The Relationship of Pituitary Hormonal Deficiencies to the Perception of Life Function Impairment in Patients with Pituitary Tumors and Diseases

Purpose:

Decline in quality of life (QOL) and functional impairments have been reported in patients treated for non-secretory and hypersecretory pituitary tumors and diseases.  Most QOL and functional evaluations have been performed post treatment and it remains unclear if the presence of pituitary deficiencies or other pre intervention factors related to the presence of a pituitary tumor impact QOL or if lower QOL may be independent of tumor related factors.

The purpose of this this study was to investigate the relationship of biochemical pituitary hormonal deficiencies to the perception of QOL, life function impairment and health status in patients newly diagnosed with pituitary tumors or diseases.  Additionally, to assess the impact of other factors such as tumor size, the presence of concomitant medical conditions, age, gender and diagnosis on perceived functional limitations and health status.

Methods:

A Prospective study of patients presenting to the OHSU Pituitary Center from 2011-2014 with newly diagnosed pituitary disease and MRI confirmed pituitary tumors. Patients were excluded for diagnosis of a malignancy or acute physical or psychological stressor within 12 months of presentation or new medications or concomitant medical diagnoses within 6 months of presentation.  All patients completed a 205 question DOLF Scale (Cronbach alpha .94) assessing their perception of overall health quality and impairment in 32 areas of physical, psychological, cognitive, social and spiritual function.   All subjects gave informed consent, received the same instructions regarding the completion of the questionnaire and completed the questionnaire during initial consultation. 

All patients underwent standardized testing at intake to evaluate pituitary hormonal function or deficiencies including: thyroid (Thyroid Stimulating Hormone, Free T4), gonadal (Lutenizing hormone, Follicle Stimulating Hormone, total Testosterone (males)), growth hormone (Insulin Growth Factor-1), prolactin and posterior pituitary function (Basic Metabolic Panel).  The hyperthalamic-pituitary-adrenal axis (HPA) function was evaluated using dynamic testing after administration of 1mcg cortrosyn IV.  Baseline serum Adrenocorticotropic Hormone (ACTH) and cortisol levels were drawn and serum cortisol level was measured again 30 minutes after cortrosyn administration. Cortisol level less than 18ug/dl at 30 minutes post drug administration was considered deficient and indicative of HPA axis dysfunction or adrenal insufficiency (AI).  Patients with suspicion of Cushing’s disease were excluded from dynamic HPA axis testing.

 This study was approved by the OHSU Institutional Review Board.  Analysis was performed using independent T test, ANOVA, bivariate correlational and crosstabs analysis using PSAW 18.

Results:

123 subjects were enrolled; 10 were excluded for incomplete data. Pituitary disease diagnoses included: Non-functional tumors (NF) (49), prolactinomas (PRL) (27), Rathke’s Cleft cyst (RCC) (10), Acromegaly (Growth hormone excess, 8), Cushing’s disease (CD) (10), hypophysitis (2), other tumors (5: craniopharygioma 2, co-secreting 3, meningioma, 2).   There was a significant gender difference overall (36 male/77 Female (p=0.01)) and a significant difference in gender distribution by diagnosis (p=0.027). More females that males (23:4) presented with prolactinomas, GH excess (6:2), RC (9:1) and CD (9:2).   Mean age  at presentation was 44.1 + 16.4 years with a significant difference in ages between diagnoses (p=0.017). Patients with prolactinomas were younger than all other diagnoses (mean 35 years).  The mean number of hormonal deficiencies was not significantly different between diagnostic groups (p=0.172).

102 patients reported on the difference between their health status compared to the previous 12 months : 90.3% felt worse and 96.2% felt they a little or much worse than their desired level of health. Mean raw life dysfunction scores correlated with both these perceptions (r= 0.421,p < 0.001; r=0.414, p<0.001 respectively)

Higher perception of dysfunction correlated only with larger tumor size and the presence of concomitant diagnoses (range 1-2).  16 patients reported diagnoses included diabetes mellitus, rheumatoid arthritis, hypertension, low back pain.  All concomitant diagnoses were treated and stable at the time of patient assessment.

Subjects with CD reported the highest Life dysfunction (raw score 662) followed by acromegaly (631), RCC (589) and PRL (537).  Scores were significantly higher for CD than NFA (p=0.004) and PRL (p=0.015) and GH excess subjects (p=0.054).  Scores were not significantly different by gender (p=0.179) but subjects with larger tumor size and older age scored significantly higher dysfunction (p=0.046 and p=0.015 respectively).

No pituitary hormonal deficiencies were found in 44.2% of patients and 37% demonstrated only one deficiency while 18.6% had two or greater deficiencies.  The prevalence of adrenal insufficiency and testosterone deficiency in males were significantly different between diagnoses (p=0.017, p=0.036 respectively).  However, there were no differences in mean raw dysfunction scores with respect to hormonal deficiencies between diagnostic groups (p=0.145).

Conclusion:

Low levels and worsening health status over the previous 12 months were perceived by all patients with pituitary disease regardless of diagnosis.  The presence of larger tumors, older age and concomitant medical diagnoses correlated with higher overall life dysfunction scores and lower QOL in patients with newly diagnosed disease.  No relationship was found between pituitary deficiencies and higher dysfunction scores.  However, patients with Cushing’s disease and Acromegaly (GH excess) reported overall higher dysfunction than other pituitary diagnoses.   Comparison with age, gender, culture and socioeconomic matched subjects and a larger patient sample is required to determine if the presence of pituitary tumor is an etiologic factor for higher life dysfunction and lower quality of life in patients with pituitary tumors and diseases.