Pituitary最新文献

Purpose: Acromegaly is a rare disease that can be challenging to treat due to residual pituitary adenoma after surgery or variable response to medical treatments. The primary aim of the study was to evaluate the path of treatment and long-term outcome of acromegaly after pituitary surgery.

Methods: Patients with acromegaly who had undergone surgery for a growth hormone-producing pituitary neuroendocrine tumor also known as a pituitary adenoma, at Sahlgrenska University Hospital between 1994 and 2019 were included in the study. Medical records from diagnosis to the end of study (November 2022) were reviewed for surgical outcome and treatment patterns related to acromegaly.

Results: In the cohort of 103 patients, 111 surgeries were performed. Mean follow-up duration was 12.7 (range: 0-37) years. Lesions were identified as a macroadenoma in 76 (76.8%) cases. At post-surgical follow-up until discharge from hospital, surgical complications and new pituitary hormone deficiency or syndrome of inappropriate antidiuretic hormone secretion occurred in 37% of cases. At 1-year post-surgery follow-up, 50% of evaluable patients achieved biochemical control of acromegaly. Of the 96 patients who had follow-up > 1 year, 53 (51.5%) had no additional medication for acromegaly after surgery until end of their follow-up. From diagnosis to the end of follow-up, 53 patients received medical therapy and seven were treated with radiotherapy.

Conclusion: About half of the patients had biochemical control of acromegaly 1-year post-surgery. Treatment patterns reflected the complexity of post-surgical management and provided an overview of the long-term clinical progression in patients with acromegaly following pituitary surgery.

Purpose: Adult growth hormone deficiency (AGHD) increases the prevalence of complications, including metabolic disorder, leading to increased cardiovascular mortality from cardiovascular diseases. However, no large database studies have evaluated AGHD patients without GH replacement therapy (GHRT). We investigated the prevalence of AGHD-related complications in patients without GHRT.

Methods: Patients with AGHD and associated complications were identified from the Medical Data Vision claims database using Japanese local disease codes mapped to ICD-10 codes. The prevalence of AGHD-related complications in 2020 was estimated to compare with the prevalence in the Japanese general population in the latest available year 2020. Risk factors for complications were evaluated by Kaplan-Meier curves and a Cox proportional hazard model.

Results: We identified 8,809 untreated patients with AGHD from April 2008 to September 2022, including 3,430 in 2020. In 2020, the prevalence of complications was higher in the AGHD population adjusted for sex and age than in the Japanese general population, e.g., diabetes mellitus, 9.3% vs. 3.6%; osteoporosis, 4.8% vs. 1.3%; and dyslipidemia, 22.0% vs. 3.9%. Age was a significant risk factor for most complications, and female sex for osteoporosis. Diabetes mellitus was a significant risk factor for dyslipidemia, ischemic heart disease, cerebrovascular disease, and all-cause death.

Conclusion: Untreated patients with AGHD have a higher prevalence of metabolic complications than the general population despite no difference in their related risk factors. Given the low use of GHRT in this study, comprehensive treatment approaches that include GHRT need to be considered to alleviate the risk of complications.

Introduction: Headache is common among patients diagnosed with pituitary adenoma (PA). There are still controversies regarding the headache presentation, pathophysiology and outcome after treatment in these patients.

Objectives: To determine the prevalence of headache among patients with PA, describe their phenotypes and identify precipitating factors. Also, to evaluate prospectively if PA treatment leads to headache improvement.

Methods: Treatment-naïve adult patients with PA were included. A questionnaire based on the beta version of the International Classification of Headache Disorders 3rd edition was created to classify the headaches. Patients submitted to surgery or medical treatment were reevaluated at least three to six months after treatment.

Results: Headache during the previous 3 months was present in 62% of the 104 patients. The most prevalent phenotypes were migraine and tension-type headache. Trigeminal autonomic cephalalgias (TACs) were observed only in prolactinoma patients. Both genders presented headache at similar rates (64% in females and 58% in males) but patients with headache were younger (41.5 ± 13.8 vs. 56.8 ± 13.6 years). Tumor characteristics were not determinant of headache. Patients with acromegaly that presented headache had higher GH levels. Headache was more frequent in prolactinomas (83%) than in NFPA (52%). After disease remission or control, resolution of headache was observed in 83%, 50% and 33% of the NFPA, somatotropinomas and prolactinomas, respectively.

Conclusions: Migraine and tension-type are the most common headache phenotypes in PA patients, and TACs were only observed in prolactinomas. Also, headache was more common in prolactinomas than in NFPA. GH levels were higher in patients with acromegaly that presented headache. Surgical and medical treatments completely resolve the headaches in 50% of the patients.

Purpose: Frailty indices are invaluable resources in risk stratification and predicting high-value care outcomes for neurosurgical patients. The Hospital Frailty Risk Score (HFRS) is a recently developed and validated method for evaluating frailty; however, its implementation has yet to be assessed in patients with non-functioning pituitary adenomas undergoing endoscopic endonasal resection. In this study, we aimed to evaluate HFRS's predictive ability for high-value care outcomes, namely postoperative complications, length of stay (LOS), and hospital charges, and to compare it to other traditionally used frailty indices.

Methods: A retrospective review of electronic medical records from 2017 to 2020. A total of 109 ICD-10 codes corresponding to various frailty-related conditions were used to identify the components of HFRS. These components were then used to calculate the HFRS for each patient, with higher scores indicative of elevated frailty. Standard multivariate logistic regression models were employed to explore the association between HFRS and high-value care outcomes. Model discrimination was assessed using the area under the ROC curves, and the DeLong test was used to compare AUCs.

Results: A total of 172 patients were included, with a mean age of 57.27 ± 12.95 years and an average HFRS score of 3.65 $\pm$ 3.27. Among patients, 56% were male, 5.2% experience postoperative complications, 23.3% endured extended LOS, 25.0% incurred high hospital charges. In multivariate regression models, greater HFRS was significantly and independently associated with postoperative complications (OR = 1.51, P < 0.001), extended LOS (OR = 1.17, P = 0.006) and high hospital charges (OR = 1.18, P = 0.004). HFRS had the highest AUC compared to other frailty indices and was the most parsimonious model, with AUC values of 0.82, 0.64, and 0.63 for predicting complications, extended LOS, and higher charges, respectively.

Conclusion: Higher HFRS scores are significantly associated with postoperative complications, prolonged LOS, and high hospital charges for patients undergoing pituitary surgery.

Purpose: Sarcopenic obesity (SO), a condition characterized by the coexistence of obesity and sarcopenia, has primarily been studied in elderly populations. However, it can also affect individuals with chronic diseases. This study aims to evaluate the prevalence of SO in patients with acromegaly.

Methods: Observational, cross-sectional study, involving patients with acromegaly followed at a tertiary center and controls matched for age and sex. Health assessment questionnaire, physical tests, body composition and bone mineral density assessment, were performed in all participants. SO was diagnosed using criteria from ESPEN and EASO Consensus Statements.

Results: 48 patients with acromegaly (acromegaly group - AG, 26 women, mean age 56.3 ± 11.6, mean BMI 31.3 ± 4.9) were compared to 48 controls (control group - CG, 26 women, mean age 56.7 ± 13.7, BMI 25.5 ± 4.7). Despite having greater total and appendicular lean mass, AG showed significant impairments in physical performance, particularly in strength, gait speed and balance (p < 0.05). The prevalence of SO in the AG was 16.7%, compared to 0% in the CG (p = 0.006), and positively correlated with increased fat mass and impaired physical performance.

Conclusions: SO is present in patients with acromegaly and is associated with notable functional impairments despite increased muscle mass.

Context: Despite prolactin´s (PRL) role in stimulating hematopoiesis, anemia is commonly observed in men with macroprolactinomas. However, hematological changes in men with microprolactinomas and women with prolactinomas remain unexplored, and the impact of erythropoietic alterations on quality of life (QoL) is still unclear.

Objective: To explore sex-related changes in red blood cell (RBC) parameters and their potential impact on QoL at initial diagnosis of prolactinoma and after normalization of PRL under dopamine agonists.

Design: Retrospective, monocentric study involving 205 patients with prolactinoma (127 women, 62%). The SF-36 QoL questionnaire was administered to 57 women and 34 men.

Results: In women, no significant changes in RBC parameters were observed at diagnosis or after PRL normalization, regardless the adenoma size. Conversely, men with microprolactinoma showed a significant increase in hematocrit (HCT) and hemoglobin (Hb) levels after PRL normalization (median HCT 42.3 vs.44.0%; Hb 14.5 vs. 15.1 g/dL; both p < 0.005). Men with macroprolactinoma exhibited similar improvements (HCT 40.2 vs. 43.9%; Hb 14.0 vs. 15.1 g/dL; both p < 0.0001). In men, hypogonadism was observed in 73% of patients at baseline, and in 11% after PRL normalization. In male patients where SF-36 was administered at diagnosis and after PRL normalization, energy improvement was observed (median 50 vs. 60, p < 0.05). While changes in Hb and HCT were not significantly impacting the QoL of women and men, persistence of hypogonadism after PRL normalization, negatively impacted all the QoL scores of men.

Conclusion: Patients with prolactinoma show sex-dependent changes in RBC parameters. Unlike women, men exhibit decreased HCT and Hb levels irrespective of adenoma size. Of note, the failure to recover from hypogonadism significantly affected the QoL of men.

Purpose: Prognostication of surgical complexity is crucial for optimizing decision-making and patient counseling in pituitary surgery. This study aimed to develop a clinical score to predict gross-total resection (GTR) in non-functioning pituitary adenomas (NFPAs) using externally validated machine-learning (ML) models.

Methods: Clinical and radiological data were collected from two tertiary medical centers. Patients had pre- and postoperative structural T1-weighted MRI with gadolinium and T2-weighted preoperative scans. Three ML classifiers were trained on the National Hospital for Neurology and Neurosurgery dataset and tested on the Foundation IRCCS Ca' Granda Polyclinic of Milan dataset. Feature importance analyses and hierarchical-tree inspection identified predictors of surgical complexity, which were used to create the grading score. The prognostic performance of the proposed score was compared to that of the state-of-the art TRANSSPHER grade in the external dataset. Surgical morbidity was also analyzed.

Results: All ML models accurately predicted GTR, with the random forest classifier achieving the best performance (weighted-F1 score of 0.87; CIs: 0.71, 0.97). Key predictors-Knosp grade, tumor maximum diameter, consistency, and supra-sellar nodular extension-were included in the modified (m)-TRANSSPHER grade. The ROC analysis showed superior performance of the m-TRANSSPHER grade over the TRANSSPHER grade for predicting GTR in NFPAs (AUC 0.85 vs. 0.79).

Conclusions: This international multi-center study used validated ML algorithms to refine predictors of surgical complexity in NFPAs, yielding the m-TRANSSPHER grade, which demonstrated enhanced prognostic accuracy for surgical complexity prediction compared to existing scales.

Aim: The differential diagnosis of cystic sellar/suprasellar lesions includes craniopharyngioma (CP) and Rathke's cleft cyst (RCC). Histological differentiation between cystic papillary craniopharyngioma (pCP) and RCC using light microscopy alone is challenging. A major point of difference is that virtually all pCPs are clonal for the BRAF V600E variant, whereas RCCs are not. Noting that BRAF testing of RCCs is not current standard practice, we hypothesised that routinely performing BRAF studies in RCCs might uncover otherwise missed pCPs.

Method: We performed a retrospective cohort study of all RCCs operated on at Flinders Medical Centre, the Memorial and Royal Adelaide Hospitals, between 2001 and 2023. In cases with sufficient tissue, we performed BRAF V600E immunohistochemistry (IHC) and BRAF next generation sequencing (NGS) of extracted tumour DNA.

Results: Of eleven patients with suitable operative specimens, one patient with an initial diagnosis of RCC was revised to pCP following BRAF testing with equivocal positivity on BRAF IHC and clear identification of the V600E variant on NGS. The patient's subsequent clinical course was aggressive and more compatible with pCP than RCC.

Conclusion: This study highlights the potential value of BRAF testing in RCCs to identify missed pCP, which is an especially timely finding given the advent of primary medical therapy with BRAF inhibition for pCP. In the absence of guidelines advising on the use of BRAF studies in sellar lesions, we suggest consideration of BRAF testing of all RCCs, particularly if there is squamous metaplasia or disease recurrence.

Background: Prolactinomas represent the most common pituitary adenoma subtype, the majority of which are microprolactinomas. Dopamine agonists (DAs) remain the first-line intervention for microprolactinomas, however, many patients either cannot tolerate DAs or require lifelong therapy to maintain hormonal control. As endoscopic endonasal surgery (EES) continues to revolutionize the surgical management of sellar lesions, we sought to reassess the feasibility and efficacy of early surgical resection for microprolactinoma.

Methods: Retrospective chart review from 2010 to 2021 of adults who underwent EES for microprolactinoma was performed across three medical centers. Surgical failure was defined as a need to restart DAs, a serum prolactin level greater than 30ng/mL at last follow-up, tumor recurrence, or a need for reoperation.

Results: A total of 56 patients were identified with a mean age of 32.9 years and an average of 26.4 months of follow-up. The majority had been on DAs preoperatively (98.2%). The most common surgical indications were DA intolerance (73.2%), tumor unresponsiveness (19.6%), and desire for pregnancy (7.1%). Gross total resection was achieved in 51 (91.1%) cases. The overall surgical remission rate was approximately 70% with failures observed in 17 (30.4%) patients. Multivariate logistic regression identified subtotal resection as the only independent predictor of surgical failure (p = 0.038*). The most common postoperative complication was transient arginine vasopressin deficiency (AVP-D) (21.4%). There were no cases of permanent AVP-D, new visual deficits, or cerebrospinal fluid leak.

Conclusions: With a surgical remission rate of nearly 70%, EES represents a safe and viable alternative strategy to long-term DA treatment for microprolactinomas.