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Surgical management of acromegaly: Long term functional outcome analysis and assessment of recurrent/residual disease

CONTEXT: Functional growth hormone producing adenomas have long-term deleterious effects on the visual apparatus, the cardiovascular and musculoskeletal systems, and often predispose to malignancies. Since persistence of acromegaly affects outcome and quality of life, therapeutic interventions becom...

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Autores principales: Banerji, Deepu, Das, Nitu K., Sharma, Siddhiraj, Jindal, Yogesh, Jain, Vijendra K., Behari, Sanjay
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Medknow Publications & Media Pvt Ltd 2016
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4849295/
https://www.ncbi.nlm.nih.gov/pubmed/27366253
http://dx.doi.org/10.4103/1793-5482.145354
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author Banerji, Deepu
Das, Nitu K.
Sharma, Siddhiraj
Jindal, Yogesh
Jain, Vijendra K.
Behari, Sanjay
author_facet Banerji, Deepu
Das, Nitu K.
Sharma, Siddhiraj
Jindal, Yogesh
Jain, Vijendra K.
Behari, Sanjay
author_sort Banerji, Deepu
collection PubMed
description CONTEXT: Functional growth hormone producing adenomas have long-term deleterious effects on the visual apparatus, the cardiovascular and musculoskeletal systems, and often predispose to malignancies. Since persistence of acromegaly affects outcome and quality of life, therapeutic interventions become mandatory. AIM: This study represents an analysis of long-term clinical and endocrinal outcome of 115 patients of acromegaly after surgical management. SETTING AND DESIGN: Tertiary care retrospective study. MATERIALS AND METHODS: One hundred and fifteen patients (male:female ratio: 1:1.09) with acromegalic features were studied. Apart from acromegalic features, their main clinical presentation also included headache, diminution of vision, field defects, ptosis, irregular menstruation, diabetes insipidus, diabetes mellitus and hypertension. Six of them presented with apoplexy. Their preoperative endocrinal evaluation included basal and suppressed growth hormone (GH), prolactin and thyroid levels. On the basis of axial and coronal CT scan or multiplanar MR imaging or both, the tumors were classified according to their suprasellar and parasellar extension (Hardy's grade). Transnasal trans-sphenoidal surgery (TSS) (n = 37) and sublabial, rhinoseptal TSS (n = 72) were the preferred approaches. Six patients with significant parasellar extensions underwent trans-cranial explorations. The patients were followed up at 6 and 12 weeks and then at 6 monthly intervals. Hormonal and CT/MR evaluation were also done. Attainment of random GH value less than 2.5 µg/L, and the nadir GH value after oral glucose tolerance test (OGTT) less than 1 µg/L were used as the criteria of cure. FINDINGS: The patients were preoperatively in Hardy's tumor grade 0 (29), A (21), A+E (3), B (21), B+E (5), C (9), C+E (10), D (1) D+E (11), E (5), respectively. One hundred and one patients were available for follow-up (FU; median FU duration: 84 months; range: 6 to 132 months). Surgical cure was achieved in 73 patients following the first surgery; and, in 10 additional patients following a second intervention. No patient with a preoperative grade 0, A, B, C had a recurrence after attaining the initial remission. Recurrence after an initial cure occurred in 7 patients (overall remission rate following surgery: 75.24%). The preoperative grade of the latter patients was A+E:1, B+E:1, C+E:1, D:1, D+E:2, E:1, respectively. All these patients underwent subsequent radiotherapy (RT). The twelve patients with persistent symptoms and high GH levels following surgery underwent RT; six others with improved symptoms despite high GH levels were kept under strict observation. There was no surgical mortality. CONCLUSIONS: A high remission rate without significant morbidity could be achieved following surgical intervention in acromegalic patients. Following surgery, tumors with greater than or equal to 3 cm suprasellar height and without parasellar extension had no clinical recurrence at FU. A continuous monitoring is mandatory to pick up relapsed cases as well as those who develop delayed signs of hypopituitarism. A subset of patients who show clinical improvement following surgery but still have higher GH levels may be followed up without additional therapy unless clinical signs reappear or the serum GH levels progressively increase.
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spelling pubmed-48492952016-07-01 Surgical management of acromegaly: Long term functional outcome analysis and assessment of recurrent/residual disease Banerji, Deepu Das, Nitu K. Sharma, Siddhiraj Jindal, Yogesh Jain, Vijendra K. Behari, Sanjay Asian J Neurosurg Original Article CONTEXT: Functional growth hormone producing adenomas have long-term deleterious effects on the visual apparatus, the cardiovascular and musculoskeletal systems, and often predispose to malignancies. Since persistence of acromegaly affects outcome and quality of life, therapeutic interventions become mandatory. AIM: This study represents an analysis of long-term clinical and endocrinal outcome of 115 patients of acromegaly after surgical management. SETTING AND DESIGN: Tertiary care retrospective study. MATERIALS AND METHODS: One hundred and fifteen patients (male:female ratio: 1:1.09) with acromegalic features were studied. Apart from acromegalic features, their main clinical presentation also included headache, diminution of vision, field defects, ptosis, irregular menstruation, diabetes insipidus, diabetes mellitus and hypertension. Six of them presented with apoplexy. Their preoperative endocrinal evaluation included basal and suppressed growth hormone (GH), prolactin and thyroid levels. On the basis of axial and coronal CT scan or multiplanar MR imaging or both, the tumors were classified according to their suprasellar and parasellar extension (Hardy's grade). Transnasal trans-sphenoidal surgery (TSS) (n = 37) and sublabial, rhinoseptal TSS (n = 72) were the preferred approaches. Six patients with significant parasellar extensions underwent trans-cranial explorations. The patients were followed up at 6 and 12 weeks and then at 6 monthly intervals. Hormonal and CT/MR evaluation were also done. Attainment of random GH value less than 2.5 µg/L, and the nadir GH value after oral glucose tolerance test (OGTT) less than 1 µg/L were used as the criteria of cure. FINDINGS: The patients were preoperatively in Hardy's tumor grade 0 (29), A (21), A+E (3), B (21), B+E (5), C (9), C+E (10), D (1) D+E (11), E (5), respectively. One hundred and one patients were available for follow-up (FU; median FU duration: 84 months; range: 6 to 132 months). Surgical cure was achieved in 73 patients following the first surgery; and, in 10 additional patients following a second intervention. No patient with a preoperative grade 0, A, B, C had a recurrence after attaining the initial remission. Recurrence after an initial cure occurred in 7 patients (overall remission rate following surgery: 75.24%). The preoperative grade of the latter patients was A+E:1, B+E:1, C+E:1, D:1, D+E:2, E:1, respectively. All these patients underwent subsequent radiotherapy (RT). The twelve patients with persistent symptoms and high GH levels following surgery underwent RT; six others with improved symptoms despite high GH levels were kept under strict observation. There was no surgical mortality. CONCLUSIONS: A high remission rate without significant morbidity could be achieved following surgical intervention in acromegalic patients. Following surgery, tumors with greater than or equal to 3 cm suprasellar height and without parasellar extension had no clinical recurrence at FU. A continuous monitoring is mandatory to pick up relapsed cases as well as those who develop delayed signs of hypopituitarism. A subset of patients who show clinical improvement following surgery but still have higher GH levels may be followed up without additional therapy unless clinical signs reappear or the serum GH levels progressively increase. Medknow Publications & Media Pvt Ltd 2016 /pmc/articles/PMC4849295/ /pubmed/27366253 http://dx.doi.org/10.4103/1793-5482.145354 Text en Copyright: © 2016 Asian Journal of Neurosurgery http://creativecommons.org/licenses/by-nc-sa/3.0 This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
spellingShingle Original Article
Banerji, Deepu
Das, Nitu K.
Sharma, Siddhiraj
Jindal, Yogesh
Jain, Vijendra K.
Behari, Sanjay
Surgical management of acromegaly: Long term functional outcome analysis and assessment of recurrent/residual disease
title Surgical management of acromegaly: Long term functional outcome analysis and assessment of recurrent/residual disease
title_full Surgical management of acromegaly: Long term functional outcome analysis and assessment of recurrent/residual disease
title_fullStr Surgical management of acromegaly: Long term functional outcome analysis and assessment of recurrent/residual disease
title_full_unstemmed Surgical management of acromegaly: Long term functional outcome analysis and assessment of recurrent/residual disease
title_short Surgical management of acromegaly: Long term functional outcome analysis and assessment of recurrent/residual disease
title_sort surgical management of acromegaly: long term functional outcome analysis and assessment of recurrent/residual disease
topic Original Article
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4849295/
https://www.ncbi.nlm.nih.gov/pubmed/27366253
http://dx.doi.org/10.4103/1793-5482.145354
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