scholarly journals MON-308 Pituitary Magnetic Resonance Imaging in the Postoperative Follow-Up of Patients with Acromegaly, Less Is More!

2020 ◽  
Vol 4 (Supplement_1) ◽  
Author(s):  
Stuti Fernandes ◽  
Elena V Varlamov ◽  
Madeleine Stack ◽  
Nathaniel Johnson ◽  
Justin S Cetas ◽  
...  
Keyword(s):  
Tumor Growth ◽  
Medical Therapy ◽  
Somatostatin Receptor ◽  
Residual Tumor ◽  
Chi Square ◽  
Less Is More ◽  
Somatostatin Receptor Ligands ◽  
Long Term Follow Up ◽  
Almost All

Abstract Background Patients (pts) with acromegaly (A) require long term follow up, as up to 15% will develop recurrence. Current guidelines for MRI surveillance recommend 12 week post-operative (postop) imaging for all pts and yearly if on pegvisomant (PEG). Many pts with residual tumor postop undergo repetitive imaging even when controlled with pituitary (PIT) directed therapies. However, gadolinium retention and healthcare costs are of increased concern. Aim Assess tumor growth postop and necessity of serial MRI in medically treated A pts. Methods Retrospective, IRB-approved, data analysis of pathology-proven A pts. Included were pts with at least 1 MRI at ≥1 year postop. Initial tumor size, invasion status, pathology, postop remission, MRIs, radiation and medical therapy data were collected. Biochemical (biochem) remission = normal IGF-1 and GH <1 at 3 mo postop. For pts with radiation, data was only collected up to radiation. Stats: t-test, chi-square. Results 83 pts were included; mean age 46±16 years, 45% female, mean follow up 7.9±5.3 years. 55 pts were on PIT-directed therapy (50 on somatostatin receptor ligands (SRL) alone, 1 on cabergoline (Cab) alone, 4 on SRL/Cab), 12 on PEG > 1 year (9 on PEG alone.) 11/83 (13.25%) had tumor growth at median 3.5 years (range 1-11). Tumors that grew were larger at diagnosis (25.21±10.93 mm vs 17.45±8.37 mm, p=0.004), had larger residuals postop (23.83±5.0 mm vs 11.86±7.47 mm, p=0.0003), and tended to be invasive (77.78% (7/9) vs 53.03% (35/66), p=NS). 7/11 were sparsely granulated and 4 mixed GH-PRL. Of 11 that grew, 8 had postop residual tumor, 3 in remission, 4 with discrepant IGF-1/GH, 2 uncontrolled and 2 with no data at 3 months postop. At the time of growth, 9/11 pts were untreated (6 had active A, 1 with discrepant IGF-1/GH and 2 with no IGF-1/GH data), 1 was controlled on pasireotide and one in biochem remission. Only 1/50 (2%) pts on pasireotide had growth and no pts on PEG >1 year. Discussion 86.75% of pts with A did not have tumor growth after surgery. Only one pt on PIT-targeted medications and none on PEG experienced tumor growth. Almost all pts who had growth had large invasive adenomas, majority were sparsely granulated, residual tumor postop, were biochemically uncontrolled and not on medication at the time of growth. A previous metanalysis of SRLs in A showed that tumor increase occurs in 1.4% (follow up 3-36 months). In our study pt follow up was longer and 1.82% (1/55) of pts who were on SRL/Cab had growth. Conclusion We recommend less frequent MRI monitoring for pts treated with PIT-targeted medications. Conversely, pts with residual adenoma not on medical therapy should be closely monitored biochemically and by serial MRIs. Further studies are needed to identify appropriate imaging interval for pts on medications and based on characteristics of aggression (such as sparsely granulated, large residual tumors, lack of biochemical control despite medications).

MRI follow‐up of patients with acromegaly treated after surgery with first‐generation somatostatin receptor ligands

2021 ◽  
Author(s):  
Naia Grandgeorge ◽  
Giovanni Barchetti ◽  
Solange Grunenwald ◽  
Fabrice Bonneville ◽  
Philippe Caron
Keyword(s):  
First Generation ◽  
Somatostatin Receptor ◽  
Receptor Ligands ◽  
Somatostatin Receptor Ligands

Diagnosis and Management of Acromegaly in 2014 (Update from 2012)

2014 ◽  
Vol 10 (02) ◽  
pp. 120
Author(s):  
Laurence Katznelson ◽  
Keyword(s):  
Tumor Growth ◽  
Medical Therapy ◽  
De Novo ◽  
Therapeutic Option ◽  
Somatostatin Receptor ◽  
Premature Mortality ◽  
Gh Secretion ◽  
Gh Receptor Antagonist ◽  
Multimodality Approach ◽  
Somatostatin Receptor Ligand

In this update to the 2012 summary, the current diagnostic and therapeutic approaches to acromegaly are reviewed. The goals of therapy are to control excess growth hormone (GH) secretion and tumor growth, and to limit, if not reverse, the long-term medical consequences and risk for premature mortality associated with acromegaly. Surgery is the preferred primary therapeutic option because it can lead to rapid reductions in GH levels and prevent mass effects from local tumor growth. Use of a somatostatin receptor ligand (SRL) preoperatively to improve surgical outcomes has not been substantiated. Medical therapy, including SRLs, dopamine agonists, and the GH receptor antagonist pegvisomant, is used most often in an adjuvant, secondary role for patients in whom surgery has been unsuccessful. Radiation therapy is most commonly recommended in the setting of failed surgery and lack of adequate control with medical therapy. A role of primary medical therapy for de novo patients has been proposed, particularly with SRLs. Using a multimodality approach, successful management of the disease and associated consequences should be achieved in the majority of subjects.

scholarly journals Symptomatic patients with intraluminal carotid artery thrombus: outcome with a strategy of initial anticoagulation

2013 ◽  
Vol 118 (1) ◽  
pp. 34-41 ◽  
Author(s):  
Ananth K. Vellimana ◽  
Yasha Kadkhodayan ◽  
Keith M. Rich ◽  
DeWitte T. Cross ◽  
Christopher J. Moran ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Medical Therapy ◽  
Anticoagulation Therapy ◽  
Retrospective Chart Review ◽  
Perioperative Period ◽  
Carotid Revascularization ◽  
Long Term Follow Up ◽  
Ischemic Attack ◽  
Angioplasty And Stenting

Object The aim of this study was to define the optimal treatment for patients with symptomatic intraluminal carotid artery thrombus (ICAT). Methods The authors performed a retrospective chart review of patients who had presented with symptomatic ICAT at their institution between 2001 and 2011. Results Twenty-four patients (16 males and 8 females) with ICAT presented with ischemic stroke (18 patients) or transient ischemic attack ([TIA], 6 patients). All were initially treated using anticoagulation with or without antiplatelet drugs. Eight of these patients had no or only mild carotid artery stenosis on initial angiography and were treated with medical management alone. The remaining 16 patients had moderate or severe carotid stenosis on initial angiography; of these, 10 underwent delayed revascularization (8 patients, carotid endarterectomy [CEA]; 2 patients, angioplasty and stenting), 2 refused revascularization, and 4 were treated with medical therapy alone. One patient had multiple TIAs despite medical therapy and eventually underwent CEA; the remaining 23 patients had no TIAs after treatment. No patient suffered ischemic or hemorrhagic stroke while on anticoagulation therapy, either during the perioperative period or in the long-term follow-up; 1 patient died of an unrelated condition. The mean follow-up was 16.4 months. Conclusions Results of this study suggest that initial anticoagulation for symptomatic ICAT leads to a low rate of recurrent ischemic events and that carotid revascularization, if indicated, can be safely performed in a delayed manner.

scholarly journals Medical Therapy of Acromegaly

2012 ◽  
Vol 2012 ◽  
pp. 1-22 ◽  
Author(s):  
U. Plöckinger
Keyword(s):  
Medical Therapy ◽  
Mechanism Of Action ◽  
Present Status ◽  
Therapeutic Efficacy ◽  
Dopamine Agonists ◽  
Somatostatin Receptor ◽  
Postoperative Treatment ◽  
Receptor Ligands ◽  
Somatostatin Receptor Ligands ◽  
Remission Criteria

This paper outlines the present status of medical therapy of acromegaly. Indications for permanent postoperative treatment, postirradiation treamtent to bridge the interval until remission as well as primary medical therapy are elaborated. Therapeutic efficacy of the different available drugs—somatostatin receptor ligands (SRLs), dopamine agonists, and the GH antagonist Pegvisomant—is discussed, as are the indications for and efficacy of their respective combinations. Information on their mechanism of action, and some pharmakokinetic data are included. Special emphasis is given to the difficulties to define remission criteria of acromegaly due to technical assay problems. An algorithm for medical therapy in acromegaly is provided.

scholarly journals MON-303 Giant Growth Hormone Secreting Pituitary Adenomas: A Single Institution Case Series

2020 ◽  
Vol 4 (Supplement_1) ◽  
Author(s):  
Bahadir Koylu ◽  
Suleyman Nahit Sendur ◽  
Seda Hanife Oguz ◽  
Selcuk Dagdelen ◽  
Tomris A Erbas
Keyword(s):  
Growth Hormone ◽  
Pituitary Adenoma ◽  
Pituitary Adenomas ◽  
Postoperative Radiotherapy ◽  
Somatostatin Receptor ◽  
Case Series ◽  
Tumor Diameter ◽  
Somatostatin Receptor Ligands ◽  
The Mean

Abstract The prevalence of growth hormone (GH)-secreting pituitary adenoma is around 11-13% of all pituitary adenomas. Giant GH-secreting pituitary adenomas (≥ 4 cm) are rare tumors, and its prevalence of among acromegalic patients is <5%. This is a retrospective cohort study including patients with giant GH-secreting pituitary adenomas. The study population consisted of 10 patients (5 M/5 F). The mean age at diagnosis was 33.0±12.9 yrs (11-55 yrs). The mean delay between first symptom onset and diagnosis was 2.9 years. The most frequent symptoms were acral enlargement and facial changes (80%), followed by headache (70%) and visual deterioration (50%). One patient had epilepsy. Amenorrhea was presented in three females but obvious galactorrhea in two. The mean adenoma diameter was 42.6±4.7 mm (40-51 mm) at diagnosis. The vast majority of adenomas presented suprasellar extension (100%) or cavernous sinus invasion (80%). Cystic adenomas accounted for 50%. At presentation, mean GH and IGF-1 levels were 40.0±21.4 ng/mL (14.8-51.0) and 2.62±1.09 x ULN (1.08-3.96), respectively. Six patients presented with PRL cosecretion. At diagnosis maximal tumor diameter was not correlated with GH or IGF-1 levels. All patients underwent pituitary surgery as first-line treatment. Three cases were treated with an endoscopic approach and four cases with a microscopic approach. Transcranial approach was also employed in three cases. Postoperative mean GH and IGF-1 levels were 14.9±16.1 ng/mL (0.6-51.0) and 2.25.±0.82 x ULN (1.48-3.74), respectively. After first surgery, only one patient had more than 50% reduction in IGF-1 levels. Five patients (50%) underwent repeat surgery on two to three procedures because remission was not achieved. Postoperative somatostatin receptor ligands (SRLs) were used by all patients. Six patients were treated with dopamine agonist in combination with SRL. Six patients (60%) received postoperative radiotherapy. The mean follow-up period was 12.6±5.3 yrs (4-21 yrs). The mean GH and IGF-1 levels were 1.47±1.54 ng/mL (0.08-5.25) and 0.73±0.44 x ULN (0.08-1.56), respectively at the last visit. Residual adenoma was present at the last MRI in eight patients (mean diameter 9.0±3.6 mm). Panhypopituitarism rose from 10% at baseline to 30% at the last visit. During follow-up, one patient diagnosed breast cancer, while another diagnosed thyroid papillary cancer. Giant GH-secreting pituitary adenomas can have a clinically aggressive behavior with mass effect. Moreover, treatment in patients with giant GH-secreting pituitary adenoma is complex and multimodal therapy is necessary.

scholarly journals MON-320 Inter-Rater Reliability of T2 MRI Intensity of Somatotroph Adenomas; Endocrinologists vs. Neuroradiologist Pilot Study

2020 ◽  
Vol 4 (Supplement_1) ◽  
Author(s):  
Elena V Varlamov ◽  
José Miguel Hinojosa-Amaya ◽  
Dawn Lim Shao Ting ◽  
Maria Fleseriu ◽  
Joao Prola
Keyword(s):  
White Matter ◽  
Pilot Study ◽  
Medical Therapy ◽  
Somatostatin Receptor ◽  
Biochemical Response ◽  
Receptor Ligands ◽  
Rater Reliability ◽  
Post Surgery ◽  
Somatostatin Receptor Ligands ◽  
T2 Mri

Abstract Background MRI T2 hypointensity of growth hormone (GH) secreting pituitary adenomas (PA) has been associated with better biochemical response to somatostatin receptor ligands and has been suggested to be useful in selecting patients with expected favorable response for pre- and post-surgery medical therapy. However, in most imaging centers, T2 intensity measurement is not part of standard neuroradiologist (NR) reporting. Objective To assess whether endocrinologists (Es) can reliably measure PA T2 signal intensity by calculating inter-rater reliability between Es and NR. Methods Retrospective review of MRI in 20 patients with pituitary somatotroph macroadenoma randomly selected from an IRB-approved PA database who had preoperative MRI available. T2 MRI intensity of the solid portion of the PA was compared to the temporal gray matter (GM) and white matter (WM): hypo- (PA< WM), hyper- (PA> GM), and isointense (WM <PA <GM). Measurements were performed separately by a NR and by two Es trained to take measurements by the same NR. Statistics: SPSS 25; Cohen kappa (κ). Results Patient mean age was 47 ± 20 years, with 12 females; mean largest PA diameter was 22.6 mm (range 11-45 mm). NR measured 12 hyper-, 7 iso- and 1 hypo-intense PA. Agreement was moderate between NR and E#1 (κ 0.72, 95%CI 0.751-1.0, p<0.001) and NR and E#2 (κ 0.638, 95%CI 0.351-0976, p<0.001) and strong between E#1 and E#2 (κ=0.90, 95%CI 0.309-0.903, p=0.001). Hypointense PA (by NR) was read by both Es as isointense. One hyperintense PA (by NR) was read by both Es as isointense. One isointense PA was read by E#2 as hypointense. Overall adenomas were; 9 densely granulated GH, 5 sparsely granulated GH, 3 mixed GH and prolactin, 1 plurihormonal, 1 not classified, and 1 no surgical intervention. Discussion Inter-rater reliability between the 2 Es was strong, however, it was moderate between each E and the NR. Factors that likely contributed to difference in measurement are heterogeneity of the PA, MRI quality, selection bias in choosing “most appropriate” site to measure intensity of adenoma, gray and white matter. Es could be trained to interpret the T2 intensity, although reliability with NR is only moderate. Interestingly, in this sample majority of T2 PA were hyperintense, but densely granulated, suggesting that preoperative identification of densely granulated tumors, which are also predictive of favorable SRL response, might be limited. More studies are needed to assess T2 correlation with pathology. Conclusion As T2 intensity (hyper-, hypo- or iso-) on MRI might be predictive of biochemical response to medical therapy in some patients with PA, we recommend T2 intensity to be part of neuroradiology reporting protocol. Our pilot study showed that endocrinologists could read MRIs after adequate training, but there is only moderate correlation with neuroradiologists.

scholarly journals Dosing 225Ac-DOTATOC in patients with somatostatin-receptor-positive solid tumors: 5-year follow-up of hematological and renal toxicity

2021 ◽  
Author(s):  
Clemens Kratochwil ◽  
Leonidas Apostolidis ◽  
Hendrik Rathke ◽  
Christos Apostolidis ◽  
Felix Bicu ◽  
...  
Keyword(s):  
Risk Factors ◽  
Renal Toxicity ◽  
Somatostatin Receptor ◽  
Dose Effect ◽  
Cancer Center ◽  
Hematological Toxicity ◽  
Starting Point ◽  
Long Term Follow Up

Abstract Purpose The aim of this retrospective analysis is to estimate the most appropriate single cycle and cumulative doses of 225Ac-DOTATOC in patients treated for somatostatin-receptor-expressing cancers. Methods 225Ac-DOTATOC was administered to thirty-nine patients with various somatostatin-receptor-positive tumors. Baseline and follow-up 68Ga-DOTATOC PET/CT, lab tests, and renal scintigraphy were obtained. Patients received long-term follow-up either at the local cancer center or in close collaboration with external oncologists. Acute and chronic hematological toxicity was evaluated quantitatively over time. Long-term follow-up of creatinine was used to approximate the annual loss of estimated GFR (eGFR). Results Dose-dependent acute hematological toxicity was seen at single doses above 40 MBq or repeated doses greater than approximately 20 MBq 225Ac-DOTATOC at 4 month intervals. Treatment-related kidney failure occurred in 2 patients after a delay of >4 years but was independent of administered radioactivity, and other clinical risk factors were important contributors to renal decline. In general, the annual decline of eGFR among patients did not follow a clear dose-effect relationship even in patients with previous β-therapy. An average eGFR-loss of 8.4ml/min (9.9%) per year was observed which is similar to the experience with β-therapy studies. Conclusion Treatment activities of approx. 20 MBq per cycle (4 monthly repetition) and cumulative doses up to 60–80 MBq generally avoided both acute and chronic grade 3/4 hematotoxicity in patients with advanced stage malignancies. Chronic renal toxicity was observed at these doses, but pre-existing renal risk factors were important co-factors. These data represent a starting point for additional research to more precisely define safety thresholds of 225Ac-DOTATOC.

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