Incidentalomas o no incidentalomas: ¿cuál es la relevancia de los adenomas hipofisarios en el adulto? / Incidentalomas or Non-Incidentalomas: What is the Relevance of Pituitary Adenomas in the Adult?

Introducción: desde el punto de vista anatómico, los adenomas hipofisarios (AH) se observan en el 10% de la población. Son en su mayoría pequeños y no funcionantes. La mayoría de los incidentalomas descubiertos en estudios de imágenes con alta resolución pedidos en situaciones clínicas frecuentes, como el traumatismo craneoencefálico, el accidente cerebrovascular y las demencias, corresponden a AH indolentes. Nos preguntamos cuál es la relevancia clínica de los adenomas hipofisarios. Desarrollo: los AH clínicamente relevantes son tumores en su mayoría benignos que conllevan, en diferentes proporciones, aumento en la morbilidad y/o mortalidad de los pacientes por mecanismos relacionados con la hipersecreción hormonal, la insuficiencia hormonal y/o los efectos de masa ocupante. La prevalencia de los AH clínicamente relevantes es mayor de la que se suponía hace 20 años. Afecta aproximadamente a 1/1000 habitantes. Los más prevalentes son los prolactinomas y los adenomas no funcionantes. La acromegalia, la enfermedad de Cushing y los tumores agresivos se traducen en pacientes complejos con mayor morbimortalidad. El diagnóstico temprano y el tratamiento multimodal proveen una razonable mejoría de la sobrevida. El estudio epidemiológico de los AH clínicamente relevantes es importante para la estimación del impacto en los sistemas de salud. Conclusiones: los estudios por imágenes de mejor resolución continuarán señalando incidentalomas hipofisarios. Una evaluación cuidadosa de los pacientes podrá identificar aquellos AH clínicamente relevantes. (AU)

Introduction: from the anatomical point of view, pituitary adenomas (HA) are observed in 10% of the population. They are mostly small and non-functioning. Most incidentalomas discovered in high-resolution imaging studies ordered in frequent clinical situations, such as head trauma, stroke and dementia, correspond to indolent HA. We wonder what is the clinical relevance of pituitary adenomas. Development: clinically relevant HAs are mostly benign tumors that lead, in different degrees, to an increased morbidity and/or mortality in patients by mechanisms related to hormone hypersecretion, hormone insufficiency and/or occupying mass effects. The prevalence of clinically relevant HA is higher from what was assumed 20 years ago. It affects approximately 1/1000 of the population. The most prevalent are prolactinomas and non-functioning adenomas. Acromegaly, Cushing's disease and aggressive tumors make for complex patients with increased morbidity and mortality. Early diagnosis and multimodal treatment provide a reasonable improvement in survival. Epidemiological study of clinically relevant HAs is important for estimating the impact on health systems. Conclusions: Higher-resolution imaging studies will continue to highlight pituitary incidentalomas. Careful evaluation of patients will identify clinically relevant HAs. (AU)

Efficacy of cabergoline therapy in patients with non-functioning pituitary adenomas: A single center clinical experience

ABSTRACT Objective: To evaluate the response to cabergoline (CBG) treatment in patients with non-functioning pituitary adenomas (NFPA). Subjects and methods: Retrospective, single tertiary care center study. A total of 44 patients were treated with 3 mg/week of CBG, 32 after surgical treatment (transsphenoidal surgery [TSS] in 27 and TC in 5 patients) and 12 as primary therapy. Mean age was 59.2 ± 12 years and 23 (52.2%) were women. Response to therapy was ascertained by serial magnetic resonance imaging. The median duration of CBG therapy was 30 months (IQR 24-48). Response to CBG therapy was defined as a greater than 20% reduction in tumor size and volume. Results: A significant reduction in tumor size was documented in 29 patients (66%), whereas in 11 patients (25%) the tumor increased in size and in 4 (9%), it remained stable. Significant tumor shrinkage was documented in 4 (33.3%) of 12 patients treated primarily and in 23 (71.8%) of those treated secondarily. The three-year progression-free survival was 0.61. Conclusion: Cabergoline therapy is effective in reducing tumor growth in over two thirds of patients with NFPA, however 16% of patients will escape to this beneficial effect and will require alternative forms of treatment to halt tumor progression.

Gamma knife radiosurgery in pituitary adenomas. A single-center experience / Radiocirugía gamma knife en adenomas hipofisarios: experiencia en un centro

Abstract Stereotactic radiosurgery with gamma knife (GKS) is a treatment option for persistent or recurrent pituitary adenoma. The aim of our study was to report Argentine experience in GKS, assessing the efficacy and safety in our patients with pituitary adenomas. We performed a retrospective analysis of patients with pituitary adenomas treated with GKS between 2002 and 2017 in a single institution. Patient characteristics, biochemical remission rate (for functioning tumors), tumor control rate and adverse effects with GKS were inves tigated. The study cohort comprised 99 patients with a mean follow-up of 63 months: 51 somatotropinomas, 28 non-functioning adenomas, 15 corticotropinomas, 2 prolactinomas and 3 mixed pituitary tumors. The mean radiation dose was 30.6Gy for corticotropinomas, 29.3Gy for somatotropinomas and 19.6Gy for non-secreting adenomas. Global tumor control rate was 94.2%. Biochemical remission rate was 55.9%, being higher in acromegaly than in Cushing's disease (OR4.7, 95%Ci 2.1-10.4, p<0.0001). The mean time to remission was 29.5 months (range: 6-156). Hypopituitarism occurred in 26% of patients and those with Cushing's disease were more prone to develop new hormone deficiency after GKS (OR 2.93, 95%Ci 1.2-7.2, p = 0.019). This study shows argentine experience with the use of GKS in patients with pituitary adenomas, with similar results to those reported by centers with large radiosurgical experience. We achieved biochemical remission in more than 50% of patients and global tumor control in most of them. Hypopituitarism was the most frequent adverse effect, while others were infrequent.

Resumen La radiocirugía gamma-knife (GKS) constituye una alternativa de tratamiento en adenomas hipofisarios persis tentes o recurrentes. El objetivo de nuestro trabajo fue comunicar la experiencia argentina con GKS, evaluando eficacia y seguridad en nuestros pacientes con adenomas hipofisarios. Realizamos un análisis retrospectivo de pacientes con adenomas hipofisarios tratados con GKS entre 2002 y 2017. Se investigaron: características basales, tasa de remisión bioquímica, tasa de control tumoral y efectos adversos del GKS. Estudiamos 99 pa cientes adultos con un seguimiento medio de 63 meses: 51 somatotropinomas, 28 adenomas no funcionantes, 15 corticotropinomas, 2 prolactinomas y 3 tumores mixtos. La do sis media de radiación fue 30.6 Gy para cortico tropinomas, 29.3 Gy para somatotropinomas y 19.6 Gy para adenomas no secretores. La tasa global de control tumoral fue 94.2%. La tasa de remisión bioquímica fue 55.9%, si endo mayor en acromegalia que en enfermedad de Cushing (OR4.7, 95% Ci 2.1-10.4, p < 0.0001). El tiempo medio hasta la remisión fue 29.5 meses (rango: 6-156). Se produjo hipopituitarismo en el 26% de los pacientes. Aquellos con enfermedad de Cushing fueron más propensos a desarrollar nuevas deficiencias hormonales después del GKS (OR2.93, 95% Ci 1.2-7.2, p = 0.019). Este trabajo muestra la experiencia argentina con GKS en pacientes con adenomas hipofisarios, con resultados similares a los reportados por centros con amplia experiencia radioquirúrgica. Logramos remisión bioquímica en más del 50% de los pacientes y control tumoral global en la mayoría de ellos. El hipopituitarismo fue el efecto adverso más frecuente, mientras que otros fueron infrecuentes.

Giant non-functioning adrenocortical carcinoma: an unusual tumour presentation

Adrenocortical carcinoma is a rare tumour with incidence of 1 per million all over the world. Age distribution is bimodal with peaks occurring at 5-20 years and 40-50 years. Tumours greater than 9 cm commonly involve inferior vena cava (IVC) or right side of heart. 80 percent of the carcinomas are functional. We describe a case report of a rare tumour of a non-functioning adrenocortical carcinoma in a 40 year old female having incidence of 0.5/million world over with no extra-adrenal spread at presentation without IVC or right heart involvement in spite of having a large size of 12 cm. Patient underwent successful surgical extirpation with adjuvant radiotherapy with regular follow ups and disease free survival since the surgery. It is imperative to determine hormone levels in symptomatic and asymptomatic patients with adrenal masses. The possibility of adrenocortical carcinoma should not be ruled out in a functioning/non-functioning tumour. All solid incidentalomas on computed tomography (CT)/magnetic resonance imaging (MRI) greater than 5 cm in size should be removed surgically with adjuvant therapy consideration after histopathological reporting.

Incidental isolated renal mucormycosis in immunocompetent patient: a rare and atypical presentation

Mucormycosis is a group of clinical syndromes resulting from infection by one of a group of related filamentous fungi. It is an opportunistic fungal infection that rarely occurs in immunocompetent individual. Isolated involvement of any organ is rare and only a few cases of renal mucormycosis have been reported. We present a case report of atypical presentation of a case of renal mucormycosis in a healthy adult with no predisposing factors. A 48 year non diabetic immunocompetent patient underwent right nephrectomy for painful non-functioning kidney. Biopsy showed chronic pyelonephritis with broad non-septate hyphae suggestive of mucormycosis. Post op followup of patient is normal. Mucormycosis of kidney causes extensive infarction and necrosis due to direct angioinvasion and vascular thrombosis leading to fulminant acute renal failure. The disease mimics pyogenic infection leading to delay in diagnosis and hence resulting in high mortality. High index of suspicion is needed for early diagnosis. Urine and blood cultures are usually sterile. Characteristic CT findings include diffuse enlargement of the kidney with absence of contrast excretion and multiple low-density areas in the renal parenchyma representing fungal abscess. Whenever suspected, FNAC or biopsy is strongly advocated as no imaging can confirm the diagnosis. Nephrectomy or debridement of necrotic tissue along with IV Amphotericin B consist the principal treatment. Renal mucormycosis presenting an indolent course and found incidentally after nephrectomy is extremely rare. In an incidentally found mucormycosis, the role of further investigations to find the source and the role of antifungals have to be further studied.

Association of Squamous Cell Carcinoma with Nonfunctioning Kidney due to Renal Stone Disease

Introduction: Sqamous cell carcinoma accounts for 0.5-0.8%of all renal tumour. Squamous cell carcinoma (SCC) of therenal pelvis is a rare neoplasm and is usually associated withlong standing renal stone disease. There is lack of definiteclinical presentation and inconclusive imaging finding, thesetumors are high grade, highly aggressive with poor prognosis.Histopathology report is hallmark for diagnosis.Material and methods: Our study is Retrospective studywith sample size of 5 patient (3 male and 2 female), presentingcomplaints of all patients had a chronic history of renal stonedisease with loin pain presented during last 2 year of period inUrology department. All patient were evaluated with routinepreoperative blood investigation, DTPA renogram, and NCCT(KUB), found to have nonfunctioning kidney underwentsimple nephrectomy.Result: In our study mean age is 52 year, 3 male and 2 female,mean operative time- 2hr,during postoperative period 3patient have uneventful postoperative course,1 patient haveatrial fibrillation,1 patient have a suture site infection, averagehospital stay 4.5 days. Postoperative histopathology reportconfirmed presence of squamous cell carcinoma, 3 patient onregular follow up with no evidence of recurrence, 1 patientdies during follow up and 1 patient lost follow up.Conclusion: Primary squamous cell carcinoma of kidney arerare aggressive tumour with poor prognosis. As this tumor isassociated with renal stone and non functioning kidney, theyshould be evaluated with newer imaging technology for earlydetection of tumour.

Transperitoneal laparoscopic nephrectomy for renal tumour disease versus non-tumour disease: What are the differences in outcomes?

@#Introduction: Laparoscopic nephrectomy is the standard of care for the removal of both non-functioning and tumourbearing kidneys. This study was conducted to compare the characteristics and outcomes follow-ing laparoscopic transperitoneal nephrectomy (TP) for tumour and nontumour disease. Methods: We retro-spectively reviewed all TP nephrectomies performed in the Hospital Sultanah Bahiyah Alor Setar, Kedah between January 2016 and July 2017. Results: A total of 36 eligible cases were identified, 10 of which were for renal tumours and the others for nonfunctioning kidneys. There were no statistically significant differ-ences between the two groups in terms of demographics and comorbidities. We also did not identify any sta-tistically significant differences between the two groups in terms of operating time, blood loss, need for transfusion, septic complications and postoperative recovery. The only significant difference between the groups was the postoperative rise in serum creatinine, which was higher in the tumour disease group (mean rise 23.4 vs 5.35µmol/l; p = 0.012). Conclusions: Our study showed that laparoscopic nephrectomy is both feasible and safe for the treatment of tumour and non-tumour renal disease with low complication rates in both groups.

Individual strategy of retroperitoneoscopic nephrectomy for benign non-functioning kidneys (84 cases) / 中国内镜杂志

Objective To explore the technique and clinical efficacy of retroperitoneoscopic nephrectomy (RN) at different anatomical plane for benign non-functioning kidneys. Method We retrospectively reviewed the clinical data of 84 patients who underwent RN for benign non-functioning kidneys from February 2010 to November 2016. Various anatomical plane was performed for differing etiology, image and plane, included radical nephrectomy (A group, n = 35), simple nephrectomy (B group, n = 27) and subcapsular nephrectomy (C group, n = 22). Clinical data and preoperative information was collected and analyzed. Result Nephrectomy was performed successfully in 84 patients. There are significantly longer mean operative time and more estimated blood loss in the C group than that in A group and B group (P < 0.05), however, postoperative hospital stay, complications and recovery time were significantly less in the three groups. There was longer mean operative time and more estimated blood in specific and nonspecific infection group compared with the other two groups (P < 0.05). Conclusion Retroperitoneoscopic nephrectomy, although challenging, is safe, reliable, and successful for treatment of benign non-functioning kidneys.Anatomical plane of avascular zone should be offered as the choice of modality to all patients with benign non-functioning kidney.

Perioperative treatment of patients with pheochromocytoma/paraganglioma combined catecholamine cardiomyopathy / 中华泌尿外科杂志

Objective To discuss the diagnosis,perioperative treatment,cardiac function changing of pheochromocytoma/paraganglioma (PHEO/PGL) patients with catecholamine cardiomyopathy.Methods Fifteen PHEO/PGL patients with catecholamine cardiomyopathy were included in our hospital from Jan 2008 to Mar 2018.There were 8 males and 7 females with an average age of 32.8 years,ranging 13-64 years old.4 cases were found left PHEO.4 cases were found right PHEO and 3 cases were bilateral PHEO,including 2 cases of VHL.One case was jugular PGL.2 cases were lift PGL and 1 case was right PGL.The tumors diameter ranged from 2.3 to 7.2 cm.14 patients were diagnosed as PHEO/PGL with catecholamine cardiomyopathy with typical clinical manifestations of PHEO/PGL,such as headache,palpitation and perspiration.Their 24 hours of urine catecholamines showed an average of 24.87 μg/24 h in epinephrine and 551.70 μg/24 h in norepinephrine.Their average value of dopamine was 395.41 μg/24 h.Among 7 cases,the octreotide scan and Iodine-131-meta-iodobenzylguanidine (131 I-MIBG) s scan were positive in 6 and 1 case,respectively.Enhanced CT showed significantly heterogeneous enhancement tumors in adrenal or retroperitoneal area.Ischemia and necrosis area were found inside tumors.The blood flow of some tumors were extremely rich and irregular vascular network with a racemose distribution around the tumors could be observed.Echocardiography showed that the left ventricular ejection fraction (LVEF) ranged from 32％ to 54％,mean (42.0 ± 7.1) ％ during catecholamine cardiomyopathy.5 cases were mild abnormal,which the LVEF ranged from 45％ to 54％.9 cases were moderate abnormal,which the LVEF ranged from 30％ to 44％.Their catecholamine cardiomyopathy performance including left ventricular hypertrophy,myocardial echo enhancement and left ventricular enlargement.9 cases combined with acute left ventricular failure manifested as pulmonary edema and pink foamy phlegm.Sensitive antibiotics were given to suspected pulmonary infection patients.14 cases accepted regular alpha blockers,beta blockers and calcium antagonists treatment for 1 to 3 months and underwent surgery after a significant improvement in cardiac function.1 non-functional PHEO patient was lack of typical clinical and imaging changing.Both of her 24 hours of urine catecholamines and octreotide scan were negative.Echocardiography showed that LVEF was 73％ before operation.She was misdiagnosed as an adrenal non-functional adenoma.All patients underwent surgical treatment,including 13 laparoscopic surgery.One case switched to open surgery.2 PGL patients all accepted open surgery.Rusults All cases accepted complete resection of the tumors.1 case of nonfunctional PHEO had severe fluctuations in blood pressure during operation.Her BP were 190/130 to 80/50 mmHg (1 mmHg =0.133 kPa) and heart rate raised to 150 bpm.Catecholamine cardiomyopathy appeared in ICU ward after operation.Echocardiography showed that LVEF was 37％.The left ventricular enlargement and myocardial systolic function decreased.Fibrous bronchoscopy showed pink foamy phlegm in both sides of lungs.Chest X ray showed bilateral pulmonary edema which predominant in left side.The diagnosis was catecholamine cardiomyopathy of this patient.The LVEF was (55.9 ± 7.6)％ after treatment in 14 PHEO/ PGL patients with catecholamine cardiomyopathy,and there was statistically significant difference between before and after treatment (P =0.041).The LVEF was (66.1 ± 8.5) ％ postoperation,and there was statistically significant difference between postoperation and after treatment (P =0.013).The non-functional PHEO case occurred severe catecholamin cardiomyopathy after operation and cardiac function recovered after treatment.15 cases were followed up from 1 months to 10 years without recurrence.Conclusions PHEO/PGL patients with catecholamine cardiomyopathy should have adequate medication.The abnormal cardiac function of patients would be reversed after surgical treatment.Cardiac function failure would be recovered after active treatment.Non-functional pheochromocytoma patients were extremely dangerous.Adequate medication should be given to any suspected non-functional pheochromocytoma patients.

Study of major genetic factors involved in pituitary tumorigenesis and their impact on clinical and biological characteristics of sporadic somatotropinomas and non-functioning pituitary adenomas

Genetic and functional aberrations of guanine nucleotide-binding protein, alpha stimulating (GNAS), aryl hydrocarbon receptor interacting protein (AIP), and pituitary tumor transforming gene (PTTG) are among the most prominent events in pituitary tumorigenesis. A cohort of Brazilian patients with somatotropinomas (n=41) and non-functioning pituitary adenomas (NFPA, n=21) from a single tertiary-referral center were evaluated for GNAS and AIP mutations and gene expression of AIP and PTTG. Results were compared to the clinical and biological (Ki67 and p53 expression) characteristics of tumors and their response to therapy, if applicable. Genetic analysis revealed that 27% of somatotropinomas and 4.8% of NFPA harbored GNAS mutations (P=0.05). However, no differences were observed in clinical characteristics, tumor extension, response to somatostatin analog therapy, hormonal/surgical remission rates, Ki67 index, and p53 expression between mutated and non-mutated somatotropinomas patients. PTTG overexpression (RQ mean=10.6, min=4.39, max=11.9) and AIP underexpression (RQ mean=0.56, min=0.46-max=0.92) were found in virtually all cases without a statistically significant relationship with clinical and biological tumor features. No patients exhibited somatic or germline pathogenic AIP mutations. In conclusion, mutations in GNAS and abnormal PTTG and AIP expression had no impact on tumor features and treatment outcomes in this cohort. Our data support some previous studies and point to the need for further investigations, probably involving epigenetic and transcriptome analysis, to improve our understanding of pituitary tumor behavior.

Tumores neuroendócrinos quísticos no funcionantes de páncreas. a propósito de un caso / Non-fuctional cystic neuroendocrine tumors of pancreas. a case report

Constituyen un grupo heterogéneo de tumores que pueden originarse virtualmente en todos los órganos; su etiopatogenia, diagnóstico y tratamiento aún generan discusiones, aunque se sabe que todos tienen algo en común: células neuroendócrinas como origen de los tumores, con similitud bioquímica e histológica con las células de la cresta neural. Se presenta el caso de una paciente, que fue operada en nuestro servicio y cuyo diagnóstico final fue tumor neuroendocrino quístico no funcionante de agresividad intermedia.

They constitute a heterogeneous group of tumors that can originate in virtually all organs; Its etiopathogenesis, diagnosis and treatment still generate arguments, although it is known that they all have something in common: neuroendocrine cells as the origin of tumors, with biochemical and histological similarity with neural crest cells. We present the case of a patient, who was operated on in our service and whose final diagnosis was non-functioning cystic neuroendocrine tumor of intermediate aggressiveness.

Tratamiento multimodal de los adenomas de hipófisis recidivantes clínicamente no funcionales. Reporte de caso y revisión de la literatura / Multimodal treatment of non-functional recidivant hypophyseal adenomas. A case report and literature review

Resumen Antecedentes: Los adenomas hipofisarios no funcionales generalmente tienen un comportamiento benigno y naturaleza no invasiva, sin embargo, pueden mostrar características de agresividad con invasión a tejidos circundantes, alto índice mitótico, un índice de Ki67 > 3%y positividad extensa para la tinción de p53, diferenciándose de los carcinomas hipofisarios por la ausencia de diseminación cerebroespinal o metástasis a distancia. Los adenomas agresivos muestran resistencia al tratamiento guirúrgico, médico y radioterapia, y los agentes guimioterapéuticos como temozolamida son una opción terapéutica prometedora de acuerdo con los reportes de la literatura médica internacional. Caso clínico: Paciente del sexo femenino en la sexta década de la vida con padecimiento caracterizado por síndrome guiasmático progresivo e hipopituitarismo ante la presencia de un macroadenoma hipofisario no funcional, con resistencia a tratamiento neuroguirúrgico inicial, tratamiento médico con un agonista dopaminérgico y análogo de receptor de la somatostatina así como radioterapia convencional fraccionada, y cumple con los criterios de agresividad. Se establece tratamiento guimioterapéutico a base de temozolamida, y durante su vigilancia muestra tanto estabilidad clínica como ausencia de progresión tumoral. Conclusiones: La determinación de agresividad es de crucial importancia para mejorar el tratamiento del paciente y, con ello, ofrecer un mejor pronóstico y efectividad terapéutica. El tratamiento de los adenomas hipofisarios no funcionales con características de agresividad es un reto clínico gue involucra un abordaje multidisciplinario. La resistencia al tratamiento quirúrgico, médico y radioterapéutico han dado lugar a la investigación de opciones terapéuticas con agentes quimioterapéuticos como la temozolamida, con tasas de respuesta prometedoras.

Abstract Background: Non-functional pituitary adenomas generally have a benign and non-invasive nature, however, it may show aggressiveness with invasion of surrounding tissues, high mitotic index, an index of Ki67> 3% and extensive positive staining for the cellular tumor antigen p53, differing from the pituitary carcinomas by the absence of craniospinal dissemination or systemic metastases. Aggressive adenomas show resistance to surgical, medical and radiation therapy, including chemotherapeutic agents such as temozolomide, a promising therapeutic option according to reports in the international literature. Case presentation: This is a woman in her 6th decade of life with a clinical presentation characterized by a progressive chiasm syndrome and hypopituitarism in the presence of non-functional pituitary macroadenoma, with initial resistance of neurosurgical treatment, medical treatment with a dopaminergic agonist plus a somatostatin receptor agonist and conventional fractionated radiotherapy, meeting the criteria of aggressive pituitary adenoma. After the treatment with temozolomide as a chemotherapy regimen, the patient showed clinical stability and absence of tumor progression during her follow-up. Conclusion: Defining aggressiveness is of crucial importance for improving the management of patients by enhancing prognostic predictions and effectiveness of treatment. The treatment of nonfunctioning pituitary adenomas with aggressiveness is a clinical challenge that involves a multidisciplinary approach. Resistance to surgical, medical and radiotherapeutic treatment have resulted in the investigation of therapeutic options with chemotherapeutic agents such as temozolomide, with promising response rates.

Comparison of Surgical Outcomes of Laparoscopic Adrenalectomy Between Patients With Nonfunctioning Adrenal Adenomas and Subclinical Cushing Syndrome: A Single-Center Experience

PURPOSE: To examine and compare the perioperative outcomes of laparoscopic adrenalectomy (LA) and to determine its efficacy in patients with nonfunctioning adrenal adenomas (NFA) and subclinical Cushing syndrome (SCS). MATERIALS AND METHODS: We retrospectively analyzed the clinical data obtained from 79 consecutive patients who underwent LA for the treatment of either NFA (n=35) or SCS (n=44) between 2011 and 2016. All patients had undergone computed tomography, as well as endocrinological tests to confirm the diagnosis prior to the adrenalectomy. The primary endpoint was improved metabolic parameters relating to diabetes, hypertension, dyslipidemia, and obesity. RESULTS: Patients with SCS compared to those with NFA showed a higher occurrence of diabetes (29.5% vs. 11.4%), hypertension (59.1% vs. 34.3%), and dyslipidemia (43.2% vs. 14.3%). Patients with SCS showed a smaller median tumor size compared to those with NFA (2.5 cm vs. 5 cm). No significant perioperative complications ≥ Clavien-Dindo classification grade III were observed in any patient (SCS or NFA group). In terms of their metabolic profile, patients with SCS showed a significant postoperative improvement in hypertension (50.0%), diabetes (53.9%), dyslipidemia (31.6%), and obesity (29.2%). However, patients with NFA showed a postoperative improvement only in dyslipidemia (40.0%) and obesity (4.8%). CONCLUSIONS: Owing to absence of significant perioperative complications and the marked postoperative improvement in metabolic impairment, LA is a useful treatment strategy in patients diagnosed with SCS. In contrast, LA was not observed to show beneficial effects in correcting/improving the metabolic profile in patients presenting with NFA.

Recent Progress in the Medical Therapy of Pituitary Tumors

Management of pituitary tumors is multidisciplinary, with medical therapy playing an increasingly important role. With the exception of prolactin-secreting tumors, surgery is still considered the first-line treatment for the majority of pituitary adenomas. However, medical/pharmacological therapy plays an important role in controlling hormone-producing pituitary adenomas, especially for patients with acromegaly and Cushing disease (CD). In the case of non-functioning pituitary adenomas (NFAs), pharmacological therapy plays a minor role, the main objective of which is to reduce tumor growth, but this role requires further studies. For pituitary carcinomas and atypical adenomas, medical therapy, including chemotherapy, acts as an adjuvant to surgery and radiation therapy, which is often required to control these aggressive tumors. In the last decade, knowledge about the pathophysiological mechanisms of various pituitary adenomas has increased, thus novel medical therapies that target specific pathways implicated in tumor synthesis and hormonal over secretion are now available. Advancement in patient selection and determination of prognostic factors has also helped to individualize therapy for patients with pituitary tumors. Improvements in biochemical and “tumor mass” disease control can positively affect patient quality of life, comorbidities and overall survival. In this review, the medical armamentarium for treating CD, acromegaly, prolactinomas, NFA, and carcinomas/aggressive atypical adenomas will be presented. Pharmacological therapies, including doses, mode of administration, efficacy, adverse effects, and use in special circumstances are provided. Medical therapies currently under clinical investigation are also briefly discussed.

A review on the diagnosis and treatment of patients with clinically nonfunctioning pituitary adenoma by the Neuroendocrinology Department of the Brazilian Society of Endocrinology and Metabolism

ABSTRACT Clinically nonfunctioning pituitary adenomas (NFPA) are the most common pituitary tumors after prolactinomas. The absence of clinical symptoms of hormonal hypersecretion can contribute to the late diagnosis of the disease. Thus, the majority of patients seek medical attention for signs and symptoms resulting from mass effect, such as neuro-ophthalmologic symptoms and hypopituitarism. Other presentations include pituitary apoplexy or an incidental finding on imaging studies. Mass effect and hypopituitarism impose high morbidity and mortality. However, early diagnosis and effective treatment minimizes morbidity and mortality. In this publication, the goal of the Neuroendocrinology Department of the Brazilian Society of Endocrinology and Metabolism is to provide a review of the diagnosis and treatment of patients with NFPA, emphasizing that the treatment should be performed in reference centers. This review is based on data published in the literature and the authors’ experience. Arch Endocrinol Metab. 2016;60(4):374-90.

Clinical Concerns about Recurrence of Non-Functioning Pituitary Adenoma

BACKGROUND: Non-functioning pituitary adenomas (NFPA) are clinically challenging because they present at a late stage with local mass effects or hypopituitarism. Surgery for non-functioning pituitary adenoma requires a special strategic approach for both minimal morbidity and radical resection. However, the clinical predictive factors associated with recurrence are limited. Here, we investigated optimal treatment of non-functioning pituitary adenoma. METHODS: We enrolled 289 patients who presented with non-functioning pituitary adenoma between January 2000 and January 2012 and who had received follow-up for at least one year for this retrospective study. Of these patients, 152 were male and 137 were female, with a median age of 51 years (range 15.79 years) and a median follow-up of four years (range 1.12.6 years). Characteristics of patients and tumors were reviewed with electronic medical records and radiologic images, retrospectively. RESULTS: Of the tumors, 193 were gross-totally resected, 53 were near-totally resected, and 43 were sub-totally resected. The extent of resection and adjuvant radiotherapy were both statistically significant prognostic factors of recurrence. Immunohistochemistry of tumor specimens did not yield consistent results. CONCLUSION: With a high rate of recurrence, NFPA should be closely followed-up over a long-term period. Improvement of surgical techniques with advanced surgical equipment and adjuvant radiosurgery would lead to reduce the recurrence rate and improve patients' outcome.

Clinical Concerns about Recurrence of Non-Functioning Pituitary Adenoma

BACKGROUND: Non-functioning pituitary adenomas (NFPA) are clinically challenging because they present at a late stage with local mass effects or hypopituitarism. Surgery for non-functioning pituitary adenoma requires a special strategic approach for both minimal morbidity and radical resection. However, the clinical predictive factors associated with recurrence are limited. Here, we investigated optimal treatment of non-functioning pituitary adenoma. METHODS: We enrolled 289 patients who presented with non-functioning pituitary adenoma between January 2000 and January 2012 and who had received follow-up for at least one year for this retrospective study. Of these patients, 152 were male and 137 were female, with a median age of 51 years (range 15.79 years) and a median follow-up of four years (range 1.12.6 years). Characteristics of patients and tumors were reviewed with electronic medical records and radiologic images, retrospectively. RESULTS: Of the tumors, 193 were gross-totally resected, 53 were near-totally resected, and 43 were sub-totally resected. The extent of resection and adjuvant radiotherapy were both statistically significant prognostic factors of recurrence. Immunohistochemistry of tumor specimens did not yield consistent results. CONCLUSION: With a high rate of recurrence, NFPA should be closely followed-up over a long-term period. Improvement of surgical techniques with advanced surgical equipment and adjuvant radiosurgery would lead to reduce the recurrence rate and improve patients' outcome.

The association of autoimmune thyroiditis and non-functional adrenal incidentalomas with insulin resistance

Objective Patients with incidental nonfunctioning adrenal adenoma are associated with increased risk of obesity, impaired glucose tolerance and dyslipidemia. We aimed to investigate the relationship between thyroid function, serum lipids and insulin resistance in patients with nonfunctioning adrenal incidentaloma. Subjects and methods Forty patients who had diagnosed as adrenal incidentaloma (AI) in our department were included in the study. Serum free triiodothyronine (fT3), free thyroxine (fT4), thyroid stimulating hormone (TSH), anti-thyroperoxidase antibody (anti-TPO Ab) and anti-thyroglobulin antibody (anti-Tg Ab), lipid profile, hs-CRP, fasting insulin levels were measured and insulin resistance calculated by HOMA-IR. Thyroid volume (TV) was assessed. Results None of the patients showed specific signs and symptoms of hormone excess. TV, TSH and fT3 levels in the patient and control groups did not differ significantly (p > 0.05). The serum fT4, anti-TG Ab, anti-TPO Ab levels in the patient group were significantly higher than in the control group (p = 0.013, p < 0.0001, p = 0.016 respectively). The HOMA-IR, hs-CRP and HDL cholesterol levels in the AI patients were significantly higher than the control group (p = 0.034, p = 0.041, p = 0.002, respectively). Statistically significant relationship was found between HOMA-IR and thyroid volume (r = 0.373, p = 0.018), fT4 (r = 0.382, p = 0.015), hs-CRP (r = 0.512, p = 0.001), HDL cholesterol (r = 0,351 p = 0.026) in AI patients. There were significant correlation between anti-TG Ab, anti-TPO Ab and TSH levels in AI patients (r = 0.431 p = 0.006, r = 0.402 p = 0.012). Conclusions Patients with nonfunctioning adrenal incidentaloma have several metabolic disturbances. At the same time autoimmune thyroid disorders are more frequent in nonfunctioning adrenal incidentaloma patient so that thyroid functions must be evaluated in those patients. Arch Endocrinol Metab. 2015;59(1):42-6 .

Standard laparoscopic vs laparoendoscopic single-site nephrectomy for benign nonfunctioning kidney: A comparison of therapeutic outcomes / 第二军医大学学报

Objective To compare the therapeutic outcomes of standard laparoscopic and laparoendoscopic single-site (LESS) nephrectomy for benign nonfunctioning kidney. Methods From September 2009 to August 2013, a single urologist group in our center performed 72 transperitoneal laparoscopic nephrectomies for benign nonfunctioning kidney, with 50 undergoing LESS (group A) and 22 undergoing standard laparoscopic surgery (group B). The clinical data of the two groups were analyzed and the therapeutic outcomes were compared between the two groups. Results The operation was successfully performed in all cases, with no conversion to open surgery. Compared with standard laparoscopic group, the LESS group had significantly lower postoperative pain score (4.3 ± 1.0 vs 3.7 ± 0.8, P = 0.015), quicker bowel function recovery ([58.1 ± 16.1] hvs [49.2 ± 14.0] h, P = 0.032) shorter drainage duration ([3.9 ± 1.5] dvs [2.8 ± 1.1] d, P = 0.003), shorter post-operative hospital stay ([7.3 ± 3.1] d vs [6.3 ± 3.4] d, P = 0.048), and a better cosmetic satisfaction score (7.4 ± 0.9 vs 8.0 ± 0.6, P = 0.001). The operative time and intraoperation blood loss were not significantly different between the two groups. Conclusion Compared to standard laparoscopic nephrectomy, transumbilical LESS nephrectomy offers a quicker recovery of bowel function, shorter drainage duration, a better postoperative pain control, and a better cosmetic satisfaction for benign nonfunctioning kidney, but its long-term therapeutic effect needs to be further verified.

Retroperitoneal laparoscopic nephrectomy for nonfunctioning kidney / 中国医师进修杂志

Objective To investigate the clinical application value of retroperitoneal laparoscopic nephrectomy for nonfunctioning kidney.Methods Fifty-four cases of retroperitoneal laparoscopic nephrectomy for nonfunctioning kidney were reviewed,including 9 cases with nonfunctioning tuberculosis pyonephrosis,18 cases with infection nonfunctioning pyonephrosis and 27 cases of nonfunctioning hydronephrosis.Fifty-four cases were received retroperitoneal laparoscopic nephrectomy,tuberculous and infection pyonephrosis underwent laparoscopic resection surrounding adipose capsule,nonfunctioning hydronephrosis underwent laparoscopic resection by pumping water to increase the peritoneal space.Results The operation of 54 cases were perfomed successfully.None of the patient required conversion to open surgery.During the surgery,1 case showed mild extravasation of cheese-like pus induced by laceration of the kidney capsule;2 cases had injuried on the peritoneum.The mean operation time was 125 (95-230) min,the mean blood loss was 84 (50-420) ml.All patients showed primary healing of the wound,the patients were discharged from the hospital in 6 to 11 d (mean 7.5 d).After followed up for 5-27 months,none of them had long-term complication.Conclusions Retroperitoneal laparscopic nephrectomy for nonfunctioning kidney has advantages of minimal invasion,less blood loss and quicker recovery,so it is a fairly safe and effective procedure for nonfunctioning kidney.