Spontaneous Remission of Functioning Pituitary Adenomas without Hypopituitarism following Infarctive Apoplexy: Two Case Reports

Nishioka, Hiroshi; Haraoka, Jo; Miki, Takeyoshi

doi:10.1507/endocrj.52.117

Cited by 37 publications

(21 citation statements)

References 17 publications

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“…7,19,23,24 Theories about the underlying pathophysiology state that sudden alterations of perfusion pressure might predispose the tumor to infarction. 15 In consistency with these reports, we found that tumors with cystic or posthemorrhagic changes showed additional postoperative volume reduction more frequently than those without such changes.…”

Section: Discussionmentioning

confidence: 99%

Tumor shrinkage after transsphenoidal surgery for nonfunctioning pituitary adenoma

Berkmann¹,

Schlaffer²,

Buchfelder³

2013

JNS

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Object Volume reduction of nonfunctioning pituitary adenomas has been described, for example, after radiotherapy and pituitary tumor apoplexy. Even when considerable remnants remain after surgery, spontaneous shrinkage and relief of mass lesion symptoms can sometimes occur. The aim of this study was to assess shrinkage of tumor residues after transsphenoidal surgery and to identify predictors of tumor shrinkage. Methods A total of 140 patients with postoperative remnants of nonfunctioning pituitary adenomas treated at the Department of Neurosurgery, University Hospital Erlangen, Erlangen, Germany, were included in this study. All patients underwent transsphenoidal procedures with guidance by 1.5-T intraoperative MRI. The intraoperative images of remnants were compared with images taken at 3 months and at 1 year after surgery. The possible predictors analyzed were age; sex; preoperative and intraoperative tumor dimensions; tumor growth pattern; endocrinological, ophthalmological, and histological characteristics; and history of previous pituitary surgery. For statistical analyses, the Fisher's exact test, Mann-Whitney U-test, and multivariate regression table analysis were used. Results Follow-up imaging 3 months after surgery showed tumor remnant shrinkage of 0.5 ± 0.6 cm3 for 70 (50%) patients. This reduction was 89% ± 20% of the residual volume depicted by intraoperative MRI. In 45 (64%) patients, the remnants disappeared completely. Age, sex, and preoperative tumor volume did not significantly differ between the shrinkage and no-shrinkage groups. Positive predictors for postoperative shrinkage were cystic tumor growth (p = 0.02), additional resection of tumor remnants guided by intraoperative MRI (p = 0.04), smaller tumor volume (p = 0.04), and smaller craniocaudal tumor diameter of remnants (p = 0.0014). Negative predictors were growth into the cavernous sinus (p = 0.009), history of previous pituitary surgery (p = 0.0006) and tumor recurrence (p = 0.04), and preoperative panhypopituitarism (p = 0.04). Multivariate regression analysis indicated a positive correlation between tumor shrinkage and smaller tumor remnants (p < 0.0001) and no history of previous pituitary surgery (p = 0.003). No spontaneous change in tumor remnant volume was detected between 3 months and 1 year postoperatively. During a mean follow-up time of 2.7 years, 1 (2%) patient with postoperative tumor shrinkage had to undergo another operation because of tumor progression. Conclusions Spontaneous volume reduction of nonfunctioning pituitary adenoma remnants can occur within 3 months after surgery. Predictors of shrinkage are smaller tumor remnant volume and no history of previous pituitary surgery.

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Section: Discussionmentioning

confidence: 99%

Tumor shrinkage after transsphenoidal surgery for nonfunctioning pituitary adenoma

Berkmann¹,

Schlaffer²,

Buchfelder³

2013

JNS

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“…Cases of spontaneous biochemical remission after PA have been reported for GH-secreting (120,121,122), ACTH-secreting (18,123,124) and prolactin-secreting (122) tumours. However, in a large case series, 90% of the functioning tumours remained active following PA, the majority of which required surgery (19).…”

Section: European Journal Of Endocrinologymentioning

confidence: 99%

“…In patients with a functioning adenoma, recurrence after the initial biochemical cure is possible (18,123,125,126), necessitating long-term follow-up. In a series of NFPA presenting with apoplexy, treated surgically and followedup for a mean period of 6.6 years, the regrowth rate was 11%.…”

Section: Recurrencementioning

confidence: 99%

MANAGEMENT OF ENDOCRINE DISEASE: Pituitary tumour apoplexy

Căpățînă

Inder

Karavitaki

et al. 2015

European Journal of Endocrinology

128

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Pituitary tumour apoplexy (PA) is a rare clinical syndrome that occurs as a result of acute haemorrhage and/or infarction within a frequently undiagnosed pituitary tumour. The sudden enlargement of the pituitary mass undergoing PA is responsible for a wide range of acute symptoms/signs (severe headache, visual loss, diplopia, hypopituitarism, impaired consciousness) which, together with the radiological evidence of a pituitary lesion, establish the diagnosis. The optimal care of PA requires involvement of a multidisciplinary team including endocrinologist, neurosurgeon, neuroophthalmologist and the management strategy that depends on the clinical manifestations, as well as the presence of co-morbidities. Prompt surgical decompression is initially indicated in cases with severe or progressive impairment of the visual acuity or the visual fields or with altered mental state and leads to visual and neurological recovery in most of the patients. The patients with mild, stable clinical picture (including those with isolated ocular palsies) can be managed conservatively (support of fluid and electrolyte balance and stress doses of steroids in most cases) with favourable visual and neurological outcome. Frequent reassessment is mandatory because the clinical course can be unpredictable; if progression of symptoms occurs, later elective surgery is indicated and is beneficial, especially in terms of visual outcome. The endocrinological outcome is less favourable, irrespective of the treatment option, with many patients remaining on long-term replacement therapy. Despite the above guidelines, clear proof of optimal outcomes in the form of randomised controlled trials is lacking. Regrowth of the pituitary tumour years after a PA episode is possible and patients require long-term surveillance.

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“…In our patients, however, cabergoline had been stopped 2.5-5.5 years making this possibility unlikely. Adenoma infarction or apoplexy either spontaneous or induced by dopamine agonist therapy has been described [24][25][26], but the patients had no history of headaches and no change in tumour size or characteristics was visible on MRI. Apoptosis of tumoral cells induced by the medication is probably one likely mechanism, as evidenced in prolactinomas [27].…”

Section: Discussionmentioning

confidence: 95%

Remission of acromegaly following long-term therapy with cabergoline: report of two cases

2007

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Dopamine agonists are effective in some patients with acromegaly and in this condition treatment is considered to be chronic. We describe two acromegalic patients who responded adequately to the long-acting dopamine agonist cabergoline, but surprisingly maintained normal GH and IGF-I levels once therapy was discontinued after 42 and 76 months because of possibly related side effects. A 32-year-old woman with mild acromegaly (IGF-I: 423 microg/l, GH after OGTT: 2.5 microg/l, adenoma 4 mm) was treated with cabergoline as primary therapy and reached safe GH levels (2 microg/l or less) and normal IGF-I levels with 3.5 mg cabergoline weekly. After 42 months of therapy the patient experienced a progressive decrease of libido, which she attributed to the intake of cabergoline. After stopping medication, serum levels of GH and IGF-I remained normal during the following 2.5 years. A 53-year-old man with moderate acromegaly (serum IGF-I: 547 microg/l, GH after OGTT: 5.9 microg/l, adenoma 7 mm) preferred cabergoline as primary therapy. Serum GH levels below 2 microg/l and normal levels of IGF-I were obtained with 3.5 mg cabergoline weekly. When the patient experienced severe stomach pains after 76 months of treatment, cabergoline was held responsible and discontinued. Serum GH and IGF-I did not increase again and stayed at the same level during a follow-up of 5.5 years. These two cases demonstrate that acromegalic patients with a good response to cabergoline may occasionally remain in remission after stopping therapy. This phenomenon has previously only been described in patients with a prolactinoma.

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Spontaneous Remission of Functioning Pituitary Adenomas without Hypopituitarism following Infarctive Apoplexy: Two Case Reports

Cited by 37 publications

References 17 publications

Tumor shrinkage after transsphenoidal surgery for nonfunctioning pituitary adenoma

Tumor shrinkage after transsphenoidal surgery for nonfunctioning pituitary adenoma

MANAGEMENT OF ENDOCRINE DISEASE: Pituitary tumour apoplexy

Remission of acromegaly following long-term therapy with cabergoline: report of two cases

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