Abstract
Purpose
To evaluate the role of IGF-I and random GH measurements 3 months after transsphenoidal surgery (TSS) in predicting long-term remission in acromegaly patients.
Methods
Retrospective analysis of 54 acromegaly patients who underwent TSS with the same neurosurgery team. Random GH and IGF-I values evaluated 3 months after TSS were related to long-term outcomes. The initiation of adjuvant therapy at any time defined surgical failure.
Results
At 3 months, 14 (25.9%) patients had controlled disease (CD; normal IGF-I and GH < 1.0 µg/L), 25 (46.3%) had uncontrolled disease (UD; high IGF-I and GH), and 15 (27.8%) had biochemical discrepancies (BD): 12 BDI (normal IGF-I + GH ≥ 1.0 μg/L) and 3 BDII (high IGF-I + GH < 1.0 μg/L). All patients of the CD group, 2 of the UD, 11 of the BDI, and 2 of the BDII, progressed with long-term remission and had IGF-I ≤ 1.25-fold the Upper Limit of Normal (ULN), in contrast with all cases of surgical failure where IGF-I was ≥1.3-fold ULN. Only one patient with normal IGF-I had recurrence, resulting in 100% sensitivity and 96% specificity of post-surgical IGF-I ≤ 1.25-fold ULN to predict long-term remission, observed in 54% of our cohort. Post-surgical random GH ≥ 1.7 µg/L was the best cutoff to identify surgical failure, but its accuracy to predict long-term outcomes was limited.
Conclusions
IGF-I levels ≤ 1.25-fold ULN 3 months after TSS was the best guide for long-term remission in acromegaly patients with both initial surgical failure and discrepant biochemical results.
Similar content being viewed by others
References
C. Beauregard, U. Truong, J. Hardy, O. Serri, Long-term outcome and mortality after transsphenoidal adenomectomy for acromegaly. Clin. Endocrinol. 58(1), 86–91 (2003)
J.A. Gondim, J.P. Almeida, L.A. de Albuquerque, E. Gomes, M. Schops, T. Ferraz, Pure endoscopic transsphenoidal surgery for treatment of acromegaly: results of 67 cases treated in a pituitary center. Neurosurg. Focus 29(4), E7 (2010). https://doi.org/10.3171/2010.7.FOCUS10167
C.P. Hofstetter, R.H. Mannaa, L. Mubita, V.K. Anand, J.W. Kennedy, A.R. Dehdashti, T.H. Schwartz, Endoscopic endonasal transsphenoidal surgery for growth hormone-secreting pituitary adenomas. Neurosurg. Focus 29(4), E6 (2010). https://doi.org/10.3171/2010.7.FOCUS10173
H. Nishioka, N. Fukuhara, K. Horiguchi, S. Yamada, Aggressive transsphenoidal resection of tumors invading the cavernous sinus in patients with acromegaly: predictive factors, strategies, and outcomes. J. Neurosurg. 121(3), 505–510 (2014). https://doi.org/10.3171/2014.3.JNS132214
R.M. Starke, D.M. Raper, S.C. Payne, M.L. Vance, E.H. Oldfield, J.A. Jane Jr, Endoscopic vs microsurgical transsphenoidal surgery for acromegaly: outcomes in a concurrent series of patients using modern criteria for remission. J. Clin. Endocrinol. Metab. 98(8), 3190–3198 (2013). https://doi.org/10.1210/jc.2013-1036
A. Giustina, P. Chanson, M.D. Bronstein, A. Klibanski, S. Lamberts, F.F. Casanueva, P. Trainer, E. Ghigo, K. Ho, S. Melmed,Acromegaly Consensus Group, A consensus on criteria for cure of acromegaly. J. Clin. Endocrinol. Metab. 95(7), 3141–3148 (2010). https://doi.org/10.1210/jc.2009-2670
M.S. Shin, J.H. Yu, J.H. Choi, C.H. Jung, J.Y. Hwang, Y.H. Cho, C.J. Kim, M.S. Kim, Long-term changes in serum IGF-1 levels after successful surgical treatment of growth hormone-secreting pituitary adenoma. Neurosurgery 73(3), 473–479 (2013). https://doi.org/10.1227/01.neu.0000431480.87160.84. quiz 479
P.U. Freda, Monitoring of acromegaly: what should be performed when GH and IGF-1 levels are discrepant? Clin. Endocrinol. 71(2), 166–170 (2009). https://doi.org/10.1111/j.1365-2265.2009.03556.x
A. Giustina, A. Barkan, F.F. Casanueva, F. Cavagnini, L. Frohman, K. Ho, J. Veldhuis, J. Wass, K. Von Werder, S. Melmed, Criteria for cure of acromegaly: a consensus statement. J. Clin. Endocrinol. Metab. 85(2), 526–529 (2000). https://doi.org/10.1210/jcem.85.2.6363
E. Sala, E. Ferrante, M. Locatelli, P. Rampini, G. Mantovani, C. Giavoli, M. Filopanti, E. Verrua, E. Malchiodi, G. Carrabba, M. Arosio, P. Beck-Peccoz, A. Spada, A.G. Lania, Diagnostic features and outcome of surgical therapy of acromegalic patients: experience of the last three decades. Hormones 13(1), 95–103 (2014)
Y.Y. Wang, C. Higham, T. Kearney, J.R. Davis, P. Trainer, K.K. Gnanalingham, Acromegaly surgery in Manchester revisited-the impact of reducing surgeon numbers and the 2010 consensus guidelines for disease remission. Clin. Endocrinol. 76(3), 399–406 (2012). https://doi.org/10.1111/j.1365-2265.2011.04193.x
A.M. Abu Dabrh, K. Mohammed, N. Asi, W.H. Farah, Z. Wang, M.H. Farah, L.J. Prokop, L. Katznelson, M.H. Murad, Surgical interventions and medical treatments in treatment-naive patients with acromegaly: systematic review and meta-analysis. J. Clin. Endocrinol. Metab. 99(11), 4003–4014 (2014). https://doi.org/10.1210/jc.2014-2900
F.F. Casanueva, A.L. Barkan, M. Buchfelder, A. Klibanski, E.R. Laws, J.S. Loeffler, S. Melmed, P. Mortini, J. Wass, A. Giustina,Pituitary Society, Expert Group on Pituitary Tumors, Criteria for the definition of Pituitary Tumor Centers of Excellence (PTCOE): a Pituitary Society statement. Pituitary 20(5), 489–498 (2017). https://doi.org/10.1007/s11102-017-0838-2
S. Melmed, A. Colao, A. Barkan, M. Molitch, A.B. Grossman, D. Kleinberg, D. Clemmons, P. Chanson, E. Laws, J. Schlechte, M.L. Vance, K. Ho, A. Giustina,Acromegaly Consensus Group, Guidelines for acromegaly management: an update. J. Clin. Endocrinol. Metab. 94(5), 1509–1517 (2009). https://doi.org/10.1210/jc.2008-2421
A. Boeving, L.A. Borba, A.M. Rodrigues, E.B. Orichowski, G.J. Paz Filho, C.M. Santos, C.L. Boguszewski, Outcome of surgical treatment for acromegaly performed by a single neurosurgeon and cumulative meta-analysis. Arq. Bras. Endocrinol. Metab. 50(5), 884–892 (2006)
E. Knosp, E. Steiner, K. Kitz, C. Matula, Pituitary adenomas with invasion of the cavernous sinus space: a magnetic resonance imaging classification compared with surgical findings. Neurosurgery 33(4), 610–617 (1993). discussion 617–618
L. Katznelson, E.R. Laws Jr., S. Melmed, M.E. Molitch, M.H. Murad, A. Utz, J.A. Wass, S. Endocrine, Acromegaly: an endocrine society clinical practice guideline. J. Clin. Endocrinol. Metab. 99(11), 3933–3951 (2014). https://doi.org/10.1210/jc.2014-2700
J.D. Carmichael, V.S. Bonert, J.M. Mirocha, S. Melmed, The utility of oral glucose tolerance testing for diagnosis and assessment of treatment outcomes in 166 patients with acromegaly. J. Clin. Endocrinol. Metab. 94(2), 523–527 (2009). https://doi.org/10.1210/jc.2008-1371. Epub 2008 Nov 25
M. Sherlock, A. Aragon Alonso, R.C. Reulen, J. Ayuk, R.N. Clayton, G. Holder, M.C. Sheppard, A. Bates, P.M. Stewart, Monitoring disease activity using GH and IGF-I in the follow-up of 501 patients with acromegaly. Clin. Endocrinol. 71(1), 74–81 (2009). https://doi.org/10.1111/j.1365-2265.2008.03461.x. Epub 2008 Oct 26
C.N. Jayasena, C. Wujanto, M. Donaldson, J.F. Todd, K. Meeran, Measurement of basal growth hormone (GH) is a useful test of disease activity in treated acromegalic patients. Clin. Endocrinol. 68(1), 36–41 (2008). https://doi.org/10.1111/j.1365-2265.2007.02996.x
N. Karavitaki, A. Fernandez, V. Fazal-Sanderson, J.A. Wass, The value of the oral glucose tolerance test, random serum growth hormone and mean growth hormone levels in assessing the postoperative outcome of patients with acromegaly. Clin. Endocrinol. 71(6), 840–845 (2009). https://doi.org/10.1111/j.1365-2265.2009.03578.x. Epub 2009 Mar 6
I.M. Holdaway, R.C. Rajasoorya, G.D. Gamble, Factors influencing mortality in acromegaly. J. Clin. Endocrinol. Metab. 89(2), 667–674 (2004)
L. Katznelson, J.L. Atkinson, D.M. Cook, S.Z. Ezzat, A.H. Hamrahian, K.K. Miller,American Association of Clinical Endocrinologists, American Association of Clinical Endocrinologists medical guidelines for clinical practice for the diagnosis and treatment of acromegaly—2011 update. Endocr. Pract. 17(Suppl 4), 1–44 (2011)
A. Ribeiro-Oliveira Jr., M.M. Abrantes, A.L. Barkan, Complex rhythmicity and age dependence of growth hormone secretion are preserved in patients with acromegaly: further evidence for a present hypothalamic control of pituitary somatotropinomas. J. Clin. Endocrinol. Metab. 98(7), 2959–2966 (2013). https://doi.org/10.1210/jc.2013-1581
K. Schilbach, C.J. Strasburger, M. Bidlingmaier, Biochemical investigations in diagnosis and follow up of acromegaly. Pituitary 20(1), 33–45 (2017)
D.R. Clemmons, Consensus statement on the standardization and evaluation of growth hormone and insulin like growth factor assays. Clin. Chem. 57(4), 555–559 (2011). https://doi.org/10.1373/clinchem.2010.150631
A.L. Espinosa-de-Los-Monteros, E. Sosa, S. Cheng, R. Ochoa, C. Sandoval, G. Guinto, V. Mendoza, I. Hernandez, M. Molina, M. Mercado, Biochemical evaluation of disease activity after pituitary surgery in acromegaly: a critical analysis of patients who spontaneously change disease status. Clin. Endocrinol. 64(3), 245–249 (2006). https://doi.org/10.1111/j.1365-2265.2006.02430.x
V. Bonert, Diagnostic challenges in acromegaly: a case-based review. Best. Pract. Res. Clin. Endocrinol. Metab. 23(Suppl 1), S23–S30 (2009). https://doi.org/10.1016/S1521-690X(09)70005-3
A. Muhammad, E.C. Coopmans, P.J.D. Delhanty, A.H.G. Dallenga, I.K. Haitsma, J.A.M.J.L. Janssen, A.J. van der Lely, S.J.C.M.M. Neggers, Efficacy and safety of switching to pasireotide in acromegaly patients controlled with pegvisomant and somatostatin analogues: PAPE extension study. Eur. J. Endocrinol. 179(5), 269–277 (2018). https://doi.org/10.1530/EJE-18-0353
A.L. Espinosa-de-los-Monteros, B. Gonzalez, G. Vargas, E. Sosa, M. Mercado, L.A.R. Octreotide, treatment of acromegaly in “real life”: long-term outcome at a tertiary care center. Pituitary 18(3), 290–296 (2015). https://doi.org/10.1007/s11102-014-0570-0
S. Ahmed, M. Elsheikh, I.M. Stratton, R.C. Page, C.B. Adams, J.A. Wass, Outcome of transphenoidal surgery for acromegaly and its relationship to surgical experience. Clin. Endocrinol. 50(5), 561–567 (1999)
I. Shimon, Z.R. Cohen, Z. Ram, M. Hadani, Transsphenoidal surgery for acromegaly: endocrinological follow-up of 98 patients. Neurosurgery 48(6), 1239–1243 (2001). discussion 1244–1235
N. Karavitaki, H.E. Turner, C.B. Adams, S. Cudlip, J.V. Byrne, V. Fazal-Sanderson, S. Rowlers, P.J. Trainer, J.A. Wass, Surgical debulking of pituitary macroadenomas causing acromegaly improves control by lanreotide. Clin. Endocrinol. 68(6), 970–975 (2008). https://doi.org/10.1111/j.1365-2265.2007.03139.x
H. Sun, J. Brzana, C.G. Yedinak, S.H. Gultekin, J.B. Delashaw, M. Fleseriu, Factors associated with biochemical remission after microscopic transsphenoidal surgery for acromegaly. J. Neurol. Surg. B Skull Base 75(1), 47–52 (2014). https://doi.org/10.1055/s-0033-1354578
Y. Marquez, A. Tuchman, G. Zada, Surgery and radiosurgery for acromegaly: a review of indications, operative techniques, outcomes, and complications. Int. J. Endocrinol. 2012, 386401 (2012). https://doi.org/10.1155/2012/386401
C.C. van Bunderen, N.C. van Varsseveld, J.C. Baayen, W.R. van Furth, E.S. Aliaga, M.J. Hazewinkel, C.B. Majoie, N.J. Freling, P. Lips, E. Fliers, P.H. Bisschop, M.L. Drent, Predictors of endoscopic transsphenoidal surgery outcome in acromegaly: patient and tumor characteristics evaluated by magnetic resonance imaging. Pituitary 16(2), 158–167 (2013). https://doi.org/10.1007/s11102-012-0395-7
X. Antunes, N. Ventura, G.B. Camilo, L.E. Wildemberg, A. Guasti, P.J.M. Pereira, A.H.S. Camacho, L. Chimelli, P. Niemeyer, M.R. Gadelha, L. Kasuki, Predictors of surgical outcome and early criteria of remission in acromegaly. Endocrine 60(3), 415–422 (2018). https://doi.org/10.1007/s12020-018-1590-8. Epub 2018 Apr 6
G. Minniti, M.L. Jaffrain-Rea, V. Esposito, A. Santoro, G. Tamburrano, G. Cantore, Evolving criteria for post-operative biochemical remission of acromegaly: can we achieve a definitive cure? An audit of surgical results on a large series and a review of the literature. Endocr. Relat. Cancer 10(4), 611–619 (2003)
A. Abosch, J.B. Tyrrell, K.R. Lamborn, L.T. Hannegan, C.B. Applebury, C.B. Wilson, Transsphenoidal microsurgery for growth hormone-secreting pituitary adenomas: initial outcome and long-term results. J. Clin. Endocrinol. Metab. 83(10), 3411–3418 (1998). https://doi.org/10.1210/jcem.83.10.5111
A. Tamasauskas, K. Sinkunas, W. Draf, V. Deltuva, A. Matukevicius, D. Rastenyte, S. Vaitkus, Management of cerebrospinal fluid leak after surgical removal of pituitary adenomas. Medicina 44(4), 302–307 (2008)
C. Romero Adel, J.E. Nora, T.E. Topczewski, P.H. Aguiar, I. Alobid, E.F. Rodriguez, Cerebrospinal fluid fistula after endoscopic transsphenoidal surgery: experience in a spanish center. Arq. Neuropsiquiatr. 68(3), 414–417 (2010)
Acknowledgements
We thank Milena Braga-Basaria, MD (Voxmed Medical Communications) for the help with the technical assistance in writing the manuscript and Rogério Ruscitto do Prado for assisting with the statistical analyses.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
The authors declare that they have no conflict of interest.
Additional information
Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Cunha, M.L.V.d., Borba, L.A.B. & Boguszewski, C.L. Random Gh and Igf-I levels after transsphenoidal surgery for acromegaly: relation with long-term remission. Endocrine 68, 182–191 (2020). https://doi.org/10.1007/s12020-020-02227-2
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s12020-020-02227-2