Clinical Course and Outcome of Nonfunctioning Pituitary Adenomas in the Elderly Compared with Younger Age Groups

doi:10.4158/EP13182.OR

Endocrine Practice

Volume 20, Issue 2, February 2014, Pages 159-164

https://doi.org/10.4158/EP13182.OR Get rights and content

ABSTRACT

Objective

Nonfunctioning pituitary adenomas (NFPAs) are the most common type of pituitary adenomas diagnosed in older patients. However, there are insufficient data regarding the clinical course, risk of regrowth, and long-term prognosis in elderly versus younger patients.

Methods

This retrospective cohort study observed 105 adult patients with NFPAs diagnosed between 1995 and 2012. Patients were stratified into 3 age groups: 18 to 44 years (29 patients), 45 to 64 years (38 patients), and 65 years and over (38 patients). The impact of age on presenting symptoms, disease course, and outcome was analyzed.

Results

Adenoma size was larger in patients < 45 years (mean, 2.9 ± 1.2 cm) compared to patients aged 45 to 64 years and those ≥ 65 years old (2.3 ± 0.9 and 2.5 ± 0.8 cm, respectively; P = .05), with transsphenoidal surgery being the treatment of choice in all 3 groups (83, 92, and 84%, not significant). After a mean follow-up of 6 years, there were higher recovery rates from hypopituitarism in patients < 45 years old (58% vs. 27% and 24%; P = .04). Visual fields improved in most affected patients in each group following surgery (74, 94, and 86%), with a trend toward more full normalization in the youngest age group (58% vs. 44% and 41%; P = .09). There were no significant differences in the risk of remnant growth (29 to 39%), rates of radiation therapy, or need for repeated surgeries. There was no disease-related mortality.

Conclusion

Elderly patients with NFPA have lower rates of recovery from hypopituitarism after treatment compared to younger patients, but the rates of regrowth and need for salvage surgery are similar. (Endocr Pract. 2014;20:159-164)

Section snippets

INTRODUCTION

Nonfunctioning pituitary adenomas (NFPAs) account for one-third of all pituitary adenomas, with peak occurrence from the fourth to the eighth decade of life (1). In the elderly, commonly defined as people older than 65 years, NFPAs are the most common type of pituitary adenoma (2). Although age is a known prognostic factor in many diseases, there are few data regarding whether disease course and response to therapy are affected by age in patients with NFPAs. It is likely that comorbidities in

Subjects

After obtaining approval from our institutional review board, we retrospectively reviewed the charts of patients with NFPAs treated in two tertiary hospitals between 1995 and March 2012. Inclusion criteria included diagnosis of NFPA and age over 18 years. Diagnosis of NFPA was based on clinical presentation, evaluation of pituitary hormone axes, imaging studies, and immunohistochemical staining of the surgical specimen. A total of 105 patients met the inclusion criteria and were included in the

Baseline Characteristics

Patients were predominantly male (69%). A total of 29 patients were < 45 years old, 38 patients were aged 45 to 64 years, and 38 patients were ≥ 65 years old (Table 1). Adenoma size was slightly larger in patients < 45 years old (group 1; mean, 2.9 cm) compared to patients in groups 2 and 3 (2.3 and 2.5 cm, respectively; P = .05), and 85% of adenomas were clinically significant (with either hormonal deficiency or mass effect). There were no statistically significant differences in visual field

DISCUSSION

The frequency of NFPA diagnosis is increasing in the elderly population, a trend that is likely to increase in the future. In this select group of patients, a thorough understanding of the natural history of NFPAs and the response to therapy is the key to balancing the risks and benefits of treatment given the slow-growing nature of this disease. In the current study, we demonstrated that after a mean follow-up of 6 years, elderly patients with NFPAs have lower rates of recovery from

CONCLUSION

In conclusion, elderly patients with NFPAs have lower rates of recovery from hypopituitarism compared to younger patients, with comparable rates of regrowth and need for salvage surgery. Further studies are needed to assess whether a different therapeutic approach may lead to better hormonal and visual outcomes and whether a less aggressive approach can be implemented in the elderly without compromising disease outcome.

DISCLOSURE

The authors have no multiplicity of interest to disclose. This research did not receive any specific grant from any funding agency in the public, commercial, or not-forprofit sector.

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Cited by (43)

Exploring endocrinological pitfalls in pituitary surgery in the elderly
2023, Heliyon
Endoscopic transsphenoidal surgery (ETSS) is performed more frequently in elderly patients. We investigated endocrinological pitfalls in pituitary surgery in the elderly by a comparative study focusing only on elderly patients.
Ninety-nine elderly patients aged 65 years and over with non-functioning pituitary adenoma (NFPA) who underwent ETSS were retrospectively examined and classified into the early (aged 65–74 years) and late (aged 75 years and over) elderly groups. The baseline characteristics and anterior pituitary function were compared between the groups.
Seventy patients were assigned to the early elderly group and 29 to the late elderly group. Thyroid-stimulating hormone (TSH) response in preoperative and postoperative thyrotropin-releasing hormone (TRH) tests revealed a significant difference between the groups. Preoperative and postoperative TSH responses were significantly correlated in both groups. Residual analysis of the correlation between preoperative free triiodothyronine (T3) secretion quantity and preoperative TSH response in both groups, which was significant, indicated that preoperative TSH response was significantly normal when preoperative free T3 secretion quantity was normal in the early elderly group, but preoperative free T3 secretion quantity was significantly lower regardless of preoperative TSH response in the late elderly group.
The present study suggested that preoperative and postoperative TSH secretory capacity was presumed to be normal when preoperative free T3 levels were normal in the early elderly patients with NFPA. On the other hand, TSH secretory capacity in the late elderly patients could only be assessed by the TRH test, which should be taken into account.
Characteristics of Preoperative Visual Disturbance and Visual Outcome After Endoscopic Endonasal Transsphenoidal Surgery for Nonfunctioning Pituitary Adenoma in Elderly Patients
2019, World Neurosurgery
Citation Excerpt :
These studies demonstrated that complete recovery occurred in 36%–39.5% of patients, and improvement of VIS occurred in 75.6%–97.7% of the patients. Other previous reports indicated that improvement of visual function was observed after microscopic and/or endoscopic transsphenoidal surgery in 70.8%-95% of patients.14,20-25 In our study, VIS was normalized from preoperative visual disturbance in 28.5% of younger patients and 9.1% of elderly patients.
Pituitary adenomas in elderly patients may become more common as the population ages. Surgical benefits, especially for visual outcome, after endoscopic endonasal transsphenoidal surgery for pituitary adenomas remain to be elucidated. This retrospective analysis investigated clinical factors affecting visual outcome.
The study included 35 patients with nonfunctional pituitary adenomas who underwent surgery and were subdivided into elderly (≥70 years old, n = 12) and younger (<70 years old, n = 23) groups for analysis. Clinical characteristics and preoperative and postoperative visual function evaluated using visual impairment score (VIS) were compared between groups.
Mean age at diagnosis was 75.1 ± 1.5 years in the elderly group and 55.5 ± 2.0 years in the younger group. VIS was improved in 91% of elderly patients and 80% of younger patients, but postoperative VIS remained higher in elderly patients. Preoperative VIS and incidence of previous cataract surgery were significantly higher in elderly patients than in younger patients. Preoperative and postoperative VISs were significantly correlated with age. Preoperative VIS was significantly higher in patients with previous cataract surgery and correlated with postoperative VIS.
Visual disturbances were improved postoperatively in most patients in both groups at similar rates, but preoperative and postoperative visual disturbances were more severe in elderly patients because the symptoms may have been masked by the presence of lens opacity. Early diagnosis and intervention may be required in elderly patients for better visual outcome.
CXCL12-regulated miR-370–3p functions as a tumor suppressor gene by targeting HMGA2 in nonfunctional pituitary adenomas
2019, Molecular and Cellular Endocrinology
Silencing of noncoding genes within the imprinted DLK1-MEG3 locus is exclusive to human nonfunctional pituitary adenomas (NFPAs), but the exact mechanism is still unclear. This study was designed to demonstrate the impact of CXCL12 on the expression of miRNAs within this locus and phenotypic alterations of NFPAs. Human NFPA samples were collected for screening differentially expressed miRNAs by CXCL12. Target mRNAs of the miRNAs were predicted and verified in vitro. Tumor phenotypic alterations were also tested. Another 51 NFPA samples were enrolled to examine the correlation and clinical features. The expression of miR-370 was decreased by CXCL12 treatment in NFPAs. miR-370–3p was predicted and verified to target HMGA2 as a tumor suppressor gene. Overexpression of HMGA2 inhibited its antitumor function. miR-370–3p was downregulated and HMGA2 was upregulated significantly in High grade NFPAs. In conclusion, the CXCL12/miR-370–3p/HMGA2 signaling pathway is involved in tumor growth and invasiveness of NFPAs.
Safety and Outcome of Transsphenoidal Pituitary Adenoma Resection in Elderly Patients
2019, World Neurosurgery
Pituitary adenomas account for 10%–20% of intracranial brain tumors but have greater incidence in elderly patients. We assessed microsurgical treatment for pituitary adenomas in this population.
A retrospective cohort of patients ≥60 years of age was identified. Patients were divided into deciles by age for evaluation of variables affecting outcome: 60–70 (group 1), 71–80 (group 2), and >80 years (group 3).
Two hundred five patients were identified among group 1 (n = 131), group 2 (n = 65), and group 3 (n = 9). Preoperative variables other than age did not differ. Most patients presented with visual disturbance, in 56.5%, 73.8%, and 50% in groups 1, 2, and 3, respectively. The next most common indication was headache, followed by endocrinopathy. Tumors were overwhelmingly nonfunctional (P = 0.97) and macroadenomas (P = 0.5) in all 3 groups. Gross total resection occurred in 56.9%–80% of patients, and this rate did not differ among groups. Complication rates of 6.9% in group 1, 9.2% in group 2, and 0.0% in group 3 were observed (P = 0.8). No perioperative mortality was identified. Mean length of follow-up ranged from 8.9 to 28.3 months.
In this series of microsurgical resection of pituitary adenomas in elderly patients, good efficacy and safety of treatment were observed. Preclusion of surgical treatment, including open resection, simply because of age is not warranted and instead a comprehensive evaluation of a patient's risk profile and surgical goals should be undertaken.
Nonfunctioning Pituitary Adenoma Recurrence and Its Relationship with Sex, Size, and Hormonal Immunohistochemical Profile
2018, World Neurosurgery
Tumor recurrence or incomplete resection in nonfunctioning pituitary adenomas (NFPAs) is relatively common. However, predictive factors of tumor recurrence in NFPAs are not well established. We evaluated possible factors related to tumor recurrence in a large cohort of NFPAs at a single pituitary neurosurgery center.
A retrospective analysis was conducted of 410 medical records of patients with NFPAs treated by transsphenoidal surgery between 2000 and 2014.
Among the participants, 210 were female (51.0%). A total of 14.1% had giant adenomas. Null-cell pituitary adenomas (n = 239; 58.9%) were the most frequent, followed by silent gonadotroph adenomas (n = 112; 27.3%). Null-cell adenomas were more frequent in women (P = 0.008) and silent gonadotroph adenomas were more frequent in men (P = 0.004). Recurrence was not related to sex or age. Tumor recurrence occurred more often among silent corticotropic adenomas and giant adenomas (hazard ratio 2.45; P < 0.0001 and hazard ratio 2.35; P = 0.001, respectively). Silent thyrotrophic adenoma presented a comparable frequency of recurrence of silent corticotropic adenomas, despite having borderline significance (P = 0.07).
NFPA tumors have a high heterogeneous hormonal profile and may have prognostic importance. Silent corticotropic adenomas and giant adenomas present a high rate of recurrence.
Transsphenoidal Surgery for Elderly Patients with Acromegaly and Its Outcomes: Comparison with Younger Patients
2018, World Neurosurgery
Citation Excerpt :
According to the recent Brain Tumor Registry of Japan, patients age >65 years account for 23.4% of the total number of patients with functioning/nonfunctioning pituitary adenomas.2 Previous studies have analyzed the outcomes in elderly patients who underwent transnasal transsphenoidal surgery (TTS) for removal of pituitary adenoma.3-10 Although these studies demonstrated the benefits of TTS in elderly patients using microscopes and endoscopes, they did not focus on the outcomes of patients with functioning adenomas.
Elderly patients with acromegaly who have comorbidities may increasingly encounter perioperative complications; however, little data are available on the risks and outcomes of surgical treatment in these patients. We aimed to analyze and compare the results of transnasal transsphenoidal surgery (TTS) in elderly and younger patients.
Eighty-seven consecutive patients with acromegaly who underwent TTS were included. We divided the patients into elderly (≥65 years) and younger (<65 years) groups and compared clinical characteristics, anesthesia risk, and surgical outcomes in these 2 groups.
The 87 patients included 24 (27.6%) in the elderly group and 63 (73.4%) in the younger group. Preoperative endocrinologic and radiologic assessments showed no significant differences between the 2 groups. Although a grade 3 American Society of Anesthesiologists Physical Status classification was more common in the elderly group (75% vs. 3%; P = 0.00001) owing to the severity of associated diseases, no significant between-group difference in perioperative complications was seen (17% vs. 6%; P = 0.142). Sixteen elderly patients and 45 younger patients achieved endocrinologic remission following surgery (67% vs. 71%; P = 0.426). The incidence rate of postoperative new pituitary deficit was similar in the elderly and younger groups (4% vs. 3%; P = 0.625). Approximately one-third of the elderly patients with diagnosed hypertension or diabetes mellitus tapered their medication after successful tumor removal.
TTS can be considered a safe treatment for both younger and elderly patients with acromegaly. Successful tumor removal provided a significant improvement in comorbidities even in elderly patients with acromegaly.

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Endocrine Practice

ABSTRACT

Objective

Methods

Results

Conclusion

Section snippets

INTRODUCTION

Subjects

Baseline Characteristics

DISCUSSION

CONCLUSION

DISCLOSURE

REFERENCES (17)

Age-related and genderrelated occurrence of pituitary adenomas

Clin Endocrinol (Oxf).

Diagnosis and management of pituitary tumours in the elderly: a review based on personal experience and evidence of literature

Eur J Endocrinol.

Non-functioning pituitary adenomas: clinical feature, laboratorial and imaging assessment

therapeutic management and outcome. Arq Bras Endocrinol Metabol.

The presentation and management of pituitary tumours in the elderly

Age Ageing.

The surgical treatment of pituitary adenomas in the eighth decade

Surg Neurol.

Pituitary tumours in the elderly: a 20 year experience

Eur J Endocrinol.

Pituitary tumours presenting in the elderly: management and outcome

Clin Endocrinol (Oxf).

Surgical treatment of pituitary tumors in the elderly: clinical outcome and long-term follow-up

J Neurooncol.

Cited by (43)

Exploring endocrinological pitfalls in pituitary surgery in the elderly

Characteristics of Preoperative Visual Disturbance and Visual Outcome After Endoscopic Endonasal Transsphenoidal Surgery for Nonfunctioning Pituitary Adenoma in Elderly Patients

CXCL12-regulated miR-370–3p functions as a tumor suppressor gene by targeting HMGA2 in nonfunctional pituitary adenomas

Safety and Outcome of Transsphenoidal Pituitary Adenoma Resection in Elderly Patients

Nonfunctioning Pituitary Adenoma Recurrence and Its Relationship with Sex, Size, and Hormonal Immunohistochemical Profile

Transsphenoidal Surgery for Elderly Patients with Acromegaly and Its Outcomes: Comparison with Younger Patients

Original ArticleClinical Course and Outcome of Nonfunctioning Pituitary Adenomas in the Elderly Compared with Younger Age Groups

ABSTRACT

Objective

Methods

Results

Conclusion

Section snippets

INTRODUCTION

Subjects

Baseline Characteristics

DISCUSSION

CONCLUSION

DISCLOSURE

Age-related and genderrelated occurrence of pituitary adenomas

Clin Endocrinol (Oxf).

Diagnosis and management of pituitary tumours in the elderly: a review based on personal experience and evidence of literature

Eur J Endocrinol.

Non-functioning pituitary adenomas: clinical feature, laboratorial and imaging assessment

therapeutic management and outcome. Arq Bras Endocrinol Metabol.

The presentation and management of pituitary tumours in the elderly

Age Ageing.

The surgical treatment of pituitary adenomas in the eighth decade

Surg Neurol.

Pituitary tumours in the elderly: a 20 year experience

Eur J Endocrinol.

Pituitary tumours presenting in the elderly: management and outcome

Clin Endocrinol (Oxf).

Surgical treatment of pituitary tumors in the elderly: clinical outcome and long-term follow-up

J Neurooncol.

Original Article
Clinical Course and Outcome of Nonfunctioning Pituitary Adenomas in the Elderly Compared with Younger Age Groups