Pituitary Micro Research Articles

A Headache - Free Journey: Managing Pituitary Micro - Adenoma in a Young Unmarried Woman

A Headache - Free Journey: Managing Pituitary Micro - Adenoma in a Young Unmarried Woman

Management of comorbid schizophrenia with prolactinome (about a case)

IntroductionProlactin adenoma, called “prolactinoma” is a benign neoplasm, it is the most common secreting pituitary tumor, and represents up to 40% of all pituitary adenomas. More than 90% are small intrasellar tumors which rarely increase in size.Objectivesthe problem of management lies in how to stabilize the patient on a psychiatric level without increasing the level of prolactin.MethodsWe report the case of a young woman who presented a comorbid schizophrenia with a prolactinoma. We will try through this clinical vignette to study the different pillars of management of such pathologies.At the same time, we did a literature review. The main search engines used were Pubmed, medline, and Science Direct. The keywords Prolatinoma schizophrenia olanzapineResultsThis is Mrs. N. Q., 39 years old She is single, an engineer but currently without a profession, from an average socio-economic level of a teacher father and a housewife mother. She is the 3rd of his siblings of 6 . She is currently hospitalized at Ar-razi Tanger hospital for treatment of decompensation of her chronic psychotic disorder. The patient would have been born following a premature delivery of 34 weeks. For her antecedent, she was followed for asthma since her childhood. Her mother and her maternal grandfather would have been psychotic. The history of the disease dates back to 2017. The patient suffered from headaches resistant to any treatment. The patient would have consulted a neurologist. Magnetic resonance brain imaging would have been requested, which objectified at the left latero-pituitary level a lesional process of 7 mm discretely intense in T2, hypo-intense in T1 and not enhanced by Gd reflecting a pituitary micro adenoma. The patient was put on Cabergoline (Dostinex®). So the psychiatric symptomatology dates back to the end of 2019, by behavioral problems, social withdrawal, she will have stopped all professional activity. At the same time, she will have stopped all medication (Cabergoline). In 2020, the patient would have been hospitalized for the first time at the Ar-razi Tangier psychiatric hospital. The diagnosis of schizophrenia was retained according to the DSM 5 criteria. After a stay of 5 weeks, the patient would be stabilized on olanzapine 20mg/d. Currently, and following non-compliance with treatment (because of adverse effects such as amenorrhea and galactorrhea), the patient has returned, suffering from a relapse, justifying her second hospitalization. During his stay, a check-up would have been requested to show hyperprolactinemia 3 times normal. We therefore switched to Aripiprazole.ConclusionsWe have proposed an approach to the management of patients with comorbid schizophrenia and prolactinoma, an approach that balances the benefits and risks of managing the psychiatric stability of the patient on antipsychotics with the management of prolactinoma and symptoms. of hyperprolactinemia.Disclosure of InterestNone Declared

Abstract #994648: Cushing Disease; A Diagnostic Puzzle.

we report here a case of cushing disease secondary to pituitary micro adenoma with diagnostic challenges due to discrepancy in radiologic and IPSS findings.

Secondary SUNCT Syndrome in a Patient with Rathke’s Cleft Cyst and Hyperprolactinemia: a Case Report

Pathophysiology of short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) remains unclear. SUNCT is considered the primary type of a headache, but several cases of secondary SUNCT syndrome were described in patients with pituitary neoplasms, mainly pituitary micro- and macroadenomas. Rathke’s cleft cyst is a suprasellar noncancerous cystic lesion. We described a new case of SUNCT in a patient with Rathke’s cleft cyst with persistent hyperprolactinemia at the beginning of the headaches. After beginning of treatment with antiepileptic drugs (topiramate 75 mg/day, followed by replacement lamotrigine 75 mg/day), the headaches regressed. Also, cabergoline 0.5 mg was added to the therapy, 1 time a week; after 4 months, the level of prolactin was normalized, after beginning of dopamine agonists. After discontinuation of all treatments, after 4 months, the patient again began to develop daily single headaches, clinically similar to those that were at the onset of the disease, against the background of an increase in blood prolactin levels. Against the background of normalization of prolactin level, the headaches disappeared. We assume that in this case, the main reason for the secondary SUNCT was an influence of anatomical structures and caused neuroendocrine changes in the hypothalamus-pituitary system, but there are still discussions about what mechanism is the main reason for SUNCT. Therefore, clinicians should also pay attention to the history of symptoms associated with tumors in the pituitary gland and perform magnetic resonance imaging of the brain, pituitary gland, and screening for hormonal disorders in the blood serum.

S216. CASE REPORT OF TREATMENT OF NEUROLEPTIC MALIGNANT SYNDROME IN CHILD ADOLESCENT

BackgroundNeuroleptic Malignant Syndrome is a rare clinical syndrome occurring due to idiosyncratic reaction after use of neuroleptics. We report a case of neuroleptic malignant syndrome in an adolescent patient with schizophrenia after treatment with antipsychotics.MethodsCase report.ResultsA 15-year-old male Schizophrenic patient was admitted to the psychiatric closed ward due to worsening of psychotic symptoms on July of 2017. Pineal cystoma and pituitary microadenoma were detected incidentally on MRI, and consultation with the department of pediatrics recommended close observation.After treatment with 6mg of risperidone in combination with 300 mg of quetiapine, psychotic symptoms improved enough to be discharged.Since March 25th of 2019, due to manifestation of paralytic ileus from worsening of underlying constipation, all the oral medications were stopped along with NPO for treatment; in addition, IM injection of haloperidol was only allowed for the symptom control. The day before the onset of neuroleptic malignant syndrome, IM injection of 15 mg of haloperidol and 10 mg of lorazepam resulted in vomiting, headache, fever of 39℃, systemic tremor and stiffness, confusion in consciousness, tachycardia and sweating. On April 1st of 2019, with suspicion of neuroleptic malignant syndrome, the patient was transferred to ICU at our institution. Blood work-up performed on day of admission at ICU indicated CPK 2836 IU/L and myoglobulin 337.2 ng/ml, and CPK, after peaking at 4493 IU/L, continuously decreased and was normalized by the 18th day at ICU. Diazepam (IV), dantrolene, domperidone, L-Dopa/benserazideand and cold blanket were applied because the patient continuously screamed due to fever, stiffness, tremor, and psychotic symptoms. Even though confusion improved after 3 days, nausea and vomiting persisted for 8 days. Tremor, stiffness, and fever were stabilized after 3 days. Tachycardia improved after 17 days. Recovery of hematologic abnormalities such as increased CPK and myoglobulin and leukocytosis were followed by stabilization of tremor, stiffness, and high fever on the 18th day.The patient was transferred out of ICU after 18 days, and symptoms were all stabilized after treatment with clozapine.DiscussionEvaluation of risk factors of NMS in patients requiring neuroleptics is most critical in order for prompt differentials and early intervention.Known risk factors are 1) male, 2) combination of more than two antipsychotic, 3) history of previous EPS symptoms or NMS, 4) psychiatric disorders such as severe agitation, mood disorder, or delirium, 5) recent initiation or increasing dose of antipsychotics, 6) IM injection of antipsychotics, 7) poor physical conditions like dehydration, infection, malnutrition, brain tumor, encephalitis, or AIDS, 8) use of zuclopenthixol acetat (clopixol acuphase), and 9) substance abuse.In this case, because the patient had 6 of the risk factors described above, which are biological vulnerabilities due to pineal cystoma and pituitary micro adenoma, dehydration and malnutrition caused by paralytic ileus, and sudden change in IM antipsychotics and dosage, it was critical to consider more carefully in medication injection and changes in dosage.Once diagnosed with NMS, immediate hydration and efforts to lower body temperature are critical to prevent complications like acute renal failure, and use of dantrolene, bromocriptine, and benzodiazepine is helpful in shortening the treatment period.In cases of NMS in patients who cannot terminate use of neuroleptics due to underlying mental disorders, ECT is an effective method to treat both NMS and mental disorders. Safety and efficacy of ECT have been already proven, and it is highly recommended when needed.

Abstract #806932: Rare Case of Cushing’s Syndrome and Primary Aldosteronism with Imaging Findings of Bilateral Adrenal Masses With Coexisting Pituitary Micro Adenoma Presenting with Severe Hypokalaemia and Unusual Electromyography Findings

Abstract #806932: Rare Case of Cushing’s Syndrome and Primary Aldosteronism with Imaging Findings of Bilateral Adrenal Masses With Coexisting Pituitary Micro Adenoma Presenting with Severe Hypokalaemia and Unusual Electromyography Findings

Long-term outcomes of tissue-based ACTH-antibody assay-guided transsphenoidal resection of pituitary adenomas in Cushing disease.

OBJECTIVE Cushing disease is caused by a pituitary micro- or macroadenoma that hypersecretes adrenocorticotropic hormone (ACTH), resulting in hypercortisolemia. For decades, transsphenoidal resection (TSR) has been an efficacious treatment but with certain limitations, namely precise tumor localization and complete excision. The authors evaluated the novel use of a double-antibody sandwich assay for the real-time quantitation of ACTH in resected pituitary specimens with the goals of augmenting pathological diagnosis and ultimately improving long-term patient outcome. METHODS This study involved a retrospective review of records and an analysis of assay values, pathology slides, and MRI studies of patients with Cushing disease who had undergone TSR in the period from 2009 to 2014 and had at least 1 year of follow-up in coordination with an endocrinologist. In the operating room, biopsy specimens from the patients had been analyzed for tissue ACTH concentration. Additional samples were simultaneously sent for frozen-section pathological analysis. The ACTH assay performance was compared against pathology assessments of surgical tumor samples using receiver operating characteristic (ROC) analysis and against pre- and postoperative MRI studies. RESULTS Fourteen patients underwent TSR with guidance by ACTH-antibody assay and pathological assessment of 127 biopsy samples and were followed up for an average of 3 years. The ACTH threshold for discriminating adenomatous from normal tissue was 290,000 pg/mg of tissue, based on jointly maximized sensitivity (95.0%) and specificity (71.3%). Lateralization discordance between preoperative MRI studies and surgical visualization was noted in 3 patients, confirming the impression that MRI alone may not achieve optimal localization. A majority of the patients (85.7%) attained long-term disease remission based on urinary free cortisol levels, plasma cortisol levels, and long-term corticosteroid therapy. Comparisons of patient-months of remission and treatment failure showed that the remission rate in the study sample statistically exceeds the rate in historical controls (71.9%; p = 0.0007, Fisher's exact test). Long-term unexpected hormonal deficiencies were statistically similar between study patients (29%) and those in a meta-analysis (25%; p = 0.7596, Fisher's exact test). CONCLUSIONS These preliminary findings reflect the promising potential of tissue-based ACTH-antibody-guided assay for improving the cure rates of Cushing disease patients undergoing TSR. Further studies with larger sample sizes, further refinements of assay interpretation, and longer-term follow-ups are needed.

Efficacy of sellar opening in the pituitary adenoma resection of transsphenoidal surgery influences the degree of tumor resection

BackgroundEndonasal transsphenoidal microsurgery is often adopted in the resection of pituitary adenoma, and has showed satisfactory treatment and minor injuries. It is important to accurately localize sellar floor and properly incise the bone and dura matter.MethodsFifty-one patients with pituitary adenoma undergoing endonasal transsphenoidal microsurgery were included in the present study. To identify the scope of sellar floor opening, CT scan of the paranasal sinus and MRI scan of the pituitary gland were performed for each subject. Intraoperatively, internal carotid artery injury, leakage of cerebrospinal fluid, and tumor texture were recorded, and postoperative complications and residual tumors were identified.ResultThe relative size of sellar floor opening significantly differed among the pituitary micro-, macro- and giant adenoma groups, and between the total and partial tumor resection groups. The ratio of sellar floor opening area to maximal tumor area was significantly different between the total and partial resection groups. Logistic regression analysis revealed that the ratio of sellar floor opening area to the largest tumor area, tumor texture, tumor invasion and age were independent prognostic factors. The vertical distance between the top point of sellar floor opening and planum sphenoidale significantly differed between the patients with and without leakage of cerebrospinal fluid.ConclusionThese results together indicated that relatively insufficient sellar floor opening is a cause of leading to residual tumor, and the higher position of the opening and closer to the planum sphenoidale are likely to induce the occurrence of leakage of cerebrospinal fluid.

Managing Prolactinomas during Pregnancy.

Prolactinomas are the most prevalent functional benign pituitary tumors due to a pituitary micro- or macroadenoma. The majority of patients presents with infertility and gonadal dysfunction. A dopamine agonist (DA) (bromocriptine or cabergoline) is the treatment of choice that can normalize prolactin levels, reduce tumor size, and restore ovulation and fertility. Cabergoline generally preferred over bromocriptine because of its higher efficacy and tolerability. Managing prolactinomas during pregnancy may be challenging. During pregnancy, the pituitary gland undergoes global hyperplasia due to a progressive increase in serum estrogens level that may lead to increase of the tumor volume with potential mass effect and visual loss. The risk of tumor enlargement may occur in 3% of those with microadenomas, 32% in those with macroadenomas that were not previously operated on, and 4.8% of those with macroadenomas with prior ablative treatment. Though both drugs appear to be safe during pregnancy, the data on fetal exposure to DAs during pregnancy have been reported with bromocriptine far exceeds that of cabergoline with no association of increased risk of pregnancy loss and premature delivery. It is advisable to stop the use of DAs immediately once pregnancy is confirmed, except in the case of women with invasive macroprolactinomas or pressure symptoms. This review outlines the therapeutic approach to prolactinoma during pregnancy, with emphasis on the safety of available DA therapy.

English

AIM: To study the proportion of patients with visual field defects in pituitary adenomas And to study the pattern of visual field defects in pituitary adenomas. MATERIALS AND METHODS: 24 patients diagnosed with a pituitary adenoma underwent complete ophthalmic and Humphrey's Perimetry 30 - 2 visual field test at Department of ophthalmology, M. S Ramaiah Hospital between November 2011 to May 2013. RESULTS: Among the 24 cases in the study, 3 cases were of pituitary micro adenoma constituting 12.5% and the remaining cases (21 cases) were pituitary macro adenoma, constituting 87.5%. Visual acuity of 6/6 - 6/12 were observed in 28 (58.3%) out of total 48 eyes. Visual field defects were observed in 19 cases (79%). Bilateral temporal hemianopia was observed in the majority (41%) of cases with field defects. One eye blind and contra lateral temporal hemianopia was observed in 20.8%. One eye temporal hemianopia and other eye involvement of 3 quadrants seen in 2 patients (8.4%). 5 patients had no visual field defects. CONCLUSION: Although ophthalmologists have a minor role in primary diagnosis of pituitary adenoma, routine ophthalmologic examination is very important. To detect early visual field defects, automated perimetry should be done as a part routine examination in patients with suspected pituitary

Coexistence of macroprolactinaemia and hyperprolactinaemia in women with oligo-/amenorrhoea is associated with high risk of pituitary adenomas

Macroprolactin may cause elevation of prolactin (PRL) concentrations measured by standard assays. In our study, we assessed the prevalence of pituitary lesions in women with macroprolactinaemia and either oligomenorrhoea or secondary amenorrhoea. Pituitary MRI scans were performed in 61 women aged 31.0 ± 6.7 years (mean ± SD), with raised PRL concentrations due to macroprolactinaemia, detected by 25% polyethylene glycol (PEG) precipitation method (PRL recovery <40%). After PEG precipitation of macroprolactin, free PRL concentrations were still raised in 36 (59%) women. Microadenomas were detected in 10 patients out of 61 (16.4%), with raised free PRL in 9 of these cases, while macroadenomas were detected in 4 out of 61 (6.6%) women, all of whom also had raised free PRL. In case of coexistence of macroprolactinaemia and raised free PRL after PEG precipitation of macroprolactin, the chance of finding of either a micro- or a macroadenoma was 36% (13 cases out of 36). We conclude that hyperprolactinaemia and macroprolactinaemia may coexist in the same patient. Furthermore, if free PRL is raised after PEG precipitation of macroprolactin, then the chance of finding either a pituitary micro- or macroadenoma in women with oligo-/amenorrhoea is over 30%. Therefore pituitary magnetic resonance imaging is mandatory in all such cases.

Pituitary Adenomas Can Appear as Hypermetabolic Lesions in 18F‐FDG PET Imaging

The 2-deoxy-2-[(18) F] fluoro-D-glucose positron emission tomography (FDG-PET) scan is commonly used in detection and staging of many malignant neoplasms. However, several benign or non-neoplastic conditions avidly accumulate (18) F-FDG, causing ambiguity in interpretation of results. It is unknown whether pituitary adenomas uptake (18) F-FDG and appear positive in PET imaging. Here, we present 2 cases of benign pituitary adenoma with elevated metabolic activity in (18) F-FDG PET scan. Medical, neurologic, and psychiatric histories; physical examination findings; laboratory work up results; and pathologic and imaging studies were documented. The (18) F-FDG-PET images revealed foci of marked FDG uptake in pituitary adenomas of 2 patients. Pituitary micro- and macro-adenomas may present as hypermetabolic foci on (18) F-FDG PET scan.

Surgical treatment of nonfunctioning pituitary adenomas

Small nonfunctioning pituitary (micro)adenomas are encountered frequently as incidental findings. Large (macro)adenomas present with visual compromise, hypopituitarism or headache. Indications for surgery include loss of vision, diplopia, other symptoms of a space occupying intracranial lesion and documented tumor progression during serial imaging. Their primary treatment is surgical resection. To exclude medical treatment options, a preoperative endocrinological investigation is mandatory. To date, more than 90% of operations in patients with nonfunctioning pituitary adenomas are performed via the transsphenoidal route. There are several variations of transnasal surgery available, with and without dissection of the nasal septum. Only tumors where the predominant mass lesion is essentially located outside the sella require transcranial operations. These are usually performed via a frontotemporal or frontolateral craniotomy. Surgical decompression of visual pathways is usually followed by a rapid improvement of vision. Whether or not the tumor mass can be completely resected depends on the size and localization of the adenoma and the surgical expertise. Several patients experience an improvement of pituitary function. Potential complications of surgery include loss of vision, vascular injury, cerebrospinal fluid fistula, meningitis and hypopituitarism. Modern technical developments, such as the use of the endoscope, intraoperative magnetic resonance imaging and neuronavigation, are being increasingly appreciated by neurosurgeons throughout the world.

Transsphenoidal microsurgery: past, present and future

In this report, we first describe the history of transsphenoidal surgery. We further elaborate on three fundamental surgical anatomy principles of transsphenoidal surgery for pituitary adenomas. First, the pituitary gland and, therefore, pituitary adenomas are extra-arachnoid structures, therefore the operation should be executed without penetration into the subarachnoid space. Second, the pituitary gland and, therefore, pituitary adenomas are midline structures, thus, veering off midline can result in potentially serious complications. Third, pituitary adenomas commence inside the pituitary gland, which distends around them as they grow. Thus, pituitary macroadenomas are surrounded on their surface by a layer of attenuated residual normal anterior pituitary. The operative technique for pituitary micro- and macroadenomas is described in detail. Finally, we discuss the likely future treatment methods for pituitary adenomas.

Commentary

BACKGROUNDThe surgical treatment of pituitary adenomas in elderly patients (i.e., over 70 years of age) is a special problem because of the increased rate of perioperative complications and the reduced tolerance of postoperative fluid and electrolyte imbalance. Therefore, the unquestionable progress in the pharmacological and radiotherapy may not allow these patients the option of radical surgical treatment. We report our experience with the transsphenoidal procedure for pituitary adenomas in aged patients in an attempt to contribute to a better definition of the actual role of surgery.METHODSTranssphenoidal surgery was performed in 11 patients over 70 years of age affected by various histological types of pituitary micro- and macroadenomas, ranging from Hardy Grade I through IIIc. Special care was dedicated to the postoperative treatment, in particular to water and electrolyte balances, and to the immediate treatment of any pathological variation of these parameters.RESULTSWe had no mortality and no postoperative adjunctive morbidity. All the patients recovered well from the operation with an average hospital stay of 20 days. The tumor removal was complete in six cases and partial in the remaining five. With an average follow-up of 2 years, we did observe only one case of symptomatic recurrence of the disease.CONCLUSIONSTranssphenoidal surgery in the elderly is feasible and quite safe in the hands of an experienced team, if special care is devoted to the preoperative selection of patients and to the postoperative treatment of fluid and electrolyte imbalance.

Adrenal Tuberculosis in Cushing's Disease with Bilateral Macronodular Adrenocortical Hyperplasia

Cushing's disease is a disorder of hypercortisolism caused by a pituitary micro- or macro-adenoma. Most patients with Cushing's disease have a bilateral adrenal enlargement, which depends on the duration of the disease, as a result of the long standing ACTH stimulation of both adrenal glands. However, in macronodular adrenocortical hyperplasia (MNH) that is caused by Cushing's disease, if the MNH gains autonomy, a bilateral adrenalectomy, as well as the removal of pituitary adenoma, is often essential. We encountered a patient diagnosed with Cushing's disease with bilateral adrenal tuberculosis simulating MNH. She had taken anti-tuberculosis medications one year prior to admission due to spinal tuberculosis. Sellar MRI revealed a pituitary macroadenoma, but adrenal CT showed enlargement in both adrenal glands that appeared to be MNH. A hormonal study and bilateral inferior petrosal sinus sampling revealed Cushing's disease. Therefore, she underwent trans-sphenoidal surgery of the pituitary mass. The pituitary surgery was successful and the serum cortisol returned to normal range. However, the adrenal mass rapidly enlarged after removing the pituitary tumor without showing evidence of a recurrence or adrenal autonomy of hypercortisolism. Accordingly, a laparoscopic left adrenalectomy was performed to examine the nature of the mass. The resected left adrenal gland was pathologically determined to have a lesion of tuberculosis with some part of the intact cortex. So we assumed that the cause of rapid adrenal enlargement might be due to adrenal tuberculosis. In summary, to the best of our knowledge, this is the first case of Cushing's disease coexisting with both adrenal tuberculosis simulating a bilateral MNH.

Effect of TRH on beta-gonadotropin subunits in patients with pituitary microincidentalomas.

To explore the hypothesis that most of the pituitary abnormalities compatible with the diagnosis of microadenoma, and detected in about 10% of the normal adult population, represent asymptomatic gonadotropinomas. Patients diagnosed with pituitary microincidentalomas at the Institute of Endocrinology of the Tel Aviv Medical Center were evaluated. Circulating beta-subunits of gonadotropin hormones were measured before and 30, 45, 60 and 90 min after the intravenous injection of 400 microgram TRH. Twenty-two patients with pituitary incidentaloma and 16 normal volunteers were tested. In 16 of the 22 patients, an abnormal beta-subunit response was detected after the TRH challenge. Three patients had an abnormal increase in both beta-FSH and beta-LH after TRH administration. Isolated pathological beta-FSH or beta-LH responses were demonstrated in five and eight patients respectively. Six patients had normal basal and stimulated gonadotropin subunit values, raising the possibility that their lesions were not pituitary microadenomas. There was a significant overall difference between the response to TRH of the patient and control groups. In the gonadotropin positive group, comprising 16 patients, serum beta-FSH increased from 6.4+/-1.6 ng/ml to 9.2+/-1.3 ng/ml (P=0.042) 1 h after TRH stimulation, whereas no changes were detected in the control group after TRH injection (basal: 4.1+/-0.8 ng/ml, peak: 5.1+/-0.8 ng/ml; P=0.15). Serum beta-LH increased from 10.5+/-3.2 ng/ml to 23.4+/-4.9 ng/ml (P=0.0037) at this time, in contrast to a lack of response in controls (basal: 6.4+/-1.5 ng/ml, peak: 8.2+/-2.3 ng/ml; P=0.24). In about 73% of patients with pituitary incidentalomas smaller than 10 mm, TRH elicits an increase in gonadotropin beta-subunits. This observation raises the possibility that non-functioning pituitary micro- and macroadenomas, which share a similar response to TRH, originate in a common ancestor cell type, probably a pituitary gonadotrope.

The surgical treatment of pituitary adenomas in the eighth decade

BACKGROUND The surgical treatment of pituitary adenomas in elderly patients (i.e., over 70 years of age) is a special problem because of the increased rate of perioperative complications and the reduced tolerance of postoperative fluid and electrolyte imbalance. Therefore, the unquestionable progress in the pharmacological and radiotherapy may not allow these patients the option of radical surgical treatment. We report our experience with the transsphenoidal procedure for pituitary adenomas in aged patients in an attempt to contribute to a better definition of the actual role of surgery. METHODS Transsphenoidal surgery was performed in 11 patients over 70 years of age affected by various histological types of pituitary micro- and macroadenomas, ranging from Hardy Grade I through IIIc. Special care was dedicated to the postoperative treatment, in particular to water and electrolyte balances, and to the immediate treatment of any pathological variation of these parameters. RESULTS We had no mortality and no postoperative adjunctive morbidity. All the patients recovered well from the operation with an average hospital stay of 20 days. The tumor removal was complete in six cases and partial in the remaining five. With an average follow-up of 2 years, we did observe only one case of symptomatic recurrence of the disease. CONCLUSIONS Transsphenoidal surgery in the elderly is feasible and quite safe in the hands of an experienced team, if special care is devoted to the preoperative selection of patients and to the postoperative treatment of fluid and electrolyte imbalance.

Twenty-four hour secretory pattern of prolactin in hyperprolactinaemic patients with pituitary micro- and macroadenomas.

No nocturnal increase of prolactin (Prl) secretion during sleep has reportedly been discernible in most cases of hyperprolactinaemic patients with pituitary tumour. However, subjects previously evaluated, were in the majority, patients with large pituitary tumour. In the present study, 24 h secretory pattern of Prl was evaluated in 4 hyperprolactinaemic women with pituitary microadenoma and in 4 hyperprolactinaemic women with pituitary macroadenoma. Nocturnal increase of Prl secretion was observed in patients with microadenoma, but not in patients with macroadenoma. The nocturnal increase of Prl secretion in patients with microadenoma may reflect the function of the adenoma cells, and may suggest that the basic central nervous system programme governing Prl secretion in normals is qualitatively preserved in these patients. Alternatively, the nocturnal increase of Prl secretion may reflect the function of the normal lactotrophs remaining in these patients.