RESUMEN
Since the 1990s, endoscopic transsphenoidal surgery for pituitary adenomas has increased in popularity. Outcomes of endoscopic surgery for clinically secretory adenomas are favorable, and results for nonfunctional tumors reveal high rates of complete resection, improvements in vision, and low rates of complications. This article discusses some of the recent studies reporting outcomes from endoscopic series for Cushing disease, acromegaly, prolactin-secreting tumors, and nonfunctioning macroadenomas.
Asunto(s)
Hiperpituitarismo/cirugía , Hipopituitarismo/cirugía , Neuroendoscopía/métodos , Neoplasias Hipofisarias/cirugía , Seno Esfenoidal/cirugía , Resultado del Tratamiento , HumanosRESUMEN
HISTORY AND ADMISSION FINDINGS: We report on a 44-year-old woman who was treated for borderline personality disorder in the Department of Psychiatry. In addition, symptoms of hyperthyroidism (anxiety, weight loss, hyperdefecation) were noticeable. Thyroid stimulating hormone (TSH) was marginally elevated, free triiodothyronine (T3) and free thyroxine (T4) were clearly elevated. Hence, the patient was transferred to the Department of Endocrinology. INVESTIGATIONS: Thyroid ultrasound revealed a diffuse goiter with a total volume of 24,8 ml. Antibody screening did not show elevated titers. The thyrotropin releasing hormone (TRH) test depicted a blunted TSH response. Serum levels of free glycoprotein hormone alpha-subunit, prolactin and insulin-like growth factor 1 were increased. DIAGNOSIS, TREATMENT AND COURSE: In cranial magnetic resonance imaging (MRI), a hypointense lesion on the left side of the anterior pituitary gland was detected indicating a thyrotropin-secreting microadenoma with concomitant secretion of prolactin and possible secretion of human growth hormone (HGH). A thyreostatic therapy was initiated aiming at euthyreosis. For symptom control, betablockers were administered. Subsequently, the patient underwent an uncomplicated transsphenoidal resection. Histological examination confirmed the diagnosis of a pituitary adenoma with expression of TSH, prolactin and HGH. As expected, thyroid hormones declined afterwards. CONCLUSIONS: TSHoma is rare. Diagnosis is confirmed by endocrinological testing and cranial imaging. Therapeutic options comprise transsphenoidal adenomectomy, drug therapy (somatostatin analogues, dopaminergic agonists) and irradiation. Resistance to thyroid hormones should be included in the differential diagnosis.
Asunto(s)
Adenoma/diagnóstico , Adenoma/metabolismo , Trastorno de Personalidad Limítrofe/diagnóstico , Trastorno de Personalidad Limítrofe/psicología , Hiperpituitarismo/diagnóstico , Hiperpituitarismo/psicología , Hipertiroidismo/diagnóstico , Hipertiroidismo/psicología , Neoplasias Hipofisarias/diagnóstico , Neoplasias Hipofisarias/metabolismo , Tirotropina/metabolismo , Adenoma/psicología , Adenoma/cirugía , Adulto , Diagnóstico Diferencial , Femenino , Hormona de Crecimiento Humana/metabolismo , Humanos , Hiperpituitarismo/cirugía , Hipertiroidismo/cirugía , Imagen por Resonancia Magnética , Neoplasias Hipofisarias/psicología , Neoplasias Hipofisarias/cirugía , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/psicología , Prolactina/metabolismo , Pruebas de Función de la Tiroides , UltrasonografíaRESUMEN
OBJECT: Surgical and medical therapies successfully achieve biochemical remission in the majority of patients with secretory pituitary adenomas. Nevertheless, continued hypersecretion after first-line therapy occurs and requires adjunctive therapy to prevent morbidity and premature mortality. For patients in whom medical and surgical therapy have failed, gamma knife surgery (GKS) is performed with the goal of controlling tumor growth and excess growth hormone (GH) production. The authors report their experience with GKS in patients in whom surgical and medical therapies failed. METHODS: The neuroendocrine service at the University of Virginia has treated 220 patients with secretory adenomas. The authors evaluated the biochemical results in patients with acromegaly followed for greater than 18 months (64 patients) as well as those with Cushing disease (45 patients), Nelson syndrome (14 patients with adequate follow up [27 overall]), and prolactinomas (19 patients) followed for at least 12 months posttreatment. Biochemical remission occurred in 36% of patients with GH-secreting adenomas, 73% of those with Cushing disease, 14% of those with Nelson syndrome, and 11% of those harboring prolactinomas. Recurrence after biochemical remission was documented in four patients with Cushing disease. New hormonal deficits have occurred in 28% of patients with acromegaly, 31% with Cushing disease, 36% with Nelson syndrome, and 21% with prolactinomas. Minor visual deterioration developed in one patient with Cushing disease. CONCLUSIONS: Gamma knife surgery offers an important treatment modality in patients with secretory adenomas refractory to surgical and medical interventions.
Asunto(s)
Adenoma/metabolismo , Adenoma/cirugía , Neoplasias Hipofisarias/metabolismo , Neoplasias Hipofisarias/cirugía , Radiocirugia/métodos , Terapia Combinada , Hormona de Crecimiento Humana/metabolismo , Humanos , Hiperpituitarismo/cirugía , Estudios RetrospectivosRESUMEN
BACKGROUND: Microsurgical selective adenomectomy is the best established method available for the treatment of Cushing's disease. However, this surgical method warrants still more efforts to improve the results in minute microadenomas. In this paper the authors evaluate a method of intraoperative cytological investigations during transsphenoidal surgery. METHOD: Between January 1997 and September 1999, transsphenoidal surgery was performed in 75 patients with the diagnosis of Cushing's disease. Fifty-one cases of proven microadenomas were reviewed. FINDINGS: Of 51 cases, 33 tumors were 3 mm or less in diameter, here after called minute adenomas. In 49 of 51 (96.1%) microadenomas, adenoma tissue was identified by intraoperative cytological techniques. Postoperatively, only 35 of 51 ACTH-secreting microadenomas (68.6%) were confirmed by immunostaining methods. This lower percentage was most probably due to the small amount of tissue obtained. Therefore, in 14 cases (including 12 minute adenomas) the presence of the adenoma was only proven by cytological preparation and clinical outcome. The sensitivity of cytological preparations in cases of confirmed Cushing's disease was 100%. INTERPRETATION: The method described here was particularly well suited for the intraoperative discrimination and documentation of minute adenomas. Cytological preparation appears to be effective in improving the adenoma finding rate and the surgical outcome in cases of Cushing's disease.
Asunto(s)
Adenoma/patología , Hormona Adrenocorticotrópica/metabolismo , Síndrome de Cushing/cirugía , Cuidados Intraoperatorios/métodos , Neoplasias Hipofisarias/patología , Adenoma/metabolismo , Adenoma/cirugía , Adolescente , Adulto , Anciano , Niño , Síndrome de Cushing/etiología , Citodiagnóstico , Femenino , Humanos , Hiperpituitarismo/cirugía , Masculino , Microcirugia/métodos , Persona de Mediana Edad , Neoplasias Hipofisarias/metabolismo , Neoplasias Hipofisarias/cirugía , Análisis de Supervivencia , Insuficiencia del Tratamiento , Resultado del TratamientoRESUMEN
It has been shown that GH excess is associated with decreased leptin levels and decreased body fat mass. Reports regarding the effect of GH on serum leptin levels are inconsistent. We studied leptin secretion in 20 acromegalics before and 2 months after trans-sphenoidal surgery and in 20 gender-, age-, and body mass index (BMI)-matched control subjects. The mean 8-h leptin concentration for each subject was measured from a pool formed of samples collected hourly beginning at 2200 h until 0600 h the next morning. In a subgroup of 10 acromegalics, leptin pulsatility was assessed for the same period of time in 10-min sampling intervals. Basal GH, insulin-like growth factor-I (IGF-I), insulin, glucose, and lipids levels were measured. Area under the curve for insulin (AUCins) during oral glucose tolerance test was calculated. Control subjects and acromegalics had similar BMI, but patients with active acromegaly had significantly lower mean leptin level (mean +/- SEM; in men, 2.6+/-0.4 vs. 7.1+/-1.1 microg/L, P = 0.003; in women, 16.0+/-3.4 vs. 23.5+/-3.1 microg/L; P = 0.036). Mean 8-h leptin correlated with BMI (r = 0.57, P = 0.007, in controls; r = 0.70, P = 0.001, in patients). In stepwise regression analysis with mean 8-h leptin as a dependent variable, BMI (P<0.001) and gender (P = 0.01) in acromegalics entered the equation, whereas in control subjects gender, free fatty acids, insulin, and age accounted for 99.3% in leptin variability. After surgery, BMI did not change significantly; and glucose (P = 0.014), GH (P<0.001), and IGF-I (P<0.001) levels together with AUCins (P = 0.002) decreased, whereas mean leptin concentration rose significantly and attained normal levels (4.1+/-0.8 microg/L, P = 0.028) in acromegalic men and (23.6+/-4.7 microg/L, P = 0.003) in acromegalic women. Correlation between leptin level and BMI was preserved after surgery (r = 0.62, P = 0.005). In stepwise regression analysis, free fatty acids (P = 0.04) contributed to 26.8% of the variance in corrected-leptin (for BMI and gender). Leptin concentration peak height and interpeak nadir level rose significantly (P = 0.033 and P = 0.037) after surgery by Cluster analysis, without significant changes in leptin pulse frequency and incremental peak amplitude. Nocturnal rise of leptin (mathematically described by a cubic curve) was characterized by an acrophase just after midnight, before and after surgery. The amplitude and the average leptin concentration of the cubic fit increased significantly after surgery (P = 0.028 and P< 0.001). In conclusion in acromegalic patients: 1) leptin secretion maintains the pulsatility and nocturnal rise; 2) the gender-based leptin differences are preserved; 3) GH-IGF-I normalization leads to a rise in leptin that is not related to changes in BMI; and 4) the possible role of rise in leptin levels when assessing clinical and metabolic outcome of therapy in acromegalic patients deserves additional studies.
Asunto(s)
Acromegalia/sangre , Hormona de Crecimiento Humana/sangre , Hiperpituitarismo/sangre , Hiperpituitarismo/cirugía , Leptina/sangre , Adulto , Anciano , Área Bajo la Curva , Biomarcadores , Glucemia/metabolismo , Análisis por Conglomerados , Femenino , Prueba de Tolerancia a la Glucosa , Humanos , Insulina/sangre , Factor I del Crecimiento Similar a la Insulina/metabolismo , Masculino , Persona de Mediana Edad , Hueso Esfenoides/cirugía , Resultado del TratamientoRESUMEN
Syndromes of hypersecretion of pituitary hormone and sellar enlargement may on occasion be caused by a gangliocytoma instead of a pituitary adenoma. At least some of these rare tumors are apparently independent of and separable from the pituitary gland, its stalk, and the hypothalamus, and are therefore surgically removable without incurring further endocrine deficit. The authors report such a case, with successful removal of the tumor via a frontal craniotomy. The associated hypersecretion of pituitary hormone was corrected without disturbing normal pituitary function.
Asunto(s)
Ganglioneuroma/cirugía , Hiperpituitarismo/cirugía , Neoplasias Hipofisarias/cirugía , Acromegalia/etiología , Adulto , Femenino , Ganglioneuroma/complicaciones , Ganglioneuroma/patología , Hormona del Crecimiento/metabolismo , Humanos , Hiperpituitarismo/etiología , Hiperpituitarismo/patología , Neoplasias Hipofisarias/complicaciones , Neoplasias Hipofisarias/patología , Silla Turca/patología , SíndromeRESUMEN
Increasing diagnostic sophistication among endocrinologists has continually expanded the horizon of surgical treatment of adenohypophyseal problems. This advancement in endocrinology has been paralleled by improvement in the technical sophistication of neurosurgeons which has resulted in an increasingly aggressive approach to these serious disorders. Neurosurgical treatment is clearly able to provide resolution of significant physical disorders with minimal sequelae. The apparent potential for transsphenoidal approaches to the sella turcica as described within this paper has intrigued a number of neurosurgeons throughout this century. Their continuing interest has carried this procedure to a secure position in the management of many of these complex problems. This paper describes the author's experience with 132 consecutive transsphenoidal hypophysectomies.