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Pituitary Tumors Follow-up

  • Author: Jorge C Kattah, MD; Chief Editor: Robert A Egan, MD  more...
 
Updated: Oct 26, 2015
 

Further Outpatient Care

See the list below:

  • Adjustment of hormonal therapy is necessary following transsphenoidal resection of the adenoma. This may be accomplished in the weeks following surgery by the consulting endocrinologist.
    • Assess the need for replacement of cortisol 4 weeks after the resection. This is done by measuring the cortisol levels following an IV injection of 250 mcg of tetracosactin. Cortisol levels greater than 500 nmol/L indicate sufficient endogenous steroid production.
    • Low thyroid levels are an indication for replacement. The same is true for low testosterone levels in symptomatic males and low estrogen/progesterone levels in females.
  • Periodic neuro-ophthalmologist follow-up is essential, particularly when residual tumor is present. Visual fields and fundus photographs should be obtained before and immediately after tumor resection. These parameters provide a baseline for follow-up examinations.
  • Radiation therapy (RT) is often necessary for managing local mass effects of large macroadenomas. The indications for RT at this time are controversial. In a recent study, Alameda et al followed 51 patients with pituitary tumor who underwent surgery; 22 with complete macroscopic resections, judged by imaging, were tumor-free 3-6 years postoperatively. Twenty-seven patients with residual tumors after surgical resection were treated with RT. Fourteen residual tumors decreased in size, 11 remained stable, 1 increased in size, and 1 patient was lost to follow-up. RT is a useful treatment alternative among patients with residual tumors after surgery. Fractionated stereotactic radiotherapy (FSR) was found to be safe and effective by Colin et al in 110 consecutive patients. Moreover, it may reduce the possibility of postradiation optic neuropathy.
  • The use of Gamma knife radiation to treat residual tumor has been the subject of reviews, which have found it effective, particularly in acromegaly and Cushing syndrome. The risk of postradiation optic neuropathy averaged less than 5%.
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Further Inpatient Care

Care of patients is primarily on an outpatient basis. Only patients who are undergoing surgery are inpatients. Additionally, a small percentage of patients with pituitary apoplexy present with a clinical picture similar to that of subarachnoid hemorrhage.

Transsphenoidal surgery

  • Careful hormonal control of these patients under the direction of an endocrinologist is essential.
  • A syndrome of inappropriate antidiuretic hormone secretion (SIADH) may be seen transiently, followed by diabetes insipidus.
  • Postoperative hypoadrenalism is a possibility that requires careful monitoring.
  • Hormonal levels should be assessed and replacements provided when appropriate.
  • In most cases, CSF rhinorrhea should be diagnosed and addressed promptly.
  • In most cases, transsphenoidal hypophysectomy involves low risk and has a good prognosis.

Pituitary apoplexy

  • As its name indicates, the apoplectic onset of hemorrhage within a pituitary adenoma may lead to hypothalamic, chiasmal, cavernous sinus, and brainstem compression.
  • Meningeal irritation results from blood in the subarachnoid space. On occasion, the degree of subarachnoid hemorrhage is significant, and a spinal tap may show evidence of acute or subacute bleeding. The acute panhypopituitarism is associated with shock and hypothalamic-brainstem compression, which could lead to coma and even death.
  • Headache, vomiting, visual loss, blindness, ophthalmoplegia, and altered consciousness may be present. In a series involving 62 patients, Semple et al found headache was the most common symptom in 87% of their cases, visual loss occurred in 56% of the patients, ophthalmoplegia in 45%, and altered level of consciousness in 13%. Hypopituitarism was present in 73% of patients and diabetes insipidus in 8%. [13]
  • In most cases, surgical intervention is required with excellent results. Candidates for emergency surgery include patients with rapidly deteriorating vision, altered mental status, and hypothalamic compression. Pituitary apoplexy may be fatal in a few instances. Conservative treatment is an option in stable cases, particularly if they are prolactinomas.
  • Factors leading to hemorrhage within a pituitary adenoma identified by Biousse et al include the following: reduced blood flow to the gland, sudden increment of blood flow, stimulation of the gland by endocrine mechanisms, anticoagulation, and trauma. [14] An upper respiratory tract infection with frequent coughing and sneezing also may trigger an apoplectic event. The best method to make the diagnosis of pituitary apoplexy is cerebral imaging. MRI preferentially but CT scan is an acceptable option if MRI is not available.
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Inpatient & Outpatient Medications

Initial hormonal deficiencies may improve over time. Therefore, frequent endocrine re-evaluation is necessary.

Perform preradiation and postradiation endocrinologic and neuro-ophthalmologic evaluations. A postoperative cerebral imaging study is important to determine the possibility of residual tumor. If residual tumor is present, serial imaging is required.

Adverse radiation effects on the hypothalamus, pituitary, and visual pathways require close monitoring.

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Transfer

Pituitary apoplexy

  • Patients with a diagnosis of pituitary apoplexy should be transferred immediately to a tertiary care center intensive care unit.
  • IV fluids and IV steroid replacement should be initiated.
  • Urgent decompression surgery is indicated.

Patients with other pituitary lesions are investigated as outpatients and admitted for transsphenoidal resection.

Inferior petrosal sinus corticotrophin levels also can be obtained on an outpatient basis.

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Complications

Treatment of pituitary tumors, particularly those resected via a transsphenoidal approach, has an excellent outcome with successful decompression of the visual pathways, cavernous sinus, and hypothalamus.

The possibility of significant loss of olfactory function following endoscopic transphenoidal pituitary surgery has been recently recognized as a frequent finding. A study by Rotenberg et al found damage to olfactory tissues to be a result of raising the vascularized septal flap that incorporates tissue rich in olfactory nerve receptors. Patients should be warned about this possibility prior to surgery. No suggestions for alternative olfactory receptor-sparing techniques were reviewed.[15]

Transfrontal resections are associated with more complications.

In cases handled by a skilled surgeon, surgical complications are minimal but can include any of the following:

  • Incomplete resection of large adenomas
  • Transient or permanent diabetes insipidus
  • CSF rhinorrhea
  • Monohormonal or polyhormonal deficiencies
  • Residual permanent visual field defects

Empty sella syndrome: An empty sella may occur after transsphenoidal surgery and is generally benign. Generally, herniation of the chiasm inside the sella typically does not cause visual field defects.

Radiation toxicity may occur as a rare complication in the treatment of pituitary adenomas, resulting in hypothalamic and chiasmal necrosis.

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Prognosis

See the list below:

  • Prolactin-secreting microadenomas
    • Surgical resection is curative.
    • Dopamine agonists provide symptom control.
  • Prolactin-secreting macroadenomas: Dopamine agonists provide symptom control.
  • Acromegaly
    • Surgical resection is curative in 60% of patients.
    • Octreotide therapy controls symptoms. In some instances, the use of PPAR-gamma ligands such as rosiglitazone or retinoic acid may be potential therapeutic options in the management of persistent or recurrent corticotropin-producing adenomas.[8]
  • Cushing disease: Surgical resection is curative. Rarely, invasive tumors produce metastatic deposits within the neuraxis via CSF pathways.
  • Rarely, distant metastases may occur.
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Patient Education

The successful management of pituitary adenomas requires a highly motivated and compliant patient.

Hormone-replacement therapy is demanding, and a noncompliant patient is at risk for complications due to misuse of these agents.

Interaction of a team of specialists is required to manage these lesions. One of the specialists should serve as team leader and coordinate the patient's care.

Prompt reporting of new symptoms is important in addition to routine follow-up visits.

If the patient has no new symptoms or problems beyond about 5 years after beginning treatment, follow-up visits can be less frequent.

The frequency of follow-up visits depends on the presence of residual tumor, visual deficit, hormonal needs, history of radiation therapy, or other complicating circumstances.

Visual prognosis is excellent with transsphenoidal surgery. Ninety-five percent of patients studied by Gnanalingham et al experienced visual improvement.[16] The extent of the visual field recovery is mainly dependent on the preoperative visual field defect. These authors also found that visual recovery may occur in a rapid fashion (3-6 mo) but may also take place slowly over several months and even a few years.

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Contributor Information and Disclosures
Author

Jorge C Kattah, MD Head, Associate Program Director, Professor, Department of Neurology, University of Illinois College of Medicine at Peoria

Jorge C Kattah, MD is a member of the following medical societies: American Academy of Neurology, American Neurological Association, New York Academy of Sciences

Disclosure: Nothing to disclose.

Coauthor(s)

Andrew J Tsung, MD Assistant Professor of Neurosurgery, University of Illinois College of Medicine at Peoria; Director, INI Brain Tumor Center, Director of Neurosurgery Research, Department of Neurosurgery, Illinois Neurological Institute; Physician Director, Intermediate Neuroscience Care Unit, OSF St Francis Medical Center; Attending Physician, Illinois Neurological Institute Physicians, LLC

Andrew J Tsung, MD is a member of the following medical societies: Alpha Omega Alpha, American Association of Neurological Surgeons, Illinois State Medical Society, Society for Neuro-Oncology, Congress of Neurological Surgeons

Disclosure: Nothing to disclose.

Joseph V Hanovnikian University of Illinois College of Medicine

Joseph V Hanovnikian is a member of the following medical societies: Illinois State Medical Society, Congress of Neurological Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Robert A Egan, MD Director of Neuro-Ophthalmology and Stroke Service, St Helena Hospital

Robert A Egan, MD is a member of the following medical societies: American Academy of Neurology, American Heart Association, North American Neuro-Ophthalmology Society, Oregon Medical Association

Disclosure: Received honoraria from Biogen Idec for speaking and teaching; Received honoraria from Teva for speaking and teaching.

Chief Editor

Robert A Egan, MD Director of Neuro-Ophthalmology and Stroke Service, St Helena Hospital

Robert A Egan, MD is a member of the following medical societies: American Academy of Neurology, American Heart Association, North American Neuro-Ophthalmology Society, Oregon Medical Association

Disclosure: Received honoraria from Biogen Idec for speaking and teaching; Received honoraria from Teva for speaking and teaching.

Additional Contributors

Frederick M Vincent, Sr, MD Clinical Professor, Department of Neurology and Ophthalmology, Michigan State University Colleges of Human and Osteopathic Medicine

Frederick M Vincent, Sr, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, American College of Forensic Examiners Institute, American College of Legal Medicine, American College of Physicians

Disclosure: Nothing to disclose.

References
  1. Chahal HS, Stals K, Unterländer M, et al. AIP mutation in pituitary adenomas in the 18th century and today. N Engl J Med. 2011 Jan 6. 364(1):43-50. [Medline].

  2. Villwock JA, Villwock M, Deshaies E, Goyal P. Significant increases of pituitary tumors and resections from 1993 to 2011. Int Forum Allergy Rhinol. 2014 Sep. 4(9):767-70. [Medline].

  3. Vlotides G, Eigler T, Melmed S. Pituitary tumor-transforming gene: physiology and implications for tumorigenesis. Endocr Rev. 2007 Apr. 28(2):165-86. [Medline].

  4. Riss D, Jin L, Qian X, et al. Differential expression of galectin-3 in pituitary tumors. Cancer Res. 2003 May 1. 63(9):2251-5. [Medline].

  5. Zhang X, Horwitz GA, Heaney AP, Nakashima M, Prezant TR, Bronstein MD, et al. Pituitary tumor transforming gene (PTTG) expression in pituitary adenomas. J Clin Endocrinol Metab. 1999 Feb. 84(2):761-7. [Medline].

  6. Kosmorsky GS, Dupps WJ Jr, Drake RL. Nonuniform pressure generation in the optic chiasm may explain bitemporal hemianopsia. Ophthalmology. 2008 Mar. 115(3):560-5. [Medline].

  7. Thomas ST. Finite Element Modleing of Chiasmal Compression. J of Undergraduate Engineering Res. 2009. 12:1-30.

  8. Ambrosi B, Dall'Asta C, Cannavo S, et al. Effects of chronic administration of PPAR-gamma ligand rosiglitazone in Cushing's disease. Eur J Endocrinol. 2004 Aug. 151(2):173-8. [Medline].

  9. Talkad AV, Kattah JC, Xu MY, et al. Prolactinoma presenting as painful postganglionic Horner syndrome. Neurology. 2004 Apr 27. 62(8):1440-1. [Medline].

  10. Paterno' V, Fahlbusch R. High-Field iMRI in transsphenoidal pituitary adenoma surgery with special respect to typical localization of residual tumor. Acta Neurochir (Wien). 2014 Mar. 156(3):463-74; discussion 474. [Medline].

  11. Kreutzer J, Fahlbusch R. Diagnosis and treatment of pituitary tumors. Curr Opin Neurol. 2004 Dec. 17(6):693-703. [Medline].

  12. Giustina A, Barkan A, Casanueva FF, et al. Criteria for cure of acromegaly: a consensus statement. J Clin Endocrinol Metab. 2000 Feb. 85(2):526-9. [Medline].

  13. Semple PL, Webb MK, de Villiers JC, Laws ER Jr. Pituitary apoplexy. Neurosurgery. 2005. 56(1):65-72; discussion 72-3. [Medline].

  14. Biousse V, Newman NJ, Oyesiku NM. Precipitating factors in pituitary apoplexy. J Neurol Neurosurg Psychiatry. 2001 Oct. 71(4):542-5. [Medline].

  15. Rotenberg BW, Saunders S, Duggal N. Olfactory outcomes after endoscopic transsphenoidal pituitary surgery. Laryngoscope. 2011 Aug. 121(8):1611-3. [Medline].

  16. Gnanalingham KK, Bhattacharjee S, Pennington R, et al. The time course of visual field recovery following transphenoidal surgery for pituitary adenomas: predictive factors for a good outcome. J Neurol Neurosurg Psychiatry. 2005 Mar. 76(3):415-9. [Medline].

  17. Alameda C, Lucas T, Pineda E, et al. Experience in management of 51 non-functioning pituitary adenomas: indications for post-operative radiotherapy. J Endocrinol Invest. 2005 Jan. 28(1):18-22. [Medline].

  18. Castinetti F, Régis J, Dufour H, Brue T. Role of stereotactic radiosurgery in the management of pituitary adenomas. Nat Rev Endocrinol. 2010 Apr. 6(4):214-23. [Medline].

  19. Ciric I, Zhao JC, Du H, Findling JW, Molitch ME, Weiss RE, et al. Transsphenoidal surgery for Cushing disease: experience with 136 patients. Neurosurgery. 2012 Jan. 70(1):70-80; discussion 80-1. [Medline].

  20. Colin P, Jovenin N, Delemer B, et al. Treatment of pituitary adenomas by fractionated stereotactic radiotherapy: a prospective study of 110 patients. Int J Radiat Oncol Biol Phys. 2005 Jun 1. 62(2):333-41. [Medline].

  21. Conomy JP, Ferguson JH, Brodkey JS, Mitsumoto H. Spontaneous infarction in pituitary tumors: neurologic and therapeutic aspects. Neurology. 1975 Jun. 25(6):580-7. [Medline].

  22. David, NJ, Gargano FP, Glaser JS. Pituitary apoplexy in clinical perspective. Neurophthalmology Symposium. St Louis: CV Mosby; 1975. Vol 8: 140-165.

  23. Dawson BH, Kothandaram P. Acute massive infarction of pituitary adenomas. A study of five patients. J Neurosurg. 1972 Sep. 37(3):275-9. [Medline].

  24. Gharib H, Frey HM, Laws ER, et al. Coexistent primary empty sella syndrome and hyperprolactinemia. Report of 11 cases. Arch Intern Med. 1983 Jul. 143(7):1383-6. [Medline].

  25. Greenberg HS, Chandler WF, Ensminger WD. Radiosensitization with carotid intra-arterial bromodeoxyuridine +/- 5-fluorouracil biomodulation for malignant gliomas. Neurology. 1994 Sep. 44(9):1715-20. [Medline].

  26. Jagannathan J, Yen CP, Pouratian N, Laws ER, Sheehan JP. Stereotactic radiosurgery for pituitary adenomas: a comprehensive review of indications, techniques and long-term results using the Gamma Knife. J Neurooncol. 2009 May. 92(3):345-56. [Medline].

  27. Jho HD. Endoscopic endonasal pituitary surgery: Technical aspects. Contemporary Neurosurgery. 1997. 19:1-8.

  28. Jho HD, Carrau RL, Ko Y, Daly MA. Endoscopic pituitary surgery: an early experience. Surg Neurol. 1997 Mar. 47(3):213-22; discussion 222-3. [Medline].

  29. Koutourousiou M, Gardner PA, Fernandez-Miranda JC, Paluzzi A, Wang EW, Snyderman CH. Endoscopic endonasal surgery for Giant Pituitary adenomas: Advantages and Limitations. J of Neursurg. January/2013. E Pubahead of print:

  30. Levy A, Lightman SL. Diagnosis and management of pituitary tumours. BMJ. 1994 Apr 23. 308(6936):1087-91. [Medline].

  31. Melmed S. Acromegaly. N Engl J Med. 1990 Apr 5. 322(14):966-77. [Medline].

  32. Molitch ME. Pregnancy and the hyperprolactinemic woman. N Engl J Med. 1985 May 23. 312(21):1364-70. [Medline].

  33. Oldfield EH, Doppman JL, Nieman LK, Chrousos GP, Miller DL, Katz DA, et al. Petrosal sinus sampling with and without corticotropin-releasing hormone for the differential diagnosis of Cushing's syndrome. N Engl J Med. 1991 Sep 26. 325(13):897-905. [Medline].

  34. Orth DN. Cushing's syndrome. N Engl J Med. 1995 Mar 23. 332(12):791-803. [Medline].

  35. Rotenberg BW, Saunders S, Duggal N. Olfactory outcomes after Endoscopic Transphenoidal Pituitary surgery. The Laryngoscope. 2011. 121:1611-1613.

  36. Thorner MO, Vance ML, Laws ER. The anterior pituitary. Williams, ed. Textbook of Endocrinology. Philadelphia: WB Saunders; 1998. 249-340.

  37. Zhang X, Horwitz GA, Heaney AP, Nakashima M, Prezant TR, Bronstein MD, et al. Pituitary tumor transforming gene (PTTG) expression in pituitary adenomas. J Clin Endocrinol Metab. 1999 Feb. 84(2):761-7. [Medline].

 
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This is a characteristic bitemporal hemianopic visual field defect.
This contrast-enhanced coronal MRI was obtained in a patient who complained of visual loss.
This visual field was plotted using a Goldman perimeter (ie, kinetic perimetry). It was obtained from a patient who reported visual loss and had a normal endocrine workup. The dark areas correspond to the impaired peripheral visual field. This visual field defect is consistent with an intrasellar lesion.
Coronal T1 precontrast MRI A (left panel), B postcontrast (middle panel) and T2 (right panel) showing a sellar mass causing obvious left and upward displacement of the optic chiasm. The mass is a histologically proven pituitary macroadenoma, which presented initially with a large cystic subfrontal extension that was successfully resected in April of 2006. This patient has been observed closely for 2.5 years and despite obvious mass effect, he has no visual complaints and the neuro-ophthalmologic evaluation is normal. Although infrequent, clinicians should be aware of this possibility. Close follow-up is required.
Axial, sagittal, and coronal MRI of the sellae in a patient with a severe headache, normal neuro-ophthalmologic examination, and no evidence of endocrine failure. A hyperintense mass is observed in the sella with suprasellar extension. This case illustrates the clinical spectrum of pituitary apoplexy. Transsphenoidal resection confirmed the diagnosis of pituitary apoplexy.
 
 
 
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