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Research Article
Revised

Spectrum of Pituitary disorders: A retrospective study from Basrah, Iraq

[version 2; peer review: 2 approved]
Previously titled: Spectrum of Sellar and Parasellar Region Lesions: A retrospective study from Basrah, Iraq
PUBLISHED 22 Jun 2018
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Abstract

Background: Pituitary disorders spectrum includes a wide variety of diseases.This study aimed at a comprehensive description of such disorders for patients from  Faiha Specialized Diabetes, Endocrine and Metabolism Center (FDEMC) in Basrah (Southern Iraq).
Methods: Retrospective data analysis of FDEMC for the period from January 2012 through June 2017. We included all patients with pituitary disorders who have MRI pituitary.
Results: The pituitary disorders were more common among women. Those with macroadenoma were older than those with microadenoma with nearly equal gender prevalence of macroadenoma. Pituitary adenoma constituted the bulk of pituitary disorders in this registry (67.2%). Growth hormone secreting adenoma were the commonest adenoma seen in 41.0% followed by clinically non-functioning pituitary adenoma(NFPA)in 31.4% and prolactinoma in 26.9%. About 64.8% of pituitary adenoma was macroadenoma. Macroadenoma was seen in 73.4 % of growth hormone secreting adenoma, 61.2% in NFPA and 62.0% of prolactinoma (of them six were giant prolactinoma)
Conclusion: Pituitary adenoma constituted the bulk of pituitary disorders in Basrah, growth hormone secreting adenoma is the commonest adenoma followed by NFPA and prolactinoma due to referral bias. A change  in  practice of pituitary adenoma treatment is needed.

Keywords

Sellar and parasellar region lesions, pituitary disease, pituitary adenoma, classification, epidemiology.

Revised Amendments from Version 1

  • The research title has been changed based on referee suggestions
  • Inclusion criteria has been made more clear
  • We have corrected typos
  • We clarify that the total number can’t be 232 because some may have more than one diagnosis
  • Miscellaneous cases has been clarified
  • Number in table 3 made more clear
  • Conclusion has been clarified

See the authors' detailed response to the review by Khaled Mohammed Al-Dahmani

Introduction

Sellar and parasellar region lesions spectrum includes a wide variety of conditions ranging from adenoma to empty sella syndrome, apoplexy, congenital or acquired condition14. Other than adenoma, genetic causes of pituitary disease are increasingly recognized3.

Pituitary adenomas are not rare and account for 20% all intracranial tumors5,6. Half of these secrete hormones, and half are microadenoma2. Clinically non-functioning adenomas (NFPA) constitute 15–54% of all adenomas. Prolactinomas accounts for 32–66%, growth hormone secreting adenoma (acromegaly) account for 8–16%, adrenocorticotropic hormone (ACTH)-secreting adenoma (Cushing's disease) forms 2–6%, and TSHoma accounts for less than 1%2,7. These pituitary adenomas behave as typical or have a more aggressive to malignant behavior6,8. They can cause mass effect, in addition to hypersecretion or hypopituitarism7,9.

Advances in neuroradiology have opened the door for earlier and easier diagnosis of pituitary disease and other sellar and suprasellar lesions10.

The Faiha Specialized Diabetes, Endocrine, and Metabolism Center (FDEMC) in Basrah is a tertiary referral center receiving patients with pituitary diseases from most of Southern Iraq. The FDEMC is trying to adapt the three mission criteria of the pituitary center of excellence, which includes care and support for patients, fellowship training and contribution to pituitary disease research11. To our knowledge, there are no studies on sellar and parasellar region lesions in Iraq.

This study aimed at a comprehensive description of pituitary disorders for patients from FDEMC in Basrah (Southern Iraq).

Methods

Study design

Retrospective data analysis of FDEMC database for the period from January 2012 through June 2017.

Inclusion criteria: We included all patients with pituitary disorders who have MRI pitutiary regardles the age.

Exclusion criteria: patients with pituitary disorders with missed MRI.

Definition of variables

Sequences of pituitary MRI imaging were classified according to the international standard12. Adenomas were classified as macroadenoma if these were 10 mm or more in size, while microadenoma if less than 10 mm and giant prolactinoma if these were 4 cm and above2.

Pituitary adenoma (NFPA, prolactinoma, growth hormone secreting adenoma [acromegaly], and adrenocorticotropic hormone (ACTH)-secreting adenoma) were defined according to the usual criteria2,8,12.

Hypopituitarism, whether postoperative or in those with or without adenoma, was considered according to the hormonal assessment with basal and dynamic hormonal tests13.

Empty sella syndrome, whether primary or secondary to surgery or apoplexy, were considered based on MRI findings14.

Craniopharyngioma diagnosis was based on clinical behavior with MRI and pathological diagnosis.

Data analysis

Analysis was done in July 2017. All patients with labeling diagnosis of pituitary disease were included. Data were included on an Excel spreadsheet and transferred to SPSS for Windows, Version 23.0 (SPSS Inc., Chicago, USA).

Continuous variables were summarized as number and percentage and dichotomous variables as mean ±SD.

Ethics statement

The ethics committee of the Medical College in Basrah University approved the study design and the Center authorities agreed to review the patients data. At the time of registeration in the Center, all patients included in this study approved the use of their clinical information for research purposes.

Results

A total of 232 patients were included in this study. Pituitary disorders were more common among women (Table 1). Those with macroadenoma were older than those with microadenoma with nearly equal gender prevalence of macroadenoma. Four patients died; two with growth hormone secreting adenoma (acromegaly) and advanced cardiovascular disease, and two with prolactinoma that caused hypopituitarism and adrenal failure.

Table 1. Pituitary disorders patients demography and characteristics.

N (%);
mean ±SD
GenderAll pituitary disordersMen84 (36.2)
Women 148 (63.8)
Pituitary adenoma*Men 67 (43)
Women 89 (57)
Age at registration, yearsAll38.2±15.3
Macroadenoma42.5±14.9
Microadenoma34.8±14.7
Macroadenoma**Men 51 (50.5)
Women 50 (49.5)
Died 4

*Of 156 pituitary adenoma

**Of 101 macroadenoma

Table 2 shows that pituitary adenoma constituted the bulk of pituitary disorders in this registry (67.2%). Growth hormone secreting adenoma (acromegaly) were the commonest adenoma seen in 41.0% followed by NFPA in 31.4% than prolactinoma in 26.9%. Hypopituitarism due to various causes was observed in 24.5% in this series. Empty sella syndrome, whether primary or secondary, were seen in 9.4%. Craniopharyngioma and Sheehan syndrome were seen in 3.9% each. Meningioma based on MRI finding was been observed in 4 patients (1.7%).

Table 2. Spectrum of pituitary disorders at the time of registry.

N (%)
Pituitary adenoma156 (67.2)
Growth hormone secreting adenoma (acromegaly)64 (41.0)
Clinically non-functioning pituitary adenoma (NFPA)49 (31.4)
Prolactinoma*42 (26.9)
GH-secreting adenoma with hyperprolactinemia*5
ACTH- secreting pituitary adenoma2 (1.2)
Hypopituitarism57 (24.5)
Empty sella syndromeAll22 (9.4)
Primary**9
Secondary13
Diabetes insipidus15
Apoplexy3
HyperprolactinemiaAll51
No
adenoma
12
Pituitary enlargement3
Stalk lesions1
Miscellaneous***11
Craniopharyngioma9 (3.9)
Sheehan syndrome9 (3.9)
Meningioma4 (1.7)
Rathke's cleft cyst3
Total232

*GH-secreting adenoma,2 of them stain on biopsy for lactotroph cell

**Acromegaly in 4

*** Miscellaneous includes galactorrhea, hypogonadotropic hypogonadism, and acromegaloidism

In this study, 64.8% of pituitary adenoma were macroadenomas (Table 3). Macroadenoma was seen in 73.4% of acromegaly, 61.2% in NFPA and 62.0% of prolactinoma (of them six were giant prolactinoma).

Table 3. Pituitary adenoma according to the size.

Microadenoma
N (%)
Macroadenoma
N (%)
Total
Pituitary adenoma55 (35.2)101 (64.8)156
Growth hormone
secreting adenoma
(acromegaly)
17 (26.5)47 (73.4)64
Clinically non-
functioning pituitary
adenoma (NFPA)
19 (38.8)30(61.2)49
Prolactinoma16 (38)26 (62.0)*42
ACTH- secreting
Pituitary adenoma
2 (100.0)02

*Of them six giant Prolactinoma

In Table 4 we see hypophysectomy whether transsphenoidal or transcranial or both was performed in 45 patients with pituitary adenoma (28.8%). Stereotactic radiosurgery is done in 5 patients (3.2%) with pituitary adenoma. Growth hormone secreting adenoma (acromegaly) and prolactinomas were treated primarily with medical therapy (71.4% and 76.1% respectively).

Table 4. Type of treatment for pituitary adenoma.

N (%)
Hypophysectomy-transsphenoidal33 (21.1)
Hypophysectomy-transcranial8 (5.1)
Hypophysectomy-transsphenoidal followed
by transcranial or reverse or repeat same
surgery,i.e., twice surgery
4 (2.5)
Stereotactic radiosurgery5 (3.2)
Radiotherapy1 (0.6)
Primary medical treatmentGrowth hormone
secreting adenoma
(acromegaly)
46 (71.4)*
Prolactinoma32 (76.1)**
Total 156

*Of patients with acromegaly

**Of patients with prolactinoma

Dataset 1.Description of patients included in the study.

Discussion

All pituitary disorders and adenoma were more common among women in this study. The gender predominance among patients with pituitary adenoma is variable in the literature depending on hormone secretion and age of the patients, the size of the tumor and female dominance is not clear15,16. However, female dominance has been seen in Saudi Arabia17 and one series from Argentina18. Those with macroadenoma tend to be older in age with no difference in the prevalence between men or women.

Seen in about two-thirds of patients, pituitary adenoma constituted the main bulk of pituitary disease in this study, which is compatible with reports in the literature16.

The commonest pituitary adenoma was growth hormone secreting adenoma (acromegaly), followed by NFPA and prolactinoma. This is entirely different from the literature on the prevalence of pituitary adenoma2,16,17,19. This could be attributed to selection bias because only growth hormone secreting adenoma (acromegaly) patients are being referred, while NFPA and prolactinoma were treated by different specialties, such as neurosurgeons or gynecologists, without referral to a specialized Center like FDEMC. In Basrah, most cases of hyperprolactinemia were seen by a gynecologist because of amenorrhea and infertility, and the neurosurgeon follows patients with NFPA without referring them.

Hypopituitarism is prevalent in a quarter of this pituitary centre, from different causes, ranging from macroadenoma to hypophysectomy. Evaluation for hypopituitarism remains an integral part of the workup for any pituitary lesions because missing such diagnosis could be catastrophic9,13. This figure is far higher than that of Saudi Arabia, which was 1.2%17.

Empty sella syndrome was seen in 9.4% of patients in this study, which can be primary or secondary to surgery or apoplexy. Empty sella syndrome needs an extensive workup to assess pituitary function20.

Craniopharyngioma and Sheehan syndrome are two diseases with a different spectrum of age distribution, but they were seen at the same frequency in this cohort. Craniopharyngioma is a disease of childhood and adolescence21. Sheehan syndrome is supposed to be rare in developed countries, but is still seen in developing countries22.

Less than two thirds of adenoma in this study were macroadenomas. While in most series macroadenomas constitute 50% of the pituitary adenomas2; however in Canada, a similar finding has been seen compared with this study23. Again this could be explained by referral bias in this study. In Saudi Arabia, microadenomas were more prevalent17.

For growth hormone secreting adenoma (acromegaly), more than two thirds were macroadenomas, which is established fact for all acromegaly2,24,25.

NFPA was a macroadenoma and seen at around 60% in this study. A similar finding was seen in a previous series2.

Prolactinomas were macroadenoma in around 60% of cases in this study. This differs from the literature, where more than 90% of prolactinomas were microadenomas2,18.

Hypophysectomy-transsphenoidal as surgical treatment was done in one third of pituitary adenomas, while transcranial approach or stereotactic radiosurgery was contemplated in the minority. This is a typical approach for most of the pituitary adenomas2,26. For growth hormone secreting adenoma (acromegaly), the primary treatment in this study was medical treatment in about two thirds of individuals. This is contrary to literature where surgery is the main mode of therapy26. The explanation is that we are just building a new neurosurgery unit for pituitary glands over the last few years, and in the future, surgery of pituitary is supposed to improve, and early referral will be the best.

For prolactinoma, primary medical treatment was done in two thirds of patients, while it should be the main treatment of choice in more than 90%, as seen in previous literature26.

Malignant disease metastasizing to the pituitary is not observed in this study because they are not referred from Oncology Center in Basrah.

Study limitation

This study supposes to involve most of the pituitary disease patients in Basrah because the Center is a tertiary referral center. However, due to referral bias among some neurosurgeons and gynecologologists, we cannot guarantee that the data includes all patients with this condition in Basrah.

Conclusion

Pituitary adenomas constituted the bulk of pituitary disorders in Basrah. Growth hormone secreting adenoma (acromegaly) is the most frequent adenoma followed by NFPA and prolactinoma due to referral bias. A change in the practice of pituitary adenoma treatment is needed.

Data availability

Dataset 1: Description of patients included in the study 10.5256/f1000research.13632.d19743927

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VERSION 2 PUBLISHED 06 Apr 2018
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how to cite this article
Mansour AA, Alhamza AHA, Almomin AMSA et al. Spectrum of Pituitary disorders: A retrospective study from Basrah, Iraq [version 2; peer review: 2 approved]. F1000Research 2018, 7:430 (https://doi.org/10.12688/f1000research.13632.2)
NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.
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Open Peer Review

Current Reviewer Status: ?
Key to Reviewer Statuses VIEW
ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions
Version 2
VERSION 2
PUBLISHED 22 Jun 2018
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Reviewer Report 09 Jul 2018
Khaled Mohammed Al-Dahmani, Divison of Endocrinology, Tawam Hospital, Al Ain, United Arab Emirates;  Department of Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Abu Dhabi, United Arab Emirates 
Approved
VIEWS 2
While the authors addressed some of the raised comments, I see a need for the following:
  1. Simplify Table 2 into 4 main groups as mentioned before. It is understandable that patients with seller masses may also have
... Continue reading
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CITE
HOW TO CITE THIS REPORT
Al-Dahmani KM. Reviewer Report For: Spectrum of Pituitary disorders: A retrospective study from Basrah, Iraq [version 2; peer review: 2 approved]. F1000Research 2018, 7:430 (https://doi.org/10.5256/f1000research.16733.r35342)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
Version 1
VERSION 1
PUBLISHED 06 Apr 2018
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Reviewer Report 14 Jun 2018
Khaled Mohammed Al-Dahmani, Divison of Endocrinology, Tawam Hospital, Al Ain, United Arab Emirates;  Department of Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Abu Dhabi, United Arab Emirates 
Approved with Reservations
VIEWS 9
The study by Mansour AA et al. is an important contribution to the limited pituitary research in the middle East and North Africa (MENA) region.

The following points need further modifications/clarifications;
  • Sellar and parasellar region
... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Al-Dahmani KM. Reviewer Report For: Spectrum of Pituitary disorders: A retrospective study from Basrah, Iraq [version 2; peer review: 2 approved]. F1000Research 2018, 7:430 (https://doi.org/10.5256/f1000research.14810.r34531)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
  • Author Response 22 Jun 2018
    Abbas Mansour, Faiha Specialized Diabetes, Endocrine and Metabolism Center (FDEMC), Diabetes, Endocrine and Metabolism Division, Department of Medicine, Basrah College of Medicine,Hattin post office. P.O Box: 142, 61013, Iraq
    22 Jun 2018
    Author Response
    The study by Mansour AA et al. is an important contribution to the limited pituitary research in the middle East and North Africa (MENA) region.

    The following points need further modifications/clarifications;
    ... Continue reading
COMMENTS ON THIS REPORT
  • Author Response 22 Jun 2018
    Abbas Mansour, Faiha Specialized Diabetes, Endocrine and Metabolism Center (FDEMC), Diabetes, Endocrine and Metabolism Division, Department of Medicine, Basrah College of Medicine,Hattin post office. P.O Box: 142, 61013, Iraq
    22 Jun 2018
    Author Response
    The study by Mansour AA et al. is an important contribution to the limited pituitary research in the middle East and North Africa (MENA) region.

    The following points need further modifications/clarifications;
    ... Continue reading
Views
5
Cite
Reviewer Report 30 Apr 2018
Abdul Al-Toma, Department of Internal Medicine, Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, The Netherlands 
Approved
VIEWS 5
Dr. Mansour and co-authors investigated the Spectrum of pituitary disease (Sellar and Parasellar Region Lesions) in a large cohort of patients from a tertiary referral center in the southern region of Iraq. This center receives patients with pituitary diseases from ... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Al-Toma A. Reviewer Report For: Spectrum of Pituitary disorders: A retrospective study from Basrah, Iraq [version 2; peer review: 2 approved]. F1000Research 2018, 7:430 (https://doi.org/10.5256/f1000research.14810.r32887)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.

Comments on this article Comments (0)

Version 2
VERSION 2 PUBLISHED 06 Apr 2018
Comment
Alongside their report, reviewers assign a status to the article:
Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions
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