habibi Z, Fernandez-Miranda JC, Gardner PA, Hodak SP, Challinor SM. Discordance between growth hormone and insulin-like growth factor-1 after pituitary surgery for acromegaly: a stepwise approach and management. Pituitary 2015; 18:48-59. [PMID: 24496953 DOI: 10.1007/s11102-014-0556-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Follow-up management of patients with acromegaly after pituitary surgery is performed by conducting biochemical assays of growth hormone (GH) and insulin-like growth factor-1 (IGF1). Despite concordant results of these two tests in the majority of cases, there is increasing recognition of patients who show persistent or intermittent discordance between GH and IGF1 (normal GH and elevated IGF1 or vice versa). METHOD In this narrative review, the last three decades materials on the issue of discrepancy between GH and IGF1 were thoroughly assessed. RESULTS Various studies have obtained different discordance rates, ranging from 5.4 to 39.5%. At present, despite the use of current sensitive assays and more stringent criteria to define remission, the rate of discordance still remains high. A number of mechanisms have been proposed to explain the postoperative discordance of GH and IGF1 including; altered dynamics of the GH secretion after surgery, early postoperative hormone assay, inaccurate or less sensitive tests and laboratory errors, too high cut-off point for GH suppression in the GH assays, GH nadir values not adjusted to age, sex, and body mass index, the influence of concomitant medication, co-existing physiologic and pathologic conditions, and many other proposed reasons. Nevertheless, the underlying mechanisms are still far from clear, and the solution continues to evade complete elucidation. Similarly, the impacts of such a discrepancy over mortality and morbidity and the risk of biochemical and/or clinical recurrence are unclear. CONCLUSION As a challenging clinical problem, a stepwise evaluation and management of these patients appears to be more rational.
Collapse
Affiliation(s)
- Mehdi Zeinalizadeh
- Department of Neurological Surgery, Imam Khomeini Hospital, Tehran University of Medical Sciences, 1419733141, Tehran, Iran,
| | | | | | | | | | | |
Collapse
|
41
|
Ku CR, Hong JW, Kim EH, Kim SH, Lee EJ. Clinical predictors of GH deficiency in surgically cured acromegalic patients. Eur J Endocrinol 2014; 171:379-87. [PMID: 24972779 DOI: 10.1530/eje-14-0304] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Even in patients with cured acromegaly, GH deficiency (GHD) after transsphenoidal adenomectomy (TSA) adversely affects body composition and inflammatory biomarkers of cardiovascular risk. In this study, clinical parameters for predicting GHD after TSA in 123 cured acromegalic patients were investigated. DESIGN AND METHODS GH levels were measured at 6, 12, 18, 24, 48, and 72 h after TSA and serial insulin tolerance tests were conducted at 6 months, 2 years, and then every 2 years after TSA. RESULTS GHD was found in 12 patients (9.8%) at 4.1 (range: 0.5-4.1) years after TSA. IGF1 levels were significantly lower at 6 months after TSA in GHD group than intact GH group (175.9 vs 316.8 μg/l, range: 32.0-425.0 and 96.9-547.3 respectively, P=0.008). Adenomas involving both sides of the pituitary gland were significantly more frequent in GHD patients (29.7 vs 83.3%; P=0.002). Furthermore, immediate postoperative 72-h GH levels after TSA were significantly lower (0.17 vs 0.45, range: 0.02-0.93 and 0.02-5.95 respectively, P=0.019) in GHD patients. In multiple logistic regression analysis, bilaterality of tumor involvement (odds ratio (OR)=10.678, P=0.003; 95% CI=2.248-50.728) and immediate postoperative 72-h GH level (OR=0.079, P=0.047; 95% CI=0.006-0.967) showed significant power for predicting GHD. CONCLUSIONS These data suggest that bilateral involvement of a pituitary adenoma and severely decreased immediate postoperative serum GH levels at 72 h after TSA may be independent risks factor for accelerated GHD in acromegalic patients.
Collapse
Affiliation(s)
- Cheol Ryong Ku
- EndocrinologyInstitute of Endocrine ResearchPituitary Tumor ClinicNeurosurgeryYonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Republic of KoreaDepartment of Internal MedicineIlsan-Paik Hospital, College of Medicine, Inje University, Koyang, Gyeonggi-do, Republic of KoreaEndocrinologyInstitute of Endocrine ResearchPituitary Tumor ClinicNeurosurgeryYonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Republic of KoreaDepartment of Internal MedicineIlsan-Paik Hospital, College of Medicine, Inje University, Koyang, Gyeonggi-do, Republic of KoreaEndocrinologyInstitute of Endocrine ResearchPituitary Tumor ClinicNeurosurgeryYonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Republic of KoreaDepartment of Internal MedicineIlsan-Paik Hospital, College of Medicine, Inje University, Koyang, Gyeonggi-do, Republic of Korea
| | - Jae Won Hong
- EndocrinologyInstitute of Endocrine ResearchPituitary Tumor ClinicNeurosurgeryYonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Republic of KoreaDepartment of Internal MedicineIlsan-Paik Hospital, College of Medicine, Inje University, Koyang, Gyeonggi-do, Republic of Korea
| | - Eui Hyun Kim
- EndocrinologyInstitute of Endocrine ResearchPituitary Tumor ClinicNeurosurgeryYonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Republic of KoreaDepartment of Internal MedicineIlsan-Paik Hospital, College of Medicine, Inje University, Koyang, Gyeonggi-do, Republic of KoreaEndocrinologyInstitute of Endocrine ResearchPituitary Tumor ClinicNeurosurgeryYonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Republic of KoreaDepartment of Internal MedicineIlsan-Paik Hospital, College of Medicine, Inje University, Koyang, Gyeonggi-do, Republic of KoreaEndocrinologyInstitute of Endocrine ResearchPituitary Tumor ClinicNeurosurgeryYonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Republic of KoreaDepartment of Internal MedicineIlsan-Paik Hospital, College of Medicine, Inje University, Koyang, Gyeonggi-do, Republic of Korea
| | - Sun Ho Kim
- EndocrinologyInstitute of Endocrine ResearchPituitary Tumor ClinicNeurosurgeryYonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Republic of KoreaDepartment of Internal MedicineIlsan-Paik Hospital, College of Medicine, Inje University, Koyang, Gyeonggi-do, Republic of KoreaEndocrinologyInstitute of Endocrine ResearchPituitary Tumor ClinicNeurosurgeryYonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Republic of KoreaDepartment of Internal MedicineIlsan-Paik Hospital, College of Medicine, Inje University, Koyang, Gyeonggi-do, Republic of KoreaEndocrinologyInstitute of Endocrine ResearchPituitary Tumor ClinicNeurosurgeryYonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Republic of KoreaDepartment of Internal MedicineIlsan-Paik Hospital, College of Medicine, Inje University, Koyang, Gyeonggi-do, Republic of Korea
| | - Eun Jig Lee
- EndocrinologyInstitute of Endocrine ResearchPituitary Tumor ClinicNeurosurgeryYonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Republic of KoreaDepartment of Internal MedicineIlsan-Paik Hospital, College of Medicine, Inje University, Koyang, Gyeonggi-do, Republic of KoreaEndocrinologyInstitute of Endocrine ResearchPituitary Tumor ClinicNeurosurgeryYonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Republic of KoreaDepartment of Internal MedicineIlsan-Paik Hospital, College of Medicine, Inje University, Koyang, Gyeonggi-do, Republic of KoreaEndocrinologyInstitute of Endocrine ResearchPituitary Tumor ClinicNeurosurgeryYonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Republic of KoreaDepartment of Internal MedicineIlsan-Paik Hospital, College of Medicine, Inje University, Koyang, Gyeonggi-do, Republic of Korea
| |
Collapse
|
42
|
Bancos I, Algeciras-Schimnich A, Woodmansee WW, Cullinane AK, Donato LJ, Nippoldt TB, Natt N, Erickson D. Determination of nadir growth hormone concentration cutoff in patients with acromegaly. Endocr Pract 2014; 19:937-45. [PMID: 23807518 DOI: 10.4158/ep12435.or] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The purpose of this study was to define an appropriate nadir growth hormone (nGH) cutoff for patients with acromegaly in remission using the Access Ultrasensitive human growth hormone (hGH) assay (Beckman Coulter, Brea, CA). METHODS This cross-sectional study included 55 acromegalic subjects and 41 healthy adult volunteers. All subjects underwent oral glucose tolerance testing (OGTT) for growth hormones (GHs). An optimal cutoff for nGH for patients with active disease versus those in remission was determined using receiver-operating curve analysis. RESULTS The nGH of 0.53 ng/mL revealed a sensitivity of 97% (95% confidence interval [CI], 83-100%) and a specificity of 100% (95% CI, 82-100%). All 22 patients with acromegaly in remission suppressed GH to <1 ng/mL, 20/22 (91%) suppressed to <0.4 ng/mL, and 19/22 (86%) of subjects suppressed to <0.3 ng/mL (the maximum nGH measured in our healthy volunteer group). CONCLUSION When using the Access Ultrasensitive hGH assay for OGTT, a cutoff of 0.53 ng/mL was found to most accurately differentiate patients with acromegaly in remission from those with active disease.
Collapse
Affiliation(s)
- Irina Bancos
- Division of Endocrinology, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota
| | | | | | | | | | | | | | | |
Collapse
|
43
|
Shin MS, Yu JH, Choi JH, Jung CH, Hwang JY, Cho YH, Kim CJ, Kim MS. Long-term changes in serum IGF-1 levels after successful surgical treatment of growth hormone-secreting pituitary adenoma. Neurosurgery 2014; 73:473-9; quiz 479. [PMID: 23728452 DOI: 10.1227/01.neu.0000431480.87160.84] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Successful treatment of acromegaly is known to normalize serum insulin-like growth factor 1 (IGF-1) levels within days after surgery. However, our clinical observations indicate that many cases of acromegaly show delayed normalization of serum IGF-1 levels after complete tumor resection. OBJECTIVE To study long-term changes of the serum IGF-1 levels in acromegalic patients for whom surgical treatment was thought to be successful. METHODS A retrospective observational study was performed with 46 acromegalic patients with no residual tumor on sellar magnetic resonance imaging, and a nadir growth hormone of less than 0.4 μg/L on a postoperative oral glucose tolerance test. RESULTS In all patients, serum IGF-1 levels returned to the normal reference values for age and sex during the observational period (12-132 months). The mean duration from the time of surgery until IGF-1 normalization was 10 months (range, 3 days-57 months). Twenty-seven patients (59%) reached normal IGF-1 ranges within 3 months of surgery, whereas 19 patients (41%) experienced delayed (>3 months) IGF-1 normalization. Eleven patients (24%) recovered normal IGF-1 levels 12 to 57 months after surgery. The possibility of delayed IGF-1 cure was increased 8.8-fold with an immediate postoperative IGF-1 level increase of 100 μg/L. CONCLUSION Satisfactory remission of acromegaly by IGF-1 criteria was delayed in a large proportion of acromegalic patients, especially those with high postoperative IGF-1 levels. Hence, additional treatment can be delayed in clinically stable acromegalic patients who show no evidence of residual tumors on postoperative magnetic resonance imaging and a normal growth hormone suppressive response to a glucose load.
Collapse
Affiliation(s)
- Mi-Seon Shin
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Asan Medical Center University of Ulsan College of Medicine, Seoul, Korea.
| | | | | | | | | | | | | | | |
Collapse
|
44
|
Shin SS, Tormenti MJ, Paluzzi A, Rothfus WE, Chang YF, Zainah H, Fernandez-Miranda JC, Snyderman CH, Challinor SM, Gardner PA. Endoscopic endonasal approach for growth hormone secreting pituitary adenomas: outcomes in 53 patients using 2010 consensus criteria for remission. Pituitary 2013. [PMID: 23179961 DOI: 10.1007/s11102-012-0440-6] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
We report the outcomes of the endoscopic endonasal approach (EEA) for resection of growth hormone secreting pituitary adenomas using 2010 consensus criteria. We also assess outcomes with additional medical therapy and radiosurgery (RS) for patients not achieving remission with EEA alone. A retrospective review of 53 patients who had follow up endocrinologic data at least 3 months post-surgery was performed among patients who were treated by EEA between 1998 and 2012. Data were analyzed for remission using GH and IGF-I levels based on 2010 consensus criteria. We also analyzed the outcomes using 2000 consensus criteria for ease in comparison to prior studies of outcomes of surgery for acromegaly. In this series of mostly large (88.2% macroadenomas), invasive (46.9% Hardy-Wilson C, D, E) adenomas, there were 27 patients (50.9%) who achieved remission after EEA only. For patients who had no remission with EEA alone, RS and/or medical therapy were used and 37 patients (69.8 %) achieved remission overall. Statistical analysis showed larger tumor size, Hardy Stages C, D, E and Knosp Scores 3, 4 to be predictive against remission for EEA only and EEA with other modalities. The volume of residual tumor after EEA was not found to be predictive of remission with additional therapies. We used stringent consensus criteria from 2010 in a series which included a high proportion of invasive GH secreting adenomas to show that EEA alone or combined with other modalities results in comparable remission rates to earlier studies which used less strict criteria, while retaining low complication rates.
Collapse
Affiliation(s)
- Samuel S Shin
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
45
|
Mori K, Iwasaki Y, Kawasaki-Ogita Y, Honjo S, Hamamoto Y, Tatsuoka H, Fujimoto K, Ikeda H, Wada Y, Takahashi Y, Takahashi J, Koshiyama H. Improvement of insulin resistance following transsphenoidal surgery in patients with acromegaly: correlation with serum IGF-I levels. J Endocrinol Invest 2013; 36:853-9. [PMID: 23665535 DOI: 10.3275/8964] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
AIM The aim of this study was to determine the correlation between the growth hormone (GH)-insulin-like growth factor-I (IGF-I) axis and glucose intolerance in acromegaly during the early postoperative period. SUBJECTS AND METHODS The study included 20 patients with acromegaly caused by GH-secreting pituitary adenoma who received transsphenoidal surgery in our hospital. Glucose tolerance was evaluated with oral glucose tolerance tests (OGTTs) performed during pre- and early postoperative periods (9 [7-18] days after surgery). Homeostasis model assessment of insulin resistance (HOMA-IR) and insulinogenic index (IGI) were calculated, and correlation analyses were performed between these values and the GH-IGF-I axis. Patients were divided according to postoperative changes of the axis, and glucose tolerance was compared between the groups. RESULTS In preoperative OGTTs, nine patients had impaired glucose tolerance and two had diabetes mellitus patterns. Postoperatively, significant reduction was observed both in fasting plasma glucose levels (p<0.01) and in HOMA-IR (p<0.01), whereas IGI showed no significant change. HOMA-IR was significantly correlated with serum IGF-I levels both before (r=0.83, p<0.01) and after (r=0.57, p<0.01) surgery, although it was not correlated with serum GH levels. Patients who achieved more than 50% postoperative reduction in serum IGF-I levels showed significant improvement in OGTTs results (p<0.05). CONCLUSIONS In patients with acromegaly, serum IGF-I levels, but not GH levels, were significantly correlated with insulin resistance. Early postoperative improvement of glucose tolerance is observed in patients who achieved postoperative reduction in serum IGF-I levels.
Collapse
Affiliation(s)
- K Mori
- Center for Diabetes and Endocrinology, The Tazuke Kofukai Foundation Medical Research Institute Kitano Hospital, Osaka, Japan
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
46
|
|
47
|
Kwon O, Song YD, Kim SY, Lee EJ. Nationwide survey of acromegaly in South Korea. Clin Endocrinol (Oxf) 2013; 78:577-85. [PMID: 22909047 DOI: 10.1111/cen.12020] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2012] [Revised: 07/20/2012] [Accepted: 08/17/2012] [Indexed: 11/29/2022]
Abstract
CONTEXT It was previously reported in Korea that there were 1.4 case per million per year of acromegaly. This was low in comparison with the extrapolated values of Western European countries. We expected that the incidence of acromegaly would be much higher now because of recently improved medical facilities, diagnostic tools and coverage of medical insurance to all the population of South Korea. OBJECTIVE The purpose of this nationwide survey was to examine the incidence and prevalence of patients with acromegaly, mode of treatment and outcome of surgical treatment of recent 5 years. DESIGN AND PATIENTS We requested and collected the medical records of all possible patients with acromegaly from 74 secondary or tertiary medical institutes in Korea from 2003 to 2007 retrospectively. MEASUREMENTS Date of diagnosis and treatment, tumour size, pre- and postoperative hormonal level, treatment modality and usage of medication were collected. RESULTS During 5 years, 1350 patients with acromegaly had been registered. The average annual incidence was 3.9 cases per million during this period, and prevalence had increased up to 27.9 cases per million in 2007. Male/female ratio was 1:1.2, and mean age at diagnosis was 44.1 years. Macroadenoma was dominant (82.9%). Transsphenoidal adenoidectomy was used the most as primary treatment (90.4%). CONCLUSIONS This Korean acromegaly survey offers a realistic overview of the predominant epidemiological characteristics of acromegaly in Korea. Annual incidence was at a similar level with western countries. Efforts to diagnose and control the disease earlier are recommended.
Collapse
Affiliation(s)
- Obin Kwon
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | | | | | | |
Collapse
|
48
|
Abstract
This article presents management options for the patient with acromegaly after noncurative surgery. The current evidence for repeat surgery, adjuvant medical therapy with somatostatin analogues, dopamine agonists, the growth hormone receptor antagonist pegvisomant, combination medical therapy, and radiotherapy in the context of persistent postoperative disease are summarized. The relative advantages and disadvantages of each of these treatment modalities are explored, and a general treatment algorithm that integrates these modalities is proposed.
Collapse
Affiliation(s)
- Nestoras Mathioudakis
- Johns Hopkins University School of Medicine, Division of Endocrinology & Metabolism, Department of Medicine, Baltimore, MD 21287, USA
| | | |
Collapse
|
49
|
Kim EH, Oh MC, Lee EJ, Kim SH. Predicting Long-term Remission by Measuring Immediate Postoperative Growth Hormone Levels and Oral Glucose Tolerance Test in Acromegaly. Neurosurgery 2012; 70:1106-13; discussion 1113. [DOI: 10.1227/neu.0b013e31823f5c16] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
|
50
|
Abstract
Disease activity of acromegaly can be measured in many ways. Growth hormone (GH) and insulin-like growth factor 1 (IGF1) concentrations are the main biochemical markers used to measure the response to treatment. Both GH and IGF1 have been associated with prognosis, in particular mortality. In this review, we discuss the available parameters to assess disease activity in acromegaly.
Collapse
Affiliation(s)
- S J C M M Neggers
- Department of Medicine, Section Endocrinology, Erasmus University Medical Center Rotterdam, CA Rotterdam, The Netherlands.
| | | | | |
Collapse
|