Functional Adenomas Research Articles

Clinical parameters and postoperative outcomes of pituitary adenomas in children: Analysis according to size of adenomas and adopted surgical procedures.

Pathologies of pediatric pituitary adenomas are uncommon and challenging to diagnose. Pituitary adenomas cause mass effects and neurological disruption in children. Postoperative evaluations of endocrine functions are challenging. The present study categorized adenomas by size and type, and evaluated outcomes based on the surgical procedures adopted. In addition, the present study analyzed the demographic parameters of children as well as the factors supposed to be influencing remission. Clinical characteristics, treatment parameters and postoperative outcomes of curative surgeries in 135 children [80 (59%) females and 55 (41%) males; age 12 (11-13) years at the time of first diagnosis] with pituitary adenomas who underwent curative surgeries operated between 1998 and 2023 in the Yichang Central People's Hospital, (Yichang, China) were included in the present retrospective study. A total of 112 (83%) children had microadenomas (<10 mm adenomas), 6 (4%) had macroadenomas (≥10 mm adenomas) and 17 (13%) had invisible adenomas. Pathological examination revealed that 59 (44%) children had functional adenomas and 10 (7%) had non-functional adenomas. Among functional adenomas, acromegaly (excess secretion of insulin-like growth factor 1) was reported to be the most common [30 (22%)] pediatric adenomas, followed by prolactinomas [prolactin secretion ≥1,000 mIU/l; 20 (15%) and Cushing syndrome (9 (7%)]. A total of 23 (17%), 3 (2%), 4 (3%), 3 (2%) and 3 (2%) children were reported to have remission and underwent re-surgery. These patients (remission) underwent microscopic trans-sphenoidal resection, endoscopic endonasal trans-sphenoidal resection, trans-sphenoidal resection alone, bilateral adrenalectomy and gross total resection adopted curative surgeries initially, respectively. Postoperative diabetes insipidus, adrenal insufficiency and cerebrospinal fluid leaks have been reported in children who have undergone curative surgeries for macroadenomas or Cushing syndrome. Female pediatric patients with clinical manifestations were more likely to have pituitary adenomas. Pediatric patients generally have functional pituitary adenomas, particularly adreno-corticotropin-secreting adenomas. Microscopic trans-sphenoidal resection is associated with a lower risk of under-treatment. Postoperative outcomes and clinical benefits of curative surgeries are based on the complete type of surgical removal and size of the pituitary adenomas mass (Level of Evidence: 3; Technical Efficacy Stage: 4).

Two-hit model for the development of aldosterone-producing adenoma: supporting from two new cases.

Recently, a two-hit model for the development of aldosterone-producing adenoma (APA) was proposed but until now, only two cases supporting the model have been reported. Here, we present two new cases of primary aldosteronism (PA), both of which had large functional adenomas with somatic mutations in aldosterone-driving genes. Furthermore, the first patient, who had a history of colorectal cancer, was found to have a germline and an additional somatic mutation in APC, and APC inactivation was confirmed by immunohistochemistry. The other patient had pathogenic somatic mutation inCTNNB1. These pro-proliferation mutations resulted in abnormal activation of the Wnt/β-catenin pathway. Two consecutive events apparent in these patients, namely, the first event leading to cell proliferation and the second driving hormonal hypersecretion, supported the two-hit model of APA development. The two-hit model usually occurs in the larger adenomas, and the driving factors of the first hit that promote cell proliferation still require further research and exploration.

PATTERNS OF RADIOTHERAPY PRACTICE FOR FUNCTIONING PITUITARY TUMOURS - A SURVEY OF UK CENTRES

Abstract AIMS Pituitary adenomas are benign tumours that are classified as functioning or non-functioning based on the production of excess pituitary hormones. Functioning adenomas (FA) typically present as hypersecretory syndromes including acromegaly and Cushing’s disease. In FA, radiotherapy is used when surgery fails to achieve hormone normalisation and/or when medical treatment does not control hormone excess. In the absence of prospective studies that clearly define the optimal radiotherapy technique in FA, it is expected that there will be variability in practice. A survey of UK neuro-oncology centres was undertaken, aiming to establish the extent of this variability in FA. METHOD A survey was distributed electronically to 20 neuro-oncology departments across the UK. Data were collected on patient numbers, radiotherapy indications, techniques, dosing, and target volume delineation. RESULTS Responses were received from eight centres (40% response rate), treating a total of approximately 32 FA per annum. There was variability in techniques employed to treat FA. While four centres treated most FA with IMRT, two treat most with stereotactic radiosurgery (SRS), and two with fractionated stereotactic radiotherapy (fSRT). The most common dose used for IMRT treatment was 45Gy in 25 fractions (n=7), with 50.4Gy in 28 fractions, 50Gy in 30 fractions and 54Gy in 30 fractions also reported. Use of margins around residual disease (n=5) and inclusion of involved cavernous sinuses and surgical tract (n=3) within clinical target volumes also varied. Most centres (n=7) would agree to a change in target volume delineation practices for the purpose of a clinical trial in FA. CONCLUSION This survey found that there is variability in radiotherapy dosing, technique, and target volume delineation practices for radiotherapy to FA across the UK. All centres but one would accept changes in their practice within the context of a prospective clinical trial of radiotherapy for FA.

PCSK1N as a tumor size marker and an ER stress response protein in corticotroph pituitary adenomas.

Silent corticotroph adenoma (SCA) exhibits more tumor aggressiveness features than functioning adenomas (FCA). We aimed to investigate PCSK1N expression in CA and examine if ER stress-induced responses affect cell survival in a corticotroph tumor cell model. Clinical and imaging characteristics were recorded in 33 patients with FCA (20 women, 11 macroadenomas) and 18 SCA (8 women, all macroadenomas). Gene expression of proopiomelanocortin (POMC), T-box transcription factor 19(TBX19)/TPIT, proprotein convertase subtilisin/kexin type 1(PCSK1)/PC1/3, and its inhibitor PCSK1N, was measured by RT-qPCR in adenoma tissue.Mouse pituitary corticotroph tumor (AtT-20) cells were treated with tanespimycin (17-AAG), a HSP90 chaperone inhibitor, to induce ER stress, followed by gene and protein analyses. POMC, TPIT, and PCSK1 expression were higher, whereas PCSK1N was lower in FCA compared to SCA. PCSK1N correlated with POMC (rs= -0.514, p <0.001), TPIT (rs= -0.386, p = 0.005), PCSK1 (rs= -0.3691, p = 0.008), and tumor largest diameter (rs= 0.645, p <0.001), in all CA. Induction of ER stress by 17-AAG in AtT-20 cells led to a decrease of POMC and an increase of PCSK1N gene expression at 24h. Moreover, a downregulation of cell cycle, apoptosis, and senescence pathways, and alterations in cell adhesion and cytoskeleton were observed at the protein level. PCSK1N is higher in SCA compared with FCA, and associated with corticotroph cell markers and tumor size. PCSK1N is likely to be part of the adaptive response to ER stress, potentially conferring a survival advantage to the corticotroph tumor cell in conjunction with other proteins.

Combined Endonasal and Transseptal Approach to Achieve Binostril Access in Endoscopic Skull Base Approaches to Minimize Nasal Morbidity: A Technical Note

IntroductionOver the years, feasibility & safety of EEAs has become well established & the focus has now shifted to minimising the nasal morbidity. To this end, several modifications in nasal stage have been described that have focussed primarily on preservation of nasal mucosa on right side of nasal cavity (NC). However, the issue of nasal mucosal preservation on left side of NC has largely been ignored. In this paper, the author describes a modified technique that can eliminate mucosal damage in left NC. MethodIn modified technique, trans-septal approach is utilised on left & endonasal on right side. A hemitransfixion incision is used to raise left submucosal tunnel. The mucosa of tunnel lies laterally in apposition with lateral nasal wall, thereby protecting it from injury by repeated passage of instruments. When tunnel mucosa is pushed back medially, left NC appears absolutely normal without any evidence of mucosal damage. ResultsCombined endonasal & trans-septal technique for nasal stage was performed in 51 patients with sellar/suprasellar lesions. Nonfunctional pituitary adenomas were the most common pathology (macroadenomas-n=14; Giant adenomas-n=10) followed by functional adenomas (acromegaly-n=10; prolactinomas- n=3; Cushings’s disease- n=1), craniopharyngiomas (n=6), clival tumours (n=5), & tuberculum sella meningiomas (n=2). ConclusionsA combination of endonasal and trans-septal approaches utilises the advantages of both endoscopic & microscopic approaches sans the disadvantage of restricted space seen in microscopic approaches. It makes binostril approach least disruptive to left nasal mucosa & thus can reduce overall morbidity of EEAs.

Comparative study on clinicopathological characteristics of functional and non-functional subtypes in pituitary adenomas

BackgroundPituitary adenomas comprise clinical and pathological characteristics of functional and non-functional subtypes. To enhance our understanding of diagnostic presentations, our study aimed to know the clinicopathological characteristics of pituitary adenomas of both functional and non-functional subtypes. The purpose of our study was to investigate the clinicopathological characteristics of pituitary adenomas, including demographic characteristics, clinical presentations, hormone secretion patterns, invasiveness, and cellular characteristics.MethodsA total of 41 cases of pituitary adenomas were analyzed, with 63.4% classified as non-functional adenomas (NFPA) and 36.6% as functional adenomas (FPA). Clinical presentations vary, with vision loss and headaches commonly occurring in both NFPA and FPA. In FPAs, serum hormone levels varied and were categorized into growth hormone-secreting (53.3%), ACTH-secreting (26.7%), PRL-secreting (13.3%), and FSH-secreting (6.7%) subtypes. Moreover, clinical presentations in FPA included diplopia, giddiness, vomiting, ptosis, and limb weakness. Clinical features varied across subtypes, with acromegaly in growth hormone-secreting adenomas, moon facies and weight gain in ACTH-secreting adenomas, poor facial growth in PRL-secreting adenomas, and vision loss in FSH-secreting adenomas. Meanwhile, NFPA were predominantly macroadenomas (88.5%) and exhibited various morphological patterns.ResultsThe proliferation index is higher in functional adenomas (mean 1.32) as compared to non-functional (mean 0.91). Clinical presentations varied across functional and non-functional adenomas. Growth hormone-secreting adenomas were the most common functional subtype, while LH and null cell adenomas were common non-functional subtypes. Two cases were invasive adenomas with a low Ki67 index. Sheets were the most common morphological pattern. PCA analysis revealed significant differences between the two groups, with PC 1 explaining 92.111% of the variance.ConclusionsOur study elucidates the clinicopathological characteristics of pituitary adenomas, highlighting significant differences between functional and non-functional subtypes. These findings underscore the importance of tailored diagnostic and management strategies to optimize outcomes for patients with pituitary adenomas.

Adrenal washout CT in patients with no history of cancer: a waste of time?

PurposeTo validate the diagnostic performance of adrenal washout CT in patients without known malignancy in a Western Australian population.MethodsA radiology information system (RIS) search for CT reports containing “adrenal” and “washout” across six networked metropolitan public hospitals between January 2005 and November 2021. Homogenous nodules ≥ 1 cm, ≥ 10 HU without a suspected functional component in patients without a history of malignancy were included. Reported absolute and relative washout percentages were recorded and re-measured from unenhanced, 60-s portal venous and 15-min delayed phase imaging and compared to either histopathological or CT follow up for growth (≥ 12 months) reference standards.Results2653 studies were screened with 191 meeting inclusion criteria. 105 nodules underwent washout CT and then had either histopathological (12 patients) or CT follow up (93 patients) reference standards available.Reported absolute washout (aWO) estimated sensitivity and specificity for malignant/indeterminate nodules was low at 33% (95% CI 25–43%) and 77% (95% CI 68–84%) respectively. Reported relative washout (rWO) sensitivity and specificity were 56% (95% CI 46–65%) and 69% (95% CI 60–77%) respectively. Negative predictive values for both aWO and rWO were reassuring at 92% (95% CI 86–96%) and 94% (95%CI 88–97%).ConclusionOur study validates a recent report suggesting that adrenal washout has poor sensitivity for and consequent limited utility to exclude malignancy in patients with no cancer history. However, patients with incidental adrenal nodules < 4 cm in size with benign washout can be reassured by the high negative predictive value and worked up to exclude functional adenoma and re-imaged in a year to confirm no growth.Graphical

The Evolution of Pituitary Surgery in an Australian Health Care Framework

Abstract Background The outcomes in pituitary surgery have dramatically changed over the past 130 years. Endoscopic endonasal transsphenoidal approaches are now an accepted method for operating on pituitary tumors, a skillset which takes time to develop. The Australian health care framework provides a unique mixture of public and private care for a geographically dispersed population. In this article, we aim to examine how outcomes for patients in South Australia changed as endoscopic pituitary surgery was adopted and how the Australian health care framework influenced the development of a skull base team. Methods The case notes of all patients undergoing pituitary surgery between 2006 and 2020 in South Australia. All patients treated by this author group were included. Results A total of 428 pituitary adenomas were surgically treated. Overall, 182 out of 249 patients (70%) had a complete resection with no recurrence at follow-up, and 49 patients (19%) had a residual that was observed and did not require treatment. Therefore, 89% of patients between the years 2006 and 2020 did not require any further treatment following their pituitary surgery. Upon examination of the 142 patients with functional adenomas, 112 (79%) patients had no recurrence in hormonal dysfunction following surgery, and the remaining 30 (21%) patients required further treatment. Conclusion We have demonstrated that acceptable outcomes can be achieved in a low-to-moderate volume setting across multiple hospitals when a coordinated effort is made to consolidate these cases within a small group of subspeciality-trained surgeons, as opposed to a more generalist approach.

500 Endoscopic Endonasal Resection of the Medial Wall of the Cavernous Sinus: Initial Experience and Impact on Pituitary Surgery Outcomes

INTRODUCTION: Invasion of the medial wall of the cavernous sinus (CS) by pituitary tumors is a factor associated with persistence of disease and subtotal resection of these tumors. Resection of the medial wall of the CSis therefore an option for maximum resection of such tumors, however, there is concern with potential complications associated with this technique and at this time, limited data is available in the literature. METHODS: Single center retrospective study evaluating patients that underwent endoscopic endonasal resection of pituitary adenomas and resection of the medial wall of the CS, between January 2022 and February 2023. Extent of resection, remission rates, complications and histopathological diagnosis were assessed. RESULTS: Out of a population of 120 pituitary surgeries, sixteen cases were eligible for this study. 5 (31.2%) patients had non-functional adenomas, and 11 (68.7%) had functional adenomas, including 4 adrenocorticotropic hormone, 3 prolactin, 3 growth-hormone, 1 pluri-hormonal (GH and prolactin)—secreting tumors. Complete tumor resection, based on intraoperative impression and postoperative MRI, was achieved in all cases. At last follow-up, complete biochemical remission (using current criteria) was seen in 11 cases (100%) of functional adenomas. One case developed pulmonary embolism and another one sino-nasal infection postoperatively. No fatalities, carotid injuries or cranial nerve palsies were reported. CONCLUSIONS: Resection of the medial wall of the cavernous sins, performed when there is potential tumor extension into the medial wall, is associated with high rates of disease control. It is particularly useful in cases of functioning but also has a role in non-functional adenomas adherent to the medial wall of the CS. Long term follow up is necessary to evaluate the durability of these results.

1235 Using Supervised Machine Learning to Validate a Novel Scoring System for the Prediction of Disease Remission of Functional Adenomas Following Transsphenoidal Resection

INTRODUCTION: Functional pituitary adenomas are common primary central nervous system tumors with potent systemic endocrinological effects. Postoperatively, remission rates range from 65-98%. METHODS: 392 adult patients who underwent primary resection of a functional pituitary adenoma at the three Mayo Clinic between 2006-2022 were retrospectively reviewed. Multivariate logistic regression was performed to identify variables predictive of disease remission. Variables found statistically significant on multivariate analysis were incorporated into our proposed pituitary-SCHEME score. Machine learning models were implemented to compare the accuracy of the pituitary-SCHEME score against the multivariate models. After training (314 patients) and cross-validation of the machine learning models, an independent testing set of 78 patients was performed. SPSS V27 and R4.2.1 were used for statistical analyses. RESULTS: 261 (66.6%) patients achieved post-operative biochemical remission. On multivariate analysis gross-total resection and Knosp-Grade 0,I,II adenomas were predictive of disease remission following resection, while macroadenomas (adenoma &gt; 10mm), male sex, mammosomatotroph and Mixed Growth-Hormone + Prolactin adenomas were predictive of continued disease. In machine learning models, without Pituitary-SCHEME score, the K-Nearest Neighbors (KNN) model achieved the highest accuracy at 75.6% followed by Naive Bayes model. An increase in model sensitivity was achieved with inclusion of Pituitary-SCHEME score with the Linear-Discriminant-Analysis (LDA) model achieving the highest accuracy at 86.9%, followed by the Classification and Regression Trees (CART) model. The random forest model had the largest AUC-ROC among models with and without pituitary-SCHEME score. Model prediction accuracy (with vs. without pituitary-SCHEME score) were found to be statistically different based on Wilcoxon rank sum testing (p &lt; 0.0001). CONCLUSIONS: The novel pituitary-SCHEME score, which incorporates perioperative and endocrinological measures, has promise as a clinical tool to predict patient outcomes following surgical resection of functional adenomas.

Delineating the Spectrum of Pituitary Adenoma Based on the WHO 2017 Classification.

The WHO 2017 classification of endocrine tumors incorporates lineage-specific transcription factors (TF) and hormone expression for the classification of pituitary adenoma (PA). There is paucity of reports describing the spectrum of PA based on this classification. The aim of this study was to delineate the spectrum of PA based on WHO 2017 classification of endocrine tumors. PA diagnosed in the year 2018 were studied. H and E and hormonal immunohistochemistry (IHC) for GH, PRL, ACTH, TSH, FSH, LH, CK, T-Pit and MIB-1 were performed and the results were analyzed. The cohort included 88 cases. M: F ratio was 2:1. Clinically, 22 (25%) were functional and 66 (75%) were non-functional adenomas. Amongst the clinically functional adenomas, GH secreting adenomas were the commonest (68%). Majority (83%) of non-functional adenomas were hormone positive with gonadotroph adenomas being the commonest (72.7%). Eleven (12.5%) PA were clinically and hormonally silent. Three of these showed intense nuclear T-Pit positivity, classifying them under silent corticotroph adenoma. Lineage of the remaining eight adenomas remained undetermined, since, IHC for Pit-1 and SF-1 was not performed. The aggressive adenomas identified by IHC included sparsely granulated somatotroph adenoma, Crooke cell adenoma, silent corticotroph adenoma, densely granulated lactotroph adenoma in men and constituted 17% of the PA. Four (4/88) cases were clinically invasive. A large majority of PA including aggressive adenomas can be identified by IHC. Addition of T-Pit helped to identify silent corticotroph adenoma. Pit -1 and SF-1 TF would help identify plurihormonal Pit-1 PA and null cell adenomas.

Management of pituitary adenoma: Preliminary experience with endoscopic endonasal transphenoidal surgery in a developing country. Example of Senegal about 180 cases

IntroductionEndoscopic endonasal transsphenoidal surgery is currently the gold-standard therapeutic approach for pituitary adenomas. Although being spread worldwide, the endoscopic endonasal approach for pituitary adenomas is recently implemented in Senegal.This study aimed to report our results and the complications observed in the context of an under-equipped facility. Materials and methodsWe conducted a retrospective study including all patients with a pituitary adenoma treated who underwent endonasal transsphenoidal resection under a single endoscopic approach from January 2014 to May 2022, in the Neurosurgery Department of Fann National Hospital Centre, Dakar. All patients were assessed according to clinical, radiological, and endocrinological criteria. They all were operated by the same team with an average follow-up of 24 months. ResultsIn this series of 180 patients, including 57.7 % women and 42.3% men with a mean age of 44.8 years (extremes of 18 and 76 years), the visual deficit was the most frequent onset symptom (69.4 %), followed by clinical forms of hormone hypersecretion (30.5 %). Twelve cases of pituitary apoplexy and 1 case of incidentaloma were reported. The most frequent tumors were non-functional tumors (61.6 %). Among the functional adenomas, the most frequent was prolactinoma (15.5 %). Regarding tumor size, 75 % were macroadenomas, 15.5 % were microadenomas, and 9.5 % were giants. Cavernous sinus invasion (Knosp grade ≥ 3) and suprasellar extension were noted in 14.4 % and 53.3 %, respectively. The resection was total in 80 % of cases, subtotal in 18.8 %, and partial in 1.2 %. Partial improvement of sight was observed in 91.1% and endocrine hypersecretion remission in 76.6 %. As for complications, the most frequent was transient diabetes insipidus (32.7 %). ConclusionDespite the scanty resources, our results are similar to the best-reported series and strengthen scientific evidence on the efficacy and safety of performing this technique in an under-equipped setting context.

Risk factors for intraoperative complications, postoperative complications, and prolonged length of stay after laparoscopic adrenalectomy by transperitoneal lateral approach: a retrospective cohort study of 547 procedures.

Laparoscopic adrenalectomy (LA) is the gold standard for the resection of most adrenal lesions. A precise delineation of factors influencing its outcomes is lacking. The aim of this study was to assess factors associated with intraoperative complications, postoperative complications, and prolonged length of stay (LOS) after LA. Patients who underwent LA from 1999 to 2021 in a single-academic-institution were included. Patient and disease-specific data, intraoperative complications, postoperative complications according to Dindo-Clavien (DC) scale, and LOS were recorded. Predictive factors of complications and prolonged LOS were determined by logistic regression. We identified 530 patients who underwent 547 LA. Intraoperative complications occurred in 33 patients (6.0%). Postoperative complications ≥ DC grade 2 occurred in 73 patients (13.35%); severe postoperative complications ≥ DC grade 3 in 14 patients (2.56%). Postoperative complications were positively associated with age ≥ 72 (OR 1.14 [95% CI 1.02-1.29]), intraoperative complications (OR 1.36 [95% CI 1.14-1.63]), and negatively associated with non functional adenomas (OR 0.88 [95% CI 0.7-0.99]), and right adrenalectomy (OR 0.91 [95% CI 0.86-0.97]). Severe postoperative complications were positively associated with chronic obstructive pulmonary disease (COPD, OR 1.08 [95% CI 1.00-1.17]), and negatively associated with right adrenalectomy (OR 0.97 [95% CI 0.92-0.99]). Prolonged LOS was associated with age ≥ 72 (OR 1.21 [95% CI 1.05-1.41]), and COPD (OR 1.20 [95% CI 1.01-1.44]). LA remains safe when performed by surgeons with expertise. Right adrenalectomy resulted in less postoperative overall and severe complications. The risk-benefit equation should be carefully assessed before left LA in older patients with COPD.

Abstract #1401801: A Late Diagnosis of Cushing's Disease

Cushing’s disease is a well-known entity that is frequently described in the literature; however, amongst all pituitary lesions, ACTH-secreting tumors are among the least prevalent and are frequently diagnosed later in the disease course when compared to other functional adenomas. Here we describe a case of Cushing’s disease in a patient who had gone without a diagnosis for many years despite her vast symptomatology. A 60-year-old woman presented for a transsphenoidal resection of a pituitary tumor. Endocrinology was consulted for post-operative monitoring. Initially thought to be the usual case of watching for diabetes insipidus and secondary adrenal insufficiency, this patient provided an extensive and unusual history. About 15 years prior, the patient abruptly began to gain weight notwithstanding a healthy diet and a busy lifestyle. After a year of dedicated lifestyle modifications failing to allow for weight loss, the patient underwent bariatric surgery alongside her sister (who had also gained a tremendous amount of weight attributed to overeating). The patient’s sister succeeded in losing a great deal of weight, however the patient plateaued after losing approximately 35 pounds. During the next few years, the patient started breaking bones, first her hip, then her sternum. Her inpatient medical team checked her ACTH, which was found to be 747 pg/mL (reference range 7.2-63.3 pg/mL). They then checked her AM cortisol, which was not surprisingly elevated to 56.5 mcg/dL (reference range 6.0-18.4 mcg/dL). The patient endorsed numerous symptoms of Cushing’s disease and was referred to an endocrinologist who ordered an MRI of her brain, revealing a macroadenoma. The patient underwent tumor resection and was able to lose over 100 pounds over the course of the next year. Over the following 10 years, the patient remained asymptomatic, until she suddenly, and familiarly, began to gain a copious amount of weight and again experienced fatigability, easy bruising, and hair growth. The patient knew to re-present to her endocrinologist, at which time both her ACTH and cortisol were both elevated (1082 pg/mL and 39.0 mcg/dL, respectively). An MRI of the brain performed at that time revealed recurrence of her pituitary tumor. The patient went for a second resection of her pituitary lesion, after which time our endocrinology team was consulted. Patient did require treatment for diabetes insipidus, secondary AI, and central hypothyroidism, however her symptoms of Cushing’s quickly resolved, and her AM cortisol two days post-operatively was found to be 0.7 mcg/dL, indicating a successful tumor removal. This particular case of Cushing’s disease recurrence highlights the importance of continued post-operative monitoring. Although frequent monitoring may not be indicated, and blood work and imaging may be spaced out, it may be good practice to watch these patients closely to prevent further disease sequalae. Furthermore, we are reminded that a secondary workup of obesity is of paramount importance, as this patient likely would not have required bariatric surgery has she been properly workup up for endocrinological causes of weight gain.

Evolution of Minimally Invasive Adrenal Surgery at a Tertiary Care Centre in Oman.

This study aimed to review the case records and report the outcomes of open and laparoscopic adrenalectomy (LA) cases. This retrospective study included patients who underwent adrenal surgery from January 2010 to December 2020 at Sultan Qaboos University, Muscat, Oman. Demographic details, indications, surgical approaches, intra-operative data, complications, final pathology and outcome at the last follow-up were analysed. A total of 52 patients underwent 61 adrenalectomies; six patients had a bilateral procedure while three patients had to undergo revision surgery resulting in a total of 55 individual procedures. Open adrenalectomy (OA) was performed on 11 patients and 44 patients underwent LA. Most patients (n = 27) were obese with a body mass index >30. Functional adenoma was excised in 36 patients with final diagnosis of Conn's syndrome in 15, pheochromocytoma in 13 and Cushing's syndrome in nine patients. Five patients had surgery for oncological indications. Non-functional adenoma was excised in 13 patients, with a mean size of 8.9 cm (range: 4-15 cm). The mean duration of surgery was less in laparoscopic procedure compared to open (199 versus 246 minutes). The mean estimated blood loss in LA was significantly less (108 versus 450 mL; P <0.05). Out of 55 procedures, only one patient developed Clavien-Dindo grade 2 complication. Both LA and OA were safely performed at the researchers' institution. There is a growing trend for LA, and with experience, the duration of surgery and estimated mean blood loss are demonstrating a positive trend.

In Memoriam: Jules Hardy, 1932 to 2022.

Dr Jules Hardy, circa 1980. Courtesy of Mr VeraHardy-Marino. Consent to publish was obtained.During the past century, we have witnessed the amazing advances of our extraordinary specialty of neurological surgery. Much of this has been the result of several cherished leaders who gave us new horizons as our specialty progressed. Among the foremost of these great pioneers was Jules Hardy of Canada, who passed away at the age 90 years in October 2022 (Figure). He was born in Sorel, Quebec, in 1932. His high school education in Montreal was followed by intense study of classical humanities with the Jesuits, and he was fascinated by the ideas of Thielhard de Chardin, a famous Archeologist, Philosopher, and Theologian. In 1956, he received an MD cum laude at the University of Montreal, after which he became the Director of the Neurosurgery program there (1979-1988). His neurosurgical training began with Claude Bertrand at the Notre Dame Hospital, University of Montreal. He also studied and experimented in neurophysiology with Herbert Jasper at the Montreal Neurological Institute. Subsequently, a fellowship from the McLaughlin Foundation led him to Paris to study stereotactic neurosurgery and pituitary surgery with Gerard Guiot, who was a pupil of Norman Dott of Edinburgh. When Dr Hardy returned to Montreal, he introduced many important innovations, including the use of intraoperative radio fluoroscopy and most importantly the incorporation of the surgical microscope, which then began to be widely used in the modern use of trans-sphenoidal surgery for pituitary tumors. These advances resulted in his discovery and identification of pituitary microadenomas, which could be successfully removed without damage to the normal pituitary gland. This concept of the “selective adenomectomy” was the key operative strategy that results in the surgical cure of functional adenomas with preservation of pituitary function that remains with us today. This began the trans-sphenoidal era of microscope assisted removal of pituitary lesions, with markedly improved accuracy, operative results, and outcomes for his patients. His thorough and elegant methods were presented and widely applied beginning in the late 1960s and were rapidly used by neurosurgeons in North America, Europe, and later throughout the world. Dr Hardy shared freely of his wisdom and skill as attested by his numerous residents, fellows, and learners from all over the world, and he was a staunch member of the International Society of Pituitary Surgeons. His many honors (Table) are testament to the importance and scope of the intellect and expertise he developed to modernize not only pituitary surgery but also to enlighten many aspects of pituitary endocrinology. TABLE. - Dr Hardy's Lifetime Honors 1974—Received the order of merit for sciences and health from the government of Lebanon 1978—Queen Elizabeth II Silver Jubilee Medal 1979—Honorary doctorate from the University of Guadalajara in Mexico 1983—Professeur itinerant du Commonwealth britannique 1987—Officer of the Order of Canada 1987—Commandeur de l’Ordre de Rio Branco—Brazil 1989—Knight of the National Order of Quebec 1989—Recipient of the Prix Léo-Pariseau 1989—Recipient of the Prix Izaak-Walton-Killam 1997—Medal of Honor, World Federation of Neurosurgical Societies 2007—Schloffer Award, Vienna Modified from wikipedia.com, “Jules Hardy: Honors,” under CC BY-SA 3.0, courtesy of Dr Mohr. Dr Hardy had a brilliant career, developing new paradigms, new techniques, new concepts, and giant advances in understanding the complexity, diagnosis, and management of the “master gland” and its disorders. He did this with the support of his loving family, his colleagues, students, and his many patients. To know him and to learn from him was unforgettable. He was one of the great pioneers of neurosurgery and a truly iconic role model for others who strive for and achieve continuing progress in our endeavors.

Clinical characteristics of incidental adrenal masses and relationship with hematological indices as indicators of inflammation

Adrenal incidentaloma (AI) is being diagnosed more frequently due to the increase in use of imaging modalities. Inflammatory processes can play a role in the development and prognosis of numerous diseases. We aimed to investigate the clinical and endocrinological characteristics of adrenal adenoma and its relationship with inflammatory markers. The present study retrospectively analysed 111 patients with adrenal incidentaloma who underwent radiological and clinical examinations between January 2018 and January 2022. Patients diagnosed with Cushing’s syndrome, pheochromocytoma or primary aldosteronism were classified as functional. Inflammation was assessed using neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), glucose lymphocyte ratio (GLR), systemic immune-inflammation index (SII) and prognostic nutritional index (PNI). Of the 111 patients included, 76.6% (n=85) had nonfunctional adenomas and 23.4% (n=26) had functional adenomas. Of the patients with functional adenomas, 50% (n=13) had Cushing’s syndrome, 26.9% (n=7) had pheochromocytoma and 23% (n=6) had primary aldosteronism. The median duration of follow-up was 22.0 (2.0–60.0) months. During the follow-up, two (2.4%) of the 85 patients with non-functional adenomas gained functionality and were diagnosed with Cushing’s disease. Functionality was not significantly associated with NLR, PLR, GLR, SII and PNI levels. There was a negative correlation between cortisol level after the overnight 1 mg dexamethasone suppression test and PNI (r:-0.207, p=0.030). Inflammatory hemogram parameters levels were not significantly different between patients with functional and non-functional adenomas. There was a significant negative correlation between the PNI level and cortisol secretion. PNI, which can be easily calculated by serum albumin level and absolute lymphocyte count, can be a useful guide for clinicians in the follow-up for the prognosis of functional adenoma.

ODP286 A Case of Synchronous Growth Hormone and Adrenocorticotrophic Hormone Secretion in a Patient with an Incidental Pituitary Adenoma.

Abstract The most common type of co-secreting functional pituitary adenoma is a tumor-producing growth hormone and prolactin. Other types of co-existing functioning adenomas are extremely rare. We present a 68-year-old male patient with a pituitary adenoma presenting with acromegaly and Cushing's disease (CD). A 68-year-old male was referred for an incidental pituitary macroadenoma found on magnetic resonance imaging (MRI) for his chronic nasal congestion. He denied headaches or blurry vision. He reported an increase in shoe size, worsening hypertension and diabetes, and a 40-pounds weight gain over several years. Past medical history included arthritis, type two diabetes mellitus, hypertension, sleep apnea, hypogonadism, chronic kidney disease, and coronary artery disease. Physical exam was notable for BMI of 51 kg/m2 and enlarged hands and feet. No stigmata of Cushing's syndrome were present. MRI showed a 2. 0×2.5 cm sellar mass involving the right cavernous sinus without a mass effect on the optic chiasm. Laboratory workup showed an elevated IGF-1 level of 703 ng/mL and 678 on repeat, growth hormone (GH) 1.1 ng/mL, adrenocorticotropic hormone (ACTH) 41 pg/mL, and am cortisol 15 mcg/dL. Am cortisol after 1 mg of dexamethasone was 6.2 mcg/dL with an appropriate dexamethasone level. His and 24-hour urine-free cortisol was elevated at 87.1 mcg/24h, HgbA1C was 8.3%, testosterone level was low, and PRL and thyroid levels were normal. He underwent transsphenoidal surgery (TSS). Postoperative morning cortisol day 1 was 18.9 mcg/dL. Pathology showed a sparsely granulated somatotroph adenoma. Seven days post-surgery, he presented with diplopia, ophthalmoplegia, and ptosis. MRI showed enlargement of the right cavernous sinus with possible residual tumor and blood products. He underwent a second TSS with evacuation of a hematoma. The patient's nadir postoperative serum cortisol was 14.4 mcg/dL and IGF-1 level 513 ng/mL one month after his initial surgery. Pathology showed organizing hemorrhage and necrotic pituitary adenoma. His ophthalmoplegia resolved, and diplopia partially improved. The synchronous occurrence of CD and acromegaly is an extremely rare condition. It can be secondary to either a plurihormonal adenoma or two functional adenomas. In our case, the pathology findings suggest double adenomas. Surgical resection is first-line therapy for acromegaly and CD. Stereotactic radiosurgery and medical therapy are second-line options in persistent disease. The 5-year remission rates with Gamma Knife radiosurgery are higher in CD (81%) as compared to acromegaly. 1 Pasireotide, a somatostatin receptor ligand approved for both CD and acromegaly. Worsening glycemic control is a significant challenging aspect of its use. Presentation: No date and time listed

Health Care Disparities in Transsphenoidal Surgery for Pituitary Tumors: An Experience from Neighboring Urban Public and Private Hospitals.

Objectives Few studies have assessed the role of socioeconomic health care disparities in skull base pathologies. We compared the clinical history and outcomes of pituitary tumors at private and public hospitals to delineate whether health care disparities exist in pituitary tumor surgery. Methods We reviewed the records of patients who underwent transsphenoidal pituitary tumor resection at NYU Langone Health and Bellevue Hospital. Seventy-two consecutive patients were identified from each hospital. The primary outcome was time-to-surgery from initial recommendation. Secondary outcomes included postoperative diabetes insipidus, cerebrospinal fluid (CSF) leak, and gross total resection. Results Of 144 patients, 23 (32%) public hospital patients and 24 (33%) private hospital patients had functional adenomas ( p = 0.29). Mean ages for public and private hospital patients were 46.5 and 51.1 years, respectively ( p = 0.06). Private hospital patients more often identified as white ( p < 0.001), spoke English ( p < 0.001), and had private insurance ( p < 0.001). The average time-to-surgery for public and private hospital patients were 46.2 and 34.8 days, respectively ( p = 0.39). No statistically significant differences were found in symptom duration, tumor size, reoperation, CSF leak, or postoperative length of stay; however, public hospital patients more frequently required emergency surgery ( p = 0.03), developed transient diabetes insipidus ( p = 0.02), and underwent subtotal resection ( p = 0.04). Conclusion Significant socioeconomic differences exist among patients undergoing pituitary surgery at our institution's hospitals. Public hospital patients more often required emergency surgery, developed diabetes insipidus, and underwent subtotal tumor resection. Identifying these differences is an imperative initial step in improving the care of our patients.

Prevalence and Characteristics of Adrenal Tumors in an Unselected Screening Population : A Cross-Sectional Study.

With the widespread use of advanced imaging technology, adrenal tumors are increasingly being identified. To investigate the prevalence and characteristics of adrenal tumors in an unselected screening population in China. Cross-sectional study. (ClinicalTrials.gov: NCT04682938). A health examination center in China. Adults having an annual checkup were invited to be screened for adrenal tumors by adrenal computed tomography. The participants with adrenal tumors had further evaluation for malignancy risk and adrenal function. A total of 25356 participants were screened, 351 of whom were found to have adrenal tumors, for a prevalence of 1.4%. The prevalence increased with age, from 0.2% in participants aged 18 to 25 years to 3.2% in those older than 65 years. Among 351 participants with adrenal tumors, 337 were diagnosed with an adrenocortical adenoma, 14 with another benign nodule, and none with a malignant mass. In 212 participants with an adenoma who completed endocrine testing, 69.3% were diagnosed with a nonfunctioning adenoma, 18.9% with cortisol autonomy, 11.8% with primary aldosteronism, and none with pheochromocytoma. Proportions of nonfunctioning adenomas were similarly high in various age groups (72.2%, 67.8%, and 72.2% in those aged <46, 46 to 65, and ≥66 years, respectively). Only 212 of 337 participants with an adrenocortical adenoma had endocrine testing. The prevalence of adrenal tumors in the general adult screening population is 1.4%, and most of these tumors are nonfunctioning regardless of patient age. Cortisol and aldosterone secretion are the main causes of functional adenomas. National Key Research and Development Program of China and National Natural Science Foundation of China.