Skip to main content

Advertisement

SpringerLink
Log in

Endoscopic endonasal approach for growth hormone secreting pituitary adenomas: outcomes in 53 patients using 2010 consensus criteria for remission

  • Published:
Pituitary Aims and scope Submit manuscript

Abstract

We report the outcomes of the endoscopic endonasal approach (EEA) for resection of growth hormone secreting pituitary adenomas using 2010 consensus criteria. We also assess outcomes with additional medical therapy and radiosurgery (RS) for patients not achieving remission with EEA alone. A retrospective review of 53 patients who had follow up endocrinologic data at least 3 months post-surgery was performed among patients who were treated by EEA between 1998 and 2012. Data were analyzed for remission using GH and IGF-I levels based on 2010 consensus criteria. We also analyzed the outcomes using 2000 consensus criteria for ease in comparison to prior studies of outcomes of surgery for acromegaly. In this series of mostly large (88.2 % macroadenomas), invasive (46.9 % Hardy–Wilson C, D, E) adenomas, there were 27 patients (50.9 %) who achieved remission after EEA only. For patients who had no remission with EEA alone, RS and/or medical therapy were used and 37 patients (69.8 %) achieved remission overall. Statistical analysis showed larger tumor size, Hardy Stages C, D, E and Knosp Scores 3, 4 to be predictive against remission for EEA only and EEA with other modalities. The volume of residual tumor after EEA was not found to be predictive of remission with additional therapies. We used stringent consensus criteria from 2010 in a series which included a high proportion of invasive GH secreting adenomas to show that EEA alone or combined with other modalities results in comparable remission rates to earlier studies which used less strict criteria, while retaining low complication rates.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

Abbreviations

EEA:

Endoscopic endonasal approach

RS:

Radiosurgery

GH:

Growth hormone

IGF-I:

Insulin growth factor-I

GHRH:

Growth hormone releasing hormone

CSF:

Cerebrospinal fluid

ICA:

Internal carotid artery

DI:

Diabetes insipidus

CN:

Cranial nerve

References

  1. Dekkers OM, Biermasz NR, Pereira AM, Romijn JA, Vandenbroucke JP (2008) Mortality in acromegaly: a metaanalysis. J Clin Endocrinol Metab 93:61–67

    Article  CAS  PubMed  Google Scholar 

  2. Chanson P, Salenave S, Kamenicky P, Cazabat L, Young J (2009) Pituitary tumours: acromegaly. Best Pract Res Clin Endocrinol Metab 23:555–574

    Article  CAS  PubMed  Google Scholar 

  3. Donangelo I, Melmed S (2005) Treatment of acromegaly: future. Endocrine 28:123–128

    Article  CAS  PubMed  Google Scholar 

  4. Melmed S, Colao A, Barkan A, Molitch M, Grossman AB, Kleinberg D, Clemmons D, Chanson P, Laws E, Schlechte J, Vance ML, Ho K, Giustina A, Acromegaly Consensus Group (2009) Guidelines for acromegaly management: an update. J Clin Endocrinol Metab 94:1509–1517

    Article  CAS  PubMed  Google Scholar 

  5. Ahmed S, Elsheikh M, Stratton IM, Page RC, Adams CB, Wass JA (1999) Outcome of transsphenoidal surgery for acromegaly and its relationship to surgical experience. Clin Endocrinol (Oxf) 50:561–567

    Article  CAS  Google Scholar 

  6. Freda PU, Wardlaw SL, Post KD (1998) Long-term endocrinological follow-up evaluation in 115 patients who underwent transsphenoidal surgery for acromegaly. J Neurosurg 89:353–358

    Article  CAS  PubMed  Google Scholar 

  7. Campbell PG, Kenning E, Andrews DW, Yadla S, Rosen M, Evans JJ (2010) Outcomes after a purely endoscopic transsphenoidal resection of growth hormone-secreting pituitary adenomas. Neurosurg Focus 29:E5

    Article  PubMed  Google Scholar 

  8. Sherlock M, Woods C, Sheppard MC (2011) Medical therapy in acromegaly. Nat Rev Endocrinol 7:291–300

    Article  CAS  PubMed  Google Scholar 

  9. Castinetti F, Régis J, Dufour H, Brue T (2010) Role of stereotactic radiosurgery in the management of pituitary adenomas. Nat Rev Endocrinol 6:214–223

    Article  PubMed  Google Scholar 

  10. Abosch A, Tyrrell JB, Lamborn KR, Hannegan LT, Applebury CB, Wilson CB (1998) Transsphenoidal microsurgery for growth hormone-secreting pituitary adenomas: initial outcome and long-term results. J Clin Endocrinol Metab 83:3411–3418

    Article  CAS  PubMed  Google Scholar 

  11. Ross DA, Wilson CB (1988) Results of transsphenoidal microsurgery for growth hormone-secreting pituitary adenoma in a series of 214 patients. J Neurosurg 68:854–867

    Article  CAS  PubMed  Google Scholar 

  12. Tindall GT, Oyesiku NM, Watts NB, Clark RV, Christy JH, Adams DA (1993) Transsphenoidal adenomectomy for growth hormone-secreting pituitary adenomas in acromegaly: outcome analysis and determinants of failure. J Neurosurg 78:205–215

    Article  CAS  PubMed  Google Scholar 

  13. Kaltsas GA, Isidori AM, Florakis D (2001) Predictors of the outcome of surgical treatment in acromegaly and the value of the mean growth hormone day curve in assessing postoperative disease activity. J Clin Endocrinol Metab 86:1645–1652

    Article  CAS  PubMed  Google Scholar 

  14. Shimon I, Cohen ZR, Ram Z, Hadani M (2001) Transsphenoidal surgery for acromegaly: endocrinological follow-up of 98 patients. Neurosurgery 48:1239–1243

    CAS  PubMed  Google Scholar 

  15. Rudnik A, Zawadzki T, Wojtacha M, Bazowski P, Gamrot J, Galuszka-Ignasiak B, Duda I (2005) Endoscopic transnasal transsphenoidal treatment of pathology of the sellar region. Minim Invasive Neurosurg 48:101–107

    Article  CAS  PubMed  Google Scholar 

  16. Frank G, Pasquini E, Farneti G, Mazzatenta D, Sciarretta V, Grasso V, Faustini Fustini M (2006) The endoscopic versus the traditional approach in pituitary surgery. Neuroendocrinology 83:240–248

    Article  CAS  PubMed  Google Scholar 

  17. Higgins TS, Courtemanche C, Karakla D, Strasnick B, Singh RV, Koen JL, Han JK (2008) Analysis of transnasal endoscopic versus transseptal microscopic approach for excision of pituitary tumors. Am J Rhinol 22:649–652

    Article  PubMed  Google Scholar 

  18. O’Malley BW Jr, Grady MS, Gabel BC, Cohen MA, Heuer GG, Pisapia J, Bohman LE, Leibowitz JM (2008) Comparison of endoscopic and microscopic removal of pituitary adenomas: single-surgeon experience and the learning curve. Neurosurg Focus 25:E10

    Article  PubMed  Google Scholar 

  19. Schaberg MR, Anand VK, Schwartz TH, Cobb W (2010) Microscopic versus endoscopic transnasal pituitary surgery. Curr Opin Otolaryngol Head Neck Surg 18:8–14

    Article  PubMed  Google Scholar 

  20. Gondim JA, Almeida JP, de Albuquerque LA, Gomes E, Schops M, Ferraz T (2010) Pure endoscopic transsphenoidal surgery for treatment of acromegaly: results of 67 cases treated in a pituitary center. Neurosurg Focus 29:E7

    Article  PubMed  Google Scholar 

  21. Hofstetter CP, Mannaa RH, Mubita L, Anand VK, Kennedy JW, Dehdashti AR, Schwartz TH (2010) Endoscopic endonasal transsphenoidal surgery for growth hormone-secreting pituitary adenomas. Neurosurg Focus 29:E6

    Article  PubMed  Google Scholar 

  22. Kabil MS, Eby JB, Shahinian HK (2005) Fully endoscopic endonasal vs. transseptal transsphenoidal pituitary surgery. Minim Invasive Neurosurg 48:348–354

    Article  CAS  PubMed  Google Scholar 

  23. Giustina A, Chanson P, Bronstein MD, Klibanski A, Lamberts S, Casanueva FF, Trainer P, Ghigo E, Ho K, Melmed S, Acromegaly Consensus Group (2010) A consensus on criteria for cure of acromegaly. J Clin Endocrinol Metab 95:3141–3148

    Article  CAS  PubMed  Google Scholar 

  24. Trainer PJ, Drake WM, Katznelson L, Freda PU, Herman-Bonert V, van der Lely AJ, Dimaraki EV, Stewart PM, Friend KE, Vance ML, Besser GM, Scarlett JA, Thorner MO, Parkinson C, Klibanski A, Powell JS, Barkan AL, Sheppard MC, Malsonado M, Rose DR, Clemmons DR, Johannsson G, Bengtsson BA, Stavrou S, Kleinberg DL, Cook DM, Phillips LS, Bidlingmaier M, Strasburger CJ, Hackett S, Zib K, Bennett WF, Davis RJ (2000) Treatment of acromegaly with the growth hormone-receptor antagonist pegvisomant. N Engl J Med 342:1171–1177

    Article  CAS  PubMed  Google Scholar 

  25. Carmichael JD, Bonert VS, Mirocha JM, Melmed S (2009) The utility of oral glucose tolerance testing for diagnosis and assessment of treatment outcomes in 166 patients with acromegaly. J Clin Endocrinol Metab 94:523–527

    Article  CAS  PubMed  Google Scholar 

  26. Wilson CB (1979) Neurosurgical management of large and invasive pituitary tumors. In: Tindall GT, Collins WF (eds) Clinical management of pituitary disorders. Raven Press, New York, pp 335–342

  27. Knosp E, Steiner E, Kitz K, Matula C (1993) Pituitary adenomas with invasion of the cavernous sinus space: a magnetic resonance imaging classification compared with surgical findings. Neurosurgery 33:610–617

    Article  CAS  PubMed  Google Scholar 

  28. Hadad G, Bassagasteguy L, Carrau RL, Mataza JC, Kassam A, Snyderman CH, Mintz A (2006) A novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap. Laryngoscope 116:1882–1886

    Article  PubMed  Google Scholar 

  29. Kassam AB, Thomas A, Carrau RL, Snyderman CH, Vescan A, Prevedello D, Mintz A, Gardner P (2008) Endoscopic reconstruction of the cranial base using a pedicled nasoseptal flap. Neurosurgery 63:ONS44–ONS52

    Article  PubMed  Google Scholar 

  30. Prevedello DM, Thomas A, Gardner P, Snyderman CH, Carrau RL, Kassam AB (2007) Endoscopic endonasal resection of a synchronous pituitary adenoma and a tuberculum sellae meningioma: technical case report. Neurosurgery 60:E401

    Article  PubMed  Google Scholar 

  31. Paisley AN, Drake WM (2005) Treatment of pituitary tumors: pegvisomant. Endocrine 28:111–114

    Article  CAS  PubMed  Google Scholar 

  32. Esposito V, Santoro A, Minniti G, Salvati M, Innocenzi G, Lanzetta G, Cantore G (2004) Transsphenoidal adenomectomy for GH-, PRL- and ACTH-secreting pituitary tumours: outcome analysis in a series of 125 patients. Neurol Sci 25:251–256

    Article  CAS  PubMed  Google Scholar 

  33. Fahlbusch R, Buchfelder M (1988) Transsphenoidal surgery of parasellar pituitary adenomas. Acta Neurochir (Wien) 92:93–99

    Article  CAS  Google Scholar 

  34. Ludecke DK, Abe T (2006) Transsphenoidal microsurgery for newly diagnosed acromegaly: a personal view after more than 1,000 operations. Neuroendocrinology 83:230–239

    Article  PubMed  Google Scholar 

  35. Mortini P, Losa M, Barzaghi R, Boari N, Giovanelli M (2005) Results of transsphenoidal surgery in a large series of patients with pituitary adenoma. Neurosurgery 56:1222–1233

    Article  PubMed  Google Scholar 

  36. Nomikos P, Buchfelder M, Fahlbusch R (2005) The outcome of surgery in 668 patients with acromegaly using current criteria of biochemical ‘cure’. Eur J Endocrinol 152:379–387

    Article  CAS  PubMed  Google Scholar 

  37. Gittoes NJ, Sheppard MC, Johnson AP, Stewart PM (1999) Outcome of surgery for acromegaly–the experience of a dedicated pituitary surgeon. QJM 92:741–745

    Article  CAS  PubMed  Google Scholar 

  38. Beauregard C, Truong U, Hardy J, Serri O (2003) Long-term outcome and mortality after transsphenoidal adenomectomy for acromegaly. Clin Endocrinol (Oxf) 58:86–91

    Article  Google Scholar 

  39. Kim MS, Jang HD, Kim OL (2009) Surgical results of growth hormone-secreting pituitary adenoma. J Korean Neurosurg Soc 45:271–274

    Article  CAS  PubMed  Google Scholar 

  40. Kreutzer J, Vance ML, Lopes MB, Laws ER Jr (2001) Surgical management of GH-secreting pituitary adenomas: an outcome study using modern remission criteria. J Clin Endocrinol Metab 86(9):4072–4077

    Article  CAS  PubMed  Google Scholar 

  41. Trepp R, Stettler C, Zwahlen M, Seiler R, Diem P, Christ ER (2005) Treatment outcomes and mortality of 94 patients with acromegaly. Acta Neurochir (Wien) 147(3):243–251 discussion 250-1

    Article  CAS  Google Scholar 

  42. De P, Rees DA, Davies N, John R, Neal J, Mills RG, Vafidis J, Davies JS, Scanlon MF (2003) Transsphenoidal surgery for acromegaly in wales: results based on stringent criteria of remission. J Clin Endocrinol Metab 88(8):3567–3572

    Article  CAS  PubMed  Google Scholar 

  43. Brzana JA, Yedinak CG, Delashaw JB, Gultelkin HS, Cook D, Fleseriu M (2011) Discordant growth hormone and IGF-1 levels post pituitary surgery in patients with acromegaly naïve to medical therapy and radiation: what to follow, GH or IGF-1 values? Pituitary [Epub ahead of print]

  44. Alexopoulou O, Bex M, Abs R, T’Sjoen G, Velkeniers B, Maiter D (2008) Divergence between growth hormone and insulin-like growth factor-i concentrations in the follow-up of acromegaly. J Clin Endocrinol Metab 93:1324–1330

    Article  CAS  PubMed  Google Scholar 

  45. Machado EO, Taboada GF, Neto LV, van Haute FR, Corrêa LL, Balarini GA, Shrank Y, Goulart M, Gadelha MR (2008) Prevalence of discordant GH and IGF-I levels in acromegalics at diagnosis, after surgical treatment and during treatment with octreotide LAR. Growth Horm IGF Res 18(5):389–393

    Article  CAS  PubMed  Google Scholar 

  46. Bates AS, Evans AJ, Jones P, Clayton RN (1995) Assessment of GH status in acromegaly using serum growth hormone, serum insulin-like growth factor-1 and urinary growth hormone excretion. Clin Endocrinol (Oxf) 42(4):417–423

    Article  CAS  Google Scholar 

  47. Jane JA Jr, Starke RM, Elzoghby MA, Reames DL, Payne SC, Thorner MO, Marshall JC, Laws ER Jr, Vance MD (2011) Endoscopic transsphenoidal surgery for acromegaly: remission using modern criteria, complications, and predictors of outcome. J Clin Endocrinol Metab 96(9):2732–2740

    Article  CAS  PubMed  Google Scholar 

  48. Feelders RA, Bidlingmaier M, Strasburger CJ, Janssen JA, Uitterlinden P, Hofland LJ, Lamberts SW, van der Lely AJ, de Herder WW (2005) Postoperative evaluation of patients with acromegaly: clinical significance and timing of oral glucose tolerance testing and measurement of (free) insulin-like growth factor I, acid labile subunit, and growth hormone-binding protein levels. J Clin Endocrinol Metab 90:6480–6489

    Article  CAS  PubMed  Google Scholar 

  49. Frank G, Pasquini E (2006) Endoscopic endonasal cavernous sinus surgery, with special reference to pituitary adenomas. Front Horm Res 34:64–82

    Article  PubMed  Google Scholar 

  50. Kassam AB, Gardner P, Snyderman C, Mintz A, Carrau R (2005) Expanded endonasal approach: fully endoscopic, completely transnasal approach to the middle third of the clivus, petrous bone, middle cranial fossa, and infratemporal fossa. Neurosurg Focus 19(1):E6

    PubMed  Google Scholar 

  51. Barges-Coll J, Fernandez-Miranda JC, Prevedello DM, Gardner P, Morera V, Madhok R, Carrau RL, Snyderman CH, Rhoton AL Jr, Kassam AB (2010) Avoiding injury to the abducens nerve during expanded endonasal endoscopic surgery: anatomic and clinical case studies. Neurosurgery 67(1):144–154

    Article  PubMed  Google Scholar 

  52. Plockinger U (2012) Medical therapy of acromegaly. Int J Endocrinol 2012:268957

    Article  CAS  PubMed  Google Scholar 

  53. Petrossians P, Borges-Martins L, Espinoza C, Daly A, Betea D, Valdes-Socin H, Stevenaert A, Chanson P, Beckers A (2005) Gross total resection or debulking of pituitary adenomas improves hormonal control of acromegaly by somatostatin analogs. Eur J Endocrinol 152(1):61–66

    Article  CAS  PubMed  Google Scholar 

  54. Colao A, Attanasio R, Pivonello R, Cappabianca P, Cavallo LM, Lasio G, Lodrini A, Lombardi G, Cozzi R (2006) Partial surgical removal of growth hormone-secreting pituitary tumors enhances the response to somatostatin analogs in acromegaly. J Clin Endocrinol Metab 91(1):85–92

    Article  CAS  PubMed  Google Scholar 

  55. Karavitaki N, Turner HE, Adams CB, Cudlip S, Byrne JV, Fazal-Sanderson V, Rowlers S, Trainer PJ, Wass JA (2008) Surgical debulking of pituitary macroadenomas causing acromegaly improves control by lanreotide. Clin Endocrinol (Oxf) 8(6):970–975

    Article  Google Scholar 

  56. Bevan JS (2005) Clinical review: the antitumoral effects of somatostatin analog therapy in acromegaly. J Clin Endocrinol Metab 90(3):1856–1863

    Article  CAS  PubMed  Google Scholar 

  57. Maiza JC, Vezzosi D, Matta M, Donadille F, Loubes-Lacroix F, Cournot M, Bennet A, Caron P (2007) Long-term (up to 18 years) effects on GH/IGF-1 hypersecretion and tumour size of primary somatostatin analogue (SSTa) therapy in patients with GH-secreting pituitary adenoma responsive to SSTa. Clin Endocrinol (Oxf) 67(2):282–289

    Article  CAS  Google Scholar 

  58. Melmed S, Sternberg R, Cook D, Klibanski A, Chanson P, Bonert V, Vance ML, Rhew D, Kleinberg D, Barkan A (2005) A critical analysis of pituitary tumor shrinkage during primary medical therapy in acromegaly. J Clin Endocrinol Metab 90(7):4405–4410

    Article  CAS  PubMed  Google Scholar 

  59. Nakashima M, Takano K, Matsuno A (2009) Analyses of factors influencing the acute effect of octreotide in growth hormone-secreting adenomas. Endocr J 56(2):295–304

    Article  CAS  PubMed  Google Scholar 

  60. Neggers SJ, van der Lely AJ (2011) Combination treatment with somatostatin analogues and pegvisomant in acromegaly. Growth Horm IGF Res 21(3):129–133

    Article  CAS  PubMed  Google Scholar 

  61. Bates PR, Carson MN, Trainer PJ, Wass JA, UK National Acromegaly Register Study Group (UKAR-2) (2008) Wide variation in surgical outcomes for acromegaly in the UK. Clin Endocrinol (Oxf) 68(1):136–142

    Article  CAS  Google Scholar 

Download references

Acknowledgments

We appreciate Stephanie Henry, Juliana Kovacs, and Lois Burkhart for their assistance in administrative support. We also acknowledge Drs. Amin Kassam, Ricardo Carrau and Steve Hodak for their involvement in the primary clinical and surgical management of many of the patients reported in this study. This research did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector.

Conflict of interest

The authors declare that they have no conflict of interest.

Author information

Authors and Affiliations

  1. University of Pittsburgh School of Medicine, Pittsburgh, PA, USA

    Samuel S. Shin

  2. Department of Neurological Surgery, University of Pittsburgh Medical Center, UPMC Presbyterian, Suite B-400, 200 Lothrop Street, Pittsburgh, PA, 15213, USA

    Matthew J. Tormenti, Alessandro Paluzzi, Yue-Fang Chang, Juan C. Fernandez-Miranda & Paul A. Gardner

  3. Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA

    Hanady Zainah & Sue M. Challinor

  4. Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA

    William E. Rothfus

  5. Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA

    Carl H. Snyderman

Authors
  1. Samuel S. Shin
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Matthew J. Tormenti
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Alessandro Paluzzi
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. William E. Rothfus
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Yue-Fang Chang
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Hanady Zainah
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Juan C. Fernandez-Miranda
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Carl H. Snyderman
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Sue M. Challinor
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Paul A. Gardner
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Paul A. Gardner.

Additional information

Sue M. Challinor and Paul A. Gardner contributed equally to this work as principle investigators.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (DOCX 30 kb)

Rights and permissions

Reprints and permissions

About this article

Cite this article

Shin, S.S., Tormenti, M.J., Paluzzi, A. et al. Endoscopic endonasal approach for growth hormone secreting pituitary adenomas: outcomes in 53 patients using 2010 consensus criteria for remission. Pituitary 16, 435–444 (2013). https://doi.org/10.1007/s11102-012-0440-6

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11102-012-0440-6

Keywords

Search

Navigation