Long-Term Outcomes of Pituitary Gland Preservation in Pituitary Macroadenoma Apoplexy: Case Series and Review of the Literature
13. Mai 2019
17. September 2019
11. November 2019 (online)
Introduction For patients presenting with neurological changes from pituitary tumor apoplexy, urgent surgical intervention is commonly performed for diagnosis, tumor resection, and optic apparatus decompression. Although identification and preservation of the pituitary gland during the time of surgery can be challenging, it may lead to improve endocrine outcomes.
Methods A retrospective case series of all patients with macroadenomas presenting with apoplexy at Loyola University Medical Center from 2016 to 2018 was studied. Demographic, radiographic, and intraoperative characteristics were collected including age, gender, comorbidities, presenting symptoms, preoperative size of pituitary adenoma, Knosp's grade, Hardy's grade, identification and/or preservation of the gland, pre- and postoperative hormonal levels, intraoperative and/or postoperative complications, and follow-up time.
Results A total of 68 patients underwent endoscopic endonasal surgery for resection of a macroadenoma. Among them, seven (10.2%) presented with apoplexy; five patients were male and two were female and presenting symptoms and signs included headache (100%), endocrinopathies (57%), visual acuity deficit (71%), visual field deficit (71%), and oculomotor palsy (57%). A gross-total resection rate was achieved in 86% of patients. Among them, 71% of patients obtained complete symptomatic neurological improvement. A statistically significant difference between gender and endocrine function was found, as no females and all males required some form of postoperative hormonal supplementation (p = 0.047).
Conclusion Endoscopic endonasal resection of macroadenomas with sparing of the pituitary gland in the setting of apoplexy is safe and effective. Preservation of the normal gland led to no posterior pituitary dysfunction, and a statistically significant difference between gender and postoperative endocrinopathy was identified. Further studies with larger samples sizes are warranted.
- 1 Annegers JF, Coulam CB, Abboud CF, Laws Jr. ER, Kurland LT. Pituitary adenoma in Olmsted County, Minnesota, 1935--1977. A report of an increasing incidence of diagnosis in women of childbearing age. Mayo Clin Proc 1978; 53 (10) 641-643
- 2 Jane Jr. JA, Laws Jr ER. The surgical management of pituitary adenomas in a series of 3,093 patients. J Am Coll Surg 2001; 193 (06) 651-659
- 3 Ezzat S, Asa SL, Couldwell WT. , et al. The prevalence of pituitary adenomas: a systematic review. Cancer 2004; 101 (03) 613-619
- 4 Oldfield EH, Merrill MJ. Apoplexy of pituitary adenomas: the perfect storm. J Neurosurg 2015; 122 (06) 1444-1449
- 5 Hardy J. The transsphenoidal surgical approach to the pituitary. Hosp Pract 1979; 14 (06) 81-89
- 6 Knosp E, Steiner E, Kitz K, Matula C. Pituitary adenomas with invasion of the cavernous sinus space: a magnetic resonance imaging classification compared with surgical findings. Neurosurgery 1993; 33 (04) 610-617 , discussion 617–618
- 7 Gittleman H, Ostrom QT, Farah PD. , et al. Descriptive epidemiology of pituitary tumors in the United States, 2004-2009. J Neurosurg 2014; 121 (03) 527-535
- 8 Costello RT. Subclinical adenoma of the pituitary gland. Am J Pathol 1936; 12 (02) 205-216 .1
- 9 Tomita T, Gates E. Pituitary adenomas and granular cell tumors. Incidence, cell type, and location of tumor in 100 pituitary glands at autopsy. Am J Clin Pathol 1999; 111 (06) 817-825
- 10 Karki M, Sun J, Yadav CP, Zhao B. Large and giant pituitary adenoma resection by microscopic trans-sphenoidal surgery: Surgical outcomes and complications in 123 consecutive patients. J Clin Neurosci 2017; 44: 310-314
- 11 Gondim JA, Almeida JP, Albuquerque LA, Gomes EF, Schops M. Giant pituitary adenomas: surgical outcomes of 50 cases operated on by the endonasal endoscopic approach. World Neurosurg 2014; 82 (1,2): e281-e290
- 12 Juraschka K, Khan OH, Godoy BL. , et al. Endoscopic endonasal transsphenoidal approach to large and giant pituitary adenomas: institutional experience and predictors of extent of resection. J Neurosurg 2014; 121 (01) 75-83
- 13 Chabot JD, Chakraborty S, Imbarrato G, Dehdashti AR. Evaluation of outcomes after endoscopic endonasal surgery for large and giant pituitary macroadenoma: A retrospective review of 39 consecutive patients. World Neurosurg 2015; 84 (04) 978-988
- 14 Hofstetter CP, Nanaszko MJ, Mubita LL, Tsiouris J, Anand VK, Schwartz TH. Volumetric classification of pituitary macroadenomas predicts outcome and morbidity following endoscopic endonasal transsphenoidal surgery. Pituitary 2012; 15 (03) 450-463
- 15 Bills DC, Meyer FB, Laws Jr. ER. , et al. A retrospective analysis of pituitary apoplexy. Neurosurgery 1993; 33 (04) 602-608 , discussion 608–609
- 16 Biousse V, Newman NJ, Oyesiku NM. Precipitating factors in pituitary apoplexy. J Neurol Neurosurg Psychiatry 2001; 71 (04) 542-545
- 17 da Motta LA, de Mello PA, de Lacerda CM, Neto AP, da Motta LD, Filho MF. Pituitary apoplexy. Clinical course, endocrine evaluations and treatment analysis. J Neurosurg Sci 1999; 43 (01) 25-36
- 18 David NJ, Gargano FP. Pituitary apoplexy in clinical perspective. In: Liu GT, Volpe NJ, Galetta SL. , eds. Neuroophthalmology. vol. VIII. Miami, FL: Symposium of the University of Miami and the Bascom Palmer Eye Institute; 1975: 140-165
- 19 Verrees M, Arafah BM, Selman WR. Pituitary tumor apoplexy: characteristics, treatment, and outcomes. Neurosurg Focus 2004; 16 (04) E6
- 20 Ammirati M, Zarzour H. Overview of skull base tumors. In: Winn HR. , ed. Youmans Neurological Surgery. China: Elsevier, Saunders; 2011: 1569-1586
- 21 Zaidi HA, Cote DJ, Burke WT. , et al. Time course of symptomatic recovery after endoscopic transsphenoidal surgery for pituitary adenoma apoplexy in the modern era. World Neurosurg 2016; 96: 434-439
- 22 Zoli M, Milanese L, Faustini-Fustini M. , et al. Corrigendum to “in reply to the letter to the editor regarding “endoscopic endonasal surgery for pituitary apoplexy: evidence on a 75 case-series from a tertiary care center.”” [World Neurosurgery 109 (2018) 502]. World Neurosurg 2018; 112: 328
- 23 Skugor M, Hamrahian AH. Pituitary disorders. In: Carey WD. , ed. Current Clinical Medicine. 2nd ed. Philadelphia, PA: Saunders-Elsevier; 2010: 408-415
- 24 Ricciuti R, Nocchi N, Arnaldi G, Polonara G, Luzi M. Pituitary adenoma apoplexy: review of personal series. Asian J Neurosurg 2018; 13 (03) 560-564
- 25 Rutkowski MJ, Kunwar S, Blevins L, Aghi MK. Surgical intervention for pituitary apoplexy: an analysis of functional outcomes. J Neurosurg 2018; 129 (02) 417-424
- 26 Linsler S, Senger S, Hero-Gross R, Steudel WI, Oertel J. The endoscopic surgical resection of intrasellar lesions conserves the hormonal function: a negative correlation to the microsurgical technique. J Neurosurg Sci 2018; ; (e-pub ahead of print) DOI: 10.23736/S0390-5616.18.04242-X.
- 27 Chang SW, Donoho DA, Zada G. Use of optical fluorescence agents during surgery for pituitary adenomas: current state of the field. J Neurooncol 2019; 141 (03) 585-593