Outcome of drug treatment in patients with prolactinoma

Aim: Prolactinoma is the most common pituitary adenoma, accounting for about one third of patients with pituitary tumors. Therapeutic options include drug treatment, pituitary surgery, and radiotherapy. However, medical therapy is the preferred initial therapy for most patients with prolactinoma. The aim of the present work was to study patients with prolactinoma attending the Mansoura University Hospital from the clinical, biochemical and radiologic aspects, and to assess the efficacy and outcome of drugs used [bromocriptine and quinagolide] in their treatment. Subjects and A series of 29 cases with prolactinoma attending the Endocrinology outpatient clinic and inpatient department at the Mansoura University Hospital, during the period from 1998 to 2001, were analyzed retrospectively. Patients were followed up for a mean of 6 months to one year. Diagnosis of prolactinoma was made on the basis of high serum prolactin levels with pituitary mass lesion, after exclusion of high GH and high TSH serum levels. Patients had full sheets of clinical data, together with biochemical profile including serum prolactin level, TSH, basal GH. Magnetic resonance imaging [MRI] was done at diagnosis and at follow up. Fundus examination and field of vision were done for patients with macroprolactinoma, at diagnosis and follow up. Bromocriptine [B] was given to 21 patients [15 with microprolactinoma and 6 with macroprolactinoma] in a dose of 7.5-15 mg/day in divided doses, while quinagolide [Q] was given to 8 cases [4 with micro-and 4 with macroprolctinoma] in a dose of 1.5-3 mg once a day. Follow up was made for 6-12 months with clinical, biochemical and MRI assessment. It was found that about 2/3 of prolactinoma patients were females. Microprolactinoma was more prevalent in women while macroprolactinoma was more prevalent in men, and in general, microprolactinoma was more prevalent than macroprolactinoma. The clinical presentation was mainly related to hypogonadism in the form of amenorrhea-galactorrhea in women and sexual impotence and infertility in men. Serum prolactin level was significantly higher in macroprolactinoma compared to microprolactinoma. Visual field defects were found in 5 out of 10 patients harboring macro-prolactinoma. There was no significant difference in efficacy between bromocriptine and quinagolide. Normalized serum prolactin was achieved in 14 out of 15 patients with microprolactinoma in the B treated group versus 4 out of 4 patients in the Q treated group, and 4 out of 6 patients with macroprolactinoma in the B treated group versus 3 out of 4 patients in the Q treated group. Microprolactinoma disappeared in 6 cases out of 15 patients in the B treated group versus 3 out of 4 patients in the Q treated group. More than 50% reduction in tumor dimensions was achieved in 6 out of 15 patients in the B treated group versus 3 out of 4 patients in the Q treated group, and less than 50% reduction in tumor dimensions was achieved in 3 patients in the B treated group. Response to both drugs was not statistically different. For macroprolactinomas there was also a nonsignificant difference in the response to both drugs used. More than 50% reduction in tumor dimensions was achieved in 4 out of 6 patients in the B treated group versus 2 out of 4 patients in the Q treated group, while less than 50% reduction in tumor dimensions was achieved in one patient in the B treated group versus 2 patients in the Q treated group. One patient with macroprolactinoma was resistant to bromocriptine without change in adenoma dimensions. Visual field defects improved in 4 macroprolactinoma cases with prior field defects with the exception of the failed case in the B treated group. Drug side effects were more severe in bromocriptine-treated patients than quinagolide, and three patients of the series were switched to quinagolide because of bromocriptine intolerance. Conclusions: It can be concluded that prolactinoma is more prevalent in females predominantly microprolactinoma. When males are affected macroprolactima predominates due to delayed diagnosis. Patients with prolactinoma respond well to medical treatment in terms of normalization of excess prolactin level and reduction or disappearance of the tumor mass. Both bromocriptine and quinagolide are similarly effective, but quinagolide has fewer side effects

Treatment of bengin thyroid nodules with perculaneous ethanol injection

Aim: Percutaneous ethanol injection for treatment of solitary benign thyroid nodules has been introduced since more than a decade. In the present work, we aimed to apply percutaneous ethanol injection [PEI] guided by ultrasound, for a group of patients with solitary benign thyroid nodules to study its efficacy, acceptance by patients, and assessment of clinical, laboratory and ultrasonographic outcomes. Subjects and Twenty-two cases were recruited. They were classified according to thyroid scintiscan and hormonal profile into 3 groups: group I comprised 8 euthyroid patients with toxic nodule, group II which comprised 8 euthyroid patients with cold nodule, and group III included 6 thyrotoxic patients with toxic nodule. All patients were subjected to fine needle aspiration cytology, assessment of serum T3, T4 and sTSH, 99Tc pertechnetate thyroid scanning in addition to clinical and ultrasonographic evaluation. Patients were subjected to injection of sterile 95% ethanol alcohol, under ultrasound guidance without anaesthesia or sedation with a 22-gauge needle using sterile disposable plastic syringes. Dose per injection was calculated to be 20-30% of the nodule volume to achieve a total amount of 1.5 times the nodule volume. Injection was done once per week, and one injection was done in one session. Patients were followed up for 6 months. There was a significant reduction in nodule volume in the three studied groups without any difference between them. For group I, the initial nodule volume was 15.8 +/- 3.1 ml. It became 9.0 +/- 2.39 ml. after 3 months [P 0.000] and at the end of 6 months it became 6.8 +/- 1.3 ml with a net reduction of 59% of the initial nodule volume. For group II the initial nodule volume was 12.5 +/- 1.7 ml. It became 6.8 +/- 1.3 ml after 3 months [P 0.000] and at the end of 6 months it became 5 +/- 0.6 with a net reduction of 60% of the initial nodule volume. For group III, the initial nodule volume was 11.7 +/- 2.4 ml. It became 6.67 +/- 1.6 ml after 3 months [P < 0.005] and at the end of 6 months it became 5.0 +/- 0.9 ml with a net reduction of 54% of the initial nodule volume. For the three groups, there was positive significant correlation between the initial nodule volume and the amount of reduction in size of the nodule [for group I: r 0.99 and P 0.000, for group II: r 0.87 and P < 0.005, while for group III: r 0.9 and P < 0.01]. Comparing the reduction in nodule volume after 6 months follow up in the three studied groups it was not significantly different [F 2.16, P > 0.05]. In the group of toxic patients [group III], thyroid hormone levels at the end of 6 months were all normalized, while for the other patients the thyroid hormone profile was kept within normal without a significant change through the period of follow up. The technique was well accepted by the patients, and the side effect profile was limited to local pain.with variable radiations. Short-term fever was recorded in 4 cases and transient dysphonia was recorded in 3 cases. All reported complications disappeared from a few hours to 3 days. Conclusions: It was concluded that PEI is cheap, convenient, well accepted by patients, effective in inducing nodule shrinkage and in controlling the thyrotoxic state, without inducing hypothyroidism, and free of the known risks of radioiodine or surgery. With all these advantages, PEI is recommended to have its place in the management options of solitary benign thyroid nodules

audit of outcome of treatment in patients with acromegaly at mansoura University Hospital

Aim: In the last decade, there has been much change concerning treatment of patients with acromegaly. Although stringent criteria for cure or remission in acromegaly are advocated by many authors, there is still much controversy about cure rates using different endocrinologic criteria and factors behind the different outcomes in different centers. Because patients with acromegaly are cared for by many specialties including the endocrinologist, the neurosurgeon, and the radiotherapist, pooled data about the outcome of different modalities of treatment are lacking in our hospital. The aim of the present study was to review our patients with acromegaly, therapeutic modalities used, and to evaluate the outcome in lights of the international reports. Subjects and A series of 26 cases with acromegaly due to pituitary adenoma attending the Mansoura Endocrinology and Neurosurgery outpatient clinics and inpatient departments, were assessed retrospectively. Clinical, full endocrinologic and biochemical assessment including serum GH, prolactin, TSH and ACTH were made. Neuroimaging data including MRI and/or CT of the pituitary were examined. Ophthalmologic examination including fundus and field of vision, both pre- and postoperatively were analyzed. Remission was considered at GH level of less than 5 ng/ml. Twenty four patients have undergone transsphenoidal pituitary adenomectomy, combined with external conventional radiotherapy and bromocriptin therapy at a dose of 10 mg/day in divided doses. Two patients accepted only medical treatment. Follow up period ranged from 1 to 6 years with an average of 3 years with serial endocrinal, biochemical and neuroimaging assessment. Patients analyzed included 6 females and 20 males with an age ranging from 27 to 62 years. All females were postmenopausal and were significantly older than males. Clinical features of acromegaly, as abnormal facial features, hyper-hidrosis, hypertension, diabetes, and musculoskeletal abnormalities were not different from those reported in the literature. Pituitary microadenoma was found only in one patient, while macroadenoma confined to the sella was found in 12 cases [46%], and macroadenoma with extrasellar extensions was found in 13 cases [50%]. Serum GH in both types of macradenoma was not significantly different [56 +/- 8ng/ml versus 59 +/- 8 ng/ml, respectively]. Serum prolactin level was high in 10 cases [38%] with a mean of 104 +/- 29 ng/ml. Preoperative defect in the field of vision was found in 10 cases. No case of central diabetes insipidus [CDI] was found at diagnosis in all patients. The outcome of surgery, in terms of postoperative GH less than 5 ng/ml, was zero%. After institution of external radiotherapy and bromocriptin therapy, 3 cases fulfilled the remission criteria after a 3 years' period. Those patients also, developed panhypopituitarism including TSH, ACTH and were given replacement thyroxine and cortisol treatment. Diabetes insipidus was found in the postoperative period in 14 cases [58%], but it vanished within one month in 12 cases and persisted in two patients. The number of patients with CDI rose to 4 [15%] with long term follow up. Pathology studies revealed eosinophil adenoma in 16 cases and chromophobe adenoma in 8 cases. Field of vision improved in 8 cases out of 10 patients with preoperative field defects. Serum postoperative prolactin level showed a significant decrease compared to the preoperative level in the 10 cases with high prolactin serum level, but only 3 cases reached the normal range. Conclusions: The poor outcome in acromegalic patients of the present series, inspite of the combined use of surgery, radiotherapy and medical treatment, is explained by the late diagnosis of the condition with higher prevalence of macroadenoma with extrasellar extensions, dispersion of operated patients among different neurosurgeons with different skills and experience, and lack of more effective drugs. Also, the relatively short period of follow up in relation to the delayed effects of radiotherapy adds to the poor results

Bone status in patients with hyperthyroidism: impact of the severity, duration, and etiology of hyperthyroidism on bone turnover markers and bone mineral density

Hyperthyroidism is accompanied by osteopenia or osteoporosis with higher incidence of fracture rates. There is paucity of data about the relation between the degree or duration of hyperthyroidism or its etiology and the resulting bone changes. The aim of the present work was to study bone status in patients with hyperthyroidism including biochemical markers of bone turnover and bone mineral density, and to elucidate the impact of severity, duration, and etiology of hyperthyroidism on biochemical markers of bone turnover and bone mineral density. Subjects and Thirty-six male patients with hyperthyroidism, 21 with Graves' disease and 15 with toxic multinodular goiter, with an age ranging from 23 to 65 years and a mean of 43 +/- 10 years, were included, together with 10 healthy men with matched age as a control group. In addition to full clinical examination, patients were subjected to radioisotope scanning and uptake of the thyroid gland with Tc 99,and DEXA scanning of the lower half of the left radius. Laboratory work up included serum free T3, free T4, TSH. Special assays done for patients and controls included serum total and B-ALP, serum OC, serum calcium, serum phosphorus urinary calcium, urinary DXP cross-links, urinary creatinine and calculated urinary DXP/urinary creatinine ratio. Biochemical markers of bone turnover were significantly higher in patients with Graves' disease compared to controls. Serum B-ALP was 9,5 +/- 5.6 KAU/I versus 2.2 +/- 0.8 KAU/I [P=0.00], serum OC was12.7 +/- 5 ng/dl versus 6.6 +/- 1.6 ng/dl [P=0.00], urinary calcium was 22.6 +/- 7.5 mg/dl versus15.5 +/- 5.1 mg/dl [P<0.05], and urinary DXP/urinary creatinine ratio was 12.6 +/- 5.5 versus 6.3 +/- 1.8 [P=0.00]. Biochemical markers of bone turnover were significantly higher in patients with toxic multinodular goiter compared to controls. Serum B-ALP was 4.3 +/- 2.6 KAU/I versus 2.2 +/- 0.8 KAU/I [P<0.05], serum OC was11.5 +/- 6.1 ng/dl versus 6.6 +/- 1.6 ng/dl [P<0.05], urinary calcium was 19.2 +/- 5 mg/dl versus15.5 +/- 5.1 mg/dl [P<0.05], and urinary DXP/urinary creatinine ratio was 13.5 +/- 7 versus 6.3 +/- 1.8 [P<0.05]. There was nonsignificant difference in the biochemical markers of turnover in patients with Graves' disease compared to those with toxic multinodualr goiter. Serum OC was 12.7 +/- 5 ng/d versus11.5 +/- 6.1 ng/dl, urinary calcium was 22.6 +/- 7.5 mg/dl versus 19.2 +/- 5 mg/dl, and urinary DXP/urinary creatinine ratio was 12.6 +/- 5.5 versus 13.5 +/- 7. However, serum B-ALP was higher in patients with Graves1 disease compared to those with multinodular goiter [9.5=/=5.6 KAU/I versus4.3 +/- 2.6 KAU/I [P< 0.05]. The Z -score at the lower half of the left radius in patients with Graves' disease [-1.7 +/- 0.5] was not significantly different from those with toxic multinodular goiter [-1.6 +/- 6]. Correlation between free T3 and biochemical markers of bone turnover revealed a significant positive correlation with all studied parameters: B-ALP [n= 0,37, P<0.05], serum OC [r= 0.62, P<0.05], urinary calcium [r=0.46, P<0.05], and urinary DXP/urinary creatinine ratio [r=0.52, P<0.05]. Correlation between free T4 and bone turnover markers revealed a significant positive correlation with B-ALP [r=0.43, P<0.05], serum OC [r=0.65, P<0.05], urinary calcium [r= 0.61, P<0.05], and urinary DXP/ urinary creatinine ratio [r=0.49, P< 0.05]. The duration of the thyrotoxic state did not correlate with the assessed bone turnover markers. However, the duration of the thyrotoxic state correlated significantly with the Z-score of the studied patients [r =0.68, P< 0.05]. The Z-score of the studied patients did not correlate with the free T3 and freeT4. Conclusions: It is concluded that men with hyperthyroidism have significant bone loss with higher biochemical markers of bone turnover. The severity of hyperthyroidism is directly related to the derangement of biochemical markers of bone turnover. Duration of the thyrotoxic state is related to the degree of bone loss. The etiology of the thyrotoxic state is not related to the degree of derangement in bone turnover markers or to the degree of bone loss