Pituitary最新文献

Purpose: The giant pituitary adenomas (GPAs) are still a challenging surgical problem. They comprise 10-15% of operated pituitary adenomas. The advances of endoscopic techniques allow the resection of pituitary tumors previously operated by transcranial approaches. The aim of the study was to review the surgical results in a series of patients with GPAs (diameter ≥ 40 mm) operated with endoscopic endonasal approach.

Methods: The study is a retrospective analysis of a series of 176 patients (66 women and 110 men) treated from the 2007 to 2023 by the endoscopic transsphenoidal surgeries for GPAs (> 40 mm). The mean age of the patients was 57.0 years (20-81 years), and the mean follow-up period was 7.5 years (0-16 years). Forty patients had 1a grade of the Lyon's clinicopathologic classification, 7 patients - 1b, 111 patients - 2a, and 18 patients - 2b.

Results: The gross total resection was accomplished in 73 cases (41.5%). Extended endoscopic approaches were used in 11 patients (6.3%). The mortality rate was 2.3%. Postoperatively 60% of the patients showed varying improvement in visual field defects and visual acuity. The morbidity rate was 33.5%. During a mean 7.5 years follow-up there were 29 (15.9%) cases of recurrences.

Conclusion: Our results indicate that resection with endoscopic endonasal approach can be a safe and effective method for the treatment of patients with GPAs. It is the alternative for transcranial approaches.

Background: Water and electrolyte disorders (WED) are common after pituitary surgery, increasing morbidity and hospital stay. We report our single-centre experience, with emphasis on tolvaptan use for syndrome of inappropriate antidiuresis (SIAD).

Methods: This retrospective study analysed 82 patients with WED following pituitary adenoma surgery. Demographics, tumour features, and WED onset, duration, and management were reviewed.

Results: The median age at surgery was 30 years, with female predominance (69.5%) and majority had macro adenoma (62.1%). Cushing's disease was the most common etiology (54.8%). Isolated arginine vasopressin deficiency (AVP-D) was the most frequent WED (40.2%), followed by isolated SIAD (39%), biphasic response (18.2%), triphasic response (1.2%), and cerebral salt wasting (1.2%). Median onset of AVP-D and SIAD was post-operative day 1 and 4, respectively. There was an inverse correlation (r=-0.43, 0.002) between the day of SIAD onset and its duration. Thirteen patients received 25 doses of oral tolvaptan 7.5 mg. The median baseline serum sodium at tolvaptan initiation was 127 (125-130) mEq/L with a 24-hour increment of 5 (2-9) mEq/L. Serum sodium correction did not correlate with baseline sodium at which tolvaptan was administered (r=-0.29, p = 0.15), but a trend toward higher correction with later postoperative use was observed (r = 0.34, p = 0.09). Overcorrection (> 10 mEq/L/24 h) occurred in 2 patients (15.3%), and none developed osmotic demyelination.

Conclusion: Tolvaptan 7.5 mg may serve as an effective alternative treatment modality in moderate-to-severe SIAD patients.

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.