Postoperative ACTH, cortisol levels may predict Cushing’s disease remission rate

Posted on March 22, 2017 by MaryO

Early and midterm nonremission after transsphenoidal surgery in people with Cushing’s disease may be predicted by normalized early postoperative values for adrenocorticotropic hormone and cortisol, study data show.

Prashant Chittiboina, MD, MPH, assistant clinical investigator in the neurosurgery unit for pituitary and inheritable diseases at the National Institute of Neurological Diseases and Stroke at the NIH, and colleagues evaluated 250 patients with Cushing’s disease who received 291 transsphenoidal surgery procedures during the study period to determine remission after the procedure. Patients were treated between December 2003 and July 2016. Early remission was assessed at 10 days and medium-term remission was assessed at 11 months.

Early nonremission was predicted by normalized early postoperative values for cortisol (P = .016) and by normalized early postoperative values for adrenocorticotropic hormone (ACTH; P = .048). Early nonremission was further predicted with 100% sensitivity, 39% specificity, 100% negative predictive value and 18% positive predictive value for a cutoff of –12 µg/mL in normalized early postoperative values for cortisol and with 88% sensitivity, 41% specificity, 96% negative predictive value and 16% positive predictive value for a cutoff of –40 pg/mL in normalized early postoperative values for ACTH.

Medium-term nonremission was also predicted by normalized early postoperative values for cortisol (P = .023) and ACTH (P = .025).

“We evaluated the utility of early postoperative cortisol and ACTH levels for predicting nonremission after transsphenoidal adenomectomy for Cushing’s disease,” the researchers wrote. “Postoperative operative day 1 values at 6 a.m. performed best at predicting early nonremission, albeit with a lower [area under the receiver operating characteristic curve]. Normalizing early cortisol and ACTH values to post-[corticotropin-releasing hormone] values improved their prognostic value. Further prospective studies will explore the utility of normalized very early postoperative day 0 cortisol and ACTH levels in identifying patients at risk for nonremission following [transsphenoidal surgery] in patients with [Cushing’s disease].” – by Amber Cox

Disclosure: The researchers report no relevant financial disclosures.

From http://www.healio.com/endocrinology/adrenal/news/in-the-journals/%7B7de200ed-c667-4b48-ab19-256d90a7bbc5%7D/postoperative-acth-cortisol-levels-may-predict-cushings-disease-remission-rate

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What You Should Know About Pituitary Tumors

Posted on February 15, 2017 by MaryO

Ask the Experts

Igor Kravets, MD
Endocrinologist, Assistant Professor Division of Endocrinology,
Diabetes and Metabolism
Stony Brook Medicine
Raphael Davis, MD
Neurosurgeon, Professor and Chair Department of Neurosurgery
Co-Director, Stony Brook University Neurosciences Institute

 

Where do pituitary tumors form?
Dr. Kravets: A pituitary tumor is an abnormal growth of cells in the pituitary gland, which is a small, pea-sized organ located in the center of the brain, behind the nose and eyes. The pituitary is a “master gland” of the body; it produces many hormones that control other endocrine glands and certain functions of the body.
Are they mostly benign or malignant?
Dr. Davis: Most pituitary tumors are benign (non-cancerous). However, because of the location of the pituitary gland at the base of the skull, pituitary tumors can cause problems since they grow upward. Eventually some will press against the area where the optic nerves intersect, causing vision problems. They can also cause hormonal imbalance.What causes pituitary tumors?
Dr. Kravets: No one knows for sure what causes pituitary tumors. About one to five percent of pituitary tumors occur within families. Most are not inherited, however there are certain, rare, inherited conditions such as multiple endocrine neoplasia type 1 (MEN 1), that carry a higher risk of pituitary tumors.

What are the different types of pituitary tumors?
Dr. Davis: Adenomas are benign tumors that develop on the pituitary gland behind the eyes. These tumors can change levels in hormone production or cause vision loss. Craniopharyngiomas are benign tumors that develop at the base of the brain where it meets the pituitary gland. They commonly affect children 5 to 10 years of age, but adults can sometimes be affected in their 50s and 60s.

What are the symptoms?
Dr. Kravets: Symptoms vary depending on the type and size of a pituitary tumor but not all pituitary tumors cause symptoms. Many pituitary tumors are not diagnosed until symptoms appear. Some pituitary tumors are found incidentally on brain imaging obtained for a reason unrelated to the pituitary. Certain symptoms may develop when pituitary tumors grow so large that they exert pressure on surrounding structures.

Such symptoms include:
• Changes in vision (particularly loss of peripheral/outer edge vision)
• Headache

Other symptoms are related to either deficiency or excessive production of certain hormones. Common symptoms caused by such hormonal disturbances include:
• Menstrual cycle changes (irregular or lack of menstrual periods
• Erectile dysfunction or loss of sex drive
• Weight changes
• Production of breast milk by a woman who has not given birth
• Accelerated or stunted growth in a child or teenager
• Growth of the hands, feet, forehead and jaw in adults
• Development of a round face, a hump between the shoulders or both

How is a pituitary tumor diagnosed?
Dr. Kravets: An endocrinologist will ask you about the symptoms you are experiencing, and about your personal and family health history. He or she will perform a physical exam and order tests of your blood and urine. A magnetic resonance imaging (MRI) scan or computerized tomography (CT or CAT) scan may also be ordered to obtain detailed images of the brain and the pituitary gland. In rare instances, a biopsy (surgical procedure to remove a small sample of the tumor for examination) is required.

What treatments are available?
Dr. Davis: Treatments may include surgery, radiation therapy or medication. Transsphenoidal surgery is surgery performed through the nose and sphenoid sinus (located in the very back part of the nose, just beneath the base of the brain) to remove a pituitary tumor. It can be performed with an endoscope, microscope or both and is a team effort between neurosurgeons and ear, nose and throat (otolaryngology/ENT) surgeons. Radiation therapy uses high-energy x-rays to kill the tumor cells and is recommended when surgery is not an option, if the pituitary tumor remains, or if the tumor causes symptoms that are not relieved by medicine.

Why choose Stony Brook?
Dr. Kravets: Our Pituitary Care Center provides access to all of the coordinated expert care you need in one location, close to home — which can make the course of your treatment easier. Our team includes specialists from endocrinology, neurosurgery, otolaryngology (ENT), radiation oncology, neuropathology, neuroradiology, neuro-ophthalmology, and patient education and support.

To make an appointment with one of our Pituitary Care Center endocrinologists, call
(631) 444-0580. To make an appointment with one of our Pituitary Care Center neurosurgeons,
call (631) 444-1213. To learn more, visit stonybrookmedicine.edu/pituitary.

All health and health-related information contained in this article is intended to be general and/or educational in nature and should not be used as a substitute for a visit with a healthcare professional for help, diagnosis, guidance, and treatment. The information is intended to offer only general information for individuals to discuss with their healthcare provider. It is not intended to constitute a medical diagnosis or treatment or endorsement of any particular test, treatment, procedure, service, etc. Reliance on information provided is at the user’s risk. Your healthcare provider should be consulted regarding matters concerning the medical condition, treatment, and needs of you and your family. Stony Brook University/SUNY is an affirmative action, equal opportunity educator and employer.

From https://www.stonybrookmedicine.edu/patientcare/pituitarytumors

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Diagnosis and Treatment of Pituitary Adenomas

Posted on February 8, 2017 by MaryO
A Review
Mark E. Molitch, MD1
Author Affiliations
JAMA. 2017;317(5):516-524. doi:10.1001/jama.2016.19699

Importance  Pituitary adenomas may hypersecrete hormones or cause mass effects. Therefore, early diagnosis and treatment are important.

Observations  Prevalence of pituitary adenomas ranges from 1 in 865 adults to 1 in 2688 adults. Approximately 50% are microadenomas (<10 mm); the remainder are macroadenomas (≥10 mm).

Mass effects cause headache, hypopituitarism, and visual field defects. Treatments include transsphenoidal surgery, medical therapies, and radiotherapy. Prolactinomas account for 32% to 66% of adenomas and present with amenorrhea, loss of libido, galactorrhea, and infertility in women and loss of libido, erectile dysfunction, and infertility in men; they are generally treated with the dopamine agonists cabergoline and bromocriptine.

Growth hormone–secreting tumors account for 8% to 16% of tumors and usually present with enlargement of the lips, tongue, nose, hands, and feet and are diagnosed by elevated insulin-like growth factor 1 levels and growth hormone levels; initial treatment is surgical. Medical therapy with somatostatin analogues, cabergoline, and pegvisomant is often also needed.

Adrenocorticotropic hormone (ACTH)–secreting tumors account for 2% to 6% of adenomas and are associated with obesity, hypertension, diabetes, and other morbidity. Measurement of a late-night salivary cortisol level is the best screening test but petrosal sinus sampling for ACTH may be necessary to distinguish a pituitary from an ectopic source.

The primary treatment of Cushing disease (hypercortisolism due to ACTH-producing adenomas, which is the cause in approximately 65% of the cases of hypercortisolism) is adenoma resection and medical therapies including ketoconazole, mifepristone, and pasireotide.

Hyperthyroidism due to thyroid-stimulating hormone–secreting tumors accounts for 1% of tumors and is treated with surgery and somatostatin analogues if not surgically cured. Clinically nonfunctioning adenomas account for 15% to 54% of adenomas and present with mass effects; surgery is generally required, although incidentally found tumors can be followed if they are asymptomatic.

Conclusions and Relevance  Patients with pituitary adenomas should be identified at an early stage so that effective treatment can be implemented. For prolactinomas, initial therapy is generally dopamine agonists. For all other pituitary adenomas, initial therapy is generally transsphenoidal surgery with medical therapy being reserved for those not cured by surgery.

Read the full text here: http://jamanetwork.com/journals/jama/article-abstract/2600472

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Endoscopic Surgery on a Pituitary Adenoma

Posted on February 4, 2017 by MaryO

Philip Theodosopoulos, M.D. is Professor and Vice-Chair of Neurological Surgery at the University of California, San Francisco. He is the Director of the Skull Base Tumor Program and has extensive experience performing endoscopic transsphenoidal pituitary surgery for pituitary tumors (over 1000 operations) and other disease processes as well as tumors of the base of the skull.

In this video Dr. Theodosopoulos illustrates portions of an endoscopic resection of a pituitary adenoma.

 

To learn more about Dr. Theodosopoulos and to schedule an appointment for consultation please copy this link:
neurosurgery.UCSF.edu/index.php/about_us_faculty_theodosopoulos.html

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Into the brain through the nostrils (Sri Lanka)

Posted on December 21, 2016 by MaryO

There is purposeful concentration, while soft and soothing music plays in the background, as different teams of doctors and nurses, scrub up and move around Operating Theatre (OT) C of the Anuradhapura Teaching Hospital.

On the operating table is a pretty middle-aged woman, but something seems unusual with her face – it seems unduly large, with the nose being pronounced.

While Consultant Anaesthetist Dr. Ayesha Abeyratne and her team are preparing the patient for surgery, two Consultants from different specialties are studying the Magnetic Resonance Imaging pictures. They are Consultant Ear, Nose and Throat (ENT) Surgeon, Dr. Daminda Dumingoarachchi who is also a Head and Neck Surgeon and Consultant Neurosurgeon, Dr. Stravinsky Perera. Although not present in the OT that day, Consultant ENT Surgeon Dr. Upul Abeysundara is also very much a part of this pioneering work in Sri Lanka.

It is a Monday morning and we too are in OT clothes and masks privy to viewing an operation not done anywhere else in the state sector, except the Anuradhapura Hospital.

Accessing the patient’s brain through the nostrils is what the ENT and Neuro Teams will do in one of many trailblazing procedures, while the Anaesthetic Team will ensure that her vitals are stable and the able theatre nursing staff will play their part.

Image-guided (navigation-assisted) endoscopic trans-nasal trans-sphenoidal pituitary surgery is what we are about to view being performed in the country only since October this year. For, the 38-year-old patient lying inert on the operating table has a tumour just above her pituitary gland, between the optic nerves and the carotid arteries, making it a difficult operation-site to access. (The pea-size pituitary gland is dubbed the ‘master gland’ as it produces many hormones for the whole body, while also stimulating other glands to produce other hormones.)

Dr. Dumingoarachchi points out that the ENT navigator which the Anuradhapura Hospital was provided with recently, is like the GPS system of the brain which shows this vital organ’s architecture.

Dr. Perera explains that the patient has acromegaly, the abnormal production of growth hormones from the pituitary, causing a large nose and big hands etc. This is while it also causes an abnormal reduction in other hormones, affecting the functioning of the whole body. The enlarged pituitary is also compressing the main artery of the brain. A major issue is that the patient’s vision is being affected and if the tumour is not decompressed, she would go blind.

Dr. Daminda Dumingoarachchi

Matters also seem complicated as the patient had undergone ‘conventional’ brain surgery to remove an earlier tumour in the same area in 2009 in another hospital, but some parts had been left behind because it was complex surgery and the slightest slip of the scalpel could cause serious harm.

We watch in fascination as the surgical teams discuss how the tumour has grown around the right carotid artery making it a challenging procedure and is pressing down (compressing) on the brain.

This pituitary macroadenoma with acute intra-tumoural haemorrhage (bleeding) is “big” — 5X3.8X3.5cms, says Dr. Perera, adding that laterally, the lesion extends to the right cavernous sinus encircling almost the full circumference of the cavernous part of the right carotid artery. The left carotid artery is spared.

Super-imposing the patient’s Computed Tomography (CT) scan with images of the real anatomy, the ‘registration’ takes place for this ‘re-do’ surgery, as he explains that the anatomy is distorted after her previous surgery done seven years ago.

In the freezing OT, we don’t feel the time passing as both the Neurosurgeon and the ENT Surgeon attend to their tasks, two pairs of hands working in tandem, not looking down at the patient but up at the two screens, while navigating the pathways through the nostrils to the brain.

Usually, such a large tumour above the pituitary gland will entail open-skull surgery, with the brain having to be retracted (drawn away from the site of the operation) to gain access to the tumour, we learn. While the dangers of such surgery are numerous, the patient also has to spend a long time in the Intensive Care Unit (ICU) in the recovery phase.

With the frontiers of medicine pushed back more and more, Dr. Dumingoarachchi says that now skull-base structures can be approached through the nose, ear and throat. “Such surgery involves dealing with pathologies located on the under-surface of the brain, with Neurosurgeons and ENT Surgeons together accessing the skull-base more easily through the nose, ear and throat.”

Pointing out that these trans-nasal and trans-labyrinthine approaches to the skull-base will help bring down the rate of revision neurosurgeries and cut down the time that the patient will have to spend in the ICU post-operatively, he adds that the patients can go back home sooner without complications and be productive more quickly. Currently, some patients even go to other countries to get these services.

With the Health Ministry providing a high definition 3-chip endoscopic camera system, an anterior skull-base set, a micro-debrider and an ENT navigator, vast strides have been made at the Anuradhapura Hospital. They include:

Dr. Stravinsky Perera

* Anterior skull-base surgeries — Endoscopic anterior skull-base surgeries, starting with pituitary surgeries using the endoscopic trans-sphenoidal approach for the first time in Sri Lanka. The latest addition, in October this year, is image-guidance (navigation).

The other procedures include cranio-pharyngioma, olfactory neuroblastoma, cerebrospinal fluid leak repairs, para-nasal sinus cancer resections and odontoid (cervical spine) decompression.

The advantages of this approach include a better field of view and ease of doing revision surgery if required, while leaving no external scars.

Nasal polyposis is also now being managed by image-guided powered full house functional endoscopic sinus surgeries, resulting in the reduction of the recurrence rate. This also cuts down revision surgeries.

*  Lateral skull-base surgeries – Through microscopic lateral skull-base surgery, trans-labyrinthine acoustic neuromas have been removed. With direct access to these eighth-nerve tumours, no brain retraction has been necessitated, resulting in less post-operative morbidity. The whole tumour can be removed while preserving the seventh cranial nerve, as the hospital has also been given intra-operative cranial nerve monitoring facilities.

Paying tribute to Dr. Palitha Mahipala, Director-General of Health Services, for making the navigator available to them, Dr. Dumingoarachchi also expresses appreciation to the Deputy Director-General (DDG) of the Biomedical Division, Muditha Jayathilake, Biomedical Engineers Apsara and Kumuduni and DDG Dr. Lakshmi Somatunga for all their support.

From http://www.sundaytimes.lk/161218/news/into-the-brain-through-the-nostrils-221019.html

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