Non-functioning Macroadenoma Research Articles

7102 Pituitary Apoplexy with Eventual Complete Tumour Involution

Abstract Disclosure: A. Ng: None. R. Lai: None. Pituitary apoplexy is an endocrinological emergency resulting from infarction or haemorrhage of the pituitary gland. We present a case of pituitary apoplexy from a non-functioning pituitary macroadenoma, complicated by pituitary insufficiency and subsequent tumour involution. An 80-year-old gentleman presented to the Emergency Department with sudden severe headaches and persistent vomiting and admitted for further evaluation. Computed tomography (CT) imaging of the brain showed a prominent pituitary gland and magnetic resonance imaging (MRI) confirmed a large sellar hyperintense lesion containing blood and proteinaceous material. It measured 1.6 cm by 1.2 cm by 1 cm and indented the optic chiasm. CT angiography did not reveal any aneurysms or intracranial haemorrhage. There were no neurological or visual field deficits at presentation. There was no indication for surgery upon neurosurgical consultation. Initial evaluation of the pituitary axis was consistent with central hypocortisolism (cortisol 75 nmol/L, adrenocorticotropic hormone 1.4 pmol/L [reference range (RR) 1.6-13.9]) and hypoprolactinaemia (prolactin 56 mIU/L, RR 73-351). Luteinising hormone levels were < 1 IU/L (RR 1-9); follicle stimulating hormone levels were 3 IU/L (RR 1-19) and testosterone levels were < 1 nmol/L (RR 5 to 30) as the patient was on androgen deprivation therapy for prostate cancer. Hydrocortisone was started and he was monitored for development of frank diabetes insipidus. He did not require regular desmopressin. He later developed anti-diuretic hormone mediated hyponatraemia (serum sodium nadir of 125 mmol/L, serum osmolality 275 mmol/kg, urine osmolality 390 mmol/kg) that was managed with fluid restriction and solute loading. He also developed central hypothyroidism on day 19 of admission (free thyroxine 11 pmol/L, thyroid stimulating hormone 0.49 mIU/L, RR 0.45-4.5) and oral levothyroxine was started. He was discharged with oral hydrocortisone and levothyroxine replacement. A repeat MRI of the pituitary 2 months later showed complete resolution of the mass and resolution of the mass effects. He was kept on oral hydrocortisone and levothyroxine replacement with regular follow-up.Most pituitary macroadenomas are non-functional, and can present with complications of apoplexy, mass effects or hormonal disturbances. However, the natural history of non-functional macroadenomas is not well known as most are operated on. Spontaneous regression of the tumour can rarely occur, notably in the setting of apoplexy and lymphocytic hypophysitis. Recovery of the pituitary axis may also accompany tumour regression. As spontaneous remission of pituitary macroadenomas may occur, close observation of tumours without visual field defects or significant mass effects may be an alternative to surgery. Presentation: 6/1/2024 12:15:00 PM

8209 Silent Somatotroph Adenoma Unmasked as Pituitary Apoplexy, Disguised as Subarachnoid Hemorrhage

Abstract Disclosure: P. Vemparala: None. S. Challagulla: None. Introduction - Pituitary apoplexy is a rare and potentially life-threatening complication associated with pituitary adenomas, particularly in cases of nonfunctioning macroadenomas. Silent somatotroph adenomas, characterized by the presence of growth hormone (GH) immunoreactivity without manifesting signs and symptoms of acromegaly, are uncommon. This case report presents a distinctive instance where pituitary apoplexy served as the initial manifestation of a GH-immunoreactive tumor. CASE PRESENTATION- A 45-year-old male with a medical history of hypertension, sleep apnea, and hypogonadism sought emergency medical attention following a syncopal episode. Post-syncope, he reported severe headache and neck pain, with no other associated symptoms. Imaging revealed a subarachnoid hemorrhage and a sellar/suprasellar mass measuring approximately 2.8 x 3.6 x 4.2 cm. CT angiography ruled out an aneurysm or vascular malformation. The subarachnoid hemorrhage was attributed to hemorrhage within the sellar mass. Treatment with Nimodipine and levetiracetam was initiated. Laboratory investigations indicated normal insulin-like growth factor 1 (IGF-1) levels. Brain MRI revealed a 4.2 x 2.3 x 2.6 cm heterogeneous enhancing cystic sellar/suprasellar lesion causing mass effect on the hypothalamus and third ventricle. The patient underwent endoscopic transsphenoidal hypophysectomy, revealing a tumor that was diffusely positive for GH and synaptophysin immunostaining and negative for prolactin and ACTH. Ki67 was less than 5%, with no apparent mitotic activity, atypia, or tumor necrosis. The postoperative course was uneventful, and the patient was discharged on oral steroids. Conclusion- Silent somatotroph adenomas constitute a small percentage (2-4.2%) of pituitary adenomas. In contrast to silent gonadotroph adenomas, these tumors are more prevalent in women, tend to present earlier and exhibit higher recurrence rates. This case emphasizes the potential of silent somatotroph adenomas to manifest initially as pituitary apoplexy. It underscores the importance of vigilant post-surgical follow-up due to the possibility of recurrence. Additionally, recognizing pituitary apoplexy as subarachnoid hemorrhage is crucial for timely intervention and appropriate management. Presentation: 6/2/2024

Hypopituitarism, Diabetes Insipidus, and Syndrome of Inappropriate Antidiuretic Hormone Secretion after Pituitary Macroadenoma Surgery with Indocyanine Green Dye.

(1) Background: Pituitary adenomas are benign tumors comprising about 18% of all intracranial tumors, and they often require surgical intervention. Differentiating pituitary tissue from adenoma during surgery is crucial to minimize complications. We hypothesized that using ICG dye would reduce the hormonal complication rates. (2) Methods: A prospective randomized study (February 2019-October 2023) included 34 patients with non-functional macroadenomas of the pituitary gland randomly assigned to receive intraoperative ICG or be in the control group. All underwent endoscopic endonasal transsphenoidal surgery. Pituitary function was assessed preoperatively, immediately postoperatively, and 3-6 months postoperatively. Adenohypophysis function was evaluated with hormonal tests (Cosyntropin stimulation test, TSH, fT3, fT4, prolactin, IGF-1, FSH, LH, and testosterone in men) and neurohypophysis function with fluid balance, plasma and urine osmolality, and serum and urinary sodium. (3) Results: Of the 34 patients (23 men, 11 women; average age 60.9 years), 5.9% in the ICG group developed diabetes insipidus postoperatively, compared to 23.5% in the control group. Adenohypophysis function worsened in 52.9% of the ICG group and in 35.3% of the control group. (4) Conclusions: Our study did not confirm the benefits of using ICG in these surgeries. Further research with a larger sample is needed.

FRI342 Hypophysitis Mimicking As Pituitary Adenoma

Abstract Disclosure: A. Chao: None. A. Dhaliwal: None. K. Yu, MD: None. S.N. Polis: None. N.J. Vernetti: None. S. Nakhle: None. Background: Hypophysitis is defined as inflammation of the pituitary gland and causes include lymphocytic, granulomatous, xanthomatous, and IgG4 related hypophysitis. Hypophysitis can sometimes mimic a pituitary mass. It is more common in the female and associated with pregnancy. Lymphocytic hypophysitis may present with symptoms related to expansion of the pituitary gland and hormone deficiency. Expansion of the gland often causes headaches. Compression of the optic chiasm results in a decrease in the visual field, color perception, and in rare cases, diplopia due to lateral expansion of the pituitary gland.It also affects hypothalamic-pituitary axis and commonly impairs hormone production from corticotrophs, gonadotrophs and thyrotrophs. Patients treated with glucocorticoids can have hormonal recovery and resolutions of imaging findings. Clinical Case: Patient is a 30-year-old, previously healthy, female who initially presented to the emergency department with a worsening headache over the preceding three months. Brain MRI demonstrated a 1.8 cm enhancing mass and the radiologist interpreted the findings as a pituitary macroadenoma. The patient was seen by neurosurgery and was started on high doses of dexamethasone at 4 mg twice a day for three months duration. After treatment, the patient’s headache improved although she reported an 80-pound weight gain. CT of the head three months later reported a prominent pituitary gland in size compatible with history of pituitary adenoma but decreased in size to 0.9 cm. Repeated brain MRI six months after treatment showed resolution of the mass. The patient also noted a cessation of her menstrual cycle around the onset of headache and laboratory evaluation consistent with hypogonadotropic hypogonadism (FSH 5.5 mIU/mL, LH 2.8 mIU/mL and estradiol 22 pg/mL). Regular menstrual cycles returned seven months after glucocorticoid treatment. Almost two years after the onset of her headaches, the patient was referred to the endocrine clinic for further evaluation of fatigue, low libido, and persistent weight gain. Repeat anterior pituitary function tests were unremarkable and showed FSH 5.6 mIU/mL, LH 3.3 mIU/mL, Estradiol 34 pg/mL, Sodium 139 mmol/L, IGF-1 129 ng/mL (-0.4 standard deviation), Ferritin 20 ng/mL, Prolactin 15.6 ng/mL, TSH 4.38 mIU/L, T4 free 1.1 ng/dL, Cortisol AM 10.9 mcg/dL, and Testosterone 13 ng/dL. Conclusion: We present a case of hypophysitis mistaken for a non-functioning macroadenoma with mild mass effect on the undersurface of the optic chiasm, headache and hypogonadotropic hypogonadism. The patient did not have risk factors such as pregnancy or other autoimmune conditions. After glucocorticoid treatment, recovery of hypogonadotropic hypogonadism and resolution of headache, and radiographic findings. Presentation: Friday, June 16, 2023

The impact of transsphenoidal surgery on pituitary function in patients with non-functioning macroadenomas

PurposeTranssphenoidal surgery for non-functioning pituitary adenomas (NFPAs) can alter pituitary function. We assessed the rates of improvement and deterioration of pituitary function by axis and searched for predictive factors of these outcomes.MethodsWe reviewed consecutive medical files from patients having had transsphenoidal surgery for NFPA between 2004 and 2018. Pituitary functions and MRI imaging were analyzed prior and after surgery. The occurrence of recovery and new deficit were documented per axis. Prognostic factors of hormonal recovery and new deficits were searched.ResultsAmong 137 patients analyzed, median tumor size of the NFPA was 24.8 mm and 58.4% of patients presented visual impairment. Before surgery, 91 patients (67%) had at least one abnormal pituitary axis (hypogonadism: 62.4%; hypothyroidism: 41%, adrenal insufficiency: 30.8%, growth hormone deficiency: 29.9%; increased prolactin: 50.8%). Following surgery, the recovery rate of pituitary deficiency of one axis or more was 46% and the rate of new pituitary deficiency was 10%. Rates of LH-FSH, TSH, ACTH and GH deficiency recovery were 35.7%, 30.4%, 15.4%, and 45.5% respectively. Rates of new LH-FSH, TSH, ACTH and GH deficiencies were 8.3%, 1.6%, 9.2% and 5.1% respectively. Altogether, 24.6% of patients had a global pituitary function improvement and only 7% had pituitary function worsening after surgery. Male patients and patients with hyperprolactinemia upon diagnosis were more likely to experience pituitary function recovery. No prognostic factors for the risk of new deficiencies were identified.ConclusionIn a real-life cohort of patients with NFPAs, recovery of hypopituitarism after surgery is more frequent than the occurrence of new deficiencies. Hence, hypopituitarism could be considered a relative indication for surgery in patients with NFPAs.

Endoscopic endonasal transsphenoidal approach during COVID-19 pandemic in Brazil.

Endoscopic endonasal transsphenoidal approach (EETA) is a well-established technique for sellar tumor resection. However, this route causes aerosol dispersion from the nasal cavity. In the context of the coronavirus (COVID-19) pandemic, new measures were taken aiming at the safety and protection of patients and health-care professionals. Herein, we present a Brazilian experience with EETA during COVID-19 pandemic. This study was based on the review of medical records and observation in the operating room of the patients undergoing endoscopic surgery in the period from May 2020 to July 2022. All patients were tested by real-time polymerase chain reaction (RT-PCR) COVID-19 before and after surgery. Since September 2021, it has been mandatory to present vaccination cards for adults (over 18 years old). This case series included 28 patients and 35 surgical procedures using the EETA, who presented of nonfunctioning macroadenomas (19 cases - 67.8%), GH-secreting tumor (three cases - 10.8%), ACTH-secreting tumor (three cases - 10.8%), meningiomas (two cases - 7.1%), and Rathke's cleft cyst (one case - 3.5%). There were eight cases of diabetes insipidus (28.5%), five cases of cerebrospinal fluid leak (17.8%), and one case of meningitis (3.5%). Three patients died due to meningitis (one case), carotid occlusion (one case), and COVID-19 complications (one case). A simple protocol was established to perform EETA during the COVID-19 pandemic. The pituitary surgeries were maintained to treat critical cases. To date, the protocol should be continually updated to improve the procedure's safety.

Magnetic resonance imaging finding of coexistence of bilateral paraclinoid aneurysms in a patient with a nonfunctioning macroadenoma, simultaneous resection, and clipping: illustrative case.

BACKGROUNDUnruptured incidental intracranial aneurysm can coexist with pituitary adenoma, however, the occurrence is extremely rare. Timely diagnosis of asymptomatic intracranial aneurysms with pituitary adenoma may lead to planning a tailored surgical strategy to deal with both pathologies simultaneously. A case of a patient who underwent transcranial resection of a pituitary adenoma with clipping of two mirror aneurysms is reported.OBSERVATIONSA 55-year-old female presented with deterioration of visual acuity that progressed over 1 year, as well as presence of right eyelid ptosis. Magnetic resonance imaging of the head showed the presence of an intrasellar pituitary macroadenoma. Bilateral paraclinoid aneurysms were documented to be in contact with the pituitary tumor. The patient underwent surgery with simultaneous aneurysm clipping and tumor resection through a standard pterional approach with intradural clinoidectomy. The aneurysms were successfully clipped after the tumoral debulking. After clipping, the pseudocapsule was fully resected.LESSONSVarious treatment options are available. Although endovascular securing of the aneurysms prior to the tumor resection would be ideal, in cases in which this resource is not readily available at all times, the surgeon must be prepared to solve pathologies with an elevated level of complexity.

Comparative analysis of rhinologic outcomes in Cushing disease and non-functioning pituitary adenoma in patients submitted to endoscopic endonasal transsphenoidal surgery.

Adrenocorticotropic hormone (ACTH) secreted by pituitary tumors lead to changes in nasal cavity anatomy and physiology. As a consequence of hormonal alteration, there is an abnormal soft tissue and an increased capillary fragility, inducting to a thinner mucosa that acts in the healing process. We compared post-operative nasal alterations in patients with Cushing's disease versus patients with non-functioning macroadenomas who underwent endoscopic endonasal transsphenoidal surgery. A retrospective study with 14 patients with Cushing's disease who underwent initial transsphenoidal endonasal surgery for an ACTH-secreting adenoma was conducted. Forty-two patients who underwent the same surgery for non-functioning adenomas were selected as controls. The following data were collected: operative technique, endoscopic alterations in late post-operative period and post-operative nasal complaints. There were 13/14 (92.9%) females with Cushing disease versus 23/42 (54.8%) in the non-functioning adenoma group. Surgical approach was similar in both groups, with no differences in flap usage, turbinectomies or ethmoidectomies. No difference occurred concerning endoscopic alterations or nasal complaints in post-operative period. Post-operative results are similar, and healing could be expected to be equal.

Suprasellar extension independently predicts preoperative pituitary hormone deficiencies in patients with nonfunctioning pituitary macroadenomas: a single-center experience.

Nonfunctioning pituitary adenomas (NFPAs) are among the commonest benign tumors of the pituitary. Hypopituitarism is frequently present at the time of diagnosis, and this has been attributed to stalk portal vessel compression and/or destruction of normal anterior pituitary cells. The aim of our study was to examine possible factors at diagnosis associated with the presence of hypopituitarism. We retrospectively evaluated the records of patients with nonfunctioning pituitary macroadenomas from the database of our department. The inclusion criterion was the availability of imaging data regarding the extension of the lesion. A total of 148 patients (89 men, 60.1%) with nonfunctioning macroadenomas and available imaging data were identified. Mean age at diagnosis was 56.0 ± 14.5years, and hypopituitarism was found in 66.2%. The maximum diameter of the adenoma, the patient's age at diagnosis, and compression of the optic chiasm were significant factors predicting the presence of hypopituitarism (OR 1.077, p = 0.006; OR 1.025, p = 0.045; and OR 2.893, p = 0.042, respectively). Suprasellar adenomas with extension to adjacent sinuses, although larger than those with only suprasellar extension, did not differ as to the degree of hypopituitarism. Moreover, in suprasellar adenomas, prolactin levels, albeit not independently, were also related to hypopituitarism (OR 1.035, p = 0.045). In patients with NFPAs, prognostic factors related to increased risk of hypopituitarism are age at diagnosis, size of the adenoma, and most importantly the presence of suprasellar extension. These data accentuate the necessity for surgical decompression in case of suprasellar extension, in order, apart from saving visual acuity, to possibly avoid or reverse hypopituitarism.

Pituitary non-functioning macroadenomas: If and when to recommend surgery

Pituitary non-functioning macroadenomas: If and when to recommend surgery

Influence of Variables on Hormone Profile in Endoscopic Transsphenoidal Surgery for Pituitary Adenomas

Objective: to evaluate the hormone profiles of patients with pituitary adenomas operated on in Hospital das Clínicas, UniversidadeFederal de Goiás (HC-UFG), correlating them with the variables age, sex, and Knosp grade. Method: This is a retrospective quantitativestudy of medical records, including a total population of 20 patients diagnosed with pituitary adenomas operated on using the pureendoscopic endonasal transsphenoidal approach. The hormone profiles of the three types of pituitary adenoma prevalent in this institutionwere analyzed: nonfunctioning macroadenoma, growth hormone-secreting pituitary adenoma (acromegaly), and adrenocorticotropichormone-secreting pituitary adenoma (Cushing’s disease). Pre and postoperative hormone values were statistically paired with thevariables selected. Results: The global levels of the specific hormones of each disease decreased after surgery. However, no statisticalsignificance was found between the variables selected in this study and the pre and postoperative hormone values. Conclusion:The main surgical goal, the specific hormones decrease, was achieved in all the surgeries performed. Analyzing the relationshipbetween the variables and the hormone profiles, we conclude that age, sex, and Knosp grade did not influence the results obtained.

Increased frequency of cataract surgery in patients over age 50 with pituitary macroadenomas and chiasmal compression.

Patients with visual loss from macroadenomas compressing their optic apparatus may also have concomitant age-related visual pathology such as cataracts. How these two pathologies interact with each other is not well documented. The interaction between these two pathologies in elderly patients is the subject of this study. We identified a series of non-functioning macroadenoma patients over age 50years with tumors compressing the chiasm who underwent transsphenoidal surgery at our institution between 2004 and 2018. Pre- and post-operative visual complaints, tumor size and extent of resection were analyzed. Prevalence of the diagnosis of cataract and prevalence of cataract surgery in each decade were compared with national averages. We identified 200 patients who met selection criteria. 18% of these patients had a diagnosis of cataract and 12.5% had cataract surgery. Compared with the Eye Diseases Prevalence Research Group (EDPRG) study, the prevalence of cataract surgery was 2.5 times the national average of 5.1%. 32% of these patients had no improvement in their vision after cataract surgery but 76% improved after transsphenoidal surgery. We reported a high prevalence of cataract surgery in patients over age 50 in patients with pituitary macroadenomas compressing the optic pathway compared with national averages in patients without adenomas. While visual loss from adenoma likely precipitated more cataract surgeries in this group of patients, some who may not have required it, those patients with cataracts who did not have their cataracts extracted were less likely to recover vision after transsphenoidal surgery. Addressing both pathologies is beneficial.

SAT-LB075 Pituitary Function after Surgery for Non-Functioning Macroadenoma: A Tertiary Single Center Retrospective Cohort

Introduction: Non-functional pituitary adenomas (NFPA) represent the second most frequent cause of pituitary tumors after prolactinomas. For those patients that harbor a macroadenoma, surgery is indicated in case of visual function disturbances, risk for future optic nerve or chiasm compression, and tumor progression during follow-up. Hypopituitarism, in this context, is only a relative indication for surgery and the available data regarding postoperative hormonal outcomes are inconsistent. The aim of this study was to evaluate the impact of transphenoidal surgery on pituitary function. Methods: We retrospectively analyzed data from 350 patients having had pituitary surgery in a tertiary center, from March 2004 to January 2018, and included 137 non-functioning or gonadotroph adenomas, on the basis of histology reports. There were 40.9% males and 59.1% females, with a mean age of 60 years old at the time of surgery. For 89.9% of patients, indication for surgery was based on visual impact or risk. Mean tumor diameter was 24.8 mm. Patients were operated on with a microscopic trans-septal transsphenoidal approach, by the same experienced surgeon. Hormonal evaluation data were retrieved and patients were classified as normal or deficient, by axis. Pituitary magnetic resonance imaging, before and after surgery, was also analyzed, and the average of the three diameters was calculated. Results: In our cohort, new insufficiencies were observed in 5.1% of patients for the GH axis, 9.2% of patients for the ACTH axis, 8.3% for the FSH/LH axis, and 1.6% for the TSH axis. Among patients with hyperprolactinemia prior to surgery, 71.4% normalized prolactin values postoperatively. Recovery of preoperative insufficiencies was observed in 45.5%, 15.4%, 35.7% and 30.4% for the GH, ACTH, FSH/LH and TSH axis respectively. Logistic regression analysis showed that patients with the smallest decrease in tumor size where at higher risk for developing new insufficiencies after surgery (odds ratio: 11.37, 95% CI: 1.13-114,96) and that male sex was associated with a higher chance of postoperative hormonal recovery (odds ratio: 2.74, 95% CI: 1.11-6.78). Conclusion: Pituitary insufficiency is restored in more than one third of patients after surgery for NFPAs, whereas, new deficiencies appear in less than 10% of patients with previously normal function, with ACTH axis being the most fragile and TSH axis being the most resistant to damage. Poor postoperative results, in terms of volume decrease, are associated with higher risk of new deficiencies. Unless otherwise noted, all abstracts presented at ENDO are embargoed until the date and time of presentation. For oral presentations, the abstracts are embargoed until the session begins. s presented at a news conference are embargoed until the date and time of the news conference. The Endocrine Society reserves the right to lift the embargo on specific abstracts that are selected for promotion prior to or during ENDO.

Infrasellar Extension of Pituitary Macro-Adenomas

AbstractBackground: Growth patterns of pituitary adenomas have been observed to vary according to the histopathological subtype.Aim of Study: The authors aimed to analyse infrasellar extension pattern in cases of functional and non-functional macroadenomas.Patients and Methods: Retrospective analysis of pituitary adenoma patients who underwent endoscopic trans-sphenoidal surgery in the time period between 2007 and 2013 at our institute. Patients with microadenomas and prior operations were excluded from the analysis. Preoperative MR images were reviewed to assess patterns of extrasellar extension in the varying tumor subtypes.Results: The cohort comprised 150 patients, after exclusion of microadenomas and previously operated patients, the analysis involved 93 cases. Most of the cases were non-functional macroadenomas (66 patients, 71%), the remaining were functional macroadenomas (GH-macroadenoma: 17 patients, 18%; Macroprolactinoma: 8 patients, 9%; TSH-producing macroadenoma: 1 patient, 1%; and ACTH-cell macroadenoma: 1 patient, 1%). Extension of the non-functional macroadenomas occurred into the following regions: Supra-sellar, 63 patients (96%); infrasellar, 11 patients (17%); and parasellar, 17 patients (26%). Extension of the GH-mac-roadenomas occurred into the following regions: Suprasellar, 7 patients (41%); infrasellar, 9 patients (53%); and parasellar, 3 patients (18%). Extension of macroprolactinomas occurred into the following regions: Suprasellar, 8 patients (100%); infrasellar, 2 patients (25%); and parasellar, 4 patients (50%). Isolated infrasellar extension was noticed in 8 patients with GH-macroadenoma (47%) and in 2 patients with non-functional macroadenoma (3%). GH-macroadenomas had higher overall rates of infrasellar extension (53%, p<0.05), and isolated infrasellar extension (47%, p<0.05).Conclusions: Extrasellar growth patterns in cases of pituitary macroadenoma showed substantial differences in relation to histological subtypes. GH-macroadenomas dem-onstrated a tendency for infrasellar extension. Existing data suggests lower surgical cure rates in adenomas with infrasellar extension. This fact may contribute particularly to the low normalisation rate after GH-adenoma surgery. If adaption of surgical technique may lead to better results, should be addressed in prospective studies.

Empirical versus progression-guided stereotactic radiosurgery for non-functional pituitary macroadenomas after subtotal resection.

There is a lack of consensus regarding whether if residual non-functional macroadenomas (NFM) should undergo empirical stereotactic radiosurgery (SRS) or be monitored until tumor progression before SRS treatment. The aim of this study is to compare the risks and benefits of empirical versus progression-guided SRS for NFM after subtotal resection. This is a retrospective study of consecutive NFM patients who subtotal surgical resection followed by SRS between 1999 and 2014. Patients were dichotomized into two groups: empirical SRS (SRS without evidence of tumor progression) and progression-guided SRS (SRS after demonstration of tumor progression) groups. Tumor response was categorized into: (1) regression, ≥ 10% decrease in tumor volume; (2) stable, < 10% increase or decrease in tumor volume; and (3) progression, ≥ 10% increase in tumor volume. Tumor control comprised stable tumor response and tumor regression. Of the 112 patients who underwent SRS for NFM, 106 patients were treated for residual NFM after surgical resection, and included in the final analysis. The empirical SRS and progression-guided SRS groups comprised 46 and 60 patients, respectively. Overall tumor control rate was 88.7%. Higher rate of tumor control was achieved in the empirical SRS group compared to the progression-guided SRS group (95.65% vs. 83.33%, p = 0.047). Rates of new visual field deficit, cranial neuropathy and endocrinopathy were comparable between the two groups. Empirical SRS group had higher rates of progression-free survival compared to progression-guided SRS group (p = 0.015). Actuarial progression-free survival rates for the empirical SRS group were 93.2%, 93.2%, and 81.5% at 3, 5, and 10years after SRS. Actuarial progression-free survival rates for the progression-guided SRS were 86.4%, 82.1%, and 68.4% at 3, 5, and 10years after SRS. Empirical SRS offers higher rates of tumor control and progression-free survival compared to progression-guided SRS in patients with residual NFM after surgical resection. Rates of new hypopituitarism and cranial neuropathies were comparable between the two groups.

Endocrine function and gland volume after endoscopic transsphenoidal surgery for nonfunctional pituitary macroadenomas.

Loss of pituitary function due to nonfunctional pituitary adenoma (NFPA) may be due to compression of the pituitary gland. It has been proposed that the size of the gland and relative perioperative gland expansion may relate to recovery of pituitary function, but the extent of this is unclear. This study aims to assess temporal changes in hormonal function after transsphenoidal resection of NFPA and the relationship between gland reexpansion and endocrine recovery. Patients who underwent endoscopic transsphenoidal surgery by a single surgeon for resection of a nonfunctional macroadenoma were selected for inclusion. Patients with prior pituitary surgery or radiosurgery were excluded. Patient characteristics and endocrine function were extracted by chart review. Volumetric segmentation of the pre- and postoperative (≥ 6 months) pituitary gland was performed using preoperative and long-term postoperative MR images. The relationship between endocrine function over time and clinical attributes, including gland volume, were examined. One hundred sixty eligible patients were identified, of whom 47.5% were female; 56.9% of patients had anterior pituitary hormone deficits preoperatively. The median tumor diameter and gland volume preoperatively were 22.5 mm (interquartile range [IQR] 18.0-28.8 mm) and 0.18 cm3 (IQR 0.13-0.28 cm3), respectively. In 55% of patients, endocrine function normalized or improved in their affected axes by median last clinical follow-up of 24.4 months (IQR 3.2-51.2 months). Older age, male sex, and larger tumor size were associated with likelihood of endocrine recovery. Median time to recovery of any axis was 12.2 months (IQR 2.5-23.9 months); hypothyroidism was the slowest axis to recover. Although the gland significantly reexpanded from preoperatively (0.18 cm3, IQR 0.13-0.28 cm3) to postoperatively (0.33 cm3, IQR 0.23-0.48 cm3; p < 0.001), there was no consistent association with improved endocrine function. Recovery of endocrine function can occur several months and even years after surgery, with more than 50% of patients showing improved or normalized function. Tumor size, and not gland volume, was associated with preserved or recovered endocrine function.

Outcome of partially irradiated recurrent nonfunctioning pituitary macroadenoma by gamma knife radiosurgery.

Gamma knife treatment outcome of large pituitary tumors which are only partially irradiated secondary to immediate proximity to critical structures such as the optic apparatus have not been rigorously studied. From July 2003 to December 2013, there were 41 cases of recurrent or residual nonfunctioning pituitary macroadenoma partially treated with gamma knife radiosurgery (GKRS) because the adenoma obscured part of the optic apparatus on planning SRS MR imaging. The follow up period after GKRS was 92.3 ± 5.6months. The percentage of tumor coverage with the full dose was 88.5 ± 0.7%. Five of 43 (11.6%) patients experienced a transient visional decrease and one patient experienced a permanent visual field defect. During the follow up, two patients underwent transphenoidal surgery and one patient had a craniotomy due to tumor progression. Seven patients (16.2%) developed cortisol and thyroxine deficiencies. In multiple variant analyses, transient visual decline was correlated to the tumor volume (> 3.5cc), percentage of tumor coverage (< 90%), the distance from the optic apparatus to the pituitary stalk (> 15mm) and percentage of tumor above the orbital apex (65%). In the limited case of this cohort, we found that partially treated pituitary nonfunctioning macroadenoma yielded a high tumor control rate. However, visual decline as a result of tumor progression or radiation effect can occur in a minority of patients. The radiosurgical technique warrants further study to better define the long-term risk to benefit profile for its use in complex pituitary macroadenoma obscuring part of the optic apparatus.

Isolated pituitary metastasis from renal cell carcinoma in a horseshoe kidney

Objective: To describe a patient with isolated symptomatic pituitary metastasis from Renal Cell Carcinoma (RCC) in a horseshoe kidney.Case report: We report a case of 56-year-old man with RCC of a horseshoe kidney with symptomatic isolated pituitary gland metastasis. He initially presented to us for evaluation of a sellar mass. He complained of fatigue, 50-pound weight loss, anorexia, constipation and nonspecific abdominal pain for 4 months. CT head showed 2.6 cm × 1.8 cm × 2.5 cm sellar mass likely with bilateral cavernous sinus extension. Pituitary function evaluation revealed panhypopituitarism. CT abdomen/pelvis for the evaluation of abdominal pain showed 12.1 cm solid mass in the right renal moiety of a horseshoe kidney. Hydrocortisone and levothyroxine therapy led to cessation of weight loss, but unmasked diabetes insipidus requiring desmopressin therapy. Right heminephrectomy confirmed RCC. Soon after he complained of progressively worsening headache and visual disturbance. Histopathology from urgent trans-sphenoidal hypophysectomy revealed RCC. The patient began post-surgical radiotherapy, but eventually he declined further treatments. In the end, he was placed on hospice where he passed away.Conclusion: Symptomatic pituitary metastasis from RCC are rare and most of those occur in the setting of diffuse metastatic disease. They typically mimic signs and symptoms of non-functioning macroadenomas. They can be synchronous, metachronous or even the presenting lesion of the primary tumor. A pituitary mass in the setting of malignancy should raise suspicion for metastatic disease even though it is extremely rare.

Perioperative hypothalamic pituitary adrenal function in patients with silent corticotroph adenomas.

Silent corticotroph adenomas (SCAs) are characterized by strong ACTH immunostaining without clinical manifestations of hypercortisolism. Patients with SCAs often present with mechanical symptoms related to tumor growth. This study investigates the hypothalamic pituitary adrenal axis (HPA) characteristics after adenomectomy in patients with SCAs. Biochemical parameters of HPA function were monitored frequently after surgical resection of non-functioning macroadenomas. Levels of ACTH, cortisol, DHEA and DHEA-S were measured frequently for 48h after adenomectomy. HPA data of patients with SCAs (n = 38) were compared to others (Controls) with non-secreting, ACTH-negative immunostaining adenomas of similar age and gender distribution (n = 182) who had adenomectomy. Plasma ACTH increased (P < 0.0001) equally in patients with SCA and controls reaching a peak at 3h (238 ± 123 vs. 233 ± 96ng/L, respectively) after extubation declining thereafter to baseline values 24-36h. Similarly, serum cortisol levels increased (P < 0.0001) equally in both groups reaching a maximum at 7h (36.8 ± 13.9 vs. 39.3 ± 13.3ug/dL). Serum DHEA also increased (P < 0.001) equally in both groups in parallel to the rise in serum cortisol. Serum DHEA-S levels similarly increased (P < 0.001) from their respective baseline (105.9 ± 67.5 and 106.5 ± 58.7ug/dL) reaching their peak (154.5 ± 69.5 and 153.5 ± 68.6ug/dL; respectively) at 15h after extubation. None of the patients acquired any hormone deficits. Under the maximal stimulation of the peri-operative stress, HPA function in patients with SCA behaved in an identical manner to others with ACTH-negative macroadenomas. Thus, despite the strong ACTH-positive immunostaining of these tumors, SCAs are truly non- functional.

Does Low-Field Intraoperative Magnetic Resonance Improve the Results of Endoscopic Pituitary Surgery? Experience of the Implementation of a New Device in a Referral Center.

To assess the contribution of low-field intraoperative magnetic resonance (iMRI) to endoscopic pituitary surgery. We analyzed a prospective series of patients undergoing endoscopic endonasal surgery for pituitary macroadenomas assisted with a low-field iMRI (PoleStarN30, 0.15 T [Medtronic]). Clinical, radiologic, and surgical variables were analyzed and compared with our fully endoscopic historic cohort operated on without iMRI assistance. A bibliographic review of pituitary surgery assisted with iMRI was conducted. Thirty patients (57% female; mean age, 55 years) were prospectively analyzed. The most frequent tumor subtype was nonfunctioning macroadenoma (50%). The average Knosp grade was 2.3 and mean tumor size was 18 mm. Surgical and positioning time were 102 and 47 minutes, respectively. Hospital stay and complication rates were similar to our historical cohort for pituitary surgery. Mean follow-up was 10 months. Complete resection (CR) was achieved in 83% of patients. Seven patients (23%) benefited from iMRI assistance and achieved a CR in their surgeries. All patients except 1 experienced hormonal activity remission. iMRI sensitivity and specificity was 0.8 and 1, respectively. Although not statistically significant, CR rates were globally 11.5% superior in iMRI series compared with our historical cohort. This difference was independent of cavernous sinus invasiveness grade (CR rate increased 12.5% for Knosp grade 0-2 and 8.1% for Knosp grade 3-4). Low-field iMRI is a useful and safe assistance even in advanced surgical techniques such as endoscopy. Its contribution is limited by the intrinsic features of the tumor. Further randomized studies are required to confirm the cost-effectiveness of iMRI in pituitary surgery.