Arthropathy in long-term cured acromegaly is characterised by osteophytes without joint space narrowing: a comparison with generalised osteoarthritis

Excess Growth Hormone Triggers Inflammation-Associated Arthropathy, Subchondral Bone Loss, and Arthralgia

Growth hormone (GH) is a key mediator of skeletal growth. In humans, excess GH secretion due to pituitary adenoma, seen in patients with acromegaly, results in severe arthropathies. This study investigated the effects of long-term excess GH on the knee joint tissues. One year-old wild-type (WT) and bovine GH (bGH) transgenic mice were used as a model for excess GH. bGH mice showed increased sensitivity to mechanical and thermal stimuli, compared with WT mice. Micro-computed tomography analyses of the distal femur subchondral bone revealed significant reductions in trabecular thickness and significantly reduced bone mineral density of the tibial subchondral bone-plate that were associated with increased osteoclast activity in both male and female bGH compared with WT mice. bGH mice showed severe loss of matrix from the articular cartilage, osteophytosis, synovitis, and ectopic chondrogenesis. Articular cartilage loss in the bGH mice was associated with elevated markers of inflammation and chondrocyte hypertrophy. Finally, hyperplasia of synovial cells was associated with increased expression of Ki-67 and diminished p53 levels in the synovium of bGH mice. Unlike the low-grade inflammation seen in primary osteoarthritis, arthropathy caused by excess GH affects all joint tissues and triggers severe inflammatory response. Data of this study suggest that treatment of acromegalic arthropathy should involve inhibition of ectopic chondrogenesis and chondrocyte hypertrophy.

Emerging Roles of miRNA, lncRNA, circRNA, and Their Cross-Talk in Pituitary Adenoma

Pituitary adenoma (PA) is a common intracranial tumor without specific biomarkers for diagnosis and treatment. Non-coding RNAs (ncRNAs), including microRNAs (miRNA), long non-coding RNA (lncRNA), and circular RNA (circRNA), regulate a variety of cellular processes, such as cell proliferation, differentiation, and apoptosis. Increasing studies have shown that the dysregulation of ncRNAs, especially the cross-talk between lncRNA/circRNA and miRNA, is related to the pathogenesis, diagnosis, and prognosis of PA. Therefore, ncRNAs can be considered as promising biomarkers for PA. In this review, we summarize the roles of ncRNAs from different specimens (i.e., tissues, biofluids, cells, and exosomes) in multiple subtypes of PA and highlight important advances in understanding the contribution of the cross-talk between ncRNAs (e.g., competing endogenous RNAs) to PA disease.

Clinical and radiographic assessment of peripheral joints in controlled acromegaly

PURPOSE

Acromegalic arthropathy is a well-known phenomenon, occurring in most patients regardless of disease status. To date, solely hips, knees, hands, and spinal joints have been radiographically assessed. Therefore, this study aimed to assess the prevalence of joint symptoms and radiographic osteoarthritis (OA) of new, and established peripheral joint sites in well-controlled acromegaly.

METHODS

Fifty-one acromegaly patients (56% female, mean age 64 ± 12 years) in long-term remission for 18.3 years (median, IQR 7.2-25.4) were included. Nineteen patients currently received pharmacological treatment. Self-reported joint complaints were assessed using standardized interviews. Self-reported disability of the upper and lower limbs, and health-related quality of life (HR-QoL) were evaluated using validated questionnaires. Radiographic OA [defined as Kellgren & Lawrence (KL) ≥ 2] was scored using (modified) KL methods.

RESULTS

Radiographic signs of OA were present in 46 patients (90.2%) with ≥ 2 joints affected in virtually all of these patients (N = 44; 95.7%). Radiographic MTP1 OA was as prevalent as radiographic knee OA (N = 26, 51.0%), and radiographic glenohumeral OA was similarly prevalent as hip OA [N = 21 (41.2%) vs. N = 24 (47.1%)]. Risk factors for radiographic glenohumeral OA were higher pre-treatment IGF-1 levels [OR 1.06 (1.01-1.12), P = 0.021], and current pharmacological treatment [OR 5.01 (1.03-24.54), P = 0.047], whereas no risk factors for MTP1 joint OA could be identified.

CONCLUSION

Similar to previously-assessed peripheral joints, clinical and radiographic arthropathy of the shoulder and feet were prevalent in controlled acromegaly. Further studies on adequate management strategies of acromegalic arthropathy are needed.

Clinical and functional outcome of total hip arthroplasty in patients with acromegaly: mean twelve year follow-up

PURPOSE

Acromegaly is a rare and chronic hormonal disorder. Persons with acromegaly frequently live well into adulthood. Patients with active acromegaly have multiple joint-related issues; however, acromegalic arthropathy (AA), which is secondary osteoarthritis (OA), is considered one of the most common musculoskeletal complications of acromegaly. This study aims to analyze a cohort of patients who underwent total hip arthroplasty (THA) for AA at our institution and present the long-term clinical outcomes and causes of revision in these patients.

METHODS

All patients, who underwent total hip arthroplasty due to secondary osteoarthritis related to acromegaly between January 2001 and December 2019 at our institution, were included in this retrospective study. There were 15 patients (22 hips) with a mean follow-up of 12 years (range 4-20). Survivorship free of component revision was determined using Kaplan-Meier analysis. Patient-reported clinical outcomes were assessed using Harris Hip Scores.

RESULTS

At the final follow-up, the status of the implant was known in all 15 hips. No patients were lost to follow-up. Five patients (9 hips) were deceased. Three hips (14%) underwent a revision surgery at a mean of six years (range 3-10). Survivorship free of component revision was 81% at 15 years. Mean Harris Hip Scores at final follow-up were fair (mean 64.3, range 32-91), but significantly improved compared to preoperative scores (p < 0.05).

CONCLUSION

Acromegaly is a rare disorder that has direct effects on bone and joints. Our results suggest that THA can result in successful clinical and functional outcomes in patients with AA of the hip however the risk of aseptic loosening should also be considered in this patient population.

Low prevalence of neuropathic-like pain symptoms in long-term controlled acromegaly

PURPOSE

Pain is a common symptom of acromegaly, impairing health-related quality of life (HR-QoL) significantly despite long-term disease remission. Neuropathic-like pain (NP-like) symptoms are invalidating, with great impact on HR-QoL. Studies characterizing or investigating the etiology of pain in acromegaly are scarce. Therefore, we aimed to assess NP-like symptoms in a cohort of controlled acromegaly patients.

METHODS

Forty-four long-term controlled acromegaly patients (aged 62.6 ± 12.6 years; 56.8% female) were included in this cross-sectional study. NP-like symptoms were assessed using the validated painDETECT questionnaire. Patients were divided in three probability-based NP-like symptoms categories based on the total score (range 0-35): unlikely (≤ 12), indeterminate (13-18) and likely (≥ 19). HR-QoL (physical component score (PCS), and mental component score (MCS)), and self-reported pain were assessed using Short Form-36 (SF-36). Potential risk factors were determined using linear regression analyses.

RESULTS

Self-reported pain was reported by 35 patients (79.5%). Likely NP-like symptoms were present in 4/44 patients (9.1%), and indeterminate NP-like symptoms in 6/44 patients (13.6%). All patients with likely NP-like symptoms were female. Higher painDETECT scores were negatively associated with HR-QoL (PCS: r = - 0.46, P = 0.003; MCS: r = - 0.37, P = 0.018), and SF-36 pain scores (r = - 0.63, P < 0.0001). Female sex was a risk factor for NP-like symptoms.

CONCLUSIONS

Pain was prevalent in controlled acromegaly patients, whereas NP-like symptoms were relatively infrequent, and only observed in females. NP-like symptoms were associated with lower HR-QoL in acromegaly. Since specific analgesic therapy is available, awareness for characterization, increased understanding, and clinical trials regarding neuropathic pain identification and treatment in acromegaly patients are warranted.

Pedabarography May Play a Role in Foot Plantar Scanning in Acromegaly

AIMS

Acromegaly is associated with symptoms in many organs, including the heart, colon, skin, bones, and many joints. Patients with long-term treatment or biochemical control still suffer from acromegaly arthropathy (AA). Primarily, the weight-bearing joints of the lower extremity are affected and at last deformation emerges. The aim of this study is to detect the changes in the feet with pedabarography in patients with acromegaly.

MATERIALS AND METHODS

Nineteen patients with acromegaly (4 males and 15 females) and 13 healthy controls (1 male and 12 females) were included in the study (p=0.31). There was no difference between acromegaly patients and controls in terms of gender, age, and BMI; median age and BMI were (54 (20-67) vs. 52 (30-58), p=0.85) and (32.5 (20.3-42.7) vs. 29.5 (22.4-38.6), p=0.93), respectively. Static plantar pressures of bilateral foot of all participants in the standing position were measured by pedabarography.

RESULTS

In pedabarographic analysis, there were only significant difference in rearfoot surface right and rearfoot surface left (p=0.04 and p=0.01), respectively. The mean of the right rearfoot surface (43.5 cm² vs. 36.6 cm²) and the mean of the left rear foot surface were higher than the controls (47.4 cm² vs. 40.2 cm²). Forefoot surface, forefoot load, forefoot weight ratio, rearfoot load, total foot surface, total load, total peak pressure, and total average pressure were higher in left foot in both groups, but there was no difference between the two groups.

CONCLUSION

In our study, there was a significant difference between acromegaly patients and healthy controls, only on the right rarefoot surface and the left rarefoot surface, and was higher on the left in both groups. These patients often experience changes in the hindfoot and heel, and foot surface area and pressure distribution may vary. Early diagnosis and proper treatment of the disease can prevent the development of complications and improve the quality of life. Foot scanning using pedabarography in the management of AA is a useful tool that can be used to manufacture customized orthopedic insoles and ergonomic shoe designs to prevent irreversible damage and reduce overload and lower extremity pain.

Progression of acromegalic arthropathy in long-term controlled acromegaly patients: 9 years of longitudinal follow-up

CONTEXT

Joint complaints in patients with acromegaly are common, although the long-term disease course is largely unknown.

OBJECTIVE

This study aims to evaluate the long-term course of acromegalic arthropathy.

DESIGN AND SETTING

A prospective longitudinal cohort study was conducted in controlled acromegaly patients followed at a tertial referral center, with 3 study visits: at baseline and after a median of 2.6 and 9.1 years.

PATIENTS

We included 31 patients with biochemically controlled acromegaly for 2 or more years (49% female; median age, 60 years) at baseline.

MAIN OUTCOME MEASURES

Radiographic arthropathy of the knee, hip, hand, and cervical and lumbar spine were evaluated using Kellgren and Lawrence (KL) scores, developed for assessment of primary osteoarthritis (OA). Radiographic progression was defined as a KL increase above the smallest detectable change. Joint symptoms were assessed using self-reported questionnaires. Progression was defined using existing clinically important cutoff values. Risk factors for progression were investigated using a multivariable model.

RESULTS

All patients had definite radiographic OA at 1 or more joints at baseline. Radiographic progression was observed in 29%, 48%, 84%, and 94% of patients in the knees, hips, hands, and axial joints, respectively. Deterioration in hand-related pain and function was observed in 10 (32.3%) and 11 patients (35.5%), respectively. Solely baseline KL scores of the hip were associated with hip OA progression (OR 1.88; 95% CI, 1.09-3.16).

CONCLUSIONS

Acromegalic arthropathy showed significant radiographic progression over 9.1 years of follow-up in patients in remission, whereas clinical progression was observed less frequently. Future studies should focus on adequate prevention and treatment strategies of acromegalic arthropathy.

Association between biochemical control and comorbidities in patients with acromegaly: an Italian longitudinal retrospective chart review study

PURPOSE

Achieving biochemical control (normalization of insulin-like growth factor-1 [IGF-1] and growth hormone [GH]) is a key goal in acromegaly management. However, IGF-1 and GH fluctuate over time. The true potential impact of time-varying biochemical control status on comorbidities is unclear and relies on multiple, longitudinal IGF-1 and GH measurements. This study assessed the association between time-varying biochemical control status and onset of selected comorbidities in patients with acromegaly.

METHODS

Medical charts of adults with confirmed acromegaly and ≥ 6 months of follow-up at an Italian endocrinology center were reviewed. Patients were followed from the first diagnosis of acromegaly at the center until loss to follow-up, chart abstraction, or death. Biochemical control status was assessed annually and defined as IGF-1 ≤ the upper limit of normal, or GH ≤ 2.5 µg/L in the few cases where IGF-1 was unavailable. Time-varying Cox models were used to assess the association between biochemical control status and comorbidities.

RESULTS

Among 150 patients, 47% were female, average age at diagnosis was 43.1, and mean length of follow-up was 10.4 years. Biochemical control was significantly associated with a lower hazard of diabetes (HR = 0.36, 95% CI 0.15; 0.83) and cardiovascular system disorders (HR = 0.54, 95% CI 0.31; 0.93), and a higher hazard of certain types of arthropathy (HR = 1.68, 95% CI 1.04; 2.71); associations for other comorbidities did not reach statistical significance.

CONCLUSION

Results further support the importance of achieving biochemical control, as this may reduce the risk of high-burden conditions, including diabetes and cardiovascular system disorders. The association for arthropathy suggests irreversibility of this impairment. Due to limitations, caution is required when interpreting these results.

Exosomal hsa-miR-21-5p derived from growth hormone-secreting pituitary adenoma promotes abnormal bone formation in acromegaly

Growth hormone-secreting pituitary adenoma (GHPA), a benign endocrine tumor located in the base of the skull, results in acromegaly. In addition to the mass effect of the tumor itself in the sellar region, GHPA can lead to the overgrowth of almost every organ. Previous findings indicated that the processes underlying acromegaly were partly attributable to hyperactivity of the growth hormone/insulin-like growth factor-1 (GH/IGF-1) axis. However, the mechanisms driving this syndrome remains largely unknown. Additionally, the roles of GHPA-derived exosomes, which contain functional microRNAs and proteins that manipulate target cell proliferation and differentiation in distal extremities, are also unknown. In this study, we demonstrated that GHPA exosomes promote bone formation in vitro and trabecula number in vivo. The mechanism of increased trabecula formation may be attributable to GHPA exosome-induced osteoblast proliferation via increased cell viability and DNA replication. We further discovered that exosomal hsa-miR-21-5p plays a distinct role from the GH/IGF-1 axis in these processes. Accordingly, the results of this study provide a novel mechanism whereby GHPA influences distal extremities and a new perspective for treating GHPA.

Liver-derived IGF-I is not required for protection against osteoarthritis in male mice

Insulin-like growth factor-I (IGF-I) is anabolic for cartilage and important for cartilage integrity, which might suggest a connection between IGF-I and osteoarthritis (OA) development. However, the results of studies performed so far are conflicting, and we aimed to clarify the role of endocrine IGF-I in rodent OA. Male mice with inducible inactivation of circulating, liver-derived IGF-I (LI-IGF-I^-/- mice, serum IGF-I reduced by ~80%) were used. Experimental OA was induced in young adult LI-IGF-I^-/- and control mice by destabilization of the medial meniscus (DMM); age-related OA was also evaluated in 1-yr-old mice. DMM-operated LI-IGF-I^-/- mice had thinner lateral subchondral bone plate in tibia compared with control mice, whereas osteophyte volume and articular cartilage damage were unaffected at the medial side of the DMM knee. However, the control mice but not the LI-IGF-I^-/- mice also developed mild OA on the lateral side of the DMM knee compared with the unoperated knee. One-year-old LI-IGF-I^-/- mice had lower mid-diaphyseal cortical bone area than the 1-yr-old control mice, whereas analyses of joint tissues displayed smaller osteophyte volume and thicker calcified cartilage than the control mice. There was no difference in OA severity in the articular cartilage between old LI-IGF-I^-/- and control mice. Our study is the first to investigate whether there is an association between circulating IGF-I and OA in mice. We conclude that, although there is an ~80% reduction of circulating IGF-I and a decrease in cortical bone in male LI-IGF-I^-/- mice, cartilage damage is clearly not intensified and may instead be slightly reduced.

Arthropathy in acromegaly: a questionnaire-based estimation of motor disability and its relation with quality of life and work productivity

PURPOSE

Arthropathy is a common and disabling complication of acromegaly. Since in this condition radiological findings rarely correspond to functional impairment, we elected to quantify in a large cohort of acromegalic patients: the degree of motor disability compared with data from general population, the impact of joint involvement on quality of life and work productivity, and to look for associated factors.

METHODS

In 211 acromegalic patients, 131 with controlled disease and 80 with active disease, eight validated scales were used to evaluate the (i) prevalence and distribution of arthropathy, (ii) degree of motor disability and joint symptoms (VAS, AIMS symptoms and WOMAC), (iii) quality of life (AcroQoL and PASQ) and work capability (WPAI:GH) as consequences of joint complications.

RESULTS

Using the WOMAC questionnaire, for which population based normative values are available, a significantly higher prevalence and severity of motor disability was detected in acromegalics compared to the general population from literature. The results provided by the different questionnaires turned out to be highly concordant. All measures of motor disability correlated both with impaired quality of life and motor disability and were worse in females and in patients with higher BMI.

CONCLUSIONS

The questionnaires VAS, AIMS symptoms, and WOMAC (this latter both as a whole and with its functionality subscale), with their scores, proved to be the most adequate tools to evaluate motor disability and its consequences on both quality of life and work productivity in acromegaly. Female gender and higher BMI are associated with worse articular symptoms.

Static and dynamic balances of patients with acromegaly and impact of exercise on balance

PURPOSE

Patients with acromegaly may have balance abnormalities due to changes in body composition. We aim to compare static and dynamic balances in patients with acromegaly and healthy volunteers, and to evaluate the effects of exercise on balance in patients with acromegaly.

METHODS

This prospective study included 25 patients with acromegaly followed at endocrinology clinic of Cerrahpasa Medical Faculty and 13 healthy volunteers. The acromegalic patients were divided into 2 groups. Group A (n = 11) attended an exercise program 3 days/week for 3 months, whereas group B (n = 14) and healthy volunteers (Group C) were exercise-free. Bipedal and unipedal stance static and dynamic balance tests were performed using a Prokin 252N device.

RESULTS

The ages, demographic characteristics, and body compositions were similar. In acromegalic patients, the static balance parameters of displacement of center-of-pressure in anterior-posterior direction (C.o.P.Y) while eyes open (p = 0.002) and on left leg (p = 0.001), in left-right direction (C.o.P.X) on right leg (p = 0.03), eyes-closed average medio-lateral velocity (AMLV) (p = 0.001) and the dynamic parameter of forward/backward front/right standard deviation (FBFRSD) (p = 0.02) were significantly different from healthy controls. When the exercise effect on balance was evaluated between group A and B, there were significant improvements in most parameters of dynamic balance measurements of both forward-backward and medial-lateral sway (FBFRSD, FBDME, and RLBLSD) (p = 0.02, p = 0.02, and p = 0.004, respectively) after exercise in group A.

CONCLUSIONS

Patients with acromegaly had impairments at various static and dynamic balance parameters, especially in posterior direction. After a 3-month exercise program, the dynamic balance profoundly improved, but static balance was relatively preserved in patients with acromegaly.

Systemic Complications of Acromegaly and the Impact of the Current Treatment Landscape: An Update

Acromegaly is a chronic systemic disease with many complications and is associated with increased mortality when not adequately treated. Substantial advances in acromegaly treatment, as well as in the treatment of many of its complications, mainly diabetes mellitus, heart failure, and arterial hypertension, were achieved in the last decades. These developments allowed change in both prevalence and severity of some acromegaly complications and furthermore resulted in a reduction of mortality. Currently, mortality seems to be similar to the general population in adequately treated patients with acromegaly. In this review, we update the knowledge in complications of acromegaly and detail the effects of different acromegaly treatment options on these complications. Incidence of mortality, its correlation with GH (cumulative exposure vs last value), and IGF-I levels and the shift in the main cause of mortality in patients with acromegaly are also addressed.

Effects of surgical treatment for acromegaly on knee MRI structural features

Acromegalic arthropathy is a common complication of acromegaly and harms the quality of life of the patients even after acromegaly is in long-term remission. A recent study demonstrated by knee MRI the characteristic structural features of acromegalic arthropathy. However, the effects of treatment for acromegaly on such structural features are almost unknown. This study was undertaken to analyze the effects of transsphenoidal surgery (TSS) on acromegalic arthropathy and elucidate whether knee MRI findings are reversible or irreversible. We analyzed 22 patients with acromegaly (63.7% females, median age 58 years) by knee MRI at diagnosis. Out of these 22 patients, 16 who underwent TSS (68.9% female, median age 58 years) were also subjected to knee MRI 2 months after TSS. As for X-ray undetectable findings, MRI detected synovial thickening, bone marrow lesion, ligament injury and meniscus injury in 22.7%, 22.7%, 4.7% and 59.1% of the patients, respectively. With respect to the 16 patients who underwent TSS, clinical and structural improvements were observed respectively in 100%, 66.7% and 66.7% of the patients who showed knee joint pain, synovial thickening and bone marrow lesion before TSS. However, no patient showed structural improvement of meniscus injury after TSS. In acromegalic arthropathy, synovial thickening and bone marrow lesions are reversible while meniscus injury is irreversible. Because all those findings are associated with the exacerbation of arthropathy, they may be therapeutic targets for preventing the progression of arthropathy by endocrinological and orthopedic intervention.

[Acromegaly and Cushing's disease: Persistence of comorbidities after the control of hypersecretion]

Acromegaly and Cushing's disease lead to common and distinct comorbidities. Currently available treatments lead to the control of hyper secretion in the majority of cases. However, the prevalence of the comorbidities does not always go back to the one of the normal population after remission. For instance, about 1/3 of acromegalic patients with diabetes and half of patients with Cushing's disease and diabetes will have normal blood glucose values after remission. In contrast, high blood pressure frequently recovers after remission in both diseases. In contrast, while patients with acromegaly improve their lipid profile, patients with Cushing's disease frequently remain hypertriglyceridemic. Many other comorbidities (cardiovascular disease, bone alterations, altered quality of life) may persist after the control of hyper secretion. The aim of this review is to focus on the outcome of patients with acromegaly and Cuhing's disease, and to suggest the optimal follow-up of such patients in a multidisciplinary approach. These points have been discussed during the 2016 European Congress of Endocrinology, notably by J.Romijn and E.Valassi.

Persistent Reduction of Circulating Myeloid Calcifying Cells in Acromegaly: Relevance to the Bone-Vascular Axis

CONTEXT

Acromegaly is a systemic disease characterized by persistent bone pathology and excess cardiovascular mortality. Despite multiple concomitant risk factors, atherosclerosis does not seem to be accelerated in acromegaly.

OBJECTIVE

To compare the levels of circulating myeloid calcifying cells (MCCs), which promote ectopic calcification and inhibit angiogenesis, in individuals with and without acromegaly.

DESIGN

Cross-sectional case-control study.

SETTING

Tertiary ambulatory referral endocrinology center.

PATIENTS

44 acromegalic patients (25 active; 19 inactive), 44 control subjects matched by age, sex, risk factors, and medications, and 8 patients cured of acromegaly.

INTERVENTION

MCCs were measured using flow cytometry based on the expression of osteocalcin (OC) and bone alkaline phosphatase (BAP) on monocytes and circulating CD34+ stem cells.

MAIN OUTCOME MEASURE

Differences in MCCs between patients and controls.

RESULTS

OC+BAP+ MCCs were severely reduced in acromegalic compared with control patients (0.17% ± 0.02% vs 1.00% ± 0.24%; P < 0.001), as were the total OC+ and BAP+ monocytic cells. Patients with inactive acromegaly and those cured of acromegaly displayed persistently reduced levels of MCCs. In the controls, but not acromegalic patients, MCCs were increased in the presence of diabetes or cardiovascular disease. A direct correlation was noted between MCCs and parathyroid hormone (r = 0.61; P < 0.0001), supporting a link between bone biology and MCCs.

CONCLUSIONS

In patients with acromegaly, the levels of MCCs are reduced and remain low, even years after a complete cure. This finding might be related to low atherosclerotic calcification and the persistence of bone pathology after acromegaly remission or cure.

Acromegalic arthropathy in various stages of the disease: an MRI study

BACKGROUND

Arthropathy is a prevalent and invalidating complication of acromegaly with a characteristic radiographic phenotype. We aimed to further characterize cartilage and bone abnormalities associated with acromegalic arthropathy using magnetic resonance imaging (MRI).

METHODS

Twenty-six patients (23% women, mean age 56.8 ± 13.4 years), with active (n = 10) and controlled acromegaly (n = 16) underwent a 3.0 T MRI of the right knee. Osteophytes, cartilage defects, bone marrow lesions and subchondral cysts were assessed by the Knee Osteoarthritis Scoring System (KOSS) method. Cartilage thickness and cartilage T2 relaxation times, in which higher values reflect increased water content and/or structural changes, were measured. Twenty-five controls (52% women, mean age: 59.6 ± 8.0 years) with primary knee OA were included for comparison.

RESULTS

Both in active and controlled acromegaly, structural OA defects were highly prevalent, with thickest cartilage and highest cartilage T2 relaxation times in the active patients. When compared to primary OA subjects, patients with acromegaly seem to have less cysts (12% vs 48%, P = 0.001) and bone marrow lesions (15% vs 80%, P = 0.006), but comparable prevalence of osteophytosis and cartilage defects. Patients with acromegaly had 31% thicker total joint cartilage (P < 0.001) with higher cartilage T2 relaxation times at all measured sites than primary OA subjects (P < 0.01).

CONCLUSIONS

Patients with active acromegaly have a high prevalence of structural OA abnormalities in combination with thick joint cartilage. In addition, T2 relaxation times of cartilage are high in active patients, indicating unhealthy cartilage with increased water content, which is (partially) reversible by adequate treatment. Patients with acromegaly have a different distribution of structural OA abnormalities visualized by MRI than primary OA subjects, especially of cartilage defects.

The chronic syndromes after previous treatment of pituitary tumours

Ultimately, almost all patients who are appropriately treated for pituitary tumours enter a chronic phase with control or cure of hormonal excess, adequate treatment of pituitary insufficiency and relief of mass effects. This phase is associated with improvement of initial signs and symptoms, but also with the persistent consequences of the initial disease and associated treatments. Pituitary insufficiency is a common denominator in many of these patients, and is associated with a reduction in quality of life, despite adequate endocrine substitution. Hypothalamic dysfunction can be present in patients previously treated for visual impairments caused by large suprasellar adenomas, or craniopharyngiomas. In addition to hypopituitarism, these patients can have multisystem morbidities caused by altered hypothalamic function, including weight gain and disturbed regulation of sleep-wake cycles. Mortality can also be affected. Patients cured of Cushing disease or acromegaly have chronic multisystem morbidities (in the case of Cushing disease, also affecting mortality) caused by irreversible effects of the previous excesses of cortisol in Cushing disease and growth hormone and insulin-like growth factor 1 in acromegaly. In addition to early diagnosis and treatment of pituitary tumours, research should focus on the amenability of these chronic post-treatment syndromes to therapeutic intervention, to improve quality of life and clinical outcomes.

Attritional Rupture of the Little Finger Flexor Digitorum Profundus Tendon in the Carpal Tunnel in a Patient with Acromegaly

Spontaneous rupture of flexor tendons within the carpal tunnel is rare in the absence of rheumatoid arthritis. Other predisposing conditions such as gout, infection, pisotriquetrial osteoarthritis, as well as hook of hamate fracture non-union, have previously been reported. However, tendon ruptures of the hand in the presence of acromegaly, as well as spontaneous ruptures within the carpal tunnel, have not been described in the literature.

Bone and Joint Disorders in Acromegaly

Acromegaly is a chronic, progressive disease caused by a growth hormone (GH)-producing pituitary adenoma, resulting in elevated GH and insulin-like growth factor 1 concentrations. Following appropriate therapy (surgery, radiotherapy and/or medical treatment), many systemic GH-induced comorbid conditions improve considerably. Unfortunately, despite biochemical control, acromegaly patients suffer from a high prevalence of late manifestations of transient GH excess, significantly impairing their quality of life. In this overview article, we summarize the pathophysiology, diagnosis, clinical picture, disease course and management of skeletal complications of acromegaly, focusing on vertebral fractures and arthropathy.

Outcome of complications in acromegaly patients after long-term disease remission

Acromegaly patients suffer from pathologically high growth hormone (GH) and IGF-1 levels that in 99% of cases is due to a GH-producing pituitary adenoma. During active disease, GH excess is associated with a number of pathological conditions, such as hypertension, hypertrophic cardiomyopathy, sleep apnea, arthropathy, vertebral fractures and insulin resistance. After adequate treatment in the form of transsphenoidal surgery, radiotherapy, medical treatment or by a combination of these treatment modalities, several comorbid conditions improve considerably. However, despite long-term biochemical disease control, the prevalence of late manifestations of GH excess is high and significantly impair quality of life. In addition, there is evidence that adequate treatment is not able to normalize mortality risk in these patients. In this review, we critically evaluate the long-term consequences of acromegaly after treatment, focusing on comorbid conditions, quality of life and mortality. We also discuss ongoing challenges in the management of acromegaly patients.

Increased clinical symptoms of acromegalic arthropathy in patients with long-term disease control: a prospective follow-up study

Arthropathy is an invalidating complication of acromegaly. This arthropathy deteriorates radiographically despite long-term disease control. However, the clinical course and its relationship to the radiographic course are currently unknown. We aimed to investigate the clinical course of arthropathy during follow-up and its relationship to radiographic progression in long-term controlled acromegaly patients. Prospective follow-up study. We studied 58 patients (mean age 62 years, women 41 %) with controlled acromegaly for a mean of 17.6 years. Clinical progression of joint disease was defined at baseline and after 2.6 years, by the Western Ontario McMaster Universities Osteoarthritis Index (WOMAC) and Australian/Canadian Osteoarthritis Index (AUSCAN) questionnaires for lower limb and hand OA, respectively, and performance tests. Potential risk factors for progression were assessed. The clinical course of arthropathy was related to the radiographic course. On average, hand and lower limb function deteriorated during follow-up, despite large interindividual variations. Joint pain was stable over time. High levels of pain and functional impairment at baseline were related to clinical progression of hand pain and functional limitations. High baseline BMI was a risk factor for functional deterioration in the lower limb. The changes in symptoms and radiographic progression during follow-up were not related. In treated acromegaly patients, joint function deteriorates during prolonged follow-up, despite biochemical disease control, although there was interindividual variation. Clinical and radiographic course of arthropathy were not related. Therefore, in clinical practice, a combination of clinical and radiographic assessment is necessary to evaluate the course of acromegalic arthropathy.

Two phenotypes of arthropathy in long-term controlled acromegaly? A comparison between patients with and without joint space narrowing (JSN)

BACKGROUND

Arthropathy is an invalidating complication of acromegaly, also in long-term controlled patients, and is radiographically characterized by osteophytes and preserved joint spaces. However, joint space narrowing (JSN) is observed in the minority of patients. It is unknown whether JSN is the end-stage of acromegalic arthropathy or whether this feature develops independently of acromegaly.

OBJECTIVE

To gain insight into the pathophysiology of acromegalic arthropathy, and, more specifically, in the process of JSN, risk factors for radiographic JSN were studied in a cross-sectional study.

METHODS

We studied hips and knees of 89 well-controlled acromegaly patients (mean age 58.3 yr, 51% female). Joints were divided into two groups based on the presence of JSN, defined as an Osteoarthritis Research Society (OARSI) score ≥ 1. Potential risk factors for JSN were assessed, and its relationship to joint complaints. Individual knees and hips were analyzed in a Generalized Estimating Equations model, adjusted for age, sex, BMI and intra-patient effect.

RESULTS

In controlled acromegaly, JSN was found in, respectively, 10.3% and 15.4% of the hips and knees. Increasing age and female sex were associated with more JSN; acromegaly-specific risk factors for JSN were joint-site specific. In the hip, JSN was related to more active disease: higher pre-treatment GH/IGF-1, longer and more severe GH exposure and immediate postoperative cure was less frequently achieved. In the knee, especially previous knee surgery, not acromegaly-specific characteristics, was associated with JSN. The presence of JSN was associated with more joint complaints.

CONCLUSIONS

JSN is an infrequent finding in patients with acromegalic arthropathy, but it is associated with more symptoms. This study indicates that, at least in the hip, early and ongoing GH/IGF-1 activity play a role in JSN development.

A consensus on the diagnosis and treatment of acromegaly complications

In March 2011, the Acromegaly Consensus Group met to revise and update the guidelines on the diagnosis and treatment of acromegaly complications. The meeting was sponsored by the Pituitary Society and the European Neuroendocrinology Association and included experts skilled in the management of acromegaly. Complications considered included cardiovascular, endocrine and metabolic, sleep apnea, bone diseases, and mortality. Outcomes in selected, related clinical conditions were also considered, and included pregnancy, familial acromegaly and invasive macroadenomas. The need for a new disease staging model was considered, and design of such a tool was proposed.

The changing face of acromegaly--advances in diagnosis and treatment

Acromegaly is a chronic disease characterized by the presence of a pituitary growth hormone (GH)-producing tumour, excessive secretion of growth hormone, raised levels of insulin-like growth factor I (IGF-I) and characteristic clinical presentation of acral enlargement. Over the past two decades, major advances have occurred in the understanding of some aspects of acromegaly--such as the biology of pituitary tumours, the physiology, molecular mechanisms of GH secretion and IGF-I generation, and the pathogenesis of comorbidities. Moreover, new approaches to diagnosis and surveillance (both in terms of screening and follow-up) of acromegaly have led to increases in the number of patients diagnosed with active disease, many of whom would previously have been missed. The development of sensitive assays for detecting plasma GH and IGF-I levels, as well as the widespread use of MRI for visualization of small tumours, have been major contributing factors to these improvements. Treatment advances have resulted in improved cure rates and disease control through novel neurosurgical techniques and pharmacological approaches. This Review summarizes and discusses the changes in our understanding of the epidemiology, diagnosis, treatment, and follow-up of acromegaly and its comorbidities.

What is active acromegaly and which parameters do we have?

Disease activity of acromegaly can be measured in many ways. Growth hormone (GH) and insulin-like growth factor 1 (IGF1) concentrations are the main biochemical markers used to measure the response to treatment. Both GH and IGF1 have been associated with prognosis, in particular mortality. In this review, we discuss the available parameters to assess disease activity in acromegaly.

Automated image analysis of hand radiographs reveals widened joint spaces in patients with long-term control of acromegaly: relation to disease activity and symptoms

OBJECTIVE

Arthropathy is an invalidating complication of acromegaly. Although acromegalic arthropathy shares features with primary osteoarthritis, joint spaces are widened rather than narrowed in patients with long-term cure of acromegaly. The late effects of acromegaly on hand joints have not been characterized. Therefore, the objective of the current study was to assess joint space widths (JSWs) of hand joints in patients with long-term control of acromegaly and to identify factors associated with JSW.

METHODS

A cross-sectional study was carried out in 89 patients (age 58 ± 12 years, 49% women) with long-term controlled acromegaly and 471 controls without hand symptoms (age 46 ± 12 years, 42% women). Radiological JSWs of individual hand joints were measured by automated image analysis.

RESULTS

Patients had wider mean joint spaces than controls: metacarpo-phalangeal (MCP) joints were ~24%, proximal interphalangeal joints ~21%, and distal interphalangeal joints were ~20% wider (patients vs controls; P < 0.001 for all joints). Mean JSW exceeded the 95th percentile of the values obtained in controls in 64% of patients. Higher IGF1 and GH concentrations at diagnosis were associated with larger JSWs (adjusted β for pretreatment GH in tertiles: 0.09 (95% confidence interval (CI) 0.03-1.84) and for IGF1 in tertiles: 0.14 (95% CI 0.05-0.23) at the MCP joints in acromegalic patients. In male patients, but not in female patients, increased JSWs were associated with more self-reported pain (P = 0.02).

CONCLUSIONS

Using a new semi-automated image analysis of hand radiographs, acromegalic patients with long-term disease control appeared to have increased joint spaces of all hand joints. JSWs were positively related to disease activity at diagnosis, but not to duration of follow-up, suggesting irreversible cartilage hypertrophy. Irreversible cartilage hypertrophy may partly explain persisting hand complaints despite long-term disease control.

Influence of diabetes mellitus on vertebral fractures in men with acromegaly

Acromegaly is frequently complicated by fragility vertebral fractures and diabetes mellitus. Since type 2 diabetes mellitus is a cause of secondary osteoporosis in the general population, in this cross-sectional study we aimed at investigating the association between diabetes mellitus and vertebral fractures in males with acromegaly. Fifty-seven patients (median age 47 years, range: 24-85) with active (21 cases) and controlled (36 cases) acromegaly and 57 control subjects were evaluated for bone mineral density (BMD) by DXA and vertebral fractures by a quantitative morphometric analysis. Diabetes mellitus was found in 18 patients and 18 control subjects. The prevalence of vertebral fractures was higher in acromegalic patients as compared with the control subjects (50.9 vs. 10.5%; χ(2): 21.8; P < 0.001). Acromegalic patients with fractures had serum IGF-I values significantly higher (P = 0.009), longer duration of active disease (P < 0.001) and higher prevalence of active acromegaly (P = 0.007) and diabetes mellitus (P = 0.04) as compared to patients who did not fracture. When acromegaly was active, the prevalence of vertebral fractures was high independently of the coexistent diabetes mellitus. On the contrary, when acromegaly was controlled the prevalence of vertebral fractures was significantly higher in patients with diabetes as compared to patients without diabetes (62.6 vs. 28.0%; P = 0.04). In both diabetic and non diabetic patients, vertebral fractures occurred independently of BMD. In conclusion, this study suggests that diabetes mellitus may be associated with an increased prevalence of vertebral fractures in males with acromegaly. However, this effect seems to be relatively attenuated in the presence of persistent GH hypersecretion.