Criteria for the definition of Pituitary Tumor Centers of Excellence (PTCOE): A Pituitary Society Statement

Introduction With the goal of generate uniform criteria among centers dealing with pituitary tumors and to enhance patient care, the Pituitary Society decided to generate criteria for developing Pituitary Tumors Centers of Excellence (PTCOE). Methods To develop that task, a group of ten experts served as a Task Force and through two years of iterative work an initial draft was elaborated. This draft was discussed, modified and finally approved by the Board of Directors of the Pituitary Society. Such document was presented and debated at a specific session of the Congress of the Pituitary Society, Orlando 2017, and suggestions were incorporated. Finally the document was distributed to a large group of global experts that introduced further modifications with final endorsement. Results After five years of iterative work a document with the ideal criteria for a PTCOE is presented. Conclusions Acknowledging that very few centers in the world, if any, likely fulfill the requirements here presented, the document may be a tool to guide improvements of care delivery to patients with pituitary disorders. All these criteria must be accommodated to the regulations and organization of Health of a given country

Conservative management of pituitary apoplexy: a prospective study

A prospective study was conducted to evaluate the usefulness and limitations of conservative treatment in patients with pituitary apoplexy. Twelve patients presenting sudden headache, visual Impair ment, or ophthalmoplegia had the diagnosis of pituitary apoplexy established by computerized tomographic scans. Initially, 11 patients received iv dexamethasone (2.0-16.0 mg/day). Surgery was indicated when dexamethasone failed to improve visual or consciousness impairment. Among the 7 patients who were treated conservatively, ophthalmoplegia recovered completely in 6 and improved in 1. Follow-up computerized tomographic scans showed resolution of the tumor in 4 patients and residual masses in 3 patients who were treated conservatively. Five patients had surgery and experienced improvement of vision and consciousness. Follow-up computerized tomographic scans showed residual masses in ail surgical patients. Recurrences were observed in 2 patients, one in each group. the prevalence of pituitary deficiencies in the conservative group (9 of 17) was similar to that of the surgical group (3 of 14), but when only patients whose tumors were resolved by the apoplexy were analyzed, a significantly higher prevalence (8 of 12) was observed (P = 0.02). A retrospective analysis of presenting clinical and computerized tomography data on the basis of the response to dexamethasone showed that visual impairment did not improve during treatment with dexamethasone, whereas the presence of a large hypodense area within the tumor predicted complete tumor resolution. These results support conservative management of pituitary apoplexy in patients who are selected on the basis of clinical and tomographic findings.ESCOLA PAULISTA MED, DEPT MED, DIV ENDOCRINOL, BR-04034970 São Paulo, BRAZILESCOLA PAULISTA MED, DEPT DIAGNOST IMAGING, BR-04034970 São Paulo, BRAZILESCOLA PAULISTA MED, DEPT MED, DIV ENDOCRINOL, BR-04034970 São Paulo, BRAZILESCOLA PAULISTA MED, DEPT DIAGNOST IMAGING, BR-04034970 São Paulo, BRAZILWeb of Scienc

Remission of acromegaly after treatment withdrawal in patients controlled by cabergoline alone or in combination with octreotide: results from a multicenter study

Purpose Remission of acromegaly has been reported after somatostatin analogs withdrawal, but not after withdrawal of combination therapy with cabergoline, and only in case reports of patients controlled by cabergoline alone. Methods To establish the remission rates (normal IGF-1 for age/sex: IGF-1 <= 1.00 xULN) after withdrawal of combined treatment with octreotide LAR and cabergoline and of cabergoline alone, we prospectively studied 16 patients with acromegaly controlled by those treatments in the preceding 2 years as part of a larger study on remission of acromegaly after withdrawal of different medical treatments. Results Among 97 patients with controlled acromegaly included in the entire study, only 16 patients had been on combination therapy (n = 12) or cabergoline alone (n = 4). At 8 weeks after treatment withdrawal, three patients (19%) were in remission (short-term remission). At 60 weeks (long-term remission), IGF-1 levels were still in the normal range in two patients (12.5%) and remained normal up to 108 weeks after treatment withdrawal (last visit). One patient had been treated with cabergoline alone and another one with combination of octreotide and cabergoline before treatment withdrawal. Conclusion Remission of acromegaly after treatment withdrawal seems to be uncommon in patients controlled by cabergoline, either as monotherapy or in combination with octreotide. In the future, larger studies and/or meta-analysis will be necessary to accurately establish the remission rates of acromegaly after withdrawal of cabergoline with or without somatostatin analogs.Coordenacao de Aperfeicoamento de Pessoal de Nivel Superior (BR)Univ Fed Sao Paulo, Div Endocrinol & Metab, Neuroendocrine Unit, Rua Botucatu 806, BR-04023062 Sao Paulo, SP, BrazilUniv Sao Paulo, Hosp Clin, Div Endocrinol & Metab, Neuroendocrine Unit, Sao Paulo, BrazilGen Hosp Fortaleza, Div Endocrinol, Fortaleza, Ceara, BrazilUniv Estado Rio De Janeiro, Div Endocrine, Dept Internal Med, Rio De Janeiro, BrazilUniv Fed Sao Paulo, Div Endocrinol & Metab, Neuroendocrine Unit, Rua Botucatu 806, BR-04023062 Sao Paulo, SP, BrazilCAPES: 528/11Web of Scienc

Hypothalamic involvement in chronic migraine

OBJECTIVES—Chronic migraine (CM), previously called transformed migraine, is a frequent headache disorder that affects 2%-3% of the general population. Analgesic overuse, insomnia, depression, and anxiety are disorders that are often comorbid with CM. Hypothalamic dysfunction has been implicated in its pathogenesis, but it has never been studied in patients with CM. The aim was to analyze hypothalamic involvement in CM by measurement of melatonin, prolactin, growth hormone, and cortisol nocturnal secretion.
METHODS—A total of 338 blood samples (13/patient) from 17 patients with CM and nine age and sex matched healthy volunteers were taken. Melatonin, prolactin, growth hormone, and cortisol concentrations were determined every hour for 12 hours. The presence of comorbid disorders was also evaluated.
RESULTS—An abnormal pattern of hypothalamic hormonal secretion was found in CM. This included: (1) a decreased nocturnal prolactin peak, (2) increased cortisol concentrations, (3) a delayed nocturnal melatonin peak in patients with CM, and (4) lower melatonin concentrations in patients with CM with insomnia. Growth hormone secretion did not differ from controls.
CONCLUSION—These results support hypothalamic involvement in CM, shown by a chronobiologic dysregulation, and a possible hyperdopaminergic state in patients with CM. Insomnia might be an important variable in the study findings.