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Sparsely granulated adenomas present acromegaly treatment challenges
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LOS ANGELES — Complete tumor resection is not reached in approximately one-quarter of adults with acromegaly after their first surgery, and this is particularly frequent in those with granulated adenomas, according to findings presented at the AACE Annual Scientific and Clinical Congress.
“Our study is important, as we comprehensively examined the presenting symptoms and clinical signs associated with acromegaly, which helps patients and providers to achieve early recognition and establish a timely diagnosis,” Lima Lawrence, MD, an endocrinology fellow at the Cleveland Clinic, told Endocrine Today. “Furthermore, our findings on treatment outcomes of surgery, radiation and medications will afford clinicians a better understanding of acromegaly and the variables that determine the clinical course.”
Lawrence and colleagues examined the medical charts of 85 adults (mean age, 49.1 years; 50.6% women) from the Cleveland Clinic who presented with a pituitary adenoma and acromegaly. The review was conducted between 2008 and August 2018.
Macroadenomas were reported in 78.8% of the patients, and somatostatin analogues were the most frequently prescribed presurgical medications. After surgery, the researchers noted that 75.3% of the total cohort had complete tumor resection. In addition, 60.9% of the entire cohort had normal insulin-like growth factor I levels 6 months after surgery; 93.4% said their symptoms improved and 79.6% reported a decrease in comorbidities.
There were 10 cases in which a second surgery was needed among the 24.7% of participants in the study who did not reach complete tumor resection after the first operation. For patients who did not respond to surgery and prior treatments, 75% were given somatostatin analogues as a first-line medical therapy, whereas pegvisomant (Somavert, Pfizer) was primarily used in seven of eight participants who required a third-line therapy.
The researchers also found that 91.9% of the adenomas underwent growth hormone staining and that this helped to identify granulated adenomas. Lawrence noted that there were 17 densely granulated adenomas and six sparsely granulated adenomas, and “more sparsely granulated adenomas remained unresponsive to therapy in our cohort.”
“Our study validates the importance of cytokeratin staining and confirms previously published studies that patients with sparsely granulated adenomas have more aggressive tumors with worse outcomes,” Lawrence said. “We found that the majority of patients who remained unresponsive to therapy demonstrated a sparsely granulated pattern on histopathology. While traditionally, the standard first-line medical therapy for acromegaly postsurgery are somatostatin analogues and dopamine agonists, these patients with sparsely granulated adenomas may respond better to growth hormone antagonists, which has significant clinical implications for treatment outcomes.” – by Phil Neuffer
Reference:
Lawrence L, et al. Acromegaly: The 10-year Cleveland Clinic experience. Presented at: AACE Annual Scientific and Clinical Congress; April 24-28, 2019; Los Angeles.
Disclosure : Lawrence reports no relevant financial disclosures.