Surgical Management Of Pituitary Adenomas Research Articles

Surgical management of pituitary adenoma during pregnancy.

Although conservative treatment is typically recommended for pregnant patients with pituitary adenoma (PA), surgical treatment is occasionally necessary for those with acute symptoms. Currently, surgical interventions utilized among these patients is poorly studied. To evaluate the surgical indications, timing, perioperative precautions and postoperative complications of PAs during pregnancy and to provide comprehensive guidance. Six patients with PAs who underwent surgical treatment during pregnancy at Peking Union Medical College Hospital between January 1990 and June 2021 were recruited for this study. Another 35 pregnant patients who were profiled in the literature were included in our analysis. The 41 enrolled patients had acute symptoms including visual field defects, severe headaches or vision loss that required emergency pituitary surgeries. PA apoplexies were found in 23 patients. The majority of patients (55.9%) underwent surgery in the second trimester of pregnancy. A multidisciplinary team was involved in patient care from the preoperative period through the postpartum period. With the exception of 1 patient who underwent an induced abortion and 1 fetus that died due to a nuchal cord, 39 patients delivered successfully. Among them, 37 fetuses were healthy until the most recent follow-up. PA surgery during pregnancy is effective and safe during the second and third trimesters. Pregnant patients requiring emergency PA surgery require multidisciplinary evaluation and healthcare management.

Quality of Life After Endoscopic Surgical Management of Pituitary Adenomas.

Patient-reported quality of life (QOL) is a vital metric for surgical success. To assess the effect of surgery on QOL in the largest prospectively collected, longitudinal cohort of surgically managed pituitary adenomas. A consecutive surgical adenoma cohort (n = 304) between late 2016 and mid-2020 underwent a scheduled overall (Anterior Skull Base Questionnaire-35) and sinonasal-specific (Sinonasal Outcome Test-22) QOL assessment. Scores were stratified by adenoma subtype and analyzed for clinical predictors of QOL changes. The average age was 53.8 ± 16 yr, and 53% of participants were female. 60.9% of adenomas were nonfunctioning while adrenocorticotropic hormone adenomas (16.4%), growth hormone adenomas (14.1%), and prolactinomas (5.9%) were the most prevalent secreting adenomas. Baseline overall QOL differed between tumor types (P = .006), with adrenocorticotropic hormone adenomas worse than growth hormone adenomas (P = .03) and nonfunctioning pituitary adenomas (NFPA) (P < .001). Sinonasal QOL worsened in the 3 wk after surgery but returned to baseline by 6 wk and beyond. Overall QOL worsened at 3 wk after surgery (P < .001) but significantly improved from baseline by 3 mo (P = .009) and beyond (P < .001). Emotional functioning improved soon after surgery, followed by performance and pain, and then, by 6 mo, physical function and vitality. Predictors of improved QOL were sellar/suprasellar lesions (P = .01), prolactinomas (P = .003), and NFPA (P = .04). Conversely, new postoperative hypopituitarism (P = .04) and larger adenoma volume (P = .04) predicted QOL worsening. QOL is worsened after surgery at early time points. Prolactinomas and NFPA enjoy significant QOL improvements from surgery as early as 3 mo postoperatively. Other functional tumors may experience early benefits in younger patients without hypopituitarism and when isolated to the sellar/suprasellar region. These findings provide valuable information for counseling patients and setting expectations for surgery.

Endoscopic endonasal lateral transellar approach for growth hormone-secreting adenomas with cavernous sinus invasion: Technical note and surgical results

BackgroundCavernous sinus (CS) invasion is found in 15–20% of pituitary adenomas; it represents a poor prognosis factor and a surgical challenge even in experienced pituitary centers. We present our experience and technical note description for surgical management of pituitary adenomas with CS invasion in acromegaly by the transsellar lateral approach with an endoscopic endonasal transsphenoidal route. Methodprospective case series of patients who underwent endoscopic endonasal surgery for Growing Hormone (GH) producing adenomas with CS invasion treated at the Neurosurgery departments of National Institute of Neurology and Neurosurgery in Mexico City, and of Toluca Medical Center of Social Security Institute of the State of Mexico and Provinces between January 2014 and March 2019. ResultsThirty-two of 94 patients with diagnosis of pituitary adenoma treated at our institutions (34%) had acromegaly; thirteen of patients with acromegaly diagnosis met the inclusion criteria for CS invasion. Postoperative images reported gross total resection in 10 patients (76.9%). Mean follow-up time was 28.3 months. Remission criteria were achieved in nine patients (69.2%), with one of these patients (11.1%) having recurrence during follow up. All patients with no biochemical remission had improvement in GH and IGF profiles. Three patients without remission underwent radiosurgery (14Gy), and one patient had remission after the procedure. ConclusionsWe consider this to be a safe and efficient approach for tumors invading CS, when surgical team have good experience in endoscopy of the skull base and reconstruction techniques, appropriate instruments are available, and tumor has soft consistency.

Frailty does not preclude surgical success after endoscopic transsphenoidal surgery for pituitary adenomas.

Frailty is a state of physiological vulnerability that negatively influences surgical outcomes. The effect of frailty on pituitary adenoma surgery, however, is not clear, and patients may be wrongly denied surgery because they are "too frail". We examined the effects of frailty on surgical outcome and quality-of-life (QoL) in patients undergoing endoscopic transsphenoidal resection of pituitary adenomas. A prospective, consecutive cohort of surgically managed pituitary adenoma was analysed. Frailty was defined by the 5-factor modified Frailty Index (mFI-5) and the Charlson Comorbidity Index (CCI). QoL was measured by the anterior skull base questionnaire (ASBQ) and sinonasal outcomes test (SNOT). Of 304 patients with pituitary adenomas, 42 (13.8%) were frail (mFI5 of > 1). Frail patients tended to have smaller adenomas (p < 0.0001) with less suprasellar extension (p < 0.0001). Both overall (ASBQ) and sinonasal-specific (SNOT) QoL were not affected by frailty on multivariate analysis. Endocrine and visual outcomes were similarly not worsened by frailty. Overall, medical complications were uncommon, and perioperative morbidity or mortality was not significantly greater in the frail group. Frail patients experience the same QoL benefits from surgery as their non-frail counterparts, and have equivalently successful visual and endocrine outcomes. Frailty should not be seen as a barrier to successful surgical management of pituitary adenomas.

Transcranial approach for pituitary adenomas – An evaluation of surgical approaches over two decades and factors influencing peri-operative morbidity

PurposeTranscranial surgery(TCS) for pituitary adenoma(PA) is mostly reserved for lesions with widespread extensions. We sought to analyse the intraoperative challenges, morbidity and the factors associated with morbidity of transcranial approaches, in a large series from a tertiary neurosurgical institute. MethodsWe retrospectively evaluated 137 patients who underwent TCS for PA in our institute. The details of their clinical features, imaging, operative and peri-operative events and complications were collected and analysed. The factors associated with morbidity were evaluated. ResultsThe mean age of the cohort was 40.86 ± 13.35 years. 21 (15.3%) patients developed significant post-operative hematoma, out of which 7 patients (5.1%) required re-exploration. Post-operative diabetes insipidus was noted in 45 patients (32.84%), while SIADH was noted in 10 patients (7.35%). Other complications were cranial nerve palsy in 14 patients (10.2%), visual deterioration in 7 patients (5.1%). Neither tumour characteristics nor the choice of approach was associated with occurrence of post op hematoma. SIADH was significantly associated with patients with tumours involving cavernous sinus (p = 0.019) and subfrontal extension (p = 0.031). Patients with post-operative hematoma had significantly higher incidence of post-op DI (57.1% vs 28.7%; p = 0.021), while similar correlation was not noticed with SIADH (4.7 vs 7.8%). ConclusionTCS plays a distinct, albeit a small role in surgical management of pituitary adenoma. Tumour related or approach related factors are not significantly associated with the incidence of hematoma. Post-operative hematoma significantly influences the incidence of DI. A proper and judicious selection of approach and meticulous surgical technique should result in a reduction in associated morbidity and mortality.

Endoscopic endonasal lateral transellar approach for growth hormone-secreting adenomas with cavernous sinus invasion: Technical note and surgical results.

Cavernous sinus (CS) invasion is found in 15-20% of pituitary adenomas; it represents a poor prognosis factor and a surgical challenge even in experienced pituitary centers. We present our experience and technical note description for surgical management of pituitary adenomas with CS invasion in acromegaly by the transsellar lateral approach with an endoscopic endonasal transsphenoidal route. prospective case series of patients who underwent endoscopic endonasal surgery for Growing Hormone (GH) producing adenomas with CS invasion treated at the Neurosurgery departments of National Institute of Neurology and Neurosurgery in Mexico City, and of Toluca Medical Center of Social Security Institute of the State of Mexico and Provinces between January 2014 and March 2019. Thirty-two of 94 patients with diagnosis of pituitary adenoma treated at our institutions (34%) had acromegaly; thirteen of patients with acromegaly diagnosis met the inclusion criteria for CS invasion. Postoperative images reported gross total resection in 10 patients (76.9%). Mean follow-up time was 28.3 months. Remission criteria were achieved in nine patients (69.2%), with one of these patients (11.1%) having recurrence during follow up. All patients with no biochemical remission had improvement in GH and IGF profiles. Three patients without remission underwent radiosurgery (14Gy), and one patient had remission after the procedure. We consider this to be a safe and efficient approach for tumors invading CS, when surgical team have good experience in endoscopy of the skull base and reconstruction techniques, appropriate instruments are available, and tumor has soft consistency.

Surgical management of pituitary adenomas: does age matter?

Along with increased life expectancy and improvements in the diagnostic tools and techniques, the number of elderly patients with symptomatic pituitary tumors being evaluated for surgery is increasing. To date, contrasting results of the safety and effectiveness of transsphenoidal surgery in patients over 65years old were published in the medical literature. An investigation concerning the extension of resection, post operative complications and, recovery rate from endocrinological and visual symptoms in elderly patients who underwent transsphenoidal surgery for pituitary adenoma was conducted. A retrospective review, which included a series of 81 patients 65years old or older who underwent endoscopic endonasal surgery for pituitary adenomas was analyzed. Pre operative and post operative data were collected and patients were then compared among four age groups: 65-69years old, 70-74years old, 75-79years old and 80years and over. The results were then compared with the findings from the medical literature review. The statistical analysis failed to highlight any difference in terms of clinical presentation or complications among the four age groups, however there seems to be a slightly higher risk of post operative hypopituitarism in patients over 74years old. The results of the study seem to confirm that transsphenoidal surgery for PA is safe and effective among patients that are 65 and over. Moreover, a partial resection is preferred over a gross total one in order to reduce the surgical risk.

Multidisciplinary Team Care in the Surgical Management of Pituitary Adenoma.

Objective Despite multidisciplinary care being commonly recommended, there remains limited evidence supporting its benefits in pituitary disease management. This study aimed to assess the impact of multidisciplinary care in pituitary surgery. Methods A retrospective cohort study was performed comparing pituitary surgery outcomes among consecutive patients within a quaternary referral center in 5 years before and after introduction of a multidisciplinary team (MDT). Primary outcomes were endocrine (transient diabetes insipidus [DI], syndrome of inappropriate antidiuretic hormone [SIADH], and new hypopituitarism) and surgical (cerebrospinal fluid [CSF] leak, epistaxis, intracranial hemorrhage, and meningitis) complications, length of hospital stay, and intrasellar residual tumor. Results 279 patients (89 pre-MDT vs. 190 post-MDT) were assessed (age 54 ± 17 years, 48% female). Nonfunctioning adenomas were most common (54%). In the post-MDT era, more clinically functioning tumors (42 vs. 28%, p = 0.03) were treated. Transient DI and SIADH occurred less often post-MDT (20 vs. 36%, p < 0.01 and 18 vs. 39%, p < 0.01), as well as new hypothyroidism (5 vs. 15, p < 0.01). Hospital stay was shorter post-MDT (5[3] vs. 7[5] days, p < 0.001) and intrasellar residuals were less common (8 vs. 35%, p < 0.001). Complications were more frequent pre-MDT independent of tumor size, hormone status, and surgical technique (odds ratio [OR] = 2.14 [1.05-4.32], p = 0.04). Conclusion Outcomes of pituitary surgery improved after the introduction of an MDT. Pituitary MDTs may benefit both patients and the health system by improving quality of care and reducing hospital stays.

Pituitary adenomas in elderly patients: clinical and surgical outcome analysis in a large series.

The increased life expectancy in the general population is causing rapid growth of the number of elderly patients. Pituitary adenomas (PAs) are one of those tumors whose incidence increases with age. Pituitary surgery in elderly has usually been considered riskier than in the younger population. The aim of this study was to evaluate the surgical outcome of a large series of patients who underwent transsphenoidal surgery for PAs. We retrospectively reviewed a series of patients who underwent transsphenoidal surgery for PAs in our institution. Inclusion criteria were: 65 years of age or more, and no previous pituitary surgery. Surgical outcomes of patients aged <70 years (group 1) was compared to those aged 70 years or more (group 2) at the time of surgery. A total of 336 patients met the inclusion criteria. Clinically, 230 (68.5%) patients had a non-functioning PAs. Among the remaining 106 patients with a hormone-secreting PA, 57 (53.8%) had acromegaly, 39 (36.8%) Cushing's disease, 5 patients (4.7%) had a prolactinoma, and 5 a thyrotropin-secreting PA (4.7%). Mortality rate was 1.5%. Groups 1 and 2 showed no significantly different surgery-related complication, visual recovery, radical surgery, and remission rates. Surgical management of PAs in the elderly has been considered riskier than in the younger population. Our results demonstrated that transsphenoidal surgery is a safe and effective treatment for PAs. No statistically significant differences in terms of outcome were found in two group ages, showing that, when clinically indicated, transsphenoidal surgery can be performed even in very old subjects.

Prediction Tumour Bed Bleeding Between MRI Features and Histopathological Findings in Atypical Pituitary Adenoma

Atypical pituitary adenomas (APAs) exhibit aggressive histological and radiological features. However, the occurrence of intra-operative tumour bed bleeding (TBB) during surgical management of pituitary adenoma remains unclear. This study aimed to investigate the correlation of TBB with MRI features and histopathological findings in APA. Pituitary adenomas of 194 patients were underwent surgical treatment in our neurosurgical centre from January 2012 to June 2014. 17 patients with final diagnosis of APAs were enrolled in the study. Clinical, radiological and histopathological data TBB volume, MRI features and immunochemical stains were assessed to predict the severity of intra-operative bleeding. The incidence of APAs was for 8.7% (17/194) found in our study. 14 patients exhibited minimal to moderate intra-operative TBB. 2 patients had severe TBB with blood loss more than 1000 mL. Total resection was achieved in 14 patients, and subtotal resection was achieved in 2 patients owing to severe bleeding or tumour involvement of the cavernous sinus. The most commonly MRI features of APAs included T1 iso-, T2 iso-hyperintensity with homogeneous enhancement after using a contrast medium. The mean MIB-1(Ki-67) positive of all atypical lesions was 7.4% ± 4.6%. The numbers of CD34+ cells are 26.8 ± 7.70 and 10.6 ± 5.34 in APAs and pituitary adenomas, significant difference between the two groups (t = 11.160, P &lt; 0.05). Histopathological staining, MRI features and CD34+ overexpression in the APAs group are suggested massive intra-operative TBB. APAs is a very rare subtype of pituitary adenomas. High CD34+ expression and hypervascularity in MRI feature are indicative of severe TBB during surgery. Large randomised controlled trials are necessary to further evaluate the potential difference between APAs and their typical counterparts.

Extended transsphenoidal approach for surgical management of pituitary adenomas invading the cavernous sinus

The authors devised an extended transsphenoidal approach involving a submucosal posterior ethmoidectomy that allows for adequate exposure of the cavernous sinus. To evaluate the adequacy of this approach for removal of adenomas invading the cavernous sinus, the authors retrospectively analyzed the surgical outcomes obtained in treated patients. During a 9-year period, 36 patients with pituitary adenomas extending into the cavernous sinus underwent tumor removal at Kinki University Hospital. In the authors' technique of extended transsphenoidal surgery, the inferior wall of the affected cavernous sinus was entirely exposed, not only to permit safe removal of the tumor but also to secure the petrous portion of the internal carotid artery (ICA). For prevention of intraoperative injury to the cranial nerves, a low-profile pressure sensor was attached on the eyelid to detect eye movements in response to electrical stimulation of the cranial nerves. Total or subtotal tumor removal was achieved in 72% of 36 patients. In eight (67%) of 12 patients with growth hormone-secreting adenomas, hormonal remission was achieved postoperatively. Postoperative transient double vision was observed in 27% of the patients, but no serious complications, such as permanent cranial nerve palsy or ICA injury, occurred. These reasonable surgical results obtained in the present series of patients suggest that the extended transsphenoidal approach is safe and effective for removal of adenomas within the cavernous sinus. These preliminary results may lead to a reevaluation of the role of surgery as the therapeutic strategy for invasive pituitary adenomas.

The surgical management of pituitary adenomas in a series of 3,093 patients.

The surgical management of pituitary adenomas in a series of 3,093 patients.

PITUITARY SURGERY

Surgical management of pituitary adenomas continues to be a safe and effective method for treating many patients with these lesions. The goal of overall management should be to provide the patient with the most effective means of long-term control of this benign but potentially disabling disease. Currently, surgery has a significant role. It is hoped that with advances in the understanding of pituitary pathophysiology and with advances in pharmacotherapy, surgical management may become even more focused, more precise, and more effective over time.

Surgical management of pituitary adenomas

Surgical management of pituitary adenomas continues to be a safe and effective method, suitable for a large number of patients suffering from the effects of these lesions. Frequently surgery is just part of an overall programme that includes medical management and radiation therapy as well. It is important for the physicians and the patients to understand that surgery alone may not be totally successful, but that with careful follow-up and appropriate adjunctive management, patients with pituitary tumours may live normal lives, and may enjoy reversal of the endocrine and visual problems that had been caused by their tumours. Careful study of surgically managed patients has contributed to some of the advances that have occurred in the overall management of pituitary adenomas and in our understanding of their biology, pathophysiology and pathogenesis.

Study of the Surgical Management of Pituitary Adenoma

Study of the Surgical Management of Pituitary Adenoma

Pituitary Surgery

Surgical management of pituitary adenomas continues to be a safe and effective method for dealing with many of these lesions. The goal of overall management should be to provide long-term control of this benign but potentially disabling disease. The history and application of surgery to the management of pituitary disorders, as well as the preoperative evaluation, technique of surgery, and surgical results, are discussed. Attention is given to complications of surgery and adjunctive forms of management of pituitary lesions.

Surgical management of pituitary adenomas

As experience with endocrine diagnosis, radiologic evaluation, and transsphenoidal microsurgery has accumulated, more effective therapy has become available for patients with pituitary adenomas. The amelioration of the various endocrinopathies and the potential for restoration of vision in patients with visual impairment make this aspect of modern neurosurgery most satisfying, both for the patient and for the surgeon.

13 - Surgical management of pituitary adenoma

The aims and the results of operations on the pituitary have evolved more in the last decade and a half than in the entire previous part of this century. When surgeons began to operate on the pituitary at the end of the 19th century they treated only patients with a large tumour, diagnosed because of advanced loss of vision; the survival of the patient and the avoidance of blindness were sufficient goals. Today large pituitary adenomas are still frequent, and the sufferers are often elderly. The surgeon is required to operate with minimal mortality and to restore sight to the maximum extent possible. But now, as Table I shows, there is a great emphasis upon the treatment of patients with endocrine disorders. This reflects the refinement of modern microsurgical trans-sphenoidal pituitary operations to the degree of precision and safety necessary to match advances in endocrinological diagnosis and assessment. In treating acromegaly, Cushing's disease or hyperprolactinaemia, the surgeon must aim to eliminate operative morbidity and also to return pituitary function to normal. This includes the restoration of normal pituitary responsiveness, either to the increasingly complex array of provocative tests devised by endocrinologists, or to the stimuli naturally imposed in the course of reproduction. How well operations on the pituitary match up to these aims is not yet agreed, and how they compare with other methods of management is controversial. Information is accumulating rapidly, but its assessment is bedevilled by the lack of uniform criteria and standards. Current knowledge will be assessed in this review, but its aim is equally to provide understanding of the principles and concepts which are the basis for current approaches to the surgical management of pituitary adenomas. It will be pointed out that the prognosis expected, and the aims of treatment, vary from patient to patient and depend in particular on the size and invasiveness of the tumour. Hence there is not a simple single sensible answer to the question 'what are the results of pituitary surgery?'