Pediatric Pituitary Adenomas

Abstract Context.—Pituitary adenomas are relatively rare occurrences in the pediatric population, and there are few studies documenting the profile of these tumors in this age group. Objective.—To study the clinical and pathologic features of pediatric pituitary adenomas in conjunction with a review of the available literature. Design.—A retrospective clinicopathologic review of 20 pediatric patients (younger than 20 years of age) with pituitary adenomas resected during a 24.5-year period (1981–2005). Results.—A total of 20 patients, including 12 females and 8 males, comprise the study group. Mean age at onset of symptoms was 14.0 years (range, 5–18 years). Four patients had onset of symptoms before the age of 12 years. The majority of patients presented with headaches (n = 12), visual disturbances (n = 12) or, in females, menstrual dysfunction (n = 9/12). Tumor size based on radiographic data was known for 19 tumors; 12 adenomas were greater than 1 cm in greatest dimension, and 7 were less than 1 cm. On follow-up, 2 patients with total gross tumor resections had recurrent adenomas; time to recurrence was 5 months and 17 months, respectively. Nine adenomas stained solely for prolactin, 5 for adrenocorticotropic hormone, and 3 for growth hormone. Two stained for growth hormone and prolactin. One did not stain with hormone antibodies. Conclusions.—Most pediatric pituitary adenomas present after the onset of puberty and present with frequent headaches, changes in visual acuity and, in females, menstrual dysfunction. Most (19/20) were secretory, with prolactinomas being the most common type.

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SURG-08. SURGICAL OUTCOMES OF PITUITARY ADENOMAS TREATED WITH TRANSSPHENOIDAL SURGERY: A SINGLE INSTITUTION’S EXPERIENCE

Neuro-Oncology ◽

10.1093/neuonc/noz175.1009 ◽

2019 ◽

Vol 21 (Supplement_6) ◽

pp. vi241-vi241

Author(s):

Young Beom Seo ◽

Oh-Lyong Kim

Keyword(s):

Growth Hormone ◽

Pituitary Adenoma ◽

Surgical Outcomes ◽

Pituitary Adenomas ◽

Transsphenoidal Surgery ◽

Cerebrospinal Fluid Leakage ◽

Time Interval ◽

Tumor Type ◽

Visual Disturbances

Abstract We retrospectively analyzed surgical outcomes of transsphenoidal surgery for pituitary adenomas. A total of 366 consecutive patients undergoing transsphenoidal surgery for a pituitary adenoma from December 1990 through May 2017 were included in this study. The most common tumor type was nonfunctioning pituitary adenoma (NFPA) (63.7%), followed by prolactin-secreting adenoma (20.5%), growth hormone-secreting adenoma (13.4%), adrenocorticotropin-secreting adenoma (2.2%), and thyrotropin-secreting adenoma (0.2%). This cohort study consisted of 164 male and 202 female patients. The median patients age was 48 years. The median follow-up duration was 63 months. Gross-total resection (GTR) was achieved in 83.7% of patients with a NFPA, 76% of prolactin-secreting adenomas, 71.4% of growth hormone-secreting adenomas, 75% of adrenocorticotropin-secreting adenomas, 100% of thyrotropin-secreting adenomas. There were 326 macroadenomas (69.1%). Surgical outcome was better in patients with microadenomas than in patients with macroadenomas (100% and 77.9%, respectively). Improvement of visual disturbances occurred in 148 (93.7%) of the 158 cases. Hormonal impairment by pituitary adenoma was improved in 105 (87.5%) of the 120 cases. There were 24 (8.2%) cases of recurrence after GTR; 17 patients underwent second surgery, 5 patients received radiotherapy, and the others continued conservative treatment. The median time interval between TSA and recurrence was 56 months. Postoperative cerebrospinal fluid leakage occurred in seven (1.9%) of 366 patients. Transsphenoidal surgery is an effective and safe treatment modality for most patients with pituitary adenoma.

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Pediatric Pituitary Adenoma: Case Series, Review of the Literature, and a Skull Base Treatment Paradigm

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0038-1625984 ◽

2018 ◽

Vol 79 (01) ◽

pp. 091-114 ◽

Cited By ~ 19

Author(s):

Avital Perry ◽

Christopher Graffeo ◽

Christopher Marcellino ◽

Bruce Pollock ◽

Nicholas Wetjen ◽

...

Keyword(s):

Systematic Review ◽

Pituitary Adenoma ◽

Skull Base ◽

Pituitary Adenomas ◽

Pediatric Population ◽

Csf Leak ◽

Persistent Disease ◽

Treatment Paradigm ◽

Surgical Cure

Background Pediatric pituitary adenoma is a rare skull base neoplasm, accounting for 3% of all intracranial neoplasms in children and 5% of pituitary adenomas. Compared with pituitary tumors in adults, secreting tumors predominate and longer disease trajectories are expected due to the patient age resulting in a natural history and treatment paradigm that is complex and controversial. Objectives The aims of this study were to describe a large, single-institution series of pediatric pituitary adenomas with extensive long-term follow-up and to conduct a systematic review examining outcomes after pituitary adenoma surgery in the pediatric population. Methods The study cohort was compiled by searching institutional pathology and operative reports using diagnosis and site codes for pituitary and sellar pathology, from 1956 to 2016. Systematic review of the English language literature since 1970 was conducted using PubMed, MEDLINE, Embase, and Google Scholar. Results Thirty-nine surgically managed pediatric pituitary adenomas were identified, including 15 prolactinomas, 14 corticotrophs, 7 somatotrophs, and 4 non-secreting adenomas. All patients underwent transsphenoidal resection (TSR) as the initial surgical treatment. Surgical cure was achieved in 18 (46%); 21 experienced recurrent/persistent disease, with secondary treatments including repeat surgery in 10, radiation in 14, adjuvant pharmacotherapy in 11, and bilateral adrenalectomy in 3. At the last follow-up (median 87 months, range 3–581), nine remained with recurrent/persistent disease (23%).Thirty-seven publications reporting surgical series of pediatric pituitary adenomas were included, containing 1,284 patients. Adrenocorticotropic hormone (ACTH)-secreting tumors were most prevalent (43%), followed by prolactin (PRL)-secreting (37%), growth hormone (GH)-secreting (12%), and nonsecreting (7%). Surgical cure was reported in 65%. Complications included pituitary insufficiency (23%), permanent visual dysfunction (6%), chronic diabetes insipidus (DI) (3%), and postoperative cerebrospinal fluid (CSF) leak (4%). Mean follow-up was 63 months (range 0–240), with recurrent/persistent disease reported in 18% at the time of last follow-up. Conclusion Pediatric pituitary adenomas are diverse and challenging tumors with complexities far beyond those encountered in the management of routine adult pituitary disease, including nuanced decision-making, a technically demanding operative environment, high propensity for recurrence, and the potentially serious consequences of hypopituitarism with respect to fertility and growth potential in a pediatric population. Optimal treatment requires a high degree of individualization, and patients are most likely to benefit from consolidated, multidisciplinary care in highly experienced centers.

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Endoscopic endonasal skull base surgery in the pediatric population

Journal of Neurosurgery Pediatrics ◽

10.3171/2012.10.peds12160 ◽

2013 ◽

Vol 11 (3) ◽

pp. 227-241 ◽

Cited By ~ 65

Author(s):

Srinivas Chivukula ◽

Maria Koutourousiou ◽

Carl H. Snyderman ◽

Juan C. Fernandez-Miranda ◽

Paul A. Gardner ◽

...

Keyword(s):

Skull Base ◽

Pituitary Adenomas ◽

Skull Base Surgery ◽

Pediatric Population ◽

Skull Base Tumors ◽

Endoscopic Endonasal Surgery ◽

Endonasal Surgery ◽

Endoscopic Endonasal ◽

The Mean

Object The use of endoscopic endonasal surgery (EES) for skull base pathologies in the pediatric population presents unique challenges and has not been well described. The authors reviewed their experience with endoscopic endonasal approaches in pediatric skull base surgery to assess surgical outcomes and complications in the context of presenting patient demographics and pathologies. Methods A retrospective review of 133 pediatric patients who underwent EES at our institution from July 1999 to May 2011 was performed. Results A total of 171 EESs were performed for skull base tumors in 112 patients and bony lesions in 21. Eighty-five patients (63.9%) were male, and the mean age at the time of surgery was 12.7 years (range 2.3–18.0 years). Skull base tumors included angiofibromas (n = 24), craniopharyngiomas (n = 16), Rathke cleft cysts (n = 12), pituitary adenomas (n = 11), chordomas/chondrosarcomas (n = 10), dermoid/epidermoid tumors (n = 9), and 30 other pathologies. In total, 19 tumors were malignant (17.0%). Among patients with follow-up data, gross-total resection was achieved in 16 cases of angiofibromas (76.2%), 9 of craniopharyngiomas (56.2%), 8 of Rathke cleft cysts (72.7%), 7 of pituitary adenomas (70%), 5 of chordomas/chondrosarcomas (50%), 6 of dermoid/epidermoid tumors (85.7%), and 9 cases of other pathologies (31%). Fourteen patients received adjuvant radiotherapy, and 5 received chemotherapy. Sixteen patients (15.4%) showed tumor recurrence and underwent reoperation. Bony abnormalities included skull base defects (n = 12), basilar invagination (n = 4), optic nerve compression (n = 3) and trauma (n = 2); preexisting neurological dysfunction resolved in 12 patients (57.1%), improved in 7 (33.3%), and remained unchanged in 2 (9.5%). Overall, complications included CSF leak in 14 cases (10.5%), meningitis in 5 (3.8%), transient diabetes insipidus in 8 patients (6.0%), and permanent diabetes insipidus in 12 (9.0%). Five patients (3.8%) had transient and 3 (2.3%) had permanent cranial nerve palsies. The mean follow-up time was 22.7 months (range 1–122 months); 5 patients were lost to follow-up. Conclusions Endoscopic endonasal surgery has proved to be a safe and feasible approach for the management of a variety of pediatric skull base pathologies. When appropriately indicated, EES may achieve optimal outcomes in the pediatric population.

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

Journal of the Endocrine Society ◽

10.1210/jendso/bvaa046.1110 ◽

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.

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Gamma Knife Radiosurgery for Pituitary Adenoma: Early Results

Neurosurgery ◽

10.1227/01.neu.0000068702.00330.47 ◽

2003 ◽

Vol 53 (1) ◽

pp. 51-61 ◽

Cited By ~ 98

Author(s):

Zbigniew Petrovich ◽

Cheng Yu ◽

Steven L. Giannotta ◽

Chi-Shing Zee ◽

Michael L.J. Apuzzo

Keyword(s):

Growth Hormone ◽

Radiation Dose ◽

Gamma Knife ◽

Pituitary Adenomas ◽

Cranial Nerve ◽

Adrenocorticotropic Hormone ◽

Tumor Volume ◽

Gamma Knife Radiosurgery ◽

Late Toxicity

Abstract OBJECTIVE In recent years, gamma knife radiosurgery (GKRS) has emerged as an important treatment modality in the management of pituitary adenomas. Treatment results after performing GKRS and the complications of this procedure are reviewed. METHODS Between 1994 and 2002, a total of 78 patients with pituitary adenomas underwent a total of 84 GKRS procedures in our medical center. This patient group comprised 46 men (59%) and 32 women (41%). All patients were treated for recurrent or residual disease after surgery or radiotherapy, with 83% presenting with extensive tumor involvement. The cavernous sinus was involved in 75 patients (96%), and 22 patients (28%) had hormone-secreting adenomas. This latter subset of patients included 12 prolactinomas (15%), 6 growth-hormone secreting tumors (8%), and 4 adrenocorticotropic hormone-secreting tumors (5%). The median tumor volume was 2.3 cm3, and the median radiation dose was 15 Gy defined to the 50% isodose line. The mean and median follow-up periods were 41 and 36 months, respectively. RESULTS GKRS was tolerated well in these patients; acute toxicity was uncommon and of no clinical significance. Late toxicity was noted in three patients (4%) and consisted of VIth cranial nerve palsy. In two patients, there was spontaneous resolution of this palsy, and in one patient, it persisted for the entire 3-year duration of follow-up. Of the 15 patients who presented with cranial nerve dysfunction, 8 (53%) experienced complete recovery and 3 (20%) showed major improvement within 12 months of therapy. Tumor volume reduction was slow, with 30% of patients showing decreased tumor volume more than 3 years after undergoing GKRS. None of the 56 patients with nonfunctioning tumors showed progression in the treated volume, and 4 (18%) of the 22 hormone-secreting tumors relapsed (P = 0.008). Of the four patients with adrenocorticotropic hormone-secreting adenomas, therapy failed in two of them. All six patients with growth hormone-producing tumors responded well to therapy. Of the 12 patients with prolactinomas 10 (83%) had normalization of hormone level and 2 patients experienced increasing prolactin level. Two patients with prolactinomas had three normal pregnancies after undergoing GKRS. CONCLUSION GKRS is a safe and effective therapy in selected patients with pituitary adenomas. None of the patients in our study experienced injury to the optic apparatus. A radiation dose higher than 15 Gy is probably needed to improve control of hormone-secreting adenomas. Longer follow-up is required for a more complete assessment of late toxicity and treatment efficacy.

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Radiosurgery of growth hormone–producing pituitary adenomas: factors associated with biochemical remission

Journal of Neurosurgery ◽

10.3171/jns.2007.106.5.833 ◽

2007 ◽

Vol 106 (5) ◽

pp. 833-838 ◽

Cited By ~ 126

Author(s):

Bruce E. Pollock ◽

Jeffrey T. Jacob ◽

Paul D. Brown ◽

Todd B. Nippoldt

Keyword(s):

Growth Hormone ◽

Pituitary Adenomas ◽

Anterior Pituitary ◽

Factors Associated ◽

Factor I ◽

Upper Limit ◽

Igf I ◽

Biochemical Remission ◽

Age And Sex

Object The authors reviewed outcomes after stereotactic radiosurgery for patients with acromegaly and analyzed factors associated with biochemical remission. Methods Retrospective analysis was performed for 46 consecutive cases of growth hormone (GH)–producing pituitary adenomas treated by radiosurgery between 1991 and 2004. Biochemical remission was defined as a fasting GH less than 2 ng/ml and a normal age- and sex-adjusted insulin-like growth factor–I (IGF-I) level while patients were not receiving any pituitary suppressive medications. The median follow up after radiosurgery was 63 months (range 22–168 months). Twenty-three patients (50%) had biochemical remission documented at a median of 36 months (range 6–63 months) after one radiosurgical procedure. The actuarial rates of biochemical remission at 2 and 5 years after radiosurgery were 11 and 60%, respectively. Multivariate analysis showed that IGF-I levels less than 2.25 times the upper limit of normal (hazard ratio [HR] 2.9, 95% confidence interval [CI] 1.2–6.9, p = 0.02) and the absence of pituitary suppressive medications at the time of radiosurgery (HR 4.2, 95% CI 1.4–13.2, p = 0.01) correlated with biochemical remission. The incidence of new anterior pituitary deficits was 10% at 2 years and 33% at 5 years. Conclusions Discontinuation of pituitary suppressive medications at least 1 month before radiosurgery significantly improved endocrine outcomes for patients with acromegaly. Patients with GH–producing pituitary adenomas should not undergo further radiation therapy or surgery for at least 5 years after radiosurgery because GH and IGF-I levels continue to normalize over that interval.

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Surgical Treatment of Clinically Nonsecreting Pituitary Adenomas in Elderly Patients

Neurosurgery ◽

10.1097/00006123-200010000-00009 ◽

2000 ◽

Vol 47 (4) ◽

pp. 843-849 ◽

Cited By ~ 41

Author(s):

Masamichi Kurosaki ◽

Dieter K. Lüdecke ◽

Jörg Flitsch ◽

Wolfgang Saeger

Keyword(s):

Growth Hormone ◽

Surgical Treatment ◽

Elderly Patients ◽

Pituitary Adenomas ◽

Transsphenoidal Surgery ◽

Serum Prolactin ◽

Safe Procedure ◽

Duration Of Symptoms ◽

Average Hospital ◽

Visual Disturbances

Abstract OBJECTIVE The goal of this study was to evaluate the efficacy and safety of transsphenoidal pituitary surgery for elderly patients, using improved techniques of the past decade. METHODS We retrospectively analyzed 32 surgically treated cases of clinically nonsecreting pituitary adenomas in patients more than 70 years of age (mean, 73.9 ± 3.4 yr). These patients were identified in a review of 982 patients with pituitary adenomas who were treated at University Hospital Eppendorf, Hamburg, between January 1991 and November 1999. RESULTS The mean preoperative duration of symptoms was 1.9 years (2 wk to 11 yr). The chiasmatic syndrome was present for 27 patients (84.4%). All patients underwent transsphenoidal surgery. Seven patients underwent reoperations. Preoperative assessments of anterior pituitary function revealed growth hormone deficiencies for 21 of 27 patients (77.8%), thyroid insufficiencies for 10 of 30 patients (33.3%), and adrenal insufficiencies for 13 of 29 patients (44.8%). Hypogonadism and hyperprolactinemia were observed for 76.7% and 46.9% of the patients, respectively. All tumors were macroadenomas, ranging from 18 to 50 mm (average, 33.6 mm) in size, including 7 enclosed and 25 invasive adenomas. Complete microscopic tumor resection was achieved in 24 cases, and subtotal removal was performed in 8 cases. There were no severe perioperative complications. In the cases involving hyperprolactinemia, serum prolactin levels were normalized for 8 of 11 patients (72.7%). Normal thyroid function was recovered for 1 of 10 patients (10.0%) with preoperative hypothyroidism. However, growth hormone or adrenal insufficiencies persisted for all patients with preoperative insufficiencies. Visual disturbances were improved for 19 of 23 patients (82.6%). All patients recovered well after surgery, with an average hospital stay of 16.3 days. Histological and immunohistochemical studies demonstrated gonadotroph adenomas in 56.7% of cases, null-cell adenomas in 26.7%, and oncocytomas in 13.3%. CONCLUSION Surgical treatment of nonsecreting pituitary adenomas causing visual disturbances is standard, even for elderly patients. In this series, transsphenoidal surgery was a safe procedure, with minimal morbidity and excellent tolerance. Age alone is not a contraindication for active treatment, particularly with transsphenoidal surgery.

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Transsphenoidal microsurgical removal of growth hormone-secreting pituitary adenomas

Journal of Neurosurgery ◽

10.3171/jns.1982.56.5.0634 ◽

1982 ◽

Vol 56 (5) ◽

pp. 634-641 ◽

Cited By ~ 77

Author(s):

David S. Baskin ◽

James E. Boggan ◽

Charles B. Wilson

Keyword(s):

Growth Hormone ◽

Pituitary Adenomas ◽

Partial Remission ◽

Transsphenoidal Surgery ◽

Content Type ◽

Group A ◽

Group B ◽

Suprasellar Extension ◽

Fine Print

✓ A series of 137 patients with growth hormone (GH)-secreting pituitary adenomas were treated by transsphenoidal surgery during a 10-year period. Group A comprised patients for whom this surgery was the first therapeutic intervention, and Group B included those who underwent the surgery after previous therapeutic intervention. The results were analyzed considering preoperative and postoperative endocrinological, neurological, ophthalmological, and neuroradiological data. Remission was defined as clinical response and a normal postoperative GH level, and partial remission as clinical response and postoperative reduction of the GH level by more than 50%. Any other result was considered failure. The mean follow-up period was 37.1 months; follow-up review was achieved in all the patients. Among the 102 patients in Group A, remission was achieved in 80 (78%) patients with transsphenoidal surgery alone, and in an additional 16 (16%) after postoperative irradiation (combined response rate, 94%). All failures and patients with partial remission had preoperative GH levels of more than 50 ng/ml and suprasellar extension of the tumor. There were no deaths; 8% of patients had minor surgical morbidity; 5% had new hypopituitarism postoperatively. Of patients subsequently irradiated, 71% developed hypopituitarism. Among the 35 patients in Group B, remission was achieved in 26 (74%), partial remission was obtained in two (6%), and seven (20%) were considered treatment failures. There were no deaths, and the morbidity rate was 14%; 66% of patients had hypopituitarism postoperatively. Of the eight patients who had received prior irradiation only, seven (88%) went into remission. All failures and partial responders had preoperative GH levels greater than 40 ng/ml; 56% had suprasellar extension. These results confirm the efficacy of the transsphenoidal approach for the treatment of GH-secreting pituitary adenomas.

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Evaluation of Factors Affecting Outcome in Growth Hormone–Secreting Pituitary Adenomas

Indian Journal of Neurosurgery ◽

10.1055/s-0037-1598091 ◽

2017 ◽

Vol 06 (03) ◽

pp. 176-183

Author(s):

Amit Padwal ◽

Jagath Gangadharan ◽

Dwarakanath Srinivas ◽

Sampath Somanna

Keyword(s):

Growth Hormone ◽

Pituitary Adenomas ◽

Menstrual Irregularity ◽

Factors Affecting ◽

Factors Influencing ◽

Case Files ◽

Main Factors ◽

Invasive Adenoma ◽

Visual Complaints

Introduction Management of functioning pituitary adenomas is challenging as they can present with features of an intracranial mass, systemic effects, or a combination of both. In this series, one of the largest in available literature from our country, we have analyzed our experience with surgical management of growth hormone (GH)-secreting pituitary adenomas and factors influencing their hormonal remission. Materials and Methods The data of all functional pituitary adenomas operated at our institute from January 2002 to December 2011 were obtained from the case files of these patients. This was studied for various clinical-radiologic features, management stratagems, and clinical and hormonal outcomes. Results Ninety-three patients of GH-secreting pituitary adenomas with a mean age of 32.7 years were included in the study. Fifty-three (57%) patients had headache at presentation; 46 (49%) had visual complaints, whereas menstrual irregularity was seen in majority of females. Mean GH level was 52.05 ng/mL. Fifty (53%) patients had invasive adenoma; 32 had cavernous sinus extension. Among 80 patients with hormonal follow-up, 43 (53.75%) achieved remission of GH level < 5 ng/mL. Conclusion In this series, one of the largest of its kind, the main factors influencing unfavorable outcome include macroadenomas, invasiveness, high basal GH > 45 ng/mL levels, and mixed adenomas.

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