Functional Pituitary Adenomas Research Articles

Medical treatment of functional pituitary adenomas, trials and tribulations.

Functioning pituitary adenomas (FPAs) include most frequently prolactinomas, somatotroph or corticotroph adenomas, while thyrotroph and gonadotroph adenomas are very rare. Despite their benign histological nature (aggressive tumors are rare and malignant ones exceptional), FPAs could cause significant morbidity and increased mortality due to complications associated with hormonal excess syndromes and/or mass effect leading to compression of adjacent structures. This mini review will focus on the increasing role of medical therapy in the multimodal treatment, which also includes transsphenoidal surgery (TSS) and radiotherapy. Most patients with prolactinomas are treated only with medications, but surgery could be considered for some patients in a specialized pituitary center, if higher chances of cure. Dopamine agonists, especially cabergoline, are efficient in reducing tumor size and normalizing prolactin. TSS is the first-line treatment for all other FPAs, but most patients require complex adjuvant treatment, including a combination of therapeutic approaches. Medical therapy is the cornerstone of treatment in all patients after unsuccessful surgery or when surgery cannot be offered and includes somatostatin receptor ligands and dopamine agonists (almost all FPAs), growth hormone receptor antagonists (acromegaly), adrenal steroidogenesis inhibitors and glucocorticoid receptor blockers (Cushing's disease). Novel medical treatments, especially for acromegaly and Cushing's disease are under research. An enlarged panel of effective drugs available with increased knowledge of predictive factors for response and/or adverse effects will enhance the possibility to offer a more individualized treatment. This would not only improve disease control and prognosis, but also quality of life.

Proton beam radiotherapy for treatment of functional pituitary adenomas

Proton beam radiotherapy for treatment of functional pituitary adenomas

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 > 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 < 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.

Elevated risk of recurrence and retreatment for silent pituitary adenomas.

Pituitary adenomas are the most common tumor of the pituitary gland and comprise nearly 15% of all intracranial masses. These tumors are stratified into functional or silent categories based on their pattern of hormone expression and secretion. Preliminary evidence supports differential clinical outcomes between some functional pituitary adenoma (FPA) subtypes and silent pituitary adenoma (SPA) subtypes. We collected and analyzed the medical records of all patients undergoing resection of SPAs or FPAs from a single high-volume neurosurgeon between 2007 and 2018 at Brigham and Women's Hospital. Descriptive statistics and the Mantel-Cox log-rank test were used to identify differences in outcomes between these cohorts, and multivariate logistic regression was used to identify predictors of radiographic recurrence for SPAs. Our cohort included 88 SPAs and 200 FPAs. The majority of patients in both cohorts were female (48.9% of SPAs and 63.5% of FPAs). SPAs were larger in median diameter than FPAs (2.1cm vs. 1.2cm, p < 0.001). The most frequent subtypes of SPA were gonadotrophs (55.7%) and corticotrophs (30.7%). Gross total resection (GTR) was achieved in 70.1% of SPA resections and 86.0% of FPA resections (p < 0.001). SPAs had a higher likelihood of recurring (hazard ratio [HR] 3.2, 95% confidence interval [95%CI] 1.6-7.2) and a higher likelihood of requiring retreatment for recurrence (HR 2.5; 95%CI 1.0-6.1). Subset analyses revealed that recurrence and retreatment were more both likely for subtotally resected SPAs than subtotally resected FPAs, but this pattern was not observed in SPAs and FPAs after GTR. Among SPAs, recurrence was associated with STR (odds ratio [OR] 9.3; 95%CI 1.4-64.0) and younger age (OR 0.92 per year; 95%CI 0.88-0.98) in multivariable analysis. Of SPAs that recurred, 12 of 19 (63.2%) were retreated with repeat surgery (n = 11) or radiosurgery (n = 1), while the remainder were observed (n = 7).There were similar rates of recurrence across different SPA subtypes. Patients undergoing resection of SPAs should be closely monitored for disease recurrence through more frequent clinical follow-up and diagnostic imaging than other adenomas, particularly among patients with STR and younger patients. Several patients can be observed after radiographic recurrence, and the decision to retreat should be individualized. Longitudinal clinical follow-up of SPAs, including an assessment of symptoms, endocrine function, and imaging remains critical.

Clinical application of combination [11C]C-methionine and [13N]N-ammonia PET/CT in recurrent functional pituitary adenomas with negative MRI or [18F]F-FDG PET/CT

BackgroundWe assessed the value of positron emission tomography/computed tomography (PET/CT) with [13N]N-ammonia ([13N]N-NH3) and [11C]C-methionine ([11C]C-MET) for the evaluation and management of recurrent secreting pituitary adenoma, which could not be detected by magnetic resonance imaging (MRI) or fluorine-18 fluorodeoxyglucose ([18F]F-FDG) PET.MethodsNine consecutive patients with biochemical and clinical evidence of active recurrent tumor not detected by MRI and [18F]F-FDG PET were enrolled in this study. All of the patients underwent [13N]N-NH3 and [11C]C-MET PET/CT, after which the pattern of tracer uptake was studied, the tumor position was located, and a clinical decision was made.ResultsIn general, [11C]C-MET had a higher uptake in pituitary adenomas (PAs) than that in pituitary tissues, while [13N]N-NH3 had a higher uptake in pituitary tissue than in pituitary adenomas. Increased [11C]C-MET uptake was observed in all nine PAs and three pituitary tissues, while all pituitary tissues and only one pituitary adenoma showed increased [13N]N-NH3 uptake. Four patients had concordant imaging and surgical findings indicative of biochemical remission without hypopituitarism after treatment. Radiotherapy was adopted in two patients, medication in another two, and follow-up observation in one case.ConclusionCombined [11C]C-MET and [13N]N-NH3 PET/CT is effective in the differentiation of PAs from pituitary tissue in recurrent functional PAs with negative MRI or [18F]F-FDG PET. These results provide a valuable reference for further disease management.

Endoscopic Endonasal Trans-Sphenoidal Minimally Invasive Pituitary Surgery with Image Guided Navigation System (Igns): Learning Experience of Ent Surgeon: First Author.

During the period of April 2015 to August 2022 a total 104 patients, diagnosed with pituitary adenoma underwent surgery and further followed up in a multidisciplinary team approach in a tertiary care hospital of Kolkata, India. The data obtained were reviewed statistically to satisfy the study objectives. Total 104 operations were done on 98 patients and total cases taken for calculation and analysis was 98, which consist of 11 microadenomas, 81 macroadenomas. Among 35 patients with normal preoperative hormonal assay, one patient developed postoperative hypopituitarism. Among 6 patients with preoperative hypopituitarism 4 patients (66.6%) recovered after surgery. Overall, 85 cases had total disease clearance as detected on post-operative MRI. In functioning pituitary adenoma (FPA) clinical and endocrinological improvement occurred after primary surgery in 85.36% (n = 35) and after revision surgery it was 84.44% (n = 38). Macroadenomas, giant adenomas were found to have statistically significant higher risk of incomplete disease clearance but large adenomas do not have statistically higher risk of incomplete clearance. IGNS requires extra time for setup, but with proper registration of tracker instruments it adds precision to the surgery. IGNS supplements endoscopic visualization with localization of target lesion by real time stereotactic feedback using preset preoperative imaging data, thus increasing accuracy, safety and effectiveness of minimally invasive surgery.

THU090 18F-FET PET-MRI; A Novel And Improved Technique For Detection Of Small Functional Pituitaryadenomas

Abstract Disclosure: I. Pruis: None. E. verbrug: None. M. smits: None. M. vernooij: None. R.A. Feelders: None. R. Blavers: None. S. velthuijzen: None. S.J. Neggers: None. Background Small functional pituitary adenomas can cause severely disabling symptoms and early death, however, surgical planning is often complicated due to inconclusive diagnostic MRI in up to 40% of patients and therefore hamper cure rates. We here introduce a novel method for the detection of small functional pituitary adenoma by O-(2-[18F]-fluoroethyl)-L-tyrosine ([18F]FET) PET-MRI. Methods Patients with Cushing’s disease (CD) or acromegaly with a suspected primary or recurrent small functional pituitary adenoma underwent [18F]FET PET-MRI. Focal uptake of [18F]FET was evaluated by a single nuclear radiologist and MRI was separately evaluated by a single neuroradiologist. Outcomes were compared with clinical follow-up and sensitivity and positive predictive values (PPV) were calculated. Findings Consecutive 28 patients, 68% female, mean age 50 years (range: 24–71), with CD (n=22; 79% or acromegaly (n=6; 21%) were scanned. 17 CD patients with a primary diagnosis had also undergone IPSS and 3 (50%) had a primary acromegaly diagnosis. 14/22 CD patients (64%) and 1/6 acromegaly underwent transsphenoidal surgery after [18F]FET PET, others are waiting or refused. Twenty-two CD patients (100%) had a positive [18F]FET PET, allowing to identify pituitary adenomas as small as 3 mm in size on accompanying MRI. 11/14 CD patients who underwent subsequent transsphenoidal surgery are biochemically in remission; rendering an estimated sensitivity of 100% and a PPV between 78–100% to detect CD. Four acromegaly patients (67%) had a positive [18F]FET PET. One acromegaly patient was biochemically in remission after transsphenoidal surgery. Conclusion [18F]FET PET-MRI shows high accuracy for localizing small functional pituitary adenoma in patients with CD and acromegaly. The diagnostic yield of this hybrid imaging technique exceeds that of MRI alone and IPSS and provides a welcome improvement for diagnosis, planning of surgery and follow-up. Presentation: Thursday, June 15, 2023

Supervised machine learning to validate a novel scoring system for the prediction of disease remission of functional pituitary adenomas following transsphenoidal surgery

Functional pituitary adenomas (FPAs) are associated with hormonal hypersecretion resulting in systemic endocrinopathies and increased mortality. The heterogenous composition of the FPA population has made modeling predictive factors of postoperative disease remission a challenge. Here, we aim to define a novel scoring system predictive of disease remission following transsphenoidal surgery (TSS) for FPAs and validate our process using supervised machine learning (SML). 392 patients with FPAs treated at one of the three Mayo Clinic campuses were retrospectively reviewed. Variables found significant on multivariate analysis were incorporated into our novel Pit-SCHEME score. The Pit-SCHEME score with a cut-off value ≥ 6 achieved a sensitivity of 86% and positive likelihood ratio of 2.88. In SML models, without the Pit-SCHEME score, the k-nearest neighbor (KNN) model achieved the highest accuracy at 75.6%. An increase in model sensitivity was achieved with inclusion of the Pit-SCHEME score with the linear discriminant analysis (LDA) model achieving an accuracy of 86.9%, which suggests the Pit-SCHEME score is the variable of most importance for prediction of postoperative disease remission. Ultimately, these results support the potential clinical utility of the Pit-SCHEME score and its prospective future for aiding in the perioperative decision making in patients with FPAs.

The "candy wrapper" of the pituitary gland: a road map to the parasellar ligaments and the medial wall of the cavernous sinus.

The anatomy of the medial wall of the cavernous sinus (MWCS) and parasellar ligaments (PLs) has acquired increasing importance in endoscopic endonasal (EE) surgery of the cavernous sinus (CS), including resection of the MWCS in functioning pituitary adenomas (FPAs). Although anatomical studies have been published, it represents a debated topic due to their complex morphology. The aim is to offer a description of the PLs that originate from the MWCS and reach the lateral wall of the cavernous sinus (LWCS), proposing the "candy wrapper" model. The relationships between the neurovascular structures and histomorphological aspects were investigated. Forty-two CSs from twenty-one human heads were studied. Eleven specimens were used for EE dissection; five underwent a microscopic dissection. Five specimens were used for histomorphological analysis. Two groups of PLs with a fan-shaped appearance were encountered. The anterior group included the periosteal ligament (55% sides) and the carotico-clinoid complex (100% sides), formed by the anterior horizontal and the carotico-clinoid ligaments. The posterior group was formed by the posterior horizontal (78% sides), and the inferior hypophyseal ligament (34% sides). The periosteal ligament originated inferiorly from the MWCS, reaching the periosteal dura. The anterior horizontal ligament was divided in a superior and inferior branch. The superior one continued as the carotid-oculomotor membrane, and the inferior branch reached the CN VI. The carotico-clinoid ligament between the middle and anterior clinoid was ossified in 3 sides. The posterior horizontal ligament was related to the posterior genu and ended at the LWCS. The inferior hypophyseal ligament followed the homonym artery. The ligaments related to the ICAform part of the adventitia. The "candy wrapper" model adds further details to the previous descriptions of the PLs. Understanding this complex anatomy is essential for safe CS surgery, including MWCS resection for FPAs.

Resection of corticotroph microadenomas invading the medial wall of the cavernous sinus in two cases of a primary and recurrent case of Cushing’s disease

Emerging evidence from multiple highly specialized groups continues to support a role for resection of the medial wall of the cavernous sinus when it is invaded by functional pituitary adenomas, to offer durable biochemical remission. The authors present two cases of Cushing’s disease that underscore the power of this surgical technique in achieving remission in microadenomas that ectopically present in the cavernous sinus or have invaded the medial wall of the sinus. This video demonstrates key steps in the safe removal of the medial wall of the cavernous sinus and successful resection of tumor burden in the cavernous sinus for sustained postoperative remission. The video can be found here: https://stream.cadmore.media/r10.3171/2023.4.FOCVID2323

Double functional pituitary adenomas causing acromegaly and subclinical Cushing disease

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

Management of pituitary incidentalomas

Pituitary incidentalomas are common findings with increasing use of modern neuroradiological imaging undertaken for symptoms unrelated to pituitary disease. The prevalence of these lesions is ∼10% in autopsy studies and the incidence varies from 10% to 38% on magnetic resonance imaging in the published literature. They are almost always benign in nature and most are non-functioning (non-secreting) adenomas. Although many individuals are asymptomatic at diagnosis, some with functioning (secreting) pituitary adenomas or larger non-functioning adenomas have symptoms. All identified cases should have a thorough clinical and endocrinological evaluation to help with precise management, which depends on the size of the lesion, hormonal status (functioning versus non-functioning adenoma) and the presence of visual deficits resulting from optic nerve compression by the pituitary adenoma. Here, we provide an overview of the initial assessment and management of pituitary incidentalomas for clinicians not routinely involved in the management of pituitary disease.

An Acromegalic Patient with Sickle Cell Disease Undergoing Endoscopic Trans-Sphenoidal Surgery: Anesthetic Concerns for a Neuroanesthesiologist

AbstractSickle cell disease (SCD) refers to a group of hemoglobinopathies that include mutations in the gene encoding the β subunit of hemoglobin. The glutamine in the heme portion of the hemoglobin molecule is abnormally substituted by valine. Sickle hemoglobin (hemoglobin type S), when gets deoxygenated, tends to polymerize and aggregate leading to vaso-occlusion and organ ischemia. Such patients are at increased risk of perioperative mortality and severe complications like vaso-occlusive crisis, acute chest syndrome, and congestive heart failure. We describe the perioperative management of a case of SCD with acromegaly scheduled for trans-sphenoidal removal of a functional pituitary adenoma. The acromegalic habitus, the cardiovascular effects of acromegaly, and the hormonal imbalances due to pituitary adenoma pose challenges in addition to the challenge of preventing complications of SCD making the anesthetic management more exigent.

Prospective evaluation of multidimensional health-related quality of life after endoscopic endonasal surgery for pituitary adenomas using the endoscopic endonasal sinus and skull base surgery questionnaire.

Social functioning is an important factor in the evaluation of postoperative health-related quality of life (HRQoL) for pituitary adenoma patients. In a prospective cohort study multidimensional HRQoL of non-functioning (NFA) and functioning (FA) pituitary adenoma patients were evaluated following endoscopic endonasal surgery using the endoscopic endonasal sinus and skull base surgery questionnaire (EES-Q). Prospectively, 101 patients were included. The EES-Q was completed preoperatively and postoperatively (2 weeks, 3months, 1year). Sinonasal complaints were completed daily during the first week postoperatively. Preoperative and postoperative scores were compared. A generalized estimating equation (uni- and multivariate) analysis was performed to identify significant HRQoL changes related to selected covariates. Two weeks postoperatively, physical (p < .05) and social (p < .05) HRQoL are worse and psychological (p < .05) HRQoL improved compared with preoperatively. Three months postoperatively, psychological HRQoL (p=.01) trended back to baseline and no differences in physical or social HRQoL were reported. One year postoperatively, psychological (p=.02) and social (p=.04) HRQoL improved while physical HRQoL remained stable. FA patients report a worse HRQoL preoperatively (social, p < .05) and 3months postoperatively (social, p < .02 and psychological, p < .02). Sinonasal complaints peak in the first days postoperatively and gradually return to presurgical levels 3months postoperatively. The EES-Q provides meaningful information on multidimensional HRQoL to improve patient-centred health care. Social functioning remains the most difficult area in which to achieve improvements. Despite the relatively modest sample size, there is some indication that the FA group continues to show a downward trend (and thus improvement) even after 3months, when most other parameters reach stability. Level II-B.

Disparities in Postoperative Endocrine Outcomes After Endoscopic-Assisted Transsphenoidal Pituitary Adenoma Resection.

Objectives Socioeconomic factors can influence morbidity in patients with pituitary adenoma. This study aims to identify associations between socioeconomic factors and postoperative outcomes in patients with pituitary adenomas. Methods A retrospective medical chart review was conducted on adultpatients who underwent resection of purely sellar nonfunctional and functional pituitary adenomas between May 1, 2014, and May 31, 2020, at the University of North Carolina Medical Center. The main outcome measures included the incidence ofpostoperative diabetes insipidus (PDI), postoperative hyponatremia (PHN), and postoperative hypopituitarism (PHP). Outcome measures were analyzed using univariate and multivariate analyses against preoperative tumor volume as well as socioeconomic and demographic factors (self-identified race/ethnicity, age, gender, address assessed by the Area Deprivation Index (ADI), and insurance status). Results On univariate analysis, patients of Hispanic race/ethnicity and patients living in more disadvantaged neighborhoods had an increased incidence of postoperative diabetes insipidus. Patients who experienced PDI were significantly younger on average in both univariate and multivariate analyses. When analyzed further, patients of Hispanic race/ethnicity were significantly younger and more likely to be uninsured compared to their respective racial/ethnic counterparts. No significant correlations were found for PHN or PHP. Conclusions Patients of Hispanic race/ethnicity and patients living in more disadvantaged neighborhoods were more likely to experience PDI. This finding, when combined with findings regarding age and insurance status, suggests complex disparities in medical care that are confirmed or corroborated by prior literature. These results may enhance clinicians' management of patients from disadvantaged socioeconomic backgrounds through increased awareness of disparities and the provision of resources for assistance.

ODP329 Long-term Effect of Daily Growth Hormone Replacement Therapy on Glucose Tolerance in Adult growth Hormone Deficiency

Abstract Background Growth hormone replacement therapy (GHRT) in adults with growth hormone deficiency (AGHD) has shown to improve body composition, lipid and bone metabolism, and quality of life (QOL), but its effect on glucose tolerance can be bidirectional. Objective To investigate the long-term effect of GHRT on glucose tolerance in AGHD patients. Patients and Methods We conducted a retrospective single-center study at Kobe University Hospital. One hundred twenty-five AGHD patients who had visited our department since January 2011 to September 2021 were enrolled. The exclusion criteria was as follows: Patients 1) who never received GHRT 2) whose HbA1c was 6.5% or higher, or under antidiabetic drugs before GHRT, 3) not available data on HbA1c at baseline or after GHRT 4) with functional pituitary adenomas, 5) who had initiated GHRT at childhood and had discontinued GH for less than 1year due to transition, 6) who receiving supraphysiological doses of steroid therapy, 7) GHRT interruption period for more than 1 year or its initiation from less than 2 months. Fifty-three AGHD patients eventually met the inclusion criteria. We collected data at baseline, 3, 6, 12 months after treatment, and at each patients’ last visit. The influence of GHRT on glucose metabolism and its associated factors were analyzed. All data were presented as median [interquartile range]. Results Fifty-three patients (27 female (51. 0%), 14 childhood onset (26.4%), age at GH initiation was 45 [32 - 60] years, the duration of GHRT was 4 [2 - 6] years) were analyzed. Both IGF-I levels and IGF-I SDS increased at the last visit compared to baseline: 56 [38 - 88] to 119 [84.5 - 181] ng/mL (P&amp;lt;0. 01), and -3.4 [-5.1 - -2.4] to -0.2 [-1.8 - 1.1] (P&amp;lt;0. 01), respectively. Waist circumference and BMI remained unchanged: 85 [78 - 90.5]cm to 78.5 [72.1 - 86. 0]cm (P=0.18), 23.1 [21.3 - 26.3] kg/m 2 to 22.9 [21.9 - 26.8] kg/m 2 (P=0.53), respectively. HbA1c at baseline, 3, 6, 12 months after treatment, and the last visit were unchanged: 5.7[5.4 - 5.9]%, 5.7 [5.5 - 5.9]%, 5.8 [5.5 - 6. 0]%, 5.7 [5.5 - 6. 0]%, and 5.7 [5.5 - 6. 0]% (P=0.27). Based on the amount of change in HbA1c (ΔHbA1c) between baseline and at the last visit, we divided into two groups; Elevated/ Unchanged (E/U), and Reduced (R). Interestingly, the amount of change in BMI increased in E/U group but decreased in R group (0.9[-0.1–1.8] vs. -1.2[-1.4 - -0.1], P=0. 02). Conclusions Overall, GHRT was safely used in regard with impaired glucose tolerance at least non-diabetes mellitus patients with AGHD. Among them, cases with impaired glucose tolerance during GHRT were associated with increased BMI. Presentation: No date and time listed

Endoscopic endonasal approach to pituitary adenomas: Impact on adenohypophyseal function. Study of 231 cases

PurposeTo identify presurgical and surgical factors associated with the development of hypopituitarism and its recovery after endoscopic endonasal transsphenoidal (EET) resection of pituitary adenomas (PAs). MethodsRetrospective study of patients with PAs operated by the same neurosurgeon through an EET approach in two Spanish tertiary hospitals in ten years. Results242 pituitary surgeries performed in 231 patients were analyzed. In the 154 surgeries performed in 146 patients with non-functioning PAs (NFPAs), 46.8% (n=72) presented presurgical hypopituitarism. After PAs resection, 41 of these (56.9%) normalized pituitary function and 11 of 82 patients with preoperative normal function (13.4%) developed new pituitary deficits. Patients with preoperative visual impairment (OR=3.9, p=0.046) and operated in the first four years of the neurosurgeon's learning curve (OR=5.7, p=0.016) presented a higher risk of developing postoperative hypopituitarism.Of the 88 surgeries in 85 patients with functioning PAs (FPAs), 23.9% presented presurgical hypopituitarism, and 47.6% of those recovered after surgery. 9% of the cases with preoperative normal function developed new pituitary deficit/s. Diabetic patients presented a higher risk of persistence of hypopituitarism (OR=10.5, p=0.024). Patients with presurgical visual impairment (OR=30.0, p=0.010) and PAs>3cm (OR=14.0, p=0.027) had higher risk of developing new pituitary deficits. ConclusionApproximately 50% of patients with PAs and preoperative hypopituitarism recover pituitary function after EET surgery. 10% of patients with normal function develop new deficits. Patients with NFPAs with visual involvement and operated in the first four years of neurosurgeon's learning curve, and FPAs patients with presurgical visual impairment and tumor size>3cm have a higher risk of postoperative hypopituitarism.

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

The Endoscopic Endonasal Transsphenoidal Approach for Thyrotropin-Secreting Pituitary Adenomas: Single-Center Experience and Clinical Outcomes of 49 Patients

To analyze surgical outcomes and tumor characteristics of 49 patients with thyrotropin-secreting pituitary adenoma, a rare functional pituitary adenoma subtype with challenging surgery, who underwent endoscopic endonasal transsphenoidal surgery. In this single-center study, clinical, radiological, surgical, and endocrinological data of 49 patients diagnosed with thyrotropin-secreting pituitary adenoma were retrospectively reviewed. Mean tumor size was 21.12 mm (6 microadenomas, 41 macroadenomas, 2 giant adenomas). Cavernous sinus invasion was present in 12 (24.48%) patients. Tumor consistency was firm in 23 (46.93%) patients. Plurihormonal secretion characteristics were present in 9 patients (5 growth hormone+ thyrotropin and 4 growth hormone+ prolactin+ thyrotropin). Mean follow-up duration was 51.73 months. Of the cases with firm tumors, 14 patients had a history of antithyroid drug use; there was no statistically significant correlation between the antithyroid medication and the firmness of the tumor. Gross total resection was achieved in 32 (65.30%) cases, near-total resection was achieved in 14 (28.57%) cases, and subtotal resection was achieved in 3 (6.12%) cases. The analysis showed that the negative effect of >2 cm tumor size and cavernous sinus invasion on resection rate was statistically significant (P < 0.001). Although early remission was achieved in 33 (67.34%) patients, 44 (89.79%) patients were in euthyroid state at >3 months' follow-up. Complications were 4 new-onset pituitary deficiencies, 3 cases of permanent diabetes insipidus, 1 thyrotoxic crisis, and 1 cerebrospinal fluid leak. Endoscopic endonasal transsphenoidal surgery is the first-line treatment in thyrotropin-secreting pituitary adenoma and should be performed in a tertiary center. Gross total resection is the goal, and early diagnosis is essential for surgical success.

Identifying risk factors for postoperative diabetes insipidus in more than 2500 patients undergoing transsphenoidal surgery: a single-institution experience.

Diabetes insipidus (DI) following transsphenoidal surgery can adversely impact quality of life and be difficult to manage. This study sought to characterize pre- and perioperative risk factors that may predispose patients to DI after pituitary surgery. A retrospective review of patients treated at a single institution from 2007 to 2019 was conducted. DI was defined as postoperative sodium > 145 mEq/L and urine output > 300 ml/hr and/or postoperative desmopressin (ddAVP) use. DI was further characterized as transient or permanent. Uni- and multivariate analyses were performed to determine variables associated with postoperative DI. The authors identified 2529 patients who underwent transsphenoidal surgery at their institution. Overall, DI was observed in 270 (10.7%) of the 2529 patients, with 114 (4.5%) having permanent DI and 156 (6.2%) with transient symptoms. By pathology type, DI occurred in 31 (46.3%) of 67 craniopharyngiomas, 10 (14.3%) of 70 apoplexies, 46 (14.3%) of 322 Rathke's cleft cysts, 77 (7.7%) of 1004 nonfunctioning pituitary adenomas (NFPAs), and 62 (7.6%) of 811 functioning pituitary adenomas (FPAs). Final lesion pathology significantly affected DI rates (p < 0.001). Multivariate analysis across pathologies showed that younger age (odds ratio [OR] 0.97, p < 0.001), intraoperative CSF encounter (OR 2.74, p < 0.001), craniopharyngioma diagnosis (OR 8.22, p = 0.007), and postoperative hyponatremia (OR 1.50, p = 0.049) increased the risk of DI. Because surgery for each pathology created specific risk factors for DI, the analysis was then limited to the 1815 pituitary adenomas (PAs) in the series, comprising 1004 NFPAs and 811 FPAs. For PAs, younger age (PA: OR 0.97, p < 0.001; NFPA: OR 0.97, p < 0.001; FPA: OR 0.97, p = 0.028) and intraoperative CSF encounter (PA: OR 2.99, p < 0.001; NFPA: OR 2.93, p < 0.001; FPA: OR 3.06, p < 0.001) increased DI rates in multivariate analysis. Among all PAs, patients with DI experienced peak sodium levels later than those without DI (postoperative day 11 vs 2). Increasing tumor diameter increased the risk of DI in FPAs (OR 1.52, p = 0.008), but not in NFPAs (p = 0.564). In more than 2500 patients treated at a single institution, intraoperative CSF encounter, craniopharyngioma diagnosis, and young age all increased the risk of postoperative DI. Patients with postoperative hyponatremia exhibited higher rates of DI, suggesting possible bi- or triphasic patterns to DI. Greater vigilance should be maintained in patients meeting these criteria following transsphenoidal surgery to ensure early recognition and treatment of DI.