Pseudo-pituitary macroadenoma due to primary hypothyriodism: one case report and literature review / 中国基层医药

Objective:To explore the clinical manifestations and differential diagnosis of pituitary hyperplasia caused by primary hypothyroidism in children.Methods:A patient with pseudo-pituitary macroadenoma caused by hypothyroidism who received treatment in Hetian District People's Hospital, Xinjiang Uygur Autonomous Region, China was reported. Meanwhile, relevant literature was searched in Pubmed to sort out the clinical and imaging manifestations of pituitary hyperplasia caused by primary hypothyroidism and the differences from pituitary tumors.Results:This patient almost had to be surgically treated. After thyroid hormone replacement therapy, the growth and development of the patient recovered, and the pituitary gland was reduced.Conclusion:For patients with enlarged thyroid and pituitary glands, a comprehensive assessment and thyroid hormone replacement therapy are required. After follow-up for 3 months, re-evaluation is performed to determine whether there are indications for surgery to avoid permanent hypophyseal hypofunction caused by surgical resection.

Correlation analysis of anterior pituitary hormone and tumor size in patients with pituitary adenomas / 中华内科杂志

Objective:To summarize the correlation between anterior pituitary function and tumor size in patients with different hormone-secreting pituitary adenomas.Methods:This was a retrospective case series study. The clinical data of 1 946 patients with pituitary adenoma hospitalized in the First Medical Center of Chinese PLA General Hospital from January 1, 2005, to December 31, 2020, were collected. The correlation between tumor size and anterior pituitary hormone levels was analyzed using Spearman rank correlation analysis in different types of pituitary adenomas.Results:The median age of the 1 946 patients was 45.1 years, of which 857 (44.0%) were men. The maximum tumor diameter of the patients [ M ( Q1, Q3)] was 22 (14, 30) mm. Tumor size in nonfunctioning adenomas ( n=1 191) was negatively correlated with adrenocorticotropic hormone (ACTH) ( r=-0.11, P<0.001), growth hormone ( r=-0.13, P<0.001), and luteinizing hormone (men: r=-0.26, P<0.001, women: r=-0.31, all P<0.001). The tumor size of somatotropic adenomas ( n=297) was positively correlated with growth hormone ( r=0.46, P<0.001), but negatively correlated with male testosterone ( r=-0.41, P<0.001). The tumor size of ACTH-secreting pituitary adenomas ( n=155) was positively correlated with the ACTH level at 8∶00 AM ( r=0.25, P<0.001); however, no correlation was found with cortisol at 8∶00 AM ( P>0.05). The tumor size of prolactinomas ( n=303) was positively correlated with the prolactin level (men: r=0.34, P=0.001; women: r=0.13, P=0.070). Conclusions:The correlation between the function of the anterior pituitary and size of the tumor depends on the cellular origin of the pituitary adenoma and specific type of hormone secretion. In somatotroph adenomas, ACTH-secreting pituitary adenomas, and prolactinomas, there is a positive correlation between tumor size and level of hormones secreted by the corresponding tumors. In patients with nonfunctioning adenomas, the tumor size was negatively correlated with the hormone levels of the pituitary-adrenal and pituitary-growth hormone axes.

Metastatic diffuse follicular variant papillary thyroid cancer without cervical lymph node metastasis presenting with symptoms related to hypopituitarism

ABSTRACT In this article, we present a case of diffuse follicular variant papillary thyroid carcinoma with pituitary metastasis, which is a rare cause of pituitary metastasis. The follicular variant of papillary thyroid carcinoma is an uncommon variant of papillary carcinoma. A 74-year-old male was presented with weakness, fatigue, and a decreased appetite. The patient was diagnosed with secondary adrenal and thyroid insufficiencies. Imaging revealed a pituitary mass with suprasellar extension, right cavernous sinus invasion, and optic chiasm compression. Thyroid ultrasonography revealed a nodule with a maximum size of 7.2cm in the right lobe. Cytological examination via fine-needle aspiration suggested papillary thyroid cancer. Total thyroidectomy with central and right lateral neck dissection confirmed the diagnosis of diffuse follicular variant of papillary thyroid carcinoma. Owing to visual field defects, the patient underwent transsphenoidal surgery. Histological and immunohistochemical evaluations confirmed pituitary metastasis from the papillary thyroid cancer. Radioactive iodine treatment and gamma knife radiotherapy of the pituitary gland were performed. The initiation of sorafenib treatment was deemed appropriate during the follow-up. A significant decrease in the thyroglobulin levels was observed after sorafenib treatment. Pituitary metastasis should be considered in patients diagnosed with hypopituitarism and pituitary lesions at initial evaluation. The presence of visual field defects may be an indication for neurosurgical intervention and guide both diagnosis and treatment. The management of papillary thyroid cancer and the role of treatment modalities in prognosis depend on the biological behavior of the tumor. Early diagnosis and multidisciplinary management are crucial for the treatment of these patients.

Endoscopic transsphenoidal endonasal surgery in pituitary adenomas / Cirugía endoscópica vía endonasal transesfenoidal en adenomas de hipófisis

The pituitary adenomas comprise the largest part of pituitary neoplasms, representing between 9 and 12% of primary brain tumors. Currently, the treatment of election is the surgical, the trans-sphenoidal endonasal path has provided a broader panoramic view, being feasible more delicate and safe procedures. The objective of this study was to describe the management of pituitary adenomas by endoscopic surgery trans-sphenoidal endonasal path. This is a study in a series of cases, with a sample of 17 patients who met the selection criteria and were attended at the José Carrasco Hospital Arteaga, Cuenca - Ecuador, period 2018 - 2019. All patients presented informed consent for the performance of the surgery and the subsequent dissemination of the results. The 53% of the population belonged to the male gender, 47% were patients between 40 and 60 years old, 65% were detected with macroadenomas, and 29% presented complications such as nasal obstruction, sphenoiditis and headache, the residual tumor stage was due 24%.Endoscopic surgery trans-sphenoidal endonasal path is a safe, minimally invasive tool, a surgical alternative with a high rate of tumor excision, better control and fewer complications, which reduces the morbidity of patients.

Los adenomas de hipófisis comprenden la mayor parte de neoplasias hipofisiarias, representando entre el 9 y 12% de los tumores cerebrales primarios. En la actualidad el tratamiento de elección es el quirúrgico, la vía endonasal transesfenoidal ha proporcionado una visión panorámica más amplia, siendo factibles procedimientos más delicados y seguros. El objetivo de este estudio fue describir el abordaje de adenomas de hipófisis mediante cirugía endoscópica vía endonasal transesfenoidal. Diseñamos un estudio de corte longitudinal, con una muestra de 17 pacientes que cumplieron con los criterios de selección y fueron atendidos en el Hospital José Carrasco Arteaga de la ciudad de Cuenca - Ecuador, periodo 2018 - 2019. Todos los pacientes presentaron consentimiento informado para la realización de la cirugía y la posterior difusión de los resultados. El 53% de la población pertenecieron al sexo masculino, 47% fueron pacientes entre 40 y 60 años, al 65% se le detectó macroadenomas, el 29% presentaron complicaciones como obstrucción nasal, esfenoiditis y cefalea, la tasa de tumor residual fue del 24%. La cirugía endoscópica vía endonasal transesfenoidal es una herramienta segura, mínimamente invasiva, una alternativa quirúrgica con una elevada tasa de exéresis tumoral, mejor control y menos complicaciones, que reduce la morbilidad de los pacientes.

Tumor de hipófise em paciente com hidrocefalia: um desafio diagnóstico / Pituitary tumor in a patient with hydrocephalus: a diagnostic challenge

RESUMO A hidrocefalia é definida como a dilatação ventricular pelo aumento da pressão intraventricular e intracraniana quando não tratada ou por insucesso do tratamento. Muitas vezes, leva ao dano das vias ópticas, podendo causar atrofia óptica, devido à proximidade dessas vias com o ventrículo lateral quando ocorre a dilatação. Assim como a hidrocefalia pode levar à atrofia óptica, outras patologias também podem. Tumores hipofisários compartilham desse mesmo sinal, além de causar hemianospsia bitemporal quando o tumor comprime quiasma óptico. Ademais, a hemianopsia bitemporal é o distúrbio visual mais comum encontrado em pacientes com tumor de hipófise. Os tumores de hipófise, por exemplo, geram manifestações clínicas que podem estar relacionadas à disfunção da glândula ou aos efeitos mecânicos da expansão tumoral. Sinais e sintomas visuais estão mais ligados ao efeito mecânico do tumor. Assim, muitas vezes, o paciente procura o oftalmologista antes do endocrinologista. Neste caso, analisaremos uma paciente portadora de hidrocefalia que apresentava, concomitantemente, um tumor hipofisário, e a investigação oftalmológica fez toda a diferença no tratamento da paciente.

ABSTRACT Hydrocephalus is defined as ventricular dilation caused by increased intraventricular and intracranial pressure when untreated or due to treatment failure. Optical pathways can often cause optic atrophy due to the proximity to the lateral hazard when dilation occurs. Hydrocephalus can lead to optic atrophy, as well as other pathologies. Pituitary tumors share this same sign, in addition to causing bitemporal hemianopia when it compresses the optic chiasm. In addition, bitemporal hemianopia is the visual disturbance most commonly found in patients with pituitary tumors. Pituitary tumors, for example, have clinical manifestations that may be related to gland dysfunction, or to mechanisms of tumor expansion. Visual signs and symptoms are more linked to the mechanical effect of the tumor. Therefore, the patient usually seeks the ophthalmologist before the endocrinologist. In this case, we analyzed a patient with hydrocephalus who presented, at the same time, a pituitary tumor, and the ophthalmological investigation made all the difference in the treatment of the patient.

Lacrimal gland atrophy and dry eye related to isotretinoin, androgen, and prolactin: differential diagnosis for Sjögren's syndrome / Atrofia das glândulas lacrimais e olho seco relacionados aisotretinoína, androgênio e prolactina: diagnóstico diferencial com a síndrome de Sjögren

ABSTRACT This report is of three cases of sicca syndrome, initially suspected to be Sjögren's syndrome, which was ruled out by clinical and laboratory investigations. The patients were a 24-year-old woman, a 32-year-old man, and a 77-year-old woman with chronic symptoms of sicca syndrome, including dry eye syndrome. The first case was associated with the use of isotretinoin, a retinoic acid. The second was associated with the use of anabolic androgenic steroids, and the third was related to a prolactin- secreting pituitary adenoma. All cases manifested sicca, including dry eye syndrome, after those events, and the manifestations persisted. Magnetic resonance imaging revealed bilateral atrophy of the lacrimal gland. The medical history, ocular examinations, laboratory exams, and magnetic resonance images confirmed dry eye syndrome; however, the exams were all negative for Sjögren's syndrome. The lacrimal gland was absent on magnetic resonance imaging in all three cases. The clinical history revealed that the signs and symptoms appeared after chronic exposure to retinoic acid, anabolic androgenic steroids, and a prolactin-secreting pituitary adenoma, respectively. Chronic isotretinoin, anabolic androgenic steroids, and prolactin-secreting pituitary adenoma or, in this last case, its inhibitory treatment, can cause lacrimal gland atrophy, sicca syndrome, and dry eye syndrome, and a differential diagnosis of Sjögren's syndrome. Further studies on doses, time, and other susceptibilities to the long-lasting adverse effects of retinoic acid, anabolic androgenic steroids, and the repercussions of prolactin-secreting pituitary adenoma are necessary to confirm and expand upon these associations.

RESUMO O relato descreve três casos de síndrome de sicca, inicialmente suspeitos de serem a síndrome de Sjögren, que fo­ram negados pela investigação clínica e laboratorial. O primeiro associado ao uso de isotretinoína, um ácido retinóico, o segundo ao uso de esteroides androgênicos anabolizantes e o terceiro relacionado ao adenoma da hipófise secretora da prolactina, todos manifestaram sicca, incluindo a síndrome do olho seco após esses eventos e as manifestações persistem. A ressonância magnética revelou atrofia bilateral da glândula lacrimal. Eles eram uma mulher de 24 anos, um homem de 32 anos e uma mulher de 77 anos com sintomas crônicos da síndrome de sicca, incluindo a síndrome do olho seco. A história médica, o exame ocular, os exames laboratoriais e a ressonância magnética foram confirmados como síndrome do olho seco, no entanto, todos os exames foram negativos para a síndrome de Sjögren. A glândula lacrimal estava ausente na ressonância magnética nos três casos. A história clínica revelou que sinais e sintomas se manifestaram após exposição crônica ao ácido retinóico, esteróides anabolizantes androgênicos e adenoma secretivo da prolactina hipofisária, respectivamente. Isotretinoína crônica, esteroides anabólicos androgênicos e adenoma hipofisário secretor de prolactina ou, neste último caso, seu tratamento inibitório pode ser a causa da atrofia da glândula lacrimal, síndrome da sicca e síndrome do olho seco e diagnóstico diferencial da síndrome de Sjögren. Estudos adicionais sobre doses, duração e outras suscetibilidades aos efeitos adversos duradouros do ácido retinóico, esteroides androgênicos anabólicos e repercussões do adenoma da hipófise secretora da prolactina são necessários para confirmar e detalhar essas associações.

Machine learning models based on radiomics in diagnosis of pituitary prolactin macroadenoma / 中华放射学杂志

Objective:To explore the effectiveness and feasibility of the machine learning models based on radiomics in the diagnosis of pituitary prolactin macroadenoma.Methods:Totally 122 histologically proven pituitary macroadenoma patients, including 70 cases of pituitary prolactin macroadenoma (PPM) and 52 cases of non-pituitary prolactin macroadenoma (NPPM), were retrospectively recruited. The differences of age, sex, serum prolactin value, bleeding, cystic degeneration and Knosp classification were compared between PPM and NPPM. The pre-processing, delineation of the region of interest and feature extraction of the preoperative axial contrast-enhanced T 1WI image were performed in the 3Dslicer software. The optimal feature set were selected by least absolute shrinkage and selection operator. All patients were randomly divided into the training group ( n=85) and the test group ( n=37) at a ratio of 7∶3. The models were established in the training group by logistic regression and support vector machine (SVM), and then verified by the test group. ROC curves were drawn respectively, and specificity, sensitivity, accuracy and area under the ROC curve (AUC) were calculated. Results:The age [(38±12) years vs . (43±11) years], gender ratio (male/female 50 cases/20 cases vs . 14 cases/38 cases) and prolactin value [366.00 (117.75, 1 156.25)μg/L vs . 47.25 (32.68, 62.40) μg/L] of patients with PPM and NPPM were statistically different ( P<0.05). The AUC values of logistic regression and SVM in the training group were 0.936 and 0.946, and the AUC values of the test group were 0.768 and 0.774, respectively. The diagnostic accuracy of logistic regression and SVM in the training group were 88.2% and 91.8%, and the accuracy of the test group were 73.0% and 77.8%. Conclusion:The machine learning models based on the radiomics can predict the pituitary prolactin macroadenoma well with a high accuracy.

Prevention and treatment of stress during recovery from general anesthesia in transnasal transphenoidal pituitary adenoma resection: efficacy of dexmedetomidine combined with compound lidocaine cream / 中华麻醉学杂志

Objective:To evaluate the efficacy of combination of dexmedetomidine and compound lidocaine cream for the prevention and treatment of the stress responses during recovery from general anesthesia in the patients undergoing transnasal transphenoidal pituitary adenoma resection.Methods:A total of 90 patients, aged 18-64 yr, with body mass index of 18-25 kg/m 2, of American Society of Anesthesiologists physical status Ⅰ or Ⅱ, undergoing elective pituitary tumor resection by transsphenoidal approach with general anesthesia, were divided into 3 groups ( n=30 each) by the random number table method: combination of dexmedetomidine and compound lidocaine cream group (D-L group), dexmedetomidine group (D group) and compound lidocaine cream group (L group). Compound lidocaine cream 2 g was applied to the anterior 1/3 of the tracheal tube and surface of the cuff in D-L and L groups, and paraffin oil was applied to the surface of the tracheal tube in group D. In D-L and D groups, dexmedetomidine 0.5 μg/kg was intravenously infused for 10 min at 30 min before the end of surgery, while the equal volume of normal saline was given in group L. Heart rate and mean arterial pressure were continuously monitored during peritracheal extubation, and the occurrence of responses to extubation was recorded.The optic nerve sheath diameter (ONSD) was measured by ultrasound after entering the operating room(t 0), after anesthesia induction(t 1), and at 5 min after extubation (t 2). The bucking and agitation scores were recorded during recovery from anesthesia. Results:Compared with group D and group L, the incidence of bucking and responses to extubation was significantly decreased in group D-L (27%, 37%, 6%; 23%, 27%, 3%, respectively, P<0.05). Compared with group L, the incidence of agitation was significantly decreased in D-L and D groups (37%, 10%, 13%, respectively, P<0.05). No severe bucking and agitation occurred in group D-L.There was no significant difference in ONSD at each time point among three groups ( P>0.05). Conclusion:Combination of dexmedetomidine and compound lidocaine cream performs better than either alone and can prevent and treat stress responses during recovery from general anesthesia in the patients undergoing transnasal transsphenoidal pituitary adenoma resection.

As consequências irreversíveis do diagnóstico tardio de macroadenoma de hipófise em paciente jovem / The irreversible consequences of late diagnosis of pituitary macroadenoma in a young patient

Resumo Os tumores de hipófise representam aproximadamente 15% de todos os tumores cerebrais e dependendo do tamanho, pressionam o quiasma óptico, resultando em comprometimento da função visual que se manifesta como defeitos no campo visual, diminuição da acuidade visual e da visão das cores. O objetivo do presente estudo foi relatar um caso de macroadenoma de hipófise com compressão do quiasma óptico e defeito no campo visual, tratado inicialmente como glaucoma, levando a um diagnóstico e tratamento tardio.

Abstract Pituitary tumors represent approximately 15% of all brain tumors and depending on size, pressure optic chiasma, resulting in impaired visual func-tion that manifests itself as defective in the visual field, decreased acuity visual and color vision. The ob-jetive of the present study was to report a case of pitui-tary macroadenoma with compression of optical chiasma and visual field de-fect, initially treated as glaucoma, leading to a late diagnosis and treatment.

Acromegalia en Paciente con Cáncer Papilar de Tiroides. Reporte de caso / Acromegaly in a patient with papillary thyroid cancer. Case report

Introducción: El cáncer de tiroides es la neoplasia endocrina más frecuenteyel Carcinoma Papilar de tiroides representa el 80% de los casos. Por otro lado, la acromegalia es un trastorno poco diagnosticado con una incidencia estimada anual de 4 casos por millón de personas. Presentamos un caso en el que se presentan las dos entidades al mismo tiempo en un paciente y la discusión del posible nexobio químico. Caso clínico: Mujer de 23 años, con masa nodular pétrea de 3 centímetros, en polo superior de lóbulo derecho de tiroides; sometida a tiroidectomía radical y linfadenectomía cervical bilateral, reporte histopatológico de carcinoma papilar. Evoluciona con cambios visuales en ojo izquierdo, cefalea, amenorrea de 1 año, galactorrea negativa, características morfo-anatómicas de acromegalia, campimetría hemianopsia homónima izquierda. IRM de cerebro lesión sellar y suprasellar hiperintensa en T2 en relación a macroadenoma hipofisario. Bioquímicos: Prolactina 131.20, GH 2.7, ACTH 18.5, IGF1 434, IGFBP 35.8, TTOG para GH que se informa: GH 0 min: 10.7, GH 30 min: 9.24, GH 60 min: 7.9. Evolución: La paciente fue sometida a hipofisectomía transesfenoidal endoscópica parcial. En tratamiento con cabergolina 0.5 mg bisemanal, levotiroxina 225 mcg día y octreótide 20 mg mensual. Conclusión: Se concluye que siendo la acromegalia una enfermedad rara se asocia a cáncer de tiroides, implicando posibles mutaciones en la subunidad α de la proteína G.

Introduction:Thyroid cancer is the most frequent endocrine neoplasia and Papillary thyroid carcinoma represents 80% of cases. On the other hand, acromegaly is a poorly diagnosed disorder with an estimated annual incidence of 4 cases per million people. We present a case in which the two entities occur at the same time in a patient and the discussion of the possible biochemical link. Clinical case: 23-year-old woman, with a 3 cm stone nodular mass in the upper pole of the right thyroid lobe; submitted to radical thyroidectomy and bilateral cervical lymphadenectomy, histopathological report of papillary carcinoma. It evolves with visual changes in the left eye, headache, 1-year amenorrhea, negative galactorrhea, morpho-anatomical characteristics of acromegaly,left homonymous hemianopia campimetry. T2 hyperintense seal and suprasellar lesion brain MRI in relation to pituitary macroadenoma. Biochemicals: Prolactin 131.20, GH 2.7, ACTH 18.5, IGF1 434, IGFBP 35.8, TTOG for reported GH: GH 0 min: 10.7, GH 30 min: 9.24, GH 60 min: 7.9. Evolution: The patient underwent partial endoscopic transsphenoidal hypophysectomy. In treatment with cabergoline 0.5 mg twice weekly, levothyroxine 225 mcg day and octreotide 20 mg monthly. Conclusion: It is concluded that, being acromegaly a rare disease, it is associated with thyroid cancer, involving possible mutations in the α subunit of the G protein.

Endonasal transsphenoidal sellar tumor resection in treating non-functioning pituitary adenomas with hyperprolactinemia: An analysis of efficacy / 第二军医大学学报

Objective To explore the therapeutic effect of endonasal transsphenoidal sellar tumor resection surgery for the treatment of non-functioning pituitary adenoma patients with hyperprolactinemia. Methods A total of 80 non-functioning pituitary adenoma patients with serum prolactin level ＞25 ng/mL and ＜200 ng/mL, who underwent endonasal transsphenoidal sellar tumor resection surgery in the Department of Neurosurgery of our hospital from Jan. 1, 2015 to Dec. 31, 2019, were retrospectively included. The clinical characteristics, surgical methods, postoperative complications, and the relief of postoperative hyperprolactinemia and clinical symptoms were analyzed. The predictive factors of postoperative hyperprolactinemia remission were analyzed using logistic regression. Results Out of the 80 patients, 21 were males and 59 were females. The preoperative prolactin level was 51.11 (25.20-136.52) ng/mL, and the tumor volume was 3.99 (0.23-37.11) cm3. Headache was the most common initial symptom (37.5%, 30/80). There was significant difference in the initial symptoms between the male and female patients (P＝0.031), and the female patients were more likely to present with hypogonadotropic hypogonadism compared with the male patients (28.8%［17/59］vs 9.5%［2/21］). The male patients were significantly more likely to have two or more hormonal axis dysfunctions (47.6%［10/21］vs 15.3%［9/59］, P＝0.025). All the 80 patients received the resection surgery and 88.8% (71/80) of them achieved gross or near total resection. Sixty-five (81.2%) patients had remission of hyperprolactinemia within 3 months after surgery, and the prolactin level was 13.44 (1.74-24.19) ng/mL 3 months after surgery; 15 patients had no remission, and the corresponding prolactin level was 32.69 (25.20-115.23) ng/mL. The prolactin levels before and 1 d after surgery were significantly lower in the remission group than those in the non-remission group (preoperative: 45.47 ［25.20-136.52］ng/mL vs 64.82［33.17-130.88］ng/mL, P＝0.003; postoperative day 1: 13.12［0.60-36.35］ng/mL vs 40.06 ［26.25-118.01］ng/mL, P＜0.01). There were no significant differences in gender, age, tumor volume, surgical methods or extent of tumor resection between the two groups (all P＞0.05). Multivariate logistic regression analysis showed that prolactin level ≤25 ng/mL on postoperative day 1 was an independent predictor of remission of hyperprolactinemia (odds ratio 13.500, 95% confidence interval 3.623-50.298, P＜0.01). The visual defect and headache improvement rates were 87.9% (29/33) and 93.9% (31/33), respectively. Among the 17 female patients with menstrual disorders before surgery, 14 (82.4%) returned to normal menstrual cycles. Conclusion Endonasal transsphenoidal sellar tumor resection surgery is a reliable treatment option for non-functioning pituitary adenoma patients with hyperprolactinemia.

Lista de chequeo preoperatorio para la cirugía endoscópica de hipófisis / Preoperative checklist for endoscopic pituitary surgery

Introducción: las listas de chequeo son herramientas que buscan evitar errores y complicaciones al momento de realizar un procedimiento. El adenoma hipofisiario es la primera causa de cirugía endoscópica transnasal de la región selar, y se estima que ocurren hasta un 20 % de complicaciones derivadas de esta cirugía. Objetivo: desarrollar una lista de chequeo preoperatoria que sirva como una guía para la evaluación prequirúrgica de los pacientes a quienes se les realicen cirugías de la región selar. Metodología: se realizó una revisión de la literatura para desarrollar una lista de chequeo preliminar y una serie de declaraciones que resumían los puntos importantes de la lista. Se construyó un comité de expertos en cirugía endoscópica de la base de cráneo conformado por neurocirujanos y otorrinolaringólogos de hospitales de Bogotá. Utilizando la metodología Delphi modificada, se llegó a un consenso para la realización de la lista de chequeo final. Resultados: se describieron 15 declaraciones; de estas, hubo una discrepancia en 6 declaraciones. Por esta razón, se realizaron modificaciones en 5 declaraciones, y se llegó a un consenso entre los expertos participantes. La lista de chequeo final aprobada está compuesta por 4 ítems. Discusión/conclusiones: la cirugía para el manejo de la patología de la región selar es compleja y requiere de un equipo quirúrgico entrenado y disciplinado para lograr los mejores desenlaces posibles. Consideramos que nuestra lista de chequeo es una herramienta que permitirá a los equipos que realizan estas cirugías en Colombia tener una visión más completa del paciente y, eventualmente, ayudar a evitar errores y posibles complicaciones.

Introduction: checklists that seek to avoid errors are very useful tools for any surgical practice. Pituitary adenomas are the leading indication to perform a transnasal endoscopic surgery in the sellar region and up to 20 % complications have been reported related to this procedure. Objetive: develop a preoperative checklist, based on an expert consensus, to serve as a guide for the skull base teams to consistently evaluate preoperatively all patients with pathologies in the sellar region. Methods: a literature review was conducted to develop a preliminary checklist and a series of statements summarizing the most important items on the list. A committee of experts in endoscopic skull base surgery was summoned, made up of neurosurgeons and otolaryngologists from hospitals in Bogotá. Using the modified Delphi methodology, a consensus was reached for the completion of the final checklist. Results: fifteen statements were developed. A discrepancy was seen in six statements. Modifications were made for five statements, thus reaching a consensus among the participating experts. The final approved checklist is made up of 4 items. Conclusion: surgery for treating different pathologies in the sellar region is complex and requires a welltrained and disciplined surgical team to achieve the best possible outcomes. We consider that our preoperative checklist is a valuable resource for skull base surgical teams performing transnasal endoscopic surgery of the sellar region. This tool will allow skull base surgical teams in Colombia to have a more comprehensive view of the patient and eventually help to avoid errors and possible complications.

Serie de Casos Clínicos: Acromegalia, Presentación Clínica y Evolución en los Pacientes del Hospital "Vicente Corral Moscoso". Cuenca - Ecuador, Mayo 2015 - Abril 2017 / Case Series: Acromegaly, Clinical Presentation and Evolution in Patients of Hospital "Vicente Corral Moscoso". Cuenca - Ecuador, May 2015 - April 201

INTRODUCCIÓN:La acromegalia es una enfermedad sistémica caracterizada por la elevada producción de hormona del crecimiento, su etiología más común es el adenoma hipofisiario. En Ecuador existe una prevalencia de 18.7 casos por millón de habitantes y una incidencia de 1.3 casos por millón de individuos cada año. Se considera que existe un retraso de aproximadamente una década entre el inicio de los síntomas y el reconocimiento de los mismos por parte del equipo de salud. CASO CLÍNICO: Se presentan a continuación tres pacientes con acromegalia, atendidos por el servicio de Endocrinología del Hospital Vicente Corral Moscoso desde Mayo del 2015 hasta Abril del 2017. En esta serie, la edad de diagnóstico fue alrededor de los 34 años. Los motivos de consulta fueron molestias visuales, dolores articulares y complicaciones microvasculares. En todos los casos, la etiología fue un adenoma hipofisario productor de hormona del crecimiento en los que era necesaria la corrección quirúrgica; sin embargo, la paciente del caso 3 rechazó este tratamiento. EVOLUCIÓN: Se presentan a continuación tres pacientes con acromegalia, atendidos por el servicio de Endocrinología del Hospital Vicente Corral Moscoso desde Mayo del 2015 hasta Abril del 2017. En esta serie, la edad de diagnóstico fue alrededor de los 34 años. Los motivos de consulta fueron molestias visuales, dolores articulares y complicaciones microvasculares. En todos los casos, la etiología fue un adenoma hipofisario productor de hormona del crecimiento en los que era necesaria la corrección quirúrgica; sin embargo, la paciente del caso 3 rechazó este tratamiento. CONCLUSIÓN: Es importante reconocer la característica insidiosa de la acromegalia y sus variables manifestaciones clínicas, puesto que un diagnóstico oportuno permite mejorar el pronóstico y la calidad de vida. Hay diversas opciones terapéuticas, siendo el tratamiento quirúrgico complementado con terapia farmacológica, el de mayor eficacia. El manejo debe ser multidisciplinario e individualizado(au)

BACKGROUND: Case Series: Acromegaly, Clinical Presentation and Evolution in Patients of Hospital "Vicente Corral Moscoso". Cuenca - Ecuador, May 2015 - April 2017. CASE REPORTS: Three patients with acromegaly are presented, attended by the Endocrinology service of the Hospital Vicente Corral Moscoso from May 2015 to April 2017. In this series, the diagnosis age was around 34 years. Patients consulted because of visual discomfort, joint pain and microvascular complications. In all cases, the etiology was a pituitary adenoma producing growth hormone, in which surgical correction was necessary; however, patient number 3 rejected surgical treatment. EVOLUTION: In the present series, case 1 is undergoing treatment with Octreotide-Cabergoline and hormone replacement therapy, case 2 achieved biochemical remission with postoperative adjuvant treatment based on somatostatin analogues and case 3 has poor expectation of cure due to her medical history and lack of adherence to treatment. CONCLUSIONS: It is important to recognize the insidious characteristic of acromegaly and its varia-ble clinical manifestations, because a timely diagnosis allows a better prognosis and quality of life. There are several therapeutic options, being the surgical treatment supplemented with pharmacological therapy, the most effective. The management must be multidisciplinary and individualize(au)

Pituitary gigantism: a case series from Hospital de San José (Bogotá, Colombia)

ABSTRACT Introduction Gigantism is a rare pediatric disease characterized by increased production of growth hormone (GH) before epiphyseal closure, that manifests clinically as tall stature, musculoskeletal abnormalities, and multiple comorbidities. Materials and methods Case series of 6 male patients with gigantism evaluated at the Endocrinology Service of Hospital de San José (Bogotá, Colombia) between 2010 and 2016. Results All patients had macroadenomas and their mean final height was 2.01 m. The mean age at diagnosis was 16 years, and the most common symptoms were headache (66%) and hyperhidrosis (66%). All patients had acral changes, and one had visual impairment secondary to compression of the optic chiasm. All patients underwent surgery, and 5 (83%) required additional therapy for biochemical control, including radiotherapy (n = 4, 66%), somatostatin analogues (n = 5, 83%), cabergoline (n = 3, 50%), and pegvisomant (n = 2, 33%). Three patients (50%) achieved complete biochemical control, while 2 patients showed IGF-1 normalization with pegvisomant. Two patients were genetically related and presented a mutation in the aryl hydrocarbon receptor-interacting protein (AIP) gene (pathogenic variant, c.504G>A in exon 4, p.Trp168*), fulfilling the diagnostic criteria of familial isolated pituitary adenoma. Conclusions This is the largest case series of patients with gigantism described to date in Colombia. Transsphenoidal surgery was the first-choice procedure, but additional pharmacological therapy was usually required. Mutations in the AIP gene should be considered in familial cases of GH-producing adenomas.

Transcriptome Analysis Identifies an Attenuated Local Immune Response in Invasive Nonfunctioning Pituitary Adenomas

BACKGROUND: Invasive nonfunctioning pituitary adenomas (NFPAs) remain challenging due to their high complication rate and poor prognosis. We aimed to identify the distinctive molecular signatures of invasive NFPAs, compared with noninvasive NFPAs, using gene expression profiling by RNA sequencing. METHODS: We obtained frozen fresh tissue samples from 14 patients with NFPAs who underwent primary transsphenoidal surgery. Three non-invasive and 11 invasive NFPAs were used for RNA sequencing. The bioinformatics analysis included differential gene expression, gene ontology analysis, and pathway analysis. RESULTS: A total of 700 genes were differentially expressed (59 up-regulated and 641 down-regulated genes) between invasive and non-invasive NFPAs (false discovery rate <0.1, and |fold change| ≥2). Using the down-regulated genes in invasive NFPAs, gene ontology enrichment analyses and pathway analyses demonstrated that the local immune response was attenuated and that transforming growth factor-β (TGF-β) RII-initiated TGF-β signaling was down-regulated in invasive NFPAs. The overexpression of claudin-9 (CLDN9) and the down-regulation of insulin-like growth factor-binding protein 5 (IGFBP5), death-associated protein kinase 1 (DAPK1), and tissue inhibitor of metalloproteinase-3 (TIMP3) may be related with invasiveness in NFPAs. CONCLUSION: Invasive NFPAs harbor different gene expression profiles relative to noninvasive NFPAs. In particular, local suppression of the immune response and TGF-β signaling can make PAs prone to invasiveness.

MicroRNA-186 targets SKP2 to induce p27(Kip1)-mediated pituitary tumor cell cycle deregulation and modulate cell proliferation

Pituitary tumors are usually benign but can occasionally exhibit hormonal and proliferative behaviors. Dysregulation of the G1/S restriction point largely contributes to the over-proliferation of pituitary tumor cells. F-box protein S-phase kinase-interacting protein-2 (SKP2) reportedly targets and inhibits the expression of p27(Kip1), a well-known negative regulator of G1 cell cycle progression. In this study, SKP2 expression was found to be upregulated while p27(Kip1) expression was determined to be downregulated in rat and human pituitary tumor cells. Furthermore, SKP2 knockdown induced upregulation of p27(Kip1) and cell growth inhibition in rat and human pituitary tumor cells, while SKP2overexpression elicited opposite effects on p27(Kip1) expression and cell growth. The expression of microRNA-186 (miR-186) was reported to be reduced in pituitary tumors. Online tools predicted SKP2 to be a direct downstream target of miR-186, which was further confirmed by luciferase reporter gene assays. Moreover, miR-186 could modulate the cell proliferation and p27(Kip1)-mediated cell cycle alternation of rat and human pituitary tumor cells through SKP2. As further confirmation of these findings, miR-186 and p27(Kip1) expression were downregulated, while SKP2 expression was upregulated in human pituitary tumor tissue samples; thus, SKP2 expression negatively correlated with miR-186 and p27(Kip1) expression. In contrast, miR-186 expression positively associated with p27(Kip1) expression. Taken together, we discovered a novel mechanism by which miR-186/SKP2 axis modulates pituitary tumor cell proliferation through p27(Kip1)-mediated cell cycle alternation.

Clinical Significance of Radical Surgery in the Treatment of Silent Corticotroph Adenoma

OBJECTIVE: Silent corticotroph adenomas (SCA) are endocrine-inactive pituitary adenomas with positive immunohistochemistry staining for adrenocorticotropic hormone (ACTH). We investigated whether SCA-associated clinical profiles were more aggressive than hormonally negative adenomas (HNA).METHODS: Among 627 patients with pathologically proven endocrine-inactive pituitary adenomas between 2004 and 2013, positive immunohistochemistry revealed 55 SCAs and 411 HNAs. Surgical outcomes and radiological and endocrinological characteristics were compared.RESULTS: Strong female predominance was observed in the SCA group (p<0.001). Cavernous sinus invasion was identified in 22 (40%) SCA patients and 72 (17.6%) HNA patients (p<0.001). There were no differences in ACTH or cortisol levels between the two groups. The incidence of preoperative hypopituitarism and postoperative hormonal outcome did not differ between two groups. Total resection was achieved in 35 patients (63.7%) with SCA and 332 patients (80.8%) with HNA (p=0.007). When tumors were completely removed, recurrence rates were not statistically different between two groups (p=0.60). When complete resection was not achieved, tumors regrew from these remnants in seven patients (35.0%) with SCA and 12 patients (15.2%) with HNA (p=0.05).CONCLUSION: Total surgical resection for SCA is often challenging as these tumors frequently invade a cavernous sinus. Early remnant tumor intervention is justified, because untreated residual pituitary tumors regrow when patients were followed up for a long time. Prophylactic radiotherapy is not warranted for completely resected SCAs as tumor recurrence is uncommon.

Application of modified pedicled nasal septum mucosa flap on cerebrospinal fluid leakage in transsphenoidal pituitary surgery / 中国医师进修杂志

Objective@#To explore the therapeutic effect of modified pedicled nasal septum mucosa flap on cerebrospinal fluid leakage in transsphenoidal pituitary surgery.@*Methods@#The clinical data of 28 patients treated with modified pedicled nasal septal mucosa flap during endoscopic transsphenoidal resection of pituitary adenoma in Dalian Central Hospital from August 2017 to December 2018 were analyzed retrospectively. Seven cases of high-flow cerebrospinal fluid leakage occurred during the operation. Skull base reconstruction was performed with modified pedicled nasal septum mucosal flap. Modified pedicled nasal septum mucosal flap was repositioned in 21 cases.@*Results@#Seven cases of modified pedicled nasal septum mucosal flap for skull base reconstruction had no postoperative cerebrospinal fluid leakage and 1 case had hypoolusia. Postoperative cerebrospinal fluid leakage occurred in One of the 21 patients with mucosal flap replacement, and stopped after 8 d of continuous lumbar drainage. One case had hypoolusia.@*Conclusions@#Modified pedicled nasal septum mucosal flap is a safe and reliable technique. It can not only achieve the effect of pedicled nasal septum mucosal flap in skull base reconstruction, but also avoid nasal complications caused by excessive application of mucosal flap.

Prediction of the consistency of large pituitary adenoma based on CT density combined with texture parameter modeling / 中国医学影像技术

Objective: To explore the value of CT density combined with texture parameters based on CT plain image in predicting the consistency of large pituitary adenoma. Methods: Totally 50 patients with large pituitary adenoma confirmed by operation and pathology were enrolled and divided into soft group (n=30) and hard group (n=20) according to intraoperative pituitary consistency. The largest slice of the tumor on the CT image was selected, then ROI was manually outlined, CT value of the lesion was measured, and the texture feature parameters were extracted. CT values and texture features were compared between the two groups. Multivariate Logistic regression analysis was used to analyze the variables, and the model for predicting the pituitary adenoma consistency was established. ROC curve was drawn to evaluate its predictive value. Results: There was statistically significant difference in CT value between soft group and the hard group (P=0.031), and AUC in predicting tumor consistency was 0.662. A total of 77 texture parameters were extracted based on plain CT images, and 4 texture parameters were found with statistically significant differences between the two groups, including the Quantile 90, inertia, variance and contrast, with AUC of 0.662, 0.663, 0.672 and 0.663, respectively. AUC of texture feature model established with multivariate Logistic regression analysis in predicting the pituitary adenoma consistency was 0.690, of CT value combined with the texture parameter model was 0.782. Conclusion: The model established with CT value combined with texture parameters has high value in predicting the pituitary adenoma consistency, which is helpful to clinical selection of surgical plans.

Application of modified pedicled nasal septum mucosa flap on cerebrospinal fluid leakage in transsphenoidal pituitary surgery / 中国医师进修杂志

explore the therapeutic effect of modified pedicled nasal septum mucosa flap on cerebrospinal fluid leakage in transsphenoidal pituitary surgery. Methods The clinical data of 28 patients treated with modified pedicled nasal septal mucosa flap during endoscopic transsphenoidal resection of pituitary adenoma in Dalian Central Hospital from August 2017 to December 2018 were analyzed retrospectively. Seven cases of high-flow cerebrospinal fluid leakage occurred during the operation. Skull base reconstruction was performed with modified pedicled nasal septum mucosal flap. Modified pedicled nasal septum mucosal flap was repositioned in 21 cases. Results Seven cases of modified pedicled nasal septum mucosal flap for skull base reconstruction had no postoperative cerebrospinal fluid leakage and 1 case had hypoolusia. Postoperative cerebrospinal fluid leakage occurred in One of the 21 patients with mucosal flap replacement, and stopped after 8 d of continuous lumbar drainage. One case had hypoolusia. Conclusions Modified pedicled nasal septum mucosal flap is a safe and reliable technique. It can not only achieve the effect of pedicled nasal septum mucosal flap in skull base reconstruction, but also avoid nasal complications caused by excessive application of mucosal flap.