Early identification of postoperative remission for thyrotropin-secreting adenomas

doi:10.21203/rs.3.rs-3348904/v1

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Early identification of postoperative remission for thyrotropin-secreting adenomas

https://doi.org/10.21203/rs.3.rs-3348904/v1

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Purpose

Thyrotropin-secreting adenoma (TSHoma) is a rare type of pituitary adenoma, occurring in one per million people. Little is known about TSHoma. We summarized the demographic, clinical and hormonal characteristics of TSHoma based on a single-center experience. Moreover, we explored the predictive value of postoperative thyroid function for long-term remission.

Methods

We retrospectively analyzed 63 patients who were diagnosed as TSHoma and surgically treated at our hospital from January 2015 to June 2021. The preoperative clinical characteristics were analyzed and compared between remission and nonremission groups. Thyroid function was measured at 1 day, 1 month, 3 months, 6 months, 12 months and over 12 months after surgery to determine whether they could predict long-term remission.

Results

The male to female ratio for TSHoma was 1.25. The mean age at diagnosis was 45 ± 12 years. Clinical presentation was varied, presenting with hyperthyroidism (68.25%), space-occupying effect (15.87%), amenorrhea (7.14% of female patients) and nonsymptoms (22.22%). 88.14% of patients achieved postoperative endocrinological remission. Larger tumor size and tumor invasion into cavernous sinus and suprasellar with chiasmal compression were strong predictors of lower rates of endocrinological remission. Postoperative thyroid function at 3 months was a viable diagnostic predictor for postoperative remission, especially for FT4 level with a 20.65pmol/L cutoff.

Conclusions

Tumor size and extent are major prognostic factors for remission. Postoperative thyroid function at 3 months could be used as a clinical prediction tool for long-term endocrinological remission

thyrotropin-secreting adenoma

thyroid function

prediction

postoperative remission

Thyrotropin-secreting adenoma (TSHoma) is a type of functional pituitary adenoma, which produces excessive TSH causing the syndrome of inappropriate secretion of TSH (SITSH), a condition of normal or elevated levels of TSH with high levels of thyroid hormones. TSHoma is extremely rare and accounts for 0.5%-2.7% of all pituitary adenomas[1–3]. Unlike growth hormone (GH)-secreting pituitary adenoma or adrenocorticotropic hormone (ACTH) -secreting pituitary adenoma, which result in typical clinical features of acromegaly or Cushing’s syndrome, the symptoms of TSHoma are similar to those of hyperthyroidism or not prominent; thus, TSHoma is frequently misdiagnosed, leading to an inappropriate treatment such as thyroidectomy[4]. The first European guidelines issued by the European Thyroid Association and update in 2019 did not apply the accurate criteria for cure of a TSHoma, and unlike GH/ACTH-secreting adenoma, early identification of remission for TSHoma has not been established[5, 6]. There was one research which enrolled 31 patients reporting that the immediate postoperative TSH level at 12 hours after surgery was the strongest predictor with a 0.62 µIU/mL cutoff[7]. TSH and free thyroxine (FT4) levels were measured at 2, 6, 12, 18 and 24 hours after the operation to determine whether these values could predict postoperative endocrinological remission[7]. Here we reviewed 63 patients with TSHoma who underwent transsphenoidal surgery at our hospital and were followed up regularly for more than 6 months after surgery. We summarized the clinical characteristics of TSHoma and further explored the predictive value of postoperative thyroid function for long-term endocrinological remission

Patient Population

We reviewed all patients who were diagnosed endocrinologically, radiologically, and pathologically as TSHoma and underwent transsphenoidal surgery at the Department of Endocrinology and Metabolism of Huashan Hospital from January 2015 to June 2021. A total of 63 patients were included in this study to analyze the preoperative clinical characteristics. Four patients were excluded when we analyzed the differences between remission group and nonremission group due to the lack of postoperative follow-up. Remission was diagnosed when tumor was completely removed based on the surgeon’s evaluation and immediate postoperative MRI findings and when serum TSH, free triiodothyronine (FT3), and FT4 were normalized or lower for at least 6 months without medical treatment or radiotherapy.

Physical Examination and Laboratory Testing

Detailed medical history was obtained and complete physical examination was performed, including weight, height and clinical presentation (hyperthyroidism-related symptoms, space-occupying effect, amenorrhea). All tests were performed in Huashan Hospital Fudan University Laboratory. Levels of serum FT3, FT4, T3, T4, TSH, thyroid peroxidase antibodies (TPOAb), thyroglobulin antibodies (TgAb), TSH receptor antibodies (TRAb), cortisol, prolactin (PRL) and plasma growth hormone (GH) were determined by electrochemiluminescence immunoassay (Roche, USA). Insulin-like growth factor 1 (IGF1) were measured by chemiluminescence immunoassay (Autobio, China).

Sandostatin (Novartis, Switzerland) was administered subcutaneously three times at a dose of 100mg every 8h as short-term somatostatin analogue (SSA) test. Serum FT3, FT4, T3, T4 and TSH levels were measured at 0, 2, 4, 6, 8 and 24 hours after the first injection.

All patients underwent preoperative dynamic MRI of the sellar region using 3-T system (Signa; General Electric). Based on the preoperative MRI findings, we defined tumor extension if TSHoma was extended to anteroinferior (extension into the sphenoid sinus), lateral (cavernous sinus invasion), or superior (suprasellar extension with chiasmal compression). We further classified lateral growth into five grades (Knosp grades 0–4). The coronal view was used to measure the maximum diameter of each tumor. Tumors with a maximum diameter < 1cm were classified as microadenomas while diameter ≥ 1cm macroadenomas. Thyroid nodules were defined by ultrasound examination (Philips iU22, 8–15 MHz).

Statistical Analysis

The results were expressed as means ± standard deviations (SD), or medians and interquartile ranges. Categorical variables were expressed as frequency percentage. The Mann-Whitney U or Student’s T test was used to compare continuous variables between groups. The Chi-square and Fisher’s exact tests were used to identify significant differences between categorical variables. Receiver operating characteristic (ROC) curves were constructed to display the sensitivities and specificities of postoperative thyroid function and remission. The predictive power was also evaluated using the area under the ROC curve (AUC) and the optimum cutoff level was determined by maximized Youden’s index. A value of p ≤ 0.05 was considered statistically significant. The SPSS (version 27) was used for all of the other analysis and drawing ROC curves.

Preoperative demographic and clinical characteristics of 63 patients with TSHoma

A total of 63 patients diagnosed with hormonally active TSHomas based on clinical and neuroimaging findings underwent transsphenoidal surgery at our hospital. One patient belonged to the remission group underwent thyroidectomy 38 years ago before transsphenoidal surgery. Four patients were excluded due to the lack of follow-up data. 88.14% of patients (52/59) achieved remission after surgery. None of these remission patients experienced recurrence during follow-up. Three patients from nonremission group eventually received gamma knife surgery, two medical treatment (cabergoline or lanreotide), one radiotherapy and another one was under observation. Demographic and clinical characteristics of 63 patients were given in Table 1. The male to female ratio was 1.25. The mean age at diagnosis was 45 ± 12 years. Symptoms and signs of hyperthyroidism were present in 68.25% (43/63) of patients while space-occupying effect such as headache or visual field defects were noticed in 15.87% (10/63) of patients. Amenorrhea was present in 7.14% (2/28) of female patients. However, 22.22% (14/63) of patients presented nonsymptoms. In the 49 patients who received thyroid ultrasonography examination, thirty-two patients (65.31%) were found to have nodules. The median tumor size was 14.5 (9, 25) mm in 63 patients. Forty-five patients (76.27%) had macroadenomas and fourteen patients (23.73%) had microadenomas. The mean postoperative follow-up time was 28.81 ± 17.18 months. Postoperative complications cerebrospinal fluid (CSF) rhinorrhea occurred in one patient.

Table 1

Preoperative demographic and clinical characteristics of 63 patients with TSHoma
Parameters	Value
Age (y)	45 ± 12
Male (%)	35(55.56)
Female (%)	28(44.44)
BMI (kg/m2)	21.52 ± 2.52
Clinical Presentation
Hyperthyroidism-related symptoms (%)	43(68.25)
Space-occupying effect (%)	10(15.87)
Amenorrhea (%) ^a	2 (7.14)
No symptoms (%)	14(22.22)
Macroadenoma (%)	45(76.27)
Diameter (mm)	14.5(9,25)
Postoperative Follow-up time (m)^b	28.81 ± 17.18

^a Included 28 females.

^bExcluded 4 patients lost to follow up.

Data are presented as the mean ± SD, median (range), or n (percentage)

Preoperative hormone levels of 63 patients with TSHoma

Preoperative hormone levels of 63 patients were given in Table 2. The median TSH, T3, T4, FT3 and FT4 levels were 5.24 (4.17,7.63) mIU/L, 3.22 (2.72,4.10) nmol/L, 168.92 (147.90, 198.13) nmol/L, 9.86 (8.50, 11.91) pmol/L and 30.55 (26.21, 38.12) pmol/L respectively. Moreover, we found that TPOAb positive rate was 28.26% (13/46), TgAb 8.7% (4/46) and TRAb 5.13% (2/39) in our analysis. No patients had co-secretion with other hormones such as GH, PRL or cortisol. All the patients were diagnosed as pure TSHomas with elevated thyroid function to exclude silent TSHomas.

Table 2

Preoperative hormone levels of 63 patients with TSHoma
Parameters	Value
TSH (mIU/L)	5.24(4.17,7.63)
T3 (nmol/L)	3.22(2.72,4.10)
T4 (nmol/L)	168.92(145.90,198.13)
FT3 (pmol/L)	9.86(8.50,11.91)
FT4 (pmol/L)	30.55(26.21,38.12)
GH (ng/mL)	0.80(0.30,2.20)
IGF1 index^a (ULN)	0.79 ± 0.33
PRL (ng/mL)	16.70(10.54,24.13)
Morning cortisol (µg/dl)	11.76 ± 5.54

^a IGF1 index was expressed as value of IGF1-to-reference (upper limits) ratio according to age and sex.

Data are presented as the mean ± SD or median (range)

Preoperative characteristics of patients between remission and nonremission

Characteristics of patients between remission and nonremission were exhibited in Table 3. T3, T4, FT4 and FT3 levels were higher in the nonremission group compared to the remission group, but there was no statistical significance. The results of the short-term SSA test did not differ between the remission and nonremission groups (75% vs. 79%). The radiological features were analyzed in 50 patients whose MRI images were available (Table 4). The median tumor size was 12 (8.5, 19.5) mm in remission group while 29.5 (17.5, 37) mm in nonremission group (P < 0.05). Patients with larger tumors tended to achieve nonremission. 6.98% of patients were consider to be Knosp grade 4 in remission group while 42.86% in nonremission group (P = 0.02). Tumor invasion into cavernous sinus or suprasellar with chiasm compression also strongly predicted nonremisson. In the non-extension group, remission was achieved in 100% of patients. However, remission was achieved in 78.57%, 78.26% and 68.75% of patients respectively in cavernous sinus, sphenoid sinus and suprasellar extension group (supplementary Fig. 1, sFigure1).

Table 3

Preoperative characteristics of patients between remission and nonremission
Characteristic	remission n = 52	nonremission n = 7	P value
Age (y)	43.71 ± 12.93	45.86 ± 10.64	P = 0.677
BMI (kg/m2)	22.48(20.00,24.25)	20.55(19.94,21.82)	P = 0.454
TSH (mIU/L)	5.34(4.00,7.81)	4.18(3.96,8.90)	P = 0.871
T3 (nmol/L)	3.23(3.03,4.53)	4.08(3.12,5.01)	P = 0.447
T4 (nmol/L)	171.1(160.2,212.68)	191.2(185.78,201.48)	P = 0.267
FT3 (pmol/L)	10(8.54,12.78)	11.5(11.45,13.20)	p = 0.131
FT4 (pmol/L)	31.9(27.87,38.31)	37.43(30.26,39.99)	P = 0.397
TSH inhibition rate by octreotide (%)	75(53,86)	79(72.75,84.5)	P = 0.525

Data are presented as the mean ± SD, median (range), or n (percentage)

^* Statistically significant at p < 0.05.

Table 4

Radiological features in 50 patients with TSHoma
Feature	Remission, n = 43	Nonremission, n = 7	P
TSHoma diameter (mm)	12(8.5,19.5)	29.5(17.5,37)	P = 0.024^*
Tumor extension
Sphenoid sinus	18(41.86%)	5(71.43%)	P = 0.099
Suprasellar	11(25.58%)	5(71.43%)	P = 0.019^*
Chiasm compression	11(25.58%)	5(71.43%)	P = 0.019^*
Knosp Grade
Knosp Grade 0	21(48.84%)	1(14.29%)	P = 0.057
Knosp Grade 1	10(23.26%)	0(0%)	P = 0.053
Knosp Grade 2	4(9.3%)	1(14.29%)	P = 0.268
Knosp Grade 3	5(11.63%)	2(28.57%)	P = 0.158
Knosp Grade 4	3(6.98%)	3(42.86%)	P = 0.02^*

Data are presented as median (range) or n (percentage)

^* Statistically significant at p < 0.05.

sFigure1. Different remission rates according to different tumor extension.

Diagnostic efficacy of postoperative hormone levels for long-term remission of TSHoma

TSH levels did not differ significantly between the remission and nonremission groups at any of the postoperative time points (1 day, 1 month, 3 months, 6 months, 12 months and over 12 months after surgery). However, T3, T4, FT3 and FT4 all differed significantly between the remission and nonremission groups at 3 months after surgery (Table 5). Distribution of postoperative hormone levels after surgery between remission and nonremission were displayed in sFigure2. ROC analysis of T3, T4, FT3 and FT4 showed that the AUCs were very high at 3 months after surgery (sFigure3). The optimal T3, T4, FT3, and FT4 cutoff levels at 3 months after surgery were 2.12 nmol/L, 129.65 nmol/L, 6.29 pmol/L and 20.65 pmol/L respectively as determined by Youden’s index (Table 6). With the optimal cutoff levels, the T3 level at 3 months after surgery reliably predicted long-term remission with 75% sensitivity and 89.5% specificity (87.72% of positive predictive value and 78.17% of negative predictive value), the T4 level with 100% sensitivity and 89.5% specificity (90.5% of positive predictive value and 89.5% of negative predictive value), the FT3 level with 80% sensitivity and 100% specificity (80% of positive predictive value and 83.33% of negative predictive value), and the FT4 level with 100% sensitivity and 94.7% specificity (94.97% of positive predictive value and 94.7% of negative predictive value). Postoperative thyroid function at 3 months was the strongest predictor, especially for FT4 level with a 20.65pmol/L cutoff.

Table 5

Postoperative hormone levels of patients between remission and nonremission in the long-term follow-up
	Postoperative course		nonremission	P value
TSH (mIU/L)	1d	0.12(0.03,0.29)	0.35(0.13,0.60)	P = 0.076
	1m	0.81(0.33,1.80)	1.76(0.44,4.61)	P = 0.295
	3m	1.08(0.38,1.31)	2.44(1.01,7.25)	P = 0.138
	6m	1.06(0.89,1.77)	2.86(0.79,4.53)	P = 0.340
	12m	1.72(1.02,3.04)	1.13(1.01,1.25)	P = 0.211
	> 12m	1.51(0.99,2.91)	2.93(1.23,7.41)	P = 0.261
TT3 (nmol/L)	1d	1.10(0.84,1.53)	1.25(0.81,1.33)	P = 0.810
	1m	1.54(1.12,1.69)	1.54(1.23,1.84)	P = 0.737
	3m	1.58(1.44,1.84)	2.62(1.78.4.01)	P = 0.035^*
	6m	1.72(1.50,2.10)	2.34(1.99,3.78)	P = 0.027^*
	12m	1.61(1.39,1.80)	1.93(1.81, -)	P = 0.229
	> 12m	1.58(1.35,1.78)	1.68(1.51,1.90)	P = 0.341
TT4 (nmol/L)	1d	110.95(85.18,145.10)	120.70(83.30,134.88)	P = 0.891
	1m	84.35(69.63,99.67)	78.55(67.55,100.15)	P = 0.970
	3m	91.50(81.00,111.90)	148.55(133.68,181.28)	P = 0.003^**
	6m	100.71(94.25,127.22)	156.60(100.70,178.85)	P = 0.160
	12m	95.50(73.59,121.85)	128.55(123.10, -)	P = 0.229
	> 12m	101.80(82.87,110.50)	115.00(85.90,116.00)	P = 0.433
FT3 (pmol/L)	1d	3.43(2.70,4.36)	3.66(2.38,4.24)	P = 0.900
	1m	3.87(3.42,4.35)	4.81(3.48,9.06)	P = 0.130
	3m	4.44(3.89,4.97)	8.89(5.57,12.04)	P = 0.001^**
	6m	4.75(4.25,5.24)	6.01(5.41,12.50)	P = 0.005^**
	12m	4.51(3.64,5.23)	5.75(4.58,6.28)	P = 0.171
	> 12m	4.52(4.16,5.01)	4.96(3.56,5.25)	P = 0.791
FT4 (pmol/L)	1d	19.54(13.84,26.41)	20.92(15.47,31.97)	P = 0.558
	1m	12.11(11.15,15.50)	14.46(10.82,19.16)	P = 0.758
	3m	14.70(11.83,17.89)	23.68(21.43,32.17)	P = 0.000^***
	6m	16.04(14.57,18.39)	20.91(18.47,35.48)	P = 0.011^*
	12m	13.64(11.79,19.50)	24.72(17.88,25.40)	P = 0.064
	> 12m	15.30(13.29,18.48)	18.18(13.24,21.67)	P = 0.311
Data are presented as median (range)

^* Statistically significant at p < 0.05.

^** Statistically significant at p < 0.01.

^*** Statistically significant at p < 0.001.

sFigure2. Distribution of postoperative hormone levels between remission and nonremission in the long-term follow-up. TSH levels did not differ significantly between the remission and nonremission groups at any of the postoperative time points. T3, T4, FT3 and FT4 all differed significantly between the remission and nonremission groups at 3 months after surgery. The statistical analysis was given in Table 5.

sFigure3. ROC curve of postoperative hormone levels (3 months after surgery). ROC analysis of T3, T4, FT3 and FT4 showed that the AUCs were very high at 3 months after surgery

Table 6

Postoperative hormone levels (3 months after surgery), their optimal cutoff, and AUC
	optimal cutoff	sensitivity (%)	specificity (%)	AUC (95%CI)
TT3 (nmol/L)	2.12	75	89.5	0.842(0.631-1.000)
TT4 (nmol/L)	129.65	100	89.5	0.947(0.856-1.000)
FT3 (pmol/L)	6.29	80	100	0.937(0.813-1.000)
FT4 (pmol/L)	20.65	100	94.7	0.979(0.928-1.000)

TSHomas are rare tumors, occurring in one per million people and representing 0.5%-2.7% of all pituitary adenomas[1–3]. It has been reported that the incidence of TSHoma is rising probably due to the routine measurement of thyroid function and ultrasound examination. The male to female ratio was 1.25 in our analysis which is higher than 0.93 in a systematic review of 535 adults[4]. Mean age at diagnosis was 45 ± 12 years, which is similar to the 46 ± 6 years in the review. 68.25% of our patients presented hyperthyroidism which is lower than 75% in the review. However, 22.22% of our patients were asymptomatic. Due to its untypical clinical features, early diagnosis of TSHoma is difficult. The majority (76.27%) of the TSHomas were macroadenoma which is similar to the 76.9% in the review. We further described a worse clinical outcome associated with larger tumor size and tumor extension, but not associated with thyroid function, age or body mass index (BMI), which is consistent to the previous studies[4, 8, 9]. However, Ki67 index was similar between two groups (1.51 ± 1.04% in remission group vs. 1.64 ± 1.19% in nonremission group).

All of our patients were administrated preoperatively with somatostatin analogs (SSAs) such as octreotide or lanreotide. As reported, SSAs may lead to thyroid function normalization in up to 73–100% of cases, reduction in tumor size between 20–70% and improvement in visual field defects[8]. Administration of SSAs preoperatively could improve surgical outcome by reducing tumor size, but until now there is no consensus since some studies did not observe improved outcomes and because preoperative euthyroid status was not associated with a higher rate of remission. Antithyroid drugs (methimazole or propylthiouracil) or SSAs, alone with propranolol, are recommended to restore euthyroidism before surgery in 2013 European Thyroid Association guidelines[5], though there is a need to be cautious of using antithyroid drugs alone due to its feedback regulation of increasing TSH levels. SSAs have inhibitory effects on the secretion of TSH via binding to somatostatin receptor (SSTR), particularly SSTR2 and SSTR5[10]. Moreover, it was shown that SSAs bind with high affinity to SSTR2 and relatively lower affinity to SSTR5. Thus, the difference in the expression levels of SSTR5 and SSTR2 in TSHomas may explain or predict the different outcomes of treatment with SSAs. 88.14% of our patients achieved postoperative endocrinological remission, higher than the reported 20–84%[2, 7, 11–14]. All tumors expressed SSTR2 and PIT-1 in our study.

Remission for patients with Cushing’s disease after surgery, typically defined as serum cortisol < 55nmol/L (< 2 µg/dL) within 7 days, is seen in approximately 80% of patients with microadenomas and 60% with macroadenomas[15]. For patients with acromegaly, a serum GH 0.14g/L suggests “surgical remission”, and a level 1g/L indicates “control” and normalization of the mortality risk, which may be performed as early as postoperative day 1 while IGF-1 level measured at 12 weeks after surgery are a valid reflection of surgical remission[16]. However, we found that few of the clinical or biochemical parameters had a predictive value for remission for TSHoma. There was one research which enrolled 31 patients reporting that the immediate postoperative TSH level at 12 hours after surgery was the strongest predictor with a 0.62 µIU/mL cutoff[7]. TSH and FT4 levels were measured at 2, 6, 12, 18 and 24 hours after the operation to determine whether these values could predict postoperative remission. Otherwise, one Chinese research reported that TSH levels at 3 days and 1 month after surgery were significantly associated with 1-year postoperative remission[17]. The 2013 European guidelines issued by the European Thyroid Association and update in 2019 propose that an undetectable TSH level one week after surgery is indicative of complete resection[1, 5, 6]. In our analysis, we found that T3, T4, FT3 and FT4 levels between remission and nonremission groups all significantly differed at 3 months after surgery. We further determined the optimal T3, T4, FT3, and FT4 level cutoffs at 3 months after surgery, which were 2.12 nmol/L, 129.65 nmol/L, 6.28 pmol/L and 20.65 pmol/L respectively. We all know that thyroid function at 1 month after surgery could be affected by preoperative SSAs administration or postoperative stress leading to low T3/T4 syndrome. Therefore, 3 months after surgery could be the proper time to evaluate thyroid function for early identification of long-term endocrinological remission. The current guidelines suggest to clinically and biochemically evaluate the patient three times in the first postoperative year and once yearly thereafter. Pituitary imaging is recommended every 2–3 years regardless of thyroid function test and earlier if thyroid hormone levels increase or visual filed defects occur[5]. According to our study, postoperative thyroid function at 3 months was the strongest predictor for remission, especially for FT4 level with a 20.65pmol/L cutoff; thus, patients possibly do not need to be evaluated frequently.

There were some limitations in our study. The number of patients was small, especially in the nonremission group, which made it difficult to further conduct logistic regression analysis and have statistical significance. The conclusion should be testified by large-scaled studies, and longitudinal follow-ups were necessary in the following investigations. All patients were treated preoperatively with SSAs, thereby potentially limiting the generalizability of the series.

We described a worse clinical outcome associated with the larger tumor size, tumor extension and higher Knosp grade, but not associated with preoperative thyroid function, age or body mass index. Postoperative thyroid function at 3 months could be used as a clinical prediction tool for long-term endocrinological remission especially for FT4 level with a 20.65pmol/L cutoff.

Acknowledgements The authors are indebted to the patients who participated in this study and all the doctors involved in the diagnosis and treatment of these patients.

Author Contributions Conception and design: Min He, Hongying Ye. Acquisition of data: Linling Fan, Zhihong Wang, Qiaoli Cui, Wei Wu, Boni Xiang, Zengyi Ma. Analysis and interpretation of data: Linling Fan, Wanwan Sun. Drafting the article: Linling Fan. Analyzing radiological features: Yue Wu. Critically revising the article: Yongfei Wang, Yao Zhao, Yiming Li, Min He, Hongying Ye. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Hongying Ye. Administrative/technical/material support: Hongying Ye. Study supervision: Min He, Hongying Ye.

Funding No funding was received for conducting this study.

Data Availability The datasets generated and analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests The authors declare no competing interests.

Ethics approval This study was performed in accordance with the ethical standards outlined in the Declaration of Helsinki. In accordance with the institutional (Huashan hospital, Fudan university) IRB-approved protocol, patients provided written informed consent prior to study participation.

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No competing interests reported.

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Early identification of postoperative remission for thyrotropin-secreting adenomas

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Abstract

Purpose

Methods

Results

Conclusions

Figures

Introduction

Materials and methods

Patient Population

Physical Examination and Laboratory Testing

Statistical Analysis

Results

Preoperative demographic and clinical characteristics of 63 patients with TSHoma

Preoperative hormone levels of 63 patients with TSHoma

Preoperative characteristics of patients between remission and nonremission

Diagnostic efficacy of postoperative hormone levels for long-term remission of TSHoma

Discussion

Conclusion

Declarations

References

Additional Declarations

Supplementary Files

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