Multimodal Management of Growth Hormone Secreting Pituitary Adenomas
Islam Mahmoud Elsaid Rass;
Abstract
The pituitary gland lies within the sella turcica at the base of the brain. Access to the sella is limited because it is surrounded by vital structures making the preferred surgical routes to gland tumors being from below through transsphenoidal approach.
The clinical manifestations of growth hormone secreting pituitary adenomas usually presented either by acromegalic features or mass effects as headache and visual dysfunction.
Diagnosis of growth hormone secreting pituitary adenomas has been established on the basis of clinical examination, neuroimaging studies and endocrinological testing. MRI with Gadolinium is the most useful modality for imaging the pituitary gland and sellar region. The role of CT in this region is assisting in preoperative planning through evaluation of the nasal cavity and type and shape of the sphenoid sinuses.
Although presented over one hundred years ago, the transsphenoidal approach to pituitary adenoma is still the most suitable and safe route to pituitary adenoma, with a series of significant evolutional steps. The transsphenoidal approach has a number of variations, including the endonasal rhinoseptoplastic, transnasal septal displacement, trans septal endoscopic, and sublabial transseptal approaches.
In this study we evaluate the multimodal management in 20 patients with growth hormone secreting pituitary adenomas, after complete preoperative clinical, endocrinological and radiological evaluation. Follow up of the patients postoperatively was done clinically, endocrinologically and radiologically to evaluate the approach.
In this study we used microscopic trans septal transsphenoidal approach in 16 patients, and transcranial approach in 3 patients and the remaining case by endoscopic Transsphenoidal approach.
Analyzing our results and comparing them to the published case studies and clinical reports in the neurosurgical literatures, we concluded that:
1. The microscopic trans septal transsphenoidal approache is more suitable approache for managing sellar tumors with suprasellar and parasellar extension than the sublabial one as it is safe, efficient and minimally invasive.
2. This technique (transsphenoidal) avoids patients’ complications of cranial surgery, shortening hospital stay and bad cosmetic results; also it is suitable for senile patients, high risk patients who can’t tolerate major cranial surgery and long anesthesia. Both techniques (trans septal and sublabial transsphenoidal) have the same advantages according to the experience of the surgeon.
3. The parasellar extension with the cavernous sinus invasion was more reliable than tumor volume for expecting incomplete excision of the tumor.
4. We advocate multilayer sellar floor reconstruction when intraoperative CSF leak occurs as this decrease the incidence of postoperative CSF leak.
5. We don’t advocate routine middle turbinectomy because it acts as air conditioner & is responsible for about 50% of nasal resistance for air entry.
6. Endoscopic endonasal approach also provides quick recovery and avoids postoperative nasal packing that reduces breathing postoperative difficulities. And also has the same advantages as Transsphenoidal trans septal approach.
7. pharmacological therapy is playing an increased role in the armamentarium against acromegaly in patients unsuitable for or refusing surgery, after failure of surgical treatment.
8. Radiation was initially delivered through conventional fractionated radiotherapy, which targets a wide area over many treatment sessions and has been shown to induce remission in 50%–60% of patients with acromegaly.
9. Stereotactic radiosurgery, of which there are several forms, including Gamma Knife surgery, CyberKnife therapy, and proton beam therapy, offers slightly attenuated efficacy but achieves remission in less time and provides more precise targeting of the adenoma with better control of the dose of radiation received by adjacent structures such as the pituitary stalk, pituitary gland, optic chiasm, and cranial nerves in the cavernous sinus. Of the forms of stereotactic radiosurgery, Gamma Knife surgery is the most widely used and, because of its long-term follow-up in clinical studies, is the most likely to compete with medical therapy for first-line adjuvant use after resection. Acromegaly is a multisystem disorder that demands highly specialized treatment protocols including neurosurgical andendocrinological intervention.
The clinical manifestations of growth hormone secreting pituitary adenomas usually presented either by acromegalic features or mass effects as headache and visual dysfunction.
Diagnosis of growth hormone secreting pituitary adenomas has been established on the basis of clinical examination, neuroimaging studies and endocrinological testing. MRI with Gadolinium is the most useful modality for imaging the pituitary gland and sellar region. The role of CT in this region is assisting in preoperative planning through evaluation of the nasal cavity and type and shape of the sphenoid sinuses.
Although presented over one hundred years ago, the transsphenoidal approach to pituitary adenoma is still the most suitable and safe route to pituitary adenoma, with a series of significant evolutional steps. The transsphenoidal approach has a number of variations, including the endonasal rhinoseptoplastic, transnasal septal displacement, trans septal endoscopic, and sublabial transseptal approaches.
In this study we evaluate the multimodal management in 20 patients with growth hormone secreting pituitary adenomas, after complete preoperative clinical, endocrinological and radiological evaluation. Follow up of the patients postoperatively was done clinically, endocrinologically and radiologically to evaluate the approach.
In this study we used microscopic trans septal transsphenoidal approach in 16 patients, and transcranial approach in 3 patients and the remaining case by endoscopic Transsphenoidal approach.
Analyzing our results and comparing them to the published case studies and clinical reports in the neurosurgical literatures, we concluded that:
1. The microscopic trans septal transsphenoidal approache is more suitable approache for managing sellar tumors with suprasellar and parasellar extension than the sublabial one as it is safe, efficient and minimally invasive.
2. This technique (transsphenoidal) avoids patients’ complications of cranial surgery, shortening hospital stay and bad cosmetic results; also it is suitable for senile patients, high risk patients who can’t tolerate major cranial surgery and long anesthesia. Both techniques (trans septal and sublabial transsphenoidal) have the same advantages according to the experience of the surgeon.
3. The parasellar extension with the cavernous sinus invasion was more reliable than tumor volume for expecting incomplete excision of the tumor.
4. We advocate multilayer sellar floor reconstruction when intraoperative CSF leak occurs as this decrease the incidence of postoperative CSF leak.
5. We don’t advocate routine middle turbinectomy because it acts as air conditioner & is responsible for about 50% of nasal resistance for air entry.
6. Endoscopic endonasal approach also provides quick recovery and avoids postoperative nasal packing that reduces breathing postoperative difficulities. And also has the same advantages as Transsphenoidal trans septal approach.
7. pharmacological therapy is playing an increased role in the armamentarium against acromegaly in patients unsuitable for or refusing surgery, after failure of surgical treatment.
8. Radiation was initially delivered through conventional fractionated radiotherapy, which targets a wide area over many treatment sessions and has been shown to induce remission in 50%–60% of patients with acromegaly.
9. Stereotactic radiosurgery, of which there are several forms, including Gamma Knife surgery, CyberKnife therapy, and proton beam therapy, offers slightly attenuated efficacy but achieves remission in less time and provides more precise targeting of the adenoma with better control of the dose of radiation received by adjacent structures such as the pituitary stalk, pituitary gland, optic chiasm, and cranial nerves in the cavernous sinus. Of the forms of stereotactic radiosurgery, Gamma Knife surgery is the most widely used and, because of its long-term follow-up in clinical studies, is the most likely to compete with medical therapy for first-line adjuvant use after resection. Acromegaly is a multisystem disorder that demands highly specialized treatment protocols including neurosurgical andendocrinological intervention.
Other data
| Title | Multimodal Management of Growth Hormone Secreting Pituitary Adenomas | Other Titles | الطرق المختلفه المستخدمه في علاج أورام الغده النخاميه المفرزه لهرمون النمو | Authors | Islam Mahmoud Elsaid Rass | Issue Date | 2014 |
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