1
|
Ragate DC, Memon SS, Sarathi V, Lila AR, Channaiah CY, Patil VA, Karlekar M, Barnabas R, Thakkar H, Shah NS, Bandgar TR. Pituitary apoplexy in cushing's disease: a single center study and systematic literature review. Pituitary 2024:10.1007/s11102-024-01411-1. [PMID: 38850401 DOI: 10.1007/s11102-024-01411-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/27/2024] [Indexed: 06/10/2024]
Abstract
INTRODUCTION Pituitary apoplexy (PA) in Cushing's disease (CD) is rare with data limited to case reports/series. METHODS We retrospectively reviewed case records of PA in CD managed at our center from 1987 to 2023 and performed a systematic literature review. RESULTS We identified 58 patients (44 females), including twelve from our center (12/315 CD, yielding a PA prevalence in CD of 3.8%) and forty six from systematic review. The median age at PA diagnosis was 35 years. The most common presentation was type A (79.3%) and symptom was headache (89.6%), with a median Pituitary Apoplexy Score (PAS) of 2. Median cortisol and ACTH levels were 24.9 µg/dl and 94.1 pg/ml, respectively. Apoplexy was the first manifestation of underlying CD in 55.2% of cases, with 31.1% (14/45) presenting with hypocortisolemia (serum cortisol ≤ 5.0 µg/dl), underscoring the importance of recognizing clinical signs/symptoms of hypercortisolism. The median largest tumor dimension was 1.7 cm (53/58 were macroadenomas). PA was managed surgically in 57.8% of cases, with the remainder conservatively managed. All five PA cases in CD with microadenoma achieved remission through conservative management, though two later relapsed. Among treatment-naïve CD patients with macroadenoma, PA-related neuro-deficit improvement was comparable between surgical and conservative groups. However, a greater proportion of surgically managed patients remained in remission longer (70% vs. 38.5%; p = 0.07), for an average of 31 vs. 10.5 months. CONCLUSION PA in CD is more commonly associated with macroadenomas, may present with hypocortisolemia, and surgical treatment tends towards higher and longer-lasting remission rates.
Collapse
Affiliation(s)
- Divya C Ragate
- Department of Endocrinology, Seth G.S. Medical College & KEM hospital, Parel, Mumbai, 4000012, Maharashtra, India
| | - Saba Samad Memon
- Department of Endocrinology, Seth G.S. Medical College & KEM hospital, Parel, Mumbai, 4000012, Maharashtra, India
| | - Vijaya Sarathi
- Department of Endocrinology, Vydehi institute of medical sciences and research Centre, Bangalore, Karnataka, India
| | - Anurag Ranjan Lila
- Department of Endocrinology, Seth G.S. Medical College & KEM hospital, Parel, Mumbai, 4000012, Maharashtra, India.
| | - Chethan Yami Channaiah
- Department of Endocrinology, Seth G.S. Medical College & KEM hospital, Parel, Mumbai, 4000012, Maharashtra, India
| | - Virendra A Patil
- Department of Endocrinology, Seth G.S. Medical College & KEM hospital, Parel, Mumbai, 4000012, Maharashtra, India
| | - Manjiri Karlekar
- Department of Endocrinology, Seth G.S. Medical College & KEM hospital, Parel, Mumbai, 4000012, Maharashtra, India
| | - Rohit Barnabas
- Department of Endocrinology, Seth G.S. Medical College & KEM hospital, Parel, Mumbai, 4000012, Maharashtra, India
| | - Hemangini Thakkar
- Department of Radiodiagnosis, Seth G.S Medical College & KEM Hospital, Mumbai, Maharashtra, India
| | - Nalini S Shah
- Department of Endocrinology, Seth G.S. Medical College & KEM hospital, Parel, Mumbai, 4000012, Maharashtra, India
| | - Tushar R Bandgar
- Department of Endocrinology, Seth G.S. Medical College & KEM hospital, Parel, Mumbai, 4000012, Maharashtra, India
| |
Collapse
|
2
|
Gheorghe AM, Trandafir AI, Ionovici N, Carsote M, Nistor C, Popa FL, Stanciu M. Pituitary Apoplexy in Patients with Pituitary Neuroendocrine Tumors (PitNET). Biomedicines 2023; 11:biomedicines11030680. [PMID: 36979658 PMCID: PMC10044830 DOI: 10.3390/biomedicines11030680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 02/17/2023] [Accepted: 02/21/2023] [Indexed: 02/26/2023] Open
Abstract
Various complications of pituitary neuroendocrine tumors (PitNET) are reported, and an intratumor hemorrhage or infarct underlying pituitary apoplexy (PA) represents an uncommon, yet potentially life-threatening, feature, and thus early recognition and prompt intervention are important. Our purpose is to overview PA from clinical presentation to management and outcome. This is a narrative review of the English-language, PubMed-based original articles from 2012 to 2022 concerning PA, with the exception of pregnancy- and COVID-19-associated PA, and non-spontaneous PA (prior specific therapy for PitNET). We identified 194 original papers including 1452 patients with PA (926 males, 525 females, and one transgender male; a male-to-female ratio of 1.76; mean age at PA diagnostic of 50.52 years, the youngest being 9, the oldest being 85). Clinical presentation included severe headache in the majority of cases (but some exceptions are registered, as well); neuro-ophthalmic panel with nausea and vomiting, meningism, and cerebral ischemia; respectively, decreased visual acuity to complete blindness in two cases; visual field defects: hemianopia, cranial nerve palsies manifesting as diplopia in the majority, followed by ptosis and ophthalmoplegia (most frequent cranial nerve affected was the oculomotor nerve, and, rarely, abducens and trochlear); proptosis (N = 2 cases). Risk factors are high blood pressure followed by diabetes mellitus as the main elements. Qualitative analysis also pointed out infections, trauma, hematologic conditions (thrombocytopenia, polycythemia), Takotsubo cardiomyopathy, and T3 thyrotoxicosis. Iatrogenic elements may be classified into three main categories: medication, diagnostic tests and techniques, and surgical procedures. The first group is dominated by anticoagulant and antiplatelet drugs; additionally, at a low level of statistical evidence, we mention androgen deprivation therapy for prostate cancer, chemotherapy, thyroxine therapy, oral contraceptives, and phosphodiesterase 5 inhibitors. The second category includes a dexamethasone suppression test, clomiphene use, combined endocrine stimulation tests, and a regadenoson myocardial perfusion scan. The third category involves major surgery, laparoscopic surgery, coronary artery bypass surgery, mitral valvuloplasty, endonasal surgery, and lumbar fusion surgery in a prone position. PA in PitNETs still represents a challenging condition requiring a multidisciplinary team from first presentation to short- and long-term management. Controversies involve the specific panel of risk factors and adequate protocols with concern to neurosurgical decisions and their timing versus conservative approach. The present decade-based analysis, to our knowledge the largest so far on published cases, confirms a lack of unanimous approach and criteria of intervention, a large panel of circumstantial events, and potential triggers with different levels of statistical significance, in addition to a heterogeneous clinical picture (if any, as seen in subacute PA) and a spectrum of evolution that varies from spontaneous remission and control of PitNET-associated hormonal excess to exitus. Awareness is mandatory. A total of 25 cohorts have been published so far with more than 10 PA cases/studies, whereas the largest cohorts enrolled around 100 patients. Further studies are necessary.
Collapse
Affiliation(s)
- Ana-Maria Gheorghe
- Department of Endocrinology, “C.I. Parhon” National Institute of Endocrinology, 011683 Bucharest, Romania
| | - Alexandra Ioana Trandafir
- Department of Endocrinology, “C.I. Parhon” National Institute of Endocrinology, 011683 Bucharest, Romania
| | - Nina Ionovici
- Department of Occupational Medicine, Faculty of Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Mara Carsote
- Department of Endocrinology, “Carol Davila” University of Medicine and Pharmacy & “C.I. Parhon” National Institute of Endocrinology, 011683 Bucharest, Romania
- Correspondence: (M.C.); (C.N.)
| | - Claudiu Nistor
- Department 4—Cardio-Thoracic Pathology, Thoracic Surgery II Discipline, Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy & Thoracic Surgery Department, “Carol Davila” Central Emergency University Military Hospital, 013058 Bucharest, Romania
- Correspondence: (M.C.); (C.N.)
| | - Florina Ligia Popa
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, “Lucian Blaga” University of Sibiu, 550024 Sibiu, Romania
| | - Mihaela Stanciu
- Department of Endocrinology, Faculty of Medicine, “Lucian Blaga” University of Sibiu, 550169 Sibiu, Romania
| |
Collapse
|
4
|
Popa Ilie IR, Herdean AM, Herdean AI, Georgescu CE. Spontaneous remission of Cushing's disease: A systematic review. ANNALES D'ENDOCRINOLOGIE 2021; 82:613-621. [PMID: 34687655 DOI: 10.1016/j.ando.2021.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 08/28/2021] [Accepted: 10/11/2021] [Indexed: 10/20/2022]
Abstract
Spontaneous remission is rare in Cushing's disease. We describe one illustrative case and provide a systematic review of cases previously reported in the literature. Case report: A 51-year-old woman diagnosed with Cushing's disease underwent 9 months' isolated metyrapone treatment. Two months after end of treatment, she was admitted with acute kidney failure. After another 4 months, in June 2020, there was no evidence of hypercortisolism, either clinically or biochemically, or of hypocortisolism. At the time of writing, 1 year later, she was still in remission. Cases reported in the literature: 23 patients were reported, including the present case. 87% were female with a median age of 32 years. Ten of those with radiologically visible tumors had microadenoma (44%) and 7 had macroadenoma (30%). Mean time from diagnosis to spontaneous remission was 5 months, and was shorter in macroadenoma (1 month) than in microadenoma (13.5 months). Treatments before spontaneous remission were: no treatment (65%), steroidogenesis enzyme inhibitors (22%), bilateral adrenalectomy and adrenal autotransplantation (5%), partial bilateral adrenalectomy (4%), and incomplete pituitary surgery (4%). Pituitary tumor apoplexy was the most frequently incriminated event (91%), radiologically documented in 43% of patients. Mean remission during follow-up was 28 months (range, 6-130 months). Recurrence occurred in 39% (n=9) of patients. Although several mechanisms responsible for this phenomenon have been proposed, clinical or subclinical pituitary tumor apoplexy, the latter sometimes presenting atypically, seems to be the most frequently incriminated event. Doctors should be aware of this, and regular follow-up is mandatory due to its unpredictability.
Collapse
Affiliation(s)
- Ioana Rada Popa Ilie
- Department of Endocrinology, "Iuliu Hatieganu" University of Medicine and Pharmacy, 3-5, Louis Pasteur street, 400349 Cluj-Napoca, Romania.
| | - Alina Maria Herdean
- Department of Endocrinology, "Iuliu Hatieganu" University of Medicine and Pharmacy, 3-5, Louis Pasteur street, 400349 Cluj-Napoca, Romania.
| | - Andrei Ioan Herdean
- Department of Anatomy and Embriology, "Iuliu Hatieganu" University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania.
| | - Carmen Emanuela Georgescu
- Department of Endocrinology, "Iuliu Hatieganu" University of Medicine and Pharmacy, 3-5, Louis Pasteur street, 400349 Cluj-Napoca, Romania.
| |
Collapse
|