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.

Successful surgical treatment of a patient with primary insulinoma of the liver

Insulinoma is the most frequent functional neuroendocrine tumor of the pancreas, which causes organic hyperinsulinism with severe hypoglycemia. There are no cases of primary insulinoma of the liver described. A 63-year-old female was admitted to our center presenting symptoms of severe hypoglycemia due to confirmed endogenic hyperinsulinism. None of the performed diagnostic procedures could reveal a pancreatic tumor. However, a pathologic mass in the sixth segment of the liver was detected. We performed arterial calcium stimulation that showed increased levels of insulin and c-peptide in almost all stimulated arteries. The highest and most prolonged peaks were detected at the points of the common hepatic artery and the right hepatic artery. After the surgical removal of the liver tumor, the blood glucose level was stabilized within the normal range. Post-operative pathomorphological investigation confirmed the diagnosis of a neuroendocrine tumor. The long-term survival results show correct treatment tactics without any signs of disease recurrence.

Factors of mineral homeostasis impairment and bone mineral density loss in women with central hypogonadism

OBJECTIVE

The aims of the study were to estimate markers of mineral turnover and bone mineral density (BMD) in young women with central hypogonadism (CH) in comparison with healthy young and postmenopausal women, and to reveal the possible impact of different factors on BMD.

METHOD

We examined 73 patients with CH (mean age 25 [21.2; 30.5] years, mean duration of amenorrhea 5 [2.3; 10.1] years), 47 young healthy women (mean age 24 [23.1; 28.0] years) and 50 healthy women in natural postmenopause (mean age 56 [53; 58] years, mean duration of 6 [2; 10] years since last menstrual period). Women with CH were examined before and after 12 months of treatment with 17β-estradiol 2 mg and dydrogesterone 10 mg in continuous sequential fashion.

RESULTS

Levels of calcium, alkaline phosphatase, and C-terminal telopeptide of type I collagen were statistically higher in women with CH without treatment than in young healthy women but did not differ from those in postmenopausal women. Prevalence of T-score ≤-2.5 standard deviations was higher in CH than in postmenopause both in lumbar vertebrae and total femur. Factors that were responsible for lower BMD in young women with CH included the duration of hypoestrogenism, primary amenorrhea, and hypoandrogenism.

CONCLUSION

Central hypogonadism at a young age poses a higher risk of bone metabolism impairment than physiological menopause.

T2-weighted MRI signal predicts hormone and tumor responses to somatostatin analogs in acromegaly

GH-secreting pituitary adenomas can be hypo-, iso- or hyper-intense on T2-weighted MRI sequences. We conducted the current multicenter study in a large population of patients with acromegaly to analyze the relationship between T2-weighted signal intensity on diagnostic MRI and hormonal and tumoral responses to somatostatin analogs (SSA) as primary monotherapy. Acromegaly patients receiving primary SSA for at least 3 months were included in the study. Hormonal, clinical and general MRI assessments were performed and assessed centrally. We included 120 patients with acromegaly. At diagnosis, 84, 17 and 19 tumors were T2-hypo-, iso- and hyper-intense, respectively. SSA treatment duration, cumulative and mean monthly doses were similar in the three groups. Patients with T2-hypo-intense adenomas had median SSA-induced decreases in GH and IGF-1 of 88% and 59% respectively, which were significantly greater than the decreases observed in the T2-iso- and hyper-intense groups (P < 0.001). Tumor shrinkage on SSA was also significantly greater in the T2-hypo-intense group (38%) compared with the T2-iso- and hyper-intense groups (8% and 3%, respectively; P < 0.0001). The response to SSA correlated with the calculated T2 intensity: the lower the T2-weighted intensity, the greater the decrease in random GH (P < 0.0001, r = 0.22), IGF-1 (P < 0.0001, r = 0.14) and adenoma volume (P < 0.0001, r = 0.33). The T2-weighted signal intensity of GH-secreting adenomas at diagnosis correlates with hormone reduction and tumor shrinkage in response to primary SSA treatment in acromegaly. This study supports its use as a generally available predictive tool at diagnosis that could help to guide subsequent treatment choices in acromegaly.

Clinical and genetic characterization of pituitary gigantism: an international collaborative study in 208 patients

Despite being a classical growth disorder, pituitary gigantism has not been studied previously in a standardized way. We performed a retrospective, multicenter, international study to characterize a large series of pituitary gigantism patients. We included 208 patients (163 males; 78.4%) with growth hormone excess and a current/previous abnormal growth velocity for age or final height >2 s.d. above country normal means. The median onset of rapid growth was 13 years and occurred significantly earlier in females than in males; pituitary adenomas were diagnosed earlier in females than males (15.8 vs 21.5 years respectively). Adenomas were ≥10 mm (i.e., macroadenomas) in 84%, of which extrasellar extension occurred in 77% and invasion in 54%. GH/IGF1 control was achieved in 39% during long-term follow-up. Final height was greater in younger onset patients, with larger tumors and higher GH levels. Later disease control was associated with a greater difference from mid-parental height (r=0.23, P=0.02). AIP mutations occurred in 29%; microduplication at Xq26.3 - X-linked acrogigantism (X-LAG) - occurred in two familial isolated pituitary adenoma kindreds and in ten sporadic patients. Tumor size was not different in X-LAG, AIP mutated and genetically negative patient groups. AIP-mutated and X-LAG patients were significantly younger at onset and diagnosis, but disease control was worse in genetically negative cases. Pituitary gigantism patients are characterized by male predominance and large tumors that are difficult to control. Treatment delay increases final height and symptom burden. AIP mutations and X-LAG explain many cases, but no genetic etiology is seen in >50% of cases.