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Orme S, McNally R, James PW, Davis J, Ayuk J, Higham C, Wass J. Increased mortality in acromegaly is due to vascular and respiratory disease and is normalised by control of GH levels-A retrospective analysis from the UK Acromegaly Register 1970-2016. Clin Endocrinol (Oxf) 2024; 100:558-564. [PMID: 38652736 DOI: 10.1111/cen.15060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 03/27/2024] [Accepted: 04/05/2024] [Indexed: 04/25/2024]
Abstract
CONTEXT Epidemiological studies involving patients with acromegaly have yielded conflicting results regarding cancer incidence and causes of mortality in relation to control of growth hormone (GH) excess. OBJECTIVE The objective of this retrospective cohort study is to clarify these questions and identify goals for treatment and monitoring patients. METHODS We studied 1845 subjects from the UK Acromegaly Register (1970-2016), obtaining cancer standardised incidence rates (SIR) and all causes standardised mortality rates (SMR) from UK Office for National Statistics, to determine the relationship between causes of mortality-age at diagnosis, duration of disease, post-treatment and mean GH levels. RESULTS We found an increased incidence of all cancers (SIR, 1.38; 95% CI: 1.06-1.33, p < .001), but no increase in incidence of female breast, thyroid, colon cancer or any measure of cancer mortality. All-cause mortality rates were increased (SMR, 1.35; 95% CI: 1.24-1.46, p < .001), as were those due to vascular and respiratory diseases. All-cause, all cancer and cardiovascular deaths were highest in the first 5 years following diagnosis. We found a positive association between post-treatment and mean treatment GH levels and all-cause mortality (p < .001 and p < .001), which normalised with posttreatment GH levels of <1.0 µg/L or meantreatment GH levels of <2.5 µg/L. CONCLUSION Acromegaly is associated with increased incidence of all cancers but not thyroid or colon cancer and no increase in cancer mortality. Excess mortality is due to vascular and respiratory disease. The risk is highest in the first 5 years following diagnosis and is mitigated by normalising GH levels.
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Affiliation(s)
- Steve Orme
- Department of Endocrinology, St James's University Hospital Leeds, Leeds, UK
| | - Richard McNally
- Population Health Science Institute, Newcastle University, Royal Victoria Infirmary, Newcastle Upon Tyne, UK
| | - Peter W James
- Population Health Science Institute, Newcastle University, Royal Victoria Infirmary, Newcastle Upon Tyne, UK
| | | | - John Ayuk
- Department of Endocrinology, Queen Elizabeth Hospital, Edgbaston, Birmingham, UK
| | - Claire Higham
- Department of Endocrinology, Christie Hospital NHS Foundation Trust, Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - John Wass
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, UK
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Korbonits M, Blair JC, Boguslawska A, Ayuk J, Davies JH, Druce MR, Evanson J, Flanagan D, Glynn N, Higham CE, Jacques TS, Sinha S, Simmons I, Thorp N, Swords FM, Storr HL, Spoudeas HA. Consensus guideline for the diagnosis and management of pituitary adenomas in childhood and adolescence: Part 2, specific diseases. Nat Rev Endocrinol 2024; 20:290-309. [PMID: 38336898 DOI: 10.1038/s41574-023-00949-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Accepted: 12/19/2023] [Indexed: 02/12/2024]
Abstract
Pituitary adenomas are rare in children and young people under the age of 19 (hereafter referred to as CYP) but they pose some different diagnostic and management challenges in this age group than in adults. These rare neoplasms can disrupt maturational, visual, intellectual and developmental processes and, in CYP, they tend to have more occult presentation, aggressive behaviour and are more likely to have a genetic basis than in adults. Through standardized AGREE II methodology, literature review and Delphi consensus, a multidisciplinary expert group developed 74 pragmatic management recommendations aimed at optimizing care for CYP in the first-ever comprehensive consensus guideline to cover the care of CYP with pituitary adenoma. Part 2 of this consensus guideline details 57 recommendations for paediatric patients with prolactinomas, Cushing disease, growth hormone excess causing gigantism and acromegaly, clinically non-functioning adenomas, and the rare TSHomas. Compared with adult patients with pituitary adenomas, we highlight that, in the CYP group, there is a greater proportion of functioning tumours, including macroprolactinomas, greater likelihood of underlying genetic disease, more corticotrophinomas in boys aged under 10 years than in girls and difficulty of peri-pubertal diagnosis of growth hormone excess. Collaboration with pituitary specialists caring for adult patients, as part of commissioned and centralized multidisciplinary teams, is key for optimizing management, transition and lifelong care and facilitates the collection of health-related quality of survival outcomes of novel medical, surgical and radiotherapeutic treatments, which are currently largely missing.
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Affiliation(s)
- Márta Korbonits
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK.
| | | | - Anna Boguslawska
- Department of Endocrinology, Jagiellonian University Medical College, Krakow, Poland
| | - John Ayuk
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Justin H Davies
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Maralyn R Druce
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Jane Evanson
- Neuroradiology, Barts Health NHS Trust, London, UK
| | | | - Nigel Glynn
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | | | - Thomas S Jacques
- Great Ormond Street Institute of Child Health, University College London, London, UK
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Saurabh Sinha
- Sheffield Children's and Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Ian Simmons
- The Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Nicky Thorp
- The Christie NHS Foundation Trust, Manchester, UK
| | | | - Helen L Storr
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Helen A Spoudeas
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- University College London Hospitals NHS Foundation Trust, London, UK
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Korbonits M, Blair JC, Boguslawska A, Ayuk J, Davies JH, Druce MR, Evanson J, Flanagan D, Glynn N, Higham CE, Jacques TS, Sinha S, Simmons I, Thorp N, Swords FM, Storr HL, Spoudeas HA. Consensus guideline for the diagnosis and management of pituitary adenomas in childhood and adolescence: Part 1, general recommendations. Nat Rev Endocrinol 2024; 20:278-289. [PMID: 38336897 DOI: 10.1038/s41574-023-00948-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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] [Accepted: 12/19/2023] [Indexed: 02/12/2024]
Abstract
Tumours of the anterior part of the pituitary gland represent just 1% of all childhood (aged <15 years) intracranial neoplasms, yet they can confer high morbidity and little evidence and guidance is in place for their management. Between 2014 and 2022, a multidisciplinary expert group systematically developed the first comprehensive clinical practice consensus guideline for children and young people under the age 19 years (hereafter referred to as CYP) presenting with a suspected pituitary adenoma to inform specialist care and improve health outcomes. Through robust literature searches and a Delphi consensus exercise with an international Delphi consensus panel of experts, the available scientific evidence and expert opinions were consolidated into 74 recommendations. Part 1 of this consensus guideline includes 17 pragmatic management recommendations related to clinical care, neuroimaging, visual assessment, histopathology, genetics, pituitary surgery and radiotherapy. While in many aspects the care for CYP is similar to that of adults, key differences exist, particularly in aetiology and presentation. CYP with suspected pituitary adenomas require careful clinical examination, appropriate hormonal work-up, dedicated pituitary imaging and visual assessment. Consideration should be given to the potential for syndromic disease and genetic assessment. Multidisciplinary discussion at both the local and national levels can be key for management. Surgery should be performed in specialist centres. The collection of outcome data on novel modalities of medical treatment, surgical intervention and radiotherapy is essential for optimal future treatment.
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Affiliation(s)
- Márta Korbonits
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK.
| | | | - Anna Boguslawska
- Department of Endocrinology, Jagiellonian University Medical College, Krakow, Poland
| | - John Ayuk
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Justin H Davies
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Maralyn R Druce
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Jane Evanson
- Neuroradiology, Barts Health NHS Trust, London, UK
| | | | - Nigel Glynn
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | | | - Thomas S Jacques
- Great Ormond Street Institute of Child Health, University College London, London, UK
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Saurabh Sinha
- Sheffield Children's and Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Ian Simmons
- The Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Nicky Thorp
- The Christie NHS Foundation Trust, Manchester, UK
| | | | - Helen L Storr
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Helen A Spoudeas
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- University College London Hospitals NHS Foundation Trust, London, UK
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4
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Parazzoli C, Prete A, Favero V, Aresta C, Pucino V, Ayuk J, Asia M, Elhassan YS, Chiodini I, Ronchi CL. Inflammation-based scores in patients with pheochromocytoma. J Clin Endocrinol Metab 2024:dgae284. [PMID: 38655872 DOI: 10.1210/clinem/dgae284] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 04/02/2024] [Accepted: 04/22/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND Pheochromocytoma is associated with systemic inflammation, but the underlying mechanisms are unclear. Therefore, we investigated the relationship between plasma metanephrine levels and haematological parameters - as a surrogate of inflammation - in patients with pheochromocytoma and the influence of preoperative α-blockade treatment. DESIGN AND METHODS We retrospectively studied 68 patients with pheochromocytoma who underwent adrenalectomy (median age 53 years, 64.7% females) and two control groups matched for age, sex, and body mass index (BMI): 68 patients with non-functioning adrenocortical tumors (NFAT) and 53 with essential hypertension (EAH). The complete blood count (CBC) and several inflammation-based scores [Neutrophil-to-Lymphocyte Ratio (NLR), Platelet-to-Lymphocyte Ratio (PLR), Lymphocyte-to-Monocyte Ratio (LMR), Systemic-Immune-Inflammation Index (SII), Prognostic-Nutrition Index (PNI)] were assessed in all patients and, in a subset of pheochromocytomas, after adrenalectomy (n=26) and before and after preoperative α-blockade treatment (n=29). RESULTS A higher inflammatory state, as indicated by both CBC and inflammation-based scores, was observed in patients with pheochromocytoma compared to NFAT and EAH. Plasma metanephrine levels showed a positive correlation with NLR (r=0.4631), PLR (r=0.3174), SII (r=0.3709), and a negative correlation with LMR (r=0.4368) and PNI (r=0.3741), even after adjustment for age, sex, ethnicity, BMI and tumor size (except for PLR). After adrenalectomy, we observed a reduction in NLR (p=0.001), PLR (p=0.003), SII (p=0.004) and a concomitant increase in LMR (p=0.0002). Similarly, α-blockade treatment led to a reduction in NLR (p=0.007) and SII (p=0.03). CONCLUSIONS Inflammation-based scores in patients with pheochromocytoma showed pro-inflammatory changes that correlated with plasma metanephrine levels and are ameliorated by adrenalectomy and α-blockade.
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Affiliation(s)
- Chiara Parazzoli
- Department of Biotechnology and Translational Medicine, University of Milan, Milan, Italy
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom
| | - Alessandro Prete
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom
- Department of Endocrinology, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
- National Institute for Health Research Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Vittoria Favero
- Department of Biotechnology and Translational Medicine, University of Milan, Milan, Italy
| | - Carmen Aresta
- Department of Endocrine and Metabolic Diseases, IRCCS, Istituto Auxologico Italiano, Milan, Italy
| | - Valentina Pucino
- Kennedy Institute of Rheumatology, University of Oxford, Oxford, United Kingdom
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
| | - John Ayuk
- Department of Endocrinology, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Miriam Asia
- Department of Endocrinology, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Yasir S Elhassan
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom
- Department of Endocrinology, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Iacopo Chiodini
- Department of Biotechnology and Translational Medicine, University of Milan, Milan, Italy
- Unit of Endocrinology, Ospedale Niguarda Cà Granda, Milan, Italy
| | - Cristina L Ronchi
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom
- Department of Endocrinology, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
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Aggarwal S, Prete A, Chortis V, Asia M, Sutcliffe RP, Arlt W, Ronchi CL, Karavitaki N, Ayuk J, Elhassan YS. Pheochromocytomas Most Commonly Present As Adrenal Incidentalomas: A Large Tertiary Center Experience. J Clin Endocrinol Metab 2023; 109:e389-e396. [PMID: 37417693 PMCID: PMC10735286 DOI: 10.1210/clinem/dgad401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 06/12/2023] [Accepted: 07/05/2023] [Indexed: 07/08/2023]
Abstract
CONTEXT Pheochromocytomas are increasingly diagnosed in incidentally detected adrenal masses. However, the characteristics of incidental pheochromocytomas are unclear. OBJECTIVE We aimed to assess the proportion and clinical, biochemical, radiological, genetic, histopathological, and follow-up characteristics of incidental pheochromocytomas. METHODS A retrospective review was conducted of patients with pheochromocytoma seen between January 2010 and October 2022 at a large UK tertiary care center. The diagnosis was confirmed histologically or by the combined presence of increased plasma and/or urinary metanephrines (MN), indeterminate adrenal mass on cross-sectional imaging, and metaiodobenzylguanidine avidity. RESULTS We identified 167 patients with pheochromocytoma; 144 (86.2%) underwent adrenalectomy, for 23 (13.8%) surgery was either awaited, deemed unsuitable due to frailty or other metastatic malignancy, or declined by the patients. Excluding pheochromocytomas diagnosed via screening genetically predisposed individuals (N = 20), 37 of 132 (28.0%) presented with adrenergic symptoms and/or uncontrolled hypertension, while 91 of 132 (69.0%) patients presented with an incidentally detected adrenal mass. Incidentally detected patients were older (median age 62 years) than those detected due to clinical suspicion (aged 42 years) or after genetic screening (aged 33 years) (all P < .05). Incidentally detected pheochromocytomas were smaller (median 42 mm) than tumors detected due to adrenergic symptoms/uncontrolled hypertension (60 mm), but larger than tumors identified by genetic screening (30 mm) (all P < .05). Increased MN excretion showed a similar pattern (symptomatic/uncontrolled hypertension > incidental > genetic screening) (all P < .05). Hereditary predisposition was detected in 20.4% of patients (incidental, 15.3%; symptomatic/uncontrolled hypertension, 42.9%). CONCLUSION The majority of pheochromocytomas are diagnosed incidentally and have distinct clinical, radiological, biochemical, and genetic features. Their detection at older age but smaller size may point to a different underlying tumor biology.
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Affiliation(s)
- Sunil Aggarwal
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham B15 2TT, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2TT, UK
- Department of Endocrinology, Queen Elizabeth Hospital Birmingham, Birmingham B15 2GW, UK
| | - Alessandro Prete
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham B15 2TT, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2TT, UK
- Department of Endocrinology, Queen Elizabeth Hospital Birmingham, Birmingham B15 2GW, UK
- NIHR Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TT, UK
| | - Vasileios Chortis
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham B15 2TT, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2TT, UK
- Department of Endocrinology, Queen Elizabeth Hospital Birmingham, Birmingham B15 2GW, UK
| | - Miriam Asia
- Department of Endocrinology, Queen Elizabeth Hospital Birmingham, Birmingham B15 2GW, UK
| | - Robert P Sutcliffe
- Department of Hepatobiliary Surgery, Queen Elizabeth Hospital Birmingham, Birmingham B15 2GW, UK
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham B15 2TT, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2TT, UK
- Department of Endocrinology, Queen Elizabeth Hospital Birmingham, Birmingham B15 2GW, UK
| | - Cristina L Ronchi
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham B15 2TT, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2TT, UK
- Department of Endocrinology, Queen Elizabeth Hospital Birmingham, Birmingham B15 2GW, UK
| | - Niki Karavitaki
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham B15 2TT, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2TT, UK
- Department of Endocrinology, Queen Elizabeth Hospital Birmingham, Birmingham B15 2GW, UK
| | - John Ayuk
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2TT, UK
- Department of Endocrinology, Queen Elizabeth Hospital Birmingham, Birmingham B15 2GW, UK
| | - Yasir S Elhassan
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham B15 2TT, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2TT, UK
- Department of Endocrinology, Queen Elizabeth Hospital Birmingham, Birmingham B15 2GW, UK
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6
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Parente A, Kamarajah SK, Thompson JP, Crook C, Aspinall S, Melvin R, Stechman MJ, Perry H, Balasubramanian SP, Pannu A, Palazzo FF, Van Den Heede K, Eatock F, Anderson H, Doran H, Wang K, Hubbard J, Aldrees A, Shore SL, Fung C, Waghorn A, Ayuk J, Bennett D, Sutcliffe RP. Risk factors for postoperative complications after adrenalectomy for phaeochromocytoma: multicentre cohort study. BJS Open 2023; 7:zrad090. [PMID: 37757753 PMCID: PMC10533033 DOI: 10.1093/bjsopen/zrad090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 06/13/2023] [Accepted: 07/16/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND To determine the incidence and risk factors for postoperative complications and prolonged hospital stay after adrenalectomy for phaeochromocytoma. METHODS Demographics, perioperative outcomes and complications were evaluated for consecutive patients who underwent adrenalectomy for phaeochromocytoma from 2012 to 2020 in nine high-volume UK centres. Odds ratios were calculated using multivariable models. The primary outcome was postoperative complications according to the Clavien---Dindo classification and secondary outcome was duration of hospital stay. RESULTS Data were available for 406 patients (female n = 221, 54.4 per cent). Two patients (0.5 per cent) had perioperative death, whilst 148 complications were recorded in 109 (26.8 per cent) patients. On adjusted analysis, the age-adjusted Charlson Co-morbidity Index ≥3 (OR 8.09, 95 per cent c.i. 2.31 to 29.63, P = 0.001), laparoscopic converted to open (OR 10.34, 95 per cent c.i. 3.24 to 36.23, P <0.001), and open surgery (OR 11.69, 95 per cent c.i. 4.52 to 32.55, P <0.001) were independently associated with postoperative complications. Overall, 97 of 430 (22.5 per cent) had a duration of stay ≥5 days and this was associated with an age-adjusted Charlson Co-morbidity Index ≥3 (OR 4.31, 95 per cent c.i. 1.08 to 18.26, P = 0.042), tumour size (OR 1.15, 95 per cent c.i. 1.05 to 1.28, P = 0.006), laparoscopic converted to open (OR 32.11, 95 per cent c.i. 9.2 to 137.77, P <0.001), and open surgery (OR 28.01, 95 per cent c.i. 10.52 to 83.97, P <0.001). CONCLUSION Adrenalectomy for phaeochromocytoma is associated with a very low mortality rate, whilst postoperative complications are common. Several risk factors, including co-morbidities and operative approach, are independently associated with postoperative complications and/or prolonged hospitalization, and should be considered when counselling patients.
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Affiliation(s)
- Alessandro Parente
- HPB Surgery Unit, Queen Elizabeth Hospital, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Sivesh K Kamarajah
- HPB Surgery Unit, Queen Elizabeth Hospital, Birmingham, UK
- Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | | | | | | | - Ross Melvin
- Department of General Surgery, Aberdeen Royal Infirmary, Aberdeen, UK
| | | | - Helen Perry
- Department of Endocrine Surgery, University Hospital Wales, Cardiff, UK
| | | | - Arslan Pannu
- Department of General Surgery, Sheffield Teaching Hospitals Foundation Trust, Sheffield, UK
| | - Fausto F Palazzo
- Department of Endocrine Surgery, Hammersmith Hospital, London, UK
| | | | - Fiona Eatock
- Department of Endocrine Surgery, Royal Victoria Hospital, Belfast, UK
| | - Hannah Anderson
- Department of Endocrine Surgery, Royal Victoria Hospital, Belfast, UK
| | - Helen Doran
- Department of Endocrine Surgery, Salford Royal Hospital, Salford, UK
| | - Kelvin Wang
- Department of Endocrine Surgery, Salford Royal Hospital, Salford, UK
| | | | | | - Susannah L Shore
- Department of Endocrine and Breast Surgery, Royal Liverpool and Broadgreen University Hospitals Trust, Liverpool, UK
| | - Clare Fung
- Department of Endocrine and Breast Surgery, Royal Liverpool and Broadgreen University Hospitals Trust, Liverpool, UK
| | - Alison Waghorn
- Department of Endocrine and Breast Surgery, Royal Liverpool and Broadgreen University Hospitals Trust, Liverpool, UK
| | - John Ayuk
- Department of Endocrinology, Queen Elizabeth Hospital, Birmingham, UK
| | - Davinia Bennett
- Department of Anaesthetics, Queen Elizabeth Hospital, Birmingham, UK
| | - Robert P Sutcliffe
- HPB Surgery Unit, Queen Elizabeth Hospital, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
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7
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Hamblin R, Fountas A, Lithgow K, Loughrey PB, Bonanos E, Shinwari SK, Mitchell K, Shah S, Grixti L, Matheou M, Isand K, McLaren DS, Surya A, Ullah HZ, Klaucane K, Jayasuriya A, Bhatti S, Mavilakandy A, Ahsan M, Mathew S, Hussein Z, Jansz T, Wunna W, MacFarlane J, Ayuk J, Abraham P, Drake WM, Gurnell M, Brooke A, Baldeweg SE, Sam AH, Martin N, Higham C, Reddy N, Levy MJ, Ahluwalia R, Newell-Price J, Vamvakopoulos J, Krishnan A, Lansdown A, Murray RD, Pal A, Bradley K, Mamoojee Y, Purewal T, Panicker J, Freel EM, Hasan F, Kumar M, Jose B, Hunter SJ, Karavitaki N. Natural history of non-functioning pituitary microadenomas - results from the UK NFPA consortium. Eur J Endocrinol 2023:lvad070. [PMID: 37345849 DOI: 10.1093/ejendo/lvad070] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 05/15/2023] [Accepted: 05/31/2023] [Indexed: 06/23/2023]
Abstract
OBJECTIVE The optimal approach to the surveillance of non-functioning pituitary microadenomas (micro-NFPAs) is not clearly established. Our aim was to generate evidence on the natural history of micro-NFPAs to support patient care. DESIGN Multi-centre, retrospective, cohort study involving 23 endocrine departments (UK NFPA consortium). METHODS Clinical, imaging, and hormonal data of micro-NFPA cases between 1/1/2008 and 21/12/2021 were analysed. RESULTS Data for 459 patients were retrieved [median age at detection 44 years [interquartile range (IQR) 31-57) - 152 males/307 females]. 419 patients had more than two MRIs [median imaging monitoring 3.5 years (IQR 1.71-6.1)]. One case developed apoplexy. Cumulative probability of micro-NFPA growth was 7.8% (95%CI 4.9%-8.1%) and 14.5% (95%CI 10.2%-18.8%) at 3 and 5 years, respectively, and of reduction 14.1% (95%CI 10.4-17.8%) and 21.3% (95%CI 16.4-26.2%) at 3 and 5 years, respectively. Median tumour enlargement was 2 mm (IQR 1-3) and 49% of micro-NFPAs that grew became macroadenomas (nearly all >5 mm at detection). Eight (1.9%) patients received surgery (only one had visual compromise with surgery required >3 years after micro-NFPA detection). Sex, age, size at baseline were not predictors of enlargement/reduction. At time of detection, 7.2%, 1.7% and 1.5% patients had secondary hypogonadism, hypothyroidism and hypoadrenalism, respectively. Two (0.6%) developed hypopituitarism during follow-up (after progression to macroadenoma). CONCLUSIONS Probability of micro-NFPA growth is low and development of new hypopituitarism is rare. Delaying first follow-up MRI to three years and avoiding hormonal re-evaluation in absence of tumour growth or clinical manifestations is a safe approach for micro-NFPA surveillance.
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Affiliation(s)
- Ross Hamblin
- Institute of Metabolism and Systems Research, 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
| | - Athanasios Fountas
- Institute of Metabolism and Systems Research, 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
| | - Kirstie Lithgow
- Institute of Metabolism and Systems Research, 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
| | - Paul Benjamin Loughrey
- Regional Centre for Endocrinology and Diabetes, Royal Victoria Hospital, Belfast, UK
- Patrick G. Johnston Centre for Cancer Research, Queen's University Belfast, Belfast, UK
| | - Efstathios Bonanos
- Regional Centre for Endocrinology and Diabetes, Royal Victoria Hospital, Belfast, UK
| | - Shah Khalid Shinwari
- Department of Endocrinology and Metabolic Medicine, Royal Stoke University Hospital, University Hospitals of North Midlands, Stoke-on-Trent, UK
| | - Kirsten Mitchell
- Department of Endocrinology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Syed Shah
- Department of Endocrinology, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Lydia Grixti
- Department of Endocrinology and Metabolic Medicine, The Newcastle-Upon-Tyne NHS Foundation Trust, Newcastle, UK
| | - Mike Matheou
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Kristina Isand
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - David S McLaren
- Leeds Centre for Diabetes & Endocrinology, St James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Ashutosh Surya
- Centre for Diabetes and Endocrinology, University Hospital of Wales, Cardiff, UK
| | - Hafiz Zubair Ullah
- Centre for Diabetes and Endocrinology, University Hospital of Wales, Cardiff, UK
| | - Katarina Klaucane
- Manx Centre for Endocrinology, Diabetes & Metabolism, Manx Care , Douglas, Isle of Man
| | - Anuradha Jayasuriya
- Department of Endocrinology and Metabolism, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Sumbal Bhatti
- Department of Endocrinology, Norfolk and Norwich University Hospitals Foundation Trust, Norwich, UK
| | - Akash Mavilakandy
- Department of Endocrinology, Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Masato Ahsan
- Department of Endocrinology, Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Susan Mathew
- Department of Endocrinology, The Christie NHS Foundation Trust, Manchester, UK
| | - Ziad Hussein
- Department of Diabetes & Endocrinology, University College London Hospital NHS Foundation Trust, London, UK
| | - Thijs Jansz
- Department of Endocrinology and Metabolism, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Wunna Wunna
- Department of Endocrinology, St Bartholomew's Hospital, Barts Health NHS trust, London, UK
| | - James MacFarlane
- Department of Endocrinology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Metabolic Research Laboratories, Wellcome MRC Institute of Metabolic Science, University of Cambridge, UK
- NIHR Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge, UK
| | - John 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
| | - Prakash Abraham
- Department of Diabetes and Endocrinology, Aberdeen Royal Infirmary, Aberdeen, UK
| | - William M Drake
- Department of Endocrinology, St Bartholomew's Hospital, Barts Health NHS trust, London, UK
| | - Mark Gurnell
- Department of Endocrinology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Metabolic Research Laboratories, Wellcome MRC Institute of Metabolic Science, University of Cambridge, UK
- NIHR Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge, UK
| | - Antonia Brooke
- Department of Endocrinology and Metabolism, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Stephanie E Baldeweg
- Department of Diabetes & Endocrinology, University College London Hospital NHS Foundation Trust, London, UK
| | - Amir H Sam
- Imperial Centre for Endocrinology, Imperial College Healthcare NHS Trust, London, UK
| | - Niamh Martin
- Imperial Centre for Endocrinology, Imperial College Healthcare NHS Trust, London, UK
| | - Claire Higham
- Department of Endocrinology, The Christie NHS Foundation Trust, Manchester, UK
- University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Narendra Reddy
- Department of Endocrinology, Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Miles J Levy
- Department of Endocrinology, Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Rupa Ahluwalia
- Department of Endocrinology, Norfolk and Norwich University Hospitals Foundation Trust, Norwich, UK
| | - John Newell-Price
- Department of Endocrinology and Metabolism, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | - Joannis Vamvakopoulos
- Manx Centre for Endocrinology, Diabetes & Metabolism, Manx Care , Douglas, Isle of Man
| | - Amutha Krishnan
- Manx Centre for Endocrinology, Diabetes & Metabolism, Manx Care , Douglas, Isle of Man
| | - Andrew Lansdown
- Centre for Diabetes and Endocrinology, University Hospital of Wales, Cardiff, UK
| | - Robert D Murray
- Leeds Centre for Diabetes & Endocrinology, St James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Aparna Pal
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Karin Bradley
- Department of Diabetes and Endocrinology, Bristol Royal Infirmary, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Yaasir Mamoojee
- Department of Endocrinology and Metabolic Medicine, The Newcastle-Upon-Tyne NHS Foundation Trust, Newcastle, UK
| | - Tejpal Purewal
- Department of Endocrinology, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Janki Panicker
- Department of Endocrinology, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - E Marie Freel
- Department of Endocrinology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Faisal Hasan
- Department of Diabetes and Endocrinology, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - Mohit Kumar
- Department of Endocrinology and Metabolic Medicine, Wrightington, Wigan and Leigh NHS Foundation Trust, Wigan, UK
| | - Biju Jose
- Department of Endocrinology and Metabolic Medicine, Royal Stoke University Hospital, University Hospitals of North Midlands, Stoke-on-Trent, UK
| | - Steven J Hunter
- Regional Centre for Endocrinology and Diabetes, Royal Victoria Hospital, Belfast, UK
| | - Niki Karavitaki
- Institute of Metabolism and Systems Research, 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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8
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Parente A, Thompson JP, Crook C, Bassett P, Aspinall S, Melvin R, Stechman MJ, Perry H, Balasubramanian SP, Pannu A, Palazzo FF, Van Den Heede K, Eatock F, Anderson H, Doran H, Wang K, Hubbard J, Aldrees A, Shore SL, Fung C, Waghorn A, Ayuk J, Bennett D, Sutcliffe RP. Risk factors for postoperative hypotension after adrenalectomy for phaeochromocytoma: derivation of the PACS risk score. Eur J Surg Oncol 2023; 49:497-504. [PMID: 36602554 DOI: 10.1016/j.ejso.2022.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 10/06/2022] [Accepted: 10/12/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Due to the risk of postoperative hypotension (PH), invasive monitoring is recommended for patients who undergo adrenalectomy for phaeochromocytoma. Due to high costs and limited availability of intensive care, our aim was to identify patients at low risk of PH who may not require invasive monitoring. METHODS Data for patients who underwent adrenalectomy for phaeochromocytoma between 2012 and 2020 were retrospectively collected by nine UK centres, including patient demographics, intraoperative and postoperative haemodynamic parameters. Independent risk factors for PH were analysed and used to develop a clinical risk score. RESULTS PH developed in 118 of 430 (27.4%) patients. On univariable analysis, female sex (p = 0.007), tumour size (p < 0.001), preoperative catecholamine level (p < 0.001), open surgery (p < 0.001) and epidural analgesia (p = 0.006) were identified as risk factors for PH. On multivariable analysis, female sex (OR 1.85, CI95%, 1.09-3.13, p = 0.02), preoperative catecholamine level (OR: 3.11, CI95%, 1.74-5.55, p < 0.001), open surgery (OR: 3.31, CI95%, 1.57-6.97, p = 0.002) and preoperative mean arterial blood pressure (OR: 0.59, CI95%, 0.48-1.02, p = 0.08) were independently associated with PH, and were incorporated into a clinical risk score (AUROC 0.69, C-statistic 0.69). The risk of PH was 25% and 68% in low and high risk patients, respectively. CONCLUSION The derived risk score allows stratification of patients at risk of postoperative hypotension after adrenalectomy for phaeochromocytoma. Postoperatively, low risk patients may be managed on a surgical ward, whilst high risk patients should undergo invasive monitoring.
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Affiliation(s)
| | | | | | | | | | - Ross Melvin
- Department of General Surgery, Aberdeen Royal Infirmary, Aberdeen, UK
| | | | - Helen Perry
- Department of Endocrine Surgery, University Hospital Wales, Cardiff, UK
| | | | - Arslan Pannu
- Department of General Surgery, Sheffield Teaching Hospitals Foundation Trust, Sheffield, UK
| | - Fausto F Palazzo
- Department of Endocrine Surgery, Hammersmith Hospital, London, UK
| | | | - Fiona Eatock
- Department of Endocrine Surgery, Royal Victoria Hospital, Belfast, UK
| | - Hannah Anderson
- Department of Endocrine Surgery, Royal Victoria Hospital, Belfast, UK
| | - Helen Doran
- Department of Endocrine Surgery, Salford Royal Hospital, Salford, UK
| | - Kelvin Wang
- Department of Endocrine Surgery, Salford Royal Hospital, Salford, UK
| | | | | | - Susannah L Shore
- Department of Endocrine and Breast Surgery, Royal Liverpool and Broadgreen University Hospitals Trust, Liverpool, UK
| | - Clare Fung
- Department of Endocrine and Breast Surgery, Royal Liverpool and Broadgreen University Hospitals Trust, Liverpool, UK
| | - Alison Waghorn
- Department of Endocrine and Breast Surgery, Royal Liverpool and Broadgreen University Hospitals Trust, Liverpool, UK
| | - John Ayuk
- Department of Endocrinology, Queen Elizabeth Hospital, Birmingham, UK
| | - Davinia Bennett
- Department of Anaesthetics, Queen Elizabeth Hospital, Birmingham, UK
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9
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Coulden A, Pepper J, Juszczak A, Batra R, Chavda S, Senthil L, Ayuk J, Pohl U, Nagaraju S, Karavitaki N, Tsermoulas G. Rathke's Cleft Cyst Abscess with a Very Unusual Course. Asian J Neurosurg 2022; 17:527-531. [PMID: 36398168 PMCID: PMC9665969 DOI: 10.1055/s-0042-1750798] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Infected Rathke's cleft cysts (RCC) are extremely rare with only a few published cases. We report the case of a 31-year-old man who presented with headaches, visual disturbance, and hypopituitarism secondary to an infected RCC with extension of abscesses along the optic tract. Magnetic resonance imaging showed ring enhancing cystic lesions within an expanded sella with suprasellar and intraparenchymal extension. The radiological appearance suggested a high-grade optic glioma, but an endoscopic transsphenoidal biopsy revealed frank pus in the pituitary fossa, which subsequently grew
Staphylococcus aureus
. Pathological examination of the cyst wall showed an inflamed RCC. Following a prolonged course of intravenous antibiotics, the infection resolved and vision improved. RCC abscesses are rare and the intracranial extension of the infection in our case makes it unique.
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Affiliation(s)
- Amy Coulden
- Department of Endocrinology, Queen Elizabeth Hospital, Birmingham, United Kingdom
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, United Kingdom
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom
| | - Joshua Pepper
- Department of Neurosurgery, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Agata Juszczak
- Department of Endocrinology, Birmingham Heartlands Hospital, Birmingham, United Kingdom
| | - Ruchika Batra
- Department of Ophthalmology, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Swarupsinh Chavda
- Department of Radiology, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Latha Senthil
- Department of Radiology, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - John Ayuk
- Department of Endocrinology, Queen Elizabeth Hospital, Birmingham, United Kingdom
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom
| | - Ute Pohl
- Department of Cellular Pathology, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Santhosh Nagaraju
- Department of Cellular Pathology, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Niki Karavitaki
- Department of Endocrinology, Queen Elizabeth Hospital, Birmingham, United Kingdom
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, United Kingdom
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom
| | - Georgios Tsermoulas
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, United Kingdom
- Department of Neurosurgery, Queen Elizabeth Hospital, Birmingham, United Kingdom
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10
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Hamblin R, Vardon A, Akpalu J, Tampourlou M, Spiliotis I, Sbardella E, Lynch J, Shankaran V, Mavilakandy A, Gagliardi I, Meade S, Hobbs C, Cameron A, Levy MJ, Ayuk J, Grossman A, Ambrosio MR, Zatelli MC, Reddy N, Bradley K, Murray RD, Pal A, Karavitaki N. Risk of second brain tumour after radiotherapy for pituitary adenoma or craniopharyngioma: a retrospective, multicentre, cohort study of 3679 patients with long-term imaging surveillance. Lancet Diabetes Endocrinol 2022; 10:581-588. [PMID: 35780804 DOI: 10.1016/s2213-8587(22)00160-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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] [Received: 03/08/2022] [Revised: 04/27/2022] [Accepted: 05/12/2022] [Indexed: 01/02/2023]
Abstract
BACKGROUND Radiotherapy is a valuable treatment in the management algorithm of pituitary adenomas and craniopharyngiomas. However, the risk of second brain tumour following radiotherapy is a major concern. We assessed this risk using non-irradiated patients with the same primary pathology and imaging surveillance as controls. METHODS In this multicentre, retrospective cohort study, 4292 patients with pituitary adenoma or craniopharyngioma were identified from departmental registries at six adult endocrine centres (Birmingham, Oxford, Leeds, Leicester, and Bristol, UK and Ferrara, Italy). Patients with insufficient clinical data, known genetic predisposition to or history of brain tumour before study entry (n=532), and recipients of proton beam or stereotactic radiotherapy (n=81) were excluded. Data were analysed for 996 patients exposed to 2-dimensional radiotherapy, 3-dimensional conformal radiotherapy, or intensity-modulated radiotherapy, and compared with 2683 controls. FINDINGS Over 45 246 patient-years, second brain tumours were reported in 61 patients (seven malignant [five radiotherapy, two controls], 54 benign [25 radiotherapy, 29 controls]). Radiotherapy exposure and older age at pituitary tumour detection were associated with increased risk of second brain tumour. Rate ratio for irradiated patients was 2·18 (95% CI 1·31-3·62, p<0·0001). Cumulative probability of second brain tumour was 4% for the irradiated and 2·1% for the controls at 20 years. INTERPRETATION Irradiated adults with pituitary adenoma or craniopharyngioma are at increased risk of second brain tumours, although this risk is considerably lower than previously reported in studies using general population controls with no imaging surveillance. Our data clarify an important clinical question and guide clinicians when counselling patients with pituitary adenoma or craniopharyngioma on the risks and benefits of radiotherapy. FUNDING Pfizer.
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Affiliation(s)
- Ross Hamblin
- 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
| | - Ashley Vardon
- 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
| | - Josephine Akpalu
- 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
| | - Metaxia Tampourlou
- 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
| | - Ioannis Spiliotis
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Emilia Sbardella
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Julie Lynch
- Department of Diabetes and Endocrinology, Leeds Teaching Hospitals NHS Trust, St James's University Hospital, Leeds, UK
| | - Vani Shankaran
- Department of Diabetes and Endocrinology, Leeds Teaching Hospitals NHS Trust, St James's University Hospital, Leeds, UK
| | - Akash Mavilakandy
- Department of Diabetes and Endocrinology, University Hospitals of Leicester NHS Trust, Leicester Royal Infirmary, Leicester, UK
| | - Irene Gagliardi
- Section of Endocrinology and Internal Medicine, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Sara Meade
- Department of Oncology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Claire Hobbs
- Department of Clinical Oncology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Alison Cameron
- Bristol Haematology and Oncology Centre, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Miles J Levy
- Department of Diabetes and Endocrinology, University Hospitals of Leicester NHS Trust, Leicester Royal Infirmary, Leicester, UK
| | - John Ayuk
- 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
| | - Ashley Grossman
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Maria Rosaria Ambrosio
- Section of Endocrinology and Internal Medicine, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Maria Chiara Zatelli
- Section of Endocrinology and Internal Medicine, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Narendra Reddy
- Department of Diabetes and Endocrinology, University Hospitals of Leicester NHS Trust, Leicester Royal Infirmary, Leicester, UK
| | - Karin Bradley
- Department of Endocrinology, Bristol Royal Infirmary, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Robert D Murray
- Department of Diabetes and Endocrinology, Leeds Teaching Hospitals NHS Trust, St James's University Hospital, Leeds, UK
| | - Aparna Pal
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Niki 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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11
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Richards E, Pankhania M, Thomas C, Jolly K, Ayuk J, Ahmed S. Perioperative management of lithium in the patient undergoing pituitary surgery: a case report. Br J Neurosurg 2022:1-3. [PMID: 35531871 DOI: 10.1080/02688697.2021.2010651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 09/21/2021] [Accepted: 11/21/2021] [Indexed: 11/02/2022]
Abstract
Lithium is a psychotropic drug used primarily in the treatment of bipolar disorder. It is renally excreted and characteristically causes nephrogenic diabetes insipidus as an adverse drug reaction. Lithium also requires serum level monitoring as there is a narrow therapeutic window and untreated toxicity can result in neurological sequelae including drowsiness, coma, seizures, and ultimately death. We present the case of a 65-year old man admitted for pituitary surgery complicated by post-operative difficult fluid management and subsequent lithium toxicity. We highlight this rare situation and the need to be vigilant in the peri-operative period with any patients on lithium who undergo pituitary surgery.
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Affiliation(s)
- Emma Richards
- CT2 in Otolaryngology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Miran Pankhania
- Anterior Skull Base & Rhinology Fellow, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Charlotte Thomas
- CT2 in Otolaryngology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Karan Jolly
- ENT Specialty Registrar, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - John Ayuk
- Consultant Endocrinologist, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Shahzada Ahmed
- Consultant ENT & Skull Base Surgeon, Queen Elizabeth Hospital Birmingham, Birmingham, UK
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12
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Wallett L, Chen W, Thomas L, Blaggan P, Ooi E, Zhou D, Hanania T, Ng CY, Evans N, Morgan G, Allison I, Pan CSC, Ponniah G, Radcliffe E, Sheikh J, Khashaba A, Hebbar M, Delson D, Reddy-Koanu V, Ayuk J, Packer G, Akufo-Tetteh E, Davitadze M, Melson E, Kempegowda P. Developing a simulation-based learning model for acute medical education during COVID-19 pandemic with Simulation via Instant Messaging - Birmingham Advance (SIMBA). BMJ Open Qual 2022; 11:bmjoq-2021-001565. [PMID: 35396253 PMCID: PMC8995572 DOI: 10.1136/bmjoq-2021-001565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 03/16/2022] [Indexed: 11/03/2022] Open
Abstract
Simulation-based learning (SBL) is well-established in medical education and has gained popularity, particularly during the COVID-19 pandemic when in-person teaching is infeasible. SBL replicates real-life scenarios and provides a fully immersive yet safe learning environment to develop clinical competency. Simulation via Instant Messaging - Birmingham Advance (SIMBA) is an exemplar of SBL, which we previously showed to be effective in endocrinology and diabetes. Previous studies reported the efficacy of SBL in acute medicine. We studied SIMBA as a learning intervention for healthcare professionals interested in acute medicine and defined our aims using the Kirkpatrick model: (i) develop an SBL tool to improve case management; (ii) evaluate experiences and confidence before and after; and (iii) compare efficacy across training levels.Three sessions were conducted, each representing a PDSA cycle (Plan-Do-Study-Act), consisting of four cases and advertised to healthcare professionals at our hospital and social media. Moderators facilitated progression through 25 min simulations and adopted patient and clinical roles as appropriate. Consultants chaired discussion sessions using relevant guidelines. Presimulation and postsimulation questionnaires evaluated self-reported confidence, feedback and intended changes to clinical practice.Improvements were observed in self-reported confidence managing simulated cases across all sessions. Of participants, 93.3% found SIMBA applicable to clinical practice, while 89.3% and 88.0% felt SIMBA aided personal and professional development, respectively. Interestingly, 68.0% preferred SIMBA to traditional teaching methods. Following participant feedback, more challenging cases were included, and we extended the time for simulation and discussion. The transcripts were amended to facilitate more participant-moderator interaction representing clinical practice. In addition, we refined participant recruitment over the three sessions. In cycle 1, we advertised incentives: participation counted towards teaching requirements, certificates and feedback. To rectify the reduction in participants in cycle 2, we implemented new advertisement methods in cycle 3, including on-site posters, reminder emails and recruitment of the defence deanery cohort.
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Affiliation(s)
- Lucy Wallett
- Acute Medical Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Wentin Chen
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Lucretia Thomas
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Parisha Blaggan
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Emma Ooi
- Medical University, RCSI & UCD Malaysia Campus, Georgetown, Malaysia
| | - Dengyi Zhou
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Thia Hanania
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Cai Ying Ng
- Medical University, RCSI & UCD Malaysia Campus, Georgetown, Malaysia
| | - Nia Evans
- Royal Glamorgan Hospital, Cwm Taf Morgannwg University Health Board, Abercynon, UK
| | - Georgia Morgan
- Princess of Wales Hospital, Cwm Taf Morgannwg University Health Board, Abercynon, UK
| | - Issy Allison
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Carina Synn Cuen Pan
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Gobeka Ponniah
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Eloise Radcliffe
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Jameela Sheikh
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Alya Khashaba
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Meghnaa Hebbar
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Dwi Delson
- College of Medicine Dentistry and Nursing, University of Dundee, Dundee, UK
| | - Vinay Reddy-Koanu
- Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - John Ayuk
- Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Gregory Packer
- Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Emily Akufo-Tetteh
- Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Meri Davitadze
- Georgian-American Family Medicine Clinic "Medical House", Georgia, Tbilisi, Georgia
| | - Eka Melson
- General Internal Medicine, Ninewells Hospital NHS Tayside, Dundee, UK.,Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Punith Kempegowda
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
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13
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Patel KR, Nahar A, Elhassan YS, Shetty S, Smith S, Vickrage S, Kemp-Blake J, Palani R, Geh I, Venkataraman H, Shah T, Ayuk J. The effects of somatostatin analogues on glycaemia in the treatment of neuroendocrine tumours. J Neuroendocrinol 2022; 34:e13064. [PMID: 35078270 DOI: 10.1111/jne.13064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 07/09/2021] [Revised: 11/10/2021] [Accepted: 11/15/2021] [Indexed: 11/30/2022]
Abstract
Long-acting somatostatin analogues (SSAs) are the most commonly used drugs in the management of neuroendocrine tumours (NETs) because of their ability to control symptoms and prolong survival. SSA use is associated with changes in glucose metabolism. However, the impacts on glycaemic control and body mass index (BMI) caused by SSAs in NETs are largely unknown. In the present study, we evaluated the effects of SSA treatment on BMI and glycated haemoglobin (HbA1c) in our cohort of patients with NETs. We also assessed changes in glycaemic control and BMI before and after SSA treatment. In addition, we assessed the incidence of new diabetes or whether there was worsening of glycaemic control for patients with pre-existing diabetes. The study comprised a retrospective study of 279 patients with NETs who were treated with SSAs between January 2014 and January 2019. Glycaemic control was assessed by measuring changes in Hba1c. A number needed to harm analysis was used to look at new cases of diabetes within the study population. Treatment with SSAs was associated with a mean increase in HbA1c of 3.35 ± 6.30 mmol mol-1 despite a mean decrease in BMI of -1.04 ± 2.79 kg m-2 . There were 19 new cases of type 2 diabetes mellitus (T2DM) in the population of 209 with a number needed to harm of 12.5. Of the 34 patients with pre-existing T2DM, five had worsening of their mean HbA1c. Treatment with SSAs for NETs is associated with an increase in HbA1c, despite a reduction in BMI and, importantly, a risk of developing T2DM with a number needed to harm of 12.5. This project was registered with the National Health Service Clinical Audit and Registries. It has a CARMS number - 17666.
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Affiliation(s)
- Kishen Rajan Patel
- Birmingham Neuroendocrine Tumour Centre, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Oncology Department, St Bartholomew's Hospital, Bart's Health NHS Foundation Trust, London, UK
| | - Ananda Nahar
- Birmingham Neuroendocrine Tumour Centre, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Yasir S Elhassan
- Birmingham Neuroendocrine Tumour Centre, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Shishir Shetty
- Birmingham Neuroendocrine Tumour Centre, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Stacey Smith
- Birmingham Neuroendocrine Tumour Centre, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Suzanne Vickrage
- Birmingham Neuroendocrine Tumour Centre, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Joanne Kemp-Blake
- Birmingham Neuroendocrine Tumour Centre, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Raghavendar Palani
- Birmingham Neuroendocrine Tumour Centre, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ian Geh
- Birmingham Neuroendocrine Tumour Centre, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Hema Venkataraman
- Birmingham Neuroendocrine Tumour Centre, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Tahir Shah
- Birmingham Neuroendocrine Tumour Centre, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - John Ayuk
- Birmingham Neuroendocrine Tumour Centre, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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14
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Kempegowda P, Robbins TD, Boelaert K, Arlt W, Ayuk J, Sankar S, Karamat MA. Improving diabetes and endocrinology specialty training with modest resources: the Health Education West Midlands model. Future Healthc J 2021; 8:e644-e647. [PMID: 34888458 DOI: 10.7861/fhj.2020-0091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Introduction In the current pandemic, there is a significant disruption for medical training. It is essential that clinicians can access high-quality, targeted educational content to support their clinical working and training development. This content must be delivered on a background of increasing clinical pressures and budgetary restrictions. Methods Educational innovations and supplementary educational content (such as digitisation, simulation, curriculum mapping, trainee representative role definition, research and innovation training) were implemented. We measured the impact of these interventions on cost reductions and changes in trainees' self-reported confidence levels to manage various clinical scenarios post-interventions. Results Using digital technologies reduced both costs and administrative burdens. Simulation-based learning helped improve trainees' self-reported confidence levels. Conclusion Collaborative working across training programme directors, specialist training committee members, educational supervisors, trainee representatives and trainees themselves can develop high-quality educational programmes that support clinical exposure. We propose that elements of the model described here can be replicated across regions and different specialties to support the highest quality of education for UK trainees.
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Affiliation(s)
- Punith Kempegowda
- Institute of Metabolism and Systems Research, Birmingham, UK and honorary specialist training registrar in endocrinology, diabetes and general internal medicine, Health Education West Midlands, Birmingham, UK
| | - Timothy D Robbins
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK and Topol digital health fellow, Health Education England, Birmingham, UK
| | - Kristien Boelaert
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK and reader in endocrinology, Institute of Applied Health Research, Birmingham, UK
| | - Wiebke Arlt
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK and William Withering chair of medicine and director, Institute of Metabolism and Systems Research, Birmingham, UK
| | - John Ayuk
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK and honorary senior lecturer, University of Birmingham, Birmingham, UK
| | - Sailesh Sankar
- Health Education West Midlands, Birmingham, UK and director of medical education and consultant endocrinologist, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Muhammad A Karamat
- Health Education West Midlands, Birmingham, UK and consultant in diabetes and endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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15
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Lithgow K, Venkataraman H, Hughes S, Shah H, Kemp-Blake J, Vickrage S, Smith S, Humphries S, Elshafie M, Taniere P, Diaz-Cano S, Dasari BVM, Almond M, Ford S, Ayuk J, Shetty S, Shah T, Geh I. Well-differentiated gastroenteropancreatic G3 NET: findings from a large single centre cohort. Sci Rep 2021; 11:17947. [PMID: 34504148 PMCID: PMC8429701 DOI: 10.1038/s41598-021-97247-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [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] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 06/21/2021] [Indexed: 11/14/2022] Open
Abstract
Neuroendocrine neoplasms are known to have heterogeneous biological behavior. G3 neuroendocrine tumours (NET G3) are characterized by well-differentiated morphology and Ki67 > 20%. The prognosis of this disease is understood to be intermediate between NET G2 and neuroendocrine carcinoma (NEC). Clinical management of NET G3 is challenging due to limited data to inform treatment strategies. We describe clinical characteristics, treatment, and outcomes in a large single centre cohort of patients with gastroenteropancreatic NET G3. Data was reviewed from 26 cases managed at Queen Elizabeth Hospital, Birmingham, UK, from 2012 to 2019. Most commonly the site of the primary tumour was unknown and majority of cases with identifiable primaries originated in the GI tract. Majority of cases demonstrated somatostatin receptor avidity. Median Ki67 was 30%, and most cases had stage IV disease at diagnosis. Treatment options included surgery, somatostatin analogs (SSA), and chemotherapy with either platinum-based or temozolomide-based regimens. Estimated progression free survival was 4 months following initiation of SSA and 3 months following initiation of chemotherapy. Disease control was observed following treatment in 5/11 patients treated with chemotherapy. Estimated median survival was 19 months; estimated 1 year survival was 60% and estimated 2 year survival was 13%. NET G3 is a heterogeneous group of tumours and patients which commonly have advanced disease at presentation. Prognosis is typically poor, though select cases may respond to treatment with SSA and/or chemotherapy. Further study is needed to compare efficacy of different treatment strategies for this disease.
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Affiliation(s)
- K Lithgow
- Division of Endocrinology, Department of Medicine, Cumming School of Medicine, 1820 Richmond Rd SW, Calgary, AB, T2T 5C7, Canada.
| | - H Venkataraman
- Department of Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - S Hughes
- Department of Radiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - H Shah
- Department of Liver Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - J Kemp-Blake
- Department of Liver Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - S Vickrage
- Department of Liver Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - S Smith
- Department of Liver Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - S Humphries
- Department of Liver Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - M Elshafie
- Department of Pathology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - P Taniere
- Department of Pathology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - S Diaz-Cano
- Department of Pathology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - B V M Dasari
- Department of Liver Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - M Almond
- Department of General Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - S Ford
- Department of General Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - J Ayuk
- Department of Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - S Shetty
- Department of Liver Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - T Shah
- Department of Liver Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - I Geh
- Department of Oncology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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Mehanna H, Mistry P, Golusinski P, Di Maio P, Nankivell P, Snider F, Ferrante AMR, Montalto N, Nicolai P, Marcantoni A, Grandi C, Zavatta M, Grego F, Malec K, Hosal S, Suslu N, Kuscu O, Torrealba I, Valdes F, Sharma N, Ayuk J, Monksfield P, Irving R, Dunn JA, Kay M, Borsetto D. Development and validation of an improved classification and risk stratification system for carotid body tumors: Multinational collaborative cohort study. Head Neck 2021; 43:3448-3458. [PMID: 34418219 DOI: 10.1002/hed.26844] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 07/20/2021] [Accepted: 08/02/2021] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND This study aims to develop and validate a new classification system that better predicts combined risk of neurological and neurovascular complications following CBT surgery, crucial for treatment decision-making. METHODS Multinational retrospective cohort study with 199 consecutive cases. A cohort of 132 CBT cases was used to develop the new classification. To undertake external validation, assessment was made between the actual complication rate and predicted risk by the model on an independent cohort (n = 67). RESULTS Univariate analyses showed statistically significant associations between developing a complication and the following factors: craniocaudal dimension, volume, Shamblin classification, and Mehanna types. In the multivariate prognostic model, only Mehanna type remained as a significant risk predictor. The risk of developing complications increases with increasing Mehanna type. CONCLUSIONS We have developed and then validated a new classification and risk stratification system for CBTs, which demonstrated better prognostic power for the risk of developing neurovascular complications after surgery.
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Affiliation(s)
- Hisham Mehanna
- Institute for Head and Neck Studies and Education (InHANSE), University of Birmingham, Birmingham, UK
| | | | - Pawel Golusinski
- Department of Head and Neck Surgery, The Greater Poland Cancer Centre, Poznan University of Medical Sciences, Poznan, Poland
| | - Pasquale Di Maio
- Section of Otolaryngology - Head and Neck Surgery, University of Perugia, Perugia, Italy
| | - Paul Nankivell
- Institute for Head and Neck Studies and Education (InHANSE), University of Birmingham, Birmingham, UK
| | - Francesco Snider
- Vascular Surgery Unit, Department of Cardiovascular Sciences, Policlinico Universitario A. Gemelli Foundation, Università Cattolica del S. Cuore, Rome, Italy
| | - Angela M R Ferrante
- Vascular Surgery Unit, Department of Cardiovascular Sciences, Policlinico Universitario A. Gemelli Foundation, Università Cattolica del S. Cuore, Rome, Italy
| | - Nausica Montalto
- Unit of Otorhinolaryngology - Head and Neck Surgery, University of Brescia, Brescia, Italy
| | - Piero Nicolai
- Unit of Otorhinolaryngology - Head and Neck Surgery, University of Brescia, Brescia, Italy
| | | | - Cesare Grandi
- Department of Otolaryngology, Ospedale S. Chiara, Trento, Italy
| | - Marco Zavatta
- Clinic of Vascular and Endovascular Surgery, Padova University School of Medicine, Padova, Italy
| | - Franco Grego
- Clinic of Vascular and Endovascular Surgery, Padova University School of Medicine, Padova, Italy
| | - Kataryna Malec
- Department of Otolaryngology - Head and Neck Surgery, 5th Military Hospital with Polyclinic, Krakow, Poland
| | - Sefik Hosal
- Department of Otolaryngology - Head and Neck Surgery, Hacettepe University School of Medicine, Ankara, Turkey
| | - Nilda Suslu
- Department of Otolaryngology - Head and Neck Surgery, Hacettepe University School of Medicine, Ankara, Turkey
| | - Oguz Kuscu
- Department of Otolaryngology - Head and Neck Surgery, Hacettepe University School of Medicine, Ankara, Turkey
| | - Ignacio Torrealba
- Department of Vascular and Endovascular Surgery, Medical School, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Francisco Valdes
- Department of Vascular and Endovascular Surgery, Medical School, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Neil Sharma
- Institute for Head and Neck Studies and Education (InHANSE), University of Birmingham, Birmingham, UK
| | - John Ayuk
- Department of Endocrinology, University Hospitals Birmingham Foundation Trust, Birmingham, UK
| | - Peter Monksfield
- Institute for Head and Neck Studies and Education (InHANSE), University of Birmingham, Birmingham, UK
| | - Richard Irving
- Institute for Head and Neck Studies and Education (InHANSE), University of Birmingham, Birmingham, UK
| | | | - Mark Kay
- Department of Vascular Surgery, University Hospitals Birmingham Foundation Trust, Birmingham, UK
| | - Daniele Borsetto
- Institute for Head and Neck Studies and Education (InHANSE), University of Birmingham, Birmingham, UK
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17
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Thomas M, Berni E, Jenkins-Jones S, Wensley S, Poole CD, Currie CJ, Brownrigg J, Ayuk J, Rees DA. Insulin-like growth factor-1, growth hormone and disease outcomes in acromegaly: A population study. Clin Endocrinol (Oxf) 2021; 95:143-152. [PMID: 33749903 DOI: 10.1111/cen.14468] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 01/27/2021] [Revised: 03/16/2021] [Accepted: 03/17/2021] [Indexed: 11/28/2022]
Abstract
CONTEXT A lack of consensus remains about the relative importance of insulin-like growth factor-1 (IGF-1) and growth hormone (GH) in predicting adverse outcomes in patients with acromegaly. OBJECTIVE To describe the differing association between IGF-1 and GH and major disease outcomes in acromegaly. DESIGN Retrospective cohort study. PATIENTS United Kingdom National Health Service patients with acromegaly who had an IGF-1 and/or a GH measurement recorded following diagnosis, prior to December 2019. MEASUREMENTS A composite endpoint including all-cause mortality (ACM), type 2 diabetes (DM), major adverse cardiovascular events (MACE) or cancer was the primary outcome. These outcomes were also analysed individually. Follow-up period was capped at 5 years. RESULTS A maximum of 417 cases and 332 cases were eligible for the IGF-1 and GH analyses, respectively, comprising 1041.5 and 938.9 years of follow-up. There was a direct association between increased IGF-1 concentration and adjusted event risk for the composite endpoint (hazard ratio [HR] = 1.2; 95% confidence interval [CI] = 1.02-1.5); in GH, the HR was 1.1 (1.0-1.2). For the individual endpoints in relation to IGF-1 level, the HRs were ACM (1.2; 0.93-1.5), MACE (1.2; 0.64-2.1), DM (1.53; 1.09-2.2) and cancer (1.3; 0.95-1.7). For GH, the HRs were ACM (1.1; 0.97-1.2), MACE (0.99; 0.73-1.3), DM (1.1; 0.99-1.2) and cancer (0.90; 0.66-1.2). CONCLUSIONS In this contemporary data set with extended follow-up, IGF-1 and GH concentrations showed an association with major adverse outcomes from acromegaly.
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Affiliation(s)
| | | | | | | | | | - Craig J Currie
- Pharmatelligence, Cardiff, UK
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | | | - John Ayuk
- Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - D Aled Rees
- Neuroscience and Mental Health Research Institute, School of Medicine, Cardiff University, Cardiff, UK
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18
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Kalaria TR, Chopra R, Ayuk J, Buch H. Retinal vein occlusion as the presenting feature of Cushing's syndrome. BMJ Case Rep 2021; 14:14/1/e238204. [PMID: 33495181 PMCID: PMC7839910 DOI: 10.1136/bcr-2020-238204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
A 53-year-old man presented to his optician with blurring of vision in the right eye and was diagnosed to have branch retinal vein occlusion. Over the following 3 months, he had further progressive visual impairment due to right central retinal vein occlusion (CRVO) and then left CRVO. Soon thereafter, during a hospital admission for infected submandibular gland, he was noted to have secondary hypothyroidism and persistent hypokalaemia which led to the diagnosis of Cushing's syndrome. This case was unusual as the patient did not manifest any classical features of Cushing's syndrome at the time of presentation with bilateral CRVO, and only 3 months later had dramatic weight loss, muscle weakness and acute psychosis. He received intravenous etomidate and underwent emergency transsphenoidal hypophysectomy with dramatic clinical and biochemical improvement and complete visual recovery in the left eye but unfortunately vision in the right eye remained limited to hand movements.
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Affiliation(s)
- Tejas R Kalaria
- Blood Sciences, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
| | - Roopa Chopra
- Endocrinology and Diabetes, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
| | - John Ayuk
- Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Harit Buch
- Endocrinology and Diabetes, New Cross Hospital, Wolverhampton, UK
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19
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Melson E, Davitadze M, Aftab M, Ng CY, Ooi E, Blaggan P, Chen W, Hanania T, Thomas L, Zhou D, Chandan JS, Senthil L, Arlt W, Sankar S, Ayuk J, Karamat MA, Kempegowda P. Simulation via instant messaging-Birmingham advance (SIMBA) model helped improve clinicians' confidence to manage cases in diabetes and endocrinology. BMC Med Educ 2020; 20:274. [PMID: 32811488 PMCID: PMC7437058 DOI: 10.1186/s12909-020-02190-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 08/04/2020] [Indexed: 05/09/2023]
Abstract
BACKGROUND Simulation-based learning (SBL) has been increasingly used in both undergraduate and postgraduate medical training curricula. The aim of Simulation via Instant Messaging-Birmingham Advance (SIMBA) is to create a simple virtual learning environment to improve trainees' self-reported confidence in diabetes and Endocrinology. METHODS This study was done as part of the continuous professional development for Health Education England West Midlands speciality trainees in diabetes and Endocrinology. Standardized transcripts of anonymized real-life endocrinology (endocrine session) and diabetes cases (diabetes session) were used in the simulation model. Trainees interacted with moderators through WhatsApp® in this model. All cases were then discussed in detail by a consultant endocrinologist with reference to local, national and international guidelines. Trainee acceptance rate and improvement in their self-reported confidence levels post-simulation were assessed. RESULTS 70.8% (n = 17/24) and 75% (n = 18/24) strongly agreed the simulation session accommodated their personal learning style and the session was engaging. 66.7% (n = 16/24) strongly felt that the simulation was worth their time. In the endocrine session, there was a significant improvement in trainees' confidence in the management of craniopharyngioma (p = 0.0179) and acromegaly (p = 0.0025). There was a trend towards improved confidence levels to manage Cushing's disease and macroprolactinoma. In diabetes session, there was a significant improvement in trainees' confidence to interpret continuous glucose monitor readings (p = 0.01). There was a trend towards improvement for managing monogenic diabetes, hypoglycaemic unawareness and interpreting Libre readings. Overall, there was a significant improvement in trainees' confidence in managing cases that were discussed post-simulation. CONCLUSION SIMBA is an effective learning model to improve trainees' confidence to manage various diabetes and endocrine case scenarios. More sessions with a variety of other speciality case scenarios are needed to further assess SIMBA's effectiveness and application in other areas of medical training.
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Affiliation(s)
- Eka Melson
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Meri Davitadze
- Clinic "Cardio", Tbilisi, Georgia
- Georgian-American Family Medicine Clinic "Medical House", Tbilisi, Georgia
| | - Manal Aftab
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Cai Ying Ng
- RCSI & UCD Malaysia Campus, George Town, Malaysia
| | - Emma Ooi
- RCSI & UCD Malaysia Campus, George Town, Malaysia
| | | | - Wentin Chen
- University of Birmingham Medical School, Birmingham, UK
| | - Thia Hanania
- University of Birmingham Medical School, Birmingham, UK
| | | | - Dengyi Zhou
- University of Birmingham Medical School, Birmingham, UK
| | - Joht Singh Chandan
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Latha Senthil
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Sailesh Sankar
- Diabetes and Endocrinology Specialist Training Committee, Health Education West Midlands, Birmingham, UK
| | - John Ayuk
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Muhammad Ali Karamat
- Diabetes and Endocrinology Specialist Training Committee, Health Education West Midlands, Birmingham, UK
| | - Punith Kempegowda
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK.
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
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20
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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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21
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Chen W, Kempegowda P, Melson E, Davitadze M, Aftab M, Ooi E, Ng CY, Blaggan P, Hanania T, Thomas L, Zhou D, Sankar S, Ayuk J, Karamat MA. Simulation training using WhatsApp (Sim-thru-WhatsApp) improves doctors' confidence in endocrine and diabetes case management. Clin Med (Lond) 2020; 20:s62-s63. [PMID: 32409381 DOI: 10.7861/clinmed.20-2-s62] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Wentin Chen
- University of Birmingham Medical School, Birmingham, UK
| | | | - Eka Melson
- Institute of Metabolism and Systems Research, Birmingham, UK
| | - Meri Davitadze
- Georgian-American Family Medicine Clinic 'Medical House', Tbilisi, Georgia
| | - Manal Aftab
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Emma Ooi
- RCSI & UCD Malaysia Campus, Pulau Pinang, Malaysia
| | - Cai Ying Ng
- RCSI & UCD Malaysia Campus, Pulau Pinang, Malaysia
| | | | - Thia Hanania
- University of Birmingham Medical School, Birmingham, UK
| | | | - Dengyi Zhou
- University of Birmingham Medical School, Birmingham, UK
| | - Sailesh Sankar
- Health Education England (West Midlands), Birmingham, UK
| | - John Ayuk
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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Thompson JP, Bennett D, Hodson J, Asia M, Ayuk J, O'Reilly MW, Karavitaki N, Arlt W, Sutcliffe RP. Incidence, risk factors and clinical significance of postoperative haemodynamic instability after adrenalectomy for phaeochromocytoma. Gland Surg 2019; 8:729-739. [PMID: 32042681 DOI: 10.21037/gs.2019.11.22] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Due to risk of haemodynamic instability (HDI), it has been recommended that patients undergoing adrenalectomy for phaeochromocytoma should be monitored in an intensive care facility. The aim of this study was to evaluate the incidence, risk factors and outcomes of postoperative HDI in these patients. Retrospective cohort study of 46 consecutive patients who underwent open (OA, N=26) or laparoscopic (LA, N=20) adrenalectomy for phaeochromocytoma at a single centre [2007-2017]. Methods HDI was defined as systolic BP >200 or <90 mmHg, heart rate >120 or <50 bpm or vasopressor therapy within 24 hours. Risk factors for intraoperative and postoperative HDI were evaluated by univariable and multivariable analyses. Results Intraoperative hypertension occurred in 25/42 patients (60%). Preoperative plasma normetanephrine levels ≥3,500 pmol/L were significantly associated with intraoperative hypertension on multivariable analysis [odds ratio (OR) 42; 95% CI: 4-429; P=0.002). Postoperative hypotension occurred in 21/45 patients (47%), and 13 (29%) required vasopressor therapy. Preoperative beta-blockade therapy was the only independent risk factor for postoperative hypotension on multivariable analysis (OR 4.0; 95% CI: 1.2-13.9, P=0.029). No patients (0/9) with tumours <5 cm treated by LA needed postoperative vasopressor therapy, compared to 39% (7/18) treated by OA (P=0.059). Complications developed in 9 patients (20%), and were less likely in those with intraoperative hypertension (8% vs. 41%; P=0.019). There was one postoperative death. Conclusions Preoperative beta-blockade therapy is an independent risk factor for postoperative HDI after adrenalectomy for phaeochromocytoma. Patients who undergo laparoscopic adrenalectomy (LA) for phaeochromocytomas <5 cm are unlikely to need postoperative vasopressor therapy, and may not require intensive care monitoring.
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Affiliation(s)
- Joseph P Thompson
- HPB Surgery Unit, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Davinia Bennett
- Anaesthetic Department, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - James Hodson
- Department of Biostatistics, Institute of Translational Medicine, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Miriam Asia
- Department of Endocrinology, Queen Elizabeth Hospital Birmingham, Birmingham, UK.,Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - John Ayuk
- Department of Endocrinology, Queen Elizabeth Hospital Birmingham, Birmingham, UK.,Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Michael W O'Reilly
- Department of Endocrinology, Queen Elizabeth Hospital Birmingham, Birmingham, UK.,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
| | - Niki Karavitaki
- Department of Endocrinology, Queen Elizabeth Hospital Birmingham, Birmingham, UK.,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
| | - Wiebke Arlt
- Department of Endocrinology, Queen Elizabeth Hospital Birmingham, Birmingham, UK.,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
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23
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Steeds RP, Sagar V, Shetty S, Oelofse T, Singh H, Ahmad R, Bradley E, Moore R, Vickrage S, Smith S, Yim I, Elhassan YS, Venkataraman H, Ayuk J, Rooney S, Shah T. Multidisciplinary team management of carcinoid heart disease. Endocr Connect 2019; 8:R184-R199. [PMID: 31751305 PMCID: PMC6933832 DOI: 10.1530/ec-19-0413] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 11/11/2019] [Indexed: 11/22/2022]
Abstract
Carcinoid heart disease (CHD) is a consequence of valvular fibrosis triggered by vasoactive substances released from neuroendocrine tumours, classically in those with metastatic disease and resulting in tricuspid and pulmonary valve failure. CHD affects one in five patients who have carcinoid syndrome (CS). Valve leaflets become thickened, retracted and immobile, resulting most often in regurgitation that causes right ventricular dilatation and ultimately, right heart failure. The development of CHD heralds a significantly worse prognosis than those patients with CS who do not develop valvular disease. Diagnosis requires a low threshold of suspicion in all patients with CS, since symptoms occur late in the disease process and clinical signs are difficult to elicit. As a result, routine screening is recommended using the biomarker, N-terminal pro-natriuretic peptide, and regular echocardiography is then required for diagnosis and follow-up. There is no direct medical therapy for CHD, but the focus of non-surgical care is to control CS symptoms, reduce tumour load and decrease hormone levels. Valve surgery improves long-term outcome for those with severe disease compared to medical management, although peri-operative mortality remains at between 10 and 20% in experienced centres. Therefore, care needs to be multidisciplinary at all stages, with clear discussion with the patient and between teams to ensure optimum outcome for these often-complex patients.
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Affiliation(s)
- Richard P Steeds
- Department of Cardiology, University Hospitals Birmingham (Queen Elizabeth), NHS Hospitals Foundation Trust, Birmingham, UK
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
- Correspondence should be addressed to R P Steeds:
| | - Vandana Sagar
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Shishir Shetty
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Tessa Oelofse
- Departments of Anaesthesia and Intensive Care, University Hospitals Birmingham (Queen Elizabeth), NHS Hospitals Foundation Trust, Birmingham, UK
| | - Harjot Singh
- Departments of Anaesthesia and Intensive Care, University Hospitals Birmingham (Queen Elizabeth), NHS Hospitals Foundation Trust, Birmingham, UK
| | - Raheel Ahmad
- Department of Cardiology, University Hospitals Birmingham (Queen Elizabeth), NHS Hospitals Foundation Trust, Birmingham, UK
| | - Elizabeth Bradley
- Therapy Services (Dietetics), University Hospitals Birmingham (Queen Elizabeth), NHS Hospitals Foundation Trust, Birmingham, UK
| | - Rachel Moore
- Departments of Anaesthesia and Intensive Care, University Hospitals Birmingham (Queen Elizabeth), NHS Hospitals Foundation Trust, Birmingham, UK
| | - Suzanne Vickrage
- Birmingham Neuroendocrine Tumour Centre, University Hospitals Birmingham (Queen Elizabeth), NHS Hospitals Foundation Trust, Birmingham, UK
| | - Stacey Smith
- Birmingham Neuroendocrine Tumour Centre, University Hospitals Birmingham (Queen Elizabeth), NHS Hospitals Foundation Trust, Birmingham, UK
| | - Ivan Yim
- Department of Cardiothoracic Surgery, University Hospitals Birmingham (Queen Elizabeth), NHS Hospitals Foundation Trust, Birmingham, UK
| | - Yasir S Elhassan
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Hema Venkataraman
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - John Ayuk
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Stephen Rooney
- Department of Cardiothoracic Surgery, University Hospitals Birmingham (Queen Elizabeth), NHS Hospitals Foundation Trust, Birmingham, UK
| | - Tahir Shah
- Birmingham Neuroendocrine Tumour Centre, University Hospitals Birmingham (Queen Elizabeth), NHS Hospitals Foundation Trust, Birmingham, UK
- Department of Hepatology and Liver Transplantation, University Hospitals Birmingham (Queen Elizabeth), NHS Hospitals Foundation Trust, Birmingham, UK
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24
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Chortis V, May CJH, Skordilis K, Ayuk J, Arlt W, Crowley RK. Double trouble: two cases of dual adrenal pathologies in one adrenal mass. Endocrinol Diabetes Metab Case Rep 2019; 2019:EDM180151. [PMID: 30909165 PMCID: PMC6432979 DOI: 10.1530/edm-18-0151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 02/27/2019] [Indexed: 11/23/2022] Open
Abstract
Context Adrenal incidentalomas (AI) represent an increasingly common problem in modern endocrine practice. The diagnostic approach to AIs can be challenging and occasionally reveals surprising features. Here we describe two rare cases of complex adrenal lesions consisting of phaeochromocytomas with synchronous metastases from extra-adrenal primaries. Case descriptions Patient 1 - a 65-year-old gentleman with a newly diagnosed malignant melanoma was found to harbour an adrenal lesion with suspicious radiographic characteristics. Percutaneous adrenal biopsy was consistent with adrenocortical adenoma. After excision of the skin melanoma and regional lymphatic metastases, he was followed up without imaging. Three years later, he presented with abdominal discomfort and enlargement of his adrenal lesion, associated with high plasma metanephrines. Adrenalectomy revealed a mixed tumour consisting of a large phaeochromocytoma with an embedded melanoma metastasis in its core. Patient 2 - a 63-year-old lady with a history of NF-1-related phaeochromocytoma 20 years ago and previous breast cancer presented with a new adrenal lesion on the contralateral side. Plasma normetanephrine was markedly elevated. Elective adrenalectomy revealed an adrenal tumour consisting of chromaffin cells intermixed with breast carcinoma cells. Conclusions Adrenal incidentalomas require careful evaluation to exclude metastatic disease, especially in the context of a history of previous malignancy. Adrenal biopsy provides limited and potentially misleading information. Phaeochromocytomas are highly vascularised tumours that may function as a sieve, extracting and retaining irregularly shaped cancer cells, thereby yielding adrenal masses with intriguing dual pathology. Learning points: Adrenal incidentalomas require careful evaluation focused on exclusion of underlying hormone excess and malignant pathology. Adrenal biopsy can be misleading and should only be considered in select cases. Phaeochromocytomas harbouring intratumoural metastases from other, extra-adrenal primary malignancies represent rare pathological entities that highlight the complexities that can be presented by adrenal tumours.
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Affiliation(s)
- Vasileios Chortis
- Institute of Metabolism and Systems Research, University of Birmingham
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- Departments of Endocrinology, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Christine J H May
- Departments of Endocrinology, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Kassiani Skordilis
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- Departments of Cellular Pathology, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - John Ayuk
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- Departments of Endocrinology, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research, University of Birmingham
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- Departments of Endocrinology, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Rachel K Crowley
- St. Vincent’s University Hospital and University College Dublin, Dublin, Ireland
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25
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Hassan-Smith Z, Faloon S, Gittoes N, Ayuk J. Response. Clin Med (Lond) 2019; 19:92. [PMID: 30651268 PMCID: PMC6399619 DOI: 10.7861/clinmedicine.19-1-92] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Zaki Hassan-Smith
- Queen Elizabeth Hospital Birmingham, Birmingham, UK
- Coventry University, Coventry, UK
| | - Sarah Faloon
- Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Neil Gittoes
- Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - John Ayuk
- Queen Elizabeth Hospital Birmingham, Birmingham, UK
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26
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Kalra S, Sahoo A, Das S, Kumar KVSH, Baliarsinha AK, Mohanty B, Kanwar J, Kota S, Satpathy S, Jayaraman M, Singh SK, Madhu SV, Shah M, Kotwal N, Priya G, George B, Dasgupta A, Pande AKR, Latey N, Dhamija P, Ayuk J, Torpy D, Shah P, Naseri MW, Maskey R, Latif ZA, Somasundaram N, Jawa A, Acharya K. The Bhubaneswar Declaration on Sports Endocrinology, 2018. Indian J Endocrinol Metab 2018; 22:S14-S16. [PMID: 30534532 PMCID: PMC6247649 DOI: 10.4103/ijem.ijem_567_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Sports and endocrinology are complex interrelated disciplines. Sports and exercise modulate endocrine and metabolic health, and are used to prevent and manage disease. Endocrine and metabolic function influence participation and performance in sports activity. The Bhubaneswar Declaration, released on the occasion of the Endocrine Society of India Conference, resolves to promote the science of sports endocrinology. The authors commit to optimize endocrine health in sports persons, encourage safe use of sports to promote health, and prevent misuse of endocrine interventions in sports.
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Affiliation(s)
- Sanjay Kalra
- Department of Endocrinology, Bharti Hospital, Karnal, Haryana, India
| | - Abhay Sahoo
- Department of Endocrinology, IMS and SUM, Bhubaneswar, Odisha, India
| | - Sambit Das
- Department of Endocrinology, Hi Tech Medical College and Hospital, Bhubaneswar, Odisha, India
| | - K. V. S. Hari Kumar
- Department of Endocrinology, Command Hospital (WC), Panchkula, Haryana, India
| | | | - Binoy Mohanty
- Department of Endocrinology, MKCG Medical College, Berhampur, Odisha, India
| | - Jayabhanu Kanwar
- Department of Endocrinology, IMS and SUM, Bhubaneswar, Odisha, India
| | - Sunil Kota
- Department of Endocrinology, Diabetes and Endocare Clinic, Berhampur, Odisha, India
| | - Sudeep Satpathy
- Department of Sports Medicine, B R Life Kalinga Hospital, Bhubaneswar, Odisha, India
| | | | - S. K. Singh
- Department of Endocrinology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - S. V. Madhu
- Department of Endocrinology, University College of Medical Science, New Delhi, India
| | - Mona Shah
- Department of Endocrinology, Harmony Clinic, Vadodara, Gujarat, India
| | - Narendra Kotwal
- Department of Endocrinology, Army Hospital (R and R), New Delhi, India
| | - Gagan Priya
- Department of Endocrinology, Fortis Hospital, Mohali, Punjab, India
| | - Belinda George
- Department of Endocrinology, St John's Medical College, Bengaluru, Karnataka, India
| | - Arundhati Dasgupta
- Department of Endocrinology, Rudraksh Superspeciality Care, Siliguri, West Bengal, India
| | - Arun Kumar R. Pande
- Department of Endocrinology, Lucknow Endocrine Diabetes and Thyroid clinic and Sahara Hospital, Lucknow, Uttar Pradesh, India
| | - Nikhil Latey
- Department of Physiotherapy, Sports Med Hospital, Mumbai, Maharashtra, India
| | - Puneet Dhamija
- Department of Pharmacology, AIIMS, Rishikesh, Uttarakhand, India
| | - John Ayuk
- Department of Endocrinology, University Hospitals, Birmingham, UK
| | - David Torpy
- Department of Endocrinology, Royal Adelaide Hospital, Adelaide, Australia
| | - Pankaj Shah
- Department of Internal Medicine, Division of Endocrinology, Mayo Clinic, Rochester, USA
| | - Mohammed Wali Naseri
- Department of Internal Medicine, Division of Endocrinology, Kabul University of Medical Sciences, Kabul, Afghanistan
| | - Robin Maskey
- Department of Internal Medicine, B.P. Koirala Institute of Health Sciences, Dharan, Nepal
| | | | - Noel Somasundaram
- Department of Endocrinology, National Hospital of Sri Lanka, Colombo, Sri Lanka
| | - Ali Jawa
- Wilshire Cardiovascular and Endocrine Center of Excellence, Lahore, Pakistan
| | - Kirtida Acharya
- Department of Endocrinology, MP Shah Hospital, Nairobi, Kenya
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27
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Santharam S, Fountas A, Tampourlou M, Arlt W, Ayuk J, Gittoes N, Toogood A, Karavitaki N. Impact of menopause on outcomes in prolactinomas after dopamine agonist treatment withdrawal. Clin Endocrinol (Oxf) 2018; 89:346-353. [PMID: 29894000 DOI: 10.1111/cen.13765] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [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: 05/03/2018] [Revised: 06/04/2018] [Accepted: 06/10/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Discontinuation of dopamine agonist (DA) treatment in women with prolactinoma after menopause is a potential approach; studies systematically assessing long-term outcomes are lacking. Our aim was to investigate the natural history of prolactinoma in this group. DESIGN/PATIENTS Retrospective cohort study of women with prolactinoma diagnosed before menopause and who after menopause were not on DA. RESULTS Thirty women were included. Twenty-eight received DA (median duration 18 years, median age at DA withdrawal 52 years). At last assessment (median follow-up 3 years) and compared with values 6-12 months after stopping DA, Prolactin (PRL) increased in 15%, decreased but not normalized in 33% and was normal in 52%; PRL levels or visible adenoma on imaging before DA withdrawal, treatment duration and presence of macro-/microadenoma at diagnosis were not predictors of normoprolactinaemia at last review, whereas PRL values 6-12 months after stopping DA were. Adenoma regrowth was detected in 2/27 patients (7%), who showed gradual increase in PRL. Comparison with 28 women who had DA withdrawal before their menopause revealed lower risk of hyperprolactinaemia recurrence in the postmenopausal group (HR:0.316, 95% CI: 0.101-0.985, P < .05). Two women with microprolactinoma diagnosed in perimenopausal period had not been offered DA; PRL decreased (but not normalized) during observation of 1 and 8 years. CONCLUSIONS Prolactin normalized over time in nearly half of the women and serum PRL 6-12 months after DA withdrawal is useful predictor. Nonetheless, 7% of the patients demonstrated adenoma regrowth which, given the life expectancy postmenopause, necessitate regular monitoring of the cases with persistent hyperprolactinaemia.
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Affiliation(s)
- Sandhya Santharam
- Institute of Metabolism and Systems Research (IMSR), 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
| | - Athanasios Fountas
- Institute of Metabolism and Systems Research (IMSR), 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
| | - Metaxia Tampourlou
- Institute of Metabolism and Systems Research (IMSR), 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
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research (IMSR), 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
| | - John 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
| | - Neil Gittoes
- Institute of Metabolism and Systems Research (IMSR), 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
| | - Andrew 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
| | - Niki Karavitaki
- Institute of Metabolism and Systems Research (IMSR), 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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28
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Trainer PJ, Newell-Price JDC, Ayuk J, Aylwin SJB, Rees A, Drake W, Chanson P, Brue T, Webb SM, Fajardo C, Aller J, McCormack AI, Torpy DJ, Tachas G, Atley L, Ryder D, Bidlingmaier M. A randomised, open-label, parallel group phase 2 study of antisense oligonucleotide therapy in acromegaly. Eur J Endocrinol 2018; 179:97-108. [PMID: 29789410 PMCID: PMC6063983 DOI: 10.1530/eje-18-0138] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 05/22/2018] [Indexed: 11/20/2022]
Abstract
OBJECTIVE ATL1103 is a second-generation antisense oligomer targeting the human growth hormone (GH) receptor. This phase 2 randomised, open-label, parallel-group study assessed the potential of ATL1103 as a treatment for acromegaly. DESIGN Twenty-six patients with active acromegaly (IGF-I >130% upper limit of normal) were randomised to subcutaneous ATL1103 200 mg either once or twice weekly for 13 weeks and monitored for a further 8-week washout period. METHODS The primary efficacy measures were change in IGF-I at week 14, compared to baseline and between cohorts. For secondary endpoints (IGFBP3, acid labile subunit (ALS), GH, growth hormone-binding protein (GHBP)), comparison was between baseline and week 14. Safety was assessed by reported adverse events. RESULTS AND CONCLUSIONS Baseline median IGF-I was 447 and 649 ng/mL in the once- and twice-weekly groups respectively. Compared to baseline, at week 14, twice-weekly ATL1103 resulted in a median fall in IGF-I of 27.8% (P = 0.0002). Between cohort comparison at week 14 demonstrated the median fall in IGF-I to be 25.8% (P = 0.0012) greater with twice-weekly dosing. In the twice-weekly cohort, IGF-I was still declining at week 14, and remained lower at week 21 than at baseline by a median of 18.7% (P = 0.0005). Compared to baseline, by week 14, IGFBP3 and ALS had declined by a median of 8.9% (P = 0.027) and 16.7% (P = 0.017) with twice-weekly ATL1103; GH had increased by a median of 46% at week 14 (P = 0.001). IGFBP3, ALS and GH did not change with weekly ATL1103. GHBP fell by a median of 23.6% and 48.8% in the once- and twice-weekly cohorts (P = 0.027 and P = 0.005) respectively. ATL1103 was well tolerated, although 84.6% of patients experienced mild-to-moderate injection-site reactions. This study provides proof of concept that ATL1103 is able to significantly lower IGF-I in patients with acromegaly.
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Affiliation(s)
- Peter J Trainer
- Department of EndocrinologyThe Christie NHS Foundation Trust, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
- Correspondence should be addressed to P J Trainer;
| | - John D C Newell-Price
- Department of Oncology and MetabolismThe Medical School, University of Sheffield, Sheffield, UK
- Royal Hallamshire HospitalSheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - John Ayuk
- Medicine EndocrinologyQueen Elizabeth Hospital Birmingham, Edgbaston, UK
| | | | - Aled Rees
- Neuroscience and Mental Health Research InstituteSchool of Medicine, Cardiff University, Hadyn Ellis Building, Cardiff, UK
| | - William Drake
- Department of EndocrinologySt Bartholomew’s Hospital, London, UK
| | - Philippe Chanson
- Assistance Publique-Hôpitaux de ParisHôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Service d’Endocrinologie et des Maladies de la Reproduction, Le Kremlin-Bicêtre, France
- Inserm 1185Fac Med Paris Sud, Univ Paris-Sud, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Thierry Brue
- Aix-Marseille UniversitéCNRS, CRN2M UMR 7286, Marseille, France
- APHMHôpital Conception, Service d’Endocrinologie, Diabète et Maladies Métaboliques, Centre de Référence des Maladies Rares d’Origine Hypophysaire, Marseille, France
| | - Susan M Webb
- Department of EndocrinologyCIBERER Group 747, IIB-S Pau, Hospital de la Santa Creu i Sant Pau, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Carmen Fajardo
- Servicio de EndocrinologíaHospital Universitario de La Ribera, Alzira, Valencia, Spain
| | - Javier Aller
- Endocrinology DepartmentHospital Universitario Puerta de Hierro Majadahonda, Majadahonda, Spain
| | - Ann I McCormack
- Garvan Institute of Medical Research and St Vincent’s HospitalDarlinghurst Sydney, New South Wales, Australia
| | - David J Torpy
- Royal Adelaide HospitalNorth Terrace, Adelaide, Australia
| | - George Tachas
- Antisense Therapeutics LimitedToorak, Victoria, Australia
| | - Lynne Atley
- Antisense Therapeutics LimitedToorak, Victoria, Australia
| | - David Ryder
- Manchester Academic Health Science Centre (MAHSC) Clinical Trials UnitThe Christie NHS Foundation Trust, University of Manchester, Manchester, UK
| | - Martin Bidlingmaier
- Endocrine LaboratoryMedizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität München, Munich, Germany
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29
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Faloon S, Venkataraman H, Skordilis K, Griffiths EA, Gittoes NJ, Hassan-Smith ZK, Ayuk J. Lesson of the month 2: Blunt abdominal trauma: atypical presentation of phaeochromocytoma. Clin Med (Lond) 2018; 18:345-347. [PMID: 30072564 PMCID: PMC6334037 DOI: 10.7861/clinmedicine.18-4-345] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [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] [Indexed: 11/27/2022]
Abstract
A 26-year-old man presented following blunt abdominal trauma to a regional major trauma centre for emergency embolisation of a retroperitoneal bleed from a presumed renal laceration. Imaging had also revealed a large right suprarenal mass. Embolisation resulted in a hypertensive crisis raising the suspicion of a metabolically active adrenal tumour. The course was further complicated by the development of ischaemic bowel requiring emergency laparotomy. Intraoperatively he became haemodynamically unstable from an actively haemorrhaging lesion. Emergency laparotomy and adrenalectomy was performed as a life-saving procedure. Histology confirmed a phaeochromocytoma. The patient made a gradual recovery and was discharged home with no sequelae. Definitive management of phaeochromocytoma is surgical resection which requires prolonged preoperative optimisation with alpha receptor blockers to adequately control blood pressure and prevent hypertensive crises. Parenteral alpha receptor blockers, such as phentolamine, are optimal treatment for intraoperative hypertensive emergencies, yet they are currently not available in the UK.
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Affiliation(s)
- Sarah Faloon
- Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Hema Venkataraman
- Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Kassiani Skordilis
- Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ewen A Griffiths
- Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Neil Jl Gittoes
- Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Zaki K Hassan-Smith
- Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Coventry University, UK
| | - John Ayuk
- Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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de Bray A, Hassan-Smith ZK, Dirie J, Littleton E, Chavda S, Ayuk J, Sanghera P, Karavitaki N. Macroprolactinoma causing VI, X, XII cranial nerve palsies nearly 30 years after initial treatment. Endocrinol Diabetes Metab Case Rep 2018; 2018:EDM180053. [PMID: 30002835 PMCID: PMC6038010 DOI: 10.1530/edm-18-0053] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 06/19/2018] [Indexed: 11/08/2022] Open
Abstract
A 48-year-old man was diagnosed with a large macroprolactinoma in 1982 treated with surgery, adjuvant radiotherapy and bromocriptine. Normal prolactin was achieved in 2005 but in 2009 it started rising. Pituitary MRIs in 2009, 2012, 2014 and 2015 were reported as showing empty pituitary fossa. Prolactin continued to increase (despite increasing bromocriptine dose). Trialling cabergoline had no effect (prolactin 191,380 mU/L). In January 2016, he presented with right facial weakness and CT head was reported as showing no acute intracranial abnormality. In late 2016, he was referred to ENT with hoarse voice; left hypoglossal and recurrent laryngeal nerve palsies were found. At this point, prolactin was 534,176 mU/L. Just before further endocrine review, he had a fall and CT head showed a basal skull mass invading the left petrous temporal bone. Pituitary MRI revealed a large enhancing mass within the sella infiltrating the clivus, extending into the left petrous apex and occipital condyle with involvement of the left Meckel's cave, internal acoustic meatus, jugular foramen and hypoglossal canal. At that time, left abducens nerve palsy was also present. CT thorax/abdomen/pelvis excluded malignancy. Review of previous images suggested that this lesion had started becoming evident below the fossa in pituitary MRI of 2015. Temozolomide was initiated. After eight cycles, there is significant tumour reduction with prolactin 1565 mU/L and cranial nerve deficits have remained stable. Prolactinomas can manifest aggressive behaviour even decades after initial treatment highlighting the unpredictable clinical course they can demonstrate and the need for careful imaging review. Learning points Aggressive behaviour of prolactinomas can manifest even decades after first treatment highlighting the unpredictable clinical course these tumours can demonstrate.Escape from control of hyperprolactinaemia in the absence of sellar adenomatous tissue requires careful and systematic search for the anatomical localisation of the lesion responsible for the prolactin excess.Temozolomide is a valuable agent in the therapeutic armamentarium for aggressive/invasive prolactinomas, particularly if they are not amenable to other treatment modalities.
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Affiliation(s)
- Anne de Bray
- Department of Endocrinology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Centre for Endocrinology, Diabetes & Metabolism, Birmingham Health Partners, Birmingham, UK.,Institute for Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Zaki K Hassan-Smith
- Department of Endocrinology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Centre for Endocrinology, Diabetes & Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Jamal Dirie
- Department of Endocrinology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Centre for Endocrinology, Diabetes & Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Edward Littleton
- Departments of Neurology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Swarupsinh Chavda
- Departments of Radiology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - John Ayuk
- Department of Endocrinology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Centre for Endocrinology, Diabetes & Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Paul Sanghera
- Departments of Oncology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Niki Karavitaki
- Department of Endocrinology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Centre for Endocrinology, Diabetes & Metabolism, Birmingham Health Partners, Birmingham, UK.,Institute for Metabolism and Systems Research, University of Birmingham, Birmingham, UK
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Fountas A, Chai ST, Ayuk J, Gittoes N, Chavda S, Karavitaki N. A rare challenging case of co-existent craniopharyngioma, acromegaly and squamous cell lung cancer. Endocrinol Diabetes Metab Case Rep 2018; 2018:EDM180018. [PMID: 29623208 PMCID: PMC5881427 DOI: 10.1530/edm-18-0018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 03/12/2018] [Indexed: 12/28/2022] Open
Abstract
Co-existence of craniopharyngioma and acromegaly has been very rarely reported. A 65-year-old man presented with visual deterioration, fatigue and frontal headaches. Magnetic resonance imaging revealed a suprasellar heterogeneous, mainly cystic, 1.9 × 2 × 1.9 cm mass compressing the optic chiasm and expanding to the third ventricle; the findings were consistent with a craniopharyngioma. Pituitary hormone profile showed hypogonadotropic hypogonadism, mildly elevated prolactin, increased insulin-like growth factor 1 (IGF-1) and normal thyroid function and cortisol reserve. The patient had transsphenoidal surgery and pathology of the specimen was diagnostic of adamantinomatous craniopharyngioma. Post-operatively, he had diabetes insipidus, hypogonadotropic hypogonadism and adrenocorticotropic hormone and thyroid-stimulating hormone deficiency. Despite the hypopituitarism, his IGF-1 levels remained elevated and subsequent oral glucose tolerance test did not show complete growth hormone (GH) suppression. Further review of the pre-operative imaging revealed a 12 × 4 mm pituitary adenoma close to the right carotid artery and no signs of pituitary hyperplasia. At that time, he was also diagnosed with squamous cell carcinoma of the left upper lung lobe finally managed with radical radiotherapy. Treatment with long-acting somatostatin analogue was initiated leading to biochemical control of the acromegaly. Latest imaging has shown no evidence of craniopharyngioma regrowth and stable adenoma. This is a unique case report of co-existence of craniopharyngioma, acromegaly and squamous lung cell carcinoma that highlights diagnostic and management challenges. Potential effects of the GH hypersecretion on the co-existent tumours of this patient are also briefly discussed.
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Affiliation(s)
- Athanasios Fountas
- 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.,Departments of Endocrinology and Radiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Shu Teng Chai
- 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.,Departments of Endocrinology and Radiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - John Ayuk
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK.,Departments of Endocrinology and Radiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Neil 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.,Departments of Endocrinology and Radiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Swarupsinh Chavda
- Departments of Radiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Niki 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.,Departments of Endocrinology and Radiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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Benetatos N, Hodson J, Marudanayagam R, Sutcliffe RP, Isaac JR, Ayuk J, Shah T, Roberts KJ. Prognostic factors and survival after surgical resection of pancreatic neuroendocrine tumor with validation of established and modified staging systems. Hepatobiliary Pancreat Dis Int 2018; 17:169-175. [PMID: 29576279 DOI: 10.1016/j.hbpd.2018.03.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 01/03/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND Pancreatic neuroendocrine tumors (PNETs) display wide heterogeneity with highly variable prognosis. This study aimed to identify variables related to survival after surgical resection of PNET. METHODS A total of 143 patients were identified from a prospectively maintained database. Patient characteristics were analyzed and prognostic factors for overall survival and progression-free survival were evaluated. The WHO, ENETS and AJCC scoring systems were applied to the cohort, and their ability to predict patient outcomes were compared. RESULTS Multivariate analysis found that female gender, lymph node metastases and increasing WHO 2010 grade to be independently associated with reduced overall survival (P < 0.05). Patients requiring multi-visceral resection or debulking surgery found to be associated with shortest survival. ROC analysis found the ENETS and AJCC scoring systems to be similarly predictive of 5-year overall survival. Modified Ki67 significantly improved its accuracy in predicting 5-year overall survival (AUROC: 0.699 vs 0.605; P < 0.01). CONCLUSIONS Multi-visceral or debulking surgery is associated with poor outcomes. There seems to be no significant difference between enucleation and anatomical segmental resection. Available scoring systems have reasonable accuracy in stratifying disease severity, with no system identified as being superior. Prognostic stratification with modified grading systems needs further validation before applied in clinical practice.
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Affiliation(s)
- Nikolaos Benetatos
- The HPB Unit, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, UK
| | - James Hodson
- Institute of Translational Medicine, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham, UK
| | - Ravi Marudanayagam
- The HPB Unit, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, UK
| | - Robert P Sutcliffe
- The HPB Unit, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, UK
| | - John R Isaac
- The HPB Unit, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, UK
| | - John Ayuk
- Endocrinology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham, UK
| | - Tahir Shah
- Liver Unit, Queen Elizabeth Hospital Birmingham, University Hospital of Birmingham NHS Foundation Trust, Birmingham, UK
| | - Keith J Roberts
- The HPB Unit, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, UK.
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Santharam S, Tampourlou M, Arlt W, Ayuk J, Gittoes N, Toogood A, Webster R, Karavitaki N. Prolactinomas diagnosed in the postmenopausal period: Clinical phenotype and outcomes. Clin Endocrinol (Oxf) 2017. [PMID: 28626987 DOI: 10.1111/cen.13399] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [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] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Most prolactinomas in females are diagnosed during the reproductive age, and the majority are microadenomas. Prolactinomas detected in the postmenopausal period are less common with limited published data on their presentation and prognosis. Our objective was to assess the presenting clinical, biochemical and imaging findings, as well as the outcomes of women diagnosed with a prolactinoma in the postmenopausal period. DESIGN AND METHODS We undertook a retrospective cohort study of women diagnosed with prolactinoma after menopause and followed up in a large UK pituitary centre. Information on presentation, management and outcomes was collected. RESULTS Seventeen women with a median age at diagnosis of 63 years (range 52-78) were identified. Headaches and/or visual deterioration were the most commonly reported complaints at detection of the adenoma (47%). Acute pituitary apoplexy was diagnosed at presentation or during follow-up in 18% of the cases. The median serum prolactin was 12 364 mU/L (range 2533-238 479). Macroprolactinomas comprised 94% of the tumours, and 88% of them had supra/parasellar extension. All patients with macroprolactinoma were offered dopamine agonist, and normal prolactin was achieved in 94% of them (median follow-up 91.5 months). Adenoma shrinkage was observed in all women. Improvement or resolution of visual disturbances documented at presentation was observed in 86% of cases. CONCLUSIONS The clinical phenotype of prolactinomas diagnosed in the postmenopausal period is characterized by dominance of macroadenomas, with frequent supra/parasellar extension and a relative high rate of acute pituitary apoplexy. In this group of patients, the response of the macroadenomas to dopamine agonists is good.
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Affiliation(s)
- Sandhya Santharam
- 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
| | - Metaxia Tampourlou
- 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
| | - Wiebke Arlt
- 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
| | - John 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
| | - Neil 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
| | - Andrew 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
| | - Rachel Webster
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- Department of Biochemistry, Queen Elizabeth Hospital, University Hospitals Birmingham, NHS Foundation Trust, Birmingham, UK
| | - Niki 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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Tampourlou M, Ntali G, Ahmed S, Arlt W, Ayuk J, Byrne JV, Chavda S, Cudlip S, Gittoes N, Grossman A, Mitchell R, O'Reilly MW, Paluzzi A, Toogood A, Wass JAH, Karavitaki N. Outcome of Nonfunctioning Pituitary Adenomas That Regrow After Primary Treatment: A Study From Two Large UK Centers. J Clin Endocrinol Metab 2017; 102:1889-1897. [PMID: 28323946 DOI: 10.1210/jc.2016-4061] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [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] [Received: 12/31/2016] [Accepted: 02/27/2017] [Indexed: 02/05/2023]
Abstract
CONTEXT Despite the major risk of regrowth of clinically nonfunctioning pituitary adenomas (CNFAs) after primary treatment, systematic data on the probability of further tumor progression and the effectiveness of management approaches are lacking. OBJECTIVE To assess the probability of further regrowth(s), predictive factors, and outcomes of management approaches in patients with CNFA diagnosed with adenoma regrowth after primary treatment. PATIENTS, DESIGN, AND SETTING Retrospective cohort study of 237 patients with regrown CNFA managed in two UK centers. RESULTS Median follow-up was 5.9 years (range, 0.4 to 37.7 years). The 5-year second regrowth rate was 35.3% (36.2% after surgery; 12.5% after radiotherapy; 12.7% after surgery combined with radiotherapy; 63.4% with monitoring). Of those managed with monitoring, 34.8% eventually were offered intervention. Type of management and sex were risk factors for second regrowth. Among those with second adenoma regrowth, the 5-year third regrowth rate was 26.4% (24.4% after surgery; 0% after radiotherapy; 0% after surgery combined with radiotherapy; 48.3% with monitoring). Overall, patients with a CNFA regrowth had a 4.4% probability of a third regrowth at 5 years and a 10.0% probability at 10 years; type of management of the first regrowth was the only risk factor. Malignant transformation was diagnosed in two patients. CONCLUSIONS Patients with regrown CNFA after primary treatment continue to carry considerable risk of tumor progression, necessitating long-term follow-up. Management approach to the regrowth was the major factor determining this risk; monitoring had >60% risk of progression at 5 years, and a substantial number of patients ultimately required intervention.
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Affiliation(s)
- Metaxia Tampourlou
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham B15 2TT, Birmingham, United Kingdom
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2TH, United Kingdom
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, United Kingdom
| | - Georgia Ntali
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford OX3 7LE, United Kingdom
| | - Shahzada Ahmed
- Department of Ear, Nose and Throat, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, United Kingdom
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham B15 2TT, Birmingham, United Kingdom
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2TH, United Kingdom
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, United Kingdom
| | - John Ayuk
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2TH, United Kingdom
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, United Kingdom
| | - James V Byrne
- Department of Neuroradiology, John Radcliffe Hospital, Oxford OX3 9DU, United Kingdom
| | - Swarupsinh Chavda
- Department of Radiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, United Kingdom
| | - Simon Cudlip
- Department of Neurosurgery, John Radcliffe Hospital, Oxford OX3 9DU, United Kingdom
| | - Neil Gittoes
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham B15 2TT, Birmingham, United Kingdom
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2TH, United Kingdom
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, United Kingdom
| | - Ashley Grossman
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford OX3 7LE, United Kingdom
| | - Rosalind Mitchell
- Department of Neurosurgery, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, United Kingdom
| | - Michael W O'Reilly
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham B15 2TT, Birmingham, United Kingdom
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2TH, United Kingdom
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, United Kingdom
| | - Alessandro Paluzzi
- Department of Neurosurgery, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, United Kingdom
| | - Andrew Toogood
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2TH, United Kingdom
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, United Kingdom
| | - John A H Wass
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford OX3 7LE, United Kingdom
| | - Niki Karavitaki
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham B15 2TT, Birmingham, United Kingdom
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2TH, United Kingdom
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, United Kingdom
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O'Reilly MW, Reulen RC, Gupta S, Thompson CA, Dineen R, Goulden EL, Bugg G, Pearce H, Toogood AA, Gittoes NJ, Mitchell R, Thompson CJ, Ayuk J. ACTH and gonadotropin deficiencies predict mortality in patients treated for nonfunctioning pituitary adenoma: long-term follow-up of 519 patients in two large European centres. Clin Endocrinol (Oxf) 2016; 85:748-756. [PMID: 27327840 PMCID: PMC5082557 DOI: 10.1111/cen.13141] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Revised: 05/09/2016] [Accepted: 06/17/2016] [Indexed: 11/30/2022]
Abstract
CONTEXT AND OBJECTIVE Nonfunctioning pituitary adenomas (NFPAs) are the most common subtype of pituitary tumour. Hypopituitarism is observed in NFPAs due to tumour- or treatment-related factors and may increase mortality risk. Here, we analysed the associations of hypopituitarism, hormone replacement and mortality in a large NFPA cohort derived from two large European centres. DESIGN, SETTING AND PARTICIPANTS Case note review of all patients treated for NFPA in University Hospitals Birmingham and Beaumont Hospital Dublin between 1999 and 2014 was performed. MAIN OUTCOME MEASURES Clinical presentation, treatment strategies, pituitary function and vitality status were recorded in each patient. A multivariate Cox regression model was used to examine the association between hypopituitarism, hormone replacement and premature mortality. RESULTS A total of 519 patients were included in the analysis. Median duration of follow-up was 7·0 years (0·5-43). A total of 81 deaths were recorded (15·6%). On multivariate analysis, adrenocorticotropic hormone (ACTH) and gonadotropin (Gn) deficiencies were associated with an increased relative risk of death (OR 2·26, 95% CI 1·15-4·47, P = 0·01 and OR 2·56, 95% CI 1·10-5·96, P = 0·01, respectively). Increased hydrocortisone (HC) (P-trend = 0·02) and lower levothyroxine (LT4) doses (P-trend = 0·03) were associated with increased risk of death. Mortality increased with the degree of pituitary failure observed (P-trend = 0·04). CONCLUSION ACTH and gonadotropin-deficient patients have higher mortality rates compared to those with intact hormonal axes. Excessive HC and suboptimal LT4 replacement may also increase risk of death. Complex associations between hormone deficiency and replacement underpin the increased mortality risk in NFPA patients.
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Affiliation(s)
- Michael W O'Reilly
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK.
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK.
- Department of Endocrinology, University Hospitals Birmingham, Birmingham, UK.
| | - Raoul C Reulen
- School of Health and Population Sciences, University of Birmingham, Birmingham, UK
| | - Saket Gupta
- Division of Endocrinology, Beaumont Hospital and RCSI Medical School, Dublin 9, Ireland
| | - Claire A Thompson
- Division of Endocrinology, Beaumont Hospital and RCSI Medical School, Dublin 9, Ireland
| | - Rosemary Dineen
- Division of Endocrinology, Beaumont Hospital and RCSI Medical School, Dublin 9, Ireland
| | - Eirena L Goulden
- Division of Endocrinology, Beaumont Hospital and RCSI Medical School, Dublin 9, Ireland
| | - Gabriella Bugg
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Harriet Pearce
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Andy A Toogood
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- Department of Endocrinology, University Hospitals Birmingham, Birmingham, UK
| | - Neil J Gittoes
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- Department of Endocrinology, University Hospitals Birmingham, Birmingham, UK
| | - Rosalind Mitchell
- Department of Neurosurgery, University Hospitals Birmingham, Birmingham, UK
| | | | - John Ayuk
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- Department of Endocrinology, University Hospitals Birmingham, Birmingham, UK
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Abstract
Based on experimental and animal models, epidemiological data from non-acromegaly populations, and longitudinal and cross-sectional cohorts of patients with acromegaly, a potential association between acromegaly and cancer has long been hypothesized, in particular colorectal cancer, and, to a lesser extent, breast, thyroid and prostate cancers. The exact mechanisms underlying this potential association have not been fully elucidated. Results from studies examining cancer incidence and mortality in acromegaly have been inconsistent, with some demonstrating increased risk, whereas others show no increase. This article reviews the existing data relating to cancer risk and mortality in acromegaly, exploring the limitations of study designs and the impact of changes in disease control and patient outcomes over time.
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Affiliation(s)
- Cesar Luiz Boguszewski
- Department of Internal MedicineEndocrine Division (SEMPR), Federal University of Paraná, Curitiba, Brazil
| | - John Ayuk
- Consultant Endocrinologist/Honorary Senior LecturerDepartment of Endocrinology, Queen Elizabeth Hospital, Edgbaston, Birmingham, UK
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Boon IS, Perera D, Ayuk J. When Occam's razor fails: hemipontine infarct on a background of previous surgery and radiotherapy for craniopharyngioma. BMJ Case Rep 2016; 2016:bcr-2016-215420. [PMID: 27056943 DOI: 10.1136/bcr-2016-215420] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Ian S Boon
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Dilani Perera
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - John Ayuk
- Department of Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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Jahagirdar V, Kamal A, Steeds R, Ayuk J. Metastatic small bowel neuroendocrine tumour with bilateral carcinoid heart disease. BMJ Case Rep 2016; 2016:bcr-2015-213693. [PMID: 26843220 DOI: 10.1136/bcr-2015-213693] [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: 11/04/2022] Open
Abstract
A 63-year-old woman was admitted with a year's history of exertional breathlessness, anxiety attacks, syncopal episodes, diarrhoea, fatigue, reduced appetite, 2 stones weight loss, and flushing affecting her face and trunk. Investigations revealed raised urine 5-hydroxy indole acetic acid (5-HIAA) and chromogranin A. CT scan demonstrated extensive soft tissue encasing the major vessels intra-abdominally, and a retroperitoneal mass. (111)In-octreotide single-photon emission CT (SPECT CT) showed increased focal activity in the mediastinum, retroperitoneum and mesenteric lymph nodes. Para aortic lymph node biopsy confirmed the diagnosis of metastatic well-differentiated grade 1 gastrointestinal neuroendocrine tumour (NET). Extensive cardiac investigations confirmed severe mitral regurgitation, moderate aortic and tricuspid regurgitation, and mild pulmonary regurgitation. The patient's symptoms of flushing and diarrhoea were controlled with octreotide LAR, and she underwent mechanical aortic and mitral valve replacement. Following discharge from surgery, she went on to develop hydronephrosis and urosepsis, followed by infective endocarditis, resulting in recurrent admissions, and eventually passed away in her sleep nearly 14 months after her initial diagnosis.
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Affiliation(s)
- V Jahagirdar
- Department of Diabetes and Endocrinology, Birmingham Heartlands Hospital, Birmingham, UK
| | - Ali Kamal
- Department of Diabetes and Endocrinology, Birmingham Heartlands Hospital, Birmingham, UK
| | - R Steeds
- Department of Cardiology, Queen Elizabeth Hospital, Birmingham, UK
| | - John Ayuk
- Department of Endocrinology, Queen Elizabeth Hospital, Birmingham, UK
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Edwards NC, Yuan M, Nolan O, Pawade TA, Oelofse T, Singh H, Mehrzad H, Zia Z, Geh JI, Palmer DH, May CJH, Ayuk J, Shah T, Rooney SJ, Steeds RP. Effect of Valvular Surgery in Carcinoid Heart Disease: An Observational Cohort Study. J Clin Endocrinol Metab 2016; 101:183-90. [PMID: 26580239 DOI: 10.1210/jc.2015-3295] [Citation(s) in RCA: 23] [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: 02/09/2023]
Abstract
CONTEXT Carcinoid heart disease (NET-CHD) is associated with the development of symptom-limited exercise capacity and high rates of morbidity and mortality. OBJECTIVE This study sought to determine the survival, cardiac function, and functional class following surgery. DESIGN AND SETTING, AND PATIENTS This was a retrospective observational cohort study between 2005 and 2015 at a European Centre of Excellence for Neuroendocrine Tumours, Queen Elizabeth Hospital Birmingham. England consisting of 62 consecutive patients referred to the NET-Cardiology Service. INTERVENTIONS Subjects were assessed at referral using transthoracic echocardiography (with saline contrast) and transesophageal echocardiography, and 77% with confirmed NET-CHD underwent cardiovascular magnetic resonance imaging. Symptomatic patients with concomitant severe valvular dysfunction were referred for surgery with stable NET disease. MAIN OUTCOME MEASURE Survival of patients with proven NET-CHD following medical and surgical treatments was measure. RESULTS In total, 47/62 patients were diagnosed with NET-CHD. Thirty-two patients (68%) underwent surgery with bioprosthetic valve replacements in all subjects; tricuspid, n = 31; pulmonary, n = 30; mitral, n = 3; and aortic, n = 3. Four patients underwent concomitant coronary artery bypass grafting. There were 4 (13%) early post-operative deaths. One- and 2-y survival rates after surgery were 75 and 69% compared with 45 and 15% in un-operated patients. Post-operatively, functional class was improved (pre-New York Heart Association Classification [NYHA], 2.6 [0.5] vs post-NYHA, 1.7 [1.1]), P < .05, right-ventricular (RV) size was reduced (136 ml/m(2) [25] vs 71 ml/m(2) [7]; P < .01) with preserved RV ejection fraction (61% ± 9 vs 55% ± 10; P = .26). CONCLUSION Valve surgery improved functional class and resulted in RV reverse remodelling with improved survival rates at 2 y compared with those not proceeding to operation. These data highlight the importance of close collaboration between NET clinicians, cardiology, and cardiothoracic surgery teams. Early referral can improve functional capacity but more research is needed to define the selection of appropriate candidates and randomized data are needed to define the effect of surgery on prognosis.
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Affiliation(s)
- N C Edwards
- Departments of Cardiology (N.C.E., M.Y., O.N., T.A.P., R.P.S.), Anaesthesia (T.O., H.S.), Radiology (H.M., Z.Z.), Oncology (J.I.G.), Endocrinology (C.J.H.M., J.A.), Hepatology (T.S.), and Cardiothoracic Surgery (S.J.R.), Queen Elizabeth Hospital Birmingham, Birmingham B15 2TT, United Kingdom; and Department of Molecular and Clinical Cancer Medicine (D.H.P.), University of Liverpool, Liverpool L69 3BX, United Kingdom
| | - M Yuan
- Departments of Cardiology (N.C.E., M.Y., O.N., T.A.P., R.P.S.), Anaesthesia (T.O., H.S.), Radiology (H.M., Z.Z.), Oncology (J.I.G.), Endocrinology (C.J.H.M., J.A.), Hepatology (T.S.), and Cardiothoracic Surgery (S.J.R.), Queen Elizabeth Hospital Birmingham, Birmingham B15 2TT, United Kingdom; and Department of Molecular and Clinical Cancer Medicine (D.H.P.), University of Liverpool, Liverpool L69 3BX, United Kingdom
| | - O Nolan
- Departments of Cardiology (N.C.E., M.Y., O.N., T.A.P., R.P.S.), Anaesthesia (T.O., H.S.), Radiology (H.M., Z.Z.), Oncology (J.I.G.), Endocrinology (C.J.H.M., J.A.), Hepatology (T.S.), and Cardiothoracic Surgery (S.J.R.), Queen Elizabeth Hospital Birmingham, Birmingham B15 2TT, United Kingdom; and Department of Molecular and Clinical Cancer Medicine (D.H.P.), University of Liverpool, Liverpool L69 3BX, United Kingdom
| | - T A Pawade
- Departments of Cardiology (N.C.E., M.Y., O.N., T.A.P., R.P.S.), Anaesthesia (T.O., H.S.), Radiology (H.M., Z.Z.), Oncology (J.I.G.), Endocrinology (C.J.H.M., J.A.), Hepatology (T.S.), and Cardiothoracic Surgery (S.J.R.), Queen Elizabeth Hospital Birmingham, Birmingham B15 2TT, United Kingdom; and Department of Molecular and Clinical Cancer Medicine (D.H.P.), University of Liverpool, Liverpool L69 3BX, United Kingdom
| | - T Oelofse
- Departments of Cardiology (N.C.E., M.Y., O.N., T.A.P., R.P.S.), Anaesthesia (T.O., H.S.), Radiology (H.M., Z.Z.), Oncology (J.I.G.), Endocrinology (C.J.H.M., J.A.), Hepatology (T.S.), and Cardiothoracic Surgery (S.J.R.), Queen Elizabeth Hospital Birmingham, Birmingham B15 2TT, United Kingdom; and Department of Molecular and Clinical Cancer Medicine (D.H.P.), University of Liverpool, Liverpool L69 3BX, United Kingdom
| | - H Singh
- Departments of Cardiology (N.C.E., M.Y., O.N., T.A.P., R.P.S.), Anaesthesia (T.O., H.S.), Radiology (H.M., Z.Z.), Oncology (J.I.G.), Endocrinology (C.J.H.M., J.A.), Hepatology (T.S.), and Cardiothoracic Surgery (S.J.R.), Queen Elizabeth Hospital Birmingham, Birmingham B15 2TT, United Kingdom; and Department of Molecular and Clinical Cancer Medicine (D.H.P.), University of Liverpool, Liverpool L69 3BX, United Kingdom
| | - H Mehrzad
- Departments of Cardiology (N.C.E., M.Y., O.N., T.A.P., R.P.S.), Anaesthesia (T.O., H.S.), Radiology (H.M., Z.Z.), Oncology (J.I.G.), Endocrinology (C.J.H.M., J.A.), Hepatology (T.S.), and Cardiothoracic Surgery (S.J.R.), Queen Elizabeth Hospital Birmingham, Birmingham B15 2TT, United Kingdom; and Department of Molecular and Clinical Cancer Medicine (D.H.P.), University of Liverpool, Liverpool L69 3BX, United Kingdom
| | - Z Zia
- Departments of Cardiology (N.C.E., M.Y., O.N., T.A.P., R.P.S.), Anaesthesia (T.O., H.S.), Radiology (H.M., Z.Z.), Oncology (J.I.G.), Endocrinology (C.J.H.M., J.A.), Hepatology (T.S.), and Cardiothoracic Surgery (S.J.R.), Queen Elizabeth Hospital Birmingham, Birmingham B15 2TT, United Kingdom; and Department of Molecular and Clinical Cancer Medicine (D.H.P.), University of Liverpool, Liverpool L69 3BX, United Kingdom
| | - J I Geh
- Departments of Cardiology (N.C.E., M.Y., O.N., T.A.P., R.P.S.), Anaesthesia (T.O., H.S.), Radiology (H.M., Z.Z.), Oncology (J.I.G.), Endocrinology (C.J.H.M., J.A.), Hepatology (T.S.), and Cardiothoracic Surgery (S.J.R.), Queen Elizabeth Hospital Birmingham, Birmingham B15 2TT, United Kingdom; and Department of Molecular and Clinical Cancer Medicine (D.H.P.), University of Liverpool, Liverpool L69 3BX, United Kingdom
| | - D H Palmer
- Departments of Cardiology (N.C.E., M.Y., O.N., T.A.P., R.P.S.), Anaesthesia (T.O., H.S.), Radiology (H.M., Z.Z.), Oncology (J.I.G.), Endocrinology (C.J.H.M., J.A.), Hepatology (T.S.), and Cardiothoracic Surgery (S.J.R.), Queen Elizabeth Hospital Birmingham, Birmingham B15 2TT, United Kingdom; and Department of Molecular and Clinical Cancer Medicine (D.H.P.), University of Liverpool, Liverpool L69 3BX, United Kingdom
| | - C J H May
- Departments of Cardiology (N.C.E., M.Y., O.N., T.A.P., R.P.S.), Anaesthesia (T.O., H.S.), Radiology (H.M., Z.Z.), Oncology (J.I.G.), Endocrinology (C.J.H.M., J.A.), Hepatology (T.S.), and Cardiothoracic Surgery (S.J.R.), Queen Elizabeth Hospital Birmingham, Birmingham B15 2TT, United Kingdom; and Department of Molecular and Clinical Cancer Medicine (D.H.P.), University of Liverpool, Liverpool L69 3BX, United Kingdom
| | - J Ayuk
- Departments of Cardiology (N.C.E., M.Y., O.N., T.A.P., R.P.S.), Anaesthesia (T.O., H.S.), Radiology (H.M., Z.Z.), Oncology (J.I.G.), Endocrinology (C.J.H.M., J.A.), Hepatology (T.S.), and Cardiothoracic Surgery (S.J.R.), Queen Elizabeth Hospital Birmingham, Birmingham B15 2TT, United Kingdom; and Department of Molecular and Clinical Cancer Medicine (D.H.P.), University of Liverpool, Liverpool L69 3BX, United Kingdom
| | - T Shah
- Departments of Cardiology (N.C.E., M.Y., O.N., T.A.P., R.P.S.), Anaesthesia (T.O., H.S.), Radiology (H.M., Z.Z.), Oncology (J.I.G.), Endocrinology (C.J.H.M., J.A.), Hepatology (T.S.), and Cardiothoracic Surgery (S.J.R.), Queen Elizabeth Hospital Birmingham, Birmingham B15 2TT, United Kingdom; and Department of Molecular and Clinical Cancer Medicine (D.H.P.), University of Liverpool, Liverpool L69 3BX, United Kingdom
| | - S J Rooney
- Departments of Cardiology (N.C.E., M.Y., O.N., T.A.P., R.P.S.), Anaesthesia (T.O., H.S.), Radiology (H.M., Z.Z.), Oncology (J.I.G.), Endocrinology (C.J.H.M., J.A.), Hepatology (T.S.), and Cardiothoracic Surgery (S.J.R.), Queen Elizabeth Hospital Birmingham, Birmingham B15 2TT, United Kingdom; and Department of Molecular and Clinical Cancer Medicine (D.H.P.), University of Liverpool, Liverpool L69 3BX, United Kingdom
| | - R P Steeds
- Departments of Cardiology (N.C.E., M.Y., O.N., T.A.P., R.P.S.), Anaesthesia (T.O., H.S.), Radiology (H.M., Z.Z.), Oncology (J.I.G.), Endocrinology (C.J.H.M., J.A.), Hepatology (T.S.), and Cardiothoracic Surgery (S.J.R.), Queen Elizabeth Hospital Birmingham, Birmingham B15 2TT, United Kingdom; and Department of Molecular and Clinical Cancer Medicine (D.H.P.), University of Liverpool, Liverpool L69 3BX, United Kingdom
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Abstract
Acromegaly is a rare condition characterized by excessive secretion of growth hormone (GH), which is almost always due to a pituitary adenoma. Acromegaly is associated with significant morbidity such as hypertension, type 2 diabetes, cardiomyopathy, obstructive sleep apnoea, malignancy and musculoskeletal abnormalities. Acromegaly has also been associated with increased mortality in several retrospective studies. This review will focus on the epidemiological data relating to mortality rates in acromegaly, the relationship between acromegaly and malignancy, the role of GH and insulin-like growth factor-I in assessing the risk of future mortality, and the impact of radiotherapy and hypopituitarism on mortality.
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Affiliation(s)
- John McCabe
- Department of Endocrinology, Adelaide and Meath Hospital incorporating the National Children's Hospital, Tallaght, Ireland
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Grant P, Ayuk J, Bouloux PM, Cohen M, Cranston I, Murray RD, Rees A, Thatcher N, Grossman A. Response to 'How we define hyponatremia?'. Eur J Clin Invest 2015; 45:1218. [PMID: 26343423 DOI: 10.1111/eci.12515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 08/05/2015] [Indexed: 11/30/2022]
Affiliation(s)
- P Grant
- Royal Sussex County Hospital, Brighton, UK
| | - J Ayuk
- Department of Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
| | - P-M Bouloux
- Diabetes and Endocrinology, Royal Free London NHS Foundation Trust, London, UK
| | - M Cohen
- Diabetes and Endocrinology, Royal Free London NHS Foundation Trust, London, UK
| | - I Cranston
- Diabetes and Endocrinology, Portsmouth Hospitals NHS Trust, Queen Alexandra Hospital, Hampshire, UK
| | - R D Murray
- Department of Diabetes and Endocrinology, Leeds Teaching Hospitals NHS Trust, St James's University Hospital, Leeds, UK
| | - A Rees
- Department of Endocrinology and Diabetes, Cardiff University School of Medicine, Cardiff, UK
| | - N Thatcher
- Department of Medical Oncology, Christie Hospital, NHS Trust Manchester, Manchester, UK
| | - A Grossman
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, University of Oxford, Oxford, UK
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Grant P, Ayuk J, Bouloux PM, Cohen M, Cranston I, Murray RD, Rees A, Thatcher N, Grossman A. The diagnosis and management of inpatient hyponatraemia and SIADH. Eur J Clin Invest 2015; 45:888-94. [PMID: 25995119 PMCID: PMC4744950 DOI: 10.1111/eci.12465] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 05/16/2015] [Indexed: 12/22/2022]
Abstract
BACKGROUND Hyponatraemia is a very common medical condition that is associated with multiple poor clinical outcomes and is often managed suboptimally because of inadequate assessment and investigation. Previously published guidelines for its management are often complex and impractical to follow in a hospital environment, where patients may present to divergent specialists, as well as to generalists. DESIGN A group of senior, experienced UK clinicians, met to develop a practical algorithm for the assessment and management of hyponatraemia in a hospital setting. The latest evidence was discussed and reviewed in the light of current clinical practicalities to ensure an up-to-date perspective. An algorithm was largely developed following consensus opinion, followed up with subsequent additions and amendments that were agreed by all authors during several rounds of review. RESULTS We present a practical algorithm which includes a breakdown of the best methods to evaluate volume status, simple assessments for the diagnosis of the various causes and a straightforward approach to treatment to minimise complexity and maximise patient safety. CONCLUSION The algorithm we have developed reflects the best available evidence and extensive clinical experience and provides practical, useable guidance to improve patient care.
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Affiliation(s)
- Paul Grant
- Royal Sussex County Hospital, Brighton, UK
| | - John Ayuk
- Department of Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
| | - Pierre-Marc Bouloux
- Diabetes and Endocrinology, Royal Free London NHS Foundation Trust, London, UK
| | - Mark Cohen
- Diabetes and Endocrinology, Royal Free London NHS Foundation Trust, London, UK
| | - Iain Cranston
- Diabetes and Endocrinology, Portsmouth Hospitals NHS Trust, Queen Alexandra Hospital, Hampshire, UK
| | - Robert D Murray
- Department of Diabetes and Endocrinology, Leeds Teaching Hospitals NHS Trust, St James's University Hospital, Leeds, UK
| | - Aled Rees
- Department of Endocrinology and Diabetes, Cardiff University School of Medicine, Cardiff, UK
| | - Nicholas Thatcher
- Department of Medical Oncology, Christie Hospital, NHS Trust Manchester, Manchester, UK
| | - Ashley Grossman
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, University of Oxford, Oxford, UK
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43
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Trainer P, Newell-Price J, Ayuk J, Aylwin S, Rees A, Drake W, Chanson P, Brue T, Webb S, Fajardo C, Aller J, McCormack A, Torpy D, Tachas G, Atley L, Bidlingmaier M. A phase 2 study of antisense oligonucleotide therapy directed at the GH receptor demonstrates lowering of serum IGF1 in patients with acromegaly. ACTA ACUST UNITED AC 2015. [DOI: 10.1530/endoabs.37.gp.19.10] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Robins JM, Ayuk J, Trainer PJ, Newell-Price J. Stereotactic gamma knife radiosurgery as an effective treatment for acromegaly. J Am Coll Surg 2014. [DOI: 10.1016/j.jamcollsurg.2014.07.448] [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: 10/24/2022]
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Robins J, Ayuk J, Trainer P, Newell-Price J. Stereotactic Gamma Knife Radiosurgery is Effective for the Treatment of Acromegaly. Skull Base Surg 2014. [DOI: 10.1055/s-0034-1384025] [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: 10/20/2022]
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46
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Sherlock M, Reulen RC, Aragon-Alonso A, Ayuk J, Clayton RN, Sheppard MC, Hawkins MM, Bates AS, Stewart PM. A paradigm shift in the monitoring of patients with acromegaly: last available growth hormone may overestimate risk. J Clin Endocrinol Metab 2014; 99:478-85. [PMID: 24243636 DOI: 10.1210/jc.2013-2450] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [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] [Indexed: 11/19/2022]
Abstract
CONTEXT Acromegaly is associated with reduced life expectancy, which has been reported to be normalized if treatment is successful in controlling GH/IGF-I levels. OBJECTIVE Most previous studies have invariably used the last available GH/IGF-I, which may be biased as it only assesses exposure at a single point in time. We compared the last available GH/IGF-I analysis to a "time-dependent" and cumulative method, during follow-up to assess risk of mortality in the West Midlands Acromegaly study (n = 501). RESULTS Using the last available GH, there was a statistically significant increase in mortality comparing groups as low as GH ≤ 1 μg/L vs >1 μg/L (relative risks [RR] 1.8, P = .03). This was not the case when using the "time-dependent method," where only comparisons of GH values of GH ≤5 μg/L vs >5 μg/L were suggestive of being associated with an increased risk of mortality (RR = 1.5, P = .08). When the time-dependent GH method of analysis was used, the RR of mortality at each level was lower and the associated P value was less significant. Irrespective of using the last available or time-dependent method, when IGF-I was divided into levels according to quartile or arbitrary cutoffs, there was no significant increase in mortality with higher levels. CONCLUSIONS This study emphasizes the potential bias of using the latest available GH/IGF-I levels to predict mortality. Our study again highlights the limitations of IGF-I in predicting mortality.
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Affiliation(s)
- Mark Sherlock
- Endocrinology, Diabetes, and Metabolism (M.S., A.A.-A., J.A., M.C.S., P.M.S.), Division of Medical Sciences, University of Birmingham, Birmingham B15 2TH, United Kingdom; Centre for Childhood Cancer Survivor Studies (R.C.R., M.M.H.), School of Health and Population Sciences, Public Health Building, University of Birmingham, Birmingham B15 2TT, United Kingdom; Department of Endocrinology (J.A.), Queen Elizabeth Hospital Birmingham, Birmingham B152TH, United Kingdom; Department of Postgraduate Medicine (R.N.C.), University of Keele, Hartshill, Stoke-on-Trent ST4 7QB, United Kingdom; Birmingham Heartlands and Solihull National Health Service Trust (A.S.B.), Birmingham B9 5SS, United Kingdom; and Department of Endocrinology and Diabetes (M.S.), Adelaide and Meath Hospitals, Incorporating the National Children's Hospital and Trinity College, Dublin, Ireland
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47
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Abstract
Magnesium is one of the most abundant cations in the body and is essential for a wide variety of metabolically important reactions. Serum magnesium concentration is regulated by the balance between intestinal absorption and renal excretion. Hypomagnesaemia is relatively common, with an estimated prevalence in the general population ranging from 2.5 to 15%. It may result from inadequate magnesium intake, increased gastrointestinal or renal loss or redistribution from extracellular to intracellular space. Drug-induced hypomagnesaemia, particularly related to proton-pump inhibitor (PPI) therapy, is being increasingly recognized. Although most patients with hypomagnesaemia are asymptomatic, manifestations may include neuromuscular, cardiovascular and metabolic features. Due to the kidney's ability to increase fractional excretion to nearly 100% when the renal magnesium threshold is exceeded, clinically significant hypermagnesaemia is uncommon, generally occurring only in the setting of renal insufficiency and excessive magnesium intake. Symptoms include hypotension, nausea, facial flushing, ileus and flaccid muscle paralysis. In most cases, simply withdrawing exogenous magnesium is sufficient to restore normal magnesium concentrations, although occasionally administration of intravenous calcium or even dialysis may be required.
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Affiliation(s)
- John Ayuk
- Department of Endocrinology, Queen Elizabeth Hospital, Edgbaston, Birmingham, UK
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48
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Abstract
Serum magnesium concentration is determined by the interplay of intestinal absorption and renal excretion. Hypomagnesemia can occur as a result of insufficient magnesium intake, increased gastrointestinal or renal loss, or redistribution from extracellular to intracellular compartments. A number of drugs are known to cause hypomagnesemia, including proton pump inhibitors (PPIs). We report the case of a patient with symptomatic hypomagnesemia due to short bowel syndrome and PPI therapy. Investigations revealed low 24-hour urinary magnesium excretion and secondary hypocalcemia. PPI treatment was withdrawn and the patient was managed with intravenous and oral magnesium and calcium replacement. This teaching case provides an evidence-based discussion of the treatment of hypomagnesemia.
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Affiliation(s)
- John Ayuk
- Department of Endocrinology, Queen Elizabeth Hospital, Edgbaston, Birmingham, United Kingdom
| | - Neil J L Gittoes
- Department of Endocrinology, Queen Elizabeth Hospital, Edgbaston, Birmingham, United Kingdom.
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Hassan-Smith ZK, Sherlock M, Reulen RC, Arlt W, Ayuk J, Toogood AA, Cooper MS, Johnson AP, Stewart PM. Outcome of Cushing's disease following transsphenoidal surgery in a single center over 20 years. J Clin Endocrinol Metab 2012; 97:1194-201. [PMID: 22278423 DOI: 10.1210/jc.2011-2957] [Citation(s) in RCA: 113] [Impact Index Per Article: 9.4] [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: 02/13/2023]
Abstract
CONTEXT Historically, Cushing's disease (CD) was associated with a 5-yr survival of just 50%. Although advances in CD management have seen mortality rates improve, outcome from transsphenoidal surgery (TSS), the current first-line treatment, varies significantly between centers. OBJECTIVES The aim of the study was to define outcome including mortality in a cohort of CD patients treated with TSS over 20 yr. DESIGN We conducted a retrospective cohort study of 80 patients who underwent TSS to treat CD between 1988 and 2009. In 72 cases, data on clinical features and outcomes were collected from medical records. In eight patients, records were unavailable, but in all cases mortality data were obtained from National Health Service (NHS) registries and recorded as standardized mortality ratio. SETTING The study was conducted in a United Kingdom tertiary referral center. PATIENTS OR OTHER PARTICIPANTS Adult patients confirmed to have CD participated in the study. INTERVENTIONS All patients underwent TSS. MAIN OUTCOME MEASURE Patients were subdivided into groups based on disease response after initial treatment. Mortality according to subgroup was also assessed. RESULTS Median follow-up for clinical data was 4.6 yr. Three outcome groups were identified: cure, 72% (52 of 72); persistent disease, 17% (12 of 72); and disease recurrence, 11% (eight of 72). Median time to recurrence after initial remission was 2.1 yr (interquartile range, 1.3-3.1 yr). Mean follow-up for mortality was 10.9 yr. Thirteen of 80 patients had died: five of 52 in the cure group, two of eight in the disease recurrence group, two of 12 with persistent disease, and four of eight of those followed up by NHS registry search only. Overall, the standardized mortality ratio was 3.17 [95% confidence interval (CI), 1.70-5.43], whereas in the cure group it was 2.47 (95% CI, 0.80-5.77), and it was 4.12 (95% CI, 1.12-10.54) for disease recurrence/persistent disease groups. CONCLUSIONS We report long-term cure rates in excess of 70%. Mortality is increased in CD and may be higher in patients with persistent/recurrent disease compared to patients cured after initial treatment.
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Affiliation(s)
- Zaki K Hassan-Smith
- Centre for Endocrinology, Diabetes, and Metabolism, Institute for Biomedical Research, School of Clinical and Experimental Medicine, University of Birmingham, Birmingham B15 2TT, United Kingdom
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50
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Abstract
Radiotherapy for pituitary adenomas is a well-established and effective treatment, but it has been linked to a number of complications, including an increased risk of cerebrovascular disease and mortality. Possible underlying mechanisms include the direct effects of radiation on cerebral vasculature and deficiencies in specific pituitary hormones. Higher administered dose of radiotherapy is one of the main predictors of stroke. Although treatment strategies for stroke prevention in patients treated with pituitary radiotherapy have not been studied, using the lowest effective radiation dose and ensuring hormone deficiencies are adequately treated may be beneficial in reducing the risk of stroke.
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Affiliation(s)
- John Ayuk
- Department of Endocrinology, Queen Elizabeth Hospital, Edgbaston, Birmingham, UK.
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