Pituitary tumors are a unique class of intracranial neoplasms with the potential to disrupt hormone function and water metabolism. Preoperative and postoperative endocrine assessment is mandatory to recognize and promptly treat new deficiencies and identify those that have resolved. Close collaboration among neurosurgical, endocrine, and anesthetic teams is equally vital during the perioperative period. Appropriate patient education at the time of discharge regarding the symptoms of diabetes insipidus, hyponatremia, and adrenal insufficiency is increasingly important.
[Show abstract][Hide abstract] ABSTRACT: Objectives/HypothesisTo evaluate the cost-effectiveness of an endoscopic versus microscopic approach to pituitary adenoma resection. Study DesignMarkov decision tree economic evaluation. Methods
An economic evaluation using a Markov decision tree model was performed. The economic perspective was that of the healthcare third-party payer. Effectiveness and probability data were obtained from a single meta-analysis of 38 studies. Costs were obtained from the Healthcare Cost and Utilization Project database and wholesale pharmaceutical pricing. Multiple sensitivity analyses were performed including a probabilistic sensitivity analysis. Comparative treatment groups were: 1) endoscopic approach and 2) microscopic approach to pituitary adenoma resection. The primary outcome was cost per quality-adjusted life year (QALY). The time horizon was 25 years, and costs were discounted at a rate of 3.5%. ResultsThe endoscopic approach cost a total of $17,244.63 and produced a total of 24.30 QALYs. The microscopic approach cost a total of $23,756.60 and produced a total of 24.20 QALYs. In the reference case, the endoscopic approach was a dominant intervention (both less costly and more effective); therefore, an incremental cost-effectiveness ratio was not calculated. The sensitivity analysis demonstrated 79% certainty that the endoscopic approach is the cost-effective decision, at a willingness to pay threshold of $50,000 per QALY. Conclusions
This economic evaluation suggests that the endoscopic approach is the more cost-effective intervention compared to the microscopic approach for patients requiring a pituitary adenoma resection. Level of EvidenceNA Laryngoscope, 125:16-24, 2015
The Laryngoscope 01/2015; 125(1). DOI:10.1002/lary.24780 · 2.14 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Cushing's disease (CD), or pituitary-dependent Cushing's syndrome (CS), is a severe endocrine disease caused by a corticotroph pituitary tumor, associated with increased morbidity and mortality. The first-line treatment for CD is pituitary surgery, which is followed by disease remission in around 75%, and relapse in around 15%, of patients during the ten-year period after surgery. Patients with persistent or recurrent CD require additional treatments, including pituitary radiotherapy, adrenal surgery and/or medical therapy. Pituitary radiotherapy is effective in controlling cortisol excess in a large percentage of patients, but it is associated with a considerable risk of hypopituitarism. Adrenal surgery is followed by a rapid and definitive control of cortisol excess nearly in the totality of patients, but it induces adrenal insufficiency. Medical therapy has recently acquired a more important role compared to the past, due to the recent employment of novel compounds able to control cortisol secretion or action. Currently, medical therapy is used as a presurgical treatment, particularly for severe disease, or as post-surgical treatment, in case of failure or incomplete surgical tumor resection, or as bridging therapy before, during and after radiotherapy while waiting for disease control or, in selected cases, as primary therapy, mainly when surgery is not an option. The adrenal-directed drug ketoconazole is the most commonly used drug, mainly because of its rapid action, whereas the glucocorticoid receptor antagonist, mifepristone, is highly effective in controlling clinical comorbidities, mainly glucose intolerance, thus being a useful treatment for CD when it is associated with diabetes mellitus. Pituitary-directed drugs have the advantage of acting at the site responsible for CD, the pituitary tumor. Among this group of drugs, the dopamine agonist cabergoline and the somatostatin analogue pasireotide result in disease remission in a consistent subgroup of patients with CD. Recently, pasireotide has been approved for the treatment of CD when surgery has failed or when surgery is not an option, and mifepristone has been approved for the treatment of CS when associated with impairment of glucose metabolism in case of lack of a surgical indication. Recent experience suggests that the combination of different drugs may be able to control cortisol excess in a great majority of patients with CD.
[Show abstract][Hide abstract] ABSTRACT: Occlusion of the intracranial internal carotid artery (ICA) by a pituitary adenoma with resulting cerebral ischemia is a very rare but devastating occurrence. The authors present a case in which a condition of symptomatic ICA occlusion due to a giant pituitary adenoma was successfully treated using a preliminary extraintracranial bypass as a "bridge" to the tumor removal. A 52-year-old patient presented with a minor stroke followed by pressure-dependent transient ischemic attacks consistent with a condition of hypoperfusion. MR imaging and a digital subtraction angiography revealed a pituitary adenoma occluding the ICA on the right side. He underwent a superficial temporal artery to middle cerebral artery (STA-MCA) bypass with the aim of revascularizing the ischemic hemisphere and reducing the risk of perioperative stroke or stroke evolution. The patient was subsequently operated on to remove the adenoma through a transsphenoidal approach. The postoperative course was uneventful and the patient has suffered no further ischemic events. When there are no emergency indications to decompress the optical pathways but the patient is at risk of impending stroke because of ICA occlusion, a two-step strategy consisting of a bypass and subsequent removal of the pituitary adenoma may be a valuable option.
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