Transsphenoidal surgery and adjuvant gamma knife treatment for growth hormone—secreting pituitary adenoma

2001 ◽  
Vol 95 (2) ◽  
pp. 285-291 ◽  
Author(s):  
Hidetoshi Ikeda ◽  
Hidefumi Jokura ◽  
Takashi Yoshimoto
Keyword(s):  
Growth Hormone ◽  
Pituitary Adenoma ◽  
Mr Imaging ◽  
Transsphenoidal Surgery ◽  
Residual Tumor ◽  
Cure Rate ◽  
Content Type ◽  
Transsphenoidal Microsurgery ◽  
Biochemical Cure ◽  
Fine Print

Object. The results of combined transsphenoidal surgery and adjuvant gamma knife surgery (GKS) for growth hormone (GH)—secreting adenoma were investigated using biochemical cure criteria for surgery and biological cure criteria for adjuvant GKS. Methods. Ninety patients (42 male and 48 female patients), ranging from 11 to 75 years of age, underwent transsphenoidal surgery for GH-secreting pituitary adenoma. Preoperative and postoperative GH and insulin-like growth factor-I levels were measured, as was the postoperative GH level after the oral glucose tolerance test. Tumor size, cavernous sinus (CS) invasion, and residual tumor were evaluated using magnetic resonance (MR) imaging. Transsphenoidal microsurgery was performed, followed by adjuvant GKS when there was persistent biochemical evidence of GH hypersecretion with residual tumor detectable in the CS on MR imaging. Patients in whom GKS was contraindicated were treated with conventional radiotherapy or by medical means. Conclusions. The overall surgical cure rate was 57% based on recently accepted biochemical cure criteria. Patients with no CS invasion achieved a 100% cure rate, whereas patients with CS invasion achieved an 82% cure rate (14 of 17 patients) after adjuvant GKS. The combination of transsphenoidal microsurgery and adjuvant GKS is the optimal therapy for patients with GH-secreting adenoma.

Pituitary adenoma producing growth hormone and adrenocorticotropin: a histological, immunocytochemical, electron microscopic, and in situ hybridization study

1998 ◽  
Vol 88 (6) ◽  
pp. 1111-1115 ◽  
Author(s):  
Kalman Kovacs ◽  
Eva Horvath ◽  
Lucia Stefaneanu ◽  
Juan Bilbao ◽  
William Singer ◽  
...  
Keyword(s):  
Growth Hormone ◽  
In Situ Hybridization ◽  
Pituitary Adenoma ◽  
Immunoelectron Microscopy ◽  
Secretory Granules ◽  
Cell Types ◽  
Content Type ◽  
Separate Cell ◽  
Fine Print

✓ The authors report on the morphological features of a pituitary adenoma that produced growth hormone (GH) and adrenocorticotropic hormone (ACTH). This hormone combination produced by a single adenoma is extremely rare; a review of the available literature showed that only one previous case has been published. The tumor, which was removed from a 62-year-old man with acromegaly, was studied by histological and immunocytochemical analyses, transmission electron microscopy, immunoelectron microscopy, and in situ hybridization. When the authors used light microscopy, the tumor appeared to be a bimorphous mixed pituitary adenoma composed of two separate cell types: one cell population synthesized GH and the other ACTH. The cytogenesis of pituitary adenomas that produce more than one hormone is obscure. It may be that two separate cells—one somatotroph and one corticotroph—transformed into neoplastic cells, or that the adenoma arose in a common stem cell that differentiated into two separate cell types. In this case immunoelectron microscopy conclusively demonstrated ACTH in the secretory granules of several somatotrophs. This was associated with a change in the morphological characteristics of secretory granules. Thus it is possible that the tumor was originally a somatotropic adenoma that began to produce ACTH as a result of mutations that occurred during tumor progression.

Transsphenoidal surgery in Cushing disease: 10 years of experience in 34 consecutive cases

2004 ◽  
Vol 100 (4) ◽  
pp. 634-638 ◽  
Author(s):  
Charlotte Höybye ◽  
Eva GrenbäcK ◽  
Marja Thorén ◽  
Anna-Lena Hulting ◽  
Lars Lundblad ◽  
...  
Keyword(s):  
Mr Imaging ◽  
Transsphenoidal Surgery ◽  
Cushing Syndrome ◽  
Preoperative Evaluation ◽  
Clinical Signs ◽  
Pituitary Hormone ◽  
Years Of Experience ◽  
Cushing Disease ◽  
Content Type ◽  
Fine Print

Object. Cushing disease is a rare disorder. Because of their small size the adrenocorticotropic hormone (ACTH)—producing tumors are often not detectable on neuroimaging studies. To obtain a cure with transsphenoidal surgery (TSS) may therefore be difficult. In this report the authors present 10 years of experience in the treatment of patients with Cushing disease who were followed up with the same protocol and treated by the same surgeon. Methods. Thirty-four patients, 26 of them female and eight of them male (mean age 40 years, range 13–74 years) were studied. All had obvious clinical signs and symptoms of Cushing syndrome. Magnetic resonance (MR) imaging was performed in all patients, and inferior petrosal sinus (IPS) sampling was done in 14. In 12 patients MR imaging indicated a pituitary tumor; 10 were microadenomas and two were macroadenomas. In six patients with no visible tumor, the results of IPS sampling supported the diagnosis. All patients underwent TSS; the mean follow-up duration was 6 ± 0.5 years. Selective adenomectomy was performed in 32 and hemihypophysectomy in the other two patients. A cure was obtained in 31 patients (91%) after one TSS and in two more patients after further TSS; one patient was not cured despite two TSSs and one underwent bilateral adrenalectomy. Disease recurrence was seen in two patients after 3 years, and they were successfully treated with stereotactic gamma knife surgery. Half of the patients had an ACTH deficiency postoperatively, whereas one third had other pituitary hormone insufficiencies. There were no serious complications attributable to the surgical intervention. Conclusions. Transsphenoidal surgery with selective adenomectomy is an effective and safe treatment for Cushing disease. In the patients presented in this study, the surgical outcome seemed to depend on careful preoperative evaluation and the surgeon's experience. For optimal results in this rare disease the authors therefore suggest that the endocrinological, radiological, and surgical procedures be coordinated in a specialized center.

Intracranial and intraspinal dissemination from a growth hormone-secreting pituitary tumor

1986 ◽  
Vol 64 (1) ◽  
pp. 140-144 ◽  
Author(s):  
Nobuo Hashimoto ◽  
Hajime Handa ◽  
Shogo Nishi
Keyword(s):  
Growth Hormone ◽  
Cerebrospinal Fluid ◽  
Radiation Therapy ◽  
Pituitary Adenoma ◽  
Pituitary Tumor ◽  
Invasive Growth ◽  
Metastatic Tumors ◽  
Content Type ◽  
Fine Print

✓ A 48-year-old woman developed multiple intracranial and intraspinal metastases from an invasive growth hormone-secreting pituitary adenoma after surgery and radiation therapy. This is the first reported case to show that the cells in the metastatic tumors and in the cerebrospinal fluid contained growth hormone.

Differential effects of octreotide treatment and transsphenoidal surgery on growth hormone—binding protein levels in patients with acromegaly

1999 ◽  
Vol 90 (4) ◽  
pp. 647-650 ◽  
Author(s):  
Irma Hernandez ◽  
Daniela Soderlund ◽  
Ana Laura Espinosa-de-los-Monteros ◽  
Raquel Ochoa ◽  
Arturo Zarate ◽  
...  
Keyword(s):  
Growth Hormone ◽  
Transsphenoidal Surgery ◽  
Binding Protein ◽  
Hormone Binding ◽  
Content Type ◽  
Growth Hormone Binding Protein ◽  
Igf I ◽  
Octreotide Treatment ◽  
Hormone Binding Protein ◽  
Fine Print

Object. The high-affinity growth hormone—binding protein (GHBP) represents the extracellular portion of the growth hormone (GH) receptor, and its serum levels are a reflection of the tissue receptor status. Levels of GHBP are decreased in patients with active acromegaly, probably because of downregulation of GH receptors. However, there are no studies of patients with acromegaly in which the effects of medical (that is, administration of somatostatin analogs) and surgical therapy on GHBP levels have been compared. That is the task the authors set out to accomplish in this study.Methods. The authors studied seven patients in whom acromegaly had been recently diagnosed. They examined these patients at baseline, 2 months after octreotide treatment (subcutaneous administration of 100 µg octreotide three times per day), and 1 month after transsphenoidal surgery. Growth hormone—binding activity was measured, as well as the following biochemical markers of the somatotropic axis: GH suppression induced by oral administration of glucose, insulin-like growth factor-I (IGF-I), and insulin-like growth factor—binding protein-3 (IGFBP3). Although octreotide treatment induced a decrease in the levels of GH, IGF-I, and IGFBP3, as well as an increase in the level of GHBP, these biochemical markers did not reach normal levels. On the other hand, after transsphenoidal surgery, GHBP levels became normal, particularly in those patients in whom serum GH could be suppressed to an undetectable level after glucose loading.Conclusions. The authors conclude that persistently low GHBP levels in patients with acromegaly are normalized by successful pituitary surgery and correlate well with disease activity.

Delayed hyponatremia after transsphenoidal surgery for pituitary adenoma

1995 ◽  
Vol 83 (2) ◽  
pp. 363-367 ◽  
Author(s):  
Daniel F. Kelly ◽  
Edward R. Laws ◽  
Damirez Fossett
Keyword(s):  
Pituitary Adenoma ◽  
Antidiuretic Hormone ◽  
Intravenous Administration ◽  
Serum Sodium ◽  
Transsphenoidal Surgery ◽  
Fluid Restriction ◽  
Content Type ◽  
Inappropriate Secretion ◽  
Average Serum ◽  
Fine Print

✓ Hyponatremia, usually attributed to the syndrome of inappropriate secretion of antidiuretic hormone, typically occurs in a delayed fashion following transsphenoidal removal of a pituitary adenoma. In a series of 99 consecutive patients who underwent transsphenoidal surgery for pituitary adenoma, nine patients developed delayed hyponatremia, seven of whom were symptomatic. Of these seven patients, four had been discharged from the hospital and required readmission on postoperative Day 7 to 9. In the nine patients who developed hyponatremia, on the average, serum sodium levels began to fall on Day 4 and reached a nadir on Day 7 (mean serum sodium nadir 123 mmol/L). The development of delayed hyponatremia was associated with the presence of a macroadenoma in eight of the nine patients. Seven of the nine patients had serum sodium levels less than 130 mmol/L and required treatment. One patient was treated with fluid restriction alone and six were treated with both fluid restriction and intravenous urea therapy. Twenty-four and 48 hours after urea administration, serum sodium levels rose by an average of 6 and 10 mmol/L, respectively, and at discharge, levels averaged 136 mmol/L. Intravenous administration of urea provides a rapid yet safe means of correcting symptomatic hyponatremia when fluid restriction alone is inadequate. In this article, the authors discuss the pathogenesis of delayed hyponatremia.

Transcranial echo-guided transsphenoidal surgical approach for the removal of large macroadenomas

2004 ◽  
Vol 100 (1) ◽  
pp. 68-72 ◽  
Author(s):  
Ryuta Suzuki ◽  
Jun-ichiro Asai ◽  
Goro Nagashima ◽  
Hiroshi Itokawa ◽  
Chih-Wei Chang ◽  
...  
Keyword(s):  
Real Time ◽  
Transsphenoidal Surgery ◽  
Residual Tumor ◽  
Brain Structures ◽  
Tumor Removal ◽  
Color Flow ◽  
Content Type ◽  
Real Time Visualization ◽  
Doppler Color ◽  
Fine Print

Object. Transsphenoidal surgery for the removal of macroadenomas has some disadvantages, including the risk of performing procedures without adequate visualization, difficulties in estimating the amount of residual tumor, and the risk of injuring major vessels. To overcome these disadvantages, the authors have developed transcranial echo-guided transsphenoidal surgery. Methods. Three patients with large macroadenomas and two patients with irregularly shaped macroadenomas were selected for this operation. In addition to standard preparations for transsphenoidal surgery, in each case the right frontal bone was trephined and an echo probe was inserted transdurally through the trephination hole. During tumor removal, brightness-mode echo images and Doppler color flow images were obtained. The echo images allowed for real-time visualization of the tumor and surrounding brain structures including major arteries and the cisterns; histological heterogeneities of the tumor could also be appreciated. The tumors were removed safely and maximal tumor removal was achieved. Conclusions. Transcranial echo-guided transsphenoidal surgery provides real-time visualization of tumor removal. The method enhances the safety of this surgery, maximizes the removal of the tumor, and is inexpensive.

Long-term evaluation of reconstruction of the sellar floor with a silicone plate in transsphenoidal surgery

1998 ◽  
Vol 88 (6) ◽  
pp. 949-953 ◽  
Author(s):  
Masanori Kabuto ◽  
Toshihiko Kubota ◽  
Hidenori Kobayashi ◽  
Hiroaki Takeuchi ◽  
Takao Nakagawa ◽  
...  
Keyword(s):  
Mr Imaging ◽  
Transsphenoidal Surgery ◽  
Septal Cartilage ◽  
Csf Rhinorrhea ◽  
Content Type ◽  
Csf Leakage ◽  
Repeated Surgery ◽  
Initial Procedure ◽  
Sellar Floor ◽  
Fine Print

Object. The authors have used a silicone plate for reconstruction of the sellar floor during rhinoseptoplastic transsphenoidal surgery because it has greater elasticity and is easier to carve than nasal septal cartilage and sphenoid sinus bone. This study was designed to evaluate the usefulness of this technique based on the authors' experience during the past 7.6 years. Methods. A silicone plate was used to reconstruct the sellar floor in 69 consecutive patients with sellar tumors that included 60 pituitary adenomas and nine Rathke's cleft cysts. The patients ranged in age from 16 to 82 years (mean 52 years). The postoperative position of the silicone plate could be clearly identified on sagittal or coronal magnetic resonance (MR) imaging as a very low intensity plate (void signal). No displacement or migration of the implanted silicone plate was observed on follow-up MR imaging in any patient. Infections of the lesion such as a pituitary abscess were not observed clinically or radiologically in any patient. Of the 16 patients with intraoperative cerebrospinal fluid (CSF) leakage, only one patient who had a ghost sella developed postoperative CSF rhinorrhea. In all seven patients who underwent repeated surgery for residual or recurrent tumor, the silicone plate that had been placed at the initial procedure was covered with a relatively thin fibrous capsule and the plate was well preserved. The silicone plate was easily removed at reoperation and was useful for detection of the sellar floor window made previously. Conclusions. These results indicate that a silicone plate can be useful for reconstruction of the sellar floor in rhinoseptoplastic transsphenoidal surgery.

Treatment of invasive growth hormone pituitary adenomas with long-acting somatostatin analog SMS 201–995 before transsphenoidal surgery

1994 ◽  
Vol 81 (1) ◽  
pp. 10-14 ◽  
Author(s):  
Tomás Lucas-Morante ◽  
José García-Uría ◽  
Javier Estrada ◽  
Gertrudis Saucedo ◽  
Ana Cabello ◽  
...  
Keyword(s):  
Growth Hormone ◽  
Transsphenoidal Surgery ◽  
Somatostatin Analog ◽  
Clinical Activity ◽  
Tumor Shrinkage ◽  
Content Type ◽  
Gh Secretion ◽  
Igf I ◽  
Long Acting ◽  
Fine Print

✓ The purpose of this study was to determine whether the long-acting somatostatin analog SMS 201–995 (octreotide) shrinks growth hormone (GH)-secreting adenomas and improves the results of subsequent transsphenoidal surgery. Ten previously untreated active acromegalic patients (nine women and one man) with invasive tumors were treated with SMS 201–995 (100 µg subcutaneously every 8 hours) for 6 weeks prior to transsphenoidal surgery. The clinical activity, mean GH secretion, insulin-like growth factor (IGF)-I concentration, and tumor volume were measured under basal conditions and on Days 14, 28, and 42 of treatment. The SMS 201–995 improved the symptoms of acromegaly in all patients. Mean levels of both GH and IGF-I (± standard deviation) were significantly decreased by Day 14 (from 92.9 ± 30.5 to 44.9 ± 20.3 µg/liter and from 10.6 ± 7.4 to 5.9 ± 2.6 U/ml, respectively), after which there were only slight further decreases. Six (60%) of the 10 patients experienced tumor shrinkage ranging from 9% to 78% (mean 30%). When it occurred, tumor shrinkage was significant by Day 14 (7.9 ± 6.3 to 6.5 ± 5.1 cu cm) and no further shrinkage was achieved by longer administration. Transsphenoidal surgery reduced postoperative GH levels to less than 2 µg/liter and IGF-I to less than 1.5 U/ml in six patients (60%). This percentage of cure is higher than expected from the literature and the authors' previous experience. However, an investigation of the influence of this drug on several parameters, such as reduction of tumor size or GH and IGF-I concentrations, has failed to prove any relationship. Only pretreatment size of the tumor was of predictive value with respect to the surgical outcome.

Novel closure technique for the endonasal transsphenoidal approach

2004 ◽  
Vol 100 (1) ◽  
pp. 161-164 ◽  
Author(s):  
James K. Liu ◽  
Richard R. Orlandi ◽  
Ronald I. Apfelbaum ◽  
William T. Couldwell
Keyword(s):  
Transsphenoidal Surgery ◽  
Nasal Packing ◽  
Transsphenoidal Approach ◽  
Closure Technique ◽  
Content Type ◽  
Submucosal Dissection ◽  
Sellar Lesions ◽  
Parasellar Region ◽  
Transsphenoidal Microsurgery ◽  
Fine Print

✓ Transsphenoidal microsurgery has been the standard approach to sellar lesions since the repopularization of the technique with modifications by Dott, Guiot, and Hardy. The endonasal transseptal transsphenoidal approach, as introduced by Hirsch, is still commonly used by pituitary surgeons to remove lesions of the sellar and parasellar region. One disadvantage of this approach is that the submucosal dissection requires postoperative nasal packing, which is a source of discomfort in patients who undergo transsphenoidal surgery. The authors describe a novel closure technique for the unilateral endonasal transsphenoidal approach that eliminates the need for full nasal packing, minimizing postoperative rhinological morbidity. This technique has been performed in 67 patients harboring sellar and parasellar lesions. All patients recovered rapidly without significant rhinological sequelae.

Transsphenoidal decompression of the optic nerve and chiasm

1977 ◽  
Vol 46 (6) ◽  
pp. 717-722 ◽  
Author(s):  
Edward R. Laws ◽  
James C. Trautmann ◽  
Robert W. Hollenhorst
Keyword(s):  
Pituitary Adenoma ◽  
Optic Nerve ◽  
Transsphenoidal Surgery ◽  
Visual Loss ◽  
Sella Turcica ◽  
Recent Experience ◽  
Content Type ◽  
Visual Status ◽  
Fine Print

✓ A review of recent experience with transsphenoidal surgery for lesions in and about the sella turcica establishes the value of this approach for the management of patients with visual loss. The lesions encountered consisted of pituitary adenoma in 45 cases, craniopharyngioma in 10 cases, and miscellaneous tumors involving the sella in the remaining seven cases. Sixty of the 62 patients in this series had quantitative determination of preoperative and postoperative visual status; after surgery, vision was improved in 81%, unchanged in 11%, and worse in 5%. Two patients (3%) died during the immediate postoperative period before their visual status could be evaluated.

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