Endonasal transsphenoidal surgery: the patient's perspective-survey results from 259 patients

BACKGROUND: Patient impressions remain an important yet often overlooked aspect of surgical success. Herein we present postoperative questionnaire results in patients after a standard direct endonasal approach, an extended suprasellar endonasal approach, and a reoperative transsphenoidal surgery for tumor removal with the operating microscope. METHODS: From July 1998 through April 2005, of 452 patients undergoing endonasal surgery, 346 were sent questionnaires, and of these, 259 (75%) completed them. Nasal packing was placed for 24 hours in the first 95 patients but not in the last 357. RESULT: Overall, 73% of patients reported a better experience than expected and 8% worse than expected. A worse than expected overall experience was noted in 15% of patients with nasal packing compared with 5% of patients without packing (P = .001). Of patients with preoperative headache, 49% resolved, 34% somewhat resolved, and 5% worsened. The frequency of rhinological complaints declined from 2 weeks to 3 months postsurgery (P < .001); by 3 months or more postsurgery, 67% to 87% of patients had no rhinological complaints and 1% to 2% had severe complaints. Of 30 patients with prior sublabial surgery, the endonasal procedure afforded easier recovery (87%), less pain (80%), better nasal airflow (79%), and a shorter hospital stay (median 3 vs 5 days) (P < .001). Of 28 patients with complications, the severity of rhinological complaints was similar to those without complications except this subgroup reported greater loss of sense of smell 3 months after surgery (P < .001). CONCLUSIONS: Rhinological recovery is typically rapid and relatively complete after direct endonasal transsphenoidal surgery using both standard and extended suprasellar approaches. Compared with the sublabial route, the endonasal approach is associated with less pain, better nasal airflow, and a shorter hospital stay.     

Pathology of invasive pituitary tumors with special reference to functional classification

Pituitary adenomas may remain intrasellar or infiltrate dura and bone. Invasive adenomas are not considered to be malignant; in biological behavior they are between non-infiltrative adenomas and pituitary carcinomas. The latter are defined as tumors with subarachnoid, brain, or systemic metastasis. Invasion may be defined radiologically, operatively, or histologically. On the basis of operatively assessed tumor size and gross invasion of dura and bone as well as immunocytochemical and ultrastructural analysis of 365 pituitary adenomas, the following data were obtained. There were 23 growth hormone (GH)-cell adenomas: 14% microadenomas and 86% macroadenomas; their overall frequency of invasion was 50%. There were 24 prolactin (PRL)-cell adenomas: 33% microadenomas and 67% macroadenomas, with an overall frequency of invasion of 52%. Mixed GH-cell and PRL-cell adenomas were found in 35 cases; 26% were microadenomas and 74% were macroadenomas, and the overall frequency of invasion was 31%. Sixty patients had adrenocorticotropic hormone (ACTH)-cell adenomas (Cushing's disease): 87% microadenomas and 13% macroadenomas; the overall frequency of invasion was 25% (in 8% of microadenomas and 62% of macroadenomas). Twenty patients had ACTH-cell adenomas (Nelson's syndrome): 30% microadenomas and 70% macroadenomas; the overall frequency of invasion in these cases was 50% (in 17% of microadenomas and 64% of macroadenomas). Silent ACTH-cell adenomas, 100% macroadenomas, were found in 11 patients, with an 82% frequency of invasion. There were 32 follicle-stimulating and luteinizing hormone adenomas, all macroadenomas, with a frequency of invasion of 21%. Four patients had thyroid-stimulating hormone adenomas, all macroadenomas, with a 75% frequency of invasion. Null-cell adenomas were found in 93 cases: 2% microadenomas and 98% macroadenomas, with a frequency of invasion of 42%. There were 63 plurihormonal adenomas (GH, PRL, glycoprotein): 25% microadenomas and 75% macroadenomas, with a 50% overall frequency of invasion. Based on this study, and on their usual frequency of occurrence, the estimated rate of gross invasion by pituitary adenomas of all types is approximately 35%. It is concluded that immunocytochemical and ultrastructural characteristics of pituitary adenomas reflect the tendency of these tumors to infiltrate and hence may be of prognostic significance.     

Transsphenoidal surgery assisted by navigation system

Microneurosurgical technique combined with precise localization of lesions, can minimize the invasiveness of neurosurgical procedures. This report describes the usefulness of the neuronavigation system in transsphenoidal surgery. Nineteen transsphenoidal operations for sellar lesions including pituitary adenoma, clival chordoma, Rathke's cleft cyst and suprasellar germinoma were assisted by the optical tracking system (OTS). Operations were performed either through the sublabial or the endonasal approach using an operative microscope and, to a certain extent, the endoscope. All five microadenomas were totally removed. The tumors could be precisely localized by the navigation system. Four out of seven macroadenomas were totally removed. The operations were assisted effectively by the excellent guidance to the lateral margin of the tumors and the internal carotid arteries provided by the navigation system. The endonasal approach, in which the surgeon looks through a nostril at the sellar floor obliquely, was especially facilitated by the three-dimensional view provided by the system. The navigation system, however, was not useful in estimating the amount of the suprasellar residual tumor because of the dislocation that occurred during the tumor removal.     

Transnasal surgery for prolactin-secreting pituitary adenomas in childhood and adolescence

BACKGROUND

Prolactin (PRL)-secreting pituitary adenomas (prolactinomas) are rare in childhood and adolescence; there are only a few published series of patients who were surgically treated. We discuss the gender-dependent differences, and the surgical indications and results for 14 patients with prolactinomas under 18 years of age at surgery.

METHODS

We reviewed the data for 14 patients (10 girls and 4 boys) treated surgically for prolactinomas between 1980 and 1996. Surgery was chosen because of intolerance and/or resistance to dopamine agonist (DA) in 9 patients, the patient’s decision in 3, rhinorrhea in 1, and pituitary apoplexy in 1 during DA therapy. All patients underwent direct transnasal explorations. Since 1988, intraoperative PRL measurements were performed. The follow-up period was at least 6 years.

RESULTS

Nine of the 10 girls had primary or secondary amenorrhea, and 3 of the 4 boys had visual field defects. The boys and girls were the same age at the onset of symptoms and had the same preoperative duration of symptoms. Boys had larger, more invasive tumors and higher preoperative and postoperative plasma PRL levels than girls. Two boys demonstrated significant extrasellar extension at the time of diagnosis. Two patients required drilling of the incompletely pneumatized sphenoid sinus to reach the sella. Radical tumor resection was achieved in seven girls and in none of the four boys. In 12 of the 14 patients, normal pituitary function was preserved by transnasal surgery. There was no severe surgical morbidity or mortality. Endocrinological remission by surgery alone was achieved for seven girls, and was achieved in 4 of the 5 patients (80%) with microadenomas. In patients with preoperative mean PRL levels of less than 200 μg/L, the surgical cure rate was 75%.

CONCLUSIONS

Prolactinomas in childhood and adolescence differ in their biology in boys and girls. Transnasal surgery is as safe in childhood patients as it is in adult patients, and it may be an effective alternative to long-term medical therapy for selected patients with prolactinomas. Successful surgical outcomes were achieved in patients with microadenomas and preoperative serum PRL levels of less than 200 μg/L.     

Treatment of prolactinoma based on the results of transsphenoidal operations

Ninety-eight patients (16 male, 82 female) with prolactinomas were treated by transsphenoidal operation. The postoperative course was closely related to the tumor size and the preoperative levels of serum prolactin. In 37 (74%) of 50 patients with microadenomas, the levels of serum prolactin returned to normal postoperatively. There were 48 patients with macroadenomas; 27 of these were expansive and 21 were invasive. In 9 (33%) of the 27 patients with expansive macroadenomas, the postoperative levels of prolactin returned to normal; this was not the case in any of the 21 patients with invasive macroadenomas. Of 81 premenopausal women, 35 (43%) resumed normal menstruation postoperatively. All patients with preoperative deficits in the visual field experienced postoperative improvement. There were no postoperative deaths or serious complications in this series. Our data indicate that microprolactinomas are highly curable by transsphenoidal operation alone. In women who plan to have children, prolactinomas should be removed immediately. On the other hand, in patients with macroprolactinomas who manifest high levels of serum prolactin, initial treatment with bromocriptine should be considered because there is little hope for surgical cure and postoperative bromocriptine treatment might be necessary.     

The neurosurgical management of prolactinomas

BACKGROUND: The objective was to discuss the neurosurgical management of the prolactinomas. METHODS: Five-hundred-fifty patients suffering from prolactinoma were treated with trans-sphenoidal and transcranial approach. The diagnosis of prolactinoma was based on various degree of high level prolactinemia, galactorrhea, gonodal disturbance, neurological examination and radiological findings. In all cases the adenoma was histologically verified. The patients were investigated according to the anatomo-radiological classification of Hardy and Vesina, and the range of preoperative PRL basal levels. RESULTS: Follow-up was ascertained in 81% of patients who were followed for a mean of 7.2 year (1-10 year). While the total removal percentage was 98% in the group with microprolactinoma, this ratio dropped to 63.9% for macroadenomas and 23.5% for giant adenomas. Early improvement of prolactin level ratio was 81.6% in microprolactinomas, 28.3 in macroadenomas and 11.7% in giant adenomas. Hormonal cure was 64.3% in microadenomas, 6.7% in macroadenomas and 0% in giant adenomas. The ratio of hormonal cure was decreasing in patients with high prolactin levels. In the follow-up recurrence of prolactinomas occurred in 39% of the patients. CONCLUSIONS: Medical treatment is the first step in prolactin secreting adenomas. Trans-sphenoidal microsurgery became popular in treatment of prolactinomas because of low operative morbidity and mortality. Patients with recurrence should be evaluated for second step treatment (surgery, bromocriptine, or radiotherapy).     

Pituitary disorders in pregnancy

During pregnancy there is a normal increase in the volume of the anterior pituitary as demonstrated by MRI and hormone secretions which increase (PRL) or decrease (FSH, LH). During pregnancy pituitary adenomas, especially prolactinomas, may evolve as in non-pregnant women (microadenomas) or differently (macroadenomas). In 35 % of cases macroprolactinomas worsen during pregnancy making their medico-surgical management mandatory prior to pregnancy. Inversely, pregnancy occurring in a subject with a microprolactinoma never induces severe local complications so such tumors may be managed surgically or medically. Surgery should be performed for acromegaly or Cushing's disease before or early in pregnancy. Subacute pituitary apoplexy (intratumoral hemorrhage) occurs in about 10 to 15 % of adenomas but, generally speaking, clinical symptoms remain mild in pregnant women. Lymphocytic hypophysitis occurs at the end of pregnancy, or during the post-partum period. The association of complete pan-hypopituitarism and hypersignal on MRI examination may mimic hypophyseal apoplexy and could lead to and inappropriate surgical procedure.     

Endoscopic Endonasal Transsphenoidal Approach to Sellar Lesions: A Detailed Account of Our Mononostril Technique

Objective The endonasal endoscopic approach is currently under investigation for perisellar tumor surgery. A higher resection rate is to be expected and nasal complications should be minimized. Here, the authors report their technique of transnasal endoscopic neurosurgery after 218 procedures.Methods Between October 2000 and September 2011, 210 patients received 218 endoscopic endonasal transsphenoidal procedures for perisellar lesions. Procedures were video recorded. The surgical technique was carefully analyzed. These cases were prospectively followed.Results Standard technique was mononostril approach with 0-degree optics. 30-degree and—after availability—45-degree optics were used for assessment of radicality. On follow-up, magnetic resonance imaging revealed radical tumor resection in 94 out of 104 cases (90.3%). Recurrent tumor growth was observed in five younger patients (2.2%). There was no mortality and a low complication rate. Three patients (1.4%) complained postoperatively of nasal congestion or reduced nasal air flow; however, no complaints were considered to be severe.Conclusion In comparison with other literature reports, the results are comparable or even better with respect to surgical radicality. The very low rate of nasal complaints is particularly remarkable. The technique has been shown to be safe and successful with a high radicality and only minor complications.     

Comparison of endonasal endoscopic surgery and sublabial microsurgery for prolactinomas

BACKGROUND

Endonasal endoscopy is a promising minimally invasive surgery for the treatment of pituitary adenomas; it is also a good alternative to traditional sublabial microsurgery. In this study, we compared endoscopic surgery with microsurgery and evaluated both for their safety and effectiveness. We chose prolactinomas for study because their hormone and symptomatic changes facilitated the comparison.

METHODS

During the past five years, 44 randomized prolactinoma patients underwent pituitary adenomectomy. Group A (22 patients) underwent endonasal endoscopic surgery for prolactinomas. Group B (22 patients) underwent sublabial transsphenoidal microsurgery for prolactinomas.

RESULTS

In groups A and B, patients with prolactinoma exhibited significantly reduced postoperative prolactin levels, return of menstrual cycle, and relief of galactorrhea, (Wilcoxon signed rank test) (p < 0.001). But there were no statistically significant differences in the effectiveness of the procedures used in group A and group B. Visual improvement in cases of macroadenoma was satisfactory in both groups. Hospital stay in group A ranged from 2–5 days, with a mean of 3.2 days. Hospital stay in group B ranged from 4–8 days with a mean of 5.3 days. The hospital stay for group A patients was shorter (2.1 days) than for group B (Student t test, p < 0.05). The operative time was shorter by 1 hour in Group A (mean: 1.7 hours vs. mean: 2.7 hours, p < 0.05). There were fewer complications in group A (4.5%) than in group B (27%), p < 0.05.

CONCLUSIONS

The endoscopic era of pituitary surgery may be coming. Endonasal endoscopic surgery may have the same effectiveness as traditional microsurgery. However, endoscopic surgery may shorten hospital stay and operative time, and lead to fewer complications. It seems to be a good minimally invasive surgical technique for prolactinomas.     

Pituitary adenomas: Trans‐sphenoidal experience of 300 cases

Objective: The main aim of the present study was to examine the effectiveness and complication rate of the 1 cm right‐sided unilateral sublabial trans‐sphenoidal surgery for patients with pituitary adenoma equal to or greater than 5 mm in diameter. Method: A total of 350 patients were surgically treated for pituitary adenomas between December 1999 and December 2003 in an academic neurosurgical unit in China. Three hundred patients (86%) were treated with the 1‐cm right‐sided unilateral sublabial trans‐sphenoidal approach. The mean age of patients was 43 years (range 10–78 years) and female patients accounted for 59% of the total. One hundred and ninety‐six (64%) patients had functioning endocrine tumours and 104 (36%) patients had non‐functioning tumours or macroadenomas. Tumours which were outside this simple and basic classification were excluded from the study. Results: There were no operative mortalities. One patient developed hypopituitarism and 16 (5%) developed transient diabetes insipidus that required pituitrin treatment. The remission rate for macroadenoma was 85% and that for microadenoma was 98.5% during a medium term follow‐up of 1–5 years. One hundred and fifteen patients had prolactin secreting tumours and 90.4% achieved endocrine remission. Fifty‐six patients had growth hormone secreting tumours and 75.4% achieved endocrine remission. Preoperatively, one hundred and fifty‐one patients presented with visual impairment and 148 (98%) achieved a documented improvement in visual acuity. The mean duration of hospital stay was 4 days (range 3–7 days). Conclusion: This minimally invasive trans‐sphenoidal surgery for pituitary adenomas could be used as the primary treatment for small pituitary tumours. The effectiveness of the tumour removal and low morbidity rate compare favourably with the conventional sublabial approach as well as the more recently developed endoscopic endonasal approaches.     

Effectiveness of second-generation fibrin glue in endonasal operations.

We evaluated the efficacy and safety of the Quixil fibrin sealant after its application to endonasal operative sites. A total of 153 patients underwent nasal surgery. The rate of hemorrhagic complications was compared in the group with nasal packing and in the group in whom fibrin glue was used to stop postoperative bleeding. Our results indicate that the application of Quixil fibrin glue to the operative sites in various endonasal operations provides effective hemostasis and sealing. This fibrin glue is a more effective hemostatic agent than foam nasal packing and provides no complications, as can occur with packing. Patients with hypertension have no greater risk for postoperative bleeding if Quixil is used.     

Endoscope-assisted microsurgery for invasive endo- and suprasellar pituitary macroadenomas: a consecutive retrospective study with 13 patients

BACKGROUND AND PURPOSE: Surgery of invasive endo- and suprasellar pituitary macroadenomas remains difficult. The records of 13 consecutive patients who underwent transsphenoidal surgery were analyzed in order to evaluate advantages and limitations of endoscopy for surgery of invasive pituitary macroadenomas. METHODS: A transseptal transsphenoidal intersepto-columellar approach was performed with a nasal 0-degree endoscope. Removal of the macroadenoma was performed under the control of a microscope. When the tumor seemed to be completely removed with microscope, a rigid 30-degree endoscope was inserted in the intrasellar and suprasellar regions in order to detect residual adenoma tissue. These residues were removed when technically possible. RESULTS: No rhinologic complication was noted. In 7 patients, the intra- and suprasellar endoscopic view detected a tumor residue which could be removed in each case. Two cases of cerebrospinal fluid leakage occurred during the complementary tumor resection. Two cases of diabetes insipidus and two of rhinorrhea were reported postoperatively. The analysis of the postoperative MRIs showed a complete removal in 23% of the patients (3/13), 75 to 100% removal in 54% of the patients (7/13), 50 to 75% removal in 8% of the patients (1/13) and 50% removal in 15% of the patients (2/13). More than 75% removal was thus achieved in 77% of the patients (10/13). The mean follow-up was 27.2 months. CONCLUSIONS: Rhinologic morbidity was reduced with the endoscopic endonasal approach. Endoscopy complemented with a microscope offered an optimal view of the intra- and suprasellar regions. Endoscopy also improved tumor resection of the invasive endo- and suprasellar pituitary macroadenomas by visualizing hidden suprasellar tumor residues. However, endoscopy was associated with a higher rate of postoperative rhinorrhea.     

Suture knot on the repair splint: a simple method to facilitate reconstruction of the sella turcica during endonasal endoscopic transsphenoidal surgery. Technical note

Reconstruction of the sellar floor after pituitary tumor removal is sometimes difficult because the repair graft is difficult to handle in the narrow space. This is especially problematic if the endonasal endoscopic approach is used. The authors devised a technique to facilitate this procedure by placing a suture knot on the repair splint. This allows the material to be grasped securely with forceps and improves manipulation even within the narrow nasal cavity. This technique has proved useful when performing the endonasal endoscopic approach, and it is also expected to be useful when conducting the conventional sublabial transsphenoidal approach.     

Endoscopic endonasal extended transsphenoidal removal of tuberculum sellae meningioma (TSM): an experience of six cases

Abstract Aims. Tuberculum sellae meningiomas (TSMs) are usually removed through a transcranial approach. Recently, the sublabial transsphenoidal microscopic approach has been used to remove such tumours. More recently, endonasal extended transsphenoidal approach is getting popular for removal of tuberculum sellae meningioma. Here, we describe our initial experience of endonasal extended transsphenoidal approach for removal of suprasellar meningiomas in six consecutive cases. Materials and method. Six patients (four female and two male) who presented for headache and visual loss were investigated with MRI of brain that showed tuberculum sellae meningioma compressing visual apparatus. Average size was 3 × 3 cm in three cases and 4 × 4 cm in rest of the three. All patients underwent endoscopic endonasal extended transsphenoidal tumour removal, but in two patients with large tumour, microscopic assistance was needed. Complete tumour removal was done in all cases except one case where perforators seemed to be encased by the tumour and resulted in incomplete removal. The surgical dural and bony defects were repaired in all patients with thigh fat graft. Nasal packing was not used, but inflated balloon of Foley's catheter was used to keep fat in position. Result. There was mild postoperative cerebrospinal fluid (CSF) leakage in one patient on the fourth postoperative day after removal of lumbar CSF drain and stopped spontaneously on the seventh postoperative day. There were no postoperative CSF leaks or meningitis in the rest of the cases. In one patient, there was visual deterioration due to pressure on optic nerve by grafted fat and improved within 4 weeks. At 4 months after surgery, three patients had normal vision, two patients improved vision comparing with that of preoperative state but with some persisting deficit; one patient had static vision, no new endocrinopathy and no residual tumour on MRI in five cases but residual tumour in remaining case was static at the end of the ninth month. Conclusion. The endoscopic endonasal extended transsphenoidal approach appears to be an effective minimally invasive method for removing relatively small to medium tuberculum sellae meningiomas. With more experience of the surgeon, larger tuberculum sellae meningioma may be removed by purely endoscopic techniques in near future.     

Endonasal transsphenoidal removal of tuberculum sellae meningiomas: technical note

OBJECTIVE: Tuberculum sellae meningiomas traditionally have been removed through a transcranial approach. More recently, the sublabial transsphenoidal approach has been used to remove such tumors. Here, we describe use of the direct endonasal transsphenoidal approach for removal of suprasellar meningiomas. METHODS: Three women, aged 32, 34, and 55 years, each sought treatment for visual loss and headaches. In each patient, magnetic resonance imaging (MRI) showed a suprasellar mass causing optic chiasmal and optic nerve compression (average size, 2 x 2 cm). All three patients underwent tumor removal via an endonasal approach with the operating microscope. Suprasellar exposure was facilitated by removal of the posterior planum sphenoidale. Ultrasound was used to help define tumor location before dural opening. The extent of tumor removal was verified with angled endoscopes in all patients, and with intraoperative MRI in one patient. The surgical dural and bony defects were repaired in all patients with abdominal fat, titanium mesh, and 2 to 3 days of cerebrospinal fluid lumbar drainage. Nasal packing was not used. RESULTS: There were no postoperative cerebrospinal fluid leaks or meningitis. One patient required a reoperation 2 weeks after surgery to reduce the size of her fat graft, which was causing optic nerve compression; within 24 hours, her vision rapidly improved. At 3 months after surgery, all three patients had normal vision, no new endocrinopathy, and no residual tumor on MRI. At 10 months after surgery, one patient had a small asymptomatic tumor regrowth seen on MRI. CONCLUSION: The endonasal approach with the operating microscope appears to be an effective minimally invasive method for removing relatively small midline tuberculum sellae meningiomas. Intraoperative ultrasound, the micro-Doppler probe, and angled endoscopes are useful adjuncts for safely and completely removing such tumors. Longer follow-up is needed to monitor for tumor recurrence in these patients.     

Transcolumellar approach in transsphenoidal pituitary surgery for patients with small nostril

OBJECTIVE: Sublabial approach has been widely used as the standard technique for transsphenoidal pituitary surgery. But it has several possible drawbacks, such as; postoperative flat nose deformity, hypesthesia of upper gum, and feeding difficulty until 2 to 3 weeks after surgery. As an alternative, an endonasal approach was adopted for patients who had large nostrils, such as white or acromegalic patients. In patients with small nostrils, especially oriental people, it requires an additional tension release incision that leaves a definitely visible scar at the base of nose. STUDY DESIGN: We applied the transcolumellar approach, which modified the external rhinoplasty approach on the 136 cases of transsphenoidal pituitary surgery that were performed from 1994 to June 1999. RESULTS: In all patients, we found we could reach the anterior portion of nasal septum in 7 to 8 mm in depth from the skin surface and eliminate the disadvantages of sublabial and endonasal approach. Also, this method can markedly reduce the surgical dissection time and blood loss. CONCLUSIONS: We concluded that this technique was relatively simple and more than adequate in most transsphenoidal pituitary surgery, even in patients with small nostrils.     

Endoscopic endonasal trans-sphenoidal approach for pituitary adenomas: Is one nostril enough?

Background

Over the past decade, the endoscopic endonasal trans-sphenoidal approach has been used to resect pituitary adenomas. However, in the use of this procedure, some research teams prefer a two-nostril method, whereas other groups are in favor of the one-nostril method. Here, we present a series of pituitary adenomas and try to confirm whether or not one nostril is enough for endoscopic resection of most pituitary adenomas.

Methods

A total of 250 consecutive patients who underwent an endoscopic endonasal trans-sphenoidal approach were reviewed retrospectively, of which 200 were via the unilateral nostril (group 1) and 50 were via bilateral nostrils (group 2). Surgical and clinical outcomes were analyzed.

Results

For microadenomas, intrasellar macroadenomas and macroadenomas with moderate extrasellar extension, the prevalence of gross total resection (GTR), hormonal outcome and visual improvement were similar between the two groups. The one-nostril group had better results for duration of surgery and blood loss, with fewer rhinological complications. However, for macroadenomas with extensive extrasellar invasion, GTR was obtained in two of seven patients in group 2 but none in group 1.

Conclusion

The one-nostril method, which is relatively fast and minimally invasive, is adequate for endoscopic resection of most pituitary adenomas with moderate extension.     

Gamma Knife radiosurgery for functioning pituitary microadenoma

Transsphenoidal microsurgery remains the treatment of choice for pituitary microadenomas One hundred and six patients were treated with Gamma Knife radiosurgery (GKRS) for pituitary adenomas, and of these, 23 patients (1 male, 22 female) had microadenomas. Twenty-two of these patients were followed up and endocrinological tests were available for 15 of these 22. Thirteen of these 15 had prolactinomas, while the remaining 2 had acromegaly. The follow-up period was from 3 to 26 months (median 12 months). The mean age was 33.6 years (range 21 to 60 years). The mean maximum tumor dose was 35.7 Gy and the mean margin dose was 22 Gy. Serum prolactin (PRL) was normalized in three patients, decreased in eight and unchanged in two. The growth hormone (GH) secretion in the acromegalic patients has remained unchanged through the follow-up period. Thus, GKRS is a valuable adjuvant to transsphenoidal microsurgery for patients with pituitary microadenomas.     

Predictive value of serum prolactin levels measured immediately after transsphenoidal surgery

OBJECT: Prolactin-secreting pituitary adenomas may be managed by surgery, medication, radiotherapy, or observation. The authors reviewed a consecutive series of patients who were followed for at least 5 years after surgery to assess the prognostic significance of preoperative factors (tumor size and prolactin level) and an immediate postoperative factor (prolactin level obtained the morning after surgery) on long-term hormonal outcome, thereby clarifying the indications for surgical removal of tumor, the definition of successful treatment outcomes, and the nature of "recurrent" tumors. METHODS: Between 1979 and 1991, 241 patients with prolactinomas underwent transsphenoidal resection. Nineteen patients were lost to follow-up review, whereas the remaining 222 patients underwent measurement of their prolactin levels on postoperative Day 1 (POD 1), at 6 and 12 weeks, and every 6 months thereafter for a minimum of 5 years. On POD 1, prolactin levels in 133 patients (Group 1) were lower than 10 ng/ml, in 43 patients (Group 2) between 10 and 20 ng/ml, and in 46 patients (Group 3) higher than 20 ng/ml. At 6 and 12 weeks, normal prolactin levels (< or = 20 ng/ml) were measured in 132 (99%) of the 133 patients in Group 1 but only in 32 (74%) of the 43 patients in Group 2. By 5 years postoperatively, normal levels of prolactin were still measured in 130 patients (98%) in Group 1 compared with only five patients (12%) in Group 2. No patient with a prolactin level lower than 3 ng/ml on POD 1 was found to have an elevated hormone level at 5 years. The likelihood of a long-term chemical cure was greater for patients with microadenomas (91% cure rate) than for those with macroadenomas (33%). Preoperative prolactin levels also correlated with hormonal outcome. CONCLUSIONS: Prolactin levels lower than 10 ng/ml on POD 1 predict a long-term chemical cure in patients with microadenomas (100% cure rate) and those with macroadenomas (93% cure rate). In contrast, a cure is not likely to be obtained in patients with normal levels ranging between 10 and 20 ng/ml on POD 1 if they harbor macroadenomas (0% cure rate). A recurrence reported several years after surgery probably represents the presence of persistent tumor that was not originally removed. If the initial operation was performed by an experienced surgeon, however, reoperation is not likely to yield a chemical cure.     

Determining Optimal MRI Follow-up after Transsphenoidal Surgery for Pituitary Adenoma: Scan at 24 Hours Postsurgery Provides Reliable Information

Summary  There is no agreed-upon schedule for MRI follow-up after pituitary adenoma removal via the transsphenoidal approach. Our aim was to establish a plan for MRI follow-up after pituitary surgery.  Eighty pituitary adenoma cases (25 microadenomas, 30 macroadenomas that did not infiltrate the cavernous sinus, and 25 macroadenomas with cavernous sinus infiltration) were prospectively studied with MRI following tumor resection via the transsphenoidal approach. Each patient was imaged at 24 hours, at 3, 6 and 9 months, and at 1 year or more postsurgery. The parameters studied were residual tumor, synthetic packing material (Gelfoam) versus fat graft, and normal pituitary, hypophyseal stalk and optic chiasma. The size of the pituitary structure as a whole was also measured. The latter was studied quantitatively, and the findings for the rest of the parameters were evaluated qualitatively, based on the examiners' confidence in their assessment. The final MRI study, done at least 1 year postsurgery in all cases, was considered the reference MRI for all scans.  MRI performed 24 hours after surgery was diagnostically accurate for residual tumor and valuable for visualizing normal sellar structures. The findings also showed that fat packing takes longer to resorb than Gelfoam, but produces no potentially confounding contrast enhancement. An algorithm based on the results is presented for postsurgical MRI assessment of pituitary adenoma patients in which the scan at 24 hours postsurgery is the major factor that determines the timing of later rechecks.