Hypothalamo-Pituitary Surveillance Imaging in Hypopituitary Patients Receiving Long-Term GH Replacement Therapy

Objective: Gamma knife radiosurgery (GKR) can be used as primary or adjuvant therapy for the treatment of an ACTH-producing pituitary tumor after bilateral adrenalectomy, called Nelson syndrome (NS). We have examined the effect of GKR on tumor growth and ACTH-hypersecretion, and characterized the adverse events of this treatment in patients with NS. Design: Cross-sectional follow-up study. First, retrospective data pre-and post-GKR were collected. Patients then underwent a predefined survey including radiological, endocrinological, ophthalmological, and neurosurgical evaluation. Subjects: Ten patients treated with GKR for NS after previous bilateral adrenalectomy. The mean followup was 7 years. No patient was lost to follow-up. Results: Tumor growth was stopped in all patients. The ACTH levels declined in eight patients, and normalized in one patient. There was a significant drop in ACTH levels, with a half-time of 2.8 years.No patient developed visual field defects or any other cranial nerve dysfunction as a result of treatment. Four patients started hormone substitution therapy during the follow-up period. The substitution therapy of three pituitary axes present at GKR treatment could be stopped during the same period. One patient developed a glioblastoma in the left parieto-occipital region 14 years after GKR, far from the field of treatment. As the radiation level was below 1Gy to this area, it is unlikely that the GKR treatment itself induced the malignant tumor. Conclusion: In patients with NS, GKR is an effective adjuvant treatment, carrying relatively few adverse effects. Although the risk of developing a secondary neoplasia after GKR is present, it is probably extremely low.

Section: Discussionmentioning

confidence: 78%

Gamma knife stereotactic radiosurgery of Nelson syndrome

Vik-Mo

Øksnes

Pedersen

et al. 2009

“…A much larger patient population was studied by Frajese et al (16). They followed a total of 100 patients and 91 of them after irradiation for at least 12 months.…”

Section: Discussionmentioning

confidence: 99%

Influence of GH substitution therapy in deficient adults on the recurrence rate of hormonally inactive pituitary adenomas: a case–control study

Buchfelder

Kann²,

Wüster³

et al. 2007

Objective: Several studies documented metabolic and psychological benefits of GH substitution in deficient adults, most of them suffering from benign pituitary adenomas. Since GH substitution is considered to promote tumour regrowth, adequate treatment is performed with some reservation. Therefore, we aimed to elucidate the effect of GH replacement therapy on tumour recurrence following surgery. Methods: In patients with hormonally inactive pituitary adenomas undergoing tumour surgery, a retrospective case-control study was performed. Pre-and postoperative magnetic resonance (MR) images of GH-treated and untreated patients were matched for best fit by two independent observers. The treated patients were retrieved from the surveillance programme of the German KIMS database and the untreated from the database of the Department of Neurosurgery, University of Erlangen. A total of 55 matched pairs were followed for at least 5 years. Tumour recurrence and progression rates were determined according to the postoperative MR. Results: There were 16 tumour progressions in the treatment group and 12 in the control group. Statistical analysis revealed no significant increase in either recurrence (PZ0.317) or progression (PZ0.617) within the follow-up period of 5 years when GH was adequately replaced. Conclusions: This study provides further observational data of substitution therapy in GH-deficient adults with pituitary adenomas. Comparing long-term surgical results, we found no evidence that GH substitution should be withheld in deficient patients. Even residual tumour does not constitute a contraindication to GH replacement. However, since pituitary tumours are slow growing, an observational period of 5 years may not have been long enough to verify any absolute influence on recurrence potential. 157 149-156 European Journal of Endocrinology

“…Abs et al reported no recurrence in 127 GH-treated adult patients with craniopharyngioma enrolled in KIMS 1994-1996 (3). In the study by Frajese et al, no recurrence was detected in a series of 13 adults with craniopharyngioma treated with GH (66). In a study reporting the results of prospective imaging in 28 consecutive patients with craniopharyngioma and adult-onset GHD, an apparent increase in tumour volume was found in one subject 6 years after the commencement of GH (76).…”

Section: Hypothalamic-pituitary Tumoursmentioning

confidence: 92%

“…In a study of GHD adults, no increase in pituitary tumour recurrence rate was found during an average of 3.6 years of GH replacement as compared with controls not receiving GH treatment (65). In a prospective study of 100 adult-onset GHD patients with pituitary and peripituitary tumours receiving GH replacement therapy, only one case of slight intrasellar tissue enlargement was noted after 1-4 years of follow-up (66). The majority of these patients had received external radiotherapy (66).…”

Section: Hypothalamic-pituitary Tumoursmentioning

confidence: 93%

“…In a prospective study of 100 adult-onset GHD patients with pituitary and peripituitary tumours receiving GH replacement therapy, only one case of slight intrasellar tissue enlargement was noted after 1-4 years of follow-up (66). The majority of these patients had received external radiotherapy (66). In a prospective study of 60 childhood brain tumour survivors receiving adult GH replacement therapy over a mean period of 6.7 years, only one incurable ependymoma and one residual meningioma progressed in size (67).…”

Section: Hypothalamic-pituitary Tumoursmentioning

confidence: 99%

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Safety aspects of GH replacement

Svensson¹,

Bengtsson²

2009

In adults, GH replacement therapy will often be maintained for decades. Owing to the long duration of GH replacement in many adults, it is essential to establish the long-term safety aspects of the treatment. In this review, studies that have investigated the safety profile of long-term GH replacement will be reviewed with an emphasis on studies based on data from the Pfizer International Metabolic Database (KIMS). These studies show that long-term GH replacement in adults is safe and that long-term GH replacement may even improve cardiovascular mortality and morbidity in GH-deficient adults.