Reassessment of the role of radiation therapy in the treatment of endocrine-inactive pituitary macroadenomas

OBJECTIVE: This prospective clinical trial was undertaken to assess the rate of tumor recurrence in patients with endocrine-inactive pituitary macroadenomas who underwent gross total surgical resection of their tumors and did not receive adjuvant radiotherapy. METHODS: Between December 1987 and July 1994, 45 patients with endocrine-inactive pituitary macroadenomas underwent transsphenoidal surgery. In 38 (84%) of these patients, gross total surgical resection was achieved and was confirmed by postoperative magnetic resonance imaging (n = 37) or computed tomography (n = 1). After receiving counseling from the neurosurgeon concerning the risks and benefits of radiation therapy, 32 of the 38 patients elected not to receive adjuvant radiotherapy. Patients were followed through March 1998 with radiographic imaging obtained every 6 months for the first 2 years, annually for postoperative Years 3 and 4, and then every 2 to 3 years thereafter. The study end point was defined as radiographic tumor recurrence or patient death. RESULTS: The mean follow-up duration for the study group was 5.5 years. During that time, 2 of 32 (6%) patients developed recurrence, at 18 and 24 months, respectively, after initial surgery. Both were successfully treated using radiation therapy, with one requiring additional surgery. Three additional patients died as a result of unrelated causes 9, 12, and 49 months, respectively, after initial surgery. Immunocytochemical analysis revealed 66% of the tumors to be weak gonadotroph cell adenomas, 22% to be null cell adenomas, 9% to be silent prolactinomas, and 3% to be silent corticotroph cell adenomas. CONCLUSION: This study demonstrates a 6% 5-year recurrence rate in patients with endocrine-inactive pituitary macroadenomas treated using gross total surgical resection alone. Reserving radiation therapy for the infrequent patient with recurrence and sparing the majority of patients the associated risks inherent in its use seems reasonable.     

Visual acuity outcome and recurrence in large or huge pituitary adenomas operated with transcranial approach: comparison between frontotemporal and interhemispheric approaches

Pituitary macroadenomas which required transcranial removal were reviewed concerning visual acuity outcome as well as recurrence. We encountered 173 pituitary adenomas of which 27 (15.6%) were removed transcranially during the past 13 years. Eight cases were excluded due to inadequate information and improper utilization. Thus, a total of nineteen cases were reviewed in which the frontotemporal (FT) approach was utilized for seven cases and the interhemispheric (IH) approach for 12 cases. The mean size and volume of the tumors in the FT group were 3.0 x 3.7 x 3.1 cm and 18.2 cm3. The main reason for utilizing this approach was the fact that the tumors extended laterally involving the unilateral cavernous sinus or that unilateral preoperative visual acuity was obstructed. The visual acuity outcome was as follows: In six cases showing useful visual acuity on both sides before surgery, no apparent aggravation on either side was found in four cases, while in two cases there was complete obstruction on the operative side. The remaining case showed aggravation on both sides, though the approach side was decided upon because of the obstructed vision on that side. The mean size and volume of the tumors in the IH group were 4.6 x 4.8 x 4.9 cm and 71.1 cm3. This approach was used due to the extreme suprasellar extension because of the large size of the tumors. Although the tumors were relatively large and the visual acuity was assessed as fair prior to surgery, visual acuity showed no significant deterioration after the operation and was found to be satisfactory in 11 out of 12 cases. The complications in the FT group were oculomotor palsy in 3 cases, hemorrhage in one case, and frontal infarction in one case. On the other hand, three cases suffered hemorrhage in the tumor cavity of the IH group, though none needed surgical evacuation. Most of the cases in the IH group showed pituitary hypofunction following the surgical removal of the tumors as compared to the cases in the FT group. Recurrence had occurred, in some cases, several years after the operation. Furthermore, some of the tumors are still growing larger following only partial or subtotal removal. The prime aim of the treatment for huge pituitary adenomas which require the transcranial removal is to retain as much visual acuity as possible. In conclusion, the IH approach has been shown to be preferable in this situation. The FT approach was found to be more dangerous in terms of visual outcome than had been expected, even if the tumors were not particularly large.     

Symptom resolution, tumor control, and side effects following postoperative radiotherapy for pituitary macroadenomas

This study reports the outcome of 70 patients who were treated by a consistent treatment plan of surgery and postoperative radiotherapy (RT) for pituitary macroadenomas in the modern era [computed tomographic scan or magnetic resonance imaging (MRI), dopamine agonist therapy (DA) added as indicated, and immunohistochemical staining]. Sixty-two patients underwent transsphenoidal surgery (vs. transcranial surgery) and 61 received 45-Gy/25 fractions postoperatively (vs. other dose fractionation schemes). Twenty-four patients received DA for prolactin-secreting tumors. With a median follow-up of 8 years (range 2-15), 68 patients have experienced continuous control of their tumors. Most symptoms related to mass effect abated, while physiologic symptoms such as amenorrhea from markedly elevated prolactin levels tended to persist. Treatment-induced hypopituitarism occurred in 42% of the patients at risk. No patients in this series have died as a result of their pituitary tumor. No gross neuropsychologic dysfunction after treatment has been noted. While it is possible at this time with serial MRI to withhold postoperative RT and observe some patients who have had a "gross total" resection of a macroadenoma, the therapeutic ratio for surgery and adjuvant radiotherapy for patients with nonfunctional tumors as well as select patients with secretory macroadenomas is favorable.     

External irradiation of macroinvasive pituitary adenomas with telecobalt: a retrospective study with long-term follow-up in patients irradiated with doses mostly of between 40-45 Gy

PURPOSE: Published dose recommendations for radiotherapy in patients with pituitary macroadenomas vary. Therefore, we retrospectively analyzed the results in our patients from the treatment period 1973-1992. METHODS AND MATERIALS: From a total of 89 patients with macroinvasive adenomas, 66 received radiation therapy immediately following subtotal surgical removal (combined treatment modality), and 22 were irradiated as primary treatment or after surgical recurrence. Only one patient was reirradiated. The surgical interventions have been performed by the same surgeon. For the majority of patients (79 out of 89) with a mean follow-up of 8.1 years (0.5-19 years) the total tumor dose ranged between 40-45 Gy at a dose per fraction of 1.8-2.25 Gy. All patients had bilateral opposed fields with telecobalt. Eleven patients had an additional arc rotation. RESULTS: The 10-year progression-free survival for all 89 patients independent of treatment modality was 88.1%. The 10-year progression-free survival for patients treated by surgery and adjuvant radiation therapy (40-45 Gy at 1.8-2.25 Gy, 60 out of 79) was 90.3%, and for radiation therapy alone (40-45 Gy at 1.8-2.25 Gy, 19 out of 79), 100% (p = 0.32). The prognostic factors for progression-free survival were the subtype of adenoma, the presence of visual symptoms at the time of diagnosis, the suprasellar extension, and the initial hormone levels. The presence of infiltration of adenoma cells in the basal dura or in the mucosa of the sinus sphenoidalis do not represent prognostic factors showing the special biological behavior of pituitary adenomas. Signs of x-ray-induced cerebral necrosis have not been observed in any patient. Long-term visual complications developed in four patients. This could be due to scar formation in the treated region, which can compress the optic nerve and provoke disturbance similar to an empty-sella syndrome. The latter occurred prevalently years after treatment, even though surgical methods of sellar plugging were used. The incidence of hypopituitarism after combined treatment modality at time of last follow-up (irradiated between 40-45 Gy at 1.8-2.25 Gy) was low (36%, 21 out of 60). CONCLUSION: In patients with pituitary macroadenomas, radiotherapy with a total dose of 40-45 Gy at 1.8-2.25 Gy per fraction resulted in a high local tumor control without serious morbidity.     

Biliary motility disorders

Incidental pituitary masses are commonly found during CT and MR imaging performed for a variety of reasons. Screening for hormone oversecretion by these tumors seems to be warranted. Patients with lesions greater than 1 cm should be screened for hypopituitarism. In the absence of visual field abnormalities or hypothalamic/stalk compression, it may be appropriate to observe such patients carefully with repeated MR imaging scans. A limited amount of data suggest that significant tumor enlargement occurs in less than 5% of patients with lesions smaller than 1 cm in diameter. However, all macroadenomas must start out as microadenomas, and thus periodic follow-up is indicated to assess for this possibility. Lesions larger than 1 cm in diameter by their very existence at the time of detection have already indicated a propensity for growth. Significant tumor growth occurs in just over one-quarter of such patients. Hemorrhage into such tumors is uncommon, but anticoagulation may predispose to this complication. When there is no evidence of visual field deficits, an attempt at medical therapy with a dopamine agonist or octreotide is reasonable, realizing that only 10% of such patients will respond with a decrease in tumor size. Alternatively, careful periodic observation without intervention may determine that the lesion is not growing. Surgery is indicated with evidence of tumor enlargement, especially when such growth is accompanied by compression of the optic chiasm, cavernous sinus invasion, or the development of pituitary hormone deficiencies.     

Daily variation of CNS gene expression in nocturnal vs. diurnal rodents and in the developing rat brain

To identify risk factors associated with an increased risk for ipsilateral breast tumor recurrence following breast-conserving surgery, a cohort of 759 women with T1-T2 tumors were studied. The majority of the patients (88%) had received postoperative radiation therapy to the breast. Median follow-up time was 10 (range: 6-17) years. There was a 1-1.5% yearly increase in ipsilateral breast tumor recurrences. For women < 50 ys the cumulative recurrence rate at 10 years was 18% and for women > or = 50 ys, 9%. Node positive women had a cumulative breast recurrence rate of 25% versus 10% for node negative women. Ten years postoperatively, irradiated patients had a cumulative recurrence rate of 11% versus 26% when no irradiation was given. The beneficial effect of radiotherapy was substantial during the first four postoperative years. The relative risk for an ipsilateral breast tumor recurrence during this period was 4.5 times higher than for non-irradiated patients. However, the protective effect of radiotherapy decreased with time. After ten years the relative risk of ipsilateral breast tumor recurrence was the same among irradiated and non-irradiated patients although the number of events during this period was low. Univariate analysis showed that seven factors were significantly associated with an increased risk of ipsilateral breast tumor recurrence, namely age < 50 ys, increasing tumor size, uncertain microscopic margins, axillary lymph node metastases, no postoperative tamoxifen treatment, premenopausal status, and no postoperative radiotherapy. Three factors remained independently significant after multivariate analysis: age < 50 ys, no postoperative radiation therapy, and positive lymph nodes. In conclusion, radiotherapy reduced the breast recurrence rate, but the effect decreased with time. Node-negative women > or = 50 were a low risk-group for ipsilateral breast tumor recurrence, with a cumulative risk at 10 years of 9% without radiation therapy and 5% with breast irradiation.     

Unilateral lobectomy for Hurthle cell adenoma

Considerable controversy exists regarding the ability to predict the biologic behavior of Hurthle cell tumors. Some have found the clinicopathologic criteria used to differentiate benign from malignant lesions to be unreliable and have advocated total thyroidectomy for all Hurthle cell neoplasms. From January 1980 to December 1995, 39 patients had surgery for Hurthle cell tumors of the thyroid. The surgical pathologic findings were reviewed by an experienced pathologist (JP). Eight patients had histologic findings of capsular or vascular invasion consistent with carcinoma and had total thyroidectomy. Four of these patients had postoperative evidence of residual disease and were treated by radiation ablation. No evidence of invasion was found in 31 patients diagnosed with Hurthle cell adenoma. Twenty-three of these patients had unilateral lobectomy; total thyroidectomy was done in the remaining 8 patients, 5 of whom were found to have an associated papillary carcinoma at the time of operation. There were no operative deaths or significant morbidity. Twenty-two adenomas (71%) were found in females, whereas males had malignant tumors in 6 of 8 cases (P = 0.025). The mean age of adenoma patients is 54.1 years, and that of the carcinoma patients is 55.8 years. Mean size of benign tumors was 2.8 cm and of malignant tumors 4.1 cm (P = 0.04). Four of seven (57%) carcinomas were larger than 4 cm as compared with 6 of 30 (20%) adenomas (P = 0.069). Follow-up has ranged from 1 month to 15 years, with a mean of 3.2 years. There have been no deaths, and no patients with Hurthle cell adenoma have had evidence of recurrence or metastases during follow-up. Our data suggest that carcinoma patients tend to be male and tumor size is larger. An association was found when trying to predict malignancy by using 4 cm as a threshold size. We conclude that pathologic evidence of capsular or angioinvasion can accurately differentiate benign from malignant tumors. Unilateral thyroid lobectomy is adequate therapy for the treatment of Hurthle cell adenoma, with total thyroidectomy reserved for those patients with histologically proven carcinoma.     

Radiation therapy in the management of desmoid tumors

PURPOSE: To evaluate the outcome of patients with extra-mesenteric desmoid tumors treated with radiation therapy, with or without surgery. METHODS AND MATERIALS: The outcome for 75 patients receiving radiation for desmoid tumor with or without complete gross resection between 1965 and 1994 was retrospectively reviewed utilizing univariate and multivariate statistical methods. RESULTS: With a median follow-up of 7.5 years, the overall freedom from relapse was 78% and 75% at 5 and 10 years, respectively. Of the total, 23 patients received radiation for gross disease because it was not resectable. Of these 23 patients, 7 sustained local recurrence, yielding a 31% actuarial relapse rate at 5 years. Radiation dose was the only significant determinant of disease control in this group. A dose of 50 Gy was associated with a 60% relapse rate, whereas higher doses yielded a 23% relapse rate (p < 0.05). The other 52 patients received radiation in conjunction with gross total resection of tumor. The 5- and 10-year relapse rates were 18% and 23%, respectively. No factor correlated significantly with disease outcome. There was no evidence that radiation doses exceeding 50 Gy improved outcome. Positive resection margins were not significantly deleterious in this group of irradiated patients. For all 75 patients, there was no evidence that radiation margins exceeding 5 cm beyond the tumor or surgical field improved local-regional control. Ultimately, 72 of the 75 patients were rendered disease-free, but 3 required extensive surgery (amputation, hemipelvectomy) to achieve this status. Significant radiation complications were seen in 13 patients. Radiation dose correlated with the incidence of complications. Doses of 56 Gy or less produced a 5% 15-year complication rate, compared to a 30% incidence with higher doses (p < 0.05). CONCLUSIONS: Radiation is an effective modality for desmoid tumors, either alone or as an adjuvant to resection. For patients with negative resection margins, postoperative radiation is not recommended. Patients with positive margins should almost always receive 50 Gy of postoperative radiation. Unresectable tumors should be irradiated to a dose of approximately 56 Gy, with a 75% expectation of local control.     

Radioiodine I-31 therapy in the management of thyroid cancer. A prospective study

The therapeutic value of I-131 ablation therapy following thyroidectomy for thyroid cancer was evaluated in 54 patients in a prospective study of 25 years. Thirteen (24%) patients had follicular, 24 (44%) papillary, 13 (24%) mixed papillary-follicular, two (4%) Hurthle cell and two (4%) had undifferentiated cell type tumor. Twenty-four (44.5%) patients had metastases at the time of I-131 therapy mainly to cervical and mediastinal lymph nodes, and less frequently to bone, brain, lung, and liver. After surgical thyroidectomy, the mean cumulative dose of I-131 required to achieve therapeutic ablation of functioning post-surgical remnants or tumor metastases was 163.4 mCi. The recurrence rate for patients with metastases was 56% and those without metastases was 25%. Ten patients showed recurrence of I-131 accumulating tissue five to 10 years after initial total ablation. The total mean cumulative dose of I-131 administered for both followup diagnostic studies, and initial and follow-up therapy was 245.3 mCi. Seven deaths were attributable to thyroid cancer, five with differentiated and two with anaplastic cell type tumors. Three of the four patients with differentiated cell type tumors had metastases to brain or bone. Their response to therapy was similar to those patients with anaplastic cell type tumors. In contrast, there were no deaths due to thyroid cancer when total ablation was achieved and maintained. After ablation, all patients were maintained on maximum tolerated doses of thyroid extract or thyroxin. No significant complications attributable to the therapeutic doses of I-131 employed in this series were noted.     

The case-control study as data missing by design: estimating risk differences

OBJECTIVE: To determine the DNA content and S-phase fraction (SPF) of pituitary adenomas by image analysis and to correlate them with clinical and morphologic parameters. STUDY DESIGN: The study group consisted of 26 prospectively collected cases of operated pituitary adenomas (3 microadenomas and 23 macroadenomas). The tumors were classified by histology, immunocytochemistry and electron microscopy. DNA measurement was performed on imprints from fresh pituitary tissue. Samples of nontumorous adenohypophysial parenchyma served as normal controls. RESULTS: Overall, 31% of adenomas, all but one functioning one, were aneuploid. The remaining nonfunctioning aneuploid tumor was a null cell adenoma with glycoprotein differentiation. All aneuploid tumors were macroadenomas, mostly at advanced stages, III and IV. Dural invasion, although frequent in macroadenomas (78%), was not correlated with DNA ploidy and SPF. An increased number of hyperpentaploid aneuploid cells was noted primarily in aneuploid tumors. The mean SPF was < 2.50%, with a statistically significant difference between aneuploid and diploid adenomas (3.60% vs. 1.70%). CONCLUSION: The results suggest that quantitative assessment of DNA content may provide important information, particularly in functioning adenomas. In addition, fresh tissue imprints represent excellent material for optimum cytometric measurements by image analysis systems, even for microadenomas.     

Surgical treatment of craniopharyngiomas: experience with 168 patients

OBJECT: The goal of this study was to assess the outcome of surgical management in 168 consecutive patients harboring craniopharyngiomas treated between January 1983 and April 1997. METHODS: In 148 patients undergoing initial (primary) surgery, the pterional approach was most frequently used (39.2%), followed by the transsphenoidal approach (23.6%). For large retrochiasmatic craniopharyngiomas, the bifrontal interhemispheric approach was used increasingly over the pterional approach and led to improved surgical results. Total tumor removal was accomplished in 45.7% of transcranial and 85.7% of transsphenoidal procedures. The main reasons for incomplete removal were attachment to and/or infiltration of the hypothalamus, major calcifications, and attachment to vascular structures. The success rate in total tumor removal was inferior in the cases of tumor recurrence. The operative mortality rate in transcranial surgery was 1.1% in primary cases and 10.5% in cases of tumor recurrence. No patient died in the group that underwent transsphenoidal surgery. The rate of recurrence-free survival after total removal was 86.9% at 5 years and 81.3% at 10 years. In contrast, the 5-year recurrence-free survival rate was only 48.8% after subtotal removal and 41.5% after partial removal. Following primary surgery, the actuarial survival rate was 92.7% at 10 years, with the best results after complete tumor removal. At last follow up, 117 (79%) of 148 patients who underwent primary surgery were independent and without impairment. CONCLUSIONS: Total tumor removal while avoiding hazardous intraoperative manipulation provides favorable early results and a high rate of long-term control in craniopharyngiomas.     

Laser therapy of villous rectocolonic tumors. Evaluation of results by multivariate analysis

One hundred and twenty-four patients (mean age: 70 years) with a villous tumour of the rectum (n = 98) or the colon (n = 26) were treated by laser therapy from 1985 to 1991. Initial complete eradication was obtained in 93.5% of cases with a median time of 16 months. Using multivariate analysis, the tumor size (> 4 cm) only was predictive of eradication (P < 0.001). At 6 and 12 months, the actuarial eradication rates were 91 and 98% for small tumours versus 45 and 74% for larger tumours respectively. The actuarial recurrence rates were 10.5, 23, and 37% at 6, 12 and 24 months, and no longer increased after 3 years. No predictive factor of recurrence was isolated by multivariate analysis. Seven complications (5.6%) and 4 malignant transformations (3.4%) occurred. This study confirms the efficiency and low morbidity of laser therapy, especially in patients with small tumors, less than 4 cm in size.     

The prognosis in acromegaly treated by transanthro-sphenoidal operation

The paper is a report of a follow-up study of 80 acromegalic patients treated by transanthro-sphenoidal removal of a pituitary adenoma. The average follow-up time was 3.7 years. Complete restitution or improvement of the visual field defects was noted in 77%. Total regression of the soft tissue swelling was observed in around 1/3 of the patients. Complete regression or improvement of the acromegalic activity was achieved in 94%. Total regression of the dominant symptoms was noted in 74%. The rate of tumour recurrence was around 5% and the total mortality rate in the disease during the follow-up period 7.5%. The transanthro-sphenoidal surgery of the pituitary adenoma in this series resulted in a high rate of regression of the acromegalic symptoms at the same time as normal anterior pituitary function often was restored.     

Improvement in cumulative response rates following implementation of a financial incentive

We present our experience in the treatment of growth hormone (GH)-producing pituitary adenomas using irradiation alone. Between 1983 and 1991, 21 patients suffering from GH-secreting pituitary adenomas were treated with radiotherapy alone. Two bilateral opposing coaxial fields were used in 10 patients and in the remaining 11 a third frontovertex field was added. Treatment was given in 1.8-2 Gy daily fractions and total dose ranged between 45 and 54 Gy. Treatment was given using a cobalt unit. Four patients treated with somatostatin prior to and 14 patients treated after the end of radiotherapy experienced symptom relief for 6-28 weeks. The 5-year actuarial rate of disease control was 72%. Five out of six failed patients had macroadenomas. Hypopituitarism was observed in 5/21 (24%) patients. Whereas RT alone is effective in the treatment of microadenomas, this is not true for large infiltrative macroadenomas.     

Surgery of spinal nerve sheath tumors with special reference to neurofibromatosis

OBJECTIVE: We conducted a retrospective study of 87 patients with spinal nerve sheath tumors to determine the overall clinical outcome and specific features in 20 patients affected with neurofibromatosis Types 1 and 2 (NF-1 and NF-2, respectively). METHODS: Case records, operation notes, outpatient files, and radiological examinations were analyzed for all patients treated between September 1977 and August 1994. Additional follow-up data were obtained using outpatient examinations, questionnaires, and telephone calls. RESULTS: During the study period, 128 spinal neuromas (i.e., schwannomas) and 6 neurofibromas in 87 patients were treated. Fifty-seven neuromas were associated with NF-2 in 17 patients and six neurofibromas with NF-1 in 3 patients. Patients with NF-2 and symptomatic neuromas presented with more severe neurological deficits compared to patients without NF-2. Eighty-six percent of the neuromas were removed completely. On average, most preoperative deficits or symptoms improved in patients without NF-2, whereas neurological symptoms remained unchanged in patients with NF-2. Multiple regression analysis revealed that partial removal, surgery of a recurrent tumor, NF-2, and old age predisposed for tumor recurrence. No increased risk of recurrence was observed for patients with NF-1. For patients without NF-2, we observed overall recurrence rates of 10.7% after 5 years and 28.2% after 10 and 15 years, respectively, as determined by Kaplan-Meier analysis. For NF-2, the recurrence rate at 5 years was 39.2%, and all tumors had recurred by 9 years. CONCLUSION: Spinal nerve sheath tumors carry an excellent prognosis in patients with NF-1 and in patients without neurofibromatosis. Symptomatic neuromas occurring in association with NF-2 present with more severe neurological deficits, demonstrate little postoperative improvement, and have a very high recurrence rate.     

Long-term preoperative management of thyrotropin-secreting pituitary adenoma with octreotide

Thyrotropin (TSH)-secreting pituitary adenomas are the less frequent form of presentation of pituitary tumors. Selective transsphenoidal surgical resection of the tumor is the treatment of choice. Given that native somatostatin inhibits TSH secretion, treatment with somatostatin analogues has been recently employed in patients with unresectable tumors or after surgery. We report on the case of a 58 year-old man with a TSH-secreting pituitary adenoma who was treated with octreotide for long-term before neurosurgery. The patient was referred to us because of a pituitary mass on CT scanning. Hormonal evaluation resulted in hyperthyroidism with high serum TSH concentrations. Serum alpha subunit concentration was elevated and TSH response to exogenous TRH stimulation was absent. Magnetic resonance imaging of the hypothalamic-pituitary area confirmed the presence of a pituitary mass (2.0 by 1.8 by 1.7 cm). Acutely administered subcutaneous octreotide (100 microg) was followed by a reduction of the serum TSH concentrations. Therefore, the patient received octreotide, 100 microg three times daily for 12 months. At first month after beginning therapy serum TSH, free thyroxine, total triiodothyronine, and alpha subunit concentrations were normalized and persisted into the normal range for the next 11 months. On the other hand, a shrinkage of the tumor mass (1.6 by 1.7 by 1.4 cm) was noted after 6 months of octreotide therapy, however, its volume did not modify in the following next months. Then, the tumor was removed by transsphenoidal surgery and the diagnosis was confirmed by immunohistochemical staining. This case demonstrates that long-term treatment with octreotide gave rise to a normalization of the thyroid function and a reduction of the tumor volume before surgery. This clinical observation suggests that octreotide therapy might be useful in preparation for pituitary surgery in patients with TSH-secreting pituitary adenomas.     

Lower respiratory tract infections in the intensive care unit: consequences of antibiotic resistance for choice of antibiotic

BACKGROUND: The glomus tumor is an uncommon tumor of the hand, which presents with much pain. It is a benign neoplasm composed of a glomus body, which is located in the dermis. Glomus tumors present a classic clinical picture of pain, sensitivity to cold and local tenderness over the lesion. METHODS: Twelve patients underwent surgical removal for glomus tumors of the upper extremity from 1983 to 1992. There were three males and nine females; their average age was 37 years (25 to 60 years). The clinical manifestations were pain and local tenderness in 12 patients, and cold intolerance in 6 patients. RESULTS: There was a difference in gender in the anatomical site of the tumor. In three male patients, only one tumor was found in the digit. In female patients, all nine tumors were located in the digits. The average tumor size was 0.6 cm in diameter. After follow-up of 4.5 years (average), no recurrence, no residual pain or cold intolerance was noted. CONCLUSIONS: The treatment of glomus tumor consisted of local excision or curettage, with or without reconstruction of the nail bed. Recurrence is not a problem after complete removal of the tumor tissue. Permanent nail deformity is still a problem. Efforts to prevent this sequelae are worth trying.     

Carcinoid tumors of the appendix

OBJECTIVE: A retrospective study of 41 patients with histologically confirmed diagnosis of appendix carcinoid tumors was undertaken by reviewing the surgical records at Massachusetts General Hospital. METHODS: There were 8 male and 33 female patients (mean age 32 years). Twenty-two patients (54%) presented with signs and symptoms suggestive of acute appendicitis. In 19 patients (46%) the lesions were discovered incidentally. The tumors were located in 32 patients at the tip, in 6 patients in the middle third, and in 3 patients at the base of the appendix. The tumor was less than 1 cm in diameter in 32 patients, between 1 and 2 cm in 7 patients, and was bigger than 2 cm in 2 patients. In 29 patients, the depth of tumor penetration was confined to the submucosa or to the muscle layers of the appendix, and in 8 patients the serosa was involved. In 4 patients, evidence of tumor extension into the meso-appendicular fat was present, including one patient with a tumor bigger than 2 cm and local lymph-node metastases. Forty patients underwent appendectomy alone. One patient with a tumor size bigger than 2 cm in diameter with positive lymph nodes in the mesoappendix underwent secondary right hemicolectomy. Complete follow-up was achieved in 35 patients, and all patients remained free of tumor recurrence. CONCLUSIONS: The authors conclude that appendiceal carcinoids are rare and most often are asymptomatic. Tumors of less than 1 cm are adequately managed by appendectomy alone. The appropriate treatment for tumors of 1 to 2 cm continues to be controversial. Right hemicolectomy is recommended for all tumors larger than 2 cm, whereas preference for an aggressive approach should be given in young patients.     

Bromocriptine therapy for "nonfunctioning" pituitary tumors

Bromocriptine therapy may cause regression of prolactinomas, but its effect on nonsecretory pituitary tumors is uncertain. Conventional treatment for such "functionless" tumors is surgery and/or radiotherapy, but recurrences pose a therapeutic dilemma. We describe a patient with such a tumor treated by surgery and radiotherapy who presented with recurrent disease 14 days later. On treatment with bromocriptine, 20 mg daily for 25 months, the intrasellar tumor recurrence had diminished in size and a suprasellar extension had almost disappeared. Bromocriptine therapy may therefore benefit some patients with nonsecretory pituitary tumors considered unsuitable for surgery or radiotherapy.     

Criteria of cure and follow-up of central hyperthyroidism due to thyrotropin-secreting pituitary adenomas

The recorded number of patients with central hyperthyroidism due to TSH-secreting pituitary adenoma doubled in the last few years after the introduction of ultrasensitive TSH assays in the assessment of thyroid function; however, information about the results and the criteria for cure after pituitary surgery is scanty. Seventeen patients with a TSH-secreting adenoma, diagnosed on the basis of detectable TSH levels in the face of high free thyroid hormone concentrations and pituitary lesion at neuroimaging, underwent pituitary surgery. Hypersecretion of other pituitary hormones was diagnosed in 5 of 17 patients. Four patients were initially misdiagnosed and treated with thyroid surgery or radioiodine therapy. The majority (86%) of hyperthyroid patients normalized thyroid hormone concentrations and regained euthyroidism, although pituitary imaging, alpha-subunit, and alpha-subunit/TSH molar ratio normalized in only 47%, 54%, and 58% of patients, respectively. Moreover, TSH secretion was normally suppressed by T3 in 40% of the patients. Interestingly, the finding of undetectable TSH levels 7 days after surgery was highly predictive of successful outcome. During long term follow-up, there was one relapse of hyperthyroidism. Early diagnosis of TSH-secreting adenomas permits a high rate of remission of hyperthyroidism after surgery. However, normalization of thyroid function alone does not necessarily reflect complete removal of the tumor, and more comprehensive criteria of cure based on pituitary imaging, hormone measurement, and suppression of TSH during T3 administration should be used. Lastly, all patients need an accurate long term follow-up to monitor the possible recurrence of the adenoma.