Postoperative GH and Degree of Reduction in IGF-1 Predicts Postoperative Hormonal Remission in Acromegaly

Suprasellar Anterior-Posterior Diameter Optimizes the Use of Intraoperative MRI in Patients Undergoing Endoscopic Pituitary Surgery

BACKGROUND AND OBJECTIVES

Intraoperative MRI (iMRI) has been demonstrated to improve the extent of resection of pituitary neuroendocrine tumors resected using endoscopic endonasal approaches. We sought to establish if preoperative clinicoradiological parameters could be used to predict which patients are most likely to benefit from iMRI and thus allow more efficient use of this technology.

METHODS

A prospectively maintained surgical database of all endoscopic pituitary tumor resections with iMRI guidance performed between May 2017 and September 2023 was accessed. Data were collected on clinical and radiological parameters that may predict reintervention after iMRI. Logistic regression models were constructed to assess the relationship between predictor variables and reintervention after iMRI.

RESULTS

Seventy-three patients were included in the study. After review of the iMRI, 24/73 (33%) patients underwent surgical reintervention. The combined rate of gross total resection/near total resection was 64/73 (88%). The rate of biochemical cure of endocrine disease after surgery for a hormonally active tumor was 15/21 (71%). On univariate logistic regression analysis, the only factor significantly associated with reintervention after iMRI was the suprasellar anterior-posterior diameter (odds ratio 1.1, 95% CI 1.01-1.2, P = .030).

CONCLUSION

Suprasellar anterior-posterior diameter ≥15 mm predicts the requirement for reintervention after endoscopic resection of pituitary neuroendocrine tumor. Use of this easily obtained radiological parameter will allow iMRI to be used in those patients who are most likely to benefit.

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.

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.

Early Predictors of Remission in Acromegaly Patients after Pure Endoscopic Endonasal Transsphenoidal Surgery

Objective Surgery is the first-line treatment in acromegaly but it takes months to confirm remission. It is crucial to determine remission early in order to inform the patient and plan further treatment options. We aimed to evaluate the predictors of remission at the early phase after endoscopic endonasal pituitary surgery in acromegaly patients.

Methods Fifty-four growth hormone (GH)-adenoma patients operated via pure endoscopic endonasal approach were analyzed in this observational study. We compared the basic clinical, radiological characteristics, and the preoperative and postoperative hormone levels in terms of remission according to current guidelines.

Results The surgical remission rate was 61.1%. When the patients were compared according to surgical remission, the age, gender, and immunohistochemical granulation type were found to be nonsignificant, while diabetes mellitus was more common (55.6 vs. 44.4%). The preoperative tumor volume (1.2 ± 0.9 vs. 4.1 ± 4.2 cm3) and postoperative GH and insulin-like growth factor-1 (IGF-1) levels were higher in the nonremission group (p < 0.05). We defined a number of cut-off values of both GH and IGF-1 levels to predict remission at the postoperative phase. Age standardized regression analyses showed that postoperative day 1 (POD-1) GH levels (odds ratio [OR]: 8.9; 95% confidence interval [CI]: 1.99–40.0, p = 0.004) and tumor volume (OR: 3.14; 95% CI: 1.09–9.0, p = 0.034) were found to be significant independent predictors for remission.

Conclusion We demonstrated that tumor volume and POD-1 GH levels are independent predictors of remission in acromegaly patients operated via the pure endoscopic endonasal technique and may be used as an early marker of remission, and this may lead to taking adjuvant medical therapies early into account to improve prognosis.

Consensus on criteria for acromegaly diagnosis and remission

PURPOSE

The 14th Acromegaly Consensus Conference was convened to consider biochemical criteria for acromegaly diagnosis and evaluation of therapeutic efficacy.

METHODS

Fifty-six acromegaly experts from 16 countries reviewed and discussed current evidence focused on biochemical assays; criteria for diagnosis and the role of imaging, pathology, and clinical assessments; consequences of diagnostic delay; criteria for remission and recommendations for follow up; and the value of assessment and monitoring in defining disease progression, selecting appropriate treatments, and maximizing patient outcomes.

RESULTS

In a patient with typical acromegaly features, insulin-like growth factor (IGF)-I > 1.3 times the upper limit of normal for age confirms the diagnosis. Random growth hormone (GH) measured after overnight fasting may be useful for informing prognosis, but is not required for diagnosis. For patients with equivocal results, IGF-I measurements using the same validated assay can be repeated, and oral glucose tolerance testing might also be useful. Although biochemical remission is the primary assessment of treatment outcome, biochemical findings should be interpreted within the clinical context of acromegaly. Follow up assessments should consider biochemical evaluation of treatment effectiveness, imaging studies evaluating residual/recurrent adenoma mass, and clinical signs and symptoms of acromegaly, its complications, and comorbidities. Referral to a multidisciplinary pituitary center should be considered for patients with equivocal biochemical, pathology, or imaging findings at diagnosis, and for patients insufficiently responsive to standard treatment approaches.

CONCLUSION

Consensus recommendations highlight new understandings of disordered GH and IGF-I in patients with acromegaly and the importance of expert management for this rare disease.

Current and Future Advances in Surgical Therapy for Pituitary Adenoma

The vital physiological role of the pituitary gland, alongside its proximity to critical neurovascular structures, means that pituitary adenomas can cause significant morbidity or mortality. While enormous advancements have been made in the surgical care of pituitary adenomas, numerous challenges remain, such as treatment failure and recurrence. To meet these clinical challenges, there has been an enormous expansion of novel medical technologies (eg, endoscopy, advanced imaging, artificial intelligence). These innovations have the potential to benefit each step of the patient's journey, and ultimately, drive improved outcomes. Earlier and more accurate diagnosis addresses this in part. Analysis of novel patient data sets, such as automated facial analysis or natural language processing of medical records holds potential in achieving an earlier diagnosis. After diagnosis, treatment decision-making and planning will benefit from radiomics and multimodal machine learning models. Surgical safety and effectiveness will be transformed by smart simulation methods for trainees. Next-generation imaging techniques and augmented reality will enhance surgical planning and intraoperative navigation. Similarly, surgical abilities will be augmented by the future operative armamentarium, including advanced optical devices, smart instruments, and surgical robotics. Intraoperative support to surgical team members will benefit from a data science approach, utilizing machine learning analysis of operative videos to improve patient safety and orientate team members to a common workflow. Postoperatively, neural networks leveraging multimodal datasets will allow early detection of individuals at risk of complications and assist in the prediction of treatment failure, thus supporting patient-specific discharge and monitoring protocols. While these advancements in pituitary surgery hold promise to enhance the quality of care, clinicians must be the gatekeepers of the translation of such technologies, ensuring systematic assessment of risk and benefit prior to clinical implementation. In doing so, the synergy between these innovations can be leveraged to drive improved outcomes for patients of the future.

Acromegaly: pathogenesis, diagnosis, and management

Growth hormone-secreting pituitary adenomas that cause acromegaly arise as monoclonal expansions of differentiated somatotroph cells and are usually sporadic. They are almost invariably benign, yet they can be locally invasive and show progressive growth despite treatment. Persistent excess of both growth hormone and its target hormone insulin-like growth factor 1 (IGF-1) results in a wide array of cardiovascular, respiratory, metabolic, musculoskeletal, neurological, and neoplastic comorbidities that might not be reversible with disease control. Normalisation of IGF-1 and growth hormone are the primary therapeutic aims; additional treatment goals include tumour shrinkage, relieving symptoms, managing complications, reducing excess morbidity, and improving quality of life. A multimodal approach with surgery, medical therapy, and (more rarely) radiation therapy is required to achieve these goals. In this Review, we examine the epidemiology, pathogenesis, diagnosis, complications, and treatment of acromegaly, with an emphasis on the importance of tailoring management strategies to each patient to optimise outcomes.

Biochemical discrepancies in the evaluation of the somatotroph axis: Elevated GH or IGF-1 levels do not always diagnose acromegaly

The most frequent diagnosis underlying the finding of an elevated growth hormone (GH) and insulin-like growth factor-1 (IGF-1) is acromegaly due to a GH-secreting pituitary tumour. However, GH and IGF-1 levels can be discordant in patients with acromegaly due to early or partially treated disease, or there might be another cause of high GH or high IGF-1 unrelated to acromegaly, such as pre-analytical and technical pitfalls, physiological circumstances and pathological conditions. High GH and normal or low serum IGF-1, or alternatively, normal GH with elevated serum IGF-1, should be carefully assessed to avoid misinterpreting the activity of acromegaly or misdiagnosing a patient with acromegaly. We summarise here these biochemical discrepancies in the evaluation of the somatotroph axis.