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Yuen KCJ, Ghalib L, Buchfelder M, Hughes J, Langlois F, Molitch ME. Surveillance Imaging Strategies for Pituitary Adenomas: When, How Frequent, and When to Stop. Endocr Pract 2024; 30:282-291. [PMID: 38160940 DOI: 10.1016/j.eprac.2023.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Revised: 12/18/2023] [Accepted: 12/19/2023] [Indexed: 01/03/2024]
Abstract
OBJECTIVE To describe a practical approach of when and how often to perform imaging, and when to stop imaging pituitary adenomas (PAs). METHODS A literature review was carried out and recommendations provided are derived largely from personal experience. RESULTS Magnetic resonance imaging is the mainstay imaging modality of choice in the assessment, treatment planning, and follow-up of PAs. These adenomas are discovered incidentally during imaging for a variety of unrelated conditions, because of clinical symptoms related to mass effects on the adjacent structures, or during workup for functional alterations of the adenoma. Imaging is also used in the preoperative and postoperative phases of assessment of PAs, for surgical and radiotherapy planning, for postoperative surveillance to assess for adenoma stability and detection of adenoma recurrence, and for surveillance to monitor for adenoma growth in unoperated PAs. Currently, because there are no evidence-based consensus recommendations, the optimal strategy for surveillance imaging of PAs is not clearly established. Younger age, initial adenoma size, extrasellar extension, mass effect, cavernous sinus invasion, functional status, histopathologic characteristics, cost considerations, imaging accessibility, patient preference, and patient contraindications (eg, implanted metallic devices and patient claustrophobia) are all important factors that influence the strategy for surveillance imaging. CONCLUSIONS This review provides a practical approach of performing surveillance imaging strategies for PAs that should be individualized based on clinical presentation, history, adenoma morphology on imaging, and histopathologic characteristics.
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Affiliation(s)
- Kevin C J Yuen
- Department of Neuroendocrinology and Neurosurgery, Barrow Pituitary Center, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; Department of Medicine, University of Arizona College of Medicine and Creighton School of Medicine, Phoenix, Arizona.
| | - Luma Ghalib
- The James Comprehensive Skull Base and Pituitary Center, Division of Endocrinology, The Ohio State University, Ohio
| | - Michael Buchfelder
- Department of Neurosurgery, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Jeremy Hughes
- Department of Neuroradiology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Fabienne Langlois
- Division of Endocrinology, Department of Medicine, Centre intégré universitaire de santé et de services sociaux de l'Estrie - Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Mark E Molitch
- Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Shaikh ST, Moughal S, Wael M, Nix P, Tyagi A, Phillips N, Sheikh A. Natural history of post-operative non-functioning pituitary adenomas - a single centre cohort analysis. Br J Neurosurg 2023:1-6. [PMID: 37997810 DOI: 10.1080/02688697.2023.2284789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 11/13/2023] [Indexed: 11/25/2023]
Abstract
PURPOSE To study behaviour of endonasally operated non-functioning pituitary adenomas (NFPA) and propose a cost-effective stratified follow-up regimen. METHODS A single centre retrospective cohort analysis from June 2009 till December 2019. All endonasally operated pituitary adenomas were identified with sub-analysis of the NFPA's. Patients of all age groups with radiological follow-up more than 30 months were included. Patients with any kind of cranial intervention performed < within 30 months of surgery were excluded. The post-operative MRI for this cohort was evaluated until either any intervention was performed or until the last follow-up. The maximal tumour diameter in any plane (mm) was measured from the MRI scans. The annual growth rate and the statistical relationship between age, sex, IHC, Ki-67, resection %, residual tumour was calculated. RESULTS Out of 610 pituitary adenomas identified in the dataset, 116 patients met the inclusion criteria. Follow-up period ranged from 30 to 142 months (mean 78.5 months). A strong relationship existed between predicting tumour progression with first post-operative residue size (p = .001). A statistically significant relationship was found to be present between tumour growth and a residue of less than 10 mm diameter and 11-20 mm in diameter (Log rank p value .0216). On average, each patient with a residue < 5mm had MRI scans costing 976 £. CONCLUSION Based on statistical analysis and internal validation of the growth rate of the residue, we have proposed MRI follow-up scans. These recommendations have the potential to save more than 300 £per patient towards MRI costs and can lay down a marker for defining time interval of serial scans for post-operative NFPA's.
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Affiliation(s)
- Salman T Shaikh
- Department of Neurosurgery, Leeds General Infirmary, Leeds, UK
| | - Saad Moughal
- Department of Neurosurgery, Leeds General Infirmary, Leeds, UK
| | - Mohamed Wael
- Department of Neurosurgery, Leeds General Infirmary, Leeds, UK
| | - Paul Nix
- Department of ENT, Leeds General Infirmary, Leeds, UK
| | - Atul Tyagi
- Department of Neurosurgery, Leeds General Infirmary, Leeds, UK
| | - Nick Phillips
- Department of Neurosurgery, Leeds General Infirmary, Leeds, UK
| | - Asim Sheikh
- Department of Neurosurgery, Leeds General Infirmary, Leeds, UK
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Pernik MN, Montgomery EY, Isa S, Sundarrajan C, Caruso JP, Traylor JI, Liu Y, Garzon-Muvdi T. The natural history of non-functioning pituitary adenomas: A meta-analysis of conservatively managed tumors. J Clin Neurosci 2021; 95:134-141. [PMID: 34929637 DOI: 10.1016/j.jocn.2021.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 11/13/2021] [Accepted: 12/02/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Non-functioning pituitary adenomas (NFPA) are often discovered incidentally. The natural history of NFPA is not well understood, obfuscating evidence-based management decisions. Meta-data of radiographically followed NFPA may help guide conservative versus operative treatment of these tumors. METHODS We searched PubMed, Medline, Embase, and Ovid for studies with NFPA managed nonoperatively with radiographic follow-up. Studies on postoperative outcomes after NFPA resection and studies that did not delineate NFPA data from functional pituitary lesions were excluded. NFPA were divided into micro- and macroadenomas based on size at presentation. We performed a meta-analysis of aggregate data for length of follow-up, change in tumor size, rate of apoplexy, and need for resection during follow-up. RESULTS Our database search yielded 1787 articles, of which 19 were included for final analysis. The studies included 1057 patients with NFPA followed radiographically. Macroadenomas were significantly more likely to undergo growth (34% vs. 12%; p < 0.01) or apoplexy (5% vs. < 1%; p = 0.01) compared to microadenomas. Resection was performed in 11% of all NFPA patients during follow-up regardless of size at presentation. Meta-regression showed that surgery during follow-up was associated with macroadenomas and negatively associated with microadenomas that decreased in size. CONCLUSION Low-quality evidence suggests that NFPA classified as macroadenomas have an increased rate of growth and apoplexy during follow-up compared to microadenomas. A significant minority of all NFPA patients ultimately underwent surgery. In select patients, nonoperative management may be the appropriate strategy for NFPA. Macroadenomas may require closer follow-up.
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Affiliation(s)
- Mark N Pernik
- UT Southwestern Medical School, Department of Neurological Surgery, Dallas, TX, USA
| | - Eric Y Montgomery
- UT Southwestern Medical School, Department of Neurological Surgery, Dallas, TX, USA
| | - Samya Isa
- UT Southwestern Medical School, Department of Neurological Surgery, Dallas, TX, USA
| | | | - James P Caruso
- UT Southwestern Medical School, Department of Neurological Surgery, Dallas, TX, USA
| | - Jeffrey I Traylor
- UT Southwestern Medical School, Department of Neurological Surgery, Dallas, TX, USA
| | - Yulun Liu
- UT Southwestern Medical School, Department of Population and Data Sciences, Dallas, TX, USA
| | - Tomas Garzon-Muvdi
- UT Southwestern Medical School, Department of Neurological Surgery, Dallas, TX, USA.
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Redjal N, Venteicher AS, Dang D, Sloan A, Kessler RA, Baron RR, Hadjipanayis CG, Chen CC, Ziu M, Olson JJ, Nahed BV. Guidelines in the management of CNS tumors. J Neurooncol 2021; 151:345-359. [PMID: 33611702 DOI: 10.1007/s11060-020-03530-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Accepted: 05/05/2020] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Evidence-based, clinical practice guidelines in the management of central nervous system tumors (CNS) continue to be developed and updated through the work of the Joint Section on Tumors of the Congress of Neurological Surgeons (CNS) and the American Association of Neurological Surgeons (AANS). METHODS The guidelines are created using the most current and clinically relevant evidence using systematic methodologies, which classify available data and provide recommendations for clinical practice. CONCLUSION This update summarizes the Tumor Section Guidelines developed over the last five years for non-functioning pituitary adenomas, low grade gliomas, vestibular schwannomas, and metastatic brain tumors.
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Affiliation(s)
- Navid Redjal
- Department of Neurosurgery, Capital Institute for Neurosciences, Two Capital Way, Pennington, NJ, 08534, USA.
| | - Andrew S Venteicher
- Center for Pituitary and Skull Base Surgery, Department of Neurosurgery, University of Minnesota, Minneapolis, MN, 55455, USA
| | - Danielle Dang
- Inova Neuroscience and Spine Institute, 3300 Gallows Rd, Falls Church, VA, 22042, USA
| | - Andrew Sloan
- Department of Neurosurgery, Case Western Reserve University, Cleveland, OH, USA
| | - Remi A Kessler
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rebecca R Baron
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Clark C Chen
- Center for Pituitary and Skull Base Surgery, Department of Neurosurgery, University of Minnesota, Minneapolis, MN, 55455, USA
| | - Mateo Ziu
- Inova Neuroscience and Spine Institute, 3300 Gallows Rd, Falls Church, VA, 22042, USA
| | - Jeffrey J Olson
- Department of Neurosurgery, Emory University, Atlanta, GA, USA
| | - Brian V Nahed
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA
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ACR Appropriateness Criteria® Neuroendocrine Imaging. J Am Coll Radiol 2019; 16:S161-S173. [DOI: 10.1016/j.jacr.2019.02.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 02/08/2019] [Indexed: 01/06/2023]
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Patel KS, Dhawan S, Wang R, Carter BS, Chen JY, Chen CC. Post-operative imaging assessment of non-functioning pituitary adenomas. Acta Neurochir (Wien) 2018; 160:1029-1039. [PMID: 29453734 DOI: 10.1007/s00701-018-3491-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 02/07/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Non-functioning pituitary adenomas (NFAs) are the most common pituitary tumors. There is significant variability in clinical practice in terms of post-operative imaging evaluation. The objective of this manuscript is to provide an exhaustive review of published articles pertaining to the post-operative imaging evaluation of NFAs. METHODS The MEDLINE database was queried for studies investigating imaging for the post-operative evaluation of pituitary adenomas. From an initial search of 5589 articles, 37 articles were evaluated in detail and included in this review. RESULTS Magnetic resonance imaging (MRI) is the gold standard for post-operative monitoring of NFAs, although functional imaging modalities may improve identification of residual tumor in conjunction with MRI. The residual tumor can be distinguished from post-operative changes by experienced practitioners using high-resolution MRI in the immediate post-operative setting (within 1 week of surgery). However, continued imaging evolution in the appearance of residual tumor or resection cavity is expected up to 3 months post-operatively. CONCLUSIONS Post-operative imaging appearance of the pituitary gland, optic apparatus, and pneumocephalus patterns, correlated with the clinical outcomes. Long-term, lifetime follow-up is warranted for NFA patients who underwent surgical resection.
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Affiliation(s)
- Kunal S Patel
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, CA, USA
| | - Sanjay Dhawan
- Department of Neurosurgery, University of Minnesota, D429 Mayo Memorial Building, 420 Delaware St. S. E., MMC96, Minneapolis, MN, 55455, USA
| | - Renzhi Wang
- Department of Neurosurgery, Peking Union Medical College Hospital, Beijing, China
| | - Bob S Carter
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - James Y Chen
- Department of Radiology, UC San Diego Health System, University of California, San Diego, La Jolla, CA, USA
- Department of Radiology, San Diego Veterans Administration Health System, San Diego, CA, USA
| | - Clark C Chen
- Department of Neurosurgery, University of Minnesota, D429 Mayo Memorial Building, 420 Delaware St. S. E., MMC96, Minneapolis, MN, 55455, USA.
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Ziu M, Dunn IF, Hess C, Fleseriu M, Bodach ME, Tumialan LM, Oyesiku NM, Patel KS, Wang R, Carter BS, Chen JY, Chen CC, Patil CG, Litvack Z, Zada G, Aghi MK. Congress of Neurological Surgeons Systematic Review and Evidence-Based Guideline on Posttreatment Follow-up Evaluation of Patients With Nonfunctioning Pituitary Adenomas. Neurosurgery 2017; 79:E541-3. [PMID: 27635964 DOI: 10.1227/neu.0000000000001392] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Nonfunctioning pituitary adenomas (NFPAs) are the most frequent pituitary tumors. Due to the lack of hormonal hypersecretion, posttreatment follow-up evaluation of NFPAs is challenging. OBJECTIVE To create evidence-based guidelines in an attempt to formulate guidance for posttreatment follow-up in a consistent, rigorous, and cost-effective way. METHODS An extensive literature search was performed. Only clinical articles describing postoperative follow-up of adult patients with NFPAs were included. To ascertain the class of evidence for the posttreatment follow-ups, the authors used the Clinical Assessment evidence-based classification. RESULTS Twenty-three studies met the inclusion criteria with respect to answering the questions on the posttreatment radiologic, endocrinologic, and ophthalmologic follow-up. Through this search, the authors formulated evidence-based guidelines for radiologic, endocrinologic, and ophthalmologic follow-up after surgical and/or radiation treatment. CONCLUSION Long-term radiologic, endocrinologic, and ophthalmologic surveillance monitoring after surgical and/or radiation therapy treatment of NFPAs to evaluate for tumor recurrence or regrowth, as well as pituitary and visual status, is recommended. There is insufficient evidence to make a recommendation on the duration of time of surveillance and its frequency. It is recommended that the first radiologic study to evaluate the extent of resection of the NFPA be performed ≥3 months after surgical intervention. The full guidelines document for this chapter can be located at https://www.cns.org/guidelines/guidelines-management-patients-non-functioning-pituitary-adenomas/Chapter_8. ABBREVIATION NFPA, nonfunctioning pituitary adenoma.
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Affiliation(s)
- Mateo Ziu
- ‡Department of Neurosurgery, Seton Brain and Spine Institute, Austin, Texas; §Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts; ¶Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California; ‖Departments of Medicine and Neurological Surgery, Oregon Health Science University, Portland, Oregon; #Guidelines Department, Congress of Neurological Surgeons, Schaumburg, Illinois; **Barrow Neurological Institute, Phoenix, Arizona; ‡‡Department of Neurosurgery, Emory University, Atlanta, Georgia; §§Center for Theoretical and Applied Neuro-Oncology, Department of Neuro-Oncology, University of California, San Diego, San Diego, California; ¶¶Department of Neurosurgery, Peking Union Medical College Hospital, Beijing, China; ‖‖Department of Radiology, UC San Diego Health System, University of California, San Diego, San Diego, California; ##Department of Radiology, San Diego Veterans Administration Health System, San Diego, California; ***Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California; ‡‡‡Department of Neurosurgery, George Washington University, Washington, DC; §§§Department of Neurological Surgery, University of Southern California, Los Angeles, California; ‖‖‖Department of Neurosurgery, University of California, San Francisco, California
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Tumor Shrinkage Assessed by Volumetric MRI in Long-Term Follow-Up After Fractionated Stereotactic Radiotherapy of Nonfunctioning Pituitary Adenoma. Int J Radiat Oncol Biol Phys 2012; 82:1262-7. [DOI: 10.1016/j.ijrobp.2011.02.053] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2010] [Revised: 01/24/2011] [Accepted: 02/01/2011] [Indexed: 11/22/2022]
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Chen Y, Wang CD, Su ZP, Chen YX, Cai L, Zhuge QC, Wu ZB. Natural history of postoperative nonfunctioning pituitary adenomas: a systematic review and meta-analysis. Neuroendocrinology 2012; 96:333-42. [PMID: 22687984 DOI: 10.1159/000339823] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2012] [Accepted: 05/27/2012] [Indexed: 01/24/2023]
Abstract
OBJECTIVE Previous studies attempting to define the natural history of postoperative nonfunctioning pituitary adenomas (pNFPAs) were somewhat limited by selection bias and/or small numbers and/or lack of consistency among the study findings. The aim of this study was to scrutinize the literature in order to analyze the natural history of pNFPAs. METHODS Electronic database including MEDLINE, PubMed and Cochrane CENTRAL were searched. The literature relating to the patients with pNFPAs without postoperative radiotherapy and pharmacotherapy was collected. Eligible studies reported on the rate of tumor recurrence, the tumor growth-free survival rate (TGFSR) at 5 and 10 years, and/or the residual tumor volume doubling time (TVDT). RESULTS 19 studies met the criteria. The pNFPAs were divided into two groups: the pooled recurrence rate of group I without detectable residual tumor (371 patients) was 12% (95% CI 6-19%), the TGFSR at 5 and 10 years were 96% (95% CI 89-99%) and 82% (95% CI 65-94%), respectively. The pooled recurrence rate of group II with residual tumor (600 patients) was 46% (95% CI 36-56%), the TGFSR at 5 and 10 years were 56% (95% CI 41-71%) and 40% (95% CI 27-53%), respectively. The mean TVDT was 3.4 years (95% CI 2.4-4.5 years). CONCLUSIONS pNFPAs, with or without detectable residual tumor, need stratification of treatment and radiological/endocrinological follow-up strategy. According to the TVDT, residual tumor regrowth is very slow, which permits an extensive and safe follow-up program for most patients.
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Affiliation(s)
- Yong Chen
- Department of Neurosurgery, First Affiliated Hospital of Wenzhou Medical College, Wenzhou, China
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Abdelmannan D, Aron DC. Incidentally discovered pituitary masses: pituitary incidentalomas. Expert Rev Endocrinol Metab 2010; 5:253-264. [PMID: 30764049 DOI: 10.1586/eem.09.68] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
With the widespread use of computed tomography and MRI, the incidental discovery of pituitary incidentalomas is increasing in frequency. The most common cause of a pituitary mass is a pituitary adenoma (90% of all pituitary masses); however, the differential diagnosis remains extensive. The challenge is to distinguish those that can or will cause morbidity/mortality from those that will not. Opinions on approaching management of these lesions vary. This article will review current data regarding the prevalence, natural history and potential morbidity associated with this entity and describe an epidemiological approach based on four questions: does an incidental mass put the patient at increased risk for an adverse outcome? Can individuals with treatable syndromes be accurately diagnosed? Is the treatment of these syndromes more effective in presymptomatic patients? And do the beneficial effects of presymptomatic detection and treatment of these patients justify the costs incurred? We recommend the following approach: recognizing that one size does not fit all and that the approach should be tailored to the needs of the particular case. If the mass was discovered on a computed tomography, an enhanced MRI is recommended. Detailed history and physical examination should be carried out to look for signs of functional or 'subclinically' functional tumor. Size and structure should be assessed, especially proximity to the optic chiasm. Laboratory evaluation with a serum prolactin for small tumors is cost effective, other lab testing is indicated if metabolic problems are present. Care should be taken to assess for hypopituitarism, clinically and biochemically, if the mass is large, that is, more than 1 cm, visual field testing is also recommended. Note that the vast majority of patients with pituitary incidentalomas that are microadenomas die with them, not from them.
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Affiliation(s)
- Dima Abdelmannan
- a Endocrinology Section 111(W), Louis Stokes Department of Veterans Affairs Medical Center, 10701 East Boulevard, Cleveland, OH 44106, USA and Division of Clinical and Molecular Endocrinology, Case Western Reserve University School of Medicine, Cleveland, OH, USA.
| | - David C Aron
- b Division of Clinical and Molecular Endocrinology, Case Western Reserve University School of Medicine, Cleveland, OH, USA and Associate Chief of Staff/Education, Co-Director VA Health Services Research and Development Service Center for Implementation Practice and Research Support, Education Office 14 (W), Louis Stokes Department of Veterans Affairs Medical Center, 10701 East Boulevard, Cleveland, OH 44106, USA.
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