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Korbonits M, Blair JC, Boguslawska A, Ayuk J, Davies JH, Druce MR, Evanson J, Flanagan D, Glynn N, Higham CE, Jacques TS, Sinha S, Simmons I, Thorp N, Swords FM, Storr HL, Spoudeas HA. Consensus guideline for the diagnosis and management of pituitary adenomas in childhood and adolescence: Part 2, specific diseases. Nat Rev Endocrinol 2024; 20:290-309. [PMID: 38336898 DOI: 10.1038/s41574-023-00949-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/19/2023] [Indexed: 02/12/2024]
Abstract
Pituitary adenomas are rare in children and young people under the age of 19 (hereafter referred to as CYP) but they pose some different diagnostic and management challenges in this age group than in adults. These rare neoplasms can disrupt maturational, visual, intellectual and developmental processes and, in CYP, they tend to have more occult presentation, aggressive behaviour and are more likely to have a genetic basis than in adults. Through standardized AGREE II methodology, literature review and Delphi consensus, a multidisciplinary expert group developed 74 pragmatic management recommendations aimed at optimizing care for CYP in the first-ever comprehensive consensus guideline to cover the care of CYP with pituitary adenoma. Part 2 of this consensus guideline details 57 recommendations for paediatric patients with prolactinomas, Cushing disease, growth hormone excess causing gigantism and acromegaly, clinically non-functioning adenomas, and the rare TSHomas. Compared with adult patients with pituitary adenomas, we highlight that, in the CYP group, there is a greater proportion of functioning tumours, including macroprolactinomas, greater likelihood of underlying genetic disease, more corticotrophinomas in boys aged under 10 years than in girls and difficulty of peri-pubertal diagnosis of growth hormone excess. Collaboration with pituitary specialists caring for adult patients, as part of commissioned and centralized multidisciplinary teams, is key for optimizing management, transition and lifelong care and facilitates the collection of health-related quality of survival outcomes of novel medical, surgical and radiotherapeutic treatments, which are currently largely missing.
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Affiliation(s)
- Márta Korbonits
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK.
| | | | - Anna Boguslawska
- Department of Endocrinology, Jagiellonian University Medical College, Krakow, Poland
| | - John Ayuk
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Justin H Davies
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Maralyn R Druce
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Jane Evanson
- Neuroradiology, Barts Health NHS Trust, London, UK
| | | | - Nigel Glynn
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | | | - Thomas S Jacques
- Great Ormond Street Institute of Child Health, University College London, London, UK
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Saurabh Sinha
- Sheffield Children's and Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Ian Simmons
- The Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Nicky Thorp
- The Christie NHS Foundation Trust, Manchester, UK
| | | | - Helen L Storr
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Helen A Spoudeas
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- University College London Hospitals NHS Foundation Trust, London, UK
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Honegger J, Nasi-Kordhishti I. Surgery and perioperative management of patients with Cushing's disease. J Neuroendocrinol 2022; 34:e13177. [PMID: 35980172 DOI: 10.1111/jne.13177] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 05/09/2022] [Accepted: 05/31/2022] [Indexed: 11/29/2022]
Abstract
Transsphenoidal surgery (TSS) is the initial treatment modality of first choice in Cushing's disease (CD). With microscopic TSS and endoscopic TSS, two operative techniques with equally favourable remission rates and operative morbidity are available. On average, remission is achieved with primary TSS in 80% of patients with microadenomas and 60% of patients with macroadenomas. The current literature indicates that remission rates in repeat TSS for microadenomas can also exceed 70%. Experience with TSS in CD plays an important role in the success rate and centralization in Pituitary Centres of Excellence has been proposed. Microadenoma stage, imaging-visible adenoma, confirmation of ACTH-positive adenoma on histopathology and noninvasiveness are positive predictors for postoperative remission. In postoperative management, a steroid-sparing protocol with early postoperative assessment of remission status is recommended. Convincing evidence suggests that prolonged postoperative prophylactic antithrombotic measures can significantly reduce the risk of postoperative thromboembolic events in CD. Prevention or successful treatment of cortisol withdrawal syndrome remains an unsolved issue that should be a focus of future research. The further development and broad availability of functional imaging hold promise for improved preoperative detection of microadenomas. Intraoperative identification of microadenomas by specific fluorescent targeting could be a promising future avenue for the treatment of patients with negative imaging.
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Affiliation(s)
- Juergen Honegger
- Department of Neurosurgery, University of Tübingen, Tübingen, Germany
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Kang KM, Muralidharan K, Knowlton H, Hassan KIA, Yekula A, Misra M, Swearingen B, Jones PS. Utility of bilateral inferior petrosal sinus sampling for diagnosis and lateralization of Cushing's disease in the pediatric population: case series and review of the literature. J Endocrinol Invest 2022; 45:617-627. [PMID: 34655038 DOI: 10.1007/s40618-021-01680-8] [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: 05/03/2021] [Accepted: 09/16/2021] [Indexed: 12/01/2022]
Abstract
OBJECTS Cushing's disease (CD) is the most common cause of ACTH-dependent hypercortisolism in children age ≥ 7. The utility of bilateral inferior petrosal sinus sampling (BIPSS), an important test in adults, is less defined in children. We present a case series of children with ACTH-dependent hypercortisolemia and review the literature to assess the utility of BIPSS in the diagnosis and localization of CD. METHODS We performed an IRB-approved chart review of patients aged ≤ 18 with ACTH-dependent hypercortisolism at MGH between 2000 and 2019 and collected clinical, laboratory, radiographic, BIPSS, surgical, and outcomes data. RESULTS In our cohort (n = 21), BIPSS had a sensitivity of 93% and specificity of 100% for diagnosis of CD. Compared to surgery, successful BIPSS correctly predicted adenoma laterality in 69% of cases vs. 70% by MRI. Among patients with lesions ≥ 4 mm (n = 9), BIPSS correctly lateralized in 50% vs. 100% by MRI. In patients with subtle lesions (< 4 mm, n = 7), BIPSS correctly lateralized in 80% vs. 71% by MRI. In patients (n = 4) with CD and negative MRIs, BIPSS correctly lateralized in 75% cases. Surgical cure was achieved in 90% of patients and 95% of patients had long-term disease control. CONCLUSIONS In our cohort (n = 21; n = 20 CD, n = 1 ectopic ACTH secretion), BIPSS was sensitive and specific for the diagnosis of CD. Compared to MRI, BIPSS was not additionally helpful for lateralization in patients with lesions ≥ 4 mm on MRI. BIPSS was helpful in guiding surgical exploration and achieving immediate postoperative remission among patients with subtle and negative MRI findings.
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Affiliation(s)
- K M Kang
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA.
- University of California San Diego, San Diego, CA, USA.
| | - K Muralidharan
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - H Knowlton
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - K I A Hassan
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - A Yekula
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - M Misra
- Division of Pediatric Endocrinology, Department of Pediatrics, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - B Swearingen
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - P S Jones
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA
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Stroud A, Dhaliwal P, Alvarado R, Winder MJ, Jonker BP, Grayson JW, Hamizan A, Harvey RJ, McCormack A. Outcomes of pituitary surgery for Cushing's disease: a systematic review and meta-analysis. Pituitary 2020; 23:595-609. [PMID: 32691356 DOI: 10.1007/s11102-020-01066-8] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE Transsphenoidal surgery (TSS) is the first-line treatment for Cushing's disease (CD). This review aimed to synthesize the remission and recurrence rates following TSS for CD and identify predictors of these outcomes. METHODS Medline (1946-) and Embase (1947-) were searched until 23rd January 2019 for original studies. A meta-analysis was performed of remission and recurrence rates. Studies were excluded if patients had prior radiosurgery/radiotherapy, mixed pathologies or interventions without separated data, follow-up not reported or population size < 20. For recurrence rate syntheses, studies with follow-up < 6 months were excluded. RESULTS The search produced 2663 studies, of which n = 68 were included, involving 5664 patients. Remission rates after primary and revision TSS were 80% [77-82] and 58% [50-66] at last follow-up. After primary TSS, predictors of remission were micro- v macroadenomas (83% v 68%, p < 0.01), imaging-visible adenomas (81% v 69%, p < 0.01), adenomas confirmed on histopathology (87% v 45%, p < 0.01), absence of cavernous sinus invasion (80% v 30%, p < 0.01), postoperative serum cortisol (MSeC) nadir < 2 μg/dL (< 55 nmol/L; 95% v 46%, p < 0.01) and lower preoperative 24-h urine free cortisol (1250 nmol v 1726 nmol, p < 0.01). For revision TSS, predictors of remission were postoperative MSeC nadir < 2 μg/dL (< 55 nmol/L; 100% v 38%, p < 0.01) and operations for recurrence v persistence (80% v 54%, p < 0.01). Recurrence rates after primary and revision TSS were 18% [14-22] and 28% [16-42]. CONCLUSIONS TSS is most effective in primary microadenomas, visible on preoperative imaging and without CS invasion, lower preoperative 24-h urine free cortisol and postoperative MSeC nadir < 2 μg/dL (< 55 nmol/L).
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Affiliation(s)
- Anna Stroud
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, Sydney, NSW, Australia.
- St Vincent's Clinical School, Faculty of Medicine, UNSW Sydney, Sydney, NSW, Australia.
- Hormones and Cancer Group, Garvan Institute of Medical Research, Sydney, NSW, Australia.
| | - Pearl Dhaliwal
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, Sydney, NSW, Australia
- St Vincent's Clinical School, Faculty of Medicine, UNSW Sydney, Sydney, NSW, Australia
| | - Raquel Alvarado
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, Sydney, NSW, Australia
| | - Mark J Winder
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, Sydney, NSW, Australia
- St Vincent's Clinical School, Faculty of Medicine, UNSW Sydney, Sydney, NSW, Australia
- Faculty of Medicine, Notre Dame University, Sydney, NSW, Australia
- Department of Endocrinology, St Vincent's Hospital, Sydney, NSW, Australia
| | - Benjamin P Jonker
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, Sydney, NSW, Australia
- Department of Endocrinology, St Vincent's Hospital, Sydney, NSW, Australia
- Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Jessica W Grayson
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, Sydney, NSW, Australia
| | | | - Richard J Harvey
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, Sydney, NSW, Australia
- Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia
| | - Ann McCormack
- St Vincent's Clinical School, Faculty of Medicine, UNSW Sydney, Sydney, NSW, Australia
- Department of Endocrinology, St Vincent's Hospital, Sydney, NSW, Australia
- Hormones and Cancer Group, Garvan Institute of Medical Research, Sydney, NSW, Australia
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Pasternak-Pietrzak K, Moszczyńska E, Roszkowski M, Kot K, Marczak E, Grajkowska W, Pronicki M, Szalecki M. Long-term outcome in patients after treatment for Cushing's disease in childhood. PLoS One 2019; 14:e0226033. [PMID: 31830115 PMCID: PMC6907843 DOI: 10.1371/journal.pone.0226033] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 11/17/2019] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Cushing's disease (CD) is a rare cause of hypercortisolemia presenting a major diagnostic and therapeutic challenge. Data on pituitary function in long-term follow-up after CD treatment in childhood is limited. AIM Long-term assessment of patients of the Children's Memorial Health Institute (CMHI) after CD treatment in childhood. MATERIALS AND METHODS Retrospective analysis of 29 CD patients, mean age at the time of diagnosis 13.46 yrs. The long-term follow-up (FU) was done by: 1) obtaining the data from a patient's questionnaire (75% of adult patients); 2) using the data from the last clinic visit for patients who did not respond to the questionnaire and for current CMHI patients. The average long-term FU from transsphenoidal pituitary surgery (TSS) was 10.23 yrs. RESULTS At the latest FU: 18 patients (62%) had long-term disease remission after TSS1, 2 patients (6.9%) after TSS2, 1 patient (3.4%) after the post-TSS radiotherapy (XRT) cycle and 3 patients (10.3%) after bilateral adrenalectomy (BA). One patient (3.4%) died after TSS2 due to postoperative complications, 1 patient (3.4%) had persistent disease at latest FU, in 1 patient (3.4%) the long-term FU was not possible to perform. CD recurrence occurred in 4 out of 28 patients (14%) at an average time 3.6 yrs. from definitive treatment. One patient (3.4%) after BA was operated because of Nelson's syndrome. Two patients (6.9%) were suspected of relapse at latest assessment. At the time of the last evaluation, 17 patients (63%) were on levothyroxine therapy since definitive treatment, 16 patients (59%) were on hydrocortisone treatment, 10 patients (37%) were taking sex hormones replacement, 4 patients (15%)-antidiuretic hormone. CONCLUSIONS Relatively large number of patients after CD treatment in childhood have hormonal pituitary deficits as well as mood and cognitive disorders. CD recurrence can occur even after a long time post effective treatment.
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Affiliation(s)
- Katarzyna Pasternak-Pietrzak
- Department of Endocrinology and Diabetology, The Children’s Memorial Health Institute (CMHI), Warsaw, Poland
- * E-mail:
| | - Elżbieta Moszczyńska
- Department of Endocrinology and Diabetology, The Children’s Memorial Health Institute (CMHI), Warsaw, Poland
| | - Marcin Roszkowski
- Department of Neurosurgery, The Children’s Memorial Health Institute (CMHI), Warsaw, Poland
| | - Karolina Kot
- Department of Endocrinology and Diabetology, The Children’s Memorial Health Institute (CMHI), Warsaw, Poland
| | - Elżbieta Marczak
- Department of Endocrinology and Diabetology, The Children’s Memorial Health Institute (CMHI), Warsaw, Poland
| | - Wiesława Grajkowska
- Pathology Department, The Children’s Memorial Health Institute, Warsaw, Poland
| | - Maciej Pronicki
- Pathology Department, The Children’s Memorial Health Institute, Warsaw, Poland
| | - Mieczysław Szalecki
- Department of Endocrinology and Diabetology, The Children’s Memorial Health Institute (CMHI), Warsaw, Poland
- Collegium Medicum, University of Jan Kochanowski, Kielce, Poland
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Zhao Y, Lian W, Xing B, Wang R. The characteristics of and surgical treatment for pituitary adenomas in patients under 14 years old. Clin Neurol Neurosurg 2019; 184:105423. [PMID: 31376772 DOI: 10.1016/j.clineuro.2019.105423] [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: 05/31/2018] [Revised: 06/30/2019] [Accepted: 07/07/2019] [Indexed: 11/27/2022]
Abstract
To investigate the clinical characteristics of pituitary adenomas in patients under 14 years old. A total of 140 children and adolescents with pituitary adenomas were admitted to Peking Union Medical College Hospital (PUMCH) from December 1987 to December 2014, and their clinical manifestations, hormone secretions, images, pathological types, surgical complications and follow-up characteristics were analyzed. Fifty-eight (41.4%) males and 82 (58.6%) females with a mean age of 12.5 years old (range, 6-14 years old) were included. Regarding tumor type, adrenocorticotropic hormone (ACTH), prolactin (PRL), growth hormone (GH), non-functioning and multiple-secreting adenomas accounted for 35.7%, 25.7%, 12.2%, 25.7%, and 0.7% of the tumors, respectively. Microadenomas, macroadenomas and giant adenomas accounted for 33.6%, 60.0% and 6.4% of the patients, respectively. Approximately 19.3% of the adenomas included in our study were invasive. Trans-sphenoidal approach surgery (TSS) was commonly used and accounted for 97.9% of the cases in our study. Total resection was achieved in 93.6% of the patients, and subtotal resection was performed in the remaining patients. Finally, 113 patients underwent full-term follow-up until 2 years after surgery, and tumors recurred in 32 patients. TSS is the most commonly used surgical procedure in patients younger than 14 years old. No significant differences in surgical outcomes, mortality during the perioperative period or complications were observed between patients younger than 14 years old and similar patients in the general population.
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Affiliation(s)
- Yi Zhao
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China.
| | - Wei Lian
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China.
| | - Bing Xing
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China.
| | - Renzhi Wang
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
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Crock PA, Lüdecke DK, Knappe UJ, Saeger W. A personal series of 100 children operated for Cushing's disease (CD): optimizing minimally invasive diagnosis and transnasal surgery to achieve nearly 100% remission including reoperations. J Pediatr Endocrinol Metab 2018; 31:1023-1031. [PMID: 30098286 DOI: 10.1515/jpem-2018-0262] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 06/29/2018] [Indexed: 01/01/2023]
Abstract
Background Transnasal surgery (TNS) is the first choice in the treatment of pediatric Cushing's disease. The question is how can high remission rates be achieved with minimally invasive investigations and TNS whilst avoiding radiotherapy or bilateral adrenalectomy in children. Methods Data from a published series 1 (n=55) of surgeon DKL will be compared with his recent series 2 (n=45) until 2009. All patients were operated by direct transnasal microsurgery. Over time, inferior petrosal sinus sampling (IPSS) was replaced by cavernous sinus sampling (CSS), restricted to unclear cases without increase of salivary cortisol in corticotropin-releasing hormone-test, difficult sellar anatomy or negative magnetic resonance imaging (MRI). Multiple direct intra-operative micro-cytology, micro-doppler and adequate visualization techniques are described. Results In series 1, IPSS was performed in 13 (24%) of whom 46% had false adenoma lateralization. All adenomas could be removed with extensive pituitary exploration. Three patients had early successful re-surgery. In series 2, with more refined MRI and endocrinology, CSS was used in only seven patients (15%) and all micro-adenomas were correctly localized. In three of four patients with persistent cortisol excess, repeat-TNS was necessary and successful. Side effects of TNS were minimal. Recurrence rates were 16% and 11% in series 1 and 2, respectively. Only four of 100 children with invasive adenomas were irradiated, significantly less than in other experienced pediatric centers. Conclusions Thus, 98% remission rate could be achieved with fewer invasive pre-surgical investigations, such as central catheter studies, refined TNS and early repeat-TNS. Repeat-TNS in recurrences minimized the need for irradiation.
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Affiliation(s)
- Patricia A Crock
- Department Paediatric Endocrinology and Diabetes, John Hunter Children's Hospital, Locked Bag 1, Hunter Region Mail Centre, Newcastle, NSW 2310, Australia.,PRC GrowUpWell®, Hunter Medical Research Institute and Department Paediatrics, University of Newcastle, Newcastle, NSW, Australia, Phone: +61249855634, Fax: +61249213599
| | - Dieter K Lüdecke
- Retired Emeritus Pituitary Surgeon, Department Neurosurgery, University Hospital Eppendorf, Hamburg, Germany
| | - Ulrich J Knappe
- Department Neurosurgery, Johannes Wesling Klinikum, University Hospital of the Ruhr University Bochum, Minden, Germany
| | - Wolfgang Saeger
- Department of Neuropathology, Pituitary Pathologist, University Hospital Eppendorf, Hamburg, Germany
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Krajewski KL, Rotermund R, Flitsch J. Pituitary adenomas in children and young adults. Childs Nerv Syst 2018; 34:1691-1696. [PMID: 29850940 DOI: 10.1007/s00381-018-3853-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 05/22/2018] [Indexed: 11/25/2022]
Abstract
PURPOSE Pituitary adenomas are rare in the pediatric population. We present a recent cohort of children operated transsphenoidally on pituitary adenoma from a single center. METHODS Inclusion criteria were age < 21 years and histopathological diagnosis of adenoma after transsphenoidal surgery. The electronic file was used for prospective and retrospective data collection on symptoms, pituitary function before/after surgical intervention, and surgical complications. Surgical reports were used for assessment of resection grade. Follow-up data were collected from outpatient clinical visit and/or correspondence concerning pituitary function and MRI. RESULTS Among 962 consecutive patients who underwent transsphenoidal surgery at the University Medical Center Hamburg-Eppendorf (Germany) between April 2013-December 2016, 50 patients (5.2%) were 21 years old or younger (range 6-21 years, mean 16.5). Twenty-five (50%) patients had pituitary adenomas; M:F = 13:12. Eight were macroadenomas (> 1cm3). Time from onset of symptoms to first operation had a range of 0-48 months (mean 18.5 months). Nine (36%) patients overall complained of headaches preoperatively. One patient had objective (hemianopsia) and four subjective visual disturbances preoperatively. Histopathological diagnosis revealed 13 (52%) ACTH adenomas, 5 (20%) prolactinomas, 3 (12%) mixed GH-prolactinoma, 1 (4%) GH adenoma, 2 (8%) TSH-producing adenomas, and 1 (4%) non-functioning adenoma. There were no surgical complications. On clinical follow-up (range 1-34.5 months, mean 11.7 months), 21/24 (88%) patients with hormonally active tumors were in biochemical remission by surgery alone; 2 patients with Cushing disease and 1 with GH-hypersecretion required further treatment. CONCLUSIONS Our recent series confirms the effectiveness and safety of transsphenoidal surgery, especially in the pediatric patient population.
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Affiliation(s)
- Kara Leigh Krajewski
- Department of Neurosurgery, University Medical Center UKSH-Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany. .,Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Roman Rotermund
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jörg Flitsch
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Abstract
A case of possible recurrent Cushing's disease (CD) is presented and data on current definitions of CD remission, persistence, and recurrence are reviewed. While prevailing guidelines recommend the use of serum cortisol in the first post-operative week for defining initial remission and predicting sustained remission, with the use of 24 h urinary free cortisol measurements if serum cortisol values are equivocal, there is debate as to which methods and thresholds best define CD remission and predict successful outcomes. Other methods used to define remission (and hence persistence and recurrence) include restoration of cortisol suppression after dexamethasone and physiologic diurnal cortisol rhythm as measured by midnight salivary free cortisol. However, the number and degree of abnormal test results needed to define recurrence, and the determination of which biochemical test has more significance when there are discrepancies between markers is inconsistent among studies. Further inquiry is warranted to examine if patients in apparent CD remission who have subtle hypothalamic pituitary adrenal (HPA) axis abnormalities represent distinctive remission subtypes versus mild or early recurrence. Additional investigation could also explore the degree to which these HPA axis abnormalities, such as alterations in cortisol circadian rhythm or partial resistance to dexamethasone, are associated with persistence of CD morbidities, including neuropsychiatric impairments, alterations in body composition, and cardiovascular risk.
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Affiliation(s)
- Eliza B. Geer
- Assistant Professor of Medicine and Neurosurgery, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1055, New York, NY 10029, Tel: 212-241-6139, Faxt: 212-423-0508,
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10
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Keil MF. Quality of life and other outcomes in children treated for Cushing syndrome. J Clin Endocrinol Metab 2013; 98:2667-78. [PMID: 23640970 PMCID: PMC3701267 DOI: 10.1210/jc.2013-1123] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2013] [Accepted: 04/22/2013] [Indexed: 11/19/2022]
Abstract
CONTEXT Cushing syndrome (CS) in children is associated with residual impairment in measures of health-related quality of life, even after successful resolution of hypercortisolemia, highlighting the need for early identification of morbidities and improvements in long-term management of these patients. EVIDENCE ACQUISITION AND SYNTHESIS A PubMed, Scopus, and Web of Science search of articles from 1900 onward identified available studies related to quality of life and complications of pediatric CS as well as important historical articles. This review summarizes studies through November 2012 and highlights recent developments. CONCLUSIONS A review of the literature identifies significant morbidities associated with CS of pediatric onset, which must not be treated in isolation. CS affects children and adolescents in many ways that are different than adults. Post-treatment challenges for the child or adolescent treated for CS include: optimize growth and pubertal development, normalize body composition, and promote psychological health and cognitive maturation. All these factors impact health-related quality of life, which is an important outcome measure to assess the burden of disease as well as the effect of treatment. Future research efforts are needed to improve management of the physical, psychological, and emotional aspects of this disease in order to diminish the residual impairments experienced by the pediatric CS patient population.
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Affiliation(s)
- Margaret F Keil
- Section on Endocrinology Genetics, Program on Developmental Endocrinology Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20892, USA.
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11
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Shah NS, George J, Acharya SV, Lila AR, Sarathi V, Bandgar TR, Jalali R, Goel AH, Menon P. Cushing disease in children and adolescents: twenty years' experience in a tertiary care center in India. Endocr Pract 2011; 17:369-76. [PMID: 21134883 DOI: 10.4158/ep10143.or] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To analyze the clinical presentation, diagnostic evaluation, treatment modalities, and follow-up of pediatric patients with Cushing disease. METHODS In this retrospective analysis, we reviewed records of children (younger than 20 years) with Cushing disease who had undergone transsphenoidal adenomectomy in a tertiary health care center in India during the period of 1988 to 2008. Endogenous hypercortisolism was identified by a serum cortisol value ≥1.8 μg/dL during a low-dose dexamethasone suppression test (LDDST) with or without elevated midnight serum cortisol (≥3.2 μg/dL). Corticotropin dependence was defined by a basal plasma corticotropin concentration ≥5 pg/mL. Patients with normal pituitary imaging underwent bilateral inferior petrosal sinus sampling (BIPSS). Those with persistent or recurrent disease after surgery were treated with second-line interventions on a case-by-case basis. RESULTS Twenty-nine boys and 19 girls were included. Mean age was 14.85 (±2.5) years. Weight gain (98%), round facies (98%), and growth arrest (83%) were the most common manifestations. LDDST and midnight cortisol had 100% sensitivity for detecting endogenous hypercortisolism, while midnight corticotropin measurement had 100% sensitivity for defining corticotropin dependence. Magnetic resonance imaging and unstimulated BIPSS had 71% and 89% sensitivity, respectively, for diagnosing Cushing disease. Twenty-seven patients (56%) achieved remission after the first transsphenoidal operation with higher remission rates in those with microadenoma (75%). Basal serum cortisol <5 mg/dL on the fifth postoperative day predicted cure. Eight patients received postoperative radiotherapy, with 4 achieving remission. CONCLUSIONS Clinical presentation and diagnostic yield with various tests were similar to those previously reported in the literature. Remission rates were poor after first transsphenoidal operation in patients with macroadenoma and outcome was dismal with a second transsphenoidal operation. Serum cortisol concentration <5 mg/dL on the fifth postoperative day predicted cure.
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Affiliation(s)
- Nalini S Shah
- Department of Endocrinology, Seth G S Medical College, Mumbai, India.
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12
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Acharya SV, Gopal RA, Goerge J, Menon PS, Bandgar TR, Shah NS. Radiotherapy in paediatric Cushing's disease: efficacy and long term follow up of pituitary function. Pituitary 2010; 13:293-7. [PMID: 20411340 DOI: 10.1007/s11102-010-0231-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Pituitary radiotherapy (RT) is an effective second-line treatment for paediatric Cushing's disease (CD). We report long-term efficacy and anterior pituitary function in a cohort of paediatric CD patients treated with RT. Between 1988 and 2008, from our cohort of 48 paediatric CD patients, eight paediatric CD patients (5 males and 3 females) underwent second-line pituitary RT (45 Gy in 25 fractions), following unsuccessful transsphenoidal surgery. Out of eight whose long term follow up is available, four patients were cured by RT. Minimum follow up of 2 years is available for all patients. Four patients achieved cure after RT. Two patients were not cured even after follow up of 60 and 132 months, respectively. Out of four uncured patients, two of them had suppressible low dose dexamethasone cortisol with altered circadian rhythm suggesting possibility of response in near future with follow up of just 26 months. Five patients were hypogonadal and one patient was hypothyroid. All patients were below their target height at the time of last follow up. None of the patients had posterior pituitary dysfunction. This series of patients illustrates the efficacy and long-term follow up of pituitary function in children with CD treated with RT. This study also emphasizes the need of growth hormone statues assessment and timely intervention.
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Affiliation(s)
- Shrikrishna V Acharya
- Department of Endocrinology, Seth G S Medical College and KEM Hospital, Mumbai, 12 Maharashtra, India.
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Knappe UJ, Fink T, Fisseler-Eckhoff A, Schoenmayr R. Expression of extracellular matrix-proteins in perisellar connective tissue and dura mater. Acta Neurochir (Wien) 2010; 152:345-53; discussion 353. [PMID: 19730772 DOI: 10.1007/s00701-009-0497-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2009] [Accepted: 08/06/2009] [Indexed: 11/29/2022]
Abstract
PURPOSE To describe the pattern of expression of extracellular matrix (ECM) proteins in perisellar connective tissue. METHODS Dural and perisellar specimens from ten individuals were investigated immunohistochemically for collagens I to IV, tenascin, fibronectin, elastin, laminin, and vitronectin. FINDINGS Collagen I and III and fibronectin were strongly expressed and collagen IV, tenascin, and vitronectin were moderately expressed in the boundaries of the sella and around the CS. In six of nine specimens from the anterior boundary of the sella, and in 11 of 19 samples from the lateral boundary of the sella (medial wall of CS), two different layers could be detected by the expression of different ECM proteins. None of the antigens generally allowed differentiation between two layers of the pituitary envelope. CONCLUSIONS The pituitary boundary may consist of a single or a double layer, infrequently differentiated from each other by the expression of different ECM proteins.
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Affiliation(s)
- Ulrich J Knappe
- Department of Neurosurgery, Johannes Wesling Klinikum, Hans-Nolte-Str. 1, 32429 Minden, Germany.
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Patil CG, Veeravagu A, Prevedello DM, Katznelson L, Vance ML, Laws ER. OUTCOMES AFTER REPEAT TRANSSPHENOIDAL SURGERY FOR RECURRENT CUSHING'S DISEASE. Neurosurgery 2008; 63:266-70; discussion 270-1. [DOI: 10.1227/01.neu.0000313117.35824.9f] [Citation(s) in RCA: 101] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Chirag G. Patil
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Anand Veeravagu
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Daniel M. Prevedello
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Laurence Katznelson
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Mary L. Vance
- Department of Internal Medicine-Endocrinology, University of Virginia Health System, Charlottesville, Virginia
| | - Edward R. Laws
- Departments of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia, and Stanford University School of Medicine, Stanford, California
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Hofmann BM, Hlavac M, Martinez R, Buchfelder M, Müller OA, Fahlbusch R. Long-term results after microsurgery for Cushing disease: experience with 426 primary operations over 35 years. J Neurosurg 2008; 108:9-18. [PMID: 18173305 DOI: 10.3171/jns/2008/108/01/0009] [Citation(s) in RCA: 132] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVES The aim of this paper was to demonstrate the long-term results following microsurgery in a single surgeon's continuous series of patients with Cushing disease (CD), to assess the influence of changes in surgical procedures, and to compare the results with those of other treatment modalities. In particular, preoperative diagnosis, tumor size, results of histological examination, and complications were considered. METHODS Between 1971 and 2004, 426 patients suffering from newly diagnosed CD underwent primary surgery. Pre-operative measures included clinical examination, endocrinological workup (testing of the hypothalamic-pituitary-adrenal axis, and 2- and 8-mg dexamethasone overnight suppression tests), sellar imaging (polytomography, computed tomography, and magnetic resonance [MR] imaging), and in patients with negative results on imaging studies, inferior petrosal sinus sampling. Follow-up examinations consisting of endocrinological workup, and imaging took place 1 week and 3 months after surgery and then at yearly intervals. RESULTS During microsurgery as first treatment, the adenoma finding rate was 86.6%. After selective adenomectomy, the remission rate was 75.9%, and this rate showed no improvement over the years. The best results were achieved in microadenomas confirmed on MR imaging or histopathological investigation. The recurrence rate (15%) and the complication rate (5.9%) declined over the years. If no adenoma was found, exploration of the sella turcica was performed in 45.6%, hypophysectomy in 3.5%, and hemihypophysectomy in 50.9% of these patients, leading to an early remission in 37.9%. In case of persistence or recurrence, further treatment (repeated operation, adrenalectomy, radio-therapy, or medical treatment) was used to control the disease. CONCLUSIONS Microsurgery remains the treatment of first choice in CD, even though no improvement in remission rates was observed over the years, because complication or remission rates for other treatment options are comparable or worse.
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Kelly DF. Transsphenoidal surgery for Cushing's disease: a review of success rates, remission predictors, management of failed surgery, and Nelson's Syndrome. Neurosurg Focus 2007; 23:E5. [PMID: 17961026 DOI: 10.3171/foc.2007.23.3.7] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Cushing's disease is a serious endocrinopathy that, if left untreated, is associated with significant morbidity and mortality rates. After diagnostic confirmation of Cushing's disease has been made, transsphenoidal adenomectomy is the treatment of choice. When a transsphenoidal adenomectomy is performed at experienced transsphenoidal surgery centers, long-term remission rates average 80% overall, surgical morbidity is low, and the mortality rate is typically less than 1%. In patients with well-defined noninvasive microadenomas, the long-term remission rate averages 90%. For patients in whom primary surgery fails, treatment options such as bilateral adrenalectomy, stereotactic radiotherapy or radiosurgery, total hypophysectomy, or adrenolytic medical therapy need to be carefully considered, ideally in a multidisciplinary setting. The management of Nelson's Syndrome often requires both transsphenoidal surgery and radio-therapy to gain disease control.
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Affiliation(s)
- Daniel F Kelly
- John Wayne Cancer Institute at Saint John's Health Center, Santa Monica, California 90404, USA.
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17
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Storr HL, Chan LF, Grossman AB, Savage MO. Paediatric Cushing's syndrome: epidemiology, investigation and therapeutic advances. Trends Endocrinol Metab 2007; 18:167-74. [PMID: 17412607 DOI: 10.1016/j.tem.2007.03.005] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2007] [Revised: 03/05/2007] [Accepted: 03/19/2007] [Indexed: 10/23/2022]
Abstract
Cushing's syndrome (CS), which is caused by excessive circulating glucocorticoid concentrations, is rare in the paediatric age range but presents a diagnostic and therapeutic challenge. Most paediatric endocrinologists have limited experience of managing children or adolescents with CS and thus benefit from close consultation with colleagues who treat adult patients. A protocol for investigation is required that broadly follows the model for adult patients. Here, the epidemiology and diagnosis of different causes of CS are discussed according to typical age of presentation. Treatment strategies for adrenocorticotrophic hormone (ACTH)-independent and ACTH-dependent CS are described and critically appraised. The management of paediatric CS patients after cure also presents challenges for optimizing growth, bone health, reproduction and body composition from childhood into and during adult life.
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Affiliation(s)
- Helen L Storr
- Department of Endocrinology, William Harvey Research Institute, Barts and the London, Queen Mary's School of Medicine and Dentistry, John Vane Science Centre, Charterhouse Square, London, EC1M 6BQ, UK
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18
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Mehrazin M. Pituitary tumors in children: clinical analysis of 21 cases. Childs Nerv Syst 2007; 23:391-8. [PMID: 17143643 DOI: 10.1007/s00381-006-0259-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2005] [Revised: 07/05/2006] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The aim of this study is to review the results of surgery for pituitary adenomas in children less than 18 years old. MATERIALS AND METHODS A retrospective review was done of pituitary adenoma patients with the age of less than 18 years who were treated in the period 1979-2003 at Dr. Shariati Hospital. CONCLUSIONS Twenty-one patients (12 girls and 9 boys) were identified. The age range (mean) in girls and boys was 9-18 (15.8) and 9-17 (14.8) years, respectively. The duration of follow-up was 1-23 (13.4) years. Eight patients (38.1%) had adrenocorticotropic hormone-secreting tumors, 33.3% had prolactin-secreting tumors, 19% had growth hormone-secreting tumors, and 9.53% had nonfunctioning adenomas. Multidisciplinary management included surgery and, if necessary, reoperation with/without radiotherapy and pharmacotherapy. Eleven patients, mostly with prolactinomas, acromegaly, and nonfunctioning adenomas, needed reoperation and radiotherapy. There were two deaths, one of which was because of apoplexy. The biological behavior of pediatric pituitary adenomas seems more aggressive than adults' adenomas. The chance of pituitary apoplexy in pediatric invasive pituitary adenoma is high.
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Affiliation(s)
- M Mehrazin
- Department of Neurological Surgery, Dr Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran.
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Abstract
Cushing's disease (CD) is rare in the pediatric age range, but may present a diagnostic and therapeutic challenge. Most pediatric endocrinologists have limited experience managing children or adolescents with CD and thus benefit from close consultation with adult colleagues. A diagnostic protocol for investigation is required which broadly follows the model for adult patients. Treatment strategies for CD are described and critically appraised. The management of pediatric CD patients after cure also presents challenges for optimizing growth, bone health, reproduction and body composition from childhood into and during adult life.
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Affiliation(s)
- Martin O Savage
- Department of Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, John Vane Science Centre, Charterhouse Square, London EC1M 6BQ, UK.
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20
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Hofmann BM, Hlavac M, Kreutzer J, Grabenbauer G, Fahlbusch R. Surgical Treatment of Recurrent Cushing's Disease. Neurosurgery 2006; 58:1108-18; discussion 1108-18. [PMID: 16723890 DOI: 10.1227/01.neu.0000215945.26764.92] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
OBJECTIVE:
The aim of this study was to evaluate the role of transsphenoidal selective adenomectomy alone or in combination with adjuvant therapy in treatment of recurrent Cushing's disease.
METHODS:
A total of 16 patients with recurrent Cushing's disease underwent reoperation, 15 via a transsphenoidal approach and one via a combined transsphenoidal/transcranial approach. Selective adenomectomies were performed in 13 patients and hemihypophysectomies were performed in three patients. Endocrinologically, recurrence was diagnosed by an overnight 2-mg dexamethasone suppression test. All patients underwent a 1.5-T magnetic resonance imaging scan, and eight patients underwent inferior petrosal sinus sampling.
RESULTS:
After selective adenomectomy, six of the 13 patients went into remission. Recurrence always occurred at the localization of the original tumor. In three patients without intraoperative tumor detection, hypophysectomy did not lead to remission. In 10 patients with persistent disease, adjuvant therapy (radiotherapy, adrenalectomy) led to normalization of basal cortisol levels in eight patients and clinical remission in one patient. One patient was lost to follow-up. In 10 patients, no evidence of an adenoma was visible on the preoperative magnetic resonance imaging scan. Inferior petrosal sinus sampling allowed correct prediction of the tumor localization in two of eight patients.
CONCLUSION:
By performing repeated selective adenomectomy, patients with recurrent Cushing's disease can be cured without the risk of endocrine deficits or major complications. Dynamic endocrine tests are of paramount importance for surgical decision making. Imaging and inferior petrosal sinus sampling are not helpful in locating the recurrent tumor. If normalization can not be achieved, adjuvant therapy is mandatory.
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Affiliation(s)
- Bernd M Hofmann
- Department of Neurosurgery, University of Erlangen-Nuremberg, Erlangen, Germany.
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Dusick JR, Esposito F, Mattozo CA, Chaloner C, McArthur DL, Kelly DF. Endonasal transsphenoidal surgery: the patient's perspective—survey results from 259 patients. ACTA ACUST UNITED AC 2006; 65:332-41, discussion 341-2. [PMID: 16531188 DOI: 10.1016/j.surneu.2005.12.010] [Citation(s) in RCA: 94] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2005] [Accepted: 12/19/2005] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patient impressions remain an important yet often overlooked aspect of surgical success. Herein we present postoperative questionnaire results in patients after a standard direct endonasal approach, an extended suprasellar endonasal approach, and a reoperative transsphenoidal surgery for tumor removal with the operating microscope. METHODS From July 1998 through April 2005, of 452 patients undergoing endonasal surgery, 346 were sent questionnaires, and of these, 259 (75%) completed them. Nasal packing was placed for 24 hours in the first 95 patients but not in the last 357. RESULT Overall, 73% of patients reported a better experience than expected and 8% worse than expected. A worse than expected overall experience was noted in 15% of patients with nasal packing compared with 5% of patients without packing (P = .001). Of patients with preoperative headache, 49% resolved, 34% somewhat resolved, and 5% worsened. The frequency of rhinological complaints declined from 2 weeks to 3 months postsurgery (P < .001); by 3 months or more postsurgery, 67% to 87% of patients had no rhinological complaints and 1% to 2% had severe complaints. Of 30 patients with prior sublabial surgery, the endonasal procedure afforded easier recovery (87%), less pain (80%), better nasal airflow (79%), and a shorter hospital stay (median 3 vs 5 days) (P < .001). Of 28 patients with complications, the severity of rhinological complaints was similar to those without complications except this subgroup reported greater loss of sense of smell 3 months after surgery (P < .001). CONCLUSIONS Rhinological recovery is typically rapid and relatively complete after direct endonasal transsphenoidal surgery using both standard and extended suprasellar approaches. Compared with the sublabial route, the endonasal approach is associated with less pain, better nasal airflow, and a shorter hospital stay.
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Affiliation(s)
- Joshua R Dusick
- Division of Neurosurgery, University of California at Los Angeles School of Medicine, 200 UCLA Medical Plaza, Los Angeles, CA 90095-7182, USA
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22
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Storr HL, Isidori AM, Monson JP, Besser GM, Grossman AB, Savage MO. Prepubertal Cushing's disease is more common in males, but there is no increase in severity at diagnosis. J Clin Endocrinol Metab 2004; 89:3818-20. [PMID: 15292311 DOI: 10.1210/jc.2003-031531] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Sex distribution and severity of biochemical indices at the diagnosis of Cushing's disease (CD) were analyzed in 50 patients (21 males and 29 females; aged <or=30 yr; range, 6.4-30.0 yr). Twenty-five (50%) presented aged 18 yr or younger (17 males and eight females) and 25 aged 18-30 yr (four males and 21 females). CD diagnosed at less than 18 yr occurred predominantly in males, contrasting with 18 yr or older, which was more common in females. The difference between the two groups was significant (P = 0.0003). There was a significant difference (chi(2)) in sex distribution depending on pubertal status (P = 0.0002); in prepubertal patients (n = 11) males predominated (91%) compared with postpubertal patients (n = 27), where females predominated (81%). In patients in puberty (n = 12), there was an equal sex incidence (50% males). In adult patients with CD, males have been reported to have more severe disease. We found no difference in hypercortisolemia or ACTH at diagnosis in males compared with females in the patients less than 18 yr of age [serum 0000 h cortisol, 510.5 +/- 75.2 vs. 415.6 +/- 63.7 nmol/liter (P = 0.52); plasma ACTH, 48.5 +/- 7.9 vs. 42.9 +/- 10.9 ng/liter (P = 0.54); percent suppression of serum cortisol during low dose dexamethasone suppression test, 57.2 +/- 8.6% vs. 33.5 +/- 13.1% (P = 0.14); high dose dexamethasone suppression test, 85.9 +/- 3.1% vs. 85.7 +/- 4.9% (P = 0.55); percent increase in cortisol after iv CRH, 180.3 +/- 15.3% vs. 189.9 +/- 20.3% (P = 0.67)]. In conclusion, female preponderance of CD in adult patients was not present in childhood. In patients 18 yr of age or younger, there was no difference in the severity of hypercortisolemia or ACTH at diagnosis between males and females.
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Affiliation(s)
- Helen L Storr
- Department of Endocrinology, St. Bartholomew's and The Royal London School of Medicine and Dentistry, West Smithfield, London, United Kingdom EC1A 7BE
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Abstract
A micro-pressure-suction-irrigation system (MPSIS) is a surgical device that cleans the operative field of blood and tumor tissues with one-hand manipulation, dissects tumor tissue with its rapid flow, and removes debris by suction without injury to the normal tissue structures. Since 1997, good transnasal surgical results for pituitary adenomas have been achieved in Japan using this system. However, the surgical results for large, fibrous pituitary adenomas were unfavorable. Ultrasonic surgical aspirators with needle-type probes and an electromagnetic field system, all recently developed in Japan, are improving the results of direct transnasal surgery on pituitary adenomas. The MPSIS effectively dissects typical adenoma tissue with rapid irrigation and removes it by suction. A tumor in the cavernous sinus was removed by this system under direct vision in combination with pituitary mirrors. Fibrous adenomas were resected using ultrasonic surgical aspirators with needle-type probes. Thick mucosa and a firm tumor were vaporized with an electromagnetic field system. The sellar floor was reconstructed with combined ceramics, used in cases requiring additional surgery or drainage of cerebrospinal fluid leakage during surgery. Direct transnasal surgery with these devices was performed to remove 143 pituitary adenomas. Most of these pituitary adenomas could be selectively removed except for those lesions with extensive cavernous sinus invasion. There was no surgical morbidity or mortality. With the advancement of surgical technique and the development of surgical devices, most pituitary adenomas, even those that are fibrous or firm, can be removed via the transnasal route.
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Affiliation(s)
- Takumi Abe
- Department of Neurosurgery, Showa University School of Medicine, 5-8 Hatanodai 1, Shinagawa-ku, Tokyo 142-8666, Japan.
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Abe T, Lüdecke DK. Transnasal surgery for prolactin-secreting pituitary adenomas in childhood and adolescence. SURGICAL NEUROLOGY 2002; 57:369-78; discussion 378-9. [PMID: 12176193 DOI: 10.1016/s0090-3019(02)00714-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Prolactin (PRL)-secreting pituitary adenomas (prolactinomas) are rare in childhood and adolescence; there are only a few published series of patients who were surgically treated. We discuss the gender-dependent differences, and the surgical indications and results for 14 patients with prolactinomas under 18 years of age at surgery. METHODS We reviewed the data for 14 patients (10 girls and 4 boys) treated surgically for prolactinomas between 1980 and 1996. Surgery was chosen because of intolerance and/or resistance to dopamine agonist (DA) in 9 patients, the patient's decision in 3, rhinorrhea in 1, and pituitary apoplexy in 1 during DA therapy. All patients underwent direct transnasal explorations. Since 1988, intraoperative PRL measurements were performed. The follow-up period was at least 6 years. RESULTS Nine of the 10 girls had primary or secondary amenorrhea, and 3 of the 4 boys had visual field defects. The boys and girls were the same age at the onset of symptoms and had the same preoperative duration of symptoms. Boys had larger, more invasive tumors and higher preoperative and postoperative plasma PRL levels than girls. Two boys demonstrated significant extrasellar extension at the time of diagnosis. Two patients required drilling of the incompletely pneumatized sphenoid sinus to reach the sella. Radical tumor resection was achieved in seven girls and in none of the four boys. In 12 of the 14 patients, normal pituitary function was preserved by transnasal surgery. There was no severe surgical morbidity or mortality. Endocrinological remission by surgery alone was achieved for seven girls, and was achieved in 4 of the 5 patients (80%) with microadenomas. In patients with preoperative mean PRL levels of less than 200 microg/L, the surgical cure rate was 75%. CONCLUSIONS Prolactinomas in childhood and adolescence differ in their biology in boys and girls. Transnasal surgery is as safe in childhood patients as it is in adult patients, and it may be an effective alternative to long-term medical therapy for selected patients with prolactinomas. Successful surgical outcomes were achieved in patients with microadenomas and preoperative serum PRL levels of less than 200 microg/L.
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Affiliation(s)
- Takumi Abe
- Department of Neurosurgery, Showa University School of Medicine, Tokyo, Japan
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25
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Acebes JJ, Cabiol J, López L, Gabarrós A, Muntanya E, Soler J. [Cushing's disease in the 90's: a review]. Neurocirugia (Astur) 2002; 12:86-103; discussion 104. [PMID: 11706450 DOI: 10.1016/s1130-1473(01)70697-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Since 1932 when Cushing's disease has been described, several important advances have been made in diagnosis and management. However several points remain obscure and there is no general agreement among authors. An accurate biological diagnosis is one of the difficulties found when we face a patient with hypercortisolism. In addition, corticotropin dependent syndrome should be distinguished from the independent one, as well as identifying the source of ACTH hypersecretion. The main problem in Cushing's disease is to localise the secreting adenoma and at the moment there is not any diagnostic method with absolute sensibility and specificity. Magnetic Resonance Imaging shows a sensibility of 77% and 87% especificity; inferior petrosal sinus sampling may help in localising the side, where the adenoma lies, although an appropriate technique is mandatory. New developing techniques, such as intraoperative doppler and assessment of ACTH levels in the peripituitary veins may help us in localising the source of ACTH hypersecretion. Sometimes the adenoma cannot be identified and a surgical exploration of the pituitary is required. If an adenoma is found, a 89% probility of curation has been reported; on the contrary, incomplete tumor removal, no tumor found at surgery, or the presence of the so-called corticotrop hyperplasia where followed of bad results and may explain the failed surgery. Then, hypofisectomy, hemi-hypofisectomy, radiotherapy, photon knife or gamma knife, may be of help in the control of this condition. We reviewed the recent literature and analysed the diagnostic strategies and teatments currently available for this illness. In addition we propose an algohritm for diagnosis and treatment and analyze our results in a consecutive series of 38 patients.
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Affiliation(s)
- J J Acebes
- Servicio de Neurocirugía, Hospital Universitario de Bellvitge, Barcelona
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Nishio S, Morioka T, Suzuki S, Takeshita I, Fukui M, Iwaki T. Pituitary tumours in adolescence: clinical behaviour and neuroimaging features of seven cases. J Clin Neurosci 2001; 8:231-4. [PMID: 11386796 DOI: 10.1054/jocn.2000.0758] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The clinicopathologic features of seven paediatric patients with pituitary adenomas (2 male, 5 female; mean age 14.3 years) were reviewed. There were three non-functioning adenomas, three prolactinomas, and one growth hormone producing adenoma. Five patients presented with visual field deficits, and six patients had endocrine symptoms, which included menstrual irregularities in all female patients, pubertal delay in two females, and growth delay and gigantism in one case each. On neuroimaging studies, five adenomas showed parasellar extension, while the remaining two prolactinomas were intrasellar microadenomas. While two patients with prolactinomas received good results with bromocriptine treatment alone, the remaining five patients underwent either craniotomy or transsphenoidal surgery. Postoperatively, visual disturbances improved markedly in all patients. Two patients also received replacement hormonal therapy. While six patients have been stable for 3.6 years on average, one non-functioning tumour recurred 2 years after the initial transcranial subtotal resection of the tumour. Although there are still many unknowns concerning the biology and optimal treatments for paediatric pituitary adenomas, many of them are assumed to be relatively rapidly growing tumours, while others merely have an earlier tumour genesis than in adults.
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Affiliation(s)
- S Nishio
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
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De Menis E, Visentin A, Billeci D, Tramontin P, Agostini S, Marton E, Conte N. Pituitary adenomas in childhood and adolescence. Clinical analysis of 10 cases. J Endocrinol Invest 2001; 24:92-7. [PMID: 11263478 DOI: 10.1007/bf03343820] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Pituitary adenomas in childhood and adolescence constitute 2-6% of all operated pituitary adenomas. We report the clinical features, treatment and follow-up of 10 pediatric patients affected by pituitary adenomas. All patients underwent clinical evaluation, endocrine tests, magnetic resonance imaging and visual field assessment. Follow-up ranged from 8 to 132 months (median 52.6). All patients were older than 10 years of age; 60% were males. In 50% the initial complaints were headache and/or visual impairment, all except one had clear evidence of endocrine dysfunction. Ninety percent were macroadenomas. According to hormone measurements and immunostaining 50% were prolactinomas, 20% were pure GH-secreting and 30% were non-functioning adenomas. Prolactinomas in two females were successfully treated with cabergoline. The other patients underwent surgery: three prolactinomas are still being treated with dopamine agonists and a GH-secreting adenoma is being treated with octreotide LAR and cabergoline. Two patients were also treated with conventional radiotherapy. Treatments were completely successful in 50% of patients: these have normal hormone secretion, full pubertal development, no significant tumor mass and normal visual field. Hypersecretion of prolactin persists in two cases; partial or complete hypopituitarism is present in four, relevant tumor remnant in another four and impairment of visual field is present in two cases. In conclusion, pediatric adenomas occur mostly in pubertal age, are prevalently macroadenomas and clinically functioning. Medical therapy should be preferred for secreting adenomas, but in some cases, notably prolactinomas in males, surgery and eventual radiotherapy may be needed.
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Affiliation(s)
- E De Menis
- I Medical Division, Regional Hospital, Treviso, Italy.
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Nagesser SK, van Seters AP, Kievit J, Hermans J, van Dulken H, Krans HM, van de Velde CJ. Treatment of pituitary-dependent Cushing's syndrome: long-term results of unilateral adrenalectomy followed by external pituitary irradiation compared to transsphenoidal pituitary surgery. Clin Endocrinol (Oxf) 2000; 52:427-35. [PMID: 10762285 DOI: 10.1046/j.1365-2265.2000.00958.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND The preferred treatment of Cushing's disease (CD) nowadays is transsphenoidal pituitary surgery (TPS). Prior to TPS, patients at the Leiden University Medical Centre were treated by unilateral adrenalectomy followed by external pituitary irradiation (UAPI). We report on long-term results of both UAPI and TPS and compare remission, relapse rates, and complications. PATIENTS AND METHODS A retrospective study was carried out on 130 patients with CD. Patients with pituitary macroadenoma were excluded. Eighty-six and 44 patients underwent UAPI and TPS, respectively. Of these patients, 85 and 41 were evaluable for long-term results. RESULTS Remission following UAPI and TPS was identical at 64% (54/85 and 27/41). Cumulative relapse was also comparable - 17% (9/54) and 22% (6/27), respectively, - for UAPI and TPS, although the mean follow-up periods were different - 21.4 years and 8.5 years, respectively. Cumulative disease-free survival curves after UAPI and TPS are identical until 5 years of follow-up, but diverge thereafter indicating more sustained remissions following UAPI (P = 0.17, Wilcoxon statistic). Pituitary dysfunction following UAPI (36%) and pituitary surgery (55%) likewise did not differ significantly. However, pituitary dysfunction was an immediate event after TPS, whereas it developed after a mean interval of 17.8 years following UAPI.Low-dose dexamethasone testing during follow-up had no value in predicting therapeutic outcome. CONCLUSIONS The results of unilateral adrenalectomy followed by external pituitary irradiation do not justify that this therapy is totally abandoned in favour of transsphenoidal pituitary surgery. Unilateral adrenalectomy followed by external pituitary irradiation is a valid therapeutic modality for the treatment of Cushing's disease, and could be considered as alternative to bilateral adrenalectomy and under some circumstances to transsphenoidal pituitary surgery.
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Affiliation(s)
- S K Nagesser
- Departments of Surgery, Leiden University Medical Centre, The Netherlands
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Carral San Laureano F, Lechuga Campoy J, Merino López J, Caro Contreras J, Aguilar Diosdado M. Eficacia terapéutica del ketoconazol en el síndrome de Cushing. An Pediatr (Barc) 2000. [DOI: 10.1016/s1695-4033(00)77363-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Flitsch J, Knappe UJ, Lüdecke DK. Direct intraoperative micromethod for hormone measurements of pituitary tissue in Cushing's disease. SURGICAL NEUROLOGY 1999; 52:585-90; discussion 590-1. [PMID: 10660024 DOI: 10.1016/s0090-3019(99)00119-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND During transsphenoidal surgery (TSS) for Cushing's disease, the surgeon depends on experience to find minute adenomas. Cytological slide preparations or frozen sections, even when successful, are not specific concerning the hormone activity. In an attempt to improve accurate localization of minute ACTH adenomas, we evaluated a new intraoperative method of ACTH measurements in adenoma and anterior lobe microsamples. As most ACTH adenomas are monohormonal, the possible benefit of a GH measurement was investigated. METHODS We included pituitary tissue of 32 patients, 22 with Cushing's disease and 10 endocrine inactive pituitary adenomas as control. All patients underwent TSS by one surgeon. Preoperative data, intraoperative and perioperative hormone measurements of homogenized, weighed pituitary tissue samples, and histological findings are presented. RESULTS In ACTH adenomas, the median ACTH content was found to be 1,688 ng/mg, minimum 345 ng/mg. The median GH was measured at 36 ng/mg. Anterior lobe tissue contained median 80 ng ACTH/mg, maximum 279 ng/mg. Median GH was 2,200 ng/mg. In hormonally inactive adenomas ACTH was less than 0.1 ng/mg, median GH was 5.5 ng/mg. There was no overlap of ACTH content in the tissues investigated. Therefore, by adopting 300 ng ACTH/mg as a cutoff level, a clear discrimination is given. Additional GH measurements are not necessary. CONCLUSION This new intraoperative method permits a clear differentiation between adenoma and pituitary tissue. In addition to intraoperative cytology and histology, this method can serve as a specific proof that the ACTH adenoma has been identified during surgery. This may be valuable in difficult cases with unclear intraoperative findings, especially after previously negative exploration.
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Affiliation(s)
- J Flitsch
- Clinic of Neurosurgery, University Hospital Eppendorf (UKE), Hamburg, Germany
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Abe T, Tara LA, Lüdecke DK. Growth Hormone-secreting Pituitary Adenomas in Childhood and Adolescence: Features and Results of Transnasal Surgery. Neurosurgery 1999. [DOI: 10.1227/00006123-199907000-00001] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Abe T, Tara LA, Lüdecke DK. Growth hormone-secreting pituitary adenomas in childhood and adolescence: features and results of transnasal surgery. Neurosurgery 1999; 45:1-10. [PMID: 10414559 DOI: 10.1097/00006123-199907000-00001] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE Pituitary tumors causing gigantism are rare in childhood and adolescence. In a review of 2367 patients with pituitary adenomas who were treated between 1970 and 1997, we found 15 cases (0.63%, 9 male and 6 female patients) of growth hormone-secreting pituitary adenomas in patients who were less than 20 years of age at the time of surgery, and we compared their characteristics with those of adenomas in an adult group. METHODS Patients were grouped according to their ages at the first operation, with five patients (33.3%) in the prepubescent group (0-11 yr), eight (53.3%) in the pubescent group (12-17 yr), and two (13.3%) in the postpubescent group (18-19 yr). All 15 patients exhibited the typical symptoms of growth hormone oversecretion. The incidence of hyperprolactinemia among patients with prepubescent onset was 66.7%. Radiological examinations demonstrated microadenomas in 4 patients (26.7%) and macroadenomas in 11 patients (73.3%). The mean follow-up period was 73.5 months. RESULTS Direct transnasal explorations were performed for all patients. Tumor invasion into the cavernous sinus was observed in six patients (40%). Radical tumor resection was performed for four patients (80%) in the prepubescent group, for five patients (62.5%) in the pubescent group, and for neither patient in the postpubescent group. Surgical morbidity was caused by permanent diabetes insipidus in three patients (20%). Rapid growth was postoperatively improved in 80% of the prepubescent age group. The recurrence rate was 13.3% (2 of 15 patients). CONCLUSION Transnasal pituitary surgery was found to be as safe in pediatric patients with gigantism as in adults. Growth hormone-secreting pituitary adenomas in childhood and adolescence were more likely to be invasive or aggressive than were those in adulthood. The clinical biological characteristics for children were different from those for adults.
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Affiliation(s)
- T Abe
- Department of Neurosurgery, Showa University School of Medicine, Tokyo, Japan
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Abe T, Lüdecke DK. Transnasal surgery for infradiaphragmatic craniopharyngiomas in pediatric patients. Neurosurgery 1999; 44:957-64; discussion 964-6. [PMID: 10232528 DOI: 10.1097/00006123-199905000-00012] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE Transnasal surgery has been performed in only a small number of cases of pediatric craniopharyngiomas, and its efficacy is still a matter of debate. METHODS We analyzed the results of transnasal surgery performed in 11 pediatric patients (6 male and 5 female patients) with infradiaphragmatic craniopharyngiomas who were younger than 15 years at the time of surgery (age range, 7.7-14.9 yr) and who were treated between 1985 and 1996, when more refined diagnostic and surgical techniques were available. Two of the patients had undergone primary surgery elsewhere. The transnasal approach was chosen because of sellar enlargement and the presence of an infradiaphragmatic tumor. The duration of the clinical follow-up period was at least 1 year. RESULTS Five patients required drilling of incompletely pneumatized sphenoid sinuses to reach the sella, but in no cases were the anatomic differences related to patient age or size thought to be a limiting factor in the transnasal procedure. The normal pituitary gland was incised to expose a dorsally located tumor in each of eight patients (72.7%). This surgical procedure has never provoked any major functional damage to the anterior pituitary gland. Complete tumor resection was achieved in three patients (27.3%) and subtotal removal in eight (72.7%). Twenty-two (95.7%) of 23 normal functions were preserved after subtotal tumor removal. In contrast, only one of four normal functions was maintained after complete tumor resection. Persistent diabetes insipidus occurred after total tumor resection in one patient. Tumor regrowth occurred in two patients. No tumor recurrence was observed during the follow-up period. CONCLUSION Based on the present findings, transnasal surgery seems to be indicated for most infradiaphragmatic craniopharyngiomas occurring in pediatric patients. Transnasal surgery is as safe to perform in pediatric patients as it is in adult patients. The concept of subtotal tumor removal with preservation of pituitary function, avoiding damage to hypothalamic structures and excessive cerebrospinal fluid leakage, seems to be justified in pediatric patients.
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Affiliation(s)
- T Abe
- Department of Neurosurgery, Showa University School of Medicine, Tokyo, Japan
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Loli P, Boccardi E, Branca V, Bramerio M, Barberis M, Losa M, Terreni MT, Lodrini S, Pollo B, Vignati F. Growth hormone and prolactin responses to corticotrophin-releasing-hormone in patients with Cushing's disease: a paracrine action of the adenomatous corticotrophic cells? Clin Endocrinol (Oxf) 1998; 49:433-9. [PMID: 9876339 DOI: 10.1046/j.1365-2265.1998.00531.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE In patients with Cushing's disease multihormonal responses to ovine corticotrophin releasing hormone (oCRH) have been detected in blood from inferior petrosal sinuses. This finding has been explained by co-secretion of other hormones, in addition to ACTH, by the pituitary adenoma itself or by paracrine effects exerted by the adenoma on normal periadenomatous pituitary cells. To assess these hypotheses we compared the presence of a CRH induced GH and/or PRL response during inferior petrosal sinus sampling to the immunohistochemical detection of PRL and GH in adenomatous tissue removed from patients with Cushing's disease. PATIENTS AND MEASUREMENTS Twenty-two patients with Cushing's disease and two patients with ectopic ACTH syndrome due to a bronchial carcinoid were studied; each patient had undergone preoperative inferior petrosal sinus sampling for diagnostic purposes with determination of GH and PRL in addition to ACTH, before and after administration of oCRH. Immunohistochemical studies for ACTH, GH and PRL detection were carried out on adenomatous tissue removed at surgery in the patients with pituitary dependent Cushing's disease and on the carcinoid tumours from the two patients with ectopic ACTH syndrome. RESULTS All pituitary adenomas immunostained for ACTH, and four adenomas immunostained for GH or PRL in addition to ACTH. A PRL increase in the inferior petrosal sinus after oCRH administration was found in 11 of 22 patients, but none of their tumours immunostained for PRL. Immunostaining for PRL was found in the pituitary tumours from two patients but in neither patient was there a PRL response after oCRH. A GH response was found in 13 of 20 patients in whom it was sought; no patient showed immunostaining in their tumour. GH immunostaining was found in two tumours but in neither patient was there a GH response after oCRH. The oCRH-induced increase of GH and PRL was always recorded in the dominant inferior petrosal sinus. The ACTH response to oCRH was significantly higher in patients who showed oCRH induced increases in GH and/or PRL than in patients who did not, both in terms of area under the response-curve (22,032 +/- 9876 vs. 4371 +/- 2870 ng/l/10 min; P < 0.05) or mean percentage increase above baseline (754 +/- 229% vs. 147.2 +/- 67%, P < 0.02). A significant correlation was observed between ACTH and GH responses to oCRH. The two patients with ectopic Cushing's syndrome did not show ACTH, GH or PRL increases after oCRH administration and did not show immunostaining for GH or PRL in their tumours. CONCLUSIONS The present data do not support the hypothesis of co-secretion of hormones by the pituitary adenoma as the cause of the GH and PRL responses to ovine corticotrophin releasing hormone observed in patients with Cushing's disease; it is suggested that a different mechanism, possibly involving an interaction between the ACTH secreting adenoma and the normal periadenomatous GH and PRL secreting cells, may be responsible.
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Affiliation(s)
- P Loli
- Division of Endocrinology, Ospedale Niguarda, Milan, Italy
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Abe T, Lüdecke DK, Saeger W. Clinically nonsecreting pituitary adenomas in childhood and adolescence. Neurosurgery 1998; 42:744-50; discussion 750-1. [PMID: 9574638 DOI: 10.1097/00006123-199804000-00037] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE AND PATIENTS Clinically nonsecreting pituitary adenomas are rare in childhood and adolescence. We analyzed five cases of clinically nonsecreting pituitary adenomas in patients (4 male and 1 female patient) under 20 years of age at surgery (0.22%), identified by a review of 2288 patients with pituitary adenomas treated from 1970 to 1996 at the Hamburg University. CLINICAL PRESENTATION AND RESULTS Patient age at the onset of symptoms ranged from 8 to 13 years (mean, 10.8 yr), and age at surgery ranged from 12.5 to 19.5 years (mean, 15.5 yr). Two patients presented with endocrine symptoms, two with headache only, and one with a visual field defect. Endocrinological examinations showed pituitary insufficiency in two patients with endocrine symptoms. The serum prolactin level was normal in all patients. Radiological investigations demonstrated resectable macroadenomas with ring enhancement in four patients and a nonresectable macroadenoma with parasellar extension in one. Transnasal explorations achieved radical tumor resection except in one patient. The latter underwent a transcranial resection and radiotherapy because of parasellar tumor rest. Surgical morbidity consisted of left oculomotor nerve palsy after transcranial exploration. In two patients, normal pituitary function was preserved by transnasal surgery. Follow-up duration was 2 to 23 years (mean, 10.9 yr). There was no recurrence except for one parasellar adenoma. Immunohistological diagnosis was null cell adenoma in two patients, silent prolactinoma in two, and silent gonadotroph adenoma in one. The proliferative activity measured by Ki-67 (as the antibody MIB-1) and p53 expression revealed a positive reaction in one adenoma with parasellar extension. CONCLUSION Clinically nonsecreting pituitary adenomas in childhood and adolescence cause different endocrine symptoms from those in adults. They caused pubertal and growth delay and/or primary amenorrhea in the patients investigated in this study. Transnasal surgery in childhood and adolescence is as safe as in adults. The characteristics of nonsecreting pituitary adenomas in this age group, including 20 patients cited from the literature, do not differ from those in adults.
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Affiliation(s)
- T Abe
- Department of Neurosurgery, Showa University School of Medicine, Tokyo, Japan
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