Transsphenoidal Adenectomy Research Articles

THU072 Association Between Nonalcoholic Fatty Liver Disease And Growth Hormone Deficiency In Patients With Nonfunctioning Pituitary Adenoma

Abstract Disclosure: Y. Hwang: None. H. Lee: None. S. Ahn: None. E. Lee: None. C. Ku: None. S. Kim: None. Objective: We investigated the association between nonalcoholic fatty liver disease (NAFLD) and growth hormone deficiency (GHD) in patients with non-functioning pituitary adenoma (NFPA). Methods: Patients with NFPA who underwent transsphenoidal adenectomy between January 2005 and December 2018 were recruited. Pituitary function was determined by the insulin tolerance test, thyroid hormone assay, and gonadal hormone levels. NAFLD was defined as a hepatic steatosis index greater than 36. Results: 278 patients were included for the analysis. Mean age was 44.2 years and 58.6%[n=163] patients were female. Among 278 patients,103 (37.0%) had GHD, 139 (50.0%) had hypogonadism. 75 out of 278 patients (27.0%) had NAFLD. The prevalence of NAFLD was significantly higher in patients with GHD than in those without (36.9% vs. 21.1%, p=0.01). Even after adjusting for age, total cholesterol level, gonadal function, and prolactin level, patients with GHD had approximately two-fold higher prevalence of NALFD than those without GHD (adjusted odds ratio [OR]=1.85, 95% confidence interval [CI]=1.05-3.28, p=0.03). Among female patients, the prevalence of NALFD was significantly higher in those with GHD than in those without (adjusted OR=2.39, 95% CI=1.03-5.55, p=0.04). On the other hand, the prevalence of NAFLD among male patients was statistically similar between patients with and without GHD (p>0.05). In addition, gonadal function did not affect the prevalence of NAFLD in patients with NFPA (29.3% with eugonadism vs. 47.8% with hypogonadism, p=0.14). Conclusion: The prevalence of NAFLD among patients with NFPA was twice as high as among patients without GHD. Thus, screening for NAFLD may be necessary in NFPA patients with GHD. Presentation: Thursday, June 15, 2023

FRI292 Asymptomatic TSH Secreting Pituitary Macroadenoma

Abstract Disclosure: B. Gautam: None. M.S. Hossain: None. H. liao: None. K. Mandal: None. D.S. Rosenthal: None. S.C. Kumar: None. Introduction: TSH-producing adenoma is a rare disorder accounting for 0.5-2% of all pituitary adenomas with prevalence of 1-2 cases/million, often diagnosed at the stage of invasive macroadenoma hence challenging to manage. Case Presentation: A 36 years old male with no PMH referred to endocrine clinic for the evaluation of insomnia with abnormal thyroid panel for last 4 years. He denied skin or hair changes, diaphoresis, tremor, change in appetite, weight or bowel habits, cold/heat intolerance, palpitations, recent use of biotin or x-ray contrast exposure. Patient denied headache, visual or hearing impairment, galactorrhea, sexual dysfunction, change in facial appearance or size of gloves & shoes. Patient also denied childhood history of developmental delay, learning disability and family history of thyroid disorder. Unremarkable physical exam with normal vitals. Thyroid was normal without palpable nodule. No thyroid bruit. Normal visual field by confrontation. No tremors, gynecomastia or galactorrhea noted. Laboratory results showed normal CBC, CMP, TSH 5.2 (0.55-4.78 uIU/ml) with FT4 2.1 (0.8-1.8 ng/dl), FT3 5.4 (2.3-4.2 pg/ml), FT4 by dialysis 3.1 (0.9-2.2 ng/dl), FT3 by dialysis 433 pg/dl, Thyroglobulin ab <1 (<1 IU/ml), TPO ab 3 (<9 IU/ml), TSI <89 (<140%), TBII <1 (<2 IU/L), HAMA <6 (<74 ng/ml). Normal ACTH 17 (6-50 pg/ml), serum cortisol level 10.5 (5.2-22.4 ug/dl), prolactin 9.2 (2-18 ng/dl), GH 0.1 (<7.1 ng/ml), IGF-1 183 (53-331 ng/ml), LH 4.7 (1.5-9.3 mIU/ml), FSH 5.9 (1.6-8 mIU/ml), free testosterone 120 (35-155 pg/ml) and total testosterone 1100 (250-1100 ng/dl), SHBG 82 (10-50 nmol/L), alpha-subunit 0.8 (0.1-0.5 ng/ml) & alpha/TSH molar ratio 1.5. MRI brain with pituitary protocol showed an expansile round enhancing soft tissue mass filling the sellar cavity measuring 1.5 x 1.5 x 1.3 cm tenting the optic chiasm without cavernous sinus involvement. Patient was diagnosed with TSH secreting pituitary adenoma and referred to Neurosurgery. Patient had successful trans-sphenoidal adenectomy. Post-surgery TFTs: TSH 2.18 (0.55-4.78 uIU/ml), FT4 1.2 (0.8-1.8 ng/dl). Pathology report showed pituitary adenoma, IM stains positive for FSH, GH patchy and TSH (patchy and weak), negative for prolactin and ACTH. Rare tumor cells positive for LH Discussion: Our case highlights the importance of early diagnosis and appropriate treatment of TSH secreting adenoma to prevent complications such as hyperthyroidism, visual field defect and pan-hypopituitarism. Diagnosis in our case was particularly challenging as the patient was completely asymptomatic, therefore emphasize the importance of correlating TSH level with FT4 and early evaluation of central cause in the presence of biochemical evidence suggesting central thyroid disorder. Presentation: Friday, June 16, 2023

Cardiovascular remodeling in active and controlled acromegaly: association with sleep-disordered breathing.

We hypothesized that anunfavorable cardiovascular profile in acromegaly is associated with sleep-disordered breathing (SDB), while acromegaly control improves both respiratory sleep characteristics and thecardiovascular profile. The patients underwent the assessment of breathing during sleep and cardiovascular profileassessment atthe start of the studyincluding arterial stiffness, blood pressure, echocardiography, nocturnal heart rate variability (HRV). The assessment was repeated in patients withacromegaly at 1 year after transsphenoidal adenectomy (TSA). A total of 47 patients with acromegaly and 55 control subjects were enrolled. At one year after TSA, 22 patients with acromegaly were reassessed.Multiple linear regression analysis with adjustment for age, sex and body mass index (BMI) showed the associations of insulin growth-like factor 1 (IGF-1) with obstructive apnea index (OAI: β=0.035/h, p<0.001), but not with cardiovascular parameters, in patients withacromegaly. The analysis of combined acromegaly and control dataset with adjustment for age, sex and BMI showed the association the presence of acromegaly with diastolic blood pressure (DBP; β=17.99 mmHg, p<0.001), ejection fraction (EF; β=6.23%, p=0.009), left heart remodeling (left ventricle posterior wall: β=0.81 mm, p=0.045) and the association of the presence of SDB (apnea-hypopnea index≥15/h) with left ventricular function (EF: -4.12%, p=0.040; end systolic volume: 10.12 ml, p=0.004). Control of acromegaly was accompanied by the decrease in OAI (5.9 [0.8, 14.5]/h and 1.7 [0.2, 5.1]/h, p=0.004) and nocturnal heart rate (66.1 [59.2, 69.8] bpm and 61.7 [54.0, 67.2] bpm, p=0.025) and by the increase in blood pressure (DBP: 78.0 [70.3, 86.0] mm Hg and 80.0 [80.0, 90.0] mm Hg, p=0.012). The comorbidities of acromegaly, including sleep-disordered breathing, appear to have a long-term effect on cardiovascular remodeling in active acromegaly. Future studies should investigate the applicability of the treatment of SDBfor the reduction of cardiovascular risk in acromegaly.

Caloric restriction as a possible pitfall for persistent acromegaly follow-up – case report

BackgroundAcromegaly diagnosis is established when plasma levels of IGF-1 are increased and the Oral Glucose Tolerance Test (OGTT) with 75gr of glucose can’t suppress Growth Hormone (GH) levels. These two parameters are also useful during follow-up, after surgical/radiologic therapy and/or during medical therapy.Case presentationA 29-year-old woman was diagnosed with acromegaly after a severe headache. Previous amenorrhea and facial and acral changes were noticed. A pituitary macroadenoma was found, biochemical evaluation was in agreement with the suspected acromegaly and a transsphenoidal adenectomy was performed. As the disease recurred, a surgical reintervention and radiosurgery (Gamma Knife, 22 Gy) were necessary. No normalization of IGF-1 was achieved during three years after radiosurgery. Surprisingly, then, and although clinical features seemed getting worse, IGF-1 levels became consistently controlled to 0.3–0.8 times the upper limit of the reference range. Questioned, the patient referred that she was following an intermittent fasting dietary plan. However, based on the dietary questionnaire, she was found to be under severe caloric restriction. First OGTT (under caloric restriction) showed absence of GH suppression and an IGF-1 value of 234 ng/dL (Reference Range 76–286 ng/mL). A second OGTT, one month after an eucaloric diet was instituted, showed an increased IGF-1 of 294 ng/dL, maintaining an unsuppressed, yet less elevated, GH.ConclusionsGHRH/GH/IGF-1 axis controls somatic growth. Regulation is complex, and nutrition status and feeding pattern have a recognized role. Like systemic inflammation or chronic liver disease, fasting and malnutrition decrease the expression of hepatic GH receptors, with consequent reduction of IGF-1 levels, through resistance to GH. This clinical report shows that caloric restriction may represent a pitfall in acromegaly follow-up.

Positive association between nonalcoholic fatty liver disease and growth hormone deficiency in patients with nonfunctioning pituitary adenoma.

Non-alcoholic fatty liver disease (NAFLD) is characterized by growth hormone deficiency (GHd). We investigated the association between NAFLD and GHd in patients with nonfunctioning pituitary adenomas (NFPA). We recruited patients with NFPA who underwent transsphenoidal adenectomy between January 2005 and December 2018. Pituitary function was determined by the insulin tolerance test, thyroid hormone assay, and gonadal hormone levels. NAFLD was defined as a hepatic steatosis index greater than 36. Among 278 patients (mean age, 44.2 years; 58.6% [n=163] female), 103 (37.0%) had GHd, 139 (50.0%) had hypogonadism, and 75 (27.0%) had NAFLD. The prevalence of NAFLD was significantly higher in patients with GHd than in those without (36.9% vs. 21.1%, p=0.01). Even after adjusting for age, total cholesterol level, gonadal function, and prolactin level, patients with GHd had approximately two-fold higher prevalence of NALFD than those without GHd (adjusted odds ratio [OR]=1.85, 95% confidence interval [CI]=1.05-3.28, p=0.03). Among female patients, the prevalence of NALFD was significantly higher in those with GHd than in those without (adjusted OR=2.39, 95% CI=1.03-5.55, p=0.04); whereas, among male patients, the prevalence of NAFLD was statistically similar between those with and without GHd (p>0.05). In addition, gonadal function did not affect the prevalence of NAFLD in patients with NFPA (29.3% with eugonadism vs. 47.8% with hypogonadism, p=0.14). Among patients with NFPA, the prevalence of NAFLD was two-fold higher in patients with GHd than that in those without GHd. Thus, screening for NAFLD might be required in NFPA patients with GHd.

Features of the incidence of postoperative complications in patients with transsphenoidal pituitary adenectomy

Features of the incidence of postoperative complications in patients with transsphenoidal pituitary adenectomy

Quantitative and functional visual field outcomes after endoscopic trans-sphenoidal pituitary adenectomy.

Quantitative data on visual outcomes after trans-sphenoidal surgery is lacking in the literature. This study aims to address this by quantitatively assessing visual field outcomes after endoscopic trans-sphenoidal pituitary adenectomy using the capabilities of modern semi-automated kinetic perimetry. Visual field area (deg2) calculated on perimetry performed before and after surgery was statistically analysed. Functional improvement was assessed against UK driving standards. Sixty-four patients (128 eyes) were analysed (May 2016-Nov 2019). I4e and I3e isopter area significantly increased after surgery (p < 0.0001). Of eyes with pre-operative deficits: 80.7% improved and 7.9% worsened; the median amount of improvement was 60% (IQR 6-246%). Median increase in I4e isopter was 2213deg2 (IQR 595-4271deg2) and in I3e isopter 1034 deg2 (IQR 180-2001 deg2). Thirteen out of fifteen (87%) patients with III4e data regained driving eligibility after surgery. Age and extent of resection (EOR) did not correlate with visual improvement. Better pre-operative visual field area correlated with a better post-operative area (p < 0.0001). However, the rate of improvement in the visual field area increased with poorer pre-operative vision (p < 0.0001). A median visual field improvement of 60% may be expected in over 80% of patients. Functionally, a significant proportion of patients can expect to regain driving eligibility. EOR did not impact on visual recovery. When the primary goal of surgery is alleviating visual impairment, optic apparatus decompression without the aim for gross total resection appears a valid strategy. Patients with the worst pre-operative visual field often experience the greatest improvement, and therefore, poor pre-operative vision alone should not preclude surgical intervention.

1351 Primary Pituitary Abscess Presenting as An Isolated Bitemporal Hemianopia

Abstract Pituitary abscesses are rare yet life-threatening entities. Most common presenting features are headache, hypopituitarism, and visual changes. Majority of patients are found to have a predisposing risk factor, such as a pre-existing pituitary lesion, recent pituitary surgery or irradiation, or a primary source of infection. We present the case of a 53-year-old male with a spontaneous pituitary abscess, who presented with an isolated bitemporal hemianopia, but was otherwise asymptomatic with no known risk factors. Magnetic resonance imaging showed a sellar and suprasellar mass, thought to be a pituitary macroadenoma. He underwent endoscopic transsphenoidal adenectomy and cystic fluid was seen intraoperatively. Microbiology analysis showed Staphylococcus Aureus, and a course of intravenous ceftriaxone was commenced. Histopathology reported no evidence of adenoma and impression was of a pituitary abscess. Following transsphenoidal resection and commencement of antibiotic therapy, the bitemporal hemianopia resolved. We therefore report a rare case of primary pituitary abscess and emphasise the importance of including this condition as a differential diagnosis in any patient with a visual deficit or new pituitary lesion.

Spinal epidural lipomatosis: a rare association of Cushing's disease.

SummaryExcess cortisol is associated with hypertrophy and redistribution of adipose tissue leading to central obesity which is classically seen in Cushing’s syndrome. Abnormal accumulation of fatty tissue in the spinal canal is most commonly associated with chronic steroid therapy and rarely reported with endogenous Cushing’s syndrome. Herein, we describe a case of spinal epidural lipomatosis (SEL) associated with Cushing’s disease. A 17-year-old man was referred with lower limb weakness, weight gain, multiple stretch marks, back pain and loss of height. He had clinical and biochemical features of Cushing’s syndrome. MRI and Inferior Petrosal Sinus Sampling (IPSS) confirmed a pituitary adenoma as the source. On day 1 post trans-sphenoidal adenectomy he developed spastic paraparesis with a sensory deficit to the level of T5. MRI spine showed increased fat deposition in the spinal canal from T2 to T9 consistent with a diagnosis of SEL. He was managed conservatively and made a good recovery following restoration of eucortisolism and a period of rehabilitation. Learning points:SEL is a serious complication of glucocorticoid excess and should be considered in any patient presenting with new lower limb neurological symptoms associated with hypercortisolism.It is important to distinguish symptomatic SEL from cortisol-induced proximal myopathy by good history and clinical examination.MRI of the spine is the gold standard investigation for making a diagnosis of SEL.Restoration of eucortisolism can lead to resolution of fat accumulation and good neurological outcome.

Fatal Iatrogenic Pituitary Apoplexy after Surgery for Neuroophthalmological Disorder

Perioperative medical management of patients undergoing transsphenoidal pituitary surgery may represent a challenge and can require expert overall knowledge.1–3 The autonomous feeding and the oral assumption of drugs is not possible in the immediate postoperative period. Accordingly, an adequate correction of water imbalance and food deficit could be achieved by feeding via gastric probe.Here, we present an image, from reconstructed tridimensional computed tomography scans, which shows a disastrous misadventure during postoperative management in a patient with neuroophthalmologic disorder. A 50-yr-old Caucasian woman was admitted to the hospital for visual impairment, headache, and vertigo. Examination disclosed a pituitary adenoma, and the transsphenoidal adenectomy was performed. Postoperatively, based on a gradual worsening of general status, the patient was transferred to the intensive care unit. During the night, at the shift change, a nasogastric tube was placed by a clinician who was not aware of the surgery performed.The patient developed hemodynamic collapse and imaging demonstrated intracranial positioning of the nasogastric tube. The cause of death was considered to be pituitary apoplexy secondary to incorrect placement of the nasogastric tube.In general, although nasal placement of gastric or tracheal tubes is considered a safe medical procedure, clinicians should consider the (very rare) risk associated with its practice.Consequently, it is of crucial importance to evaluate the use of guidance systems (imaging or endoscopy) to verify the correct position of the tube during its insertion in these circumstances.The authors would like to thank Ernesto d’Aloja, M.D., Ph.D., Maurizio Fossarello, M.D., and Gabriele Finco, M.D., of the University of Cagliari, Cagliari, Italy, for their help in critical manuscript revision.The authors declare no competing interests.

Delayed Remission of Growth Hormone-Secreting Pituitary Adenoma After Transsphenoidal Adenectomy

To investigate the clinical characteristics of delayed remission (DR) of growth hormone (GH)-secreting pituitary adenoma after transsphenoidal adenectomy and inform follow-up treatments. We retrospectively reviewed 87 patients who had undergone transsphenoidal surgery for acromegaly. Demographic, radiological, and endocrinological data were reviewed before, immediately after, 3 months after, and in the long term (2.4 ± 1.1 years) after surgery. The definition of DR was that patients did not achieve GH remission immediately, 3 months, or later after surgery, but did so in the long term without any additional postoperative treatment. Fifty-one patients (58.6%) achieved long-term GH remission. There were 24 (27.6%) DR patients immediately postoperatively and 9 (10.3%) DR patients 3 months postoperatively. On average, the 24 DR patients achieved remission at 10.2 (range, 3-32) months. Immediate postoperative random and nadir GH after an oral glucose load were significantly lower in the DR group than in the nonremission group (2.73 ± 3.17 and 2.03 ± 2.59 vs. 8.05 ± 10.35 and 5.55 ± 5.91 μg/L, respectively). Three-month postoperative nadir GH was significantly lower in the DR group than in the nonremission group (1.63 ± 2.82 vs. 3.48 ± 4.25 μg/L, P= 0.007). Immediate postoperative random GHeffectively predicted long-term remission (Spearman's ρ= 0.513, area under the curve= 0.905 > 0.90). However, the best predictor of long-term remission was 3-month postoperative nadir GH (Spearman's ρ= 0.728, area under the curve= 0.944 > 0.90), with 76.5% sensitivity and 97.2% specificity. For certain groups of patients likely to achieve DR, additional treatments should not be performed early after surgery. Prolonged follow-up and close observation could help determine the therapeutic effect of surgery and guide postoperative treatments.

Body mass index and insulin-like growth factor 1 as risk factors for discordant growth hormone and insulin-like growth factor 1 levels following pituitary surgery in acromegaly

Growth hormone (GH)-secreting pituitary adenoma is a chronic disease characterized by excess levels of GH and insulin-like growth factor 1 (IGF-1). Based on our clinical experience and observations, we identified discordant GH and IGF-1 levels after surgery. The risk factors for this phenomenon are unclear, and individualized cure, control criteria, and management after surgery should be considered. This study aims to investigate the factors affecting the discordant GH and IGF-1 levels after pituitary surgery in acromegalic patients. We retrospectively analyzed 146 patients diagnosed with acromegaly caused by GH-secreting pituitary adenoma who had undergone trans-sphenoidal adenectomy (TSA) at Peking Union Medical College Hospital in 2013. Medical histories were obtained for all patients. Hormone levels, biochemical measurements of liver and renal function, and tumor size were recorded before and 3months after surgery. Among the GH-cured patients who had normal GH levels after TSA, 39.2% (20 of 51) had elevated IGF-1. Acromegalic patients with elevated IGF-1 and normal GH levels after TSA had a significantly higher mean body mass index and percentage of upper limit of normal range IGF-1 than the cured patients (p<0.05). A body mass index greater than >25.0kg/m2 and a percentage of upper limit of normal range IGF-1 higher than 141.5 before TSA might predict the occurrence of hormone-level discordance after surgery. Body mass index and percentage of upper limit of normal range IGF-1 before TSA might constitute prognostic risk factors for discordance in IGF-1 and GH levels in acromegaly. Additional attention should be devoted to potential risk factors for this phenomenon, and methods for modifying the cure and control criteria for acromegaly should be developed.

Effect of Transsphenoidal Adenectomy on Glucose Tolerance Status in Patients with Growth Hormone-secreting Pituitary Adenoma.

To explore the effect of transsphenoidal adenectomy on glucose tolerance status in patients with growth hormone (GH)-secreting pituitary adenoma. The clinical data of 105 patients with GH-secreting pituitary adenoma who underwent transsphenoidal adenectomy in our department in 2013 were retrospectively analyzed. The glucose tolerance status, GH level, and insulin-like growth factor-1 (IGF-1) level before and after surgery were compared. Among these 105 patients, the blood glucose tolerance status included normal glucose tolerance (NGT) in 47 cases (44.8%), early carbohydrate metabolism disorders (ECMDs) in 26 cases (24.8%), and diabetes mellitus (DM) in 32 cases (30.5%) before surgery. After the surgery, the fasting blood glucose (P=0.006, P=0.017) and postprandial blood glucose (P=0.000, P=0.000) in the ECMDs and DM groups were significantly improved. Also, the random GH (P=0.001, P=0.004, P=0.001), nadir GH (P=0.000, P=0.001, P=0.001), and IGF-1 (P=0.005, P=0.000, P=0.000) significantly decreased during the follow-up period in NGT, ECMDs and DM groups. Compared with ECMDs and DM groups, the decrease in fasting blood glucose (P=0.029, P=0.000), postprandial blood glucose (P=0.003, P=0.000), and serum IGF-1 (P=0.048, P=0.000) were more significant in DM group. Transsphenoidal adenectomy can improve the blood glucose, GH, and IGF-1 levels in patients with growth hormone-secreting pituitary adenoma. Meanwhile,the surgery has a better effect in improving the glucose tolerance status and IGF-1 in patients with preoperatively confirmed DM.

The influence of pituitary adenoma size on vision and visual outcomes after trans-sphenoidal adenectomy: a report of 78 cases.

ObjectiveThe aims of this study were to investigate the quantitative relationship between pituitary macroadenoma size and degree of visual impairment, and assess visual improvement after surgical resection of the tumor.MethodsThe medical records of patients with pituitary adenoma, who had undergone trans-sphenoidal adenectomy between January 2009 and January 2011, were reviewed. Patients underwent an ocular examination and brain MRI before and after surgery. The visual impairment score (VIS) was derived by combining the scores of best-corrected visual acuity and visual field. The relationship between VIS and tumor size/tumor type/position of the optic chiasm was assessed.ResultsSeventy-eight patients were included (41 male, 37 female). Thirty-two (41%) patients experienced blurred vision or visual field defect as an initial symptom. Receiver operating characteristic curve analysis showed that tumors <2.2 cm tended to cause minimal or no visual impairment. Statistical analysis showed that 1) poor preoperative vision is related to tumor size, displacement of the optic chiasm in the sagittal view on MRI and optic atrophy, and 2) poorer visual prognosis is associated with greater preoperative VIS. In multivariate analysis the only factor significantly related to VIS improvement was increasing pituitary adenoma size, which predicted decreased improvement.ConclusionResults from this study show that pituitary adenomas larger than 2 cm cause defects in vision while adenomas 2 cm or smaller do not cause significant visual impairment. Patients with a large macroadenoma or giant adenoma should undergo surgical resection as soon as possible to prevent permanent visual loss.

Predictors of Mortality and Long-term Outcomes in Treated Cushing's Disease: A Study of 346 Patients

Active Cushing's disease (CD) confers a 4-fold increase in mortality and is associated with significant morbidities. Although excess mortality risk may persist even after CD treatment, predictors of risk in treated CD are not well understood. To identify predictors of mortality, cardiovascular (CV) disease, and recurrence after long-term follow-up among patients with treated CD. A retrospective chart review was conducted to evaluate patients with CD who underwent transsphenoidal adenectomy with a single surgeon. Patients were categorized based on disease response after initial treatment. Cox proportional hazard models identified predictors of mortality, recurrence, and CV outcomes in the overall cohort and each subgroup. Three hundred forty-six subjects were included. Mean age was 39.9 years, and mean duration of follow-up was 6.3 years (range, 1 mo to 30 y). Duration of exposure to excess glucocorticoids, estimated by duration of symptoms before diagnosis until remission was achieved by any means, was 40.0 months. Multivariate analyses demonstrated that duration of glucocorticoid exposure elevated the risk of death (P = .038), as did older age at diagnosis (P = 0.0001) and preoperative ACTH concentration (P = .007). Among patients who achieved remission, depression increased the hazard of death (P < .01). Male sex, age at diagnosis, diabetes, and depression elevated the risk of CV disease (P < .05). Long-term follow-up of a large cohort of treated patients with CD identified several novel predictors of mortality. These data illustrate the importance of early recognition and treatment of CD. Long-term follow-up, with management of persistent comorbidities, is needed even after successful treatment of CD.

Management of Large Sellar Diaphragm Herniation During Transsphenoidal Pituitary Adenectomy

Management of Large Sellar Diaphragm Herniation During Transsphenoidal Pituitary Adenectomy

Acromegaly as a cause of 1,25-dihydroxyvitamin D-dependent hypercalcemia: case reports and review of the literature

Growth hormone excess has been associated with hypercalciuria and nephrolithiasis. Hypercalcemia in acromegaly is rare and usually due to coexistent primary hyperparathyroidism. To report two cases of 1,25-dihydroxyvitamin D (1,25 (OH)(2) D)-dependent hypercalcemia in cromegaly. A 50 year-old female with 2 years history of hypercalcemia presented with features of acromegaly. Serum calcium (Ca) was 10.9 mg/dl (8.6-10.2), parathyroid hormone (PTH) 20 pg/ml (10-65), PTH-related peptide undetectable, and 1,25 (OH)(2) D 119 pg/ml (15-75). Insulin-like growth factor 1 (IGF1) was 911 ng/ml (49-292) and growth hormone (GH) 14.5 ng/ml (0.03-10). MRI showed a 1.7 cm pituitary tumor. Transsphenoidal adenectomy (TSA) resulted in normalization of IGF1, GH, Ca, and 1,25 (OH)(2) D (50 pg/ml) and complete tumor resection. A 52-year-old female was diagnosed with visual field deficits on routine exam. MRI showed a 3 cm invasive pituitary macroadenoma. IGF1 was 416 ng/ml (87-238) and GH 75.8 (0-6.0) ng/ml. Incidentally, she was found with high Ca of 10.8 mg/dl (8.9-10.3) associated with PTH 19 pg/ml and 1,25 (OH)(2) D66 pg/ml. Postoperatively, IGF1 and GH remained abnormal (440 and 12.8 ng/ml, respectively), while MRI showed parasellar tumor residue. Ca remained high (10.1-11.1 mg/dl), along with elevated 1,25 (OH)(2) D level (81.3 pg/ml). In both cases, other causes of hypercalcemia were ruled out. We present 2 cases of 1,25 (OH)(2) D-dependent hypercalcemia associated with growth hormone excess. Complete resection of tumor produced biochemical remission of acromegaly and normalization of calcium and 1,25 (OH)(2) D levels, while incomplete resection was associated with persistent 1,25 (OH)(2) D-dependent hypercalcemia. Acromegaly should be considered a cause of 1,25 (OH)(2) D-dependent hypercalcemia.

Pregnancy with macroprolactinoma.

A macroprolactinoma recurred in a 25-year-old lady, who had initially presented with inability to conceive, secondary amenorrhea, galactorrhea and persistent headache. She was diagnosed as a patient of pituitary macroadenoma of 1.7 cm with elevated serum prolactin level. She was given Bromocriptine, which normalized her menstruation as well as the prolactin level followed by conception during treatment. Pregnancy remained uneventful till 27 weeks when she developed severe headache and total loss of vision from left eye and partial from right eye at 27 weeks. MRI showed enlargement of macroadenoma upto 2.5 cm with compression on optic chiasma. Transsphenoidal adenectomy was performed. After surgery visual field defect improved but plasma prolactin level remained elevated. She delivered vaginally at 39 weeks. Later, treatment with Bromocriptine (15 mg/day) failed to keep prolactin level normal and Lisuride hydrogen (0.8 mg/day) reduced the prolactin levels.

A case of lymphocytic hypophysitis with masked diabetes insipidus unveiled by glucocorticoid replacement

Lymphocytic hypophysitis may involve the pituitary gland and various hormonal abnormalities. A 72-year-old man presented with euvolemic hyponatremia caused by glucocorticoid deficiency. After glucocorticoid replacement, hypernatremia in the presence of dilute urine was found. Central diabetes insipidus (DI) was confirmed later by a significant increase in urine osmolality after vasopressin administration. Brain magnetic resonance imaging showed a pituitary mass and loss of hyperintense signal in the posterior pituitary gland on T1-weighted imaging. The patient underwent a transsphenoidal adenectomy, and pathological examination of dissected tissues showed a typical finding of lymphocytic hypophysitis. Two months after surgery, the patient's central DI had resolved sufficiently that 1-desamino-8- d -arginine vasopressin therapy was discontinued without polyuria. However, he was kept on glucocorticoid and levothyroxine therapy. In conclusion, lymphocytic hypophysitis may feature a concealed central DI caused by glucocorticoid deficiency-associated hyponatremia.

A survey of pituitary incidentaloma in Japan.

The development of computed tomography (CT) and magnetic resonance imaging (MRI) has resulted in the discovery of unsuspected endocrinologically silent pituitary masses (pituitary incidentalomas). The aim of this study was to perform a national survey on pituitary incidentalomas in order to establish an appropriate approach to them. Five hundred and six patients with pituitary incidentalomas were obtained by questionnaire from March 1999 to May 2000 under the auspices of the Ministry of Health, Labor and Welfare in Japan. Two hundred and fifty-eight patients underwent surgery (surgical group), while 248 patients were followed up conservatively for a mean period of 26.9 Months (range 6-173 Months) (non-surgical group). Clinical and biochemical assessment, CT or MRI of the pituitary, and visual field testing by Goldman perimetry were assessed at baseline and 6 Months and Yearly thereafter. Thirty-three patients with pituitary incidentalomas (13.3%) developed tumor enlargement during the mean follow-up period of 45.5 Months. Of 115 estimated non-functioning adenomas, 23 tumors (20.0%) increased during a mean follow-up period of 50.7 Months (range 10-173 Months), while 5 of 94 (5.3%) estimated Rathke's cysts increased in size during follow-up. Pituitary apoplexy occurred in one of 248 patients (0.4%). Pituitary incidentalomas usually follow a benign course. We recommend transsphenoidal adenectomy for a solid mass attached to the optic chiasma estimated to be a pituitary adenoma by MRI. Other patients should be followed up by MRI every 6 Months for the first 2 Years, and then Yearly.