Functional Adenomas Research Articles

Fractionated Stereotactic Radiotherapy for Pituitary Adenomas: Single-Center Experience in 75 Consecutive Patients.

Early results of postoperative fractionated stereotactic radiotherapy (FSRT) for functional and nonfunctional pituitary adenomas appear promising, but the majority of available evidence draws from small series with insufficient follow-up data to draw meaningful conclusions. To evaluate the long-term outcomes of a large series of patients undergoing FSRT for both functional and nonfunctional pituitary adenomas with the Novalis system (BrainLAB, Heimstetten, Germany). Chart data for 75 consecutive patients undergoing FSRT for a pituitary tumor (21 functional and 54 nonfunctional adenomas) at our institution between January 2004 and June 2013 were reviewed. Radiographic progression-free survival was 100% over a mean of 47.8 months of radiographic follow-up (range, 12.0-131.2 months). Hormonal normalization was seen in 69.2% of patients with functional adenomas after FSRT, whereas 30.8% experienced partial hormonal control. Mild, grade I acute adverse effects were observed during radiotherapy treatment in 36 patients (48%), and objective, persistent worsening of vision occurred in a single patient (1.5%) after FSRT. New hormonal deficits were seen in 28.0% of patients after FSRT. Radiographic responses were inversely related to tumor volume. FSRT delivers radiographic and functional outcomes similar to those seen with stereotactic radiosurgery and conventional radiotherapy with less resultant toxicity. FSRT is most beneficial for smaller tumors (those <3 cm in diameter). EBRT, external beam radiotherapyFSRT, fractionated stereotactic radiotherapyOR, odds ratioPTV, planning target volumeSRS, stereotactic radiosurgery.

GENO-09LANDSCAPE OF GENOMIC ALTERATIONS IN PITUITARY ADENOMAS

BACKGROUND: The genetic underpinnings of sporadic pituitary adenomas remain incompletely understood, despite their prevalence in adults. We describe a comprehensive genetic characterization of the largest mixed cohort of pituitary macroadenomas, including hormonally active and atypical adenomas. METHODS: 42 pituitary adenomas were selected to represent a spectrum of histopathologic subtypes, de novo and recurrent tumors, and MIB-1 proliferative indices to interrogate the heterogeneity intrinsic to pituitary tumors. Whole-exome sequencing was performed on tumor and paired blood to identify somatic copy-number alterations, mutations, insertions and deletions. RESULTS: We appreciated two classes of pituitary tumors based upon the fraction of the genome disrupted. The first class (71% of tumors) had somatic copy-number alterations involving less than 6% of the genome; the other class (29%) had significantly greater levels of genomic disruption, up to 99% of the genome involved. The widespread genomic disruption observed in the second class was largely accounted for by arm-level events, with minimal involvement of focal events, which is rare among tumor types. Levels of genomic disruption were associated with phenotype. Among the less disrupted group, 87% (26/30) were clinically non-functional adenomas, whereas the majority of the disrupted group were functional or atypical null-cell adenomas. The high and low genomic disruption classes did not differ in mean MIB-1 proliferative index. Frequent loss of chromosomes 11 and 1p were observed, as well as significant recurrent amplifications of chromosome 5, 7, 9, 12, and 14q. On the whole, the tumors harbored a low rate of mutations, similar to other benign brain tumors. CONCLUSIONS: Genomic characterization of a large series of sporadic pituitary adenomas reveals two distinct classes of tumor, based on genomic disruption from broad copy-number alterations, and associates with tumor subtype.

Surgical approach in adrenal incidentalomas: Report of thirteen cases and review of the literature.

The rate of adrenal incidentalomas detected in routine diagnostic imaging techniques is approximately 4-7%. Although the lesions are generally benign, carcinoma and functional adenomas can be diagnosed with careful clinic and laboratory evaluation. Data of 13 patients who underwent surgery for an adrenal mass between January 2010-June 2014 were analyzed retrospectively. Seven (54%) patients were male, 6 (46%) were female, and the mean age was 38.2. The clinical diagnosis was pheochromacytoma in 5 patients (38.4%), non-functional adenoma in 5 (38.4), and metastatic lesion, Cushing syndrome, and adrenal carcinoma each in one patient (7.6%). Conventional open adrenalectomy was performed in 8 patients, while 5 patients underwent laparoscopic adrenalectomy. Adrenal incidentalomas should be carefully evaluated for hormonal activity even if asymptomatic, and non-functional lesions should be considered as suspicious-for-malignancy. Laparoscopic adrenalectomy has become the gold standard for patients with a mass less than 6 cm, and without infiltration to adjacent organs.

Pituitary macroadenomas (>3 cm) in young adulthood: Pathologic and proliferative characteristics

BackgroundThere are scarce data regarding the significance of the tumor size, hormonal activity and size of the pituitary tumor of the young; therefore, the study was designed to define the relation of the hormonal status of the large pituitary adenomas. ObjectiveWe compared those features with tumors of the elderly (>40) with the young patients, and analyzed the clinicopathologic and proliferative features of pituitary macroadenomas in young adulthood (≤40). Methods20-year archives of pituitary tumors in our clinics were reviewed and macroadenomas with diameter ≥3cm were included in the study. We identified 46 pituitary adenomas and immunohistochemically stained them with pituitary hormones, p53 and Ki-67. Twenty-four cases were ≤40-year with an age range of 11–40 years (mean 28.0). Twenty-two cases were >40 with an age range of 44–78 years (mean 58.8). ResultsIn the young patient group, 15 (62.5%) were functional adenomas (6 prolactinomas, six growth hormone [GH], one adrenocorticotrophic hormone [ACTH] adenoma, two multihormonal [GH+ACTH]) and nine (37.5%) were either gonadotrophic or null cell adenomas. In the elderly group, five (22.7%) were functional adenomas (two adrenocorticotrophic hormone [ACTH] adenoma, one prolactinoma, one growth hormone [GH], one multihormonal [GH+ACTH]) and 17 (77.3%) were either gonadotrophic or null cell adenomas. Ki-67 proliferation index in adenomas of the young was approximately two-folds higher than the elderly (2.7% vs. 1.2%). ConclusionIn both groups, rare p53 positivity was identified. In conclusion, pituitary macroadenomas of the young show hormonal expression frequently with relatively high Ki-67 proliferation indices.

KI-67 labeling index and expression of P53 are non-predictive on invasiveness and tumour size in functional and nonfunctional pituitary adenomas: A large series of 421 patients

KI-67 labeling index and expression of P53 are non-predictive on invasiveness and tumour size in functional and nonfunctional pituitary adenomas: A large series of 421 patients

Evolution of a surgical service for adrenal pathology and impact of surgical intervention on resistant hypertension

An insight into the impact of adrenalectomy on the management of hypertension is helpful in counselling patients when deciding on surgical intervention. We prospectively studied the outcome after surgical intervention for proven functional adrenal adenomas, particularly in regard to post-operative requirement of antihypertensive medications. All patients were prospectively logged onto a comprehensive database, which allowed subsequent long-term follow-up. Account was taken of morbidity encountered. A total of 77 patients (78 adrenal glands) underwent adrenal surgery between 1995 and 2013. In all, 44 patients (44/77) had proven functional adenomas, phaeochromocytoma (15/44, 34 %), Conn’s (25/44, 56 %), Cushing’s 4 (4/44, 10 %). A minimum follow-up of 12 months revealed all patients to have a reduction in their disease-specific medication with 75 % Cushing’s, 72 % Conn’s and 60 % phaeochromocytoma patients medicine free. Despite the potential for functioning adenomas to produce irreversible change, the intervention of adrenalectomy appears to be beneficial in the vast majority of patients with at least half independent of antihypertensive medication. A reduction in morbidity was demonstrated as experience increased.

Comparative Pharmacotherapy of Thyroid Diseases in Dogs and Cats--- What Should the Retail Pharmacist Filling Pet Prescriptions Understand?

Community pharmacies are increasingly receiving prescriptions from veterinarians for dogs and cats to receive human medications. However, retail pharmacists are not routinely trained in relevant aspects of veterinary-specific pharmacotherapy, such as, signs of improvement, time to improvement, drug administration techniques and potential adverse effects. Thyroid diseases in dogs and cats are treated with human-approved drugs that may be referred to pharmacies. Hypothyroidism is far more frequent in dogs, while hyperthyroidism is far more frequent in cats. Important comparative aspects of canine hypothyroidism pharmacotherapy can be summarized as follows: 1) Canine hypothyroid disease is similar to Hashimoto’s thyroiditis in humans in many of its signs and is treated using levothyroxine; 2) The doses of levothyroxine given to dogs are strikingly higher than in people; 3) A reasonable therapeutic goal is resolution of symptoms in two weeks to two months and a normal total T4 value (≈04-3.7 μg/dL). Important comparative aspects of feline hyperthyroidism pharmacotherapy are: 1) Cats usually have a functional thyroid adenoma, while people usually have an autoimmune condition referred to as Grave’s disease; 2) Common signs noticed by cat owners are weight loss and increased appetite; 3) Methimazole is used for therapy as it often is in people; 4) Clinical improvement follows in approximately 3-4 weeks; 5) Adverse reactions occur and are most often vomiting, anorexia, and lethargy; 6) Transdermal methimazole from a compounding pharmacy will be a consideration for some cats.

Pituitary Adenoma: Early Results after Gamma Knife Radiosurgery in Iran

Purpose: To study early treatment outcomes and complications of Gamma Knife Radiosurgery(GKRS) in patients with functional and nonfunctional adenomas.Methods: One hundred patients with a pituitary adenoma who were treated between 2011 and2014 at Iran Gamma Knife Center were studied. The patients were followed up at least 2 years.Radiosurgery was performed using the Leksell Gamma Unit. The median radiation dose was18 Gy for non-functional and 24 Gy for functional adenoma. The MRI were compared pre andpost operation for any change in tumor size. Endocrine follow up was used to determine theonset of new hormone deficiency when available or decrease in hormonal level.Results: Our study group comprised 42 men (42%) and 58 women (58%). Ninety-three patientswere treated for recurrent or residual disease after Trans-sphenoidal surgery or craniotomy and 7patients were treated as primary modality because of extensive involvement of cavernous sinus orhigh risk for surgery. Forty-six patients (46%) had a diagnosis nonfunctional and 54 of patients(54%) had hormone-secreting tumors including growth hormone secreting (23%), prolactinoma(15%) and ACTH-secreting tumor (6%). No mortality was reported. Acute complication wasuncommon and of no clinical significance. Late complication was noted in two patients (2%)and consisted of VI cranial nerve palsy with spontaneous resolution. None of the patientsdeveloped visual loss. Before GKRS, 8 patients had cranial nerve palsy. After the treatment, thepalsy resolved in six (75%) of these patients. Only 9.5% of patients developed hypopituitarismand required replacement therapy. Overall control was 92% (28% decreased in volume and64% were unchanged), 8% experienced an increase in volume size. Normalization of GH andIGF-1 for GH-secreting hormone was 48% with overall control of 73%. PRL normalization forprolactinoma was 46% with overall control of 67%. ACTH normalization for ACTH-secretinghormone was 35% with overall control of 70%.Conclusion: It seems that GKRS to be safe and effective method for tumor control and optimalhormonal function.

Decreased expression of APAF-1 and increased expression of cathepsin B in invasive pituitary adenoma.

PurposeApoptotic protease-activating factor-1 (APAF-1) and cathepsin B are important functional proteins in apoptosis; the former is involved in the intrinsic (mitochondrial) pathway, while the latter is associated with both intrinsic and extrinsic pathways. Changes in the expression of apoptosome-related proteins could be useful indicators of tumor development since a priori defects in the mitochondrial pathway might facilitate the inception and progression of human neoplasms. Our aim was to evaluate the profiles of APAF-1 and cathepsin B in relation with other molecules involved in apoptosis/proliferation and to correlate them with the aggressive behavior of invasive pituitary adenomas.Materials and methodsAPAF-1 and cathepsin B were assessed in tissue samples from 30 patients with pituitary adenomas, of which 16 were functional adenomas and 22 were invasive adenomas.ResultsA positive relationship between high proliferation and invasiveness was observed in invasive pituitary adenomas when compared to their noninvasive counterparts (Ki-67 labeling index – 4.72% versus 1.75%). Decreased expression of APAF-1 was recorded in most of the invasive adenomas with a high proliferation index, while the cathepsin B level was elevated in this group. We have noticed a negative correlation between the low level of APAF-1 and invasiveness (63.63%; P<0.01); at the same time, a positive correlation between cathepsin B expression and invasiveness (59.09%; P<0.01) was found. In all, 81.25% out of the total APAF-1-positive samples were cathepsin B negative (P<0.01); 76.92% out of the total cathepsin B-positive samples were APAF-1-negative (P<0.01). These results were reinforced by an apoptosis protein array examination, which showed inhibition of the extrinsic apoptotic pathway in an invasive pituitary adenoma.ConclusionA bidirectional–inverted relationship between APAF-1 and cathepsin B expressions was noticed. One might hypothesize that shifting the balance between mediators of cell death could result in changes in tumor behavior.

Aromatase enzyme expression in acromegaly and its possible relationship with disease prognosis.

The purpose of this study was to evaluate aromatase enzyme expression in growth hormone (GH) secreting adenomas and comparison with prolactinomas, nonfunctional adenomas, and normal pituitary tissues. Also the impact of its expression on clinical and prognostic features was evaluated. 38 acromegaly, 26 prolactinoma, and 31 nonfunctional pituitary adenoma and 11 normal pituitary gland samples from autopsies were included. Aromatase and estrogen receptor-alpha (ERα) were evaluated by Immunohistochemical method; demographic, pre- and postoperative features of the patients were noted. Aromatase was expressed in varying degrees in all cases in study including controls. Aromatase expression in patients with acromegaly was significantly higher than patients with prolactinoma, nonfunctional adenoma, and controls (p = 0.04, p = 0.01 and p < 0.001, respectively). Taken together two functional adenoma groups, prolactinoma and acromegaly, aromatase expression was negatively correlated with ER-alpha (p = 0.02, r = -0.34). Also, Ki-67 immunohistochemical results were negatively correlated with aromatase expression (p = 0.03, r = -0.27) while positively correlated with ER expression (p < 0.01). Consistent with the growing evidence about testosterone effect on pituitary functions, aromatase expression was found to be higher in GH-secreting pituitary adenoma. Aromatase was expressed in all pituitary tissues including autopsy samples; however, it was highest in patients with acromegaly. In patients with acromegaly and prolactinoma, aromatase expression was negatively correlated with Ki-67 score, and also it was higher in patients with complete postoperative remission than without remission. Therefore, aromatase expression may be a good prognostic marker predominantly in acromegaly.

Endoscopic endonasal transsphenoidal surgery of 1,166 pituitary adenomas.

AimTo report the results of a series of patients undergoing pure endoscopic endonasal pituitary surgery and to evaluate the efficacy and safety of this procedure.Materials and methodsThe data of 1,166 patients that underwent endoscopic endonasal transsphenoidal adenoma removal between December 2006 and June 2013 were retrospectively reviewed. Pre- and postoperative hormonal status (3 months after surgery) were analyzed and compared with the clinical parameters originally presented by the patients. The incidences of tumor removal, hormonal control, and tumor removal complications were retrospectively analyzed.ResultOut of 577 nonfunctioning adenomas, 180 were growth hormone (GH) secreting, 308 prolactin (PRL) secreting, 26 mixed GH/PRL adenomas, 68 adrenocorticotropin secreting, and 7 thyroid-stimulating hormone-secreting adenomas. The gross total removal of pituitary adenomas was achieved in 98 % of microadenomas, 92 % of macroadenomas, and 76 % of giant adenomas. Hormonal control was achieved in 47 (69 %) cases of ACTH adenomas, 119 (66 %) GH adenomas, 262 (85 %) PRL adenomas, and 6 (86 %) TSH adenomas. Postoperative complications were observed in 168 (14.4 %) patients. The most frequent complications were diabetes insipidus (7 %), epistaxis (1.7 %), hyposmia (1.5 %), anterior lobe insufficiency (1.3 %) ,and CSF leaks (0.6 %).ConclusionThe pure endoscopic approach is a safe, efficacious, and minimally invasive technique for the removal of pituitary adenomas. A higher gross total resection rate is vital for non-functional and functional adenomas. For patients with functional adenomas, while hormonal remission is unlikely to be achieved by surgery, the use of adjuvant therapy is advocated to obtain long-term hormonal control.

Analysis of operative efficacy for giant pituitary adenoma.

BackgroundSurgical treatment of giant pituitary adenomas is difficult due to complicated dissection of the sellar area. The extent of tumor resection affects the efficacy of surgical treatment. This study is to investigate the efficacy of microsurgical treatment for giant pituitary adenoma and to analyze the relationship between treatment efficacy and tumor resection extent.MethodsA retrospective analysis was performed in 36 patients who received microsurgery to remove giant pituitary adenomas. The sizes of tumors before and after surgery were calculated with a novel method called the “platform-like volume calculation formula”. The relationships between extent of resection and the visual impairment recovery, and improvement of serum hormone level before and after operation were analyzed.ResultsTwo deaths were observed after surgery. And the gross and near-total resection was achieved in 8 cases, subtotal resection in 8 cases, mostly partial resection in 15 cases, and partial resection in 5 cases. The average resection rate was 72.8%. The resection rate of tumor with cavernous sinus invasion was significantly lower than those of patients without cavernous sinus invasion (P < 0.05). The improvement rate of hormone level in functional adenoma was 80.0%. Follow-up observations were carried out for 3 ~ 28 months in 25 cases. Visual improvement was observed in 64.0% of the cases.ConclusionsMicrosurgical treatment can improve the visual impairment of the majority of cases and significantly decrease the serum hormone levels of functional adenoma. The extent of resection was significantly associated with cavernous sinus invasion.

Pituitary adenoma with gangliocytic component: report of 5 cases with focus on immunoprofile of gangliocytic component

Pituitary adenomas with gangliocytic component are rare tumors of the sellar region that are composed of pituitary adenoma cells and a ganglion cell component. Their histogenesis and hence nosology is not yet resolved because of the small number of cases reported and lack of large series in the literature. Herein we report five cases of pituitary adenoma with gangliocytic component to add knowledge to this rare neoplasm. Three cases are functional mammosomatotroph adenomas, one case is functional sparsely granulated somatotroph adenoma and the other is functional corticotroph adenoma. Gangliocytic component showed immunohistochemical expression of hormones in three cases. The ganglion cells were prolactin immunoreactive in case 1, GH and TSH immunoreactive in case 5 and showed expression of prolactin, TSH, ACTH and FSH in case 4. Three cases had undergone more than one surgery of which two had gangliocytic cells only in the recurrent tumors whereas the third case showed gangliocytic cells only in the initial tumor. The cases are discussed with clinical and histological features and a brief review of the literature considering the histogenesis is included.

Atypical subacute thyroiditis and functional thyroid adenoma: Case report

Subacute thyroiditis (SAT), also known as DeQuervain's or granulomatous thyroiditis is an inflammatory condition of the thyroid gland, which is usually fully affected. Severe pain and tenderness in the thyroid bed occur typically and are followed by weakness, fatigue, pain in muscles and joints, and light to moderate fever and symptoms of thyrotoxicosis - nervousness, sweating and rapid heartbeat and trembling. Temporary elevated serum thyroxine, suppressed TSH and elevated serum markers of inflammation in the acute phase are pathognomonic for the SAT, with diffusely absent binding of radioactive iodine or technetiumpertechnetate in the thyroid gland due to thyrocytes destruction. Rare cases of atypical SAT - painless or with minimal pain, SAT limited to one thyroid lobe or focal thyroiditis, are reported in literature. We report a rare case of a minimally painful SAT associated with functional adenoma in the right lobe of the thyroid gland, which was, in thyrotoxic, acute phase, scintigraphicaly presented as toxic adenoma, in fact representing a functional adenoma tissue unaffected by destructive thyroiditis.

ADRENAL INCIDENTALOMAS: DIAGNOSIS AND MANAGEMENT

Adrenal incidentaloma is an unsuspected and asymptomatic mass, usually detected by an imaging study performed for other purposes. The widespread use of diagnostic ultrasound, computed tomography, magnetic resonance imaging has resulted in the frequent incidental discovery of asymptomatic adrenal mass. Adrenal incidentalomas represent a public health challenge because they are increasingly recognized in current medical practice. The majority of adrenal incidentalomas are benign, but careful evaluation of all patients is warranted to be certain that malignant tumours and functional adenomas are not missed. The article reviews the presentation, evaluation and management of adrenal incidentalomas.

Outcomes following Purely Endoscopic Endonasal Resection of Pituitary adenomas

Background: The use of endoscope for the management of pituitary adenoma is not new. The better magnification and illumination provided by the endoscope gives better outcome than microscopic pituitary surgery. Objective: To find out the benefits of endoscope in relation to microscopic surgery. Materials and Methods: We performed 45 cases of pituitary adenoma surgery by endoscopic endonasal approach from July 2008 to July 2010. Results: Forty five cases underwent endoscopic transsphenoidal approach. Gross total removal was done in 35 cases and subtotal removal was done in 10 cases. Residual tumours were seen in 10 cases (22%) in postoperative follow-up MRI scan. Visual improvement was satisfactory, and hormonal improvement of functional adenoma was nice. Postoperative visual acuity and visual field were improved in 75% cases. There were 37% cases of temporary diabetes insipidus and about 4.5% cases of permanent diabetes insipidus. The average duration of follow-up was 20 months. One patient required reexploration to correct visual deterioration in the immediate postoperative period. There were 4.5% cases of CSF leak and 6.6% mortality. Mortality was due to electrolyte imbalance and improper management of infection and hydrocephalus. Conclusion: Endoscopic endonasal pituitary surgery now has become a gold standard surgery for most of the pituitary adenomas because of its better advantages in relation to microscopic surgery and less complications and less hospital stay. DOI: http://dx.doi.org/10.3329/jemc.v3i1.13869 J Enam Med Col 2013; 3(1): 18-23

Adrenal incidentaloma: A puzzle for clinician

An adrenal incidentaloma (AI) is a puzzle for clinician. In the era of widespread use of CT and MRI, it is becoming an increasingly frequent diagnosis. A detailed list of investigations is ordered to diagnose pathology responsible for AI. Most likely etiology of AI is pathology of AI is benign non-functional adenoma. But looking to the need of specific preoperative preparation for functional adrenal adenoma and importance of early diagnosis in adrenal carcinoma, a complete workup is essential. CT scan of adrenals with contrast gives maximum information about nature of lesion. In general, a lesion more than 6cm or a functioning AI or tumor signal intensity of more than 10HU on unenhanced image, significant enhancement on contrast and deenhancement in signal intensity of less than 50% is suggestive of carcinoma and must be removed. Those AI which are left for observation, also needs regular testing and if found functional on subsequent follow-up or if their size enlarge, they must be removed.

Optimización del uso de las imágenes en la patología suprarrenal (parte 1)

Objectives of trainingThe aim of this study is to propose an algorithm for the evaluation of adrenal lesions in order to arrive at the correct diagnosis in the shortest possible time.This method would favor the most appropriate therapeutic procedures for each pathology and may substantially modified a given treatment. In spite of the fact that the structural features of lesions are generally non-specific, it is possible with imaging techniques, to establish compatible features which could help us differentiate benign from malignant lesions and with the contribution of the endocrinologist and the laboratory, to distinguish functional from non-functional ones. Topic revisionA retrospective evaluation was carried out from May 2009 to December 2011 on 157 patients with adrenal diseases, including 95 females and 61 males, from 33 to 78 years of age (mean age 55). The study protocol consisted of non-contrasted intravenous computed tomography, with lesion density measurement, followed by contrasted intravenous computed tomography and wash out time with lesion density determination in portal time and later at 15’ during wash out.Measurements and calculations were: adrenal lesion size, medium density and absolute and relative washing percentiles. Magnetic resonance and 18F-fluorodesoxyglucose positron emission tomography was only performed on those patients who required these techniques. A comparison of the present results with those in the literature is included. Imaging findingsFifty-nine patients with non-functional adenoma were identified (49 unilateral and 10 bilateral), 29 functional adenomas, 9 with bilateral hyperplasia, 4 myelolipomas (2 in a female patient with simple virilizing congenital adrenal hyperplasia), 2 cysts, 2 hematomas, 3 lymphomas (2 secondary and 1 primary bilateral), 30 metastases, 5 adrenocortical carcinomas, 12 pheochromocytomas,1 malignant pheochromocytoma, and 1 ganglioneuroma. ConclusionThe use of an appropriate study algorithm, with proper diagnostic tools, allows the correct characterization of adrenal lesions. Moreover, this approach prevents loss of time, a wrong diagnosis, excessive irradiation of the patient, and incorrect use of resources.

Primary Hyperaldosteronism Decoded: A Case of Curable Resistant Hypertension

Patients with resistant hypertension have a higher incidence of secondary causes of hypertension compared with the general hypertensive population. It is important to screen such patients for secondary causes of hypertension because appropriate treatment can lead to improved blood pressure control or even cure these patients, and thus avoid the cardiovascular morbidity and mortality associated with uncontrolled hypertension. One common cause of secondary hypertension, often associated with hypokalemia, is primary hyperaldosteronism or Conn syndrome. Aldosterone is a mineralocorticoid hormone produced in the outer layer of the adrenal cortex (the zona glomerulosa); its primary action is to increase sodium and water reabsorption by the kidney. Once the diagnosis of primary aldosteronism is made, it is necessary to determine if aldosterone production is unilateral or bilateral. When production is unilateral (most often from a functional adenoma), surgery is potentially curative. The authors report a case and review the diagnostic workup of Conn syndrome in which resistant hypertension and hypokalemia were cured by unilateral adrenalectomy.

Single-surgeon fully endoscopic endonasal transsphenoidal surgery: outcomes in three-hundred consecutive cases

The objective of this study was to evaluate outcomes of endoscopic transsphenoidal surgery using a single-surgeon technique as an alternative to the more commonly employed two-surgeon, three-hand method. Three hundred consecutive endoscopic transsphenoidal procedures performed over a 5 year period from 2006 to 2011 were reviewed. All procedures were performed via a binasal approach utilizing a single surgeon two handed technique with a pneumatic endoscope holder. Expanded enodnansal cases were excluded. Surgical technique, biochemical and surgical outcomes, and complications were analyzed. 276 patients underwent 300 consecutive surgeries with a mean follow-up period of 37 ± 22 months. Non-functioning pituitary adenoma (NFPA) was the most common pathology (n = 152), followed by growth hormone secreting tumors (n = 41) and Rathke's cleft cysts (n = 30). Initial gross total cyst drainage based on radiologic criteria was obtained in 28 cases of Rathke's cleft cyst, with 5 recurrences. For NFPA and other pathologies (n = 173) gross total resection was obtained in 137 cases, with a 92% concordance rate between observed and expected extent of resection. For functional adenoma, remission rates were 30/41 (73%) for GH-secreting, 12/12 (100%) for ACTH-secreting, and 8/17 (47%) for prolactin-secreting tumors. Post-operative complications included transient (11%) and permanent (1.4%) diabetes insipidus, hyponatremia (13%), and new anterior pituitary hormonal deficits (1.4%). CSF leak occurred in 42 cases (15%), and four patients required surgical repair. Two carotid artery injuries occurred, both early in the series. Epistaxis and other rhinological complications were noted in 10% of patients, most of which were minor and diminished as surgical experience increased. Fully endoscopic single surgeon transsphenoidal surgery utilizing a binasal approach and a pneumatic endoscope holder yields outcomes comparable to those reported with a two-surgeon method. Endoscopic outcomes appear to be better than those reported in microscope-based series, regardless of a one or two surgeon technique.