Biochemical acromegaly in patients with prolactinoma during treatment with dopaminergic agonists

Rosário, Pedro Weslley; Purisch, Saulo

doi:10.1590/s0004-27302010000600006

Cited by 9 publications

(7 citation statements)

References 15 publications

(19 reference statements)

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“…The interval between prolactinoma diagnosis and biochemical evidence of GH excess was not reported in this study. Taken together, both studies (9, 10) suggest that acromegaly can develop in about 4% of the prolactinoma patients during long-term follow-up. The interval from the diagnosis of prolactinoma to the development of acromegaly can be up to 20 years (our “case #2” section).…”

Section: Discussionmentioning

confidence: 80%

“…Two studies describe the development of  acromegaly in patients with well-controlled prolactinoma and initial normal screening for GH excess (9, 10). Anderson et al .…”

Section: Discussionmentioning

confidence: 99%

“…(9) performed a cross-sectional study of 121 patients with diagnosis of prolactinoma. All patients were lacking symptoms of acromegaly.…”

Section: Discussionmentioning

confidence: 99%

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Late presentation of acromegaly in medically controlled prolactinoma patients

Manuylova

Calvi

Hastings³

et al. 2016

Endocrinology, Diabetes &Amp; Metabolism Case Reports

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SummaryCo-secretion of growth hormone (GH) and prolactin (PRL) from a single pituitary adenoma is common. In fact, up to 25% of patients with acromegaly may have PRL co-secretion. The prevalence of acromegaly among patients with a newly diagnosed prolactinoma is unknown. Given the possibility of mixed GH and PRL co-secretion, the current recommendation is to obtain an insulin-like growth factor-1 (IGF-1) in patients with prolactinoma at the initial diagnosis. Long-term follow-up of IGF-1 is not routinely done. Here, we report two cases of well-controlled prolactinoma on dopamine agonists with the development of acromegaly 10–20 years after the initial diagnoses. In both patients, a mixed PRL/GH-cosecreting adenoma was confirmed on the pathology examination after transsphenoidal surgery (TSS). Therefore, periodic routine measurements of IGF-1 should be considered regardless of the duration and biochemical control of prolactinoma.Learning points:Acromegaly can develop in patients with well-controlled prolactinoma on dopamine agonists.The interval between prolactinoma and acromegaly diagnoses can be several decades.Periodic screening of patients with prolactinoma for growth hormone excess should be considered and can  lead to an early diagnosis of acromegaly before the development of complications.

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Section: Discussionmentioning

confidence: 80%

“…Two studies describe the development of  acromegaly in patients with well-controlled prolactinoma and initial normal screening for GH excess (9, 10). Anderson et al .…”

Section: Discussionmentioning

confidence: 99%

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Late presentation of acromegaly in medically controlled prolactinoma patients

Manuylova

Calvi

Hastings³

et al. 2016

Endocrinology, Diabetes &Amp; Metabolism Case Reports

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“…В 2010 г. были опубликованы данные одномоментного исследования с участием 121 пациента с пролактиномой без фенотипических признаков акромегалии, находящихся на терапии агонистами дофаминовых рецепторов [18]. По итогам исследования, у 4,1% пациентов, находящихся на эффективной терапии агонистами дофаминовых рецепторов (нормализация уровня пролактина и уменьшение размеров аденомы на фоне лечения один из критериев включения в исследование), была обнаружена активная акромегалия.…”

Section: клинические особенности аденом со смешанной секрециейunclassified

Difficulties in diagnosis of adenomas with mixed prolactin and growth hormone secretion: case presentation

et al. 2020

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Hyperpolactinemia is a persistent excess of prolactin in the blood serum. The symptom complex of hyperprolactinemia primarily consists of disturbances in function of the reproductive system. The secretion of prolactin is under complex neuroendocrine control, which involves factors of different nature: neurotransmitters, hormones of the peripheral endocrine glands. In most cases, prolactin is secreted by pituitary cells - lactotrophs, but in some cases, hypersecretion of prolactin is combined with an excess production of growth hormone, which is typical for tumors originating from the line of progenitor cells of lactotrophs and somatotrophs of the pituitary gland, mammosomatotrophs. In this case, the symptom complex of hyperprolactinemia is accompanied by clinical manifestations of acromegaly. In patients with acromegaly, the cause of hyperprolactinemia may be pituitary stalk compression or mixed secretion of prolactin and growth hormone. Differentiation of lactotropic and somatotropic pituitary cells is determined by transcription factor Pit-1. These cell lineages are closely connected, and this may be one of the reasons for formation of tumors with mixed secretion. Reports of late presentation of acromegaly in patients previously diagnosed with prolactinomas have also been described in literature.Clinical manifestations of hyperprolactinemia can cause the patient to seek doctor’s attention before acromegalic changes in appearance develop. Careful attention is needed both to the primary diagnosis and to the clinical course of the disease in patients with hyperprolactinemia and pituitary adenoma: full assessment of hormonal status with mandatory evaluation of IGF-1 is crucial at initial examination, during further observation it may be advised to consider periodic evaluation of IGF-1 in addition to assessment of prolactin and the size of adenoma. Pituitary adenomas with mixed secretion may have a poorer prognosis.

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“…Ressalta-se a relevância das considerações anteriores, pois, para alcançarmos o objetivo do diagnóstico mais precoce da acromegalia (1), obrigatoriamente maior número de indivíduos deverão ter a doença suspeitada e ser investigados laboratorialmente, o que tende a reduzir o VPP dos testes laboratoriais (4), quando comparado à investigação restrita a pacientes com alta suspeita para acromegalia (7,8).…”

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Diagnóstico laboratorial da acromegalia

Rosário

2011

Arq Bras Endocrinol Metab

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R ecentemente, foram apresentadas as recomendações do Departamento de Neuroendocrinologia da Sociedade Brasileira de Endocrinologia e Metabologia (SBEM) para o diagnóstico e tratamento da acromegalia no Brasil (1). Os comentários a seguir visam contribuir especificamente em relação ao diagnóstico laboratorial.Embora nas recomendações seja ressaltado que "não existe uma faixa de normalidade para o GH basal que diferencie indivíduos normais daqueles com acromegalia", reconhece-se que, em pacientes com IGF-1 indubitavelmente elevado, o valor do GH basal pode definir o diagnóstico, dispensando o teste de supressão com sobrecarga oral de glicose [Quadro 1 (1)]. Conclui-se, portanto, que existe um valor de GH basal acima do qual, combinado com IGF-1 indubitavelmente alto, seja possível identificar pacientes acromegálicos. Com base nos resultados do GH basal (Immulite) obtidos em adultos saudáveis, os limites de 5 µg/L para homens e 10 µg/L para mulheres parecem razoáveis, pois valores acima desses raramente são vistos em indivíduos normais, especialmente pela manhã, quando picos de secreção de GH em adultos são excepcionais (2). Em relação ao IGF-1 sérico, tivemos a oportunidade de analisar adultos (exceto gestantes) que exibiam níveis persistentemente acima do limite superior da normalidade (LSN) para idade, mas sem acromegalia e com adequada supressão do GH. Foram 25 indivíduos saudáveis (3), 50 pacientes com diabetes ou intolerância à glicose (4) e 15 com hipertireoidismo não tratado (informação não publicada), com valores repetidamente elevados de IGF-1 na ausência de acromegalia (falso-positivo). Em todos, exceto dois, os valores de IGF-1 foram abaixo de 1,5 vez o LSN. Assim, como forma de melhor definir o que nas recomendações é chamado de valores "indubitavelmente" elevados (1), os limites de 5 µg/L em homens e 10 µg/L em mulheres para o GH basal e 1,5 vez o LSN para o IGF-1 sérico em adultos (exceto gestantes) são interessantes. A combinação de valores acima desses limites estabeleceria o diagnóstico de acromegalia, sem necessidade da supressão com glicose oral.Pelas recomendações (1), pacientes com GH basal > 0,4 µg/L e/ou IGF-1 elevado, exceto se ambos indubitavelmente alterados, devem ser submetidos ao teste de supressão [Figura 1 (1)]. Considerando que o objetivo do teste é suprimir o GH e não explorar a resposta paradoxal eventualmente presente em alguns casos de acromegalia, é difícil justificá-lo quando o nível de GH em condições basais já se encontra inferior ao que se espera após supressão. Se o objetivo do teste é suprimir o GH para < 0,4 µg/L, é pouco razoável realizá-lo em pacientes que já apresentam GH < 0,4 µg/L em condições basais. Assim, ainda que acromegalia seja possível em pacientes com IGF-1 elevado e GH basal < 0,4 µg/L, não seria o teste de supressão auxiliar nessa definição.Outro aspecto que merece reflexão é a recomendação de que pacientes com GH basal > 0,4 µg/L, a despeito do IGF-1 normal, sejam submetidos à supressão do GH (1).

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Biochemical acromegaly in patients with prolactinoma during treatment with dopaminergic agonists

Cited by 9 publications

References 15 publications

Late presentation of acromegaly in medically controlled prolactinoma patients

Late presentation of acromegaly in medically controlled prolactinoma patients

Difficulties in diagnosis of adenomas with mixed prolactin and growth hormone secretion: case presentation

Diagnóstico laboratorial da acromegalia

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