Pituitary最新文献

Purpose: To analyze the prevalence of hypertension in patients with acromegaly and assess the impact of acromegaly treatment on blood pressure (BP) outcomes.

Methods: Retrospective multicenter study of 434 patients with acromegaly surveilled at 25 tertiary hospitals in Spain and Portugal. The cohort was divided into two subgroups: patients with (n = 209) and without (n = 225) hypertension at the time of acromegaly diagnosis.

Results: Of the 434 patients, 209 (48.2%) had hypertension at the time of acromegaly diagnosis. Patients with acromegaly and hypertension were older and had a higher prevalence of cardiovascular disease and risk factors. A significant BP improvement was observed 3 months after pituitary surgery, with a marked reduction of the SBP (ΔSBP - 5.0mmHg, 95%CI -2.37 to -7.61) and DBP (ΔDBP - 2.2mmHg, 95% CI -0.66 to -3.75). Over a median follow-up of 8.4 years [IQR 4.8-12.8], 16% (n = 35/218) of initially normotensive patients developed hypertension, while 14.1% (n = 27/192) of hypertensive patients achieved hypertension remission. Hypertension remission was more likely in patients taking fewer antihypertensive drugs and with higher IGF1 levels at diagnosis, and in those who had a greater decrease in GH and IGF-1 after surgery.

Conclusion: At the time of acromegaly diagnosis up to 50% of patients have hypertension, and around 15% of them experience hypertension remission after pituitary surgery. The probability of remission is higher in patients with milder baseline hypertension and higher IGF-1 levels and in those achieving a greater postoperative decrease of GH and IGF-1.

Objective: Distinguishing between pituitary corticotropin (ACTH)-dependent Cushing disease (CD) and ectopic ACTH-dependent Cushing syndrome (EADCS) is diagnostically challenging. This study compared the diagnostic performance of bilateral inferior petrosal sinus sampling (BIPSS) and bilateral internal jugular vein sampling (BIJVS).

Methods: We retrospectively reviewed 109 patients at Mayo Clinic (1998-2018) who underwent simultaneous BIPSS and BIJVS. Eighty-four patients proceeded to pituitary surgery based on BIPSS results, and 81 ultimately received confirmed diagnoses: 74 with CD and 7 with EADCS. Sensitivity and specificity were calculated using pre- and post-corticotropin-releasing hormone (CRH) stimulation criteria.

Results: BIJVS was positive in 35/74 CD patients at baseline and 59/74 post-CRH, compared with 68/74 and 72/74, respectively, for BIPSS. Combined pre- and post-CRH criteria yielded 82% sensitivity and 86% specificity for BIJVS, compared with 100% sensitivity and specificity for BIPSS.

Conclusion: BIPSS is superior to BIJVS for establishing the source of ACTH hypersecretion in ACTH-dependent Cushing syndrome. BIJVS demonstrates limited diagnostic utility in clinical practice.

Purpose: Data on mortality risk in patients with hyperprolactinemia is limited. This study aimed to evaluate all-cause mortality in a cohort of dopamine agonist (DA)-treated patients with hyperprolactinemia.

Methods: A nationwide retrospective study (2000-2023) using the Clalit Health Services database evaluated all-cause mortality in patients with DA-treated hyperprolactinemia, matched 1:5 with controls by age, sex, socioeconomic status, and BMI. The primary outcome was all-cause mortality. Secondary outcomes included the impact of hyperprolactinemia severity, prolactin (PRL) normalization, and other mortality risk factors.

Results: The study included 2,492 patients with hyperprolactinemia (mean age ± SD:38.7 ± 14.8 years, 59.6% women) and 12,456 controls (38.7 ± 14.8 years, 59.6% women). Over > 17 years of follow-up, 182 patients (7.3%) and 936 controls (7.5%) died (HR = 0.972, 95% CI 0.829-1.139), with similar mean age at death. Causes of death in both groups were mainly infectious, cardiovascular, and malignancies. Compared to controls, patients achieving PRL normalization within 1 year had lower mortality (HR = 0.730), while those without normalization had similar risk. Patients with baseline PRL < 5×ULN had lower mortality (6.9% vs. 7.9%, HR = 0.725) than those with ≥ 5×ULN. Mortality was higher in men than in women with hyperprolactinemia but not versus controls. Independent predictors for all-cause mortality included older age, higher BMI, male sex, heart failure, malignancy, hypertension, diabetes, and ischemic heart disease.

Conclusion: All-cause mortality in patients with DA-treated hyperprolactinemia is not increased compared to matched controls, however is higher in men vs. women. Mortality is primarily influenced by age, sex, BMI, and comorbidities. Achieving PRL normalization within a year decreases mortality compared with controls.

Purpose: We evaluated the effectiveness of a less invasive skull base reconstruction technique using a fibrin glue-soaked gelatin sponge (FGGS) and collagen matrix to prevent cerebrospinal fluid (CSF) leakage following endoscopic transsphenoidal surgery (ETSS). This approach minimizes the need for fascia harvesting and the use of nasoseptal flaps.

Methods: We retrospectively analyzed data from 558 ETSS, excluding Rathke's cleft cysts, performed at our institution. Surgeries were classified by intraoperative CSF leakage grade according to Esposito's classification. Patients' characteristics and intraoperative findings were analyzed to assess potential risk factors for postoperative CSF leakage. Postoperative CSF leakage rates were compared between the pre-collagen matrix (428 surgeries) and collagen matrix (130 surgeries) periods.

Results: FGGS-based reconstruction without fat grafts was performed in 73.7% of surgeries, including 99.4% of grade 0 and 88.5% of grade 1 leaks. Nasoseptal flaps were used in only eight surgeries (1.4%), and fascia was not used at all, either for watertight dural suturing or for multilayer reconstruction. The overall postoperative CSF leakage rate was 1.8% (10/558). The leakage rates by intraoperative CSF leak grade were 0%, 1.7%, 5.6%, and 1.1% for grades 0, 1, 2, and 3, respectively. Postoperative CSF leakage was associated with unfamiliar techniques and excessive bucking during extubation. During the collagen matrix period, although 33.8% of surgeries involved grade 3 high-flow CSF leaks, only one surgery (0.8%; 1/130) resulted in postoperative CSF leakage.

Conclusions: As a less invasive technique, skull base reconstruction using FGGS and/or a collagen matrix was effective in reducing postoperative CSF leakage.

Background: Pituitary adenomas are common, and transsphenoidal surgery remains the standard treatment for symptomatic cases. While most postoperative complications are well described, symptomatic arterial vasospasm after pituitary surgery is exceptionally rare but potentially life-threatening, and no consensus exists regarding its management.

Methods: A systematic review was conducted following PRISMA 2020 guidelines across PubMed, Embase, Cochrane Library, Springer Nature, Academic Search Premier, JAMA Network, MEDLINE Complete, and ScienceDirect, without date restrictions. Eligible studies included case reports and reviews describing postoperative arterial vasospasm after pituitary adenoma surgery. Extracted data included demographics, tumor characteristics, surgical approach, presentation, diagnosis, treatment, and outcomes.

Results: Of 180 records screened, 28 met inclusion criteria, representing 40 patients, supplemented by one case from our series. In total, 41 patients were analyzed. Most tumors were macroadenomas (mean size 39 mm), with 80% treated via a transsphenoidal approach. Intraoperative cerebrospinal fluid leakage occurred in 84%, and postoperative sellar hematoma or subarachnoid hemorrhage in 94%. Vasospasm typically developed around day 7 (mean 7.3 days), most often presenting with motor deficits or decreased consciousness, and consistently involved the anterior circulation, frequently affecting multiple vessels. Management strategies included triple-H therapy (68%), nimodipine (46%), and angioplasty (44%). Outcomes were poor, with 22.5% mortality, 32.5% residual deficits, and only 45% discharged without sequelae.

Conclusion: Symptomatic arterial vasospasm following pituitary surgery is rare but life-threatening. Intraoperative CSF leakage, sellar hematoma, or postoperative subarachnoid hemorrhage appear to increase risk. Vigilant monitoring and early, aggressive management following principles of aneurysmal subarachnoid hemorrhage are essential to optimize outcomes.

Clinical relevance statement: Symptomatic arterial vasospasm after pituitary surgery, though rare, carries a high risk of mortality and long-term disability, making early recognition and aggressive management in high-risk patients essential to improving outcomes.

Purpose: Reduction in exercise capacity and peak oxygen uptake (V̇O₂) are common in acromegaly, but ventilatory alterations during exercise remain unstudied. We evaluated the exercise ventilatory response in terms of efficiency in patients with acromegaly.

Methods: We prospectively evaluated 10 patients with acromegaly in a phase of disease control. To minimise confounders related to ventilatory response and anthropometric differences, acromegalic patients were matched with 10 control subjects according to age, body mass index, and body surface area. Chronic diseases, any cardio-respiratory condition likely to alter ventilatory response, and evidence of cardiac dysfunction were excluded. Pulmonary function tests and maximal cardiopulmonary exercise testing were performed. Ventilatory response was assessed via minute ventilation (V̇_E)/carbon dioxide(CO₂) output slope (V̇_E/V̇CO_2slope) and end-tidal carbon dioxide pressure (PETCO₂). Exercise ventilatory inefficiency (EVin) was defined according to reference values for healthy individuals.

Results: No alterations in lung function were observed in either group. Compared with controls, patients with acromegaly showed lower power output and V̇O₂ at peak (1.38 ± 0.20 vs. 1.90 ± 0.64 L·min^-1; p = 0.033). Breathing patterns were similar to those of controls, but acromegalic patients exhibited higher values of V̇_E/V̇CO_2slope (31.8 ± 3.7 vs. 28.0 ± 2.7; p = 0.018), lower PETCO₂ at peak (31.1 ± 5.3 vs. 36.9 ± 3.0 mmHg; p = 0.008), and a greater prevalence of EVin (60% vs. 10%; p = 0.019). No correlations emerged between ventilatory inefficiency and biochemical or clinical variables.

Conclusion: Patients with acromegaly display ventilatory inefficiency during exercise. These findings suggest subclinical alveolar-capillary impairment or altered CO₂ chemosensitivity. Exercise testing may help unmask these abnormalities, supporting its role in risk stratification and rehabilitation planning.

Purpose: To investigate nervous and vasculare structure of retina in naïve acromegaly patients using Spectral Domain Optical Coherence Tomography (SD-OCT) and Optical Coherence Tomography Angiography (OCTA).

Methods: Prospective case-control study. Twenty-four eyes of 12 naïve acromegaly patients (8 men, 4 women, mean age 49.1 ± 12.3 years) without chiasmal compression by pituitary adenoma and 24 eyes of 12 healthy controls were evaluated in this study. In both groups were performed SD-OCT, to assess ganglion cell complex (GCC) and retinal nerve fiber layers (RNFL) thickness, and OCTA, to assess the vessel density (VD) of the superficial capillary plexus (SCP), deep capillary plexus (DCP), radial peripapillary capillary (RPC) and choriocapillaris (CC). In patient group, OCT parameters were correlated to hormonal (GH, IGF-I) and metabolic (glucose and lipid profile) parameters.

Results: GCC (p = 0.001) and RNFL average (p = 0.007) were significantly lower in patients than in controls. At the regression analysis, adenoma volume (p < 0.001) and diagnostic delay (p < 0.001) before diagnosis were the best predictor of GCC and RNFL average, respectively. VD in SCP (p < 0.001), DCP (p = 0.009), and RPC (p = 0.03) was significantly lower in patients as compared to controls. VD in RPC was significantly lower in patients with diagnostic delay above 8.5 years (median, p = 0.009) and fasting glucose above 90 mg/dl (median, p = 0.04) as compared to those below.

Conclusion: As acromegaly patients exhibited an impairment either in nervous and in vascular retinal structure at diagnosis, even in the absence of chiasmal compression, SD-OCT and OCTA may represents potential tools to detect retinal damage in these patients.

Purpose: Clinical screening systems (CSSs) for Cushing syndrome (CS) validated in Europe have not been evaluated for CS or Cushing disease (CD) in the United States (US). We aimed to evaluate existing CSSs in US patients and develop two new symptom-based CSSs to identify patients with high pre-test probability of disease warranting referral for definitive biochemical workup-one for broad CS screening and one specifically for CD.

Methods: Data were obtained from the Registry of Adenomas of the Pituitary and Related Disorders (RAPID)-comprising 615 patients who underwent transnasal transsphenoidal resection for CD at one of 11 US pituitary centers, the Centers for Disease Control and Prevention's 2019 National Health Interview Survey (NHIS)-comprising 31,997 US respondents, and a single institution CD-NFA cohort-comprising 468 US patients diagnosed with either CD (n = 385) or nonfunctioning adenoma (n = 83). The RAPID Community Cushing CSS was derived from differences between the RAPID and NHIS cohorts, and the RAPID CD CSS from differences between patients with CD versus NFA.

Results: In external validation using US-based cohorts, the RAPID Community CSS achieved an AUC of 0.707, compared to the Spanish (AUC = 0.691) and Italian (AUC = 0.685) models, and the RAPID CD CSS demonstrated greater external sensitivity (0.836, threshold = 0.5) at the Youden-optimized threshold than the Spanish (0.605, threshold = 4) and Italian (0.735, threshold = 6) CSSs.

Conclusions: In US patient populations, the RAPID Community Cushing CSS demonstrated superior discriminative ability for CD compared to the Italian and Spanish CSSs, and the RAPID CD CSS achieved the highest sensitivity for CD among all CSSs evaluated.