[The treatment of Cushing's disease]. / Le traitement de la maladie de Cushing.

The differential diagnosis of Cushing's disease remains difficult to establish. The selective transsphenoidal adenomectomy is the initial treatment of choice. In a group of 65 patients, 50 (77%) initially responded to surgery with correction of their hypercortisolism. Forty-three out of 51 (84%) patients with small pituitary tumors responded favourably to surgery, but recurrency occurred in 10% of the cases. Medical treatment with steroids inhibitors or antagonists is only an adjuvant treatment. In case of surgery failure or recurrency, bilateral adrenalectomy is usually performed. Conventional radiotherapy may be used after surgery in presence of macroadenomas or invasive adenomas. Correction of the hypercortisolism, after a second surgery, was achieved in 50% of the cases and was always associated with a panhypopituitarism.

[The treatment of acromegaly]. / Le traitement de l'acromégalie.

Acromegaly is a rare disease which can significantly reduce life expectancy. Clinical features are diverse and the patient may consult a variety of medical and surgical specialists before the diagnosis is suspected. However, the disease is easily confirmed by the appropriate laboratory tests, namely GH and IGF1 measurements. In most cases, acromegaly is secondary to a micro or macrosomatotrope pituitary adenoma. Those lesions are easily visualized by a pituitary CT Scan or Magnetic Resonance Imaging. Visual fields have to be evaluated by a neuro-ophthalmologist, and a thorough evaluation of other pituitary functions have to be performed. Selective removal of the adenoma by the transsphenoidal route is the treatment of choice for acromegaly. When performed by an experienced neurosurgeon, normalization of GH secretion can be expected in approximately 75% of cases. The surgical outcome is modulated by the volume, the extension of the tumor and the preoperative GH level. Octreotide, radiotherapy or bromocriptine are indicated whenever the patient remains with an elevated level of GH with persistency of symptoms.

[Treatment of the non-functioning hypophyseal adenoma]. / Le traitement de l'adénome hypophysaire non fonctionnel.

Non-functioning pituitary adenoma is a lesion usually large enough to produce loss of vision and often loss of libido. Transsphenoidal microsurgery is the treatment of choice of these patients. Postoperative radiation therapy should be performed in patients with significant residual pituitary adenoma. Some studies have recently reported that somatostatin analogue may be useful as adjuvant medical therapy, at least in order to improve visual field defects.

[The treatment of prolactinoma]. / Le traitement du prolactinome.

Prolactinoma is the most common type of secretory pituitary tumor. The clinical presentation varies with age and sex, and the size of the adenoma. The differential diagnosis with nonfunctioning adenoma and hyperprolactinemia is particularly important in selecting an appropriate therapy. The choice of therapy depends on a number of factors including the patient's preference. In cases of radiologically undetectable microprolactinomas, we prefer observation only. However, hypogonadic patients are treated with bromocriptine. Generally, it is our recommendation that almost all of the patients with micro--and macroprolactinomas undergo a primary medical therapy, provided they are willing to continue such therapy on a long term basis. We recommend transsphenoidal surgery for patients who refuse long term medical therapy and in rare cases of prolactinomas which are unresponsive to medical therapy. We also consider surgery as a valuable alternative to medical therapy in patients with microprolactinomas and prolactin below 200 micrograms/L.

Comparison of obese and non-obese patients with gestational diabetes.

The aim of this study was to assess the effect of obesity on the outcome of gestational diabetes (GD). The age of the subject (31 +/- 5 years) and duration of pregnancy (29 +/- 5 weeks) were similar at the time of diagnosis for the 19 obese (34 +/- 6 kg/m2) and 19 non-obese (23.0 +/- 2.1 kg/m2) subjects. Before treatment, the area under the curve of the glucose tolerance test and the mean capillary blood glucose levels were similar in both groups; however, the baseline blood glucose levels of the obese patients (6.0 +/- 0.8 mmol/l) were higher than those of the non-obese patients (5.3 +/- 0.8 mmol/l; P < 0.01). During pregnancy, the total weight gain of the obese patients was less (10.6 +/- 5.0 vs. 15.2 +/- 4.7 kg, P < 0.006). Fifteen of the obese patients required treatment with insulin, while only six of the non-obese women required insulin (P < 0.005). During insulin therapy, the mean capillary blood glucose, glycosylated haemoglobin and fructosamine levels were similar in both groups. In conclusion, our data suggest that GD in obese patients is characterized by lower weight gain and higher baseline glucose with the result that insulin therapy is more frequently instituted.

The clinical and endocrine outcome to trans-sphenoidal microsurgery of nonsecreting pituitary adenomas.

From 1962 to 1987, 126 patients underwent trans-sphenoidal surgery for primary treatment of pituitary adenomas unassociated with clinical or biochemical evidence of hormonal overproduction. There were 73 male and 53 female patients (mean age, 50 +/- 12 years). Before surgery, 56% of the patients (70 of 124) had headaches, 74% (94 of 126) had deterioration of vision, and 12% (15 of 126) had ophthalmoplegia. Endocrine evaluation revealed the presence of hypogonadism in 75% (87 of 115), adrenal insufficiency in 36% (46 of 126), and hypothyroidism in 18% (21 of 122). Plasma prolactin was increased in 65% (56 of 86) with a mean level of 39 +/- 14 micrograms/l (normal, 3 to 20 micrograms/l). Radiologic enlargement of the sella turcica was documented in all cases: 67% (84 of 126) had enclosed and 33% (42 of 126) had invasive adenomas. After surgery, vision was normalized or improved in 75% (71 of 94) of the patients. Thyroid, adrenal, and gonadal functions were improved in 14% (three of 22), 41% (19 of 46), 11% (ten of 87), were unchanged in 82% (100 of 122), 77% (97 of 126), 89% (102 of 115), and worsened in 15% (19 of 22), 8% (ten of 126), 3% (102 of 115), respectively. Permanent diabetes insipidus occurred in 5% (seven of 126). Two patients died during the immediate postoperative period. The recurrence rate in patients with a mean follow-up of 6.4 +/- 4.2 years was 21% (15 of 71). These data indicate that trans-sphenoidal microsurgery is an effective and safe initial treatment for patients with nonsecreting pituitary adenoma and may reverse hypopituitarism.