A Pituitary Society update to acromegaly management guidelines

The paradoxical GH response at OGTT does not predict Pasireotide efficacy but matters for glucose metabolism

PURPOSE

A paradoxical increase in GH after oral glucose load (GH-Par) characterizes about one-third of acromegaly patients and is associated with a better response to first-generation somatostatin receptor ligands (fg-SRLs). Pasireotide is typically considered as a second-/third-line treatment. Here, we investigated the predictive role of GH-Par in pasireotide response and adverse event development.

METHODS

we collected a multicenter Italian retrospective cohort of 59 patients treated with pasireotide for at least 3 months, all having GH profile from OGTT. IGF-1 normalization or at least 30% reduction at the last follow-up visit defined a responder patient.

RESULTS

Considering the entire cohort, median IGF-1 levels before pasireotide (available in 57 patients) were 1.38 times the upper limit of normal (ULN) in patients with large (median size 18 mm) and invasive (82%) adenomas after failure of fg-SRL treatment. After a 40-month median treatment, pasireotide effectively reduced IGF-1 ULN levels in 41 patients, 37 of whom achieving normalization, and 4 with a ≥ 30% reduction. Thirteen patients were classified as GH-Par. The median pasireotide duration, dosage, and efficacy (9/12 responder in the GH-Par group and 32/45 in the GH-NPar) were similar between groups. However, the occurrence of new-onset or worsening glucose metabolism alterations (GMAs) after pasireotide was more frequent in GH-NPar (from 37 to 80%; p < 0.001) compared to GH-Par patients (from 69 to 76%), likely due to the higher prevalence of pre-existing GMAs in the GH-Par group before starting pasireotide (p = 0.038).

CONCLUSIONS

The GH-Par does not predict the response to pasireotide in acromegaly but can predict a worse metabolic profile.

Prospective, Longitudinal Study of Cancer Predictors and Rates in a New York City Cohort of 598 Patients With Acromegaly

CONTEXT

Long-term growth hormone/insulin-like growth factor-1 (GH/IGF-1) excess could increase the risk of cancer in acromegaly, but individual levels of these hormones do not relate to this risk.

OBJECTIVE

We newly investigated longitudinally-measured IGF-1 levels as a potential predictor of cancer in a large New York City acromegaly cohort.

METHODS

We conducted a prospective, longitudinal study of 598 acromegaly (309 men, 289 women) and 292 clinically nonfunctioning pituitary adenoma (CNFPA) (140 women, 152 men) patients from the same underlying population. GH and IGF-1 levels were measured longitudinally and outcomes were observed during long-term follow-up. Cumulative exposure to IGF-1 excess was tested as a predictor of cancer. We compared cancer prevalence in acromegaly and CNFPA cohorts and incidence in each to that expected from Surveillance, Epidemiology, and End Results (SEER) data.

RESULTS

Cancer prevalence by last follow-up was 22.6% in acromegaly and 12.7% in CNFPAs (odds ratio [OR] = 1.99 [95% CI, 1.34-2.97]) (P = .0005). Overall standardized incidence ratio for cancer was 1.78 (1.51-1.81) in the acromegaly and 1.26 (0.89-1.70) in the CNFPA cohorts. Cumulative exposure to IGF-1 excess, OR = 1.278 (1.060-1.541) (P = .01), years from acromegaly diagnosis to cancer or last follow-up, OR = 1.03 (1.004-1.057) (P = .024), and age at follow up, OR = 1.064 (1.047-1.082) (P < .001), were predictors of cancer.

CONCLUSION

Cancer risk is increased in acromegaly, but not in CNFPA patients. Cumulative exposure to IGF-1 excess is a predictor of cancer in acromegaly. Our data suggest that cancer risk in acromegaly relates to the degree and duration of IGF-1 excess and that full appreciation of this risk requires long-term follow up.

Promising therapies for the treatment of acromegaly

INTRODUCTION

Acromegaly is a rare systemic disorder caused by an excess of growth hormone. Since surgical resection of the underlying tumor is not always successful, pharmacotherapy plays an invaluable role in managing this condition. While current treatment options are generally effective and well-tolerated, there remains significant room for improvement.

AREAS COVERED

This paper explores recent developments in the treatment of acromegaly that either propose new mechanisms of delivering established agents or introduce entirely new treatment strategies. It reviews available clinical data and discusses the progress of various new pharmacological agents.

EXPERT OPINION

Advancements in acromegaly pharmacotherapy are focused on overcoming current treatment limitations by developing more effective, tolerable, and personalized therapies. Emerging approaches, including small molecules, monoclonal antibodies, and antisense oligonucleotides, along with biomarker-driven precision medicine, aim to improve patient outcomes, minimize side effects, and enhance long-term disease management.

New treatments for acromegaly: Is a revolution underway?

The first-line treatment for acromegaly is transsphenoidal surgery. Somatostatin receptor ligands are usually prescribed if surgery fails, or, in some patients, as pre-surgical medical treatment. The efficacy and tolerance of first-generation somatostatin receptor ligands is well established, but they incur unmet medical needs due to their mode of administration and side effects. We report results for new compounds that may be used in the near future as alternatives to first-generation somatostatin receptor ligands, with data on efficacy and tolerance: oral octreotide, paltusotine and long-acting subcutaneous octreotide are reviewed in detail, together with potential new compounds under investigation. We also discuss their potential role in the therapeutic armamentarium for acromegaly.

Evaluation of pituitary tumor volume as a prognostic factor in acromegaly: A cross-sectional study in two centers

BACKGROUND

Acromegaly is caused by a pituitary neuroendocrine tumor (PitNET) with excessive production of growth hormone (GH), leading to multisystem complications. Previous studies have identified predictors of disease persistence following surgery and poor response to medical treatment, including tumor size, vertical and horizontal extensions of the adenoma, hyperintensity in T2-weighted magnetic resonance imaging, granulation density, and pre- and postoperative GH and insulin-like growth factor 1 (IGF-1) levels.

AIM

To evaluate PitNET volume as a complementary prognostic factor in patients with acromegaly.

METHODS

This is a retrospective descriptive study with an analytical component evaluating the correlation between the volumetric analysis of GH-producing PitNETs, IGF-1 levels before and after surgery, disease control during follow-up, and the line of therapy required for disease control in a cohort of patients treated at two centers: Endocrinology Department of the Central Military Hospital and Centros Médicos Colsanitas, Bogotá, Colombia.

RESULTS

A total of 77 patients with acromegaly (42 men, 35 women) were included in this study. The mean age at diagnosis was 42 years (standard deviation [SD]: 12), with a mean disease duration of 9.9 years (SD: 7.2). The mean pituitary tumor volume was 4358 mm³ (SD: 6291, interquartile range [IQR]: 13602). Patients with controlled acromegaly had a mean PitNET volume of 3202 mm³ (SD: 4845, 95%CI: 621-5784) compared to 5513 mm³ (SD: 7447, 95%CI: 1545-9482) in the uncontrolled group (P = 0.15). A PitNET volume exceeding 3697 mm³ was associated with a higher likelihood of requiring third or fourth-line therapy (50% vs 36%; P = 0.03).

CONCLUSION

PitNET volume was associated with the need for higher-line therapy to manage acromegaly but did not correlate with long-term disease control or with pre- or postsurgical IGF-1 levels. Nevertheless, a trend towards an inverse relationship between tumor volume and future disease control was observed. While macroadenoma classification remains crucial, among patients with macroadenomas, those with a volume exceeding 3697 mm³ could have worse prognosis.

Evaluation of pituitary tumor volume as a prognostic factor in acromegaly: A cross-sectional study in two centers

BACKGROUND

Acromegaly is caused by a pituitary neuroendocrine tumor (PitNET) with excessive production of growth hormone (GH), leading to multisystem complications. Previous studies have identified predictors of disease persistence following surgery and poor response to medical treatment, including tumor size, vertical and horizontal extensions of the adenoma, hyperintensity in T2-weighted magnetic resonance imaging, granulation density, and pre- and postoperative GH and insulin-like growth factor 1 (IGF-1) levels.

AIM

To evaluate PitNET volume as a complementary prognostic factor in patients with acromegaly.

METHODS

This is a retrospective descriptive study with an analytical component evaluating the correlation between the volumetric analysis of GH-producing PitNETs, IGF-1 levels before and after surgery, disease control during follow-up, and the line of therapy required for disease control in a cohort of patients treated at two centers: Endocrinology Department of the Central Military Hospital and Centros Médicos Colsanitas, Bogotá, Colombia.

RESULTS

A total of 77 patients with acromegaly (42 men, 35 women) were included in this study. The mean age at diagnosis was 42 years (SD: 12), with a mean disease duration of 9.9 years (SD: 7.2). The mean pituitary tumor volume was 4358 mm³ (SD: 6291, interquartile range [IQR]: 13602). Patients with controlled acromegaly had a mean PitNET volume of 3202 mm³ (SD: 4845, 95%CI: 621-5784) compared to 5513 mm³ (SD: 7447, 95%CI: 1545-9482) in the uncontrolled group (P = 0.15). A PitNET volume exceeding 3697 mm³ was associated with a higher likelihood of requiring third or fourth-line therapy (50% vs 36%; P = 0.03).

CONCLUSION

PitNET volume was associated with the need for higher-line therapy to manage acromegaly but did not correlate with long-term disease control or with pre- or postsurgical IGF-1 levels. Nevertheless, a trend towards an inverse relationship between tumor volume and future disease control was observed. While macroadenoma classification remains crucial, among patients with macroadenomas, those with a volume exceeding 3697 mm³ could have worse prognosis.

Hyperostosis frontalis interna and association of disease control with frontal bone thickness in acromegaly

PURPOSE

Studies investigating hyperostosis frontalis interna (HFI) in acromegaly are limited. We aimed to investigate HFI and the association of disease control with frontal bone thickness (FBT) in acromegaly.

METHODS

Adult patients with acromegaly were grouped according to the presence of HFI on the baseline MRI: Group 1 absent, Group 2 present. We measured FBT, parietal bone thickness (PBT) and occipital bone thickness (OBT) in the mid-sagittal plane on MRI. The changes between first and last measurements were analyzed. We grouped the patients as controlled vs. uncontrolled acromegaly, and as established disease control for at least 5-year vs. 1-5-years.

RESULTS

Group 1/Group 2 comprised of 23/29 patients, female/male ratio was 34/18, and mean age 55.41(± 14.21) years. Median follow-up duration was 108 months (6-408). FBTfirst (p = 0.001), FBTlast (p < 0.001), PBTlast (p = 0.025), and OBTlast (p = 0.028) were higher in Group 2 than in Group 1. FBTchange, PBTchange, and OBTchange were positive in Group 2 (p < 0.001, p = 0.008, and p = 0.008; respectively). The ratio of patients with FBT(increased) was higher in Group 2 than in Group 1 (p = 0.001). FBTfirst, FBTlast, PBTfirst, PBTlast, OBTfirst, OBTlast, FBTchange, PBTchange and OBTchange were similar in controlled or uncontrolled acromegaly groups. FBTchange and OBTchange were positive in patients with disease control established for at least 5 years (n = 30) (p = 0.027 and p = 0.002, respectively).

CONCLUSION

HFI was common in patients with acromegaly. HFI is associated with a continuous increase in FBT, PBT and OBT. HFI, bone thickness, or increase in bone thickness seems independent of disease activity. Since headaches can be related to an increase in bone thickness, patients should be evaluated and graded during baseline imaging.

Cancer screening in patients with acromegaly: a plea for a personalized approach and international registries

Acromegaly is a rare condition, and often diagnosis is delayed by several years, for most patients. Acromegaly is characterized by short and long-term respiratory, cardiovascular and metabolic comorbidities, with possible impact on mortality. In the last two decades, life expectancy has progressively increased in part due to a reduction in biochemically active disease, multidisciplinary treatment approaches and a reduction in complications, and the availability of new drugs. Of note, a leading cause of mortality, cardiovascular comorbidity, has been replaced by cancer(s). As such, neoplasms more frequently observed (colon, thyroid, breast, prostate, and stomach) in patients with acromegaly are receiving increased attention. Chronic exposure to increased growth hormone serum levels may contribute to an increase in the occurrence and progression of cancers. Various efforts have been made to determine the pathogenetic mechanisms involved. However, there are no clear medical-related societal agreement(s) in relation to screening methods or timing regarding neoplasm(s) diagnosis in patients with acromegaly. Additionally, independent and dependent risk factor data in patients with acromegaly is lacking. International/national registries could help lay the groundwork to better study the impact of cancer(s) in patients with acromegaly and subsequently lead to and validate the most appropriate diagnostic and therapeutic path forward.

Growth Hormone Action as a Target in Cancer: Significance, Mechanisms, and Possible Therapies

Growth hormone (GH) is a pituitary-derived endocrine hormone required for normal postnatal growth and development. Hypo- or hypersecretion of endocrine GH results in 2 pathologic conditions, namely GH deficiency (GHD) and acromegaly. Additionally, GH is also produced in nonpituitary and tumoral tissues, where it acts rather as a cellular growth factor with an autocrine/paracrine mode of action. An increasingly persuasive and large body of evidence over the last 70 years concurs that GH action is implicit in escalating several cancer-associated events, locally and systemically. This pleiotropy of GH's effects is puzzling, but the association with cancer risk automatically raises a concern for patients with acromegaly and for individuals treated with GH. By careful assessment of the available knowledge on the fundamental concepts of cancer, suggestions from epidemiological and clinical studies, and the evidence from specific reports, in this review we aimed to help clarify the distinction of endocrine vs autocrine/paracrine GH in promoting cancer and to reconcile the discrepancies between experimental and clinical data. Along this discourse, we critically weigh the targetability of GH action in cancer-first by detailing the molecular mechanisms which posit GH as a critical node in tumor circuitry; and second, by enumerating the currently available therapeutic options targeting GH action. On the basis of our discussion, we infer that a targeted intervention on GH action in the appropriate patient population can benefit a sizable subset of current cancer prognoses.

Identifying research priorities for pituitary adenoma surgery: an international Delphi consensus statement

PURPOSE

Pituitary surgery is the mainstay treatment for most pituitary adenomas, but many questions remain about perioperative and long-term management and outcomes. This study aimed to identify the most pressing research priorities in pituitary surgery with input from patients, caregivers, and healthcare professionals.

METHODS

An initial survey of patients, caregivers, and healthcare professionals assembled priorities related to preoperative care, surgical techniques, and postoperative management in pituitary surgery. Priorities were thematically grouped into summary priorities, and those answered by existing evidence were omitted following a literature review. An interim survey asked patients, caregivers, and healthcare professionals to select their top 10 priorities from the remaining list. The highest-ranked priorities advanced to a consensus meeting, where the top 10 questions were prioritized.

RESULTS

In the initial survey, 147 participants-60.5% of whom were patients, caregivers, or patient support group representatives-submitted 785 priorities, which were then condensed into 52 summary priorities. After a literature review, 33 unanswered priorities were included in the interim survey, completed by 155 respondents, of whom 54.2% were patients, caregivers, or patient support group representatives. The top-ranked priorities were discussed by 14 participants (7 patients and 7 healthcare professionals) during a consensus meeting. The top 10 priorities covered a variety of themes including enhancing diagnosis and management of pituitary adenomas, advancing surgical techniques and technologies, optimizing the prediction of outcomes and complications, and improving patient support and follow-up.

CONCLUSIONS

The top 10 research priorities in pituitary surgery aim to align researchers and direct funding in order to maximize impact and champion patient representation.

The Spectrum of GH Excess in Carney Complex and Genotype-phenotype Correlations

CONTEXT

Carney complex (CNC) is a familial neoplasia syndrome associated with GH excess (GHE).

OBJECTIVE

To describe the frequency of GHE in a large cohort of patients with CNC and to identify genotype-phenotype correlations.

METHODS

Patients with CNC with at least 1 biochemical evaluation of GH secretion at our center from 1995 to 2021 (n = 140) were included in the study. Diagnosis of GHE was based on levels of IGF-1, GH suppression during oral glucose tolerance test, GH stimulation after thyrotropin administration and overnight GH secretion.

RESULTS

Fifty patients (35.7%) had GHE, and 28 subjects (20%) had symptomatic acromegaly, with median age at diagnosis of 25.3 and 26.1 years, respectively. Most of the patients (99.3%) had a PRKAR1A gene defect. There was a higher risk of GHE in patients harboring a variant that led to no expression of the affected allele [hazard risk (HR): 3.06, 95% confidence interval (CI): 1.2-7.8] and for patients harboring the hotspot variant c.491_492delTG (HR: 2.10, 95% CI: 1.1-4.1). Almost half of patients with CNC had an abnormal finding on pituitary imaging. CNC patients with abnormal pituitary imaging had a higher risk of GHE (HR: 2.94, 95% CI: 1.5-5.8), especially when single or multiple adenoma-like lesions were identified. Management of patients with symptomatic acromegaly involved surgical and medical approaches.

CONCLUSION

Dysregulation of GH secretion is a common finding in CNC. Knowing the clinical spectrum of this disorder and its association with genetic and imaging characteristics of the patient make more likely its prompt diagnosis and better management.

Predictors of biochemical and structural response to medical therapy in patients with active acromegaly following surgery: a real-world perspective

BACKGROUND

Somatostatin receptor analogs (SRAs) and dopamine agonists (DAs) are the main medical treatments for patients with acromegaly who fail to achieve remission after surgery. We aimed to explore the potential role of select clinical, biochemical, and radiological factors in predicting biochemical and structural responses to medical therapy in a real-world setting.

METHODS

This retrospective cohort study included 58 patients with active acromegaly following surgery treated with Octreotide long-acting release (LAR) (± Cabergoline). Biochemical outcomes were defined as the tight biochemical response (TBR; normal insulin-like growth factor-1(IGF-1)) and biochemical control (BC; IGF-1 ≤ 1.2 upper limit of normal (ULN)). The structural response was defined as > 25% reduction in one dimension of the tumor at the last visit. Univariate and multivariate analyses assessed the predictors of biochemical and structural response.

RESULTS

The mean age of the participants was 41.5 ± 11.7 years. They were followed for a median of 27.6 (19.2-43.2) months. At the last visit, TBR and BC were achieved in 48.3% and 51.7% of the patients. Moreover, 51.4% of the patients showed a structural response. Applying the age-sex adjusted model, post-operative IGF-1 was inversely associated with TBR [OR 0.34, P = 0.006] and BC [OR 0.30, P = 0.004]. Moreover, Knosp grading < 3 compared to ≥ 3, and T2-hypointensity compared to the non-T2-hypointensity were associated with higher odds of TBR [OR 3.98, P = 0.04], [OR 27.63, P = 0.01], and BC [OR 5.80, P = 0.01], [OR 35.15, P = 0.01], respectively.

CONCLUSIONS

Post-operative IGF-1, Knosp grading, and T2-hypointensity could be considered for an individualized treatment plan in acromegaly. Accordingly, we propose an individual multidisciplinary treatment approach for patients not achieving remission after surgery.

Paraneoplastic endocrine syndromes: a contemporary overview

INTRODUCTION

Endocrine paraneoplastic syndromes (ePNS) are caused by malignant cells that induce hormonal alterations unrelated to the tissue of origin of the neoplasm. The aim of this manuscript is to review the pathophysiology, diagnosis, and treatment of endocrine paraneoplastic syndromes (ePNS).

AREAS COVERED

We searched the PubMed/Medline, Embase, and Scielo databases, including 96 articles. The pathogenesis of ePNS involves mutations that activate hormonal genes. Hypercalcemia, the most common ePNS, is marker of poor prognosis in most cases. The syndrome of inappropriate antidiuresis causes euvolemic hyponatremia. Ectopic Cushing's syndrome is commonly associated with lung cancer. Paraneoplastic acromegaly is very rare and is associated with pancreatic and lung tumors. Paraneoplastic hypoglycemia usually requires surgical treatment. Other endocrine paraneoplastic syndromes include ectopic secretion of hormones such as calcitonin, renin, vasoactive intestinal polypeptide, fibroblast growth factor 23, paraneoplastic autoimmune hypophysitis, and others.

EXPERT OPINION

In addition to the local manifestations and metastasis of neoplasms, some secrete bioactive substances causing PNS. Recognizing and treating PNS early improves clinical outcomes. Larger-scale studies and clinical trials are needed to enhance their management and prognosis.

Acromegaly: diagnostic challenges and individualized treatment

INTRODUCTION

Acromegaly is due in almost all cases to a GH-secreting pituitary tumor. GH and IGF-1 excesses lead to its multi-system clinical manifestations and comorbidities. Acromegaly is under-diagnosed and typically presents with advanced disease. When early or mild, clinical recognition and biochemical confirmation are especially challenging. Individualized treatment may optimize patient outcome.

AREAS COVERED

This review covers challenges to diagnosing acromegaly and reviews therapies for acromegaly with a focus on those aspects that can be individualized.

EXPERT OPINION

The first step in diagnosing acromegaly is recognizing it clinically. To improve this, increase awareness and education of the general population and healthcare professionals about the acromegaly phenotype is needed. Once suspected clinically, IGF-1 measurement is the initial step in making the biochemical diagnosis. GH may be < 1.0 µg/L after oral glucose suppression in early/mild cases. GH and IGF-1 should be considered in concert. Providers should be aware of conditions that can alter GH and IGF-1 levels and each assay's performance. An individualized treatment approach is best employed. Surgery is preferred as initial treatment and medical therapy as initial adjuvant therapy. In individualizing therapy, the advantages and disadvantages of each option and predictors of response to them should be considered.

Ends of the spectrum best practices for early detection and multidisciplinary management of acromegaly

PURPOSE

Acromegaly is characterized by an insidious clinical presentation and delayed diagnosis. Longer delays are associated with more comorbidities which can persist after treatment of the growth hormone-secreting pituitary adenoma (GH-PA). Surgery is the primary therapy of GH-secreting PA, which can lead to durable remission. However, approximately 50% of patients require medical treatment postoperatively. Survival normalizes after achieving biochemical control. This mini-review will address ends of the spectrum challenges in acromegaly, including delayed diagnosis and management of the residual tumor and persistent comorbidities.

METHODS

We synthesize relevant literature and present a case of acromegaly that highlights the complexity of clinical decision-making in the diagnosis and treatment of persistent acromegaly.

RESULTS

Despite improved biochemical assays, most patients with acromegaly are diagnosed on average five years after initial symptoms. A high index of suspicion does not rely exclusively on acral enlargement, but also a constellation of manifestations and comorbidities suggestive of acromegaly. Medical therapy is required in patients with persistent biochemical disease. Somatostatin receptor ligands are the cornerstone of medical treatment and can be used alone or in combination with dopamine agonists and growth hormone receptor antagonists. Improved options of medical treatment and careful consideration of comorbidities enables individualized patient management. Reoperation and radiation are considered for tumor progression despite medical therapy. In rare cases of resistant and aggressive tumors, neuro-oncology expertise is required.

CONCLUSIONS

Increased awareness through education targeting the multifaceted clinical presentation of acromegaly shortens the time to diagnosis and treatment. Multidisciplinary management by specialists increases the likelihood of biochemical and tumor control.

Personalized Medicine in Acromegaly: The ACROFAST Study

CONTEXT

Medical treatment of acromegaly is currently performed through a trial-and-error approach using first-generation somatostatin receptor ligands (fgSRLs) as first-line drugs, with an effectiveness of about 50%, and subsequent drugs are indicated through clinical judgment. Some biomarkers can predict fgSRLs response.

OBJECTIVE

Here we report the results of the ACROFAST study, a clinical trial in which a protocol based on predictive biomarkers of fgSRLs was evaluated.

METHODS

This was a prospective trial (21 university hospitals) comparing the effectiveness and time-to-control of 2 treatment protocols during 12 months: (A) a personalized protocol in which the first options were fgSRLs as monotherapy or in combination with pegvisomant, or pegvisomant as monotherapy depending on the short acute octreotide test (sAOT) results, tumor T2 magnetic resonance (MRI) signal or immunostaining for E-cadherin; and (B) a control group with treatment always started by fgSRLs and the other drugs included after demonstrating inadequate control.

RESULTS

Eighty-five patients participated; 45 in the personalized and 40 in the control group. More patients in the personalized protocol achieved hormonal control compared to those in the control group (78% vs 53%, P < .05). Survival analysis revealed a hazard ratio for achieving hormonal control adjusted by age and sex of 2.53 (CI, 1.30-4.80). Patients from the personalized arm were controlled in a shorter period of time (P = .01).

CONCLUSION

Personalized medicine is feasible using a relatively simple protocol, and it allows a higher number of patients to achieve control in a shorter period of time.

Acromegaly Disease Control Maintained After Switching From Injected Somatostatin Receptor Ligands to Oral Paltusotine

CONTEXT

Paltusotine is a nonpeptide selective somatostatin receptor 2 agonist in development as once-daily oral treatment for acromegaly.

OBJECTIVE

To evaluate the efficacy and safety of paltusotine in the treatment of patients with acromegaly previously controlled with injected somatostatin receptor ligands (SRLs).

METHODS

This phase 3, randomized, double-blind, placebo-controlled trial enrolled adults with acromegaly who had IGF-I ≤1.0 times the upper limit of normal (×ULN) while receiving a stable dose of depot octreotide or lanreotide. Patients were switched from injected SRLs and randomized to receive paltusotine or placebo orally for 36 weeks. The primary endpoint was proportion of patients maintaining IGF-I ≤1.0× ULN. Secondary endpoints were change in IGF-I level, change in Acromegaly Symptom Diary score, and maintenance of mean 5-sample GH <1.0 ng/mL.

RESULTS

The primary endpoint was met: 83.3% (25/30) of patients receiving paltusotine and 3.6% (1/28) receiving placebo maintained IGF-I ≤1.0× ULN (odds ratio, 126.53; 95% CI, 13.73->999.99; P < .0001). Paltusotine was also superior to placebo for all secondary endpoints: mean (± SE) change in IGF-I of 0.04 ± 0.09× ULN vs 0.83 ± 0.1× ULN (P < .0001); mean (± SE) change in Acromegaly Symptom Diary score of -0.6 ± 1.5 vs 4.6 ± 1.6 (P = .02); mean GH maintained at <1.0 ng/mL in 20/23 (87.0%) vs 5/18 (27.8%) patients (odds ratio, 16.61; 95% CI, 2.86-181.36; P = .0003). The most common adverse events were acromegaly symptoms and gastrointestinal effects characteristic of SRLs.

CONCLUSION

Replacement of injected SRLs by once-daily oral paltusotine was effective in maintaining both biochemical and symptom control in patients with acromegaly and was well tolerated.

Real-Life Data on the Safety of Pasireotide in Acromegaly: Insights from EudraVigilance

BACKGROUND/OBJECTIVES

Pasireotide (PAS) is a somatostatin receptor ligand (SRL) used to treat acromegaly, a chronic condition caused by excess growth hormone. While it offers significant benefits as a second-line treatment for uncontrolled acromegaly, its use raises major concerns due to hyperglycemic side effects and gastrointestinal issues, the latter being similar to those seen with first-generation SRLs. The aim of this study is to evaluate the real-world evidence on adverse drug reactions (ADRs) reported for PAS in the EudraVigilance database, in comparison to other established drug-based therapies for acromegaly.

METHODS

A descriptive analysis and a disproportionality analysis were conducted.

RESULTS

The fewest individual case safety reports (ICSRs) and adverse drug reactions (ADRs) were reported for PAS, with 698 (4%) ICSRs and 1,647 (4%) ADRs, which is even lower than for pegvisomant (PEG), which had 1765 (11%) ICSRs and 4842 (10%) ADRs. Both PAS and lanreotide (LAN) exhibited the lowest proportion of cases classified as serious. Among the total reported ADRs, those categorized as "Metabolic and nutrition disorders" were most frequent and severe for PAS (PAS-17.5% vs. OCT-4.6%, LAN-4.5%, and PEG-2.7%). Additionally, PAS demonstrated a higher likelihood of reporting endocrine disorders, which were frequently classified as serious, as well as stones affecting the hepatobiliary system compared to other drugs.

CONCLUSIONS

Although PAS had the fewest ICSRs and ADRs, and less frequent serious ADRs, it had more reports frequently classified as serious in the "Metabolism and Nutrition Disorders" category (including events such as elevated blood glucose levels or diabetes) and "Endocrine Disorders" category compared to other SRLs and PEG. Furthermore, there was a higher likelihood of reporting hepatobiliary stones with PAS compared to OCT and PEG. This highlights the importance of adequately monitoring glycemic control and the biliary tract through ultrasound at the initiation and during follow-up of PAS therapy. Improved monitoring and reporting of these ADRs could enhance care for patients with acromegaly.

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.

Remission of Acromegaly: The Sooner the Better

Remission of acromegaly is defined by normalization of GH/IGF-1 values according to age and gender. While treatment strategies, biochemical cut-off to reach, and morbidities related to the persistence of the disease are well described in the literature, there is little data focusing on the delay to reach remission and its consequences. In this commentary, the authors discussed the results obtained from the UK acromegaly registry showing that the time to biochemical remission predicts the overall survival of patients in acromegaly.

Could low prolactin levels after radiotherapy predict the onset of hypopituitarism?

Both local and external cranial radiotherapy (RT) can induce neurotoxicity and vascular damage of the hypothalamic-pituitary area, which can promote neuroendocrine alterations. While anterior pituitary insufficiency after RT has been extensively characterized, data on the effect of RT on prolactin (PRL) secretion are limited and heterogeneous, with different patterns of PRL behavior described in the literature. A progressive decline in PRL levels, reflecting a time-dependent, slowly evolving radiation-induced damage to the pituitary lactotroph cells has been reported. To date, the association between hypopituitarism and hypoprolactinemia in patients undergoing RT has not yet been fully investigated. The few available data suggest that lower PRL levels can predict an extent damage of the pituitary tissue and a higher degree of hypothalamic dysfunction. However, most studies on the effect of RT on pituitary function do not properly assess PRL secretion, as PRL deficiency is usually detected as part of hypopituitarism and not systematically investigated as an isolated disorder, which may lead to an underestimation of hypoprolactinemia after RT. In addition, the often-inadequate follow-up over a long period of time may contribute to the non-recognition of PRL deficiency after RT. Considering that hypoprolactinemia is associated with various metabolic complications, there is a need to define appropriate diagnostic and management criteria. Therefore, hypoprolactinemia should enter in the clinical investigation of patients at risk for hypopituitarism, mainly in those patients who underwent RT.

Biochemical Control in a Colombian Cohort of Patients With Acromegaly: A 12-Month Follow-Up Study (2017-2023)

BACKGROUND

Acromegaly, although rare, is associated with multiple manifestations and complications; its high morbidity and mortality makes it a challenge. Treatment involves surgery and pharmacological therapies, focusing on biochemical normalization. This study analyzes the biochemical control in Colombian patients with acromegaly, seeking to improve the understanding of the effects of treatments in the management of the disease.

METHODS

A multicenter retrospective cohort study was conducted with data from a national acromegaly registry in Colombia (2017-2023), analyzing the biochemical control for 12 months according to the treatment modalities received.

RESULTS

A total of 117 patients were analyzed, with 54 individuals from Valle del Cauca and 63 being women, representing different population groups in Colombia. The median age was 52 years, and the median disease duration was six years. Clinically, arterial hypertension and sleep apnea were observed in 53.8% (n = 63) and 45.3% (n = 53) of the cohort, respectively. Biomarker analysis revealed elevated levels of insulin-like growth factor-1 (IGF-1) and growth hormone (GH). The majority of tumors were macroadenomas, and among the 103 surgically removed tumors, all secreted GH. Of these, 58.3% (n = 60) had GH as the sole marker, while 12.6% (n = 13) co-expressed prolactin (PRL). At first, 92.3% (n = 108) of patients had no biochemical control. At six and 12 months, 34.1% (n = 40) and 21.2% (n = 25) achieved biochemical control, respectively. The reduction in tumor size was significant during follow-up, with a median size at the month of admission of 16 mm, with a reduction >20% at month 12 in 92.3% (n = 108) of patients.

CONCLUSION

In Colombian patients with acromegaly, biochemical control at 12 months is lower than that reported in the literature, suggesting that pharmacological management could be associated with greater biochemical control.

Insights from an Italian Delphi panel: exploring resistance to first-generation somatostatin receptor ligands and guiding second-line medical therapies in acromegaly management

PURPOSE

First-line medical therapy for acromegaly management includes first-generation somatostatin receptor ligands (fgSRLs), but resistance limits their use. Despite international guidelines, the choice of second-line therapy is debated.

METHODS

We aim to discuss resistance to fgSRLs, identify second-line therapy determinants and assess glycemia's impact to provide valuable insights for acromegaly management in clinical practice. A group of Italian endocrinologists expert in the pituitary field participated in a two-round Delphi panel between July and September 2023. The Delphi questionnaire encompassed a total of 75 statements categorized into three sections: resistance to fgSRLs therapy and predictors of response; determinants for the selection of second-line therapy; the role of glycemia in the therapeutic management. The statements were rated on a 6-point Likert scale.

RESULTS

Fifty-nine (79%) statements reached a consensus. IGF-1 levels resulted central for evaluating resistance to fgSRLs, that should be defined considering also symptomatic clinical response, degree of tumor shrinkage and complications, using clinician- and patient-reported outcome tools available. Factors to be evaluated for the choice of second-line medical therapy are hyperglycemia-that should be managed as in non-acromegalic patients-tumor remnant, resistant headache and compliance. Costs do not represent a main determinant in the choice of second-line medical treatment.

CONCLUSION

The experts agreed on a holistic management approach to acromegaly. It is therefore necessary to choose currently available highly effective second-line medical treatment (pegvisomant and pasireotide) based on the characteristics of the patients.

Quantitative and qualitative assessment of a pituitary neuroendocrine tumor's T2-signal intensity in acromegaly - a call for unification

Introduction

The T2-signal intensity (SI) of somatotroph pituitary neuroendocrine tumors (sPitNET) is associated with treatment response and granulation pattern. Our aim was to evaluate SI assessment methods and their clinical implications, including responsiveness to preoperative first-generation somatostatin analogs (SSA).

Methods

This single-center, observational study included unselected, consecutive patients with newly diagnosed acromegaly. Out of 109 treatment-naïve patients, 69 were eligible. The qualitative Visual Method involved a visual comparison of the sPitNET with the temporal gray matter. The Three Tissue Method compared the quantified SI of the sPitNET, temporal white matter, and gray matter. The signal intensity ratio of the sPitNET vs. gray matter (GM-SIR) was calculated. Tumors were divided into three groups: hyperintense (HYPER), isointense (ISO), and hypointense (HYPO) according to the Visual Method, Three Tissue Method, and GM-SIR. These groups were compared in terms of demographic, radiological, and biochemical features. The SI assessment methods were investigated for their ability to predict preoperative SSA responsiveness.

Results

SI assessment methods classified SI type correspondingly in 58-75.4% of cases. ISO constituted 39-49% of the analyzed sPitNETs. All methods identified significant differences in tumor volume between the SI groups, with HYPO being more biochemically active per tumor volume unit. According to the Three Tissue Method, patients with ISO had the youngest age at diagnosis and onset. According to the Visual Method, ISO had a lower chance of achieving insulin-like growth factor 1 (IGF1) normalization compared to HYPO (odds ratio (OR) 0.089, confidence interval (CI) 0.015-0.538, p= 0.008)), with no differences between HYPER and HYPO. Only the Visual Method predicted the IGF1 normalization after SSA. HYPER and ISO sPitNETs were classified in electron microscopy as both densely and sparsely granulated. Bihormonal tumors presented only as HYPO and ISO. According to the Three Tissue Method, no HYPO was diagnosed with sparse granulation.

Discussion

We demonstrated discrepancies between the SI assessment methods. The Visual Method predicted the outcome of preoperative treatment with SSA. Clinically, ISO behaved similarly to HYPER. Further studies are needed to unify SI assessment and improve its clinical applicability in acromegaly.

Differences Between GH- and PRL-Cosecreting and GH-Secreting Pituitary Adenomas: a Series of 604 Cases

CONTEXT

Few data exist about the clinical course of acromegaly, surgical and medical outcomes in patients with GH- and prolactin cosecreting pituitary adenomas (GH&PRL-PAs). Nevertheless, some series described a more aggressive clinic-radiological behavior than in growth hormone-secreting pituitary adenomas (GH-PAs).

OBJECTIVE

This work aims to evaluate differences in clinical presentation and in surgical outcomes between GH-PAs and GH&PRL-PAs.

METHODS

A multicenter retrospective study was conducted of 604 patients with acromegaly who underwent pituitary surgery. Patients were classified into 2 groups according to serum PRL levels at diagnosis and immunohistochemistry (IHC) for PRL: a) GH&PRL-PAs when PRL levels were above the upper limit of normal (ULN) and IHC for GH and PRL was positive or PRL levels were greater than 100 ng/dL and PRL IHC was not available (n = 130) and b) GH-PA patients who did not meet the previously mentioned criteria (n = 474).

RESULTS

GH&PRL-PAs represented 21.5% (n = 130) of patients with acromegaly. The mean age at diagnosis was lower in GH&PRL-PAs than in GH-PAs (P < .001). GH&PRL-PAs were more frequently macroadenomas (90.6% vs 77.4%; P = .001) and tended to be more invasive (33.6% vs 24.7%; P = .057) than GH-PAs. Furthermore, they had presurgical hypopituitarism more frequently (odds ratio 2.8; 95% CI, 1.83-4.38). Insulin-like growth factor ULN levels at diagnosis were lower in patients with GH&PRL-PAs (median 2.4 [interquartile range (IQR) 1.73-3.29] vs 2.7 [IQR 1.91-3.67]; P = .023). There were no differences in the immediate (41.1% vs 43.3%; P = .659) or long-term postsurgical acromegaly biochemical cure rate (53.5% vs 53.1%; P = .936) between groups. However, there was a higher incidence of permanent arginine-vasopressin deficiency (AVP-D) (7.3% vs 2.4%; P = .011) in GH&PRL-PA patients.

CONCLUSION

GH&PRL-PAs are responsible for 20% of acromegaly cases. These tumors are more invasive, larger, and cause hypopituitarism more frequently than GH-PAs and are diagnosed at an earlier age. The biochemical cure rate is similar between both groups, but patients with GH&PRL-PAs tend to develop permanent postsurgical AVP-D more frequently.

Prevalence of Neoplasms in Patients with Acromegaly-A Single-Center Polish Study

Background/Objectives: Neoplasms are one of the three most common causes of death in patients with acromegaly. Our study aimed to assess the incidence of benign and malignant neoplasms among patients with acromegaly and the associations between this prevalence and the disease activity, the time of acromegaly diagnosis, and the time of its first symptoms. The correlation between neoplasm occurrence and pituitary somatotropic axis hormone levels was also studied, and the prevalence of different types of neoplasms was compared between the patients with acromegaly and the Polish population. Methods: A retrospective study included a statistical analysis of the medical documentation of 230 patients with acromegaly diagnosed and treated in the Department of Endocrinology, Diabetes, and Isotope Therapy in Wrocław (Poland) between 1976 and 2023. Results: We observed 171 cases of neoplasms (144 benign and 27 malignant). All types of neoplasms and benign tumors were diagnosed more frequently, in both the short and long term, after a diagnosis of acromegaly, but, after a long time, only malignant neoplasms were more frequently diagnosed. In the cases of controlled acromegaly, all types of neoplasms and benign neoplasms were more common than in cases of cured acromegaly. The incidence of neoplasms was higher, regardless of type, in patients with active acromegaly compared to the cured disease. Malignant neoplasms of the thyroid, renal, and stomach type were more common among our subjects compared to the Polish population. Conclusions: This study confirms the association between acromegaly, as well as its activity level and the time from its diagnosis, and the prevalence of neoplasms.

[Cephalgic syndrome in patients with acromegaly]

The aim of this review is to summarize the data available in the literature on the causes of headache in patients with acromegaly, as well as on the effect of various methods of acromegaly treatment on headache. Publications were searched in the PubMed database using the keywords «Headache in patients with acromegaly», «Headache in patients with pituitary adenomas», «Tension-type headache», «Migraine». Headache in patients with pituitary adenomas secreting somatotropic hormone (STH) is not uncommon: according to various authors, cephalgic syndrome occurs in 30-70% of patients with acromegaly and can worsen their quality of life, along with other factors, up to disability. By the nature of development, headache with acromegaly is classified into primary (migraine, tension headache, trigeminal autonomic cephalgia, for example, SUNCT syndrome and cluster headaches), and can also be caused by various causes directly related to the tumor. All this requires differential diagnosis. The factors causing headaches in somatotropinomas have not yet been well studied and require further research. These include the mass effect of the tumor, hormonal hypersecretion, pathology of the temporomandibular joint, sodium and fluid retention in the body, psychological factors, etc. The authors evaluated the effect on headache of various methods of acromegaly treatment: transnasal transsphenoidal adenomectomy, radiation therapy and drug therapy with somatostatin analogues, dopamine agonists and growth hormone receptor antagonist. However, even when normal levels of STH and insulin-like growth factor 1 (IGF-1) are reached, cephalgic syndrome may persist, therefore patients should be warned about this in advance and referred to a cephalgologist to select adequate headache therapy.

Advancement in perioperative management of pituitary adenomas-Current concepts and best practices

Pituitary adenomas are very common representing 18.1% of all brain tumors and are the second most common brain pathology. Transsphenoidal surgery is the mainstay of treatment for all pituitary adenomas except for prolactinomas which are primarily treated medically with dopamine agonists. A thorough endocrine evaluation of pituitary adenoma preoperatively is crucial to identify hormonal compromise caused by the large sellar mass, identifying prolactin-producing tumors and comorbidities associated with Cushing and acromegaly to improve patient care and outcome. Transsphenoidal surgery is relatively safe in the hands of experienced surgeons, but still carries a substantial risk of causing hypopituitarism that required close follow-up in the immediate postoperative period to decrease mortality. A multidisciplinary team approach with endocrinologists, ophthalmologists, and neurosurgeons is the cornerstone in the perioperative management of pituitary adenomas.

Comprehensive mapping of somatotroph pituitary neuroendocrine tumour heterogeneity using spatial and single-cell transcriptomics

BACKGROUND

Pituitary neuroendocrine tumours (PitNETs) are common intracranial tumours that are highly heterogeneous with unpredictable growth patterns. The driver genes and mechanisms that are crucial for tumour progression in somatotroph PitNETs are poorly understood.

METHODS

In this study, we performed integrative spatial transcriptomics (ST) and single-cell RNA sequencing (scRNA-seq) analysis on somatotroph tumours and normal pituitary samples to comprehensively characterize the differences in cellular characteristics.

RESULTS

By analyzing combined copy number variations (CNVs), tumour tissues were divided into two regions, which included the CNVhigh and CNVlow areas. The protumour genes DLK1 and RCN1 were highly expressed in the CNVhigh area, which might be related to tumour progression and could be targeted for precision therapy. We also found that the transforming growth factor beta signalling pathway participated in tumour progression and identified heterogeneity in the expression profiles of key genes. We assessed the intertumoral and intratumoral heterogeneity in somatotroph PitNETs and emphasized the importance of individualized treatment.

CONCLUSION

In summary, we visualized the cellular distribution and transcriptional differences in normal pituitary and somatotroph PitNETs by ST and scRNA-seq for the first time. This study provides a strong theoretical foundation to comprehensively understand the crucial mechanisms involved in tumour progression and develop new strategies to treat somatotroph PitNETs.

KEY POINTS

The first-ever visualization of cellular distributions in normal and tumor pituitary tissues. The inter- and intra-tumoral transcriptomic heterogeneity of somatotroph PitNETs was comprehensively revealed. Identification of potential protumor factors and critical signaling pathways, opening new avenues for therapeutic intervention.

In Vivo Effects of a GHR Synthesis Inhibitor During Prolonged Treatment in Dogs

Background: The activation of the growth hormone receptor (GHR) is a major determinant of body growth. Defective GHR signaling, as seen in human Laron dwarfism, resulted in low plasma IGF-1 concentrations and limited growth, but also marked absence in the development of breast cancer and type 2 diabetes. In vitro, we identified a small molecule (C#1) that inhibits the translation of GHR mRNA to receptor protein. Methods: Before its application in humans as a potential anticancer drug, C#1 was tested in animals to evaluate whether it could be administered to achieve a plasma concentration in vivo that inhibits cell proliferation in vitro without causing unwanted toxicity. To evaluate the efficacy and toxicity of C#1, a group of six intact female Beagle dogs was treated daily each morning for 90 days with an oral solution of C#1 in Soiae oleum emulgatum at a dose of 0.1 mg/kg body weight. During treatment, dogs were closely monitored clinically, and blood samples were taken to measure plasma C#1 concentrations, complete blood counts (CBC), clinical chemistry, and endocrinology. At the end of the treatment, dogs were euthanized for gross and histopathological analysis. An additional group of six female Beagle dogs was included for statistical reasons and only evaluated for efficacy during treatment for 30 days. Results: Daily administration of C#1 resulted in a constant mean plasma concentration of approximately 50 nmol/L. In both groups, two out of six dogs developed decreased appetite and food refusal after 4-5 weeks, and occasionally diarrhea. No significant effects in CBC or routine clinical chemistry were seen. Plasma IGF-1 concentrations, used as biomarkers for defective GHR signaling, significantly decreased by 31% over time. As plasma growth hormone (GH) concentrations decreased by 51% as well, no proof of GHR dysfunction could be established. The measured 43% decrease in plasma acylated/non-acylated ghrelin ratios will also lower plasma GH concentrations by reducing activation of the GH secretagogue receptor (GHSR). C#1 did not directly inhibit the GHSR in vivo, as shown in vitro. There were no significant effects on glucose, lipid, or folate/homocysteine metabolism. Conclusions: It is concluded that with daily dosing of 0.1 mg C#1/kg body weight, the induction of toxic effects prevented further increases in dosage. Due to the concomitant decrease in both IGF-1 and GH, in vivo inhibition of GHR could not be confirmed. Since the concept of specific inhibition of GHR synthesis by small molecules remains a promising strategy, searching for compounds similar to C#1 with lower toxicity should be worthwhile.

LONG-TERM NATURAL HISTORY OF GIANT NULL CELL PITUITARY ADENOMA

Pituitary adenomas that extend to the ventricular system are extremely rare. We present a 5-year natural history of a giant null cell pituitary adenoma with invasion into the cavernous sinus extending to the third ventricle. MRI series that were available could be useful for neurosurgeons, ophthalmologists, and endocrinologists as well as radiologists. Patients with the diagnosis of pituitary adenoma that are certain according to the radiological and clinical examination should be consulted by a neurosurgeon experienced in endoscopic endonasal surgery, a neuroendocrinologist, and an ophthalmologist. The surgery postponement in such cases results in disability and quality of life worsening. At that time, the surgery of giant pituitary adenomas demands high skills, and the risk of postoperative complications is high. The proper treatment modality including earlier surgery seems to be favorable for patient outcome.

[Difficulties of treating acromegaly in the light of 12 years of experience]

Az acromegaliás betegek várható túlélése, életminősége rosszabb, mint az egészséges populációé. Ennek hátterében a diagnózis késése és a műtét után is sokszor megmaradó acromegalia-aktivitás áll. Így esetükben különösen fontos a gyors, hatékony és egyénre szabott endokrinológiai kezelés és gondozás. 1965-ös születésű nőbetegünket 2008 óta gondozták tenziós jellegű fejfájás miatt. 2012-ben sella-MR-vizsgálat 13 mm-es hypophysis-macroadenomát igazolt, melynek teljes, transsphenoidalis műtéti eltávolítása megtörtént. A szövettani vizsgálat somatrotrop adenomát mutatott. Posztoperatív orális glükóztolerancia-teszt során biokémiailag aktív acromegaliát észleltünk negatív sella-MR-kép mellett, így dopaminagonista kezelés indult, majd az inzulinszerű növekedési faktor-1 emelkedő szintje és fokozódó fejfájás miatt első generációs szomatosztatinreceptorligand (SRL)-kezelésre tértünk át. Új keletű cukorbetegség miatt a beteg biguanid-, majd izulinterápiát igényelt. Progrediáló panaszok miatt növekedésihormonreceptor-antagonista kezelésre váltottunk, mely részleges betegségkontrollt eredményezett, és nem változtak a páciens életminőségét jelentősen rontó fejfájásos panaszok sem. Ezért egy évtizednyi terápiás próbálkozás után a fennálló diabetes mellitus ellenére második generációs SRL-kezelés mellett döntöttünk, mely a fejfájást azonnal megszüntette, és az addig aktív acromegaliát kontrollálta. A szomatosztatin-receptor (SSTR) altípusának utólagos vizsgálata domináns SSTR5-expressziót igazolt. Diabetes mellitusszal szövődött acromegalia esetén is lehet optimális terápia a pazireotid, amennyiben a daganat SSTR5-expressziót mutat. Orv Hetil. 2024; 165(40): 1587–1593.

Medical treatment of acromegaly - When the tumor size matters: A narrative review

Medical treatment of acromegaly is generally positioned as a second line of treatment after pituitary adenoma surgery. With the rising availability and variety of medications for acromegaly increases our understanding of their effectiveness and safety. Volume of the published data on the impact of medical therapy on biochemical control of acromegaly, contrasts a relative lack of publications which comprehensively address pituitary tumor alterations under different drug modalities. Assessment of changes in GH-secreting adenoma volume is often overshadowed by clinicians' focus on GH and IGF-I levels during acromegaly treatment. Close analysis of studies published in the last two decades, reveals that both an increase and decrease in somatotropinoma volume are possible during treatment with any of available drugs for acromegaly. Changes in pituitary tumor size may arise from the biological nature of adenoma itself, independently of the administered medications. Therefore, an individual approach is necessary in the treatment of patients with acromegaly, based on repeated insight to their clinical, biochemical, pathological and imaging characteristics. In this review, we summarize and comment how pituitary tumor size is affected by the treatment with all currently available drugs in acromegaly: long-acting somatostatin receptor ligands of the first generation (octreotide LAR and lanreotide autogel) and the second generation (pasireotide-LAR), as well as pegvisomant (PEG) and cabergoline (CAB).

Glucose metabolism outcomes after pituitary surgery in patients with acromegaly

AIM

To investigate the impact of pituitary surgery on glucose metabolism and to identify predictors of remission of diabetes after pituitary surgery in patients with acromegaly.

METHODS

A national multicenter retrospective study of patients with acromegaly undergoing transsphenoidal surgery for the first time at 33 tertiary Spanish hospitals (ACRO-SPAIN study) was performed. Surgical remission of acromegaly was evaluated according to the 2000 and 2010 criteria.

RESULTS

A total of 604 acromegaly patients were included in the study with a total median follow up of 91 months (interquartile range [IQR] 45-163). At the acromegaly diagnosis, 23.8% of the patients had diabetes mellitus (DM) with a median glycated hemoglobin (HbA1c) of 6.9% (IQR 6.4-7.9) [51.9 mmol/mol (IQR 46.4-62.8)]. In the multivariate analysis, older age (odds ratio [OR] 1.02, 95% CI 1.00-1.05), dyslipidemia (OR 5.25, 95% CI 2.81 to 9.79), arthropathy (OR 1.39, 95% CI 2.82 to 9.79), and higher IGF-I levels (OR 1.30, 95% CI 1.05 to 1.60) were associated with a greater prevalence of DM. At the last follow-up visit after surgery, 21.1% of the DM patients (56.7% of them with surgical remission of acromegaly) experienced diabetes remission. The cure rate of DM was more common in older patients (hazard ratio [HR] 1.77, 95% CI 1.31 to 2.43), when surgical cure was achieved (HR 2.10, 95% CI 1.01 to 4.37) and when anterior pituitary function was not affected after surgery (HR 3.38, 95% CI 1.17 to 9.75).

CONCLUSION

Glucose metabolism improved in patients with acromegaly after surgery and 21% of the diabetic patients experienced diabetes remission; being more frequent in patients of older age, and those who experienced surgical cure and those with preserved anterior pituitary function after surgery.

Efficacy and safety of pasireotide treatment in acromegaly: A systematic review and single arm meta-analysis

BACKGROUND

Acromegaly is a rare chronic endocrine disorder associated with significant comorbidities. Many patients fail to achieve biochemical control with current medical therapies, including surgery and first-generation somatostatin ligands (fg-SRLs). We aimed to perform a systematic review and single-arm meta-analysis to evaluate the efficacy of the multi-receptor somatostatin ligand pasireotide in patients with active or uncontrolled acromegaly.

METHODS

We systematically searched PubMed, Embase, and Cochrane databases for studies that assessed the efficacy of pasireotide in patients with acromegaly and reported the outcomes of (1) biochemical control and its composite indicators; (2) normalized IGF-1 level and (3) low GH level. For the statistical analysis, we used R software.

RESULTS

We included nine studies with a total of 590 patients: four clinical trials and five observational cohorts. 82.2% of the overall population consisted of inadequately controlled acromegaly patients. After a follow-up of 12 months, the pooled biochemical control rate was 26.50% (95% CI 14.87-42.66). The prevalence of normalized IGF-1 and low GH levels was 36.27% (95% CI 29.15-43.39) and 34.76% (95% CI 24.58-44.95), respectively. Additionally, biochemical response rates were sustained throughout the extension phase of these studies. In a pooled analysis including four studies with extension phase results, the prevalence of biochemical control rate was 29.03% (95% CI 11.49-46.58) with 76 events out of 281 patients. The most commonly reported adverse events were gastrointestinal disturbances in 31.26% (95% CI 7.44-72.01) and hyperglycemia in 29.55% (95% CI 21.80-37.29) of patients. The incidence of new-onset diabetes mellitus significantly increased after pasireotide treatment, with a rate of 23.36% (95% CI 19.58-27.13).

CONCLUSION

Pasireotide demonstrates biochemical control in patients with active or uncontrolled acromegaly. Although a high rate of hyperglycemic adverse events and diabetes mellitus related to the treatment were observed, most of them were manageable.

Diagnosis and management of pituitary adenomas in children and adolescents

BACKGROUND

Pituitary adenomas (PAs)-also now called pituitary neuroendocrine tumours or Pit-NETS-are rare in children and adolescents and exceptional below the age of 10. Most evidence-based high-quality data are derived from larger studies in adult patients.

AIMS

We will review recent knowledge on the epidemiology, clinical features, diagnosis, and treatment modalities of the different types of pituitary adenomas diagnosed in children and adolescents, emphasizing the many reasons why these cases should be discussed within pituitary-specific multidisciplinary teams with experts from both paediatric and adult practice.

CONCLUSIONS

Paediatric PA presents multiple peculiarities that may challenge their adequate management. They are overall proportionally larger and more aggressive than in adults, with potential mass effects including hypopituitarism. Hormonal hypersecretion is frequent, resulting in clinical syndromes affecting normal growth and pubertal development. Prolactinomas represent the most frequent subtype of PA found during childhood, followed by adrenocorticotropin (ACTH) and growth hormone (GH)-secreting adenomas, while clinically non-functioning adenomas are exceptionally diagnosed before the age of 16. The occurrence of a pituitary tumour in a young individual should also prompt genetic testing in each case, searching for either germline mutations in one of the known genes that may drive inherited/familial PA (such as the multiple endocrine neoplasia type 1 or MEN1 gene, or the aryl hydrocarbon receptor interacting protein or AIP gene), or for a mosaic activating mutation of GNAS as found in the McCune-Albright syndrome.

FTO-mediated DSP m6A demethylation promotes an aggressive subtype of growth hormone-secreting pituitary neuroendocrine tumors

BACKGROUND

Growth hormone-secreting pituitary neuroendocrine tumors can be pathologically classified into densely granulated (DGGH) and sparsely granulated types (SGGH). SGGH is more aggressive and associated with a poorer prognosis. While epigenetic regulation is vital in tumorigenesis and progression, the role of N6-methyladenosine (m6A) in aggressive behavior has yet to be elucidated.

METHODS

We performed m6A-sequencing on tumor samples from 8 DGGH and 8 SGGH patients, complemented by a suite of assays including ELISA, immuno-histochemistry, -blotting and -fluorescence, qPCR, MeRIP, RIP, and RNA stability experiments, aiming to delineate the influence of m6A on tumor behavior. We further assessed the therapeutic potential of targeted drugs using cell cultures, organoid models, and animal studies.

RESULTS

We discovered a significant reduction of m6A levels in SGGH compared to DGGH, with an elevated expression of fat mass and obesity-associated protein (FTO), an m6A demethylase, in SGGH subtype. Series of in vivo and in vitro experiments demonstrated that FTO inhibition in tumor cells robustly diminishes hypoxia resistance, attenuates growth hormone secretion, and augments responsiveness to octreotide. Mechanically, FTO-mediated m6A demethylation destabilizes desmoplakin (DSP) mRNA, mediated by the m6A reader FMR1, leading to prohibited desmosome integrity and enhanced tumor hypoxia tolerance. Targeting the FTO-DSP-SSTR2 axis curtailed growth hormone secretion, therefor sensitizing tumors to octreotide therapy.

CONCLUSION

Our study reveals the critical role of FTO in the aggressive growth hormone-secreting pituitary neuroendocrine tumors subtype and suggests FTO may represent a new therapeutic target for refractory/persistent SGGH.

Acromegaly management in the Nordic countries: A Delphi consensus survey

OBJECTIVE

Acromegaly is associated with increased morbidity and mortality if left untreated. The therapeutic options include surgery, medical treatment, and radiotherapy. Several guidelines and recommendations on treatment algorithms and follow-up exist. However, not all recommendations are strictly evidence-based. To evaluate consensus on the treatment and follow-up of patients with acromegaly in the Nordic countries.

METHODS

A Delphi process was used to map the landscape of acromegaly management in Denmark, Sweden, Norway, Finland, and Iceland. An expert panel developed 37 statements on the treatment and follow-up of patients with acromegaly. Dedicated endocrinologists (n = 47) from the Nordic countries were invited to rate their extent of agreement with the statements, using a Likert-type scale (1-7). Consensus was defined as ≥80% of panelists rating their agreement as ≥5 or ≤3 on the Likert-type scale.

RESULTS

Consensus was reached in 41% (15/37) of the statements. Panelists agreed that pituitary surgery remains first line treatment. There was general agreement to recommend first-generation somatostatin analog (SSA) treatment after failed surgery and to consider repeat surgery. In addition, there was agreement to recommend combination therapy with first-generation SSA and pegvisomant as second- or third-line treatment. In more than 50% of the statements, consensus was not achieved. Considerable disagreement existed regarding pegvisomant monotherapy, and treatment with pasireotide and dopamine agonists.

CONCLUSION

This consensus exploration study on the management of patients with acromegaly in the Nordic countries revealed a relatively large degree of disagreement among experts, which mirrors the complexity of the disease and the shortage of evidence-based data.

Diagnosis and Management of Aggressive/Refractory Growth Hormone-Secreting Pituitary Neuroendocrine Tumors

The majority of acromegaly and gigantism are caused by growth hormone-secreting pituitary neuroendocrine tumors (PitNETs). Most cases can be cured or controlled by surgery, medical therapy, and/or radiotherapy. However, a few of these tumors are resistant to traditional therapy and always have a poor prognosis. The title aggressive/refractory is used to differentiate them from pituitary carcinomas. To date, there is no definitive conclusion on how to diagnose aggressive/refractory growth hormone-secreting PitNETs, which may have slowed the process of exploring new therapeutical strategies. We summarized the literature described diagnosis and treatment of the disease. Potential disease markers and prospective therapies were also included.

Predicting Response to Medical Treatment in Acromegaly via Granulation Pattern, Expression of Somatostatin Receptors Type 2 and 5 and E-Cadherin

Resistance to first-generation somatostatin receptor ligand (fgSRL) treatment in acromegaly is common, making the identification of biomarkers that predict fgSRL response a desired goal. We conducted a retrospective analysis on 21 patients with acromegaly who underwent surgery and subsequent pharmacological treatment. Through immunohistochemistry (IHC), we assessed the expression of the somatostatin receptor subtypes SSTR2 and SSTR5, E-Cadherin, and cytokeratin granulation pattern (sparsely or densely). Patients were divided into responders and non-responders based on their biochemical response to fgSRL and/or the newer agent, Pasireotide, or the GH-blocker, Pegvisomant. Patients resistant to fgSRL (n = 12) exhibited lower SSTR2 and E-Cadherin expressions. Sparsely granulated tumors were more frequent in the non-responder group. SSTR2 (p = 0.024, r = 0.49) and E-Cadherin (p = 0.009, r = 0.64) positively correlated with the Insulin-like Growth Factor 1 (IGF-1) decrease after fgSRL, while SSTR5 (p = 0.107, r = -0.37) showed a trend towards negative correlation. SSTR5 positivity seemed to be associated with Pasireotide response, albeit the number of treated patients was too low (n = 4). No IHC markers correlated with Pegvisomant response. Our findings suggest that densely granulated tumors, with positive SSTR2 and E-Cadherin seem to be associated with favorable fgSRL responses. The strongest predictive value of the studied markers was found for E-Cadherin, which seems to surpass even SSTR2.

Uterine fibroids in women diagnosed with acromegaly: a systematic review

The review discusses the relationship between acromegaly and uterine fibroids. It highlights variations in research methodologies and inconsistent findings, emphasizing the complex nature of fibroid development and the role of the somatotropic axis. Additionally, it addresses demographic factors and examines the potential impact of therapies on the risk and prevalence of uterine fibroids in individuals with acromegaly. We conducted an analysis of previously published literature that examined the repercussions of acromegaly on gynecological health in female cohorts, with specific attention directed towards elucidating the prevalence of uterine fibroids. We suggest that larger, more focused studies are needed to understand the specific impact of different treatments on the occurrence of gynecological issues in acromegaly patients. Additionally, our study emphasizes the importance of factors such as disease duration and treatment effectiveness. We hypothesize that a relationship between acromegaly and uterine fibroids may occur. However, it remains an area of ongoing research, with the need for larger, multi-center studies to draw more definitive conclusions.

Rapid Resolution of Recalcitrant Headache With Pasireotide in an Adult Patient With Acromegaly

Acromegaly is a chronic hormonal disorder caused by excessive GH secretion. In addition to physiological symptoms, it is often accompanied by debilitating headaches. Although effective treatment options exist, achieving complete symptom control and disease management can still be challenging. This case report chronicles the clinical journey of a 38-year-old male diagnosed with acromegaly in 2013. Despite prior interventions, including surgery and treatment with first-generation somatostatin analogues, severe frequent headaches persisted. Following a switch to pasireotide, the patient reported rapid and complete resolution of headaches and normalization of IGF-1 levels within a month of the treatment switch. This report underscores the challenges in acromegaly management and confirms the potential utility of pasireotide for patients suffering from treatment-resistant headache.

Standards of care for medical management of acromegaly in pituitary tumor centers of excellence (PTCOE)

PURPOSE

A series of consensus guidelines on medical treatment of acromegaly have been produced in the last two decades. However, little information is available on their application in clinical practice. Furthermore, international standards of acromegaly care have not been published. The aim of our study was to report current standards of care for medical therapy of acromegaly, using results collected through an audit performed to validate criteria for definition of Pituitary Tumor Centers of Excellence (PTCOE).

METHODS

Details of medical treatment approaches to acromegaly were voluntarily provided by nine renowned international centers that participated in this audit. For the period 2018-2020, we assessed overall number of acromegaly patients under medical treatment, distribution of patients on different treatment modalities, overall biochemical control rate with medical therapy, and specific control rates for different medical treatment options.

RESULTS

Median number of total patients and median number of new patients with acromegaly managed annually in the endocrinology units of the centers were 206 and 16.3, respectively. Median percentage of acromegaly patients on medical treatment was 48.9%. Among the patients on medical treatment, first-generation somatostatin receptor ligand (SRL) monotherapy was used with a median rate of 48.7%, followed by combination therapies with a median rate of 29.3%. Cabergoline monotherapy was used in 6.9% of patients. Pegvisomant monotherapy was used in 7 centers and pasireotide monotherapy in 5 centers, with median rates of 7.9% and 6.3%, respectively.

CONCLUSIONS

Current standards of care in PTCOEs include use of first-generation SRLs as the first medical option in about 50% of patients, as recommended by consensus guidelines. However, some patients are kept on this treatment despite inadequate control suggesting that cost-effectiveness, availability, patient preference, side effects, and therapeutic inertia may play a possible role also in PTCOE. Moreover, at odds with consensus guidelines, other monotherapies for acromegaly appear to have a marginal role as compared to combination therapies as extrapolated from PTCOE practice data. Presence of uncontrolled patients in each treatment category suggest that further optimization of medical therapy, as well as use of other therapeutic tools such as radiosurgery may be needed.

[Clinically active pituitary tumors]

The widespread use of diagnostic imaging has led to an increase in the incidence of pituitary tumors. The majority of incidentalomas are hormone-inactive (HI) pituitary microadenomas. The most common clinically relevant pituitary adenomas are prolactin-secreting, followed by HI, and far less common are growth hormone (GH)-, adrenocorticotropic hormone (ACTH)- and thyroid-stimulating hormone (TSH)-secreting adenomas. Pituitary adenomas are usually benign, although aggressive growth and invasion occurs in individual cases. Very rarely, they give rise to metastases and are then termed pituitary carcinomas. All pituitary tumors require endocrine testing for pituitary hormone excess. In addition to the medical history and clinical examination, laboratory diagnostics are very important. Symptoms such as irregular menstruation, loss of libido or galactorrhea often lead to the timely diagnosis of prolactinomas, and hyperprolactinemia can easily confirm the diagnosis (considering the differential diagnoses). Diagnosis is more difficult for all other hormone-secreting pituitary adenomas (acromegaly, Cushing's disease, TSHoma), as the symptoms are often non-specific (i.e., headaches, weight gain, fatigue, joint pain). Furthermore, comorbidities such as hypertension, diabetes, and depression are such widespread diseases that pituitary adenomas are rarely considered as the underlying cause. Timely diagnosis and appropriate treatment have a significant impact on morbidity, mortality, and quality of life. Therefore, the role of primary care physicians is very important for achieving an early diagnosis. In addition, patients with pituitary adenomas should always be referred to endocrinologists to ensure optimal diagnosis as well as treatment.

Oral octreotide capsules for acromegaly treatment: application of clinical trial insights to real-world use

INTRODUCTION

Acromegaly is a rare endocrine disorder usually caused by a benign growth hormone‒secreting pituitary adenoma. Surgical adenoma resection is typically the first line of treatment, and medical therapy is used for patients with persistent disease following surgery, for adenoma recurrence, or for patients ineligible for, or declining, surgery. Approved somatostatin receptor ligands (SRLs) have been limited to injectable options, until recently. Oral octreotide capsules (OOC) are the first approved oral SRL for patients with acromegaly.

AREAS COVERED

We review published reports and provide case study examples demonstrating practical considerations on the use of OOC. Using two hypothetical case scenarios, we discuss current treatment patterns, breakthrough symptoms and quality of life (QoL), efficacy of SRLs, OOC dose titration, evaluation of OOC treatment response, and incidence and management of adverse events.

EXPERT OPINION

OOC are an option for patients with acromegaly including those who experience breakthrough symptoms, who have preference for oral therapies, or other reasons for declining injectable SRLs. OOC have been associated with improved patient-reported QoL measures compared with those reported for lanreotide and octreotide. Continued real-world experience will determine whether OOC, alone or in combination with other therapies, provides further advantages over current injectable acromegaly treatments.

Growth hormone receptor antagonist pegvisomant and its role in the medical therapy of growth hormone excess

Pegvisomant is a growth-hormone (GH) receptor antagonist that prevents the formation of the active heterotrimer of the dimerised GH receptor and the GH molecule necessary for downstream signal transduction. Over the past 20 years, it has become a key therapeutic option for physicians treating syndromes of GH/IGF-1 excess. Sufficient longitudinal follow-up data suggest that it can be deemed both safe and effective. It is the drug with the greatest potential for achieving an amelioration of the biochemical effects of GH excess with a corresponding normalisation of IGF-1 levels; however, insufficient dose titration has lessened real-world therapeutic outcomes. Theoretical concerns about stimulating tumour growth have been resolved as this has not been observed, while derangement of liver enzymes and local skin-related adverse reactions may occur in a minority of the patients. It may be a particularly impactful medication for the treatment of children, young people, and those with inherited disorders of GH excess, where other treatment modalities often fail. Combination therapy of pegvisomant with first- and second-generation somatostatin receptor ligands or with dopamine agonists remains an ongoing area of interest and research. High cost remains a barrier to the use of pegvisomant in many settings.

Treatment of acromegaly with oral octreotide

Acromegaly is a rare disease caused by a growth hormone excess, usually due to a secreting pituitary adenoma. Somatostatin receptor ligands (SRL) are the mainstay of medical therapy for patients with acromegaly who fail to achieve biochemical control post-operatively or are not eligible for surgical treatment. SRLs are typically administered as monthly injections and have shown to be effective in maintaining biochemical and radiological control of acromegaly. However, these injections may cause local adverse events and are associated with increased psychological burden in some patients. Oral octreotide provides a new alternative for patients responding to injectable SRLs. This new formulation has shown to have similar safety and efficacy profiles compared to injectable SRLs and may be a preferable option for some patients with acromegaly. The aim of this review is to provide an overview of the role of oral octreotide in the management of acromegaly.

Pharmacokinetics and pharmacodynamics of a pasireotide subcutaneous depot (CAM4071) and comparison with immediate and long-acting release pasireotide

PURPOSE

To assess the pharmacokinetics, pharmacodynamics, safety and tolerability of subcutaneous depot CAM4071, a novel, ready-to-use pasireotide formulation.

METHODS

This was a phase 1, randomised, open-label study in healthy volunteers. After a single 600 µg dose of pasireotide immediate release (IR), participants were randomised to one of eight groups to receive either a CAM4071 upper thigh (5, 10, 20, 40 or 80 mg) or buttock (20 mg) injection or multiple pasireotide IR 900 µg upper thigh injections twice daily or a single pasireotide long-acting release (LAR) 60 mg intramuscular buttock injection.

RESULTS

Ninety-four participants were randomised. For all CAM4071 doses, initial pasireotide release was relatively rapid compared to pasireotide LAR and sustained over the 2-month observation period, with a slow decay in plasma concentrations. CAM4071 maximum plasma concentrations increased slightly greater than dose proportionally; area under the curve extrapolated to infinity increased approximately dose proportionally. Relative bioavailability of pasireotide for different doses of CAM4071 versus pasireotide IR 600 μg ranged from 0.752 (90% confidence interval [CI]: 0.58, 0.98) to 1.68 (1.32, 2.14), and versus pasireotide LAR: 0.517 (0.37, 0.72) to 1.15 (0.84, 1.58). CAM4071 doses >5 mg exhibited rapid initial reductions of insulin-like growth factor 1 (IGF-1) compared to pasireotide LAR. Maximum IGF-1 inhibition was greatest for CAM4071 80 mg. CAM4071 injections ≤40 mg were well tolerated and comparable with currently available pasireotide formulations.

CONCLUSION

CAM4071 provided long-acting release of pasireotide over at least one month, with high bioavailability and onset and duration of IGF-1 suppression similar to pasireotide LAR.

TRIAL REGISTRATION

EudraCT: 2014-003783-20.