Case Report

Jesper Weile

Beth Israel Deaconess Medical Center Department of Neurosurgery

Friday October 23rd

Transsphenoidal approaches in pituitary adenomas

The Case

VD, 37 yo female with known pituitary mass. Initially presenting in the department in July 2009.

2-3 years ago went camping developed cold, fever, and headache.

Seen at OSH and pituitary mass was discovered during the workup. Diagnosed adenoma.

Saw endocrinologist and neurologist outside BIDMC. No notes on these visits. Pt does not recall the results or discussions at that time.

Radiographic imaging

MRI 7/27/2009

Consistent with adenoma

Most pituitary tumors are noncancerous, nonspreading adenomas. Adenomas remain confined to the pituitary gland or surrounding tissues and do not metastasize.

Generally adenomas divided into two groups:- Functional (secrets prolactin, ACTH, Growth Hormone, or rarely: TSH, LH, or FSH)

- Nonfunctional (symptoms will be caused by mass effect)

Tumor growth

Tumor dimensions:

9/06 19 x 17 x 16mm (TV, CC, AP)11/07 25 x 18 x 18mm11/08 25 x 19-21 x 17mm7/09 25 x 26 x 17mm (at BIDMC)

Techniques not described. But there is growth.

Surgery is recommended

Is this worrisome?No. Not by it self.

Pituitary adenomas are exceedingly common at autopsy and on pituitary imaging, with a prevalence of 15-25%.

In 2006, Buurman and Saeger reported 334 pituitary adenomas in 3048 autopsy cases and the mean adenoma diameter was only 1.97 mm.

The majority of these will have no clinical relevance.

However if the patient presents with symptoms it is a different matter.

Back to the patient...Did she present with symptoms?

Following complaints were noted at the first visit in July:

- baseline headache - weight gain of 30-40 lb over the last 6 months- cold intolerance- intermittent visual blurriness- easily fatigued- daytime sleepiness

These are all consistant with secreting adenoma symptoms can be secondary to ACTH secretion.

Except the visual blurriness, which might be due to a mass effect on the optic chiasm. This is however not likely as the optic deficits would present as field deficits.

Endocrinologic evaluationLaboratory Results 07/02/2009:

Notable for prolactin of 55 however repeated:“prolactin was verified by dilution and the level of 64 was accurate. This is consistent with stalk compression”

LH < 1 FSH 3TSH 1.6 T4 0.96 Cortisol 4.2

ACTH stimulation test: normal at 9.8 mcg/24h

“consistent with a non-secretory pituitary macroadenoma”

PresentationOn day of operation complaints of:

FatigueWeight gainCold intoleranceHeadachesIntermittent blurry vision

Negative:

No field cut deficitsNo bruising or purple strechmarkesNo complaints of dysmenorrhea

SurgeryIs this indicated?

“In a patient with a nonfunctioning adenoma, the initial treatment is surgical removal. Although published reports have described a few patients who have responded to a dopamine agonist, a suitable response (shrinkage of the tumor) is uncommon. A more likely response is that the tumor will continue to enlarge over time.”

(From: Mary Lee Vance, MD, PITUITARY ADENOMA: A CLINICIAN’S PERSPECTIVE, Endocr Pract. 2008;14(No. 6))

(From: Dekkers et al. Nonfunctioning Pituitary Macroadenomas J Clin Endocrinol Metab, October 2008, 93(10):3717–3726)

Transcranial surgery might be indicated in cases where tumor mass largely exceeds the sella.

Open transsphenoidal approach utilizes operating microscope, requiring introduction of a nasal speculum of sufficient width to allow illumination and binocular visualization from the anterior nasal spine to the sella.

Light sources, cameras, and modern endoscopic instruments have made entirely endoscopic access to the sphenoid sinuses relatively safe.

Surgery

Hormonal imbalanceSecondary empty sella syndromeHydrocephalusInfectionCHF rhinorrheaCarotid artery ruptureInjury of structures in the cavernous sinusNasal septal perforationOther

Recurrence!!

Possible complications of the operation?

The Question

What is the evidence behind the different approaches?

Transcranial approach

The approach is used in 1-4% of pituitary tumor surgeries.The indication is a prediction that transsphenoidal approach will fail.Not relevant to compare to other techniques.Note that this will have a place in the surgery.(From Youssef et al., TRANSCRANIAL SURGERY FOR PITUITARY ADENOMAS, Neurosurgery 57[ONS Suppl 1]:ONS-168–ONS-175, 2005)

Endoscopic vs Microscopic

14 specific complications of transsphenoidal surgery were reported from 3172 neurosurgeons.(From: Ciric et al., Complications of Transsphenoidal Surgery: Results of a National Survey, Review of the Literature, and Personal Experience, Neurosurgery, volume 40(2), feb 1997, pp 225-237)

All procedures were assisted by endoscope. 881 operations were performed (From: Fatemi et al., THE ENDONASAL MICROSCOPIC APPROACH FOR PITUITARY ADENOMAS AND OTHER PARASELLAR TUMORS: A 10-YEAR EXPERIENCE. Neurosurgery, 63(4) October 2008.)

Length of hospital stay

Comparison made on endoscopic versus a combination of different open approaches.Operative time is notably different.(From: Graham Et al., Endoscopic Approach for Pituitary Surgery Improves Rhinologic Outcomes, Annais of Otology. Rhinology & Laryngology 118(9):630-635.)

Comparing length of stay in different procedures.“last 100 TTA is different approaches and different aggressive approaches” (From: Cappabianca et al., Endoscopic Endonasal Transsphenoidal Approach: Outcome Analysis of 100 Consecutive Procedures, Minim Invasive Neurosurg 2002; 45: 193-200)

RecurrenceSince the endoscopic approach is so new it is impossible to review the recurrence rate.

Based on a study of 108 macroadenomas the incidence of recurrence was shown to be:

12% within 4 to 8 years.

(Mikhael et al. Transsphenoidal microsurgery of pituitary macroadenomas with longterm followup, J. Neurosurg. 59:395-401, 1983)

Correlation between the resection and recurrence has been validated.

(Noh et al. Recurrence of Nonfunctioning Pituitary Adenomas J Clin Endocrinol Metab, November 2009, 94(11))

Following markers (long and interesting discussion)

Suggestions of independent biomarkers of tumor progression and recurrence in pituitary adenomas.

Markers may have a place in recommendations for post operative followup.

(Noh et al. Recurrence of Nonfunctioning Pituitary Adenomas J Clin Endocrinol Metab, November 2009, 94(11))

This evolution goes hand in hand with the development in understanding of origins and biochemical structure and genetic origin of pituitary adenomas.

(Vera Popović-Brkić, Advances in Understanding Pituitary Adenomas, Horm Res 2009;71(suppl 2):75–77, april 2009)

ConclusionScott M. Graham et al. find not statistically significant difference in outcome in a study of 146 resections (44 endoscopic approaches and 102 open approaches) However they do state a trend towards worse outcome for the open surgery.

“The endoscopic endonasal transsphenoidal approach to sellar and parasellar disease offers improved nasal quality of life compared to open techniques.”

All groups state that it is too early to speak about the recurrence rate.

In a literature review by Michael Powell in 2009 it is concluded that:

“the evidence that endoscopic approach has a clear advantage in the management of endocrine tumors is lacking; time will tell. No one should change their style simply because of fashion.”

Interesting aspects in the future

Surgical advancements:

Future development of surgical techniques are discussed widely:

“this imaging technique has led to a more radical one-stage resection of these tumors and to a decrease of perioperative morbidity and mortality, especially in macroadenomas with suprasellar extension.”

(Baunmann et al, Intraoperative magnetic resonance imaging-guided transsphenoidal surgery for giant pituitary adenomas, Neurosurgery Rev. 2009 Oct 13. [Epub ahead of print])

Given the evolution of techniques it is hard to imagine that the field will not evolve rapidly.

References- Greenberg, Handbook of Neurosurgery, Sixth Edition, Thieme 2006, pp. 438-468

-- Noh et al. Recurrence of Nonfunctioning Pituitary Adenomas J Clin Endocrinol Metab, November 2009, 94(11)

-- Vera Popović-Brkić, Advances in Understanding Pituitary Adenomas, Horm Res 2009;71(suppl 2):75–77, april 2009

-- Baunmann et al, Intraoperative magnetic resonance imaging-guided transsphenoidal surgery for giant pituitary adenomas, Neurosurg Rev. 2009 Oct 13.

-- Graham Et al., Endoscopic Approach for Pituitary Surgery Improves Rhinologic Outcomes, Annais of Otology. Rhinology & Laryngology 118(9):630-635

-.- Dekkers et al. Nonfunctioning Pituitary Macroadenomas J Clin Endocrinol Metab, October 2008, 93(10):3717–3726

-- Youssef et al, Transcranial Surgery for Pituitary Adenomas, Vol 57, Operative Neurosurgery 1, July 2005

-- Gandhi et al., The historical evolution of transsphenoidal surgery: facilitation by technological advances, Neurosurg Focus 27 (3):E8, 2009

-- Analysis of transnasal endoscopic versus transseptal microscopic approach for excision of pituitary tumors

-- Neal, Jeffrey G.et al., Comparison of techniques for transsphenoidal pituitary surgery., American Journal of Rhinology, Volume 21, Number 2, March-April 2007 , pp. 203-206(4)

-- Mary Lee Vance, MD, PITUITARY ADENOMA: A CLINICIAN’S PERSPECTIVE, Endocr Pract. 2008;14(No. 6)

-- Fatemi et al., THE ENDONASAL MICROSCOPIC APPROACH FOR PITUITARY ADENOMAS AND OTHER PARASELLAR TUMORS: A 10-YEAR EXPERIENCE. Neurosurgery, 63(4) October 2008

- Ciric et al., Complications of Transsphenoidal Surgery: Results of a National Survey, Review of the Literature, and Personal Experience, Neurosurgery, volume 40(2), feb 1997, pp 225-237

- Cappabianca et al., Endoscopic Endonasal Transsphenoidal Approach: Outcome Analysis of 100 Consecutive Procedures, Minim Invasive Neurosurg 2002; 45: 193-200

-Mikhael et al. Transsphenoidal microsurgery of pituitary macroadenomas with longterm followup, J. Neurosurg. 59:395-401, 1983

-- Powell, Microscope and endoscopic pituitary surgery, Acta Neurochir (2009) 151:723–728

Questions?