Incidence Of Hypopituitarism Research Articles

Incidence of hypopituitarism in adults undergoing radiotherapy for neck and head cancer: protocol for a systematic review and meta-analysis

IntroductionWhen children with head and neck cancer receive radiation therapy as part of their treatment, a considerable frequency of hypopituitarism has been recognised. However, in adults, it has been little...

MON-274 Analysis of Perioperative Prophylactic Steroid for Pituitary Surgery Using a National Inpatient Database in Japan

BACKGROUND: There is not enough evidence regarding the need for perioperative prophylactic steroid at the time of transsphenoidal pituitary surgery [1], and it is currently administered empirically. In patients with normal preoperative adrenal function, the meta-analysis of nonrandomized studies [2] and only two randomized controlled studies [3,4] suggested no necessity to routine steroid administration, but the number of the studies subjects was small. Analysis using big data has not been performed. Therefore, this study examined the relationship between perioperative steroid administration and complications using a nationwide Diagnosis Procedure Combination database in Japan.Method: We performed a retrospective study on patients who had undergone pituitary surgery (excluding meningiomas, Cushing’s disease, and preoperative steroid administration) between July 2010 and March 2016. To this end, a nationwide inpatient database in Japan was used, and the patients were divided into a prophylactic steroid-administered group and a nonadministered group. Patients’ complications, including hypopituitarism, diabetes insipidus, meningitis, hyponatremia, and hypokalemia, and discharge status were examined by inverse probability of treatment weighting using propensity score.Result: A total of 7,725 inpatients received prophylactic steroids, whereas 864 did not. The inverse probability of treatment weighting using propensity score revealed that the incidence of hypopituitarism and diabetes insipidus was significantly higher in the prophylactic steroid group than in the nonsteroid group (3.5% vs. 0.5%, P 0.001 and 9.6% vs. 6.0%, P = 0.001, respectively). There were no significant differences in the incidences of meningitis, electrolyte abnormalities, and length of hospital stay.This study using big data suggests that prophylactic steroid administration may not be necessary in patients with an intact adrenocortical function undergoing transsphenoidal pituitary surgery.1. Fleseriu M, et al. J Clin Endocrinol Metab. 101:3888–3921 (2016)2. Tohti M, et al. PLoS One 10: e0119621 (2015)3. Sterl K, et al. Neurosurgery 85: E226-e232 (2019)4. Lee HC, et al. Neurosurg (2020, in press)

Pituitary Dysfunction after Radiation for Anterior Skull Base Malignancies: Incidence and Screening.

Background Management of anterior cranial base malignancies requires multidisciplinary care. Radiation therapy remains a mainstay of definitive or adjuvant treatment. Apart from primary hypothyroidism, the effects of radiation on the hypothalamic-pituitary axis after high-dose treatment of head and neck malignancies remain poorly described. We describe a comprehensive screening protocol for surveillance and characterize the incidence of pituitary dysfunction after radiation for anterior cranial base malignancies. Methods A review of patients prospectively enrolled in a skull base registry at an academic center was performed. Included patients had a history of anterior skull base malignancy and external beam radiation to the primary site, with comprehensive post-treatment pituitary serologies and at least 1 year of post-radiation follow-up. Routine hormonal screening was initiated during the study period for all patients with anterior skull base irradiation. Results Eighty-one patients met inclusion. Fifty-eight patients (71%) demonstrated some laboratory abnormality. Thirty patients (37%) demonstrated evidence of hypopituitarism. Twenty-four (29%) demonstrated central hypogonadism, and 16% of patients showed central hypothyroidism. Ten patients (12%) displayed central adrenal insufficiency with six patients demonstrating panhypopituitarism. Primary tumor location and maximum dose of radiation to the gland appeared to correlate with incidence of hypopituitarism. Conclusion Radiation for malignancies of the anterior skull base resulted in a 37% incidence of hypopituitarism in our study. Given the potential morbidity of hypopituitarism, we recommend annual post-treatment screening in these patients. We describe a comprehensive set of serologies that can be utilized, and recommend updating clinical guidelines to reflect the necessity of this screening.

A clinical analysis of 123 cases of primary empty sella

Objective: This study was conducted to analyze the clinical characteristics and pituitary function of patients with primary empty sella (PES). Methods: The clinical data from 123 hospitalized adult patients with PES from January 2010 to May 2016 were retrospectively studied. Results: (1) The average age of the 123 (male 43, female 80) PES patients was (59.2±13.6) years (ranging 24-92 years), among whom 61% patients were in the age group between 50-69 years. (2) The symptoms of the patients included fatigue (56.1%), headache (34.1%), nausea and vomiting (17.9%), gonadal dysfunction (17.1%), visual disturbance (5.7%) and hypopituitarism crisis (3.3%). (3) Hypopituitarism was found in 66 of the 123 patients. Among them, 36.6%, 31.7% and 17.1% were central hypoadrenalism, hypogonadism, and hypothyroidism, respectively.The percentage of hypopituitarism in complete PES was significantly higher than that in partial PES (P<0.05). (4) Sixteen patients were concomitant with other autoimmune diseases including 11 patients with Graves' disease and 2 with Cushing's syndrome due to adrenal adenoma. Conclusions: The incidence of hypopituitarism in PES was 53.7%, in which the pituitary-adrenal axis hypofunction was more common. An overall evaluation of the pituitary function was essential for the patients who had headache and fatigue, or with suspected PES. The patients with hypopituitarism should be given hormone replacement therapy in time and followed up afterword.

Hypopituitarism patterns among adult males with prolactinomas

ObjectivesThe objective of this study was to characterize hypopituitarism in adult males with prolactinomas. Patients and methodsWe retrospectively analyzed the records of 102 consecutive patients, classified under three categories based on adenoma size at diagnosis: 1.0–2.0cm (group A), 2.1–4.0cm (group B), and >4.0cm (group C). Further, 76 patients had successful outcomes at follow-up. We compared different forms of pituitary hormone dysfunction (growth hormone deficiency, hypogonadism, hypothyroidism, and hypocortisolism) based on the maximal adenoma diameter. ResultsSerum prolactin levels were significantly correlated with the maximal adenoma diameter (r=0.867; P=0.000). Of the patients, 89.2% presented with pituitary failure, which included 74.5% with growth hormone deficiency, 71.6% with hypogonadism, 28.4% with hypothyroidism, and 12.7% with hypocortisolism. The three groups did not differ significantly (P>0.05) in the incidence of hypopituitarism, including the extent of pituitary axis deficiency, at presentation and following treatment. However, there was a statistically significant difference in the degree of hypogonadism in cases of acquired pituitary insufficiency at diagnosis (P=0.000). ConclusionIn adult males with prolactin-secreting adenomas, the most common form of pituitary hormone dysfunction was growth hormone deficiency and hypogonadism, whereas hypocortisolism was less common. The maximal adenoma diameter and prolactin secretion did not determine hormone insufficiency in adult males with prolactinomas, but these factors did affect the degree of both hypogonadism and hypothyroidism. Smaller tumors were found to recur more frequently than large tumors, and recovery was more common in cases of growth hormone deficiency and hypogonadism.

Profile of adult hypopituitarism: A single-center experience

Context : The incidence of hypopituitarism in the general population is 4 in 100,000, but there is a paucity of data on hypopituitarism. There are only two studies published from India on hypopituitarism. Aims: To study the clinical profile of hypopituitarism in a tertiary care center in Kerala. Settings and Design: This study was carried out in patients attending medicine and endocrinology outpatient and inpatient departments in Pushpagiri Medical College Hospital, Tiruvalla, Kerala between September 2013 and November 2014. Subjects and Methods: The study included 36 subjects of adult acquired hypopituitarism. Relevant clinical, hormonal, and imaging data were collected. Dynamic testing was done when necessary. Deficiency of hormones was defined based on standard recommendations. Results: The mean age was 48.6 years. There were 22 (59%) males and 14 females (41%). The most common presentation included altered sensorium (44.4%), hypogonadism, and menstrual irregularity (22.22%). As for the etiology of hypopituitarism, tumors (pre- and post-operative) comprised 58.3% of cases. Empty sella was found in 19.4% of patients with postsnake bite hypopituitarism (Simmonds syndrome) in 13.8%. Panhypopituitarism was seen in 86% of patients. Conclusions: Hypopituitarism is much more common than previously thought, and there is a delay in diagnosis either due to clinical inertia or due to its late and subtle presentation. The most common cause of hypopituitarism in a tertiary care center is pituitary tumors, and the most common presenting complaint is altered sensorium.

Pituitary and/or hypothalamic dysfunction following moderate to severe traumatic brain injury: Current perspectives.

There is an increasing deliberation regarding hypopituitarism following traumatic brain injury (TBI) and recent data have suggested that pituitary dysfunction is very common among survivors of patients having moderate-severe TBI which may evolve or resolve over time. Due to high prevalence of pituitary dysfunction after moderate-severe TBI and its association with increased morbidity and poor recovery and the fact that it can be easily treated with hormone replacement, it has been suggested that early detection and treatment is necessary to prevent long-term neurological consequences. The cause of pituitary dysfunction after TBI is still not well understood, but evidence suggests few possible primary and secondary causes. Results of recent studies focusing on the incidence of hypopituitarism in the acute and chronic phases after TBI are varied in terms of severity and time of occurrence. Although the literature available does not show consistent values and there is difference in study parameters and diagnostic tests used, it is clear that pituitary dysfunction is very common after moderate to severe TBI and patients should be carefully monitored. The exact timing of development cannot be predicted but has suggested regular assessment of pituitary function up to 1 year after TBI. In this narrative review, we aim to explore the current evidence available regarding the incidence of pituitary dysfunction in acute and chronic phase post-TBI and recommendations for screening and follow-up in these patients. We will also focus light over areas in this field worthy of further investigation.

Long-Term Outcomes and Toxicities of Growth Hormone (Somatotroph)–Secreting Pituitary Macroadenomas Treated With Adjuvant Fractionated Stereotactic Radiation Therapy (FSRT)

Somatotroph-secreting pituitary adenomas (SSPA) require long term follow-up to assess response to radiation therapy. There is a paucity of data pertaining to long term tumor control and treatment complication outcomes published for SSPAs treated with adjuvant FSRT. A recent review of the literature showed biochemical control rates 20-50% and local control 91-100% with median follow-up ranging from 39-80 months. These studies reported 10.9-37% incidence of hypopituitarism and 0-5.4% rate of visual deficits.

Chronic hypopituitarism is uncommon in survivors of aneurysmal subarachnoid haemorrhage.

The incidence of hypopituitarism after aneurysmal subarachnoid haemorrhage (SAH) is unclear from the conflicting reports in the literature. As routine neuroendocrine screening for hypopituitarism for all patients would be costly and logistically difficult, there is a need for precise data on the frequency of hypopituitarism and on factors which might predict the later development of pituitary dysfunction. We aimed to: (i) Establish the incidence of long-term hypopituitarism in patients with aneurysmal SAH. (ii) Determine whether data from patients' acute admission with SAH could predict the occurrence of long-term hypopituitarism. One hundred patients were studied prospectively from the time of presentation with acute SAH. Plasma cortisol, plasma sodium and a variety of clinical and haemodynamic parameters were sequentially measured for the first 12 days of their acute admission. Forty-one patients then underwent dynamic pituitary testing at median 15 months following SAH (range 7-30 months), with insulin tolerance test (ITT) or, if contraindicated, a glucagon stimulation test (GST) plus short synacthen test (SST). If symptoms of cranial diabetes insipidus (CDI) were present, a water deprivation test was also performed. Forty-one patients attended for follow-up dynamic pituitary testing. Although 14 of 100 had acute glucocorticoid deficiency immediately following SAH, only two of 41 had long-term adrenocorticotrophic hormone (ACTH) deficiency and four of 41 had growth hormone (GH) deficiency. None were hypothyroid or gonadotrophin deficient. None had chronic CDI or hyponatraemia. There was no association between acute glucocorticoid deficiency, acute CDI or acute hyponatraemia and long-term pituitary dysfunction. Both anterior and posterior hypopituitarism are very uncommon following SAH and are not predicted by acute clinical, haemodynamic or endocrinological parameters. Routine neuroendocrine screening is not justified in SAH patients.

The incidence of hypopituitarism in post interventional subarachnoid haemorrhage (SAH) survivors in a tertiary neurosurgical unit

The incidence of hypopituitarism in post interventional subarachnoid haemorrhage (SAH) survivors in a tertiary neurosurgical unit

Epidemiology, mortality rate and survival in a homogeneous population of hypopituitary patients

Hypopituitarism is associated with higher prevalence of cardiovascular risk factors and premature death. Furthermore, some clinical and therapeutic features of hypopituitarism have been associated with a worse prognosis. We reviewed, retrospectively, a large series of adult patients with hypopituitarism using stringent epidemiological criteria. Prevalence, association with cardiovascular risk factors, mortality and survival have been analysed. Two hundred and nine adult hypopituitary patients (56·9% females) from a population of 405218 inhabitants, followed for 10years. Prevalence of hypopituitarism at the end of the study was 37·5cases/100000 inhabitants. Incidence of hypopituitarism was 2·07cases/100000 inhabitants and year. Thirty-two patients died during the period of the study. Standardized mortality rate (SMR) was 8·05, higher in males (8·92 vs 7·34) and in younger patients (84·93 vs 5·26). Diagnosis of acromegaly (P=0·033), previous radiotherapy (P=0·02), higher BMI (P=0·04), diabetes mellitus (P=0·03) and cancer (P<0·0001) were associated with mortality. A lower survival was associated with older age at diagnosis, nontumoural causes, previous radiotherapy, diabetes mellitus with poor metabolic control and malignant disease. Prevalence of hypopituitarism was 37·5 cases/100000 inhabitants, and annual incidence was 2·07 cases/100000 inhabitants. SMR was 8 times higher in hypopituitarism than in general population and was also higher in males and younger patients. Reduced survival was significantly related to cancer, nontumoural causes of hypopituitarism, older age at diagnosis, previous radiotherapy and diabetes mellitus with poor metabolic control.

Is Hypothyroidism and Hypogonadism an Issue after Aneurysmal Subarachnoid Hemorrhage-An Institutional Experience?

BackgroundThe incidence of hypopituitarism in aneurysmal subarachnoid hemorrhage ranges from 0% to 45%. Also the screening for hypopituitarism in survivors of aneurysmal SAH is not a routine. This has led to a controversy in the management of such patients.ObjectivesThe aim of the study was to evaluate the endocrine profile of our patients who had presented with aneurysmal SAH.Patients and MethodsThis was a prospective study conducted over a period of three years in patients of aneurysmal subarachnoid hemorrhage. The serum samples for levels of free T4, free T3, TSH, prolactin, FSH, LH and testosterone were analyzed at the time of admission and at a follow-up period between 9-12 months. Patients with known endocrine abnormalities, liver or kidney disease and patients with hemodynamic abnormalities were excluded from the study. Abnormalities in levels were noted and a comparative analysis of the hormone levels between the 2-time periods was done. A total of 73 patients were enrolled in the study.ResultsSerum prolactin was raised in 17.80% (13/73) and FSH, LH and testosterone levels were reduced in 12.32% (9/73) of patients in the acute phase at admission. After 9 months follow-up, serum prolactin normalized in all except one patient and in all the males, testosterone level increased significantly. Two patients (3%) developed central hypothyroidism on follow-up.ConclusionsChronic hypothyroidism and hypogonadism is not an issue in aneurysmal SAH patients

Outcome in acromegaly: A retrospective analysis

Introduction:Many of the treatment modalities recommended for acromegaly are either too expensive or not available in large parts of India. There is a dearth of treatment and outcome data in Indian patients.Aims and Objectives:The purpose of this study was to analyze the treatment modalities used and the respective outcomes which include remission, recurrence, hypopituitarism, other complications, and mortality.Materials and Methods:This is a retrospective data analysis of 15 acromegaly patients treated at a tertiary care hospital in eastern India. A remission criteria of nadir growth hormone level <1 μg/dl after Oral Glucose tolerance test (OGTT) and normal age related IGF-1 levels was used.Results:All patients (100%) had macroadenomas. Surgery could not be done in five (33%); three (19.8%) refused, two (13.2%) had comorbidities. Transsphenoidal surgery (TSS) achieved remission in four out of ten (40%). Conventional radiotherapy (CRT) failed in all five patients and caused hypopituitarisn in three (60%). Cabergoline (CAB) either alone or following surgery achieved remission in one out of four (25%) though symptomatic relief and tolerability were remarkable. One patient (7%) had pituitary apoplexy with remission, two patients (14.3%) died due to CVA.Conclusions:TSS remains the treatment of choice in acromegaly, though in macroadenomas the success is limited. A sizeable proportion of patients refuse or are unfit for surgery. As most of the recommended options are very costly or unavailable, alternative treatment options generally used are CRT or CAB which have limited efficacy. Incidence of hypopituitarism, following CRT is very high.

Pituitary dysfunction in survivors of spontaneous subarachnoid hemorrhage of anterior communicating artery and middle cerebral artery aneurysms: A comparative study

The data on incidence of hypopituitarism after SAH are conflicting. Furthermore, it is still not known whether there is any difference in hormonal deficiencies between SAH due to anterior communicating artery (A-com) and middle cerebral artery (MCA) aneurysms. This study includes both retrospective and prospective arms. The data collected included baseline demographic profile, clinical severity on admission to the hospital by the Hunt and Hess grading system and World Federation of Neurological Surgeons (WFNS) grading, radiological severity of bleed by the Fisher's classification, and treatment details. All the patients underwent detailed hormonal evaluation at baseline and 6 months in prospective group while at the end of 1 year in the retrospective group. Hormonal deficiencies between patients with A-com and MCA aneurysmal SAH were compared using appropriate statistical tests. Of 60 patients studied, 47 patients (A-com: 28 and MCA: 19) were in the retrospective group, while 13 patients (A-com-9, MCA-4) were in the prospective group. The baseline data were comparable between the two groups. At or after 6 months follow-up, 19 (31.6%) patients, 10 patients with A-com and 9 patients with MCA aneurysmal SAH, had some form of hormone deficiency. Furthermore, there was no difference in endocrine dysfunctions between the two groups. There was no correlation between the severity of hormonal deficiency and the clinical severity of SAH grade by Hunt and Hess and radiological grade of SAH by Fisher's grade. Hormonal deficiencies are not uncommon in patients with SAH. There is no difference in hormonal deficiencies and severity of hypopituitarism in patients with SAH due to A-com and MCA bleed.

Is it possible to avoid hypopituitarism after irradiation of pituitary adenomas by the Leksell gamma knife?

Radiation therapy is one of the treatment options for pituitary adenomas. The most common side effect associated with Leksell gamma knife (LGK) irradiation is the development of hypopituitarism. The aim of this study was to verify that hypopituitarism does not develop if the maximum mean dose to pituitary is kept under 15 Gy and to evaluate the influence of maximum distal infundibulum dose on the development of hypopituitarism. We followed the incidence of hypopituitarism in 85 patients irradiated with LGK in 1993-2003. The patients were divided in two subgroups: the first subgroup followed prospectively (45 patients), irradiated with a mean dose to pituitary <15 Gy; the second subgroup followed retrospectively 1993-2001 and prospectively 2001-2009 (40 patients), irradiated with a mean dose to pituitary >15 Gy. Serum TSH, free thyroxine, testosterone or 17β-oestradiol, IGF1, prolactin and cortisol levels were evaluated before and every 6 months after LGK irradiation. Hypopituitarism after LGK irradiation developed only in 1 out of 45 (2.2%) patients irradiated with a mean dose to pituitary <15 Gy, in contrast to 72.5% patients irradiated with a mean dose to pituitary >15 Gy. The radiation dose to the distal infundibulum was found as an independent factor of hypopituitarism with calculated maximum safe dose of 17 Gy. Keeping the mean radiation dose to pituitary under 15 Gy and the dose to the distal infundibulum under 17 Gy prevents the development of hypopituitarism following LGK irradiation.

Editorial

median follow-up of 10 years, 6 46% of patients with acromegaly who underwent radiosurgery had endocrine remission at 10 years and 50% developed new anterior pituitary insufficiencies, the majority of which appeared more than 5 years after treatment. This incidence of hypopituitarism is similar to that reported in many studies of radiation therapy with follow-up of similar duration. Other factors that influence a perception of radiosur gery’s increased utility of and lower risk of loss of pituitary function include comparison of the results of the 2 modalities in different eras. The summary of radiation therapy experience is almost always from period before the general use of radiosurgery. The imaging modalities used to detect the tumor and define its anatomy in the pre-radiosurgery era were less sensitive (before MR imaging), and modern surgery is more effective at removing tumor. Considering the 2 treatment eras and the smaller tumor size and more minimally damaged pituitary before delivery of radiosurgery, differences in tumor size at di

The German Database on Hypopituitarism after Traumatic Brain Injury and Aneurysmal Subarachnoid Hemorrhage – Description, Objectives and Design

Within the last years, a number of clinical studies have addressed the topic of hypothalamo-pituitary dysfunction following traumatic brain injury (TBI) and aneurysmal subarachnoid hemorrhage (SAH). Clinical studies oftentimes reflect the investigation of highly selective patient groups, very standardized test procedures and may be influenced by a publication bias. Epidemiological data on the prevalence and incidence of hypopituitarism after TBI and SAH in the general population still do not exist. Moreover, very little is known about risk factors and clinical characteristics of pituitary impairment after brain damage. Epidemiologic surveys which aggregate information of many different treatment centers become an increasingly important means of bridging the gap between standardized study situations and clinical practice. Therefore, a multi-center, structured data assessment to create a national registry of TBI and SAH patients has been established in 2005. The Structured Data Assessment of Hypopituitarism after TBI and SAH is coordinated by the Department of Endocrinology, Max-Planck-Institute in Munich with participation of at present 13 neurosurgical, rehabilitation and endocrinological centers in Germany and one Austrian center. Within this database, a large scope of very detailed, clinical, endocrine and outcome information is collected. It also offers the possibility of long-term follow up of the recorded patients. This is the first report of the registry describing goals, organization, methodology, funding and the descriptive data of the first 1,242 patients entered until November 20th, 2008.

017--Growth Hormone Deficiency Following Head Trauma—Case Presentation

Traumatic brain injury is a major public health problem with an overall incidence of 235 per 100,000 persons per year. Approximately 180 children per 100,000 population sustain closed head injuries each year, with only 5.6 per 100,000 in the severest category. Adults have a much higher incidence than children. Traffic accidents, falls, sports, and child abuse are the most common etiological factors for children. It is estimated that the incidence of hypopituitarism caused by these disorders is more than 30 patients per 100,000 population per year—a much higher prevalence than previously suspected.

The role of pegvisomant in the treatment of acromegaly

Background: Expert surgery in acromegaly is curative in about only 60% of cases. Postsurgical radiation therapy is associated with a high incidence of hypopituitarism and its effect on growth hormone decrease is slow. Therefore, effective adjuvant medical treatment is mandatory. Objective: To delineate the role of pegvisomant in the treatment of acromegaly. Methods: A search of the Medline, Embase and Web of Science databases for clinical studies on pegvisomant was performed. In addition, abstracts of the major endocrine society meetings in 2007 were searched. Results: When treatment with somatostatin analogues after non-curative surgery does not lead to normalisation of serum IGF-I and growth hormone concentrations, pegvisomant alone or in combination with somatostatin analogues can control disease in a substantial number of patients. The most important side effects are disturbed liver function tests and, rarely, growth of the adenoma. The efficacy in non-operated patients and the long-term safety have yet to be ascertained.

The need for patients' endocrine function vigilance following treatment of head and neck cancer

The aim of this article is to examine the need for screening of endocrine dysfunction following treatment of head and neck cancer. The incidence of occult hypothyroidism following treatment of head and neck cancer is high. Patients who develop hypothyroidism after treatment may have an increased survival compared with patients who did not become hypothyroid. Because of the growing body of evidence that supports a permissive role for thyroid hormone in the growth of certain solid tumours thyroid hormone replacement therapy may not be indicated in patients with subclinical hypothyroidism and prior or current cancer. Although the incidence of hypoparathyroidism after treatment for head and neck cancer is low, testing of serum calcium is easily performed during thyroid function evaluation. The incidence of hypopituitarism after irradiation of the nasopharynx or skull base is very high warranting regular evaluation of endocrine functions. Owing to the high incidence of endocrine dysfunction, all head and neck cancer patients who undergo treatment of the lower neck, nasopharynx or base of skull need regular endocrine evaluation during long-term follow-up to determine the need to start hormone replacement therapy and maintain optimal quality of life.