Tag: acromegaly

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Is Knosp enough? A novel classification for Acromegaly: a retrospective analysis of cure rates and outcome predictors in a large tertiary centre

Acta Neurochirurgica (2025) 167:61

The study introduces the MI Ratio, a novel radiological metric, to predict surgical remission in acromegaly patients, demonstrating its utility alongside demographics and hormone profiles. Conducted at King’s College Hospital, the study highlights improved prediction accuracy over Knosp classification, emphasizing a personalized approach to treatment planning.

Study Overview

• Purpose: Evaluate surgical outcomes for acromegaly at King’s College Hospital.

• Methods: Retrospective analysis of 150 patients with somatotroph tumours.

• Novel Metric: Introduced MI Ratio for predicting clinical remission post-surgery.

Key Findings

• Cure Rates: 72% for microadenomas, 48% for macroadenomas, 53% overall.

• Significant Predictors: MI Ratio, microadenomas, Knosp score < 2, post-op GH level, gender.

• ROC Analysis: MI + Gender had the highest AUC of 0.76.

Methodology Details

• MI Ratio Calculation: Distance from the midline to a lateral maximum of tumour divided by intercarotid distance.

• Statistical Tools: Univariate and multivariate analysis, logistic regression.

Conclusions

• MI Ratio Utility: Effective in predicting surgical remission and improving treatment planning.

• Future Research: Larger prospective studies are needed to validate the MI Ratio for general use.

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Quality of Life After Endoscopic Surgical Management of Pituitary Adenomas

Neurosurgery 90:81–91, 2022

Patient-reported quality of life (QOL) is a vital metric for surgical success.
OBJECTIVE: To assess the effect of surgery on QOL in the largest prospectively collected, longitudinal cohort of surgically managed pituitary adenomas.
METHODS: A consecutive surgical adenoma cohort (n=304) between late 2016 and mid- 2020 underwent a scheduled overall (Anterior Skull Base Questionnaire-35) and sinonasal- specific (Sinonasal Outcome Test-22) QOL assessment. Scores were stratified by adenoma subtype and analyzed for clinical predictors of QOL changes.
RESULTS: The average age was 53.8 ± 16 yr, and 53% of participants were female. 60.9% of adenomas were nonfunctioning while adrenocorticotropic hormone adenomas (16.4%), growth hormone adenomas (14.1%), and prolactinomas (5.9%) were the most prevalent secreting adenomas. Baseline overall QOL differed between tumor types (P = .006), with adrenocorticotropic hormone adenomas worse than growth hormone adenomas (P = .03) and nonfunctioning pituitary adenomas (NFPA) (P < .001). Sinonasal QOL worsened in the 3 wk after surgery but returned to baseline by 6 wk and beyond. Overall QOL worsened at 3 wk after surgery (P < .001) but significantly improved from baseline by 3 mo (P = .009) and beyond (P < .001). Emotional functioning improved soon after surgery, followed by performance and pain, and then, by 6 mo, physical function and vitality. Predictors of improved QOL were sellar/suprasellar lesions (P = .01), prolactinomas (P = .003), and NFPA (P = .04). Conversely, new postoperative hypopituitarism (P = .04) and larger adenoma volume (P = .04) predicted QOL worsening.
CONCLUSION: QOL is worsened after surgery at early time points. Prolactinomas and NFPA enjoy significant QOL improvements from surgery as early as 3 mo postoperatively. Other functional tumors may experience early benefits in younger patients without hypopituitarism and when isolated to the sellar/suprasellar region. These findings provide valuable information for counseling patients and setting expectations for surgery.

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Low-Dose Gamma Knife Radiosurgery for Acromegaly

Neurosurgery, Volume 85, Issue 1, July 2019, Pages E20–E30

Remission rate is associated with higher dose of Gamma Knife Radio- surgery (GKRS; Gamma Knife: Elekta AB, Stockholm, Sweden) for acromegaly, but the dose ≥25 Gy is not always feasible when the functioning adenoma is close to optic apparatus

OBJECTIVE: To evaluate the efficacy and safety of low-dose (<25 Gy) GKRS in the treatment of patients with acromegaly.

METHODS: Single-center retrospective review of acromegaly cases treated with GKRS between June 1994 and December 2016. A total of 76 patients with the diagnosis of acromegaly who were treated with low-dose GKRS were selected for inclusion. Patients were treated with a median margin dose, isodose line, and treatment volume of 15.8 Gy, 57.5%, and 4.8 mL, respectively. Any identifiable portion of the optic apparatus was limited to a radiation dose of 10 Gy. All patients underwent full endocrine, ophthalmological, and imaging evaluation prior to and after GKRS treatments, and results of these were analyzed.

RESULTS: Biochemical remission was achieved in 33 (43.4%) patients. Actuarial remission rates were 20.3%, 49.9%, and 76.3% at 4, 8, and 12 yr, respectively. Absence of cavernous sinus invasion (P = .042) and lower baseline insulin-like growth factor-1 levels (P = .019) were significant predictors of remission. New hormone deficiencies were found in 9 (11.8%) patients. Actuarial hormone deficiency rates were 3%, 14%, and 22.2% at 4, 8, and 10 yr, respectively. Two (2.6%) patients who achieved initial remission experienced recurrence. No optic complications were encountered.

CONCLUSION: Reasonable remission and new hormone deficiency rates can be achieved with low-dose GKRS for acromegaly. These rates may be comparable to those with standard GKRS margin doses.

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Treatment of acromegaly by endoscopic transsphenoidal surgery

Treatment of acromegaly by endoscopic transsphenoidal surgery

J Neurosurg 119:1467–1477, 2013

Acromegaly is a disease that has significant morbidity and mortality related to high levels of growth hormone (GH) and insulin-like growth factor–I (IGF-I), and is usually caused by pituitary adenomas. The goal in this study was to investigate the role of endoscopic transsphenoidal surgery and surgical experience in the treatment of GH adenoma cases in relation to surgical results and hormonal cure rates, and to perform a review of the literature.

Methods. The authors present a retrospective analysis of 214 GH adenoma cases. Restoration of IGF-I levels to normal for age and sex, suppression of GH levels below 0.4 μg/L on the oral glucose tolerance test, and demonstration of the total removal of the tumor on MRI studies obtained after administration of contrast material at the 3-month postoperative follow-up visit were the criteria for cure.

Results. In total 214 patients with a mean age of 41.9 ± 12 years (range 17–75 years) and a male/female ratio of 106/108 were enrolled in the study. Cure was achieved in 134 (62.6%) of 214 patients. One hundred sixty-nine patients were primary cases, and of these 109 (64.5%) were cured, whereas 61 patients were previously operated cases and of these 25 (41%) were cured. With a 51.1% decrease in the 1st month postoperatively, IGF-I levels were found to be predictive of cure (74.4% sensitivity and 73.7% specificity). Cut-off values for GH levels in predicting cure for the 1st day, 1st week, and 1st month postoperatively were 2.33, 2.05, and 2.25 μg/L, respectively. The cut-off value for surgical experience was 57 for primary surgeries (58.5% cure rate before this cut-off value compared with 72.6% after it; p = 0.025) and 108 for all operations (45.8% vs 79.4%, p = 0.037). Although 28 patients were found to be in remission according to the criteria in 2000, they were not in remission according to the new consensus criteria. Nine of these cases (32.1%) had random GH levels < 1 μg/L at the 1-year follow-up. The 1-year IGF-I and GH levels in these 28 patients showed no significant difference when compared with the cases defined as cured according to the current criteria.

Conclusions. In acromegaly treatment, transsphenoidal endoscopic surgery performed by an expert senior surgeon and increased surgical experience are important for higher cure rates. Random GH levels < 2.33 μg/L after the 1st day postoperatively and a > 50% decrease in IGF-I levels after the 1st month postoperatively are predictive of cure. Moreover, there is no urgency for additional therapy in patients with GH levels of 0.4–1 μg/L and MRI sequences showing no tumor at the 3-month follow-up, because for these cases remission can be achieved at the 1-year follow-up.

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Transphenoidal surgery in acromegalic patients: anatomical considerations and potential pitfalls

Transphenoidal surgery in acromegalic patients- anatomical considerations and potential pitfalls.1 Transphenoidal surgery in acromegalic patients- anatomical considerations and potential pitfalls

Acta Neurochir (2013) 155:125–130

Transphenoidal surgery is an effective treatment for acromegalic patients with growth hormone (GH) producing pituitary adenomas. Since acromegaly is a systemic disease which causes multiple bony alterations, we hypothesized that it could affect the sphenoid sinus anatomy. The aim of the study was to determine whether acromegalic patients have sphenoid sinus alterations with potential surgical impact.

Methods Fourty-six consecutive patients (23 acromegalics- GH group, 23 non-acromegalics-nGH group) undergoing transphenoidal surgery were included in this study. Preoperative volumetric CT scan of the head was used to assess the following anatomic characteristics: type of sphenoid sinus (sellar, pre-sellar, conchal); number of intrasphenoid septa; number of carotid-directed septa; intercarotid distance; depth of the sphenoid sinus; depth and size of the sella.

Results The sphenoid sinus was of the pre-sellar/conchal type in 26 % of the patients with acromegaly (n023) versus 9 % of the patients of the nGH group (n023). The number of intrasphenoid septations was significantly higher in the GH group than in the nGH group (P=.03). Interestingly, the intercarotid distance was smaller in GH patients than in nGH displaying a trend toward significance (P=.05). The sphenoid bone was deeper in the GH group as compared to the nGH group (P=.01) but the distance sphenoid sinus-sella was reduced (P<.01). Finally, the sella was not deeper, nor larger in acromegalic patients.

Conclusions The sphenoid sinus of acromegalic patients resulted in being deeper, characterized by more septa and by a reduced intercarotid distance. These alterations deserve special pre- and intraoperative care, being potentially responsible for surgical difficulties.

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Repeat Transsphenoidal Surgery for the Treatment of Remaining or Recurring Pituitary Tumors in Acromegaly

Neurosurgery 67:949–956, 2010 DOI: 10.1227/NEU.0b013e3181ec4379

Acromegaly is a disorder characterized by hypersecretion of growth hormone caused by a growth hormone–secreting pituitary adenoma.

OBJECTIVE: To evaluate the long-term efficacy and safety of repeat transsphenoidal surgery for persistent or recurrent acromegaly.

METHODS: We retrospectively reviewed records for 53 acromegalic patients who underwent repeat transsphenoidal surgery for persistent or progressive acromegaly at Toranomon Hospital between 1987 and 2006. Multivariate logistic regression was performed to evaluate preoperative factors influencing the surgical outcome.

RESULTS: Thirty-one patients (58.5%) met the criteria for cure on long-term follow-up endocrine findings. Furthermore, 17 patients were well controlled with normal insulinlike growth factor I levels without (2 patients) or with medication (15 patients), whereas insulin-like growth factor I levels were still above normal in 5 patients after postoperative adjuvant therapy. Only 1 patient was undergoing additional hormonal replacement after surgery, although transient cerebrospinal fluid leak, transient abducens nerve palsy, severe nasal bleeding, and pituitary abscess occurred in each patient, respectively. Multivariate analysis clarified that a favorable surgical outcome was achieved in patients without cavernous sinus invasion (hazard ratio 12.56), tumor segmentation (hazard ratio 5.82), or in those older than 40 years old (hazard ratio 3.21).

CONCLUSION: Repeat surgery can be performed safely with an approximately 60% long-term cure rate in this series. Reoperation should therefore be considered for persistent or recurrent disease in acromegalic patients in whom adjuvant therapy is not effective enough or cannot be accepted. The careful study of initial or preoperative magnetic resonance imaging and the use of micro-Doppler, endoscope, and eye movement monitoring device during surgery can help increase cure rate with a lower complication rate.

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Outcomes after a purely endoscopic transsphenoidal resection of growth hormone

Neurosurg Focus 29 (4):E5, 2010. DOI: 10.3171/2010.7.FOCUS10153

Using strict biochemical remission criteria, the authors assessed surgical outcomes after endoscopic transsphenoidal resection of growth hormone (GH)–secreting pituitary adenomas and identified preoperative factors that significantly influence the rate of remission.

Methods. A retrospective review of a prospectively maintained database was performed. The authors reviewed cases in which an endoscopic resection of GH-secreting pituitary adenomas was performed. The cohort consisted of 26 patients who had been followed for 3–60 months (mean 24.5 months). The thresholds of an age-appropriate, normalized insulin-like growth factor–I concentration, a nadir GH level after oral glucose load of less than 1.0 μg/l, and a random GH value of less than 2.5 μg/l were required to establish biochemical cure postoperatively.

Results. Overall, in 57.7% of patients undergoing a purely endoscopic transsphenoidal pituitary adenectomy for acromegaly, an endocrinological cure was achieved. The mean clinical follow-up duration was 24.5 months. In patients with microadenomas (4 cases) the cure rate was 75%, whereas in patients harboring macroadenomas (22 cases) the cure rate was 54.5%. Cavernous sinus invasion (Knosp Grades 3 and 4) was associated with a significantly lower remission rate (p = 0.0068). Hardy Grade 3 and 4 tumors were also less likely to achieve biochemical cure (p = 0.013). The overall complication rate was 11.5% including 2 incidents of transient diabetes insipidus and 1 postoperative CSF leak, which were treated nonoperatively.

Conclusions. A purely endoscopic transsphenoidal approach to GH-secreting pituitary adenomas leads to similar outcome for noninvasive macroadenomas compared with traditional microsurgical techniques. Furthermore, this approach may often provide maximal visualization of the tumor, the pituitary gland, and the surrounding neurovascular structures.

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