Pituitary

, Volume 16, Issue 4, pp 435–444 | Cite as

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

  • Samuel S. Shin
  • Matthew J. Tormenti
  • Alessandro Paluzzi
  • William E. Rothfus
  • Yue-Fang Chang
  • Hanady Zainah
  • Juan C. Fernandez-Miranda
  • Carl H. Snyderman
  • Sue M. Challinor
  • Paul A. Gardner
Article

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.

Keywords

Endoscopic endonasal Acromegaly Transsphenoidal Transnasal Pituitary adenoma 

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

Supplementary material

11102_2012_440_MOESM1_ESM.docx (31 kb)
Supplementary material 1 (DOCX 30 kb)

References

  1. 1.
    Dekkers OM, Biermasz NR, Pereira AM, Romijn JA, Vandenbroucke JP (2008) Mortality in acromegaly: a metaanalysis. J Clin Endocrinol Metab 93:61–67CrossRefPubMedGoogle Scholar
  2. 2.
    Chanson P, Salenave S, Kamenicky P, Cazabat L, Young J (2009) Pituitary tumours: acromegaly. Best Pract Res Clin Endocrinol Metab 23:555–574CrossRefPubMedGoogle Scholar
  3. 3.
    Donangelo I, Melmed S (2005) Treatment of acromegaly: future. Endocrine 28:123–128CrossRefPubMedGoogle Scholar
  4. 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 94:1509–1517CrossRefPubMedGoogle Scholar
  5. 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) 50:561–567CrossRefGoogle Scholar
  6. 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 89:353–358CrossRefPubMedGoogle Scholar
  7. 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:E5CrossRefPubMedGoogle Scholar
  8. 8.
    Sherlock M, Woods C, Sheppard MC (2011) Medical therapy in acromegaly. Nat Rev Endocrinol 7:291–300CrossRefPubMedGoogle Scholar
  9. 9.
    Castinetti F, Régis J, Dufour H, Brue T (2010) Role of stereotactic radiosurgery in the management of pituitary adenomas. Nat Rev Endocrinol 6:214–223CrossRefPubMedGoogle Scholar
  10. 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 83:3411–3418CrossRefPubMedGoogle Scholar
  11. 11.
    Ross DA, Wilson CB (1988) Results of transsphenoidal microsurgery for growth hormone-secreting pituitary adenoma in a series of 214 patients. J Neurosurg 68:854–867CrossRefPubMedGoogle Scholar
  12. 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 78:205–215CrossRefPubMedGoogle Scholar
  13. 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 86:1645–1652CrossRefPubMedGoogle Scholar
  14. 14.
    Shimon I, Cohen ZR, Ram Z, Hadani M (2001) Transsphenoidal surgery for acromegaly: endocrinological follow-up of 98 patients. Neurosurgery 48:1239–1243PubMedGoogle Scholar
  15. 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 48:101–107CrossRefPubMedGoogle Scholar
  16. 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 83:240–248CrossRefPubMedGoogle Scholar
  17. 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 22:649–652CrossRefPubMedGoogle Scholar
  18. 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:E10CrossRefPubMedGoogle Scholar
  19. 19.
    Schaberg MR, Anand VK, Schwartz TH, Cobb W (2010) Microscopic versus endoscopic transnasal pituitary surgery. Curr Opin Otolaryngol Head Neck Surg 18:8–14CrossRefPubMedGoogle Scholar
  20. 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:E7CrossRefPubMedGoogle Scholar
  21. 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:E6CrossRefPubMedGoogle Scholar
  22. 22.
    Kabil MS, Eby JB, Shahinian HK (2005) Fully endoscopic endonasal vs. transseptal transsphenoidal pituitary surgery. Minim Invasive Neurosurg 48:348–354CrossRefPubMedGoogle Scholar
  23. 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 95:3141–3148CrossRefPubMedGoogle Scholar
  24. 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 342:1171–1177CrossRefPubMedGoogle Scholar
  25. 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 94:523–527CrossRefPubMedGoogle Scholar
  26. 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 335–342Google Scholar
  27. 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 33:610–617CrossRefPubMedGoogle Scholar
  28. 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 116:1882–1886CrossRefPubMedGoogle Scholar
  29. 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–ONS52CrossRefPubMedGoogle Scholar
  30. 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:E401CrossRefPubMedGoogle Scholar
  31. 31.
    Paisley AN, Drake WM (2005) Treatment of pituitary tumors: pegvisomant. Endocrine 28:111–114CrossRefPubMedGoogle Scholar
  32. 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 25:251–256CrossRefPubMedGoogle Scholar
  33. 33.
    Fahlbusch R, Buchfelder M (1988) Transsphenoidal surgery of parasellar pituitary adenomas. Acta Neurochir (Wien) 92:93–99CrossRefGoogle Scholar
  34. 34.
    Ludecke DK, Abe T (2006) Transsphenoidal microsurgery for newly diagnosed acromegaly: a personal view after more than 1,000 operations. Neuroendocrinology 83:230–239CrossRefPubMedGoogle Scholar
  35. 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 56:1222–1233CrossRefPubMedGoogle Scholar
  36. 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 152:379–387CrossRefPubMedGoogle Scholar
  37. 37.
    Gittoes NJ, Sheppard MC, Johnson AP, Stewart PM (1999) Outcome of surgery for acromegaly–the experience of a dedicated pituitary surgeon. QJM 92:741–745CrossRefPubMedGoogle Scholar
  38. 38.
    Beauregard C, Truong U, Hardy J, Serri O (2003) Long-term outcome and mortality after transsphenoidal adenomectomy for acromegaly. Clin Endocrinol (Oxf) 58:86–91CrossRefGoogle Scholar
  39. 39.
    Kim MS, Jang HD, Kim OL (2009) Surgical results of growth hormone-secreting pituitary adenoma. J Korean Neurosurg Soc 45:271–274CrossRefPubMedGoogle Scholar
  40. 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):4072–4077CrossRefPubMedGoogle Scholar
  41. 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 250-1CrossRefGoogle Scholar
  42. 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):3567–3572CrossRefPubMedGoogle Scholar
  43. 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]Google Scholar
  44. 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 93:1324–1330CrossRefPubMedGoogle Scholar
  45. 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):389–393CrossRefPubMedGoogle Scholar
  46. 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):417–423CrossRefGoogle Scholar
  47. 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):2732–2740CrossRefPubMedGoogle Scholar
  48. 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 90:6480–6489CrossRefPubMedGoogle Scholar
  49. 49.
    Frank G, Pasquini E (2006) Endoscopic endonasal cavernous sinus surgery, with special reference to pituitary adenomas. Front Horm Res 34:64–82CrossRefPubMedGoogle Scholar
  50. 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):E6PubMedGoogle Scholar
  51. 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):144–154CrossRefPubMedGoogle Scholar
  52. 52.
    Plockinger U (2012) Medical therapy of acromegaly. Int J Endocrinol 2012:268957CrossRefPubMedGoogle Scholar
  53. 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):61–66CrossRefPubMedGoogle Scholar
  54. 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):85–92CrossRefPubMedGoogle Scholar
  55. 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):970–975CrossRefGoogle Scholar
  56. 56.
    Bevan JS (2005) Clinical review: the antitumoral effects of somatostatin analog therapy in acromegaly. J Clin Endocrinol Metab 90(3):1856–1863CrossRefPubMedGoogle Scholar
  57. 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):282–289CrossRefGoogle Scholar
  58. 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):4405–4410CrossRefPubMedGoogle Scholar
  59. 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):295–304CrossRefPubMedGoogle Scholar
  60. 60.
    Neggers SJ, van der Lely AJ (2011) Combination treatment with somatostatin analogues and pegvisomant in acromegaly. Growth Horm IGF Res 21(3):129–133CrossRefPubMedGoogle Scholar
  61. 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):136–142CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2012

Authors and Affiliations

  • Samuel S. Shin
    • 1
  • Matthew J. Tormenti
    • 2
  • Alessandro Paluzzi
    • 2
  • William E. Rothfus
    • 4
  • Yue-Fang Chang
    • 2
  • Hanady Zainah
    • 3
  • Juan C. Fernandez-Miranda
    • 2
  • Carl H. Snyderman
    • 5
  • Sue M. Challinor
    • 3
  • Paul A. Gardner
    • 2
  1. 1.University of Pittsburgh School of MedicinePittsburghUSA
  2. 2.Department of Neurological SurgeryUniversity of Pittsburgh Medical Center, UPMC PresbyterianPittsburghUSA
  3. 3.Department of MedicineUniversity of Pittsburgh Medical CenterPittsburghUSA
  4. 4.Department of RadiologyUniversity of Pittsburgh Medical CenterPittsburghUSA
  5. 5.Department of OtolaryngologyUniversity of Pittsburgh Medical CenterPittsburghUSA

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