Hyperprolactinemia due to pituitary metastasis: A case report

BACKGROUND Pituitary metastasis is an uncommon manifestation of systemic malignant tumors.Moreover,hyperprolactinemia and overall hypopituitarism caused by metastatic spread leading to the initial symptoms are rare.CASE SUMMARY A 53-year-old male patient was admitted to our hospital with complaints of bilateral blurred vision,dizziness,polyuria,nocturia,severe fatigue and somnolence,decreased libido,and intermittent nausea and vomiting for more than 6 mo.During the last 7 d,the dizziness had worsened.Laboratory investigations revealed overall hypofunction of the pituitary gland,but the patient had an elevated serum prolactin level(703.35 mg/mL).Preoperative magnetic resonance imaging revealed a tumor in the sellar region,accompanied by intratumoral hemorrhage and calcification.Thus,transnasal subtotal resection of the lesion in the sellar region was performed.The histopathological and immunohistochemical examinations of the resected lesion revealed metastasis of lung adenocarcinoma to the pituitary gland.Oral hydrocortisone(30 mg/d)and levothyroxine(25 mg/d)were given both pre-and postoperatively.Postoperatively,the clinical symptoms were significantly improved.However,4 mo following the surgery,the patient succumbed due to multiple organ failure.CONCLUSION Hyperprolactinemia is one of the markers of poor prognosis in patients with carcinoma that metastasizes to the pituitary gland.Exogenous hormone supplementation plays a positive role in relieving the symptoms of patients and improving quality of life.

Diagnosis and management of pituitary apoplexy:a Tunisian data

Background Pituitary apoplexy(PA)is defined as the hemorrhage or the infraction of a pituitary adenoma.Aiming to determine the epidemiological,clinical,paraclinical characteristics as well as management and outcomes of PA in our population,we conducted this cross-sectional study.Methods This cross-sectional study was conducted at the Department of Endocrinology of Hedi chaker university hospital,Sfax.Data was collected from medical charts of patients with pituitary apoplexy admitted in our department between 2000 and 2017.Results We included 44 patients with PA.Their mean age was 50±12.6 years.Among them,31.8%had a known pituitary adenoma,and it was in all cases a macroadenoma,predominantly a prolactin secreting tumor(42.8%).A triggering factor of PA was encountered in 31.8%of cases and it was mainly:head trauma,dopamine antagonists,and hypertension.The clinical presentation of PA encompassed headaches(84.1%),visual disturbances(75%),and neurological signs(40.9%).Gonadotropin deficiency was the most frequent form of hypopituitarism noted(59.1%),followed by corticotropin deficiency(52.3%),thyrotropin deficiency(47.7%),and somatotropin deficiency(2.3%).Hormonal assessment at PA onset,concluded that 23 had a secreting adenoma:18 prolactinomas,3 ACTH-secreting adenomas,and 2 GH-secreting adenomas.In the 21 remaining cases,the tumor was non-functioning(47.7%).Pituitary MRI was performed in 42 cases(95.5%),revealing infraction and or hemorrhage in the pituitary gland in 33 cases;a heterogenous signal or a fluid level within the adenoma,in nine cases.Urgent administration of intra venous hydrocortisone was required in 19 cases.Mannitol administration was mandatory in a patient who had severe intracranial hypertension.Surgical management of the PA was imperative in 24 patients(54.5%):15 suffered from severe visual impairment,4 had an intracranial hypertension,2 cases demonstrated an impaired consciousness,2 patients experienced a tumor enlargement and one case had a severe Cushing’s disease.Operative complications found were rhinorrhea attributable to cerebral spinal fluid leakage,insipidus diabetes associated with rhinorrhea,isolated insipidus diabetes,and hydrocephalus in one case each.Long-term follow-up concluded that headaches persisted in five cases,owing to the tenacity of a macroprolactinoma regardless of cabergoline treatment in one case,the recurrence of an adenoma in two cases and its persistence despite the medical and the surgical treatment in two patients.Concerning the visual acuity defects,only two patients had persistent diminished visual acuity at long-term follow-up.Among 25 patients,13 were diagnosed with definitive thyrotropin deficiency.Similarly,14 patients had persistent corticotropin deficiency(CD).Additionally,CD was de novo diagnosed in two patients.Otherwise,gonadotropin deficiency prevailed in all cases.Persistent prolactin deficiency was seen in two patients.Disappearance of the pituitary tumor was encountered in 11 out of 24 cases at long-term follow-up.Overall,surgery was associated with better outcome than conservative management.Pituitary apoplexy is a challenging condition due to its variable course,its diagnosis difficulty and management,as gaps remain to determine the best approach to treat this condition.Conclusions To conclude,pituitary apoplexy is a challenging condition due to its variable course,its diagnosis difficulty and management,as gaps remain to determine the best approach to treat this condition.Further studies are thus needed.

Applied anatomy for pituitary adenoma resection

Background Pituitary adenomas are common intracranial tumors, with a rising incidence in China. Excision is a mainstay therapy for this disease, and is often carried out via transfr0ntal, transsphenoidal or transpterional approaches. However, few studies have systematically addressed the regional anatomy involved in these microsurgical procedures. The present study attempted to establish some key anatomic measurements relevant to pituitary adenoma resection based on cadaver and computer tomography （CT） image studies. Methods Head specimens from 30 randomly selected formalin-fixed adult cadavers were used for anatomical analysis. Measurements were made on the base of the skull following removal of brain structures above the pituitary gland, and on the mid-sagittal plane of the cranium. Parameters were designed by considering the 3 above-mentioned common microsurgical approaches, and obtained on each head using a sliding caliper. Multi-level CT images from 30 individuals were also used for distance measurements between landmark structures that are relevant to these surgeries. All data were subjected to statistical analysis using the SPSS 11.5 software. Results There was statistically significant difference （P〈0.05） of distance measured on cadavers relative to CT images in 3 sets of measurements related to the transfrontal surgical approach, i.e., distances from the midpoint of superciliary arch superior border to the cranial entrance of internal carotid arteries （ICAs）, the opposite side entrance of ICA and to the genu of ICA. While regional anatomical analyses were carried out according to the transpterional approach, statistically significant difference was also found in 3 sets of distance measurements between cadaver and CT image data, with regard to the distances between the pterion and some landmark structures around the pituitary. Conclusions The present study provides key anatomical and CT image measurements involving the 3 conventionally used surgical approaches for pituitary tumor resection. The data implicate that while CT scan results can provide valuable guidelines for operations, cautions and adjustments are needed during surgery for sufficient tumor excision and protection of key blood vessels and nerves in the vicinity of the pituitary gland and around the surgical pathway.

Prospective study of transsphenoidal pituitary surgery： is tumor volume a predictor for the residual tumor？

Background The presence of residual tumor after surgery for pituitary adenoma may necessitate further treatment. The suprasellar and parasellar extension of the tumor have been widely considered as the predictors for residual tumor. However there is scarcity of studies regarding the preoperative tumor volume and residual tumor. This study was conducted to evaluate if tumor volume could predict the outcome of transsphenoidal pituitary surgery. Methods A prospective study was designed and 48 patients who underwent transsphenoidal pituitary surgery within 1 year in the First Affiliated Hospital of Xi＇an Jiaotong University were included in this study. The preoperative tumor volume and immediate postoperative tumor volume （within 4-7 days） were calculated in the contrast magnetic resonance imaging by using the formula of ellipsoid. All these volumes were divided into three subgroups, i.e. group 1, group 2 and group 3 with preoperative volume of less than 4 cm3, 4-8 cm3, and more than 8 cm3 respectively. The parasellar and suprasellar extension of the tumor were also classified by Knosp and modified Hardy＇s classifications. Results Baseline characteristics were comparable. The preoperative tumor volume of more than 8 cm3 （group 3, （12.1±1.1） cm3） had increased risk on postoperative tumor residue （P 〈0.01） than the other two groups （（2.1±0.3） cm3 and （6.1±0.3） cm3 in groups 1 and 2）. The mean postoperative volume in group 3 patients （（2.2±0.1） cm3） was significantly higher than the other two groups （P 〈0.01）. Conclusion Preoperative volume of more than 8 cm3 can be considered as a predictor for postoperative residual volume.

A new plastic model of endoscopic technique training for endonasal transsphenoidal pituitary surgery

Background Endoscopic transsphenoidal approach is a minimally invasive surgical technique for the removal of sellar and parasellar lesions, which has been progressively accepted by neurosurgeons. However, frustration is often expressed by neurosurgeons when first attempting endoscopic endonasal pituitary surgery. To overcome the learning curve from microscope to endoscope in a smooth way, a new human nasal model has been developed. The present study assessed this new model of the human paranasal sinuses for endonasal surgery training, particularly for endonasal pituitary surgery training. Methods The procedure for endonasat transsphenoidal endoscopy was performed using this model. Three approaches were used to observe the endonasal structures and sphenoidal sinus： paraseptal; middle turbinectomy; and middle meatal. Attempts were made to identify anatomical landmarks in the nasal cavity and sphenoidal sinus. Model landmarks were compared with those in a cadaver and a real patient. Results This model precisely reproduced nasal bone structure. Compared with cadavers and living bodies, intranasal structures displayed very good color and texture, providing a close facsimile of the operative environment, and good morphology, with similar hardness and tactile feel on resection. All intranasal anatomical landmarks were easily identified, including choanae, inferior, middle and superior turbinates, and even the natural ostium of the sphenoidal sinus. Conclusion This human nasal model is very useful for training neurosurgeons in endoscopic endonasal transsphenoidal pituitary surgery, but typical anatomical landmarks in the posterior wall of the sphenoidal sinus in this model should be improved.

Frontolateral Approach Applied to Sellar Region Lesions： A Retrospective Study in 79 Patients

Background： Various surgical approaches for the removal of sellar region lesions have previously been described. This study aimed to evaluate the reliability and safety of the frontolateral approach （FLA） to remove sellar region lesions. Methods： We presented a retrospective study of 79 patients with sellar region lesions who were admitted and operated by the FLA approach from August 2011 to August 2015 in Department of Neurosurgery of Beijing Tian Tan Hospital. We classified FLA into three types, compared the FLA types to the areas of lesion invasion, and analyzed operation bleeding volume, gross total resection （GTR） rate, visual outcome, and mortality. Results： Seventy-nine patients were followed up from 2.9 to 50.3 months with a mean follow-up of 20.5 months. There were 42 cases of meningiomas, 25 cases of craniopharyngiomas, and 12 cases of pituitary adenomas. The mean follow-up Karnofsky Performance Scale was 90.4. GTR was achieved in 75 patients （94.9%）. Two patients （2.5%） had tumor recurrence. No patients died perioperatively or during short-term follow-up. Three patients （3.8%） with craniopharyngioma died 10, 12, and 23 months, respectively, after surgery. The operative bleeding volume of this study was no more than that of the other approaches in the sellar region （P = 0.783）. In this study, 35 patients （44.3%） had visual improvement after surgery, 38 patients （48.1%） remained unchanged, and three patients＇ visual outcome （3.8%） worsened. Conclusions： FLA was an effective approach in the treatment of sellar region lesions with good preservation of visual function. FLA classification enabled tailored craniotomies for each patient according to the anatomic site of tumor invasion. This study found that FLA had similar outcomes to other surgical approaches of sellar region lesions.