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The Journal of Clinical Endocrinology... Mar 2020The improved remission and complication rates of current transsphenoidal surgery warrant reappraisal of the position of surgery as a viable alternative to dopamine... (Meta-Analysis)
Meta-Analysis
CONTEXT
The improved remission and complication rates of current transsphenoidal surgery warrant reappraisal of the position of surgery as a viable alternative to dopamine agonists in the treatment algorithm of prolactinomas.
OBJECTIVE
To compare clinical outcomes after dopamine agonist withdrawal and transsphenoidal surgery in prolactinoma patients.
METHODS
Eight databases were searched up to July 13, 2018. Primary outcome was disease remission after drug withdrawal or surgery. Secondary outcomes were biochemical control and side effects during dopamine agonist treatment and postoperative complications. Fixed- or random-effects meta-analysis was performed to estimate pooled proportions. Robustness of results was assessed by sensitivity analyses.
RESULTS
A total of 1469 articles were screened: 55 (10 low risk of bias) on medical treatment (n = 3564 patients) and 25 (12 low risk of bias) on transsphenoidal surgery (n = 1836 patients). Long-term disease remission after dopamine agonist withdrawal was 34% (95% confidence interval [CI], 26-46) and 67% (95% CI, 60-74) after surgery. Subgroup analysis of microprolactinomas showed 36% (95% CI, 21-52) disease remission after dopamine agonist withdrawal, and 83% (95% CI, 76-90) after surgery. Biochemical control was achieved in 81% (95% CI, 75-87) of patients during dopamine agonists with side effects in 26% (95% CI, 13-41). Transsphenoidal surgery resulted in 0% mortality, 2% (95% CI, 0-5) permanent diabetes insipidus, and 3% (95% CI, 2-5) cerebrospinal fluid leakage. Multiple sensitivity analyses yielded similar results.
CONCLUSIONS
In the majority of prolactinoma patients, disease remission can be achieved through surgery, with low risks of long-term surgical complications, and disease remission is less often achieved with dopamine agonists.
Topics: Critical Pathways; Dopamine Agonists; Female; Humans; Hypophysectomy; Microsurgery; Pituitary Gland; Pituitary Neoplasms; Practice Guidelines as Topic; Prolactin; Prolactinoma; Remission Induction; Retrospective Studies; Treatment Outcome
PubMed: 31665485
DOI: 10.1210/clinem/dgz144 -
Scientific Reports Oct 2019Biochemical remission after transsphenoidal surgery is still unsatisfied in acromegaly patients with macroadenomas, especially with invasive macroadenomas. Concerning... (Comparative Study)
Comparative Study Meta-Analysis
Biochemical remission after transsphenoidal surgery is still unsatisfied in acromegaly patients with macroadenomas, especially with invasive macroadenomas. Concerning the impact of preoperative somatostatin analogues (SSAs) on surgical outcomes, previous studies with limited cases reported conflicting results. To assess current evidence of preoperative medical treatment, we performed a systematic review and meta-analysis of comparative studies. A literature search was conducted in Pubmed, Embase, and the Cochrane Library. Five randomized controlled trials (RCT) and seven non-RCT comparative studies were included. These studies mainly focused on pituitary macroadenomas though a small number of microadenoma cases were included. For safety, preoperative SSAs were not associated with elevated risks of postoperative complications. With respect to efficacy, the short-term cure rate was improved by preoperative SSAs, but the long-term cure rate showed no significant improvement. For invasive macroadenomas, the short-term cure rate was also improved, but the long-term results were not evaluable in clinical practice because adjuvant therapy was generally required. In conclusion, preoperative SSAs are safe in patients with acromegaly, and the favorable impact on surgical results is restricted to the short-term cure rate in macroadenomas and invasive macroadenomas. Further well-designed RCTs to examine long-term results are awaited to update the finding of this meta-analysis.
Topics: Acromegaly; Combined Modality Therapy; Growth Hormone-Secreting Pituitary Adenoma; Humans; Somatostatin; Treatment Outcome
PubMed: 31575930
DOI: 10.1038/s41598-019-50639-6 -
World Neurosurgery Dec 2019To systematically review and analyze clinical, diagnostic, and management trends in sellar and parasellar brown tumors reported in existing literature.
OBJECTIVE
To systematically review and analyze clinical, diagnostic, and management trends in sellar and parasellar brown tumors reported in existing literature.
METHODS
In this systematic review, PubMed, Ovid MEDLINE, Scopus, and Google Scholar databases were searched for reported cases of sellar/parasellar brown tumors. Relevant titles and abstracts were screened in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol. Articles meeting inclusion criteria were subjected to data extraction, summarization, and analysis. A rare case of parasellar brown tumor was also presented.
RESULTS
Eight reports (including the current report) were eligible for inclusion. Mean patient age was 42.75 years. Reported symptoms included visual disturbances (n = 6), headache (n = 5), fatigue (n = 3), nausea/vomiting (n = 2), chest pain (n = 1), neck pain (n = 1), and dysphagia (n = 1). In cases where computed tomography findings were provided (n = 6), lesions were noted to be expansile and lytic. Lesions were hyperintense on T2-weighted magnetic resonance imaging (66.7%) and demonstrated contrast enhancement (83.3%). Histology unanimously showed multinucleated giant cells in a fibrovascular connective tissue stroma. Dramatic symptom resolution was noted in all patients who underwent resection of the sellar/parasellar brown tumor (n = 4; 50%).
CONCLUSIONS
Sellar/parasellar brown tumors are a rare, tertiary manifestation of hyperparathyroidism and can be elusive to diagnose. Diagnosis requires a high index of clinical suspicion in addition to comprehensive biochemical testing, imaging, and histopathologic analysis. Surgical extirpation is favored in cases where the lesion is causing compressive symptoms, or if it is unresponsive to management of hyperparathyroidism.
Topics: Adolescent; Adult; Female; Humans; Hyperparathyroidism; Male; Middle Aged; Pituitary Neoplasms; Young Adult
PubMed: 31470158
DOI: 10.1016/j.wneu.2019.08.126 -
Endocrine Connections Jul 2019Machine learning methods in sellar region diseases present a particular challenge because of the complexity and the necessity for reproducibility. This systematic review...
INTRODUCTION
Machine learning methods in sellar region diseases present a particular challenge because of the complexity and the necessity for reproducibility. This systematic review aims to compile the current literature on sellar region diseases that utilized machine learning methods and to propose a quality assessment tool and reporting checklist for future studies.
METHODS
PubMed and Web of Science were searched to identify relevant studies. The quality assessment included five categories: unmet needs, reproducibility, robustness, generalizability and clinical significance.
RESULTS
Seventeen studies were included with the diagnosis of general pituitary neoplasms, acromegaly, Cushing's disease, craniopharyngioma and growth hormone deficiency. 87.5% of the studies arbitrarily chose one or two machine learning models. One study chose ensemble models, and one study compared several models. 43.8% of studies did not provide the platform for model training, and roughly half did not offer parameters or hyperparameters. 62.5% of the studies provided a valid method to avoid over-fitting, but only five reported variations in the validation statistics. Only one study validated the algorithm in a different external database. Four studies reported how to interpret the predictors, and most studies (68.8%) suggested possible clinical applications of the developed algorithm. The workflow of a machine-learning study and the recommended reporting items were also provided based on the results.
CONCLUSIONS
Machine learning methods were used to predict diagnosis and posttreatment outcomes in sellar region diseases. Though most studies had substantial unmet need and proposed possible clinical application, replicability, robustness and generalizability were major limits in current studies.
PubMed: 31234143
DOI: 10.1530/EC-19-0156 -
Journal of Neuro-oncology Feb 2019Differentiation of normal pituitary from abnormal tumor tissue remains a surgical challenge despite improvements in optical visualization technology for pituitary...
INTRODUCTION
Differentiation of normal pituitary from abnormal tumor tissue remains a surgical challenge despite improvements in optical visualization technology for pituitary adenoma (PA) surgery. During neurosurgical procedures for other tumor types, 5-aminolevulinic acid (5-ALA) has become a focus of investigation based on its high specificity in differentiating tumor tissue. However, the role of 5-ALA and other optical fluorescent agents in PA surgery remains less clear.
OBJECTIVE
To perform a systematic review on the use of various optical fluorescent agents in PA surgery.
METHOD
Using PRISMA guidelines, a systematic literature review to identify reports describing 5-ALA and other optical agents for fluorescence-guided surgery for PA was performed. Eleven research studies met inclusion criteria and were reviewed.
RESULTS
In two studies, 5-ALA was not shown to be effective in aiding PA resection using standard neurosurgical endoscopic/microscopic approaches. 5-ALA photodynamic therapy was evaluated in two in-vitro models with inconsistent results. Intraoperative use of indocyanine green (ICG) concluded with varying results, but showed a tendency towards improved differentiation of functional PA. OTL38 showed potential for intraoperative identification of nonfunctioning PA, particularly in tumors with high folate receptor expression. One study reported clinically useful fluorescence following sodium fluorescein administration.
CONCLUSION
We conclude that selected optical fluorescent agents, including ICG and folate receptors, are most likely to hold promise for clinical use in differentiating PA from normal tissue.
Topics: Adenoma; Aminolevulinic Acid; Fluorescent Dyes; Humans; Optical Imaging; Pituitary Neoplasms; Surgery, Computer-Assisted
PubMed: 30523607
DOI: 10.1007/s11060-018-03062-2 -
Clinical Interventions in Aging 2018Whether conservative treatment or surgical management is the most appropriate treatment for pituitary apoplexy (PA) is controversial. In general, if severe symptoms of...
Conservative treatment cures an elderly pituitary apoplexy patient with oculomotor paralysis and optic nerve compression: a case report and systematic review of the literature.
BACKGROUND
Whether conservative treatment or surgical management is the most appropriate treatment for pituitary apoplexy (PA) is controversial. In general, if severe symptoms of compression occur, such as oculomotor nerve palsy, neurosurgery is performed to relieve the compression of anatomical structures near the PA.
CASE DESCRIPTION
We describe the case of a 79-year-old man who was found to have an intrasellar pituitary incidentaloma. The tumor was discovered accidentally, during an investigation into the cause of his dizziness. Two months later, he suddenly developed headaches, left ophthalmoplegia, decreased vision, severe blepharoptosis and diplopia. He was diagnosed with PA and hypocortisolemia based on magnetic resonance imaging (MRI) and blood tests, respectively. His symptoms of oculomotor palsy and optic nerve compression were serious, but his ophthalmological deficits were nonprogressive and his hormone levels improved through conservative treatment (hydrocortisone supplementation). Due to this older patient's poor physical condition and serious coronary heart disease, after multidisciplinary consultation and according to his family's wishes, we continued the conservative treatment and watched closely for any changes in the patient's condition. After 6 months of conservative treatment, the patient's symptoms of oculomotor nerve paralysis, pupil and vision defects completely disappeared, and no new complications occurred. Repeated MRI tests showed that the PA lesion gradually improved. The patient's hypocortisolemia was completely relieved through oral supplementation with low-dose hydrocortisone.
CONCLUSION
In older PA patients who have surgical contraindications, even with symptoms of compression, such as oculomotor nerve palsy, according to the international guidelines, if conservative treatment is effective and the condition is not progressing, it is possible to monitor patients' condition closely and continue conservative treatment, which may yield good results.
Topics: Aged; Conservative Treatment; Humans; Hydrocortisone; Incidental Findings; Male; Nerve Compression Syndromes; Ophthalmoplegia; Optic Nerve; Pituitary Apoplexy; Pituitary Neoplasms; Vision Disorders
PubMed: 30349217
DOI: 10.2147/CIA.S181109 -
Pituitary Oct 2018Systematic review and meta-analysis comparing endoscopic and microscopic transsphenoidal surgery for Cushing's disease regarding surgical outcomes (remission,... (Meta-Analysis)
Meta-Analysis
PURPOSE
Systematic review and meta-analysis comparing endoscopic and microscopic transsphenoidal surgery for Cushing's disease regarding surgical outcomes (remission, recurrence, and mortality) and complication rates. To stratify the results by tumor size.
METHODS
Nine electronic databases were searched in February 2017 to identify potentially relevant articles. Cohort studies assessing surgical outcomes or complication rates after endoscopic or microscopic transsphenoidal surgery for Cushing's disease were eligible. Pooled proportions were reported including 95% confidence intervals.
RESULTS
We included 97 articles with 6695 patients in total (5711 microscopically and 984 endoscopically operated). Overall, remission was achieved in 5177 patients (80%), with no clear difference between both techniques. Recurrence was around 10% and short term mortality < 0.5% for both techniques. Cerebrospinal fluid leak occurred more often in endoscopic surgery (12.9 vs. 4.0%), whereas transient diabetes insipidus occurred less often (11.3 vs. 21.7%). For microadenomas, results were comparable between both techniques. For macroadenomas, the percentage of patients in remission was higher after endoscopic surgery (76.3 vs. 59.9%), and the percentage recurrence lower after endoscopic surgery (1.5 vs. 17.0%).
CONCLUSIONS
Endoscopic surgery for patients with Cushing's disease reaches comparable results for microadenomas, and probably better results for macroadenomas than microscopic surgery. This is present despite the presumed learning curve of the newer endoscopic technique, although confounding cannot be excluded. Based on this study, endoscopic surgery may thus be considered the current standard of care. Microscopic surgery can be used based on neurosurgeon's preference. Endocrinologists and neurosurgeons in pituitary centers performing the microscopic technique should at least consider referring Cushing's disease patients with a macroadenoma.
Topics: Cerebrospinal Fluid Leak; Confidence Intervals; Neoplasm Recurrence, Local; Neurosurgical Procedures; Pituitary ACTH Hypersecretion; Pituitary Neoplasms
PubMed: 29767319
DOI: 10.1007/s11102-018-0893-3 -
Journal of Cellular and Molecular... Mar 2018Both microscopic and endoscopic transsphenoidal surgery are effective approaches for nonfunctioning pituitary adenomas. The issue on the comparison of their efficacy and... (Meta-Analysis)
Meta-Analysis
Both microscopic and endoscopic transsphenoidal surgery are effective approaches for nonfunctioning pituitary adenomas. The issue on the comparison of their efficacy and safety remains inconsistent. A thorough search of the literatures (PubMed, EMBASE, MEDLINE) were performed up to March 2017. Studies reporting outcomes of microscopic or endoscopic transsphenoidal surgery on nonfunctioning pituitary adenomas were included. A meta-analysis was performed focusing on the early stage and long term outcomes. The final search yielded 19 eligible studies enrolling 3847 patients, 389 of them underwent microscopic approach and 3458 of them with endoscopic approach. As to the early stage outcomes, the rate of gross tumor resection was significantly higher in the endoscopic group than that in microscopic group (73% versus 60%, P < 0.001). Meanwhile, endoscopic approach showed priority over microscopy on postoperative hypopituitarism (63% versus 65%, P < 0.001) and CSF leakage (3% versus 7%, P < 0.001). For the long term outcomes, the rate of visual improvement was significant higher in the endoscopic group than that in microscopic group (77% versus 50%, P < 0.001). However, there was no significant difference between the groups regarding the rate of permanent diabetic insipidus and meningitis. The endoscopic approach may be associated with higher rate of gross tumor movement and lower risk of postoperatively complications for treating nonfunctioning pituitary adenoma, when compared with microscopic approach. However, the confidence was shorted due to limited high quality evidence (largely randomized and controlled studies).
Topics: Adenoma; Diabetes Insipidus; Endoscopy; Female; Humans; Hypopituitarism; Male; Meningitis; Middle Aged; Pituitary Neoplasms; Postoperative Complications; Sphenoid Bone; Treatment Outcome; Visual Acuity
PubMed: 29314715
DOI: 10.1111/jcmm.13445 -
Journal of B.U.ON. : Official Journal... 2017Hypothalamic-pituitary axis is susceptible to radiotherapy, causing endocrine disorders to childhood cancer survivors. We conducted a systematic review in order to...
PURPOSE
Hypothalamic-pituitary axis is susceptible to radiotherapy, causing endocrine disorders to childhood cancer survivors. We conducted a systematic review in order to assess the radiation-induced toxicity that leads to hormone secretion abnormalities and their severity in children with brain tumors.
METHODS
The data were collected by relevant studies on PubMed and EMBASE. Articles up to December 2016 were included. We selected studies which focused on children patients (<18 yr old) with brain tumors treated with radiotherapy and the consequences for their endocrine system.
RESULTS
Growth hormone (GH) deficiency was the most common post-irradiation abnormality among children cancer survivors, followed by gonadotrophin (GT), thyroid stimulating hormone (TSH), corticotropin (ACTH) and prolactin (PRL) disorders.
CONCLUSIONS
The age of the patient, total radiotherapy dose, number of fractions, fraction size and the duration of treatment seem to determine the severity of these disturbances.
Topics: Adolescent; Brain Neoplasms; Child; Child, Preschool; Female; Humans; Hypothalamus; Male; Pituitary Gland; Radiation Injuries
PubMed: 29135108
DOI: No ID Found -
World Neurosurgery Jan 2018A systematic review and meta-analysis were conducted to examine the effect of growth hormone-replacement therapy (GHRT) on the recurrence of craniopharyngioma in... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
A systematic review and meta-analysis were conducted to examine the effect of growth hormone-replacement therapy (GHRT) on the recurrence of craniopharyngioma in children.
METHODS
PubMed, Embase, and Cochrane databases were searched through April 2017 for studies that evaluated the effect of GHRT on the recurrence of pediatric craniopharyngioma. Pooled effect estimates were calculated with fixed- and random-effects models.
RESULTS
Ten studies (n = 3487 patients) met all inclusion criteria, including 2 retrospective cohorts and 8 case series. Overall, 3436 pediatric patients were treated with GHRT after surgery and 51 were not. Using the fixed effect model, we found that the overall craniopharyngioma recurrence rate was lower among children who were treated by GHRT (10.9%; 95% confidence interval 9.80%-12.1%; I = 89.1%; P for heterogeneity <0.01; n = 10 groups) compared with those who were not (35.2%; 95% confidence interval 23.1%-49.6%; I = 61.7%; P for heterogeneity = 0.11; n = 3); the P value comparing the 2 groups was <0.01. Among patients who were treated with GHRT, subgroup analysis revealed that there was a greater prevalence of craniopharyngioma recurrence among studies conducted outside the United States (P < 0.01), single-center studies (P < 0.01), lower impact factor studies (P = 0.03), or studies with a lower quality rating (P = 0.01). Using the random-effects model, we found that the results were not materially different except for when stratifying by GHRT, impact factor, or study quality; this led to nonsignificant differences. Both Begg's rank correlation test (P = 0.7) and Egger's linear regression test (P = 0.06) indicated no publication bias.
CONCLUSIONS
This meta-analysis demonstrated a lower recurrence rate of craniopharyngioma among children treated with GHRT than those who were not.
Topics: Child; Craniopharyngioma; Hormone Replacement Therapy; Human Growth Hormone; Humans; Neoplasm Recurrence, Local; Pituitary Neoplasms
PubMed: 28987837
DOI: 10.1016/j.wneu.2017.09.164