Complications and Comorbidities of Acromegaly-Retrospective Study in Polish Center

Lipoprotein alterations in endocrine disorders - a review of the recent developments in the field

Dyslipidemia is one of the most common disorders worldwide, which, if left untreated, results in a multitude of complications. Thus proper diagnostics, which includes identifying of secondary causes of dyslipidemia is crucial. Endocrine disorders are an important cause of secondary dyslipidemia. This paper aims to review the publications on lipoprotein alterations in endocrine disorders from the past two years and provide an overview of the recent discoveries in this dynamically developing and large field. Significant changes in lipoprotein serum concentrations are present in most endocrinological diseases and can be modified with proper treatment. Some lipoproteins have also been proposed as markers in some endocrine diseases, e.g., thyroid carcinoma. From the scope of endocrine disorders, the largest number of studies explored the lipoprotein changes in polycystic ovary syndrome and in women during the menopausal and peri-menopausal period. Even though the association of thyroid disorders with dyslipidemia is already well studied, new research has delivered some exciting findings about lipoprotein alterations in euthyroid patients with either positive antithyroid peroxidase antibodies or reduced sensitivity to thyroid hormones. The problem of the adverse metabolic profile, including dyslipidemia in hypoprolactinemia has been recognized. Moreover, this review describes other significant discoveries encompassing lipoprotein alterations in disorders of the adrenals, thyroid, parathyroid glands, pituitary, and gonads. The up-to-date knowledge of the influence of endocrine disorders and hormonal changes on serum lipoproteins is prudent as it can significantly impact therapeutic decisions.

Orofacial traits related to oral health-related quality of life in Brazilian acromegaly patients

OBJECTIVE

To investigate orofacial traits and general factors related to oral health-related quality of life in acromegaly patients.

MATERIALS AND METHODS

A cross-sectional study with 34 acromegaly patients was conducted. The OHIP-14 questionnaire was used to assess oral health-related quality of life scores. To assess orofacial and occlusion morphology, an oral evaluation was performed. Correlation measures, multiple linear regression and a structural equation model (SEM) were used in the statistical analysis.

RESULTS

The presence of arthrosis (SC = 0.467, SE = 0.155, p = 0.003) and smoking history (SC = 0.459, SE = 0.206, p = 0.026) were associated with a negative impact on oral health-related quality of life. Mandibular protrusion was related to physical pain (β = 2.74, p = 0.029). Anterior open bite (β = 4.44, p = 0.004) and anterior crossbite (β = 2.61, p = 0.026) were related to psychological disability. Diastema was related to social disability (β = 3.42, p = 0.037) and handicap (β = 2.74, p = 0.044).

CONCLUSION

The findings suggest that smoking, arthrosis and orofacial alterations (mandibular protrusion, open bite, crossbite and diastema) have a negative impact on oral health-related quality of life in acromegaly patients.

Validity of galactin-3 in acromegaly: comparison with traditional markers

BACKGROUND

Acromegaly occurs due to overproduction of growth hormone (GH) and insulin-like growth factor-1 (IGF-1). Galectin-3 (Gal-3) has recently emerged as a novel biomarker, related to IGF-1. This study aimed to assess Gal-3 in patients with acromegaly and compare its effectiveness with traditional biomarker tests.

MATERIALS AND METHODS

A randomized case control study conducted in a single center included 50 acromegaly patients and 40 apparently healthy subjects (HS) serve as control group matched both age and BMI. Laboratory test was measured by routine assay used in center. Gal-3, GH, and IGF-1 were measured by enzyme-linked immunosorbent assay (ELISA).

RESULT

There were 50 patients with an average age of 50.40 ± 12.229 (50% of males). Compared with HS, patients' serum GAL-3 levels have increased significantly. The serum GAL-3 exceeds 14.363 ng/ml, with a sensitivity of 100.0 and a specificity of 100.0. Furthermore, serum Gal-3 levels in combination with traditional tests (GH and IGF-1) by DeLoongs test had a significant difference in discriminating acromegaly more accurately than traditional tests.

CONCLUSION

In a summary, this study recommended clinicians measure serum Gal-3 as biomarkers for patients with acromegaly. In addition, the result above shed light on role of Gal-3 on acromegaly pathogenesis and might provide a therapeutic target of acromegaly patients.

Acromegaly among a Moroccan population

Acromegaly is defined as an acquired dysmorphytic syndrome due to excessive secretion of growth hormone (GH) and consequently of insulin-like growth factor-1 (IGF-1). This is a retrospective study of patients who were hospitalized in the Endocrinology Department of the Mohammed V Military Academic Hospital in Rabat over a period of 14 years (2008 to 2022), reporting on their clinical, paraclinical and evolutionary profiles and comparing the results with the data in the literature. Nineteen patients were included in our study. The mean age was 42.7 ± 11.6 years, with a male predominance. The clinical manifestations were dominated by a dysmorphic syndrome present in 97.4% of cases, followed by complications related to acromegaly in 88.9% of cases. The diagnosis was made when GH and IGF-1 values were elevated in 88.9% and 93.8% of cases, respectively; with a mean GH value of 25.1 μg/L. Magnetic resonance imaging (MRI) was used to diagnose the location of pituitary adenoma in all cases, 78.9% of which were macroadenomas and 21.1% microadenomas. The majority of patients (78.9%) had recourse to transsphenoidal surgery. Medical treatment was carried out in 89.5% of cases. Postoperative radiotherapy was performed in 33% of cases. Disease control was achieved in 30.1% of cases. This study shows the complex management of acromegaly. Disease control is a necessary condition in order to avoid complications, but is often difficult to obtain.

Osteosarcopenia in acromegaly: reduced muscle quality and increased vertebral fat deposition

PURPOSE

Musculoskeletal disorders are among the most disabling comorbidities in patients with acromegaly. This study examined muscle and bone quality in patients with acromegaly.

METHODS

Thirty-three patients with acromegaly and nineteen age- and body mass index-matched healthy controls were included in the study. Body composition was determined using dual-energy X-ray absorptiometry. The participants underwent abdominal magnetic resonance imaging (MRI) for cross-sectional evaluation of muscle area and vertebral MRI proton density fat fraction (MRI-PDFF). Muscular strength was measured using hand grip strength (HGS). Skeletal muscle quality (SMQ) was classified as weak, low, or normal, according to HGS/ASM (appendicular skeletal muscle mass) ratio.

RESULTS

Groups had similar lean tissues, total body fat ratios, and total abdominal muscle areas. Acromegalic patients had lower pelvic BMD (p = 0.012) and higher vertebral MRI-PDFF (p = 0.014), while total and spine bone mineral densities (BMD) were similar between the groups. The SMQ score rate was normal only 57.5% in the acromegaly group, and 94.7% of the controls had a normal SMQ score (p = 0.01). Subgroup analysis showed that patients with active acromegaly (AA) had higher lean tissue and lower body fat ratios than controlled acromegaly (CA) and control groups. Vertebral MRI-PDFF was higher in the CA group than that in the AA and control groups (p = 0.022 and p = 0.001, respectively). The proportion of participants with normal SMQ was lower in the AA and CA groups than that in the control group (p = 0.012 and p = 0.013, respectively).

CONCLUSION

Acromegalic patients had reduced SMQ and pelvic BMD, but greater vertebral MRI-PDFF. Although lean tissue increases in AA, this does not affect SMQ. Therefore, increased vertebral MRI-PDFF in controlled acromegalic patients may be due to ectopic adiposity.

The Relationship between the Burden of Acromegaly, Associated Comorbidities, Complications and Disease Status

Uncontrolled acromegaly causes increased morbidity and mortality. The analysis of acromegaly comorbidities and complications is important when establishing a standard of care for the entire population of acromegaly patients. The aim of this study was to determine the frequency of comorbidities and complications of acromegaly and their dependence on the activity of the disease. A retrospective analysis of medical records from 124 patients with acromegaly was carried out, including 39 who were cured, 73 treated with somatostatin analogs and 12 newly diagnosed patients. The incidence of comorbidities and complications was very high, and those most frequently observed were arterial hypertension, multinodular goiter, lipid disorders, hypopituitarism and degenerative changes. At least one complication of acromegaly was observed in 92% of patients undergoing successful neurosurgery and in all pharmacologically treated patients. By contrast, two or more complications were observed in 77% of cured patients and in pharmacologically controlled and uncontrolled patients, 82% and 91%, respectively. Conclusions: Acromegaly is associated with a high prevalence of complications. Active acromegaly is associated with a higher incidence of complications than in treated groups. Untreated patients have more complications than treated patients. Successfully cured patients have significantly fewer complications than pharmacologically controlled patients and patients with active acromegaly.

Uric acid levels correlate with disease activity in growth hormone-secreting pituitary adenoma patients

Objective

Few studies reported the effects of growth hormone-secreting pituitary adenoma (GHPA) on uric acid (UA) metabolism and the relationship between growth hormone (GH)/insulin-like growth factor-1 (IGF-1) levels and UA are controversial. This study aimed to evaluate the relationship between IGF-1 and UA in patients with GHPA and to further clarify whether UA levels are associated with GHPA disease activity by follow-up.

Methods

A longitudinal study of 424 GHPA patients presenting to Beijing Tiantan Hospital, Capital Medical University between January 2015 and January 2023 was conducted. Spearman's correlation tests were performed to examine the relationship between IGF-1 and UA at baseline. Univariate and multivariate linear regression analysis was conducted to investigate the independent association between UA and IGF-1. Changes in postoperative IGF-1 and UA levels were followed prospectively, and the differences in UA levels between the biochemical remission and nonremission groups were compared.

Results

At baseline, male patients, the lower the age, the higher the IGF-1 and body mass index (BMI), and the higher the UA levels. IGF-1 was significantly associated with UA after controlling for sex, age, and BMI (r = 0.122, P = 0.012). In adjusted multiple linear regression analysis, IGF-1 was independently associated with UA, and UA levels increased significantly with increasing IGF-1. During postoperative follow-up, UA decreased gradually as IGF-1 levels decreased. At 12 months postoperatively, UA levels were significantly lower in the biochemical remission group than in the nonremission group (P = 0.038).

Conclusions

In patients with GHPA, UA levels are associated with disease activity. Changes in UA levels should be taken into account in the comprehensive treatment of GHPA, patients presenting with HUA should be given lifestyle guidance and appropriate urate-lowering treatment according to their condition to better improve their prognosis.

Treatment Patterns, Adherence, Persistence, and Health Care Resource Utilization in Acromegaly: A Real-World Analysis

Context

Treatment of acromegaly is multimodal for many patients, and medical treatments include somatostatin receptor ligands (SRLs), dopamine agonists (DAs), and growth hormone receptor antagonists (GHRAs). However, recent real-world evidence on treatment patterns for patients with acromegaly is limited.

Objective

This study evaluated medication usage, treatment changes, adherence, persistence, comorbidities, and health care resource utilization using deidentified data from MarketScan, a US claims database.

Methods

Eligible patients (n = 882) were those receiving monotherapy or combination therapy for ≥90 days without treatment gaps.

Results

Mean age at diagnosis was 48.6 years; 50.1% of patients were female. Over half (59.4%) had 1 line of treatment (LOT); 23.1% had 2 LOTs; 17.5% had at least 3 LOTs. Most patients (94.6%) initiated treatment with monotherapies. The most common first-line monotherapy treatments were cabergoline (DA, 36.8%), octreotide long-acting release (first-generation SRL, 29.5%), and lanreotide depot (first-generation SRL, 22.5%). Adherence for first-line treatments (proportion of days covered) was higher for first-generation SRLs (lanreotide depot: 0.8) compared with DAs (0.7). Treatment persistence (time between the first treatment record and a change in LOT/censoring) in LOT 1 was higher for GHRAs (24.8 months) and first-generation SRLs (20.0 months) compared with DAs (14.4 months). Female patients and those diagnosed at a younger age were more likely to have shorter treatment persistence. The most prevalent comorbidities were hyperlipidemia, essential hypertension, and sleep apnea.

Conclusion

Patients with more comorbidities had more health care visits during the first year after diagnosis, suggesting increased disease burden. Real-world evidence on treatment patterns provides insights into recommendations for individualized therapy.

FTO Gene Polymorphisms and Their Roles in Acromegaly

The major causes of both morbidity and mortality in patients with acromegaly are cardiovascular diseases (CVDs). The polymorphisms of the fat mass and obesity-associated gene (FTO) are associated with obesity, as well as with an increased risk of CVDs. The aim of the study was to determine the relationship of risk alleles of four FTO gene polymorphisms with selected parameters of lipid and glucose metabolism as well as with IGF-1 and GH levels in the group of patients with acromegaly compared to the control group. The study group consisted of 104 patients with acromegaly and 64 healthy subjects constituting the control group. In the whole acromegaly group, the data reveal that the homozygous for risk allele carriers (rs1421085, rs9930506, rs9939609) as well as carriers of only one risk allele have lower IGF-1 concentrations. In the well-controlled acromegaly group, the homozygous for three risk allele carriers of FTO gene polymorphisms have lower HDL cholesterol concentration (rs1121980, rs1421085, rs993609). In the cured acromegaly group, homozygous risk allele carriers rs9930506 tend to have higher levels of total cholesterol and LDL cholesterol. These associations are not observed in the control group. Conclusion: there is an association between FTO gene polymorphisms and the metabolism of lipids, suggesting that the FTO gene may be associated with higher CVD risk in patients with acromegaly. In addition, there is an association between FTO gene polymorphisms and IGF-1, implying that FTO gene may influence/modify IGF-1 synthesis. Further investigation on a larger scale is required to provide more precise evidence.

Is H19 RNA a Useful Marker of Acromegaly and Its Complications? A Preliminary Study

Acromegaly is a rare endocrine disorder caused by somatotroph pituitary adenoma. Besides its typical symptoms, it contributes to the development of cardiovascular, metabolic, and bone comorbidities. H19 RNA is a long non-coding RNA and it is suspected to be involved in tumorigenesis, cancer progression, and metastasis. H19 RNA is a novel biomarker for the diagnosis and monitoring of neoplasms. Moreover, there might be an association between H19 and cardiovascular and metabolic diseases. We enrolled 32 acromegaly patients and 25 controls. We investigated whether whole blood H19 RNA expression is associated with the diagnosis of acromegaly. Correlations between H19 and tumour dimension, invasiveness, and biochemical and hormonal parameters were evaluated. We analysed the coincidence of acromegaly comorbidities with H19 RNA expression. In the results, we did not observe a statistically significant difference in H19 RNA expression between acromegaly patients and the controls. There were no correlations between H19 and the adenoma size and infiltration and patients' biochemical and hormonal statuses. In the acromegaly group, hypertension, goitre, and cholelithiasis were observed more frequently. The diagnosis of acromegaly was a factor contributing to the occurrence of dyslipidaemia, goitre, and cholelithiasis. We found an association between H19 and cholelithiasis in acromegaly patients. To conclude, H19 RNA expression is not a relevant marker for diagnosis and monitoring of acromegaly patients. There is a higher risk of hypertension, goitre, and cholelithiasis related to acromegaly. Cholelithiasis is associated with a higher H19 RNA expression.

Multidisciplinary management of difficult/aggressive growth-hormone pituitary neuro-endocrine tumors

Growth Hormone-secreting adenomas exhibits variable biological behavior and heterogeneous natural history, ranging from small adenomas and mild disease, to invasive and aggressive neoplasms with more severe clinical picture. Patients not cured or controlled after neurosurgical and first-generation somatostatin receptor ligands (SRL) therapy could require multiple surgical, medical and/or radiation treatments to achieve disease control. To date, no clinical, laboratory, histopathological, or neuroradiological markers are able to define the aggressiveness or predict the disease prognosis in patients with acromegaly. Therefore, the management of these patients requires careful evaluation of laboratory assessments, diagnostic criteria, neuroradiology examinations, and neurosurgical approaches to choose an effective and patient-tailored medical therapy. A multidisciplinary approach is particularly useful in difficult/aggressive acromegaly to schedule multimodal treatment, which includes radiation therapy, chemotherapy with temozolomide and other, recent emerging treatments. Herein, we describe the role of the different members of the multidisciplinary team according to our personal experience; a flow-chart for the therapeutic approach of difficult/aggressive acromegaly patients is proposed.

Corneal Tonometric and Morphological Changes in Patients with Acromegaly

(1) Purpose: This study aimed to investigate the changes in Reichert Ocular Response Analyzer (ORA) parameters, corneal endothelium parameters, central corneal thickness (CCT), and intraocular pressure (IOP) before and after the transsphenoidal resection of pituitary adenoma in patients with acromegaly. (2) Methods: This was a single-center, prospective, interventional study. Twenty patients with newly diagnosed acromegaly were examined before and 19 ± 9 months after transsphenoidal resection. The participants underwent a comprehensive ophthalmological examination including pneumatic IOP (IOP air puff), Goldmann applanation tonometry (IOP GAT), CCT measured using the iPac pachymeter (CCT_UP), IOP value corrected for CCT_UP using the Ehlers formula (IOPc) ORA measurements included corneal hysteresis (CH), corneal resistance factor (CRF), corneal-compensated IOP (IOPcc), and Goldmann-correlated IOP (IOPg). CCT from non-contact specular microscopy (CCT_NSM), the number of endothelial cells (CD) per mm2, and average cell size (AVG) were determined with non-contact specular microscopy. (3) Results: A statistically significant decrease was observed in CCT_UP (p = 0.007), and IOP air puff (p = 0.012) after surgery. Moreover, we noted a statistically significant increase in CD (p = 0.001), and a statistically significant decrease in AVG (p = 0.009) and CCT_NSM (p = 0.004) after surgery. A statistically significant decrease was also observed in IOPg (p = 0.011), CH (p = 0.016), and CRF (p = 0.001) after surgery. The mean value of IOP GAT and IOPc was lower after the surgery. However, the difference was not statistically significant. (4) Conclusions: Our study revealed significant changes in biomechanics, corneal endothelium, CCT and IOP after pituitary adenoma resection in patients with acromegaly. It proves that the eye might be sensitive to long-term overexposure to growth hormone (GH) and insulin-like growth factor-1 (IGF-1). We suggest that disease activity be taken into consideration on ophthalmological examination.

Acromegaly: Clinical Care in Central and Eastern Europe, Israel, and Kazakhstan

Acromegaly is a rare condition typically caused by benign pituitary adenomas, resulting in excessive production of growth hormone. Clinical manifestations of acromegaly are diverse, varying from the overgrowth of body tissue to cardiovascular, metabolic, and osteoarticular disorders. Symptoms may emerge slowly, overlapping with other diseases and often involve many different healthcare specialists. In the last decade, efforts to provide an accurate and timely diagnosis of acromegaly have improved disease management and clinical experience. Despite this progress, marked differences in the diagnosis, treatment, and management of acromegaly exist from country-to-country. To address these inconsistencies in the region comprising Central and Eastern Europe, Israel, and Kazakhstan, a panel of acromegaly experts from 13 of these countries was convened. Acromegaly experts from each country provided available information on the approaches from their country, including regional treatment centers and multidisciplinary teams, treatment access, reimbursement and availability, and physician education, disease awareness, and patient advocacy. Across several areas of acromegaly management, divergent approaches were identified and discussed, including the provision of multidisciplinary care, approved and available treatments, and disease awareness programs. These were recognized as areas of potential improvement in the management of acromegaly, in addition to participation in national and regional acromegaly registries. Further experience exchange will facilitate the identification of specific strategies that can be adapted in each country, and widespread participation in acromegaly registries will enable their evaluation. It is anticipated that this approach will support the optimization of acromegaly patient care across this region.

Acromegaly Caused by Ectopic Growth Hormone Releasing Hormone Secretion: A Review

INTRODUCTION

Ectopic acromegaly is a rare condition caused most frequently by growth hormone releasing hormone (GHRH) secretion from neuroendocrine tumors. The diagnosis is often difficult to establish as its main symptoms do not differ from those of acromegaly of pituitary origin.

OBJECTIVES

To determine most common clinical features and diagnostic challenges in ectopic acromegaly.

PATIENTS AND METHODS

A search for ectopic acromegaly cases available in literature was performed using PubMed, Cochrane, and MEDline database. In this article, 127 cases of ectopic acromegaly described after GHRH isolation in 1982 are comprehensively reviewed, along with a summary of current state of knowledge on its clinical features, diagnostic methods, and treatment modalities. The most important data were compiled and compared in the tables.

RESULTS

Neuroendocrine tumors were confirmed in 119 out of 121 patients with histopathological evaluation, mostly of lung and pancreatic origin. Clinical manifestation comprise symptoms associated with pituitary hyperplasia, such as headache or visual field disturbances, as well as typical signs of acromegaly. Other endocrinopathies may also be present depending on the tumor type. Definitive diagnosis of ectopic acromegaly requires confirmation of GHRH secretion from a tumor using either histopathological methods or GHRH plasma concentration assessment. Hormonal evaluation was available for 84 patients (66%) and histopathological confirmation for 99 cases (78%). Complete tumor resection was the main treatment method for most patients as it is a treatment of choice due to its highest effectiveness. When not feasible, somatostatin receptor ligands (SRL) therapy is the preferred treatment option. Prognosis is relatively favorable for neuroendocrine GHRH-secreting tumors with high survival rate.

CONCLUSION

Although ectopic acromegaly remains a rare disease, one should be aware of it as a possible differential diagnosis in patients presenting with additional symptoms or those not responding to classic treatment of acromegaly.