Hemorrhagic pituitary macroadenoma: characteristics, endoscopic endonasal transsphenoidal surgery, and outcomes.
ABSTRACT This study aims to assess the effect of endoscopic endonasal transsphenoidal surgery (EETSS) of hemorrhagic pituitary macroadenoma (HPMA).
We retrospectively reviewed 52 cases with HPMA collected from the Xijing Hospital from April 1995 to April 2009. There were 39 males and 13 females, ranging in age from 18 to 79 years (average 51.6 years). Patients presented with headache or acute ophthalmological symptoms after adenoma hemorrhage. Computed tomography (CT) scan and magnetic resonance imaging (MRI) showed pituitary macroadenoma with hemorrhage in all cases. Twenty-eight adenomas showed marked suprasellar extension, 19 showed moderate extension, and another 5 showed slight extension. All patients were promptly treated by emergency EETSS, usually within 24 h after hospitalization.
Total removal of tumor was achieved in 46 cases (88.5%), and subtotal removal in 6 cases (11.5%). Postoperative radiotherapy and reoperation of the tumor were required in five patients with either residual or relapsed tumors. Follow-up ranged from 8 to 93 months (mean 41.6 months) for 43 cases. Visual acuity and visual field recovery and improvement was recorded in 92.1% and 94.3% of patients who had preoperative visual symptoms, respectively.
The majority of macroadenomas are hemorrhagic, and they often occur in middle-aged, male subjects. Detection by imaging in the setting of pituitary apoplexy accurately predicts the nature of the apoplectic process and helps to guide the type and timing of surgery. Early EETSS is the most effective therapy and significantly improves visual outcomes and systemic conditions.
- [Show abstract] [Hide abstract]
ABSTRACT: Giant prolactinoma are rare tumours, representing only 2-3 % of all prolactin-secreting tumours and raising special diagnostic and therapeutic challenges. Based on several considerations developed in this review, their definition should be restricted to pituitary adenomas with a diameter of 40 mm or more, significant extrasellar extension, very high prolactin concentrations (usually above 1000 µg/L), and no concomitant GH or ACTH secretion. Giant prolactinomas are much more frequent in young to middle-aged men than in women with a male to female ratio of about 9:1. Endocrine symptoms are often present but overlooked for a long period of time and diagnosis is eventually made when neurological complications arise from massive extension into the surrounding structures, leading to cranial nerve palsies, hydrocephalus, temporal epilepsy or exophthalmos. Prolactin concentrations are usually in the range of 1,000 to 100,000 µg/L, but may be underestimated by the so-called 'high dose hook effect'. As in every prolactinoma, dopamine agonists are the first-line treatment allowing rapid alleviation of neurologic symptoms in the majority of the cases, a significant reduction of tumour size in ¾ of the patients and PRL normalization in 60-70%. These extensive tumours are usually not completely resectable and neurosurgery has significant morbidity and mortality. It should therefore be restricted to acute complications such as apoplexy or leakage of cerebrospinal fluid (often induced by medical treatment), or to patients with insufficient tumoral response or progression. Irradiation and temozolomide are useful adjuvant therapies in a subset of patients with aggressive/invasive tumours which are not controlled despite combined medical and surgical treatments. Because of these various challenges, we advocate a multidisciplinary management of these giant tumours in expert centres.European Journal of Endocrinology 02/2014; · 3.69 Impact Factor
- [Show abstract] [Hide abstract]
ABSTRACT: Endoscopic endonasal trans-sphenoid surgery (EETS) is increasingly used for pituitary lesions. Pre-operative CT and MRI scans and peroperative endoscopic visualization can provide useful anatomical information. EETS is indicated in sellar, suprasellar, intraventricular, retro-infundibular, and invasive tumors. Recurrent and residual lesions, pituitary apoplexy and empty sella syndrome can be managed by EETS. Modern neuronavigation techniques, ultrasonic aspirators, ultrasonic bone curette can add to the safety. The binostril approach provides a wider working area. High definition camera is much superior to three-chip camera. Most of the recent reports favor EETS in terms of safety, quality of life and tumor resection, hospital stay, better endocrinological, and visual outcome as compared to the microscopic technique. Nasal symptoms, blood loss, operating time are less in EETS. Various naso-septal flaps and other techniques of CSF leak repair could help reduce complications. Complications can be further reduced after achieving the learning curve, good understanding of limitations with proper patient selection. Use of neuronavigation, proper post-operative care of endocrine function, establishing pituitary center of excellence and more focused residency and endoscopic fellowship training could improve results. The faster and safe transition from microscopic to EETS can be done by the team concept of neurosurgeon/otolaryngologist, attending hands on cadaveric dissection, practice on models, and observation of live surgeries. Conversion to a microscopic or endoscopic-assisted approach may be required in selected patients. Multi-modality treatment could be required in giant and invasive tumors. EETS appears to be a better surgical option in most pituitary adenoma.Journal of neurosciences in rural practice. 09/2012; 3(3):328-37.
- [Show abstract] [Hide abstract]
ABSTRACT: Pituitary apoplexy is an uncommon clinical emergency arising from hemorrhage into or infarction of a pituitary adenoma. The most common presentation is sudden headache, visual field defects and signs of hypopituitarism. It usually occurs in the age group from 20 to 50 years and affects more male than female. Sudden death due to pituitary apoplexy without common symptoms is rarely reported. Here, we described a scarcely-reported case of sudden death in custody caused by pituitary apoplexy resulting from stress-induced hemorrhage of gonadotroph adenoma, a kind of pituitary adenoma, without common clinical symptoms. In this case, a 49-year-old man was restrained in a sitting position for 4 days and died unexpectedly. At autopsy, external examination showed free of trauma. Destruction of bony structure and a circumscribed pituitary tumor were observed in sella turcica. Immunohistochemically, the tumor cells were particular positive for follicle-stimulating hormone (FSH) and luteinizing hormone (LH), thus clarifying the presence of a pituitary gonadotroph adenoma. We provide the case description and a short review of pituitary apoplexy and pituitary adenoma as a rare cause of sudden death.Journal of Forensic and Legal Medicine 10/2013; 20(7):812-815. · 0.99 Impact Factor