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Papanikolaou N, Coulden A, Parker N, Lee S, Kelly C, Anderson R, Rees A, Cox J, Dhillo W, Meeran K, Al-Memar M, Karavitaki N, Jayasena C. P-698 Pituitary functioning gonadotroph adenomas (FGA)-induced ovarian hyperstimulation syndrome (OHSS): results from tertiary neuroendocrine centres in the UK. Hum Reprod 2022. [DOI: 10.1093/humrep/deac107.647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Study question
There are no published series of OHSS due to FGA. What FGA features should clinicians look for during OHSS, and what treatments are effective?
Summary answer
FGA tumour size is always >10mm. Other pituitary hormones may be deficient. Surgical resection of FGA is an effective treatment for OHSS.
What is known already
Pituitary adenomas affect 1:1000 adults and are classified as functioning or non-functioning. Non-functioning pituitary adenomas do not secrete hormones, but most commonly stain histologically gonadotroph cells. Functional pituitary adenomas secrete hormones such as prolactin causing prolactinoma. However, it is rare for a pituitary tumour to cause clinical features of excessive gonadotrophins (functioning gonadotroph adenoma; FGA).
Single case reports, but no case series, have been published on the presentation of FGA-induced OHSS in women.
Surgical excision of adenomas has been reported to cause remission of symptoms, though systematic data are lacking owing to rarity of these tumours.
Study design, size, duration
National case series from tertiary neuroendocrine units in England, Wales and Scotland.
Participants/materials, setting, methods
Eight high-volume pituitary endocrine tertiary units within England, Wales and Scotland audited their records for any cases of FGA-induced OHSS; only seven patients have been identified to date. In all cases, there had been no recent exposure to assisted reproductive technologies (ART) or drugs known to induce OHSS including gonadotrophins or selective oestrogen receptor modulators (SERMS).
Main results and the role of chance
Seven cases of FGA were identified with mean age 31.6 years (range 16-48) at diagnosis. Two-of-seven women presented acutely unwell with abdominal pain, distention and palpable mass requiring oophorectomy for ovarian torsion/ruptured ovarian cyst. The remaining five women presented with abdominal pain (n = 2), thyrotoxicosis (n = 1), menstrual irregularities/galactorrhoea (n = 1) and visual disturbances (n = 1). All women experienced intermittent pelvic pain during medical attendance. Pelvic ultrasound demonstrated enlarged multiseptated ovaries (volume ranging 27-442cm3). Ascites was noted in one woman. Six women had visual field defects due to optic chiasm compression on formal assessment. Median FSH was 26.10 u/L (8.3-33), but LH was <2.5 u/L in all cases. Estradiol (E2) far exceeded the reference range in 5/7 women (2990 to > 18000pmol/L);E2 was at the upper limit of normal in the remaining 2/7 women (960-1450pmol/L). Hyperprolactinaemia, hyperthyroidism and other pituitary hormones deficiency were noted in 6/7, 1/7 and 4/7 women respectively. All FGAs were macroadenomas with diameters ranging 16-48mm. Two patients were administered a somatostatin analogue prior to surgery, but FSH, E2 and tumour size did not change. Transsphenoidal surgery was performed in 6/7 women, and always improved symptomatic and biochemical features of OHSS; however, residual FGA tumour was present post-operatively in all cases studied.
Limitations, reasons for caution
It is possible that some ‘non-functioning’ gonadotroph adenomas cause subclinical problems including menstrual irregularity and mild OHSS which were never diagnosed.
We have insufficient data to determine the prognosis for future pregnancy after FGA-induced OHSS.
This study utilised historical case-notes, so some data is missing.
Wider implications of the findings
The ‘spontaneous’ presentation of OHSS may be confusing for clinicians. We report that FGA is an important cause of spontaneous OHSS which has well-defined biochemical and radiological characteristics, which may be treated effectively in the short-to-medium with pituitary surgery. Results of this study may provide greater awareness of FGA-induced OHSS.
Trial registration number
N/A
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Affiliation(s)
- N Papanikolaou
- Imperial College London, Metabolism-Digestion and Reproduction , London, United Kingdom
| | - A Coulden
- University hospitals Birmingham NHS Foundation Trust , Endocrinology, Birmingham, United Kingdom
| | - N Parker
- Imperial College Healthcare NHS Trust, Obstetrics and Gynaecology , London, United Kingdom
| | - S Lee
- Royal Infirmary of Edinburgh , Endocrinology, Edinburgh, United Kingdom
| | - C Kelly
- NHS Forth Valley , Endocrinology, Larbert, United Kingdom
| | - R Anderson
- University of Edinburgh, Obstetrics and Gynaecology- Center for Reproductive health , Edinburgh, United Kingdom
| | - A Rees
- Cardiff University- School of Medicine , Endocrinology, Cardiff, United Kingdom
| | - J Cox
- Imperial College Healthcare NHS Trust , Endocrinology, London, United Kingdom
| | - W Dhillo
- Imperial College London, Metabolism- Digestion and Reproduction , London, United Kingdom
| | - K Meeran
- Imperial College Healthcare NHS Trust , Endocrinology, London, United Kingdom
| | - M Al-Memar
- Imperial College Healthcare NHS Trust, Obstetrics and Gynaecology , London, United Kingdom
| | - N Karavitaki
- University hospitals Birmingham NHS Foundation Trust , Endocrinology, Birmingham, United Kingdom
| | - C Jayasena
- Imperial College London, Metabolism-Digestion and Reproduction , London, United Kingdom
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Lithgow K, Siqueira I, Senthil L, Chew HS, Chavda SV, Ayuk J, Toogood A, Gittoes N, Matthews T, Batra R, Meade S, Sanghera P, Khan N, Ahmed S, Paluzzi A, Tsermoulas G, Karavitaki N. Pituitary metastases: presentation and outcomes from a pituitary center over the last decade. Pituitary 2020; 23:258-265. [PMID: 32189207 PMCID: PMC7181548 DOI: 10.1007/s11102-020-01034-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE Highlight and characterize manifestations, diagnostic/management approaches and outcomes in a contemporary cohort of patients with pituitary metastases (PM) from a large European pituitary center-over 10 years. METHODS Retrospective review of PM cases between 1/2009 and 12/2018. Clinical, laboratory, imaging data at PM detection and during follow-up were analysed. RESULTS 18 cases were identified (14 females; median age at diagnosis 61.5 years). Most common primary malignancies were lung (39%) and breast (32%). Most frequent presenting manifestation was visual dysfunction (50%). Gonadotrophin, ACTH, TSH deficiency were diagnosed in 85%, 67%, 46% of cases, respectively; diabetes insipidus (DI) was present in 17%. 33% of cases were detected during investigation for symptoms unrelated to PM. PM management included radiotherapy (44%), transsphenoidal surgery (17%), transsphenoidal surgery and radiotherapy (6%) or monitoring only (33%). One-year survival was 49% with median survival from PM detection 11 months (range 2-47). CONCLUSIONS In our contemporary series, clinical presentation of PM has evolved; we found increased prevalence of anterior hypopituitarism, decreased rates of DI and longer survival compared with older literature. Increased availability of diagnostic imaging, improvements in screening and recognition of pituitary disease and longer survival of patients with metastatic cancer may be contributing factors.
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Affiliation(s)
- K Lithgow
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - I Siqueira
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - L Senthil
- Department of Radiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - H S Chew
- Department of Radiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - S V Chavda
- Department of Radiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - J Ayuk
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - A Toogood
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - N Gittoes
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - T Matthews
- Department of Ophthalmology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - R Batra
- Department of Ophthalmology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - S Meade
- Department of Oncology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - P Sanghera
- Department of Oncology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - N Khan
- Department of Ear, Nose & Throat, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - S Ahmed
- Department of Ear, Nose & Throat, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - A Paluzzi
- Department of Neurosugery, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - G Tsermoulas
- Department of Neurosugery, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - N Karavitaki
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK.
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
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Abstract
Consensus guidelines recommend dopamine agonists (DAs) as the mainstay treatment for prolactinomas. In most patients, DAs achieve tumor shrinkage and normoprolactinemia at well tolerated doses. However, primary or, less often, secondary resistance to DAs may be also encountered representing challenging clinical scenarios. This is particularly true for aggressive prolactinomas in which surgery and radiotherapy may not achieve tumor control. In these cases, alternative medical treatments have been considered but data on their efficacy should be interpreted within the constraints of publication bias and of lack of relevant clinical trials. The limited reports on somatostatin analogues have shown conflicting results, but cases with optimal outcomes have been documented. Data on estrogen modulators and metformin are scarce and their usefulness remains to be evaluated. In many aggressive lactotroph tumors, temozolomide has demonstrated optimal outcomes, whereas for other cytotoxic agents, tyrosine kinase inhibitors and for inhibitors of mammalian target of rapamycin (mTOR), higher quality evidence is needed. Finally, promising preliminary results from in vitro and animal reports need to be further assessed and, if appropriate, translated in human studies.
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Affiliation(s)
- P Souteiro
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Universitário de São João, Porto, Portugal
- Faculty of Medicine of University of Porto, Porto, Portugal
- Instituto de Investigação e Inovação em Saúde, University of Porto, Porto, Portugal
- Institute of Metabolism and Systems Research (IMSR), College of Medical and Dental Sciences, University of Birmingham, IBR Tower, Level 2, Birmingham, B15 2TT, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - N Karavitaki
- Institute of Metabolism and Systems Research (IMSR), College of Medical and Dental Sciences, University of Birmingham, IBR Tower, Level 2, Birmingham, B15 2TT, UK.
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK.
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
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Diamanti-Kandarakis E, Duntas L, Kanakis GA, Kandaraki E, Karavitaki N, Kassi E, Livadas S, Mastorakos G, Migdalis I, Miras AD, Nader S, Papalou O, Poladian R, Popovic V, Rachoń D, Tigas S, Tsigos C, Tsilchorozidou T, Tzotzas T, Bargiota A, Pfeifer M. DIAGNOSIS OF ENDOCRINE DISEASE: Drug-induced endocrinopathies and diabetes: a combo-endocrinology overview. Eur J Endocrinol 2019; 181:R73-R105. [PMID: 31242462 DOI: 10.1530/eje-19-0154] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Accepted: 06/03/2019] [Indexed: 11/08/2022]
Abstract
In the currently overwhelming era of polypharmacy, the balance of the dynamic and delicate endocrine system can easily be disturbed by interfering pharmaceutical agents like medications. Drugs can cause endocrine abnormalities via different mechanisms, including direct alteration of hormone production, changes in the regulation of the feedback axis, on hormonal transport, binding and signaling, as well as similar changes to counter-regulatory hormone systems. Furthermore, drugs can interfere with the hormonal assays, leading to erroneous laboratory results that disorientate clinicians from the right diagnosis. The purpose of this review is to cover a contemporary topic, the drug-induced endocrinopathies, which was presented in the monothematic annual Combo Endo Course 2018. This challenging part of endocrinology is constantly expanding particularly during the last decade, with the new oncological therapeutic agents, targeting novel molecular pathways in the process of malignancies. In this new context of drug-induced endocrine disease, clinicians should be aware that drugs can cause endocrine abnormalities via different mechanisms and mimic a variety of clinical scenarios. Therefore, it is extremely important for clinicians not only to promptly recognize drug-induced hormonal and metabolic abnormalities, but also to address the therapeutic issues for timely intervention.
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Affiliation(s)
| | - L Duntas
- Endocrine Clinic Evgenidion Hospital, University of Athens
| | - G A Kanakis
- Department of Endocrinology, Athens Naval & VA Hospital, Athens, Unit of Reproductive Endocrinology, Athens, Greece
| | - E Kandaraki
- Department of Endocrinology, Diabetes and Metabolism, Hygeia Hospital
| | - N Karavitaki
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - E Kassi
- Department of Biological Chemistry, First Department of Internal Medicine, Laikon Hospital Medical School, NKUA
| | - S Livadas
- Endocrine Unit, Metropolitan Hospital
| | - G Mastorakos
- Endocrine Unit, 2nd Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, 'Aretaieion' University Hospital
| | - I Migdalis
- Second Medical Department and Diabetes Centre, NIMTS Hospital, Athens, Greece
| | - A D Miras
- Division of Endocrinology Diabetes and Metabolic Medicine, Imperial College London, London, UK
| | - S Nader
- Department of Internal Medicine-Endocrine Division, McGovern Medical School, Houston, Texas, USA
| | - O Papalou
- Department of Endocrinology, Diabetes and Metabolism, Hygeia Hospital
| | - R Poladian
- Department of Endocrinology, MLH University Hospital, Beirut, Lebanon
| | - V Popovic
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - D Rachoń
- Department of Clinical and Experimental Endocrinology, Medical University of Gdańsk, Gdańsk, Poland
| | - S Tigas
- Department of Endocrinology, Ioannina University Hospital, Ioannina, Greece
| | - C Tsigos
- Harokopio University of Athens and HYGEIA Hospital, Athens, Greece
| | | | - T Tzotzas
- St. Luke's Hospital, Panorama, Thessaloniki, Greece
| | - A Bargiota
- Department of Internal Medicine - Endocrinology, University of Thessaly, Larissa, Greece
| | - M Pfeifer
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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5
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Jolly K, Darr A, Arlt W, Ahmed S, Karavitaki N. Surgery for Cushing's disease in pregnancy: our experience and a literature review. Ann R Coll Surg Engl 2019; 101:e26-e31. [PMID: 30286651 PMCID: PMC6303815 DOI: 10.1308/rcsann.2018.0175] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2018] [Indexed: 12/23/2022] Open
Abstract
Cushing's syndrome in pregnancy is a rare phenomenon and there is limited literature on its management. Cushing's disease in pregnancy is even less common and there is little guidance to help in the treatment for this patient group. Diagnosis of Cushing's syndrome in pregnancy is often delayed due to overlap of symptoms. In addition, there are no validated diagnostic tests or parameters documented. We present a case of a 30-year-old woman presenting to the antenatal clinic at 13 weeks of pregnancy with high suspicion of Cushing's disease. Her 21-week fetal scan showed a congenital diaphragmatic hernia and she underwent pituitary magnetic resonance imaging, which confirm Cushing's disease. She successfully underwent transsphenoidal adenomectomy with histology confirming a corticotroph adenoma. Tests following transsphenoidal surgery confirmed remission of Cushing's disease and she underwent an emergency caesarean section at 38 weeks. Unfortunately, her baby died from complications associated with the congenital abnormality 36 hours after birth. The patient remains in remission following delivery. To date, there have been no reported cases of congenital diaphragmatic hernia associated with Cushing's disease in pregnancy. In addition, we believe that this is only the eighth reported patient to have undergone successful transsphenoidal surgery for Cushing's disease in pregnancy.
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Affiliation(s)
- K Jolly
- Ear, Nose and Throat Department, University Hospital Birmingham, Birmingham, UK
| | - A Darr
- Ear, Nose and Throat Department, University Hospital Birmingham, Birmingham, UK
| | - W Arlt
- Department of Endocrinology, University Hospital Birmingham, Birmingham, UK
| | - S Ahmed
- Ear, Nose and Throat Department, University Hospital Birmingham, Birmingham, UK
| | - N Karavitaki
- Department of Endocrinology, University Hospital Birmingham, Birmingham, UK
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6
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Asa SL, Casar-Borota O, Chanson P, Delgrange E, Earls P, Ezzat S, Grossman A, Ikeda H, Inoshita N, Karavitaki N, Korbonits M, Laws ER, Lopes MB, Maartens N, McCutcheon IE, Mete O, Nishioka H, Raverot G, Roncaroli F, Saeger W, Syro LV, Vasiljevic A, Villa C, Wierinckx A, Trouillas J. From pituitary adenoma to pituitary neuroendocrine tumor (PitNET): an International Pituitary Pathology Club proposal. Endocr Relat Cancer 2017; 24:C5-C8. [PMID: 28264912 DOI: 10.1530/erc-17-0004] [Citation(s) in RCA: 214] [Impact Index Per Article: 30.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 02/01/2017] [Indexed: 11/08/2022]
Abstract
The classification of neoplasms of adenohypophysial cells is misleading because of the simplistic distinction between adenoma and carcinoma, based solely on metastatic spread and the poor reproducibility and predictive value of the definition of atypical adenomas based on the detection of mitoses or expression of Ki-67 or p53. In addition, the current classification of neoplasms of the anterior pituitary does not accurately reflect the clinical spectrum of behavior. Invasion and regrowth of proliferative lesions and persistence of hormone hypersecretion cause significant morbidity and mortality. We propose a new terminology, pituitary neuroendocrine tumor (PitNET), which is consistent with that used for other neuroendocrine neoplasms and which recognizes the highly variable impact of these tumors on patients.
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Affiliation(s)
- S L Asa
- Department of Pathology and Endocrine Oncology Site GroupPrincess Margaret Cancer Centre, University Health Network, Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - O Casar-Borota
- Department of PathologyUppsala University Hospital, Uppsala, Sweden
| | - P Chanson
- Service of Endocrinology and Reproductive DiseasesBicêtre Hospital, Paris, France
| | - E Delgrange
- Department of MedicineUniversity of Louvain, Mont-sur-Meuse, Belgium
| | - P Earls
- Department of Anatomical PathologySt Vincent's Hospital, Sydney, Australia
| | - S Ezzat
- Department of Medicine and Endocrine Oncology Site GroupPrincess Margaret Cancer Centre, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - A Grossman
- Department of EndocrinologyUniversity of Oxford, Oxford, UK
| | - H Ikeda
- Research Institute for Pituitary DiseaseSouthern Tohoku General Hospital, Fukushima, Japan
| | - N Inoshita
- Department of PathologyToranomon Hospital, Tokyo, Japan
| | - N Karavitaki
- Department of EndocrinologyQueen Elizabeth Hospital, University of Birmingham, Birmingham, UK
| | - M Korbonits
- Division of EndocrinologyQueen Mary Hospital, Barts and the London School of Medicine, London, UK
| | - E R Laws
- Department of NeurosurgeryHarvard Medical School, Brigham & Women's Hospital, Boston, Massachusetts, USA
| | - M B Lopes
- Departments of Pathology and Neurological SurgeryUniversity of Virginia, Charlottesville, Virginia, USA
| | - N Maartens
- Department of NeurosurgeryRoyal Melbourne Hospital, The University of Melbourne, Melbourne, Australia
| | - I E McCutcheon
- Department of NeurosurgeryUT MD Anderson Cancer Center, Houston, Texas, USA
| | - O Mete
- Department of Pathology and Endocrine Oncology Site GroupPrincess Margaret Cancer Centre, University Health Network, Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - H Nishioka
- Department of NeurosurgeryToranomon Hospital, Tokyo, Japan
| | - G Raverot
- Department of EndocrinologyGroupement Hospitalier EST, Hospices Civils de Lyon, University of Lyon, Lyon, France
| | - F Roncaroli
- Department of NeuropathologyImperial College, London, UK
| | - W Saeger
- Institute of Neuropathology of the University of HamburgHamburg, Germany
| | - L V Syro
- Department of NeurosurgeryHospital Pablo Tobon Uribe, Medellin, Colombia
| | - A Vasiljevic
- Department of PathologyGroupement Hospitalier EST, Hospices Civils de Lyon, University of Lyon, Lyon, France
| | - C Villa
- Department of PathologyHôpital Foch, Suresnes, France
| | - A Wierinckx
- INSERM U1052Cancer Research Center of Lyon, University of Lyon, Lyon, France
| | - J Trouillas
- Faculty of Medicine Lyon-EstUniversity of Lyon, Lyon, France
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7
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Affiliation(s)
- C J H May
- From the Endocrinology Department, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners Birmingham, Birmingham B15 2TH, UK
| | - M Asia
- From the Endocrinology Department, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners Birmingham, Birmingham B15 2TH, UK
| | - N Karavitaki
- From the Endocrinology Department, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners Birmingham, Birmingham B15 2TH, UK
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham B15 2TT, UK
| | - W Arlt
- From the Endocrinology Department, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners Birmingham, Birmingham B15 2TH, UK
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham B15 2TT, UK
| | - P Guest
- Radiology Department, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, UK
| | - M W O'Reilly
- From the Endocrinology Department, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners Birmingham, Birmingham B15 2TH, UK
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham B15 2TT, UK
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8
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Affiliation(s)
- A Rogers
- From the Oxford Centre for Diabetes, Endocrinology and Metabolism, Radcliffe Department of Medicine, Churchill Hospital, University of Oxford, OX3 7LE, UK and Department of Histopathology, John Radcliffe Hospital, University of Oxford, OX3 9DU, UK
| | - L M Wang
- From the Oxford Centre for Diabetes, Endocrinology and Metabolism, Radcliffe Department of Medicine, Churchill Hospital, University of Oxford, OX3 7LE, UK and Department of Histopathology, John Radcliffe Hospital, University of Oxford, OX3 9DU, UK
| | - N Karavitaki
- From the Oxford Centre for Diabetes, Endocrinology and Metabolism, Radcliffe Department of Medicine, Churchill Hospital, University of Oxford, OX3 7LE, UK and Department of Histopathology, John Radcliffe Hospital, University of Oxford, OX3 9DU, UK
| | - A B Grossman
- From the Oxford Centre for Diabetes, Endocrinology and Metabolism, Radcliffe Department of Medicine, Churchill Hospital, University of Oxford, OX3 7LE, UK and Department of Histopathology, John Radcliffe Hospital, University of Oxford, OX3 9DU, UK
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9
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Affiliation(s)
- T I M Korevaar
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Headington, Oxford OX3 7LE, UK.
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10
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Abstract
Craniopharyngiomas are rare epithelial tumours arising along the path of the craniopharyngeal duct. Their pathogenesis remains uncertain and they can present with a variety of manifestations attributed to pressure effects to surrounding structures. The optimal management of craniopharyngiomas remains challenging mainly due to their sharp, irregular borders and their tendency to adhere to vital neurovascular structures making surgical manipulations potentially hazardous to vital brain areas. Non-aggressive surgery followed by radiotherapy is currently the most widely used option possibly achieving the most optimal long-term outcome. Other treatment modalities including intracystic irradiation, intracystic instillation of antineoplasmatic agents and stereotactic radiotherapy are also available in our armamentarium. The long-term morbidities related with the craniopharyngiomas and their treatment remain significant, with hypothalamic damage playing the protagonist role and requiring further studies to identify measures that will improve the prognosis of the patients.
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11
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Ntali G, Asimakopoulou A, Siamatras T, Komninos J, Vassiliadi D, Tzanela M, Tsagarakis S, Grossman AB, Wass JAH, Karavitaki N. Mortality in Cushing's syndrome: systematic analysis of a large series with prolonged follow-up. Eur J Endocrinol 2013; 169:715-23. [PMID: 23996696 DOI: 10.1530/eje-13-0569] [Citation(s) in RCA: 90] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVE In this study, we aim to assess the long-term survival and causes of death in a retrospective cohort study on patients with all aetiologies of endogenous Cushing's syndrome (CS) (except adrenal cancer), presenting to two large tertiary endocrine referral centres, and to identify variables predicting mortality. SUBJECTS AND METHODS The records of all patients presenting with endogenous CS in the Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford, UK and the Department of Endocrinology, 'Evangelismos' General Hospital, Athens, Greece between 1967-2009 (Oxford series) and 1962-2009 (Athens series) were reviewed. The standardised mortality ratio (SMR) was calculated for the Oxford series. RESULTS In total, 418 subjects were identified (311 with Cushing's disease (CD), 74 with adrenal Cushing's (AC) and 33 with ectopic Cushing's (EC)). In CD, the probability of 10-year survival was 95.3% with 71.4% of the deaths attributed to cardiovascular causes or infection/sepsis. SMRs were significantly high overall (SMR 9.3; 95% CI, 6.2-13.4, P<0.001), as well as in all subgroups of patients irrespective of their remission status. In AC, the probability of 10-year survival was 95.5% and the SMR was 5.3 (95% CI, 0.3-26.0) with P=0.2. Patients with EC had the worst outcome with 77.6% probability of 5-year survival. CONCLUSIONS In this large series of patients with CS and long-term follow-up, we report that in CD the mortality is significantly affected, even after apparently successful treatment. The SMR of patients with AC was high, but this was not statistically significant. The implicated pathophysiological mechanisms for these findings need to be further elucidated aiming to improve the long-term outcome.
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Affiliation(s)
- G Ntali
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Old Road, Headington, Oxford OX3 7LJ, UK
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Walker JN, Shillo P, Ibbotson V, Vincent A, Karavitaki N, Weetman AP, Wass JAH, Allahabadia A. A thyroxine absorption test followed by weekly thyroxine administration: a method to assess non-adherence to treatment. Eur J Endocrinol 2013; 168:913-7. [PMID: 23554450 DOI: 10.1530/eje-12-1035] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE For patients who remain hypothyroid despite the administration of what would seem adequate doses of levothyroxine (L-T4), the underlying cause can be difficult to determine. The possibility of a biological cause should first be explored; however, in the majority of cases, poor adherence to medication is likely to be the main cause of treatment failure. When non-adherence is suspected but not volunteered, options to confirm the suspicion are limited. In this study, we identified patients for whom known drugs and pathological causes of L-T4 malabsorption were excluded, and despite often high doses of L-T4, the patients remained hypothyroid. DESIGN Using a weight-determined oral L-T4 bolus administration, absorption was initially assessed in 23 patients. In nearly all patients, this was shown to be maximal at 120 min post-ingestion. This was then followed by the continued administration of a weekly T4 bolus for a 4-week period after which TSH and free T4 (fT4) levels were recorded. RESULTS All patients showed a rise in fT4 at 120 min following the administration of the L-T4 bolus, with a mean increase of 54±3% from baseline. Following the treatment period, using an equivalent weekly L-T4 dose, which was significantly less than that of the daily dose taken by the patients before the test, TSH reduced from baseline in ~75% of cases. CONCLUSION Using this combination of tests allows significant malabsorptive problems to be identified first and then potential non-adherence to be demonstrated. A management plan can then be implemented to increase adherence, aiming to improve treatment outcomes.
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Affiliation(s)
- J N Walker
- Department of Endocrinology, Oxford University Hospitals NHS Trust, OCDEM, Oxford OX3 7LJ, UK.
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13
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Plaha P, Chari A, Haslam N, Pereira E, Rogers A, Korevaar T, Karavitaki N, Grossman A, Cudlip S. Pituitary Tumor Surgery in the Elderly: Perioperative Complications and Long-Term Outcome. Skull Base Surg 2012. [DOI: 10.1055/s-0032-1314047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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14
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Korevaar T, Wass JAH, Grossman AB, Karavitaki N. Disconnection hyperprolactinaemia in nonadenomatous sellar/parasellar lesions practically never exceeds 2000 mU/l. Clin Endocrinol (Oxf) 2012; 76:602-3. [PMID: 21942983 DOI: 10.1111/j.1365-2265.2011.04226.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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15
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Pal A, Capatina C, Tenreiro AP, Guardiola PD, Byrne JV, Cudlip S, Karavitaki N, Wass JAH. Pituitary apoplexy in non-functioning pituitary adenomas: long term follow up is important because of significant numbers of tumour recurrences. Clin Endocrinol (Oxf) 2011; 75:501-4. [PMID: 21521336 DOI: 10.1111/j.1365-2265.2011.04068.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The frequency of pituitary tumour regrowth after an episode of classical pituitary apoplexy is unknown. It is thus unclear whether regrowth, if it occurs, does so less frequently than with non-apoplectic non-functioning pituitary macroadenomas that have undergone surgery without postoperative irradiation. This has important repercussions on follow up protocols for these patients. DESIGN Retrospective cohort study of patients diagnosed with classical pituitary apoplexy in Oxford in the last 24 years. MEASUREMENTS MRI/CT scans of the pituitary were performed post-operatively and in those patients who did not receive pituitary irradiation, this was repeated yearly for 5 years and 2 yearly thereafter. RESULTS Thirty-two patients with non-functioning pituitary adenomas who presented with classical pituitary apoplexy were studied. There were 23 men and the mean age was 56·6 years (range 29-85). The mean follow up period was 81 months (range 6-248). Five patients received adjuvant radiotherapy within 6 months of surgery and were excluded from further analysis. In this group, there were no recurrences during a mean follow up of 83 months (range 20-150). In the remaining 27 cases there were 3 recurrences, with a mean of 79 months follow up (range 6-248) occurring 12, 51 and 86 months after surgery. This gives a recurrence rate of 11·1% at a mean follow up of 6·6 years post surgery. All recurrences had residual tumour on the post operative scan. CONCLUSIONS Patients with classical pituitary apoplexy may show recurrent pituitary tumour growth and therefore these patients need continued post-operative surveillance if they have not had post-operative radiotherapy.
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Affiliation(s)
- A Pal
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, University of Oxford, Oxford, UK
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16
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Trifanescu R, Stavrinides V, Plaha P, Cudlip S, Byrne JV, Ansorge O, Wass JAH, Karavitaki N. Outcome in surgically treated Rathke's cleft cysts: long-term monitoring needed. Eur J Endocrinol 2011; 165:33-7. [PMID: 21502327 DOI: 10.1530/eje-11-0142] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To clarify the outcome of all cases of Rathke's cleft cysts (RCC) treated surgically and followed up in Oxford during a long-term period. SUBJECTS AND METHODS The records of all patients with RCC seen in the Department of Endocrinology between January 1978 and June 2009 were reviewed. RESULTS A total of 33 patients (20 females, median age 43 years) were identified. At presentation, major visual field defects were detected in 58% of patients and gonadotrophin, ACTH and TSH deficiency in 60, 36 and 36% of patients respectively. Desmopressin treatment was required in 18% of patients. Treatment consisted of cyst evacuation combined with or without biopsy/removal of the wall. Post-operatively, visual fields improved in 83% of patients with impairment, whereas there was no reversal of ACTH or TSH deficiency or of diabetes insipidus. All but one subject had imaging follow-up during a mean period of 48 months (range 2-267). Cyst relapse was detected in 22% of patients at a mean interval of 29 months (range 3-48 months); in 57% of them, the recurrence was symptomatic. Relapse-free rates were 88% at 24-months and 52% at 48-months follow-up. At last assessment, at least quadrantanopia was reported in 19% of patients, gonadotrophin, ACTH and TSH deficiency in 50, 42 and 47% of patients respectively. Desmopressin treatment was required in 39% of patients. CONCLUSIONS In this study of patients with RCC and long-term follow-up, we showed a considerable relapse rate necessitating long-term monitoring. Surgical intervention is of major importance for the restoration of visual field defects, but it does not improve endocrine morbidity, which in the long-term affects a substantial number of patients.
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Affiliation(s)
- R Trifanescu
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Old Road, Headington, Oxford OX3 7LJ, UK
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17
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Abstract
Nelson's syndrome is a potentially life-threatening condition that does not infrequently develop following total bilateral adrenalectomy (TBA) for the treatment of Cushing's disease. In this review article, we discuss some controversial aspects of Nelson's syndrome including diagnosis, predictive factors, aetiology, pathology and management based on data from the existing literature and the experience of our own tertiary centre. Definitive diagnostic criteria for Nelson's syndrome are lacking. We argue in favour of a new set of criteria. We propose that Nelson's syndrome should be diagnosed in any patient with prior TBA for the treatment of Cushing's disease and with at least one of the following criteria: i) an expanding pituitary mass lesion compared with pre-TBA images; ii) an elevated 0800 h plasma level of ACTH (>500 ng/l) in addition to progressive elevations of ACTH (a rise of >30%) on at least three consecutive occasions. Regarding predictive factors for the development of Nelson's syndrome post TBA, current evidence favours the presence of residual pituitary tumour on magnetic resonance imaging (MRI) post transsphenoidal surgery (TSS); an aggressive subtype of corticotrophinoma (based on MRI growth rapidity and histology of TSS samples); lack of prophylactic neoadjuvant pituitary radiotherapy at the time of TBA and a rapid rise of ACTH levels in year 1 post TBA. Finally, more studies are needed to assess the efficacy of therapeutic strategies in Nelson's syndrome, including the alkylating agent, temozolomide, which holds promise as a novel and effective therapeutic agent in the treatment of associated aggressive corticotroph tumours. It is timely to review these controversies and to suggest guidelines for future audit.
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Affiliation(s)
- T M Barber
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, University of Oxford, Headington, Oxford, UK
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18
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Walker JN, Rourke D, Allen K, Karavitaki N, Levy J, Wass JAH. An e-mail GP advisory service: a more efficient way of dealing with clinical enquiries. Br J Hosp Med (Lond) 2010; 70:532-3. [PMID: 19749645 DOI: 10.12968/hmed.2009.70.9.43872] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Good communication between primary and secondary care is vital for patient management. This article describes how an e-mail enquiry service for endocrinology and diabetes was established within one hospital and the potential benefits that it offers.
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Affiliation(s)
- J N Walker
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford
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19
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Karavitaki N, Fernandez A, Fazal-Sanderson V, Wass JAH. The value of the oral glucose tolerance test, random serum growth hormone and mean growth hormone levels in assessing the postoperative outcome of patients with acromegaly. Clin Endocrinol (Oxf) 2009; 71:840-5. [PMID: 19320648 DOI: 10.1111/j.1365-2265.2009.03578.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The nadir GH value following an oral glucose tolerance test (OGTT) and the mean GH levels obtained from a GH day curve (GHDC) are among the tools currently used for assessing therapeutic end-points in surgically treated acromegaly. The latter test, however, is cumbersome and costly. OBJECTIVES To evaluate, by using a modern, two-site chemiluminescent immunometric GH assay, the degree of discordance between the nadir GH following an OGTT and the mean GH obtained from a GHDC after surgical treatment of acromegaly and to check whether the OGTT can replace reliably the GHDC for the assessment of the disease status postoperatively. PATIENTS AND METHODS Forty-nine patients [25 males/24 females, median age 52 years (range 18-70)] with a GH-secreting pituitary adenoma who had been surgically treated previously underwent hormonal evaluation of their disease status. The GHDC comprised of 9 x 30-min samples for GH collected in the morning after an overnight fast and rest. RESULTS Seven per cent of patients with mean GH <1.7 mug/l (5 mU/l) in the GHDC had nadir GH >0.7 mug/l (2 mU/l) in the OGTT, and 10% of those with mean GH >1.7 mug/l had nadir GH <0.7 mug/l in the OGTT (all cases with discrepancies had normal IGF-I). GH value at time 0 min <0.6 mug/l in the OGTT had positive predictive value 100% and negative predictive value 75% in predicting nadir GH <0.3 mug/l (1 mU/l) in the OGTT. Nadir GH <0.8 mug/l in the OGTT had positive predictive value 97% and negative predictive value 95% in predicting mean GH <1.7 mug/l in the GHDC. Mean GH in the OGTT <1.4 mug/l had a positive predictive value 90% and negative predictive value 95% in predicting mean GH <1.7 mug/l in the GHDC. Mean GH in the OGTT <2.5 mug/l had positive predictive value 100% and negative predictive value 81% in predicting normal IGF-I. GH at time 0 min in the GHDC <2.1 mug/l had positive predictive value 90% and negative predictive value 90% in predicting mean GH <1.7 mug/l in the GHDC. CONCLUSIONS The hormonal data obtained from an OGTT (mean and nadir GH) can provide comprehensive information on the status of acromegaly following surgery and can replace the GHDC cost-effectively. Furthermore, a morning fasting GH sample has an excellent positive predictive value in predicting biochemical cure and an optimal prognostic profile in predicting "safe" mean GH levels.
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Affiliation(s)
- N Karavitaki
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Headington, Oxford, UK
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20
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Arnold JR, Arnold DF, Marland A, Karavitaki N, Wass JAH. GH replacement in patients with non-functioning pituitary adenoma (NFA) treated solely by surgery is not associated with increased risk of tumour recurrence. Clin Endocrinol (Oxf) 2009; 70:435-8. [PMID: 19236640 DOI: 10.1111/j.1365-2265.2008.03391.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Subjects with non-functioning pituitary adenomas (NFAs) frequently develop GH deficiency due to tumour expansion or as a consequence of tumour therapy. The safety of GH replacement (GHR) in these individuals remains unclear. OBJECTIVE To assess the effect of GHR on tumour recurrence in patients with NFAs solely treated by surgical removal. PATIENTS AND METHODS The study involved all patients with NFA who presented to the Department of Endocrinology in Oxford between January 1989 and July 2005 and were treated solely by surgical removal of the tumour. Patients with follow up < 1 year were excluded. Recurrence was diagnosed on the basis of radiological appearances (detectable tumour after gross total removal or regrowth of pre-existing residue) on regular imaging surveillance. RESULTS One hundred and thirty patients were included in the study, and were followed up for a mean period of 6.8 +/- 4.2 years (median 5.7, range 1.2-17.6). Twenty-three patients received GHR [16 male, 7 female, mean age at tumour diagnosis 53.7 +/- 14.6 years (range 20-80)]. The mean duration of GHR was 4.6 +/- 2.5 years (median 5.3, range 0.4-8.7). One hundred and seven subjects did not receive GH therapy [61 male, 46 female, mean age at tumour diagnosis 56.2 +/- 14.0 years (range 20-87)]. Tumour regrowth occurred in 38 non-GH treated subjects (36%) and 8 GHR subjects (35%). Regrowth was detected at a mean of 4.8 +/- 2.8 years (range 1-11 years) in the non-GH treated group, and at 6.5 +/- 2.3 years in the GHR group. In the GHR group, recurrence occurred after a mean of 2.9 +/- 2.2 years (range 0.4-5.9 years) following commencement of GH treatment. The Cox regression analysis showed that after adjusting for sex, age at tumour diagnosis, cavernous sinus invasion at diagnosis and type of tumour removal (partial or complete based on postoperative scan), GH treatment was not a significant independent predictor of recurrence (P = 0.09; hazard ratio = 0.51; 95% CI, 0.24-1.12). CONCLUSION GH replacement in patients with NFA treated by surgery alone is not associated with an increased risk of tumour recurrence.
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Affiliation(s)
- J R Arnold
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, UK
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21
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Abstract
Radiotherapy has been used as primary or adjuvant treatment in a number of non-adenomatous masses arising from within the sella. It is particularly important in the therapeutic algorithm of craniopharyngiomas and meningiomas and has also been used in chordomas/chordosarcomas and less commonly, in other lesions. This review describes the place of irradiation in the management of these masses.
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Affiliation(s)
- N Karavitaki
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Old Rd, Headington, Oxford OX3 7LJ, UK.
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22
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Karavitaki N, Turner HE, Adams CBT, Cudlip S, Byrne JV, Fazal-Sanderson V, Rowlers S, Trainer PJ, Wass JAH. Surgical debulking of pituitary macroadenomas causing acromegaly improves control by lanreotide. Clin Endocrinol (Oxf) 2008; 68:970-5. [PMID: 18031313 DOI: 10.1111/j.1365-2265.2007.03139.x] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Macroadenomas causing acromegaly are cured surgically in only around 50% of patients. Primary medical treatment with somatostatin analogues has been suggested to be a means of treating patients with a potentially poor surgical outcome. Previous retrospective studies have also suggested that surgical debulking of pituitary tumours causing acromegaly improves control by somatostatin analogues. No prospective study using lanreotide has been carried out thus far to assess whether this is the case. OBJECTIVE We carried out a prospective study to assess whether surgical debulking of pituitary macroadenomas causing acromegaly improved the subsequent control of acromegaly by the somatostatin analogue lanreotide. PATIENTS AND METHODS We treated 26 consecutive patients [10 males and 16 females--median age 53.5 years (range 22-70)] with macroadenoma causing acromegaly unselected for somatostatin response for 16 weeks with lanreotide, maximizing GH and IGF-I suppression, if necessary, by incremental dosing. Surgical resection was carried out and the patients were re-assessed off medical treatment at 16 weeks following surgery. Those with nadir GH > 2 mU/l in the oral glucose tolerance test (OGTT) and a mean GH in the GH day curve (GHDC) > 5 mU/l were subsequently restarted on lanreotide and the responses were assessed at the same time points as during the preoperative lanreotide treatment. RESULTS GH values fell on lanreotide treatment and prior to surgery they were considered 'safe' (mean GH in GHDC < 5 mU/l) in eight patients (30.7%). After surgery, they were 'safe' in 18 patients (69.2%). The figures for normal IGF-I were 11 (42.3%) before surgery and 23 (88.5%) after surgery. After surgery, six patients had nadir GH > 2 mU/l in the OGTT and 'unsafe' GH levels (mean GH in GHDC > 5 mU/l); on re-exposure to lanreotide, GH levels fell in all patients and at the end of 16 weeks postsurgery, they were 'safe' in three of them (50%) (P < 0.05). Pituitary tumour volume was also assessed prospectively, preoperatively on lanreotide and showed a mean fall of 33.1%. Eighty-three percent of patients had > 20% shrinkage. CONCLUSIONS In this first prospective study using lanreotide, surgical debulking of pituitary tumours causing acromegaly improved subsequent postoperative control by the somatostatin analogue lanreotide. Surgery should, therefore, be considered in patients with macroadenoma causing acromegaly, even if there is little prospect of surgical cure. Lanreotide causes significant pituitary tumour shrinkage in the majority of patients.
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Affiliation(s)
- N Karavitaki
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, UK
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23
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Karavitaki N, Scheithauer BW, Watt J, Ansorge O, Moschopoulos M, Llaguno AV, Wass JAH. Collision lesions of the sella: co-existence of craniopharyngioma with gonadotroph adenoma and of Rathke's cleft cyst with corticotroph adenoma. Pituitary 2008; 11:317-23. [PMID: 17917812 DOI: 10.1007/s11102-007-0070-6] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Collision lesions of the sellar region are relatively uncommon. Most contributions include a pituitary adenoma or a cyst/cystic tumor, particularly a Rathke cleft cyst. The association of craniopharyngioma with an adenoma is particularly rare. Among reported cases, some have included secondary prolactin cell hyperplasia due to pituitary stalk section effect. Herein, we report two collision lesions, including a gonadotroph adenoma with adamantinomatous craniopharyngioma and a corticotroph adenoma with Rathke's cleft cyst. Clinicopathologic correlation and a review of the literature are undertaken.
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Affiliation(s)
- N Karavitaki
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, UK
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24
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Abstract
BACKGROUND Series of patients systematically investigating the outcome of clinically nonfunctioning pituitary adenomas (NFAs) not treated by surgery or radiotherapy during long follow-up periods are limited. Most reports involve the follow-up of selected cases of incidentally found lesions, rendering their results unreliable on the assessment of the pros and cons of a 'watch and wait' policy. OBJECTIVE To investigate the outcome of a series of consecutive patients with presumed NFA (microadenoma or macroadenoma), who were not offered treatment at presentation (for a number of reasons) and were regularly followed up, and to identify possible factors predicting subsequent increase in tumour size. PATIENTS AND METHODS All patients presenting to the Department of Endocrinology in Oxford between 1989 and 2005 with presumed NFA were studied retrospectively. Inclusion criteria were: (i) imaging features suggestive of a pituitary adenoma, (ii) no clinical and/or biochemical evidence of hormonal hypersecretion by the tumour, (iii) monitoring being the initial choice of management, and (iv) at least one repeat scan during the follow-up period. Subjects presenting with acute apoplexy were excluded. Follow-up management included clinical evaluation, assessment of the visual acuity and fields and imaging at regular intervals. The duration of observation was estimated from the dates of first and last scan. RESULTS Forty subjects were included in the study [18 males/22 females, median age 52 years (range 18-89), 16 with microadenoma/24 with macroadenoma]. The mean follow-up period was 42 months (range 8-128). During the observation interval, 12.5% of the microadenomas and 50% of the macroadenomas increased in size. The 48-month probability for enlargement was 19% for the microadenomas and 44% for the macroadenomas. Among the subjects with tumour enlargement, 57% showed new or worse visual field defects (all had macroadenomas) and 21% showed chiasmatic involvement on imaging without visual deterioration (all had macroadenomas). New or worse visual field defects were found in 67% of the macroadenomas showing increase in size. No microadenoma enlarged to cause visual deterioration. In microadenomas, sex and age at presentation were not predictors of enlargement. In macroadenomas, sex, age, visual field defects or cavernous sinus invasion at presentation were not predictors of enlargement. CONCLUSIONS The 'watch and wait' policy seems reasonable for microadenomas but is probably not a safe approach for macroadenomas, which appear to have a significant growth potential; in these cases, given the lack of established medical treatment, the decision for surgical intervention should balance the presence of significant comorbidities and the anaesthetic/peri-operative risks at presentation against the probability of tumour enlargement and its consequences, as well as the possible loss of advantages associated with early operation.
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Affiliation(s)
- N Karavitaki
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, UK
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25
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Karavitaki N, Wass J, Henderson Slater JD, Wade D. A case of post-traumatic isolated ACTH deficiency with spontaneous recovery 9 months after the event. J Neurol Neurosurg Psychiatry 2006; 77:276-7. [PMID: 16421141 PMCID: PMC2077606 DOI: 10.1136/jnnp.2005.070482] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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26
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Tzanela M, Zianni D, Stylianidou C, Karavitaki N, Tsagarakis S, Thalassinos NC. Evaluation of GH reserve in patients with adrenal incidentalomas and biochemical evidence of subclinical autonomous glucocorticoid hypersecretion. Clin Endocrinol (Oxf) 2005; 62:597-602. [PMID: 15853831 DOI: 10.1111/j.1365-2265.2005.02266.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Although it is well established that overt hypercortisolism in patients with active Cushing's syndrome leads to a profound suppression of stimulated GH secretion, the role of subclinical autonomous glucocorticoid hypersecretion (SAGH), currently detected with increasing frequency in patients with adrenal incidentalomas, on GH secretory reserve has received little attention. The aim of the present study was to evaluate whether SAGH in patients presented with adrenal incidentalomas has a negative effect on GH secretory reserve. DESIGN AND PATIENTS Sixteen patients with overt Cushing's syndrome (CS) and 36 patients with adrenal incidentalomas were investigated. The latter group was further divided in 23 patients who demonstrated an adequate suppression of cortisol levels (of < 70 nmol/l) following the low-dose dexamethasone suppression test (LDDST) and in 13 patients, who failed to suppress (cortisol levels post-LDDST > 70 nmol/l). The former group was defined as normocortisolaemic (NC) and the latter group as representing patients with SAGH. The combined pyridostigmine + GHRH test (PD + GHRH) was used to assess the GH secretory reserve of these patients. RESULTS Peak GH levels following PD + GHRH administration were significantly lower in CS patients compared to both the NC and SAGH group of patients with adrenal incidentalomas (2.2 +/- 0.7 vs. 18.9 +/- 2.6 and 21.5 +/- 3.6 microg/l, respectively, P < 0.05); no difference was observed in peak GH responses between the NC and SAGH group of patients. A subnormal GH response (defined as GH(max) < 12.8 microg/l) was observed in all 16 patients with CS. However, only seven NC and three SAGH patients failed to respond adequately. Correlation analysis revealed a negative correlation between peak GH response to PD + GHRH and plasma cortisol concentrations in CS patients (R =-0.6, P = 0.012), while in patients with adrenal incidentalomas such a correlation was absent. Contrary to patients with CS in whom body mass index (BMI) was not correlated to peak GH, a significant negative correlation between peak GH response to PD + GHRH and BMI was disclosed in patients with adrenal incidentalomas (R =-0.49, P = 0.003). In these patients, again contrary to CS patients, a significant negative correlation was also found between peak GH post PD + GHRH and age (R = -0.46, P = 0.002). CONCLUSIONS In conclusion, our results provide evidence that, contrary to patients with overt CS, SAGH does not affect the GH secretory response to provocative stimulation.
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Affiliation(s)
- M Tzanela
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
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27
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Karavitaki N, Brufani C, Warner JT, Adams CBT, Richards P, Ansorge O, Shine B, Turner HE, Wass JAH. Craniopharyngiomas in children and adults: systematic analysis of 121 cases with long-term follow-up. Clin Endocrinol (Oxf) 2005; 62:397-409. [PMID: 15807869 DOI: 10.1111/j.1365-2265.2005.02231.x] [Citation(s) in RCA: 360] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Craniopharyngiomas account for 2-5% of all primary intracranial tumours. Despite their benign histological appearance, they are often associated with an unfavourable prognosis and their optimal treatment remains controversial. AIM To analyse the natural history and treatment outcome of children and adults presenting to the Departments of Paediatrics and Endocrinology with craniopharyngioma between 1964 and 2003. PATIENTS AND METHODS The records of 121 patients (age range 2.5-83 years, 42 aged < 16 and 79 aged > or = 16) were identified. The mean follow-up period since presentation was 103 months (8.6 years) (range 0.3-468 months). Sixteen patients underwent gross total removal (A), 3 gross total removal + radiotherapy (B), 51 partial removal (C), 33 partial removal + radiotherapy (D), 6 cyst evacuation alone (E) and 3 cyst evacuation + radiotherapy (F). The clinical, imaging and endocrinological data at presentation and during follow-up were analysed. RESULTS Headache and visual field defects were the most common presenting clinical features (64% and 55%, respectively). Ninety-four per cent of the tumours had an extrasellar component and 23% of them were associated with hydrocephalus. There was a significant difference in the recurrence-free survival rates between groups A-D [at 10 years: 100% (A), 100% (B), 38% (C) and 77% (D), P < 0.01], which persisted even when analysing patients operated after 1980. The median time of first recurrence was 2.5 years (range 0.5-36). The peri-operative mortality of the patients who had any type of neurosurgical intervention due to recurrence was higher than that observed after primary surgery (24%vs. 1.8%) (P < 0.01). The rate of re-accumulation of the cyst fluid was 58% during the first year in patients of group E, whereas none of the subjects of group F experienced such an event during their follow-up period. There was no reversal of pre-existing pituitary hormone deficits after any surgical intervention. The probabilities of GH, FSH/LH, ACTH, TSH deficiency and diabetes insipidus at the 10-year follow-up were 88%, 90%, 86%, 80% and 65%, respectively. After excluding the non-tumour-related deaths, the 10-year survival rate following presentation was 90%. Patients with recurrence had a significantly lower probability for survival compared with those without it (at 10 years: 70%vs. 99%, P < 0.01). At the 10-year follow-up the probability of the presence of major visual field defects was 48%, hyperphagia/obesity 39%, epilepsy 12% and hemi-/monoparesis 11%. In this large series no substantial differences in the outcome of tumours diagnosed during childhood or adult life were found. CONCLUSIONS Craniopharyngiomas remain tumours associated with significant morbidity. Gross total removal provides favourable results in terms of recurrences. If this cannot be achieved safely, adjuvant radiotherapy is beneficial in preventing tumour re-growth. Childhood- and adult-onset lesions generally behave similarly.
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Affiliation(s)
- N Karavitaki
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Old Road, Headington, Oxford OX3 7LJ, UK.
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Karavitaki N, Ioannidis G, Giannakopoulos F, Mavrokefalos P, Thalassinos N. Evaluation of bone mineral density of the peripheral skeleton in pre- and postmenopausal women with newly diagnosed endogenous Cushing's syndrome. Clin Endocrinol (Oxf) 2004; 60:264-70. [PMID: 14725690 DOI: 10.1111/j.1365-2265.2004.01968.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Cushing's syndrome (CS) is a well recognized cause of bone loss. Although many previous studies have shown decreased bone mineral density (BMD) in the lumbar spina and proximal femur of patients with endogenous CS, so far, the data estimating BMD in their peripheral skeleton are sparse. The aim of the present study was to evaluate BMD in the forearm and heel of women with newly diagnosed CS and to investigate its possible correlation with serum osteocalcin (BGP) and 24-hour urinary free cortisol levels (UFC). PATIENTS AND METHODS BMD in the forearm (distal and ultradistal area) of 29 (13 premenopausal and 16 postmenopausal) women with newly diagnosed CS (18 with pituitary adenoma, 10 with adrenal tumor and 1 with ectopic) was measured by dual x-ray absorptiometry (DEXA) and was compared with BMD of 29 age, body mass index (BMI)- and oestrogen status matched healthy controls. Furthermore, in 18 (9 premenopausal and 9 postmenopausal) of the above patients (14 with pituitary adenoma, 5 with adrenal tumor and 1 with ectopic) broadband ultrasound attenuation (BUA) by quantitative ultrasound (QUS) of the heel was estimated and 18 age-, BMI- and oestrogen status matched healthy women served as controls. In all the patients serum BGP and UFC were measured at the time of diagnosis of CS. RESULTS Compared to their matched controls, BMD in the forearm and BUA values in the heel did not differ in the premenopausal women with CS, while in the postmenopausal group BMD in the forearm was decreased (P < 0.05) but not BUA. Apart from a weak negative correlation between serum BGP and BMD in the ultradistal site of the forearm in premenopausal women (P = 0.05), serum BGP and UFC did not show significant correlation with BMD or BUA. CONCLUSIONS BMD in the forearm is reduced only in postmenopausal women with newly diagnosed endogenous CS, while BUA in the heel is unaffected in both pre- and postmenopausal patients. Moreover, serum BGP and UFC do not seem to be relevant markers for assessing bone loss in the peripheral skeleton at the time of diagnosis of hypercortisolemia.
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Affiliation(s)
- N Karavitaki
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
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