Abstract
Today, more than 95% of pituitary adenomas are removed using transsphenoidal surgery. The complication rates both for the traditional microscopic technique and for the more recently introduced endoscopic technique are comparably low. In acromegaly, the overall surgical cure rate of the transsphenoidal operation is approximately 50% in experienced hands. In Cushing’s disease, the cure rate is high if an adenoma is visible on MRI. In prolactinomas, surgery should be preferentially offered to patients with microadenomas (<10 mm) as their chance of surgical cure is >90%.
Adequate perioperative endocrinological management is pivotal. Replacement therapy for adrenal insufficiency must be adapted to the perioperative demand. Diabetes insipidus (DI) with impaired ADH secretion is encountered frequently on days 1–5 after surgery while the opposing syndrome of inappropriate antidiuretic hormone secretion (SIADH) with excessive ADH release typically presents on days 3–10. Thorough surveillance of water and electrolyte balance in the postoperative course is paramount for early detection and treatment of these typical postoperative dysregulations of the posterior pituitary lobe. Postoperative endocrine care includes early assessment of remission status and pituitary function. It is recommended that neuro-endocrine and neurosurgical follow-up appointments be scheduled prior to discharge to guarantee professional ongoing follow-up.
For non-functioning pituitary adenomas (NFPA), radiotherapy (RT) may be considered for invasive residual tumour after surgery. The timing of radiotherapy is still a subject of controversy. For functioning adenomas, radiotherapy is indicated if surgery and medical therapy cannot control hormonal oversecretion. Fractionated radiotherapy (fRT) is used for large adenoma volumes to minimize secondary injury to surrounding structures. Stereotactic radiosurgery (SRS) is used for small target volumes with a sufficient distance from the optic apparatus. These two principle techniques have different risk profiles. Both fRT and SRS are highly effective in preventing further adenoma growth. Biochemical cure is less frequent. Reportedly, the biochemical cure rates are slightly higher for Cushing’s disease than for acromegaly and are least favourable in prolactinomas. Biochemical remission is often delayed and the cure rates increase over the years after RT.
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Abbreviations
- ACTH:
-
Adreno-corticotrophic hormone
- ADH:
-
Antidiuretic hormone
- CD:
-
Cushing’s disease
- CS:
-
Cushing’s syndrome
- CSF:
-
Cerebro-spinal fluid
- DA:
-
Dopamine-agonist
- DI:
-
Diabetes insipidus
- fRT:
-
Fractionated radiotherapy
- GH:
-
Growth hormone
- GKRS:
-
Gamma-knife radiosurgery
- Gy:
-
Gray
- IGF-1:
-
Insulin-like growth factor 1
- LINAC:
-
Linear accelerator based radiosurgery
- MRI:
-
Magnetic resonance imaging
- NFPA:
-
Non-functioning pituitary adenoma
- RT:
-
Radiotherapy
- SIADH:
-
Syndrome of inappropriate antidiuretic hormone secretion
- SRS:
-
Stereotactic radiosurgery
References
Ammirati M, Wei L, Ciric I. Short-term outcome of endoscopic versus microscopic pituitary adenoma surgery: a systematic review and meta-analysis. J Neurol Neurosurg Psychiatry. 2013;84:843–9.
Buchfelder M, Kreutzer J. Transcranial surgery for pituitary adenomas. Pituitary. 2008;11:375–84.
Bulters DO, Shenouda E, Evans BT, et al. Visual recovery following optic nerve decompression for chronic compressive neuropathy. Acta Neurochir. 2009;151:325.
Casanueva FF, Molitch ME, Schlechte JA, Abs R, Bonert V, Bronstein MD, Brue T, Cappabianca P, Colao A, Fahlbusch R, Fideleff H, Hadani M, Kelly P, Kleinberg D, Laws E, Marek J, Scanlon M, Sobrinho LG, Wass JAH, Giustina A. Guidelines of the Pituitary Society for the diagnosis and management of prolactinomas. Clin Endocrinol. 2006;65:265–73.
Chandler WF, Barkan AL, Hollon T, Sakharova A, Sack J, Brahma B, Schteingart DE. Outcome of transsphenoidal surgery for Cushing disease: a single-center experience over 32 years. Neurosurgery. 2016;78:216–23.
Chang EF, Sughrue ME, Zada G, Wilson CB, Blevins LS, Kunwar S. Long term outcome following repeat transsphenoidal surgery for recurrent endocrine-inactive pituitary adenomas. Pituitary. 2010;13(3):223–9. https://doi.org/10.1007/s11102-010-0221z.
Estrada J, Boronat M, Mielgo M, Magallón R, Millán I, Díez S, Lucas T, Barceló B. The long-term outcome of pituitary irradiation after unsuccessful transsphenoidal surgery in Cushing’s disease. N Engl J Med. 1997;336:172–7.
Fatemi N, Dusick JR, de Paiva Neto MA, Kelly DF. The endonasal microscopic approach for pituitary adenomas and other parasellar tumors: a 10-year experience. Neurosurgery. 2008;63(4 Suppl 2):244–56.
Griffith HB, Veerapen R. A direct transnasal approach to the sphenoid sinus. Technical note. J Neurosurg. 1987;66:140–2.
Hadad G, Bassagasteguy L, Carrau RL, Mataza JC, Kassam A, Snyderman CH, Mintz A. A novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap. Laryngoscope. 2006;116:1882–6.
Hardy J. Transsphenoidal microsurgery of the normal and pathological pituitary. Clin Neurosurg. 1969;16:185–217.
Honegger J, Tatagiba M. Craniopharyngioma surgery. Pituitary. 2008;11:361–73.
Honegger J, Ernemann U, Psaras T, Will B. Objective criteria for successful transsphenoidal removal of suprasellar nonfunctioning pituitary adenomas. A prospective study. Acta Neurochir. 2007;149:21–9.
Jenkins PJ, Bates P, Carson N, Stewart PM, Wass JAH, On behalf of the UK National Acromegaly Register Study Group. Conventional pituitary irradiation is effective in lowering serum growth hormone and insulin-like growth factor-I in patients with acromegaly. J Clin Endocrinol Metab. 2006;91:1239–45.
Jeswani S, Nuno M, Wu A, Bonert V, Carmichael JD, Black KL, Chu R, King W, Mamelak AN. Comparative analysis of outcomes following craniotomy and expanded endoscopic endonasal transsphenoidal resection of craniopharyngioma and related tumors: a single-institution study. J Neurosurg. 2016;124:627–38.
Jho HD, Carrau RL, Ko Y, Daly MA. Endoscopic pituitary surgery: an early experience. Surg Neurol. 1997;47:213–23.
Juraschka K, Khan OH, Godoy BL, Monsalves E, Kilian A, Krischek B, Ghare A, Vescan A, Gentili F, Zadeh G. Endoscopic endonasal transsphenoidal approach to large and giant pituitary adenomas: institutional experience and predictors of extent of resection. J Neurosurg. 2014;121:75–83.
Kim EH, Ahn JY, Kim SH. Technique and outcome of endoscopy-assisted microscopic extended transsphenoidal surgery for suprasellar craniopharyngiomas. J Neurosurg. 2011;114:1138–349.
Knappe UJ, Moskopp D, Gerlach R, Conrad J, Flitsch J, Honegger JB. Consensus on postoperative recommendations after transsphenoidal surgery. Exp Clin Endocrinol Diabetes 2018 doi: 10.1055/a-0664-7710. [Epub ahead of print].
Kreutzer J, Buslei R, Wallaschofski H, Hofmann B, Nimsky C, Fahlbusch R, Buchfelder M. Operative treatment of prolactinomas: indications and results in a current consecutive series of 212 patients. Eur J Endocrinol. 2008;158:11–8.
Lee CC, Vance ML, Lopes MB, Xu Z, Chen CJ, Sheehan J. Stereotactic radiosurgery for acromegaly: outcomes by adenoma subtype. Pituitary. 2015;18(3):326–34. https://doi.org/10.1007/s11102-014-0578-5.
Marek J, Jezková J, Hána V, Krsek M, Liscák R, Vladyka V, Pecen L. Gamma knife radiosurgery for Cushing’s disease and Nelson’s syndrome. Pituitary. 2015;18:376–84.
Minniti G, Jaffrain-Rea ML, Esposito V, Santoro A, Tamburrano G, Cantore G. Evolving criteria for post-operative biochemical remission of acromegaly: can we achieve a definitive cure? An audit of surgical results on a large series and a review of the literature. Endocr Relat Cancer. 2003;10(4):611–9. https://doi.org/10.1677/erc.0.0100611.
Minniti G, Esposito V, Amichetti M, Enrici RM. The role of fractionated radiotherapy and radiosurgery in the management of patients with craniopharyngiomas. Neurosurg Rev. 2009;32:125–32.
Mortini P, Barzaghi LR, Albano L, Panni P, Losa M. Microsurgical therapy of pituitary adenomas. Endocrine. 2018;59(1):72–81. https://doi.org/10.1007/s12020-017-1458-3. Epub 2017 Oct 24.
Pollock BE, Brown PD, Nippoldt TB, Young WF. Pituitary tumor type affects the chance of biochemical remission after radiosurgery of hormone-secreting pituitary adenomas. Neurosurgery. 2008;62:1271–8.
Schloffer H. Erfolgreiche Operation eines Hypophysentumors auf nasalem Wege. Wien Klin Wochenschr. 1907;20:621–4.
Schöfl C, Franz H, Grussendorf M, Honegger J, Jaursch-Hancke C, Mayr B, Schopohl J. Long-term outcome in patients with acromegaly: analysis of 1344 patients from the German Acromegaly Register. Eur J Endocrinol. 2013;168:39–47.
Sheehan JP, Xu Z, Lobo MJ. External beam radiation therapy and stereotactic radiosurgery for pituitary adenomas. Neurosurg Clin N Am. 2012;23:571–86.
Tanaka S, Link MJ, Brown PD, Stafford SL, Young WF, Pollock BE. Gamma knife radiosurgery for patients with prolactin-secreting pituitary adenomas. World Neurosurg. 2010;74:147–52.
Key Reading
Ammirati M, Wei L, Ciric I. Short-term outcome of endoscopic versus microscopic pituitary adenoma surgery: a systematic review and meta-analysis. J Neurol Neurosurg Psychiatry. 2013;84:843–9.
Chandler WF, Barkan AL, Hollon T, Sakharova A, Sack J, Brahma B, Schteingart DE. Outcome of transsphenoidal surgery for Cushing disease: a single-center experience over 32 years. Neurosurgery. 2016;78:216–23.
Honegger J, Tatagiba M. Craniopharyngioma surgery. Pituitary. 2008;11:361–73.
Sheehan JP, Xu Z, Lobo MJ. External beam radiation therapy and stereotactic radiosurgery for pituitary adenomas. Neurosurg Clin N Am. 2012;23:571–86.
Schöfl C, Franz H, Grussendorf M, Honegger J, Jaursch-Hancke C, Mayr B, Schopohl J. Long-term outcome in patients with acromegaly: analysis of 1344 patients from the German Acromegaly Register. Eur J Endocrinol. 2013;168:39–47.
Acknowledgement
The editors acknowledge manuscript review by Justin Cetas MD who is the Associate Professor of Department of Neurosurgery, Oregon Health & Sciences University, Portland, Oregon, USA.
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Honegger, J. (2019). Pituitary Surgery. In: Llahana, S., Follin, C., Yedinak, C., Grossman, A. (eds) Advanced Practice in Endocrinology Nursing. Springer, Cham. https://doi.org/10.1007/978-3-319-99817-6_22
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