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  • Impact of Selective Pituitary Gland Resection or Incision on Hormonal Function in Endonasal Tumor or Cyst Removal

    Final Number:

    Aaron Cutler MD; Amy Eisenberg NP; Garni Barkhoudarian; Pejman Cohan MD; Daniel F. Kelly MD

    Study Design:

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2013 Annual Meeting

    Introduction: In the resection of pituitary adenomas or Rathke’s cleft cysts (RCC), the anterior pituitary gland is often partially or completely obstructing transsphenoidal access to the lesion. In such cases, a gland incision and/or partial gland resection may be required to obtain adequate tumor/cyst exposure. We investigated the frequency with which this technique was performed in our practice and determined the associated risk of post-operative hypopituitarism.

    Methods: All patients who underwent endoscopic-assisted or fully endoscopic removal of a pituitary adenoma or RCC between January 2011 and January 2013 (minimum 3 month follow-up) and had a gland incision or resection were included. Pre- and post-operative pituitary hormonal status was evaluated.

    Results: Of 137 operations, an anterior gland incision or resection was performed in 41 cases (30%) in 39 patients. In 25 cases a vertical gland incision was made. In 16 cases a partial gland resection was performed including 8 partial hemi-hypophysectomies and 8 resections of thinned/ attenuated anterior gland draped over a large macroadenoma. Diagnoses included 32 pituitary adenomas (12 endocrine-inactive, 11 Cushing’s, 7 prolactinomas, 2 acromegaly) and 9 RCCs. Of 33 patients with complete endocrine follow-up data, new permanent hypopituitarism occurred in 1 (3%) patient with a 3 cm macroadenoma who had partial gland resection; 2 patients experienced transient hyponatremia. Overall gland improvement occurred in 7/13 (54%) patients with pre-operative hypopituitarism, including 5 with resolution of 1 axis or of stalk-effect hyperprolactinemia and 2 with resolution of 2 or more axes.

    Conclusions: Pituitary gland incisions and partial gland resections are generally well-tolerated and can be performed when necessary to gain access to pituitary adenomas or RCCs. This technique, performed in 30% of our cases, appears to minimize traction on the normal pituitary gland during removal of large tumors or cysts and facilitates better visualization of microadenomas embedded in the anterior gland.

    Patient Care: We hope to prove that incisions and partial resections of the pituitary gland improve tumor or cyst visualization while minimzing traction on the normal gland and preserving postoperative gland function. Therefore this practice should be utilized when necessary in endonasal transsphenoidal approaches for pituitary adenomas or Rathkes Cleft Cysts.

    Learning Objectives: By the conclusion of this session, participants should be able to: 1) Describe the importance of performing a pituitary gland resection or incision during endonasal transsphenoidal removal of a pituitary adenoma or Rathke's Cleft Cyst and the associated low risk of postoperative gland dysfunction 2) Discuss in small groups the risk factors for postoperative hypopituitarism 3) Identify when a partial pituitary gland incision or resection is necessary during endonasal transsphenoidal surgery

    References: 1. Chee GH, Mathias DB, James RA, Kendall-Taylor P: Transsphenoidal pituitary surgery in Cushing's disease: can we predict outcome? Clin Endocrinol (Oxf) 54:617-626, 2001. 2. Fatemi N, Dusick JR, Mattozo C, McArthur DL, Cohan P, Boscardin J, Wang C, Swerdloff RS, Kelly DF: Pituitary hormonal loss and recovery after transsphenoidal adenoma removal. Neurosurgery 63:709-718; discussion 718-709, 2008. 3. Jagannathan J, Smith R, DeVroom HL, Vortmeyer AO, Stratakis CA, Nieman LK, Oldfield EH: Outcome of using the histological pseudocapsule as a surgical capsule in Cushing disease. J Neurosurg 111:531-539, 2009. 4. McCance DR, Gordon DS, Fannin TF, Hadden DR, Kennedy L, Sheridan B, Atkinson AB: Assessment of endocrine function after transsphenoidal surgery for Cushing's disease. Clin Endocrinol (Oxf) 38:79-86, 1993. 5. Oldfield EH, Vortmeyer AO: Development of a histological pseudocapsule and its use as a surgical capsule in the excision of pituitary tumors. J Neurosurg 104:7-19, 2006. 6. Randeva HS, Schoebel J, Byrne J, Esiri M, Adams CB, Wass JA: Classical pituitary apoplexy: clinical features, management and outcome. Clin Endocrinol (Oxf) 51:181-188, 1999. 7. Rees DA, Hanna FW, Davies JS, Mills RG, Vafidis J, Scanlon MF: Long-term follow-up results of transsphenoidal surgery for Cushing's disease in a single centre using strict criteria for remission. Clin Endocrinol (Oxf) 56:541-551, 2002. 8. Semple PL, Webb MK, de Villiers JC, Laws ER J: Pituitary apoplexy. Neurosurgery 56:65-72, 2005.

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