Pituitary adenomas and neuropsychological status: a systematic literature review

Risk Factors for Suicidal Ideation and Attempt in Patients With Skull Base Tumors

OBJECTIVE

Patients with head and neck cancer experience suicide rates significantly higher than the general population. However, the relationship between skull base tumors (SBTs) and suicidal ideation and attempt (SIA) remains underexplored. This study aims to identify sociodemographic and clinical risk factors for SIA among patients with SBTs.

METHODS

A retrospective cohort study was conducted using the National Inpatient Sample (2016-2019) to analyze 275,195 hospitalizations involving SBTs. Survey-weighted methods were used to assess univariable and multivariable risk factors for SIA.

RESULTS

Among SBT patients, 2160 (0.78%) were diagnosed with SIA. Younger age (adjusted odds ratio [aOR]: 0.98; P < .001) and emergent admissions (aOR: 2.25; P < .001) were strongly associated with SIA. Socioeconomic difficulties were one of the most significant predictors (aOR: 7.57; P < .001). Depressive, bipolar, and adjustment disorders were the strongest mental health comorbidity predictors (aOR: 8.18, 7.24, 5.19, respectively; P < .001). Alcohol and cannabis use disorders also elevated SIA risk (aOR: 2.79, 2.29, respectively; P < .001). Protective factors included treatment in Western hospitals (aOR: 0.52; P < .001) and undergoing surgery (aOR: 0.29-0.36; P < .001). Meningiomas were associated with lower SIA odds (aOR: 0.68; P = .013), while pituitary adenomas showed a significant association in univariable analysis.

CONCLUSION

Younger age, socioeconomic difficulties, mental health comorbidities, and substance use are key risk factors for SIA in SBT patients, while surgery and treatment in Western hospitals are protective. Regular suicidality screening and proactive mental health interventions are essential for improving outcomes in this vulnerable population.

Social functioning longitudinal trajectory and its predictors in young and middle-aged postoperative pituitary tumor patients: A growth mixture model

PURPOSE

Pituitary adenoma and its treatments can significantly impact the social function of young and middle-aged patients. Monitoring social functioning trajectories over time provides a more holistic understanding of patients' quality of life. We aimed to study the social functional trajectories and their predictors to achieve individualized and comprehensive management.

METHODS

A longitudinal prospective survey was conducted from January 2021 to December 2022 in Nanjing, China. The convenience sampling method was adopted to recruit the patients with pituitary adenoma who underwent transsphenoidal surgery at the neurosurgery department in a tertiary-grade A hospital. The general information questionnaire, social disability screening scale and postoperative pituitary adenoma symptom distress scale were applied in different stages. Growth mixture modeling and the Logistic regression were utilized to identify the trajectory subgroups and their predictors of the social function.

RESULTS

Of 225 patients, 33 (14.67%) experienced "progressively recovered function", while 192 (85.33%) exhibited "persistently impaired social function". Factors associated with persistently impaired social function included fertility status (OR = 0.167, p = 0.001), visual loss (OR = 0.154, p = 0.012), and electrolyte disturbances at 6th month (OR = 0.047, p = 0.003). Conversely, patients with high monthly income (OR = 0.116, p = 0.000), good family support (OR = 3.890, p = 0.006), and preoperative headache (OR = 4.129, p = 0.006) were more likely to show progressively recovered function after surgery.

CONCLUSIONS

Patients with pituitary adenoma still experience social dysfunction six months after surgery. Fertility status, family support, economic status, and symptom distress were significant predictors. This study emphasizes the crucial role of symptom distress and family support, providing a basis for follow-up and intervention strategies.

Acromegaly and COVID-19, lessons, and new opportunities

The COVID-19 pandemic created challenges in effective management of patients with acromegaly. Specifically, with regards to timely diagnosis, delays in surgeries, and disruption(s) to routine patient care. A transition to telemedicine did help to overcome safety restrictions that were placed on in-person care. Creation of surgical safety protocols in conjunction with widespread testing for COVID-19 has also helped with the resumption of pituitary surgery cases. However, acromegaly related comorbidities including cardiovascular disease, diabetes mellitus, sleep apnea and respiratory disease, vertebral fractures, and hypopituitarism, may increase the risk of a more severe COVID-19 infection course. Of note and to date, no negative trends in COVID-19 related outcomes have been reported in patients with acromegaly. Nevertheless, anxiety and depression rates in patients with acromegaly are higher than those in the general population. More studies are needed to assess the true impact of the COVID-19 pandemic on morbidity, mortality, and neuropsychiatric health of patients with acromegaly.

Comparative Analysis of Cognitive and Psychiatric Functioning in People With Cushing's Disease in Biochemical Remission and People With Nonfunctioning Adenomas

People with Cushing's disease (CD) often experience both mood/anxiety disorders and cognitive impairments that persist during long-term biochemical remission. The relationship between persistent neurocognitive and psychiatric problems in patients with CD is not well understood. Also, mechanisms other than hypercortisolism are poorly understood, and studies comparing CD with nonfunctioning adenomas (NFA) patients postoperatively are scarce. We compared neuropsychological functioning in two groups: individuals with CD in remission (n = 20; 80% female; 61.6 [44.13] months since remission) and individuals with NFAs (n = 20). Evaluation was performed, on average, 4.9 years following pituitary surgery. We used mediation models to evaluate psychiatric dysfunction as a possible mediator of cognitive outcomes and assessed the influence of demographic and medical factors (age at diagnosis, remission duration, and radiation therapy) on neuropsychological outcomes. Neuropsychological outcomes did not differ significantly between groups; however, up to 30% of patients demonstrated mild impairments in attention, processing speed, executive functioning, and visual memory. Time since remission in the CD group was inversely correlated with processing speed; however, this relationship was no longer significant after controlling for the presence of hypertension and diabetes mellitus. Levels of anxiety, depression, or somatization were reported in up to 40% of people with CD. Further, 70% of people with CD and 35% of people with NFA reported continuous depressive symptoms lasting at least 2 years. In conclusion, neuropsychological screening in clinical practice and longitudinal studies in individuals with NFA and CD are needed to identify patients at risk for long-term neuropsychological dysfunction. Appropriate support and treatment are recommended for persistent cognitive and/or psychiatric dysfunction for both patient groups.

The gut microbiome in patients with Cushing's disease affects depression- and anxiety-like behavior in mice

BACKGROUND

Depression and anxiety significantly impact the quality of life in individuals with Cushing's disease (CD), which originates from pituitary neuroendocrine tumors (PitNETs), yet our understanding of the underlying mechanisms is limited. There is substantial evidence linking gut microbes to depression, anxiety, and endocrinology.

RESULTS

The gut bacterial phenotype of patients with Cushing's disease was significantly different from that of the control group, and when the mice were treated with fecal bacteria from these patients, both anxiety- and depression-like behavior were significantly increased. However, this effect can be alleviated by supplementing with 2-(14, 15-epoxyeicosatrienoyl) glycerol (2-14,15-EG) which was found at reduced levels in the peripheral blood of mice treated with coprofecal bacteria from Cushing's disease. In this process, the effects of hormone levels and immune factors were not significant. In addition, in an animal model, corticosterone has been observed to affect behavioral changes in mice through gut microbiota composition, clarifying the cause-and-effect relationship between hormones, microbiota, and behavior. Finally, there was no significant difference in gut microbiome composition and its effects on mouse behavior in patients with Cushing's disease with different levels of depression and anxiety.

CONCLUSIONS

In summary, this research enhances our current understanding of how gut microbes in patients with Cushing's disease contribute to depression and anxiety, offering novel insights for clinical treatment approaches. Video Abstract.

A medical chart audit to assess endocrinologist perceptions of the burden of endogenous Cushing's syndrome

PURPOSE

This study was undertaken to assess the unmet needs within the endogenous Cushing's syndrome (CS) care paradigm from the endocrinologist's perspective, including data abstracted from patient charts. The study evaluated endocrinologists' perceptions on burden of illness and treatment rationale along with the long-term clinical burden of CS, tolerability of CS treatments, and healthcare resource utilization for CS.

METHODS

Retrospective medical chart data from treated patients with a confirmed diagnosis of CS was abstracted using a cross-sectional survey to collect data from qualified endocrinologists. The survey included a case report form to capture patient medical chart data and a web-enabled questionnaire to capture practitioner-level data pertaining to endocrinologists' perceptions of disease burden, CS treatments, and treatment attributes.

RESULTS

Sixty-nine endocrinologists abstracted data from 273 unique medical charts of patients with CS. Mean patient age was 46.5 ± 13.4 years, with a 60:40 (female:male) gender split. The mean duration of endogenous CS amongst patients was 4.1 years. Chart data indicated that patients experienced a high burden of comorbidities and symptoms, including fatigue, weight gain, and muscle weakness despite multi-modal treatment. When evaluating treatments for CS, endocrinologists rated improvement in health-related quality of life (HRQoL) as the most important treatment attribute (mean score = 7.8; on a scale of 1 = Not at all important to 9 = Extremely important). Surgical intervention was the modality endocrinologists were most satisfied with, but they agreed that there was a significant unmet treatment need for patients with CS.

CONCLUSION

Endocrinologists recognized that patients with CS suffered from a debilitating condition with a high symptomatic and HRQoL burden and reported that improvement in HRQoL was the key treatment attribute influencing their treatment choices. This study highlights unmet needs for patients with CS. Patients with CS have a high rate of morbidity and comorbidity, even after treatment.

Sleep and cognition in South African patients with non-functioning pituitary adenomas

Strong lines of evidence in the neuroscience literature indicate that (a) healthy sleep facilitates cognitive processing, and (b) sleep disruption is associated with cognitive dysfunction. Despite the fact that patients with pituitary disease often display both disrupted sleep and cognitive dysfunction, few previous studies investigate whether these clinical characteristics in these patients might be related. Hence, we explored whether sleep disruption in patients with pituitary disease mediates their cognitive dysfunction. We recruited 18 patients with non-functioning pituitary adenomas (NFPA) and 19 sociodemographically matched healthy controls. They completed the Global Sleep Assessment Questionnaire (thus providing self-report data regarding sleep disruption) and were administered the Brief Test of Adult Cognition by Telephone, which assesses cognitive functioning in the domains of processing speed, working memory, episodic memory, inhibition, and reasoning. We found no significant differences in cognition between patients and controls. Furthermore, spectra of sleep disturbance did not differ significantly between patients and controls. Our data suggest that NFPA patients' cognition and sleep quality is relatively intact, and that sleep disruption does not mediate cognitive dysfunction. Larger studies should characterize sleep and cognition in patients with NFPA (and other pituitary diseases) to confirm whether disruption of the former mediates impairment in the latter.

Holistic burden of illness in patients with endogenous Cushing's syndrome: A systematic literature review

OBJECTIVE

The objective of this systematic literature review (SLR) was to summarize the latest studies evaluating the burden of illness in endogenous Cushing's syndrome (CS), including the impact of CS on overall and domain-specific health-related quality of life (HRQoL) and the economic burden of CS to provide a holistic understanding of disease and treatment burden.

METHODS

An SLR was conducted in PubMed, MEDLINE and Embase using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist to identify peer-reviewed manuscripts and conference abstracts published in English from 2015 to December 4, 2020.

RESULTS

Forty-five publications were eligible for inclusion; data were extracted from 37 primary studies while 8 SLRs were included for reference only. Thirty-one studies reported HRQoL using validated patient reported outcome (PRO) measures in pre- or post-surgery, radiotherapy and pharmacotherapy patients. Overall, this SLR found that patients with CS have worse outcomes relative to healthy populations across specific dimensions, such as depression, despite an improvement in HRQoL post-treatment. These findings reveal that CS symptoms are not fully resolved by the existing care paradigm. Few studies report on the economic burden of CS and currently available data indicate a high direct healthcare system cost burden.

CONCLUSIONS

Patients with CS experience a significant, complex and multifactorial HRQoL burden. Symptom-specific burden studies are sparse in the literature and the understanding of long-term CS symptomatic burden and economic burden is limited. This review intends to provide an updated reference for clinicians, payers and other stakeholders on the burden of CS as reported in published literature and to encourage further research in this area.

PitNETs and the gut microbiota: potential connections, future directions

The role of the gut microbiome has been widely discussed in numerous works of literature. The biggest concern is the association of the gut microbiome with the central nervous system through the microbiome-brain-gut axis in the past ten years. As more and more research has been done on the relationship between the disease of the central nervous system and gut microbes. This fact is being revealed that gut microbes seem to play an important role from the onset and progression of the disease to clinical symptoms, and new treatments. As a special tumor of the central nervous system, pituitary neuroendocrine tumors (PitNETs)are closely related to metabolism, endocrinology, and immunity. These factors are the vectors through which intestinal microbes interact with the central nervous system. However, little is known about the effects of gut microbes on the PitNET. In this review, the relationship of gut microbiota in PitNETs is introduced, the potential effects of the gut-brain axis in this relationship are analyzed, and future research directions are presented.

Cognitive dysfunction in patients with primary adrenal insufficiency: A systematic review

Addison's disease (AD) entails a chronic insufficient production of gluco- and mineralocorticoids. Fatigue and decreased quality of life are frequently reported symptoms, but little is known about its effects on cognition. This study aims to explore the existence of cognitive impairment in patients with AD and the influence of treatment regimens. We conducted a systematic review. Inclusion criteria were met by 10 articles, most of them ranked as intermediate quality. Three studies analyzed the relationship between AD and cognitive impairment; one explored the effect of delaying treatment showing no effect on cognitive performance, and another one studied the effect of fludrocortisone treatment. Episodic memory was the most frequent cognitive domain impaired across studies, in comparison to healthy controls. Two papers investigated the relationship between impaired sleep quality and poor cognitive performance. Two studies related cognitive impairments with hypocortisolism-derived brain neuroglycopenia. Two studies investigated the effect of DHEA substitution. In conclusion, patients exhibit a moderately reduced performance in verbal learning. The pathophysiology of this impairment is likely multifactorial. Future studies should include larger sample sizes, the use of comprehensive and multi-domain neuropsychological and behavioral protocols, and neuroimaging.

Glucocorticoids and cognitive function: a walkthrough in endogenous and exogenous alterations

PURPOSE

The hypothalamic-pituitary-adrenal (HPA) axis exerts many actions on the central nervous system (CNS) aside from stress regulation. Glucocorticoids (GCs) play an important role in affecting several cognitive functions through the effects on both glucocorticoid (GR) and mineralocorticoid receptors (MR). In this review, we aim to unravel the spectrum of cognitive dysfunction secondary to derangement of circulating levels of endogenous and exogenous glucocorticoids.

METHODS

All relevant human prospective and retrospective studies published up to 2022 in PubMed reporting information on HPA disorders, GCs, and cognition were included.

RESULTS

Cognitive impairment is commonly found in GC-related disorders. The main brain areas affected are the hippocampus and pre-frontal cortex, with memory being the most affected domain. Disease duration, circadian rhythm disruption, circulating GCs levels, and unbalanced MR/GR activation are all risk factors for cognitive decline in these patients, albeit with conflicting data among different conditions. Lack of normalization of cognitive dysfunction after treatment is potentially attributable to GC-dependent structural brain alterations, which can persist even after long-term remission.

CONCLUSION

The recognition of cognitive deficits in patients with GC-related disorders is challenging, often delayed, or mistaken. Prompt recognition and treatment of underlying disease may be important to avoid a long-lasting impact on GC-sensitive areas of the brain. However, the resolution of hormonal imbalance is not always followed by complete recovery, suggesting irreversible adverse effects on the CNS, for which there are no specific treatments. Further studies are needed to find the mechanisms involved, which may eventually be targeted for treatment strategies.

Glymphatic transport is reduced in rats with spontaneous pituitary tumor

Background and objective

Pituitary tumor in patients induces adverse alterations in the brain, accompanied by cognitive deficits. Dysfunction of glymphatic waste clearance results in accumulation of neurotoxic products within the brain, leading to cognitive impairment. However, the status of glymphatic function in the brain with pituitary tumor is unknown. Using magnetic resonance imaging (MRI) and an advanced mathematical modeling, we investigated the changes of glymphatic transport in the rats carrying spontaneous pituitary tumor.

Methods

Rats (22-24 months, female, Wistar) with and without pituitary tumor (n = 7/per group) underwent the identical experimental protocol. MRI measurements, including T2-weighted imaging and dynamic 3D T1-weighted imaging with intracisternal administration of contrast agent, were performed on each animal. The contrast-induced enhancement in the circle of Willis and in the glymphatic influx nodes were observed on the dynamic images and verified with time-signal-curves (TSCs). Model-derived parameters of infusion rate and clearance rate that characterize the kinetics of glymphatic tracer transport were evaluated in multiple representative brain regions.

Results

Our imaging data demonstrated a higher incidence of partially enhanced circle of Willis (86 vs. 14%; p < 0.033) and a lower incidence of enhancement in glymphatic influx nodes of pituitary (71 vs. 100%) and pineal (57 vs. 86%) recesses in the rats with pituitary tumor than in the rats with normal appearance of pituitary gland, indicating an intensification of impaired peri-vascular pathway and impeded glymphatic transport due to the presence of pituitary tumor. Consistently, our kinetic modeling and regional cerebral tissue quantification revealed significantly lower infusion and clearance rates in all examined regions in rats with spontaneous pituitary tumor than in non-tumor rats, representing a suppressed glymphatic transport in the brain with pituitary tumor.

Conclusion

Our study demonstrates the compromised glymphatic transport in the rat brain with spontaneous pituitary tumor. The reduced efficiency in cerebral waste clearance increases the risk for neurodegeneration in the brain that may underlie the cognitive impairment commonly seen in patients with pituitary tumors.

The socioeconomic burden of acromegaly

Acromegaly is a rare and insidious disease characterized by chronic excess growth hormone, leading to various morphological changes and systemic complications. Despite its low prevalence, acromegaly poses a significant socioeconomic burden on patients and healthcare systems. This review synthesizes the current state of knowledge on the psychosocial burden, disability, impact on daily life, and cost of acromegaly disease, focusing on the quality of life, partnership, medical care and treatment afflictions, participation in daily activities, professional and leisure impairment, and cost of treatment for acromegaly and its comorbidities. It also examines management strategies, coping mechanisms, and interventions aimed at alleviating this burden. A comprehensive understanding of the extent of the socioeconomic burden in acromegaly is crucial to develop effective strategies to improve treatment and care. Further research is warranted to explore the myriad factors contributing to this burden, as well as the efficacy of interventions to alleviate it, ultimately enhancing the quality of life for patients with acromegaly.

Evaluating the burden of endogenous Cushing's syndrome using a web-based questionnaire and validated patient-reported outcome measures

INTRODUCTION

Endogenous Cushing's syndrome (CS) is a rare endocrine condition caused by chronic oversecretion of cortisol, resulting in a diverse constellation of symptoms. This study examined the ongoing burden of illness (BOI), from the first appearance of symptoms through treatment, which is currently not well evaluated.

METHODS

A quantitative, cross-sectional, web-enabled survey including 5 validated patient reported outcomes (PRO) measures was conducted in patients with CS who had been diagnosed ≥ 6 months prior and who had received ≥ 1 treatment for their endogenous CS at the time of the survey.

RESULTS

Fifty-five patients participated in this study; 85% were women. The mean age was 43.4 ± 12.3 years (± standard deviation, SD). On average, respondents reported a 10-year gap between the first occurrence of symptoms and diagnosis; 80% underwent surgical treatment for CS. Respondents experienced symptoms on 16 days in a typical month, and their health-related quality of life was moderately impacted based on the CushingQoL score. Weight gain, muscle fatigue, and weakness were the most common symptoms and 69% percent of patients reported moderate or severe fatigue using the Brief Fatigue Inventory. Following treatment, the occurrence of most symptoms declined over time, although anxiety and pain did not significantly decrease. Overall, 38% of participants reported an annual average of 25 missed workdays due to CS symptoms.

CONCLUSIONS

These results demonstrate a BOI in CS despite ongoing treatment and illustrate the need for interventions to address persistent symptoms, particularly weight gain, pain, and anxiety.

Altered hemispheric asymmetry of attentional networks in patients with pituitary adenoma: an event-related potential study

Background

Emerging evidence has been reported of attentional dysfunction in pituitary adenoma patients. However, the effect of pituitary adenomas on lateralized attention network efficiency remained to be clear. Thus, the present study aimed to investigate the impairment of lateralized attention networks in patients with pituitary adenoma.

Methods

Eighteen pituitary adenoma patients (PA group) and 20 healthy controls (HCs) were included in this study. Both behavioral results and event-related potentials (ERPs) were acquired while subjects performed the Lateralized Attention Network Test (LANT).

Results

Behavioral performances indicated the PA group had a slower reaction time and a similar error rate relative to the HCs group. Meanwhile, significantly increased executive control network efficiency suggested the dysfunction of inhibition control in PA patients. Regarding ERP results, there were no group differences in the alerting and orienting networks. The target-related P3 was significantly reduced in the PA group, suggesting an impairment of executive control function and attentional resources allocation. Moreover, the mean amplitude of P3 was significantly lateralized to the right hemisphere, and interacted with the visual field, exhibiting that the right hemisphere dominated the bilateral visual field, whereas the left hemisphere dominated the left visual field. In the specific high-conflict condition, the pattern of hemispheric asymmetry in the PA group was altered due to a mixed effect resulting from the compensatory recruitment of attentional resources in the left central parietal area and the destructive effects of hyperprolactinemia.

Conclusion

These findings suggested that, in the lateralized condition, the decreased P3 in the right central parietal area and the diminished hemispheric asymmetry under high conflict load, may serve as the potential biomarkers of attentional dysfunction in patients with pituitary adenoma.

Fatigue and Its Contributing Factors in Chinese Patients with Primary Pituitary Adenomas

BACKGROUND

Pituitary adenomas (PAs) refers to a group of benign tumors that develop in the pituitary gland and are often characterized by fatigue. However, fatigue has not been documented in any Chinese research involving people with primary PA. The study sought to examine the prevalence, predictors, and correlation of fatigue with the quality of life (QoL) among PA patients in China.

METHODS

In total, 203 primary PA patients were included in this cross-sectional study. A series of questionnaires were administered, including the Multidimensional Fatigue Inventory (MFI), M. D. Anderson Symptom Inventory Brain Tumor (MDASI-BT), Short-Form 36 Health Survey (SF-36), Pittsburgh Sleep Quality Index (PSQI), and the Hospital Anxiety and Depression Scale (HADS). Data analysis was accomplished by Pearson or Spearman correlations, linear regression, and simple path analysis.

RESULTS

Severe fatigue prior to the initial diagnosis and preparation for surgery affected 50% of PA patients. Depression, sleep disturbance, and MDASI-BT symptom total scores were independently able to predict patient fatigue. Sleep disturbance mediates the influence of depression on fatigue (IE sleep = 0.296, 95% CI: LB = 0.148 to UB = 0.471).

CONCLUSIONS

Chinese patients with primary PA often report experiencing fatigue. Depression and poor sleep quality were shown to be significant contributors to PA patients' fatigue. Depression affects PA patients' fatigue directly or indirectly. Medical professionals should take a proactive approach to PA patients suffering from fatigue before initial diagnosis and preoperative preparation to determine necessary interventions early, thus reducing fatigue and ultimately enhancing their QoL.

Brain Tumor at Diagnosis: From Cognition and Behavior to Quality of Life

BACKGROUND

The present narrative review aims to discuss cognitive-emotional-behavioral symptoms in adults with brain tumors at the time of diagnosis.

METHODS

The PubMed database was searched considering glioma, pituitary adenoma, and meningioma in adulthood as pathologies, together with cognitive, neuropsychological, or behavioral aspects.

RESULTS

Although a significant number of studies describe cognitive impairment after surgery or treatment in adults with brain tumors, only few focus on cognitive-emotional-behavioral symptoms at diagnosis. Furthermore, the importance of an effective communication and its impact on patients' quality of life and compliance with treatment are seldom discussed.

CONCLUSIONS

Adults with brain tumors have needs in terms of cognitive-emotional-behavioral features that are detectable at the time of diagnosis; more research is needed to identify effective communication protocols in order to allow a higher perceived quality of life in these patients.

Pre-Surgery Patient Health Contributes to Aggravated Sino-Nasal Outcome and Quality of Life after Pituitary Adenomectomy

Objectives: The transphenoidal bi-nostril endoscopic resection of pituitary adenomas is regarded as a minimally invasive treatment nowadays. However, sino-nasal outcome and health-related quality of life (HRQoL) might still be impaired after the adenomectomy, depending on patients' prior medical history and health status. A systematic postoperative comparison is required to assess differences in perceived sino-nasal outcome and HRQoL. Methods: In this single-center observational study, we collected data from 81 patients, operated between August 2016 and August 2021, at a 3-6-month follow-up after adenomectomy. We employed the sino-nasal outcome test for neurosurgery (SNOT-NC) and the HRQoL inventory Short Form (SF)-36 to compare sino-nasal and HRQoL outcome in patients with or without allergies, previous nose surgeries, presence of pain, snoring, sleep apnea, usage of continuous positive airway pressure (cpap), and nose drop usage. Results: At the 3-6-month follow-up, patients with previous nasal surgery showed overall reduced subjective sino-nasal health, increased nasal and ear/head discomfort, increased visual impairment, and decreased psychological HRQoL (all p ≤ 0.026) after pituitary adenomectomy. Patients with pain before surgery showed a trend-level aggravated physical HRQoL (p = 0.084). Conclusion: Our data show that patients with previous nasal surgery have an increased risk of an aggravated sino-nasal and HRQoL outcome after pituitary adenomectomy. These patients should be thoroughly informed about potential consequences to induce realistic patient expectations. Moreover, the study shows that patients with moderately severe allergies, snoring, and sleep apnea (± cpap) usually do not have to expect a worsened sino-nasal health and HRQoL outcome.

Evaluating the Impact of Acromegaly on Quality of Life

Acromegaly has a substantial negative impact on quality of life (QoL). This review aims to discuss the impact of acromegaly on QoL from the clinical perspective as well as from the patient perspective. Furthermore, it aims to evaluate the use of patient-reported outcome measures (PROMs) in acromegaly and how PROMs aid decision-making. The recommendations presented in this review are based on recent clinical evidence on the impact of acromegaly on QoL combined with the authors' own clinical experience treating patients with acromegaly. We recommend that a patient-centered approach should be considered in treatment decisions, integrating conventional biochemical outcomes, tumor control, comorbidities, treatment complications, and PROMs, including QoL measures. This more integrated approach seems effective in treating comorbidities and improving patient-reported outcomes and is critical, as many patients do not achieve biochemical or tumor control and comorbidities, impairment in QoL may not remit even when full biochemical control is achieved.

Hyperprolactinemia Associated with Attentional Processing and Interference Control Impairments in Patients with Prolactinomas

The cognitive impairment of pituitary adenomas (PAs) has received increasing attention. Hyperprolactinemia and tumor mass effect are the potential causes. The aim of this study was to identify possible cognitive impairment and to further explore the correlation between these indices and prolactin (PRL) levels, based on the control of tumor size. Twenty-seven patients with prolactinomas (patient group) and twenty-six matched health control group (HC group) were enrolled in this study. All participants performed the flanker task while we continuously recorded electroencephalography data. On the behavioral performance level, patients showed a significantly slower reaction time (RT) in both flanker types. Concerning the event-related potentials level, patients elicited reduced P2 and enhanced N2 amplitudes compared with the HC group, suggesting an impairment of attentional processing (P2) and conflict monitoring (N2). Moreover, the patient group also induced lower P3 amplitudes relative to the HC group in both types, indicating that there were deficits in attentional resource allocation ability. We also found a significant correlation between the P3 amplitudes and incongruent condition RTs, as well as the subsequent PRL levels in the patient group. In conclusion, this is an innovative study that reveals the impaired cognition abilities in prolactinomas, and also proposes the possible cognitive toxicity of oversecreted PRL levels, which provides evidence for further research on the cognitive decline in PAs.

Variables Associated With Body Image Concerns in Acromegaly Patients: A Cross-Sectional Study

Objective

Acromegaly is often characterized by altered physical (including facial) appearance. However, there is little medical or psychological research on body image concerns in patients with acromegaly. The aim of this study was to identify factors influencing the body image distress in patients with acromegaly and to explore the possible effects of stigma on body image concerns.

Design

Cross-sectional study.

Methods

A total of 68 individuals with acromegaly were enrolled in the study. A total of 70 persons with nonfunctional pituitary adenomas were randomly recruited as a healthy control group. Using structured questionnaires, we explored perceived body image using the Body Image Concern Inventory. We also used the Hamilton Anxiety Scale, the Stigma Scale for Chronic Illness, the Brief Illness Perception Questionnaire, and the 36-Item Short-Form Health Survey to evaluate health-associated variables and to analyze factors that affect body image concerns in patients with acromegaly.

Results

Of the 68 participants, 31 were men and 37 women (mean age ± standard deviation: 46.36 ± 12.47 years). The mean body image concern score was 47.49 ± 13.81 for patients with acromegaly and 21.10 ± 7.44 for patients with nonfunctional pituitary adenoma. The difference between the two groups was statistically significant. A multiple stepwise regression analysis showed that the related factors for body image distress were gender (P = 0.001), age at diagnosis (P = 0.01), and internalized stigma (P < 0.001, Adj. R² = 0.756).

Conclusions

People with acromegaly have substantial body image concerns, and these concerns are increased by the stigma associated with this disease; such concerns lead to poor quality of life (QoL). Physicians need to find better ways to control patients' hormone levels, and nurses should provide more information on how to improve body image or find ways to reduce patients' body image distress.

Stigma and unhealthy psychological characteristics in patients with acromegaly: A cross-sectional study and identification of the associated factors

BACKGROUND

Stigma, besides aggravating the damage caused by the disease, may also lead to unhealthy characteristics in patients and unhealthy situations in society. Individuals with acromegaly disease may suffer from stigma concerns, and the associated factors remain largely unknown. Therefore, the present cross-sectional study aimed to investigate the levels of perceived stigma in patients with acromegaly and explore the associated factors.

METHODS

A total of 138 patients with acromegaly were evaluated for having stigma using five previously validated scales: (i) the Stigma Scale for Chronic Illness, (ii) the Hamilton Anxiety Scale, (iii) the Rosenberg Self-Esteem Scale, (iv) the Body Image Concern scale, and (v) the Acromegaly Quality of Life scale. The potential determinants of stigma were evaluated using the univariate statistical analysis. A multivariate linear regression model was adopted to assess the predictors of stigma in patients with acromegaly. Pearson's correlation analysis was performed to analyze the relationship between stigma and the quality of life of the patients.

RESULTS

Among the 138 respondents, 102 provided consent for participation.The evaluated patients exhibited critically high levels of perceived stigma. The multiple regression analysis revealed high BMI, serious body image concerns, inferiority complex personality, and critical levels of anxiety as the potential predictors of stigma in patients with acromegaly. The overall stigma and internalized stigma were significantly correlated with QoL in these patients.

CONCLUSION

The patients with acromegaly exhibited critically high levels of perceived stigma, which led to psychological distress and disruptions in their daily lives. This finding highlights the importance of addressing the stigma concerns and the necessity for providing additional support to these patients in this regard during follow-up sessions. Further research should focus on developing intervention strategies to decrease the levels of perceived stigma in patients with acromegaly to promote their quality of life and for the psychosocial rehabilitation of these patients.

Case report: Treatment of psychiatric symptoms for an acromegalic patient with pituitary adenoma

Acromegalic patients always demonstrate a wide range of clinic manifestations, including typical physical changes such as acral and facial features, as well as untypical neuropsychiatric and psychological disturbances. However, there is still a lack of clinical guidance on the treatment for acromegalic patients with psychiatric comorbidities. We therefore share this case to provide a reference for clinicians to manage the acromegalic patients with psychiatric symptoms. This case report describes a 41-year-old male with an 8-year history of acromegaly due to growth hormone-secreting pituitary adenoma, the maximum cross-sectional area of which was 42 mm × 37 mm demonstrated by pituitary magnetic resonance imaging (MRI). The patient received conservative medicine treatment by regularly injecting with Sandostatin LAR 10 mg per month. Two days before admission, he suddenly presented with an acute psychotic episode. In addition to the typical acromegaly-associated changes, his main clinical presentations were olfactory/auditory hallucinations, reference/persecutory delusions, instable emotion and impulsive behavior. Considering the schizophrenic-like psychoses and course features, he was diagnosed with Brief Psychotic Disorder according to Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) after a multidisciplinary consultation and evaluation. He was prescribed Aripiprazole, which had less extrapyramidal symptoms and minimal influence on prolactin elevation, with the dose of 5 mg per day to control the psychiatric symptoms and he responded quite well. At the time of discharge and the follow-up 2 month later, the patient was stable without recurrence of any psychotic symptoms. The levels of growth hormone (GH) and insulin-like growth factor 1 (IGF-1) 1 week after discharge were 2.22 ng/mL [normal range (0-2.47 ng/mL)] and 381 μg/L [normal range (94-284 μg/L)], respectively, which were similar to those before the psychotic episode. Results from this report further supported that small dose of Aripiprazole had little influence on hormonal levels and the development of pituitary macroadenoma. This particular case emphasizes the importance for the clinician to master and carefully identify the possible symptoms of mental disorders associated with acromegaly, and also highlights the need for further investigation in more efficient treatment strategies for acromegalic cases with psychiatric comorbidities.

Altered Connectivity of the Frontoparietal Network During Attention Processing in Prolactinomas

Prolactinomas have been reported for the failure of cognitive functions. However, the electrophysiological mechanisms of attention processing in prolactinomas remain unclear. In a visual mission, we monitored the scalp electroencephalography (EEG) of the participants. Compared with the healthy controls (HCs), larger frontoparietal theta and alpha coherence were found in the patients, especially in the right-lateralized hemisphere, which indicated a deficit in attention processing. Moreover, the frontoparietal coherence was positively correlated with altered prolactin (PRL) levels, implying the significance of PRL for adaptive brain compensation in prolactinomas. Taken together, this research showed the variations in attention processing between the HCs and prolactinomas. The coherence between frontal and parietal regions may be one of the possible electrophysiological biomarkers for detecting deficient attention processing in prolactinomas.

Identification of the Extradural and Intradural Extension of Pituitary Adenomas to the Suprasellar Region: Classification, Surgical Strategies, and Outcomes

Objective

Suprasellar pituitary adenomas (PAs) can be located in either extradural or intradural spaces, which impacts surgical strategies and outcomes. This study determined how to distinguish these two different types of PAs and analyzed their corresponding surgical strategies and outcomes.

Methods

We retrospectively analyzed 389 patients who underwent surgery for PAs with suprasellar extension between 2016 to 2020 at our center. PAs were classified into two main grades according to tumor topography and their relationships to the diaphragm sellae (DS) and DS-attached residual pituitary gland (PG). Grade 1 tumors were located extradurally and further divided into grades 1a and 1b, while grade 2 tumors were located intradurally.

Results

Of 389 PAs, 292 (75.1%) were surrounded by a bilayer structure formed by the DS and the residual PG and classified as grade 1a, 63 (16.2%) had lobulated or daughter tumors resulting from the thinning or absence of the residual PG and subsequently rendering the bilayer weaker were classified as Grade 1b, and the remaining 34 (8.7%) PAs that broke through the DS or traversed the diaphragmic opening and encased suprasellar neurovascular structures were classified as Grade 2. We found that the gross total removal of the suprasellar part of grade 1a, 1b, and 2 PAs decreased with grading (88.4%, 71.4%, and 61.8%, respectively). The rate of major operative complications, including cerebrospinal fluid leakage, hemorrhage, and death, increased with grading.

Conclusions

It is essential to identify whether PAs with suprasellar extension are located extradurally or intradurally, which depends on whether the bilayer structure is intact. PAs with an intact bilayer structure were classified as grade 1. These were extradural and usually had good surgical outcomes and lower complications. PAs with no bilayer structure surrounding them were classified as grade 2. These were intradural, connected to the cranial cavity, and had increased surgical complications and a lower rate of gross total removal. Different surgical strategies should be adopted for extradural and intradural PAs.

Updates in the outcomes of radiation therapy for Cushing's disease

External radiation therapy (RT) directed to the pituitary gland is generally recommended in patients with Cushing's disease (CD) as adjuvant to transsphenoidal surgery, among other second-line therapies offered to patients with residual or recurrent hypercortisolism (i.e., medical treatment, repeat surgery or bilateral adrenalectomy). RT is effective for the control of tumor growth, even in invasive tumors and in Nelson's syndrome. Progress in radiation stereotactic techniques lead to improved tumor targeting and radiation delivery, thus sparing the adjacent brain structures. Stereotactic RT is associated with a 55-65% rate of cortisol normalization after several months to a few years and potentially with a lower risk of long-term complications, compared with conventional RT. Cortisol-lowering medical therapy is recommended while awaiting the radiation effects. Hypopituitarism is the most frequent side-effect, damage to optic or cranial nerves or second brain tumors are rarely reported. This review presents the updates in the efficacy and safety of the stereotactic radiation techniques in CD patients. Practical points which should be considered by the clinician before recommending RT are also presented.

Investigating the effects of cerebellar transcranial direct current stimulation on saccadic adaptation and cortisol response

BACKGROUND

Transcranial Direct Current Stimulation (tDCS) over the prefrontal cortex has been shown to modulate subjective, neuronal and neuroendocrine responses, particularly in the context of stress processing. However, it is currently unknown whether tDCS stimulation over other brain regions, such as the cerebellum, can similarly affect the stress response. Despite increasing evidence linking the cerebellum to stress-related processing, no studies have investigated the hormonal and behavioural effects of cerebellar tDCS.

METHODS

This study tested the hypothesis of a cerebellar tDCS effect on mood, behaviour and cortisol. To do this we employed a single-blind, sham-controlled design to measure performance on a cerebellar-dependent saccadic adaptation task, together with changes in cortisol output and mood, during online anodal and cathodal stimulation. Forty-five participants were included in the analysis. Stimulation groups were matched on demographic variables, potential confounding factors known to affect cortisol levels, mood and a number of personality characteristics.

RESULTS

Results showed that tDCS polarity did not affect cortisol levels or subjective mood, but did affect behaviour. Participants receiving anodal stimulation showed an 8.4% increase in saccadic adaptation, which was significantly larger compared to the cathodal group (1.6%).

CONCLUSION

The stimulation effect on saccadic adaptation contributes to the current body of literature examining the mechanisms of cerebellar stimulation on associated function. We conclude that further studies are needed to understand whether and how cerebellar tDCS may module stress reactivity under challenge conditions.

Theta oscillations in prolactinomas: Neurocognitive deficits in executive controls

Impairment of cognitive functions has been reported in prolactinomas. However, the electrophysiological mechanisms of response activation and response inhibition in prolactinomas remain unclear. We recorded participants' scalp electroencephalography (EEG) in a visual Go/Nogo task. Compared to the healthy controls (HCs), the patients demonstrated worse performance and their prolactin (PRL) levels negatively correlated with behavioral results. Meanwhile, patients' P300 amplitudes in the Go and Nogo conditions were smaller than the HCs. The amplitudes of N200nogo in patients were smaller than the HCs as well. Lower frontal theta power was found in the patients than the HCs in both Go and Nogo conditions, which indicated a deficit in response activation and inhibition. Moreover, the PRL levels mediated the relationship between frontal theta power and behavior performance, implying that lower frontal theta power caused the dysfunction of response control by abnormally high PRL levels. Patients also showed lower occipital alpha power than the HCs, which suggested that the impaired response inhibition may arise from deficient attention control. Taken together, the present study revealed the neurocognitive discrepancies between prolactinomas and the HCs. The frontal theta oscillation was highlighted as the electrophysiological markers of the impaired response control in prolactinomas.

Subclinical hemorrhagic nonfunctionning pituitary adenoma: pituitary gland function status, endoscopic endonasal transsphenoidal surgery, and outcomes

OBJECTIVE

How do subclinical hemorrhages into nonfunctioning pituitary adenomas (NFPAs) influence the hormonal status and surgical outcomes remains unclear, our study aim at evaluating its definite effects on pituitary gland function and surgical outcomes.

METHODS

All 103 consecutive patients who underwent initial endoscopic endonasal approach (EEA) for NFPAs resection from June 2016 to June 2018 were retrospectively reviewed, depending on magnetic resonance imaging (MRI), operative and pathological findings, patients were divided into the non-hemorrhagic NFPAs group and the subclinical hemorrhagic NFPAs group. A comparative analysis was conducted between these two groups to investigate the effects of subclinical hemorrhages in NFPAs on pituitary endocrine function and surgical outcomes.

RESULTS

The incidence of subclinical hemorrhage on NFPAs was 22.3% (23/103), which was more frequently observed in larger adenomas (28.9 ± 9.6 mm vs 19.2 ± 9.2 mm, p = 0.001). The incidence of preoperative hypopituitarism was 69.6% (16/23) for subclinical hemorrhagic NFPAs group and 31% (25/80) for non-hemorrhagic NFPAs group (p = 0.001), a high incidence of hypopituitarism for subclinical hemorrhagic NFPAs finally was found to be owing to the large tumor rather than the intratumoral hemorrhage. All those NFPAs were resected via EEA with the technology of extra-pseduocapusual dissection in a standard elective fashion. Postoperatively, there were more than 75.6% of patients with preoperative hypopituitarism had at least one axis recovered, with hyperprolactinemia resolved in 91.7% of patients, 94.7% headaches and 90% visual symptoms resolved or improved after surgery, there was no significant difference between these two groups (p > 0.05), indicates there was no any surgical outcome difference between NFPAs with or without subclinical hemorrhage. A very low postoperative complication was achieved with new postoperative anterior pituitary failure occurred in 9.7% of patients and permanent diabetes insipidus (DI) occurred in 9.7% of patients, which advocated that EEA can be chosen as a safe surgical treatment for subclinical hemorrhagic NFPAs. Furthermore, with the technology of extra-pseduocapusual dissection, more than 87% subclinical hemorrhagic NFPAs had achieved gross total resection (GTR) with a low incidence of new postoperative hypopituitarism (14%).

CONCLUSION

Subclinical hemorrhage in NFPAs does not aggravate pituitary gland function. A surgical management strategy by EEA with the technology of extra-pseduocapusual dissection for the subclinical hemorrhagic NFPAs usually yields satisfactory endocrine and surgical outcomes, but it does not necessitate emergent tumor decompression.

Response Activation and Inhibition in Patients With Prolactinomas: An Electrophysiological Study

Impairment of executive function has been reported in patients with prolactinomas. However, few studies have investigated the electrophysiological mechanisms of response activation and response inhibition in these patients. In this study, we employ an event-related potentials (ERPs) technique to quantitatively assess response activation and inhibition before and after the surgical treatment of prolactinomas. A 64-electrode electroencephalogram (EEG) skullcap was used to record the brain activity in 20 pre-operative patients, 20 follow-up post-operative patients, and 20 healthy controls (HCs) while performing the visual Go/Nogo task. As expected, we identified P300 across all study populations that could reflect response activation and inhibition. Across the three groups, the Nogo stimuli evoked larger frontal-central P300 than the Go stimuli did. In contrast, the Go trials elicited larger parietal P300 than the Nogo trials did. The peak latency of P300 was significantly delayed in both the pre-operative and the post-operative groups compared to the HCs. The amplitude of P300 in both the Go and the Nogo conditions was significantly decreased in the pre-operative patients compared with that of the HCs. At 6 months post-operatively, the prolactinoma patients showed an increase in amplitude of P300 during both the Go and the Nogo tasks. These findings indicate that the prolactinoma patients suffer from deficits in response activation and inhibition, which could be improved by surgical treatment.