Radiotherapy in Non-Functioning Pituitary Macroadenoma： Mansoura Experience

OBJECTIVE The current retrospective study aims to evaluate the management of non-functioning the assessment of experience on pituitary macroadenoma through clinical, biochemical, radiological features, and treatment outcome of patients, and to identify prognostic factors affecting progression-free survival （PFS）. METHODS Data of 55 patients macroadenoma presented to the with non-functioning pituitary Clinical Oncology and Nuclear Medicine department between 1998 and 2009 were investigated. RESULTS The most common symptom was visual disturbance （38.2%） followed by headache （27.3%）. The presence of male predominance was observed （1.4：1）. Ten patients received radio-therapy （RT） only. Extrasellar extension was the more common treatment. The overall response rate was 72.8% with completed response at 16.4%. Memory and intellectual sequelae were the most common late complications of treatment （14%）. The ten-year PFS was at 84.6%. PFS was found to be significantly better with higher dose of RT （up to 54 Gy）, treatment by both surgery and RT, absence of visual field defect, and tumor localized to sella, whereas it was not significantly affected by age and sex. CONCLUSION The data confirmed that the prevalence of mass effect and hypopituitarism in patients with non-functioning pituitary macroadenoma is elevated. Conventional external RT up to 54 Gy is safe and effective in controlling non-functioning pituitary macro- adenoma with tolerable and acceptable morbidity.

Extra-pseudocapsular Transnasal Transsphenoidal Resection of Pituitary Macroadenoma:Technique Note and Evaluation of Endocrine Function

Objective In this study,we investigated the surgical technique and endocrine assessment of pituitary function of patients with macroadenoma treated by extra-pseudocapsular transnasal transsphenoidal surgery(ETTS).Methods Clinical data of 144 patients with pituitary macroadenomas in the same surgical group at the Department of Neurosurgery,Tongji Hospital,Tongji Medical College,Huazhong University of Science and Technology were retrospectively analyzed from January 2019 to June 2021.Based on the results of the endocrinological evaluation and MRI examinations before and after surgery,the fluctuation of pituitary function and the extent of resection were analyzed.Multiple Logistic regression analysis was used to determine the predictors affecting postoperative tumor residual.Results Among the 144 patients with pituitary macroadenomas,72(50.0%)were female and 72(50.0%)were male,the median age was 50 years,26(18.1%)had invasiveness grade 0,46(31.9%)had grade I,57(39.6%)had grade II,and 15(10.4%)had grade III according to Lu’s classification method.Based on observation during surgery,37 cases(25.7%)had no pseudocapsule,54 cases(37.5%)had incomplete pseudocapsule,and 53 cases(36.8%)had intact pseudocapsule.In addition,91(63.2%)patients had total resection,39(27.1%)had subtotal resection,and 14(9.7%)had partial resection.As for anterior pituitary function,13 of 19 hypothyroid patients had recovery after surgery,with a remission rate of 68.4%.Eighteen of the 26 decreased cortisol patients got back to normal,with a remission rate of 69.2%.A total of 27 of 51 patients with hypogonadism improved,with a remission rate of 52.9%.Univariate and multivariate analyses indicated that gender,tumor size,and invasiveness were predictors of postoperative residual in patients(P<0.05).Conclusion The results showed that ETTS is an effective treatment modality for restoring the function of pituitary gland of the patients with macroadenomas.Tumor size and invasiveness are predictors of the extent of surgical resection and postoperative residual of macroadenomas.

Pituitary macroadenoma apoplexy as a rare complication of Bruton tyrosine kinase inhibitor in chronic lymphoid leukaemia

Background Pituitary apoplexy is a neurosurgical emergency and is a known yet rare complication of pituitary macroadenoma.Patients typically present with visual field defects,headache and altered sensorium.There are multiple risk factors for this complication and a thorough drug history is essential to exclude iatrogenic causes of disease.We present an extremely rare case of newly diagnosed pituitary insufficiency unveiled by ibrutinib therapy(a Bruton tyrosine kinase inhibitor).Furthermore,after initial withdrawal of ibrutinib because of the erroneous diagnosis of Syndrome of Inappropriate Antidiuretic Hormone Secretion(SIADH),its re-administration led to the development of classical pituitary apoplexy 4 months after treatment was restarted.Case presentation A male patient in his 60s with a background of chronic lymphocytic leukaemia(CLL)on ibrutinib and venetoclax presents with acute confusion and deranged electrolytes.He is found to be hyponatraemic and is diagnosed with Syndrome of Inappropriate Antidiuretic Hormone Secretion(SIADH)and treated with fluid restriction.He represents again 3 weeks later with hyponatraemia and further investigations reveal pituitary insufficiency and macroadenoma.He was restarted on ibrutinib and venetoclax at the time of discharge.Four months later,he presents with sudden retro-orbital headache associated with vomiting.Clinical findings include cranial nerve III,IV and XI palsy.Humphrey’s visual field examination revealed a left visual field index(VFI)of only 1%while the right was 64%with temporal hemianopia.Both pupils were mid-dilated and poorly reactive to light.MRI pituitary with contrast showed features of pituitary apoplexy and optic nerve compression.He was urgently referred to the neurosurgical team and underwent an emergency trans-sphenoidal hypophysectomy with circumferential excision of the macroadenoma.Post-operative recovery was uneventful with marked improvement in vision bilaterally.The patient was restarted on ibrutinib and venetoclax 2 weeks post-operatively.Approximately 1 year post-treatment,he remains in radiological,clinical and biochemical remission from CLL and all medications have been withdrawn.Conclusions This is a unique and rare case of pituitary macroadenoma apoplexy following the commencement of ibrutinib for CLL.Central nervous system haemorrhage is a rare side effect of ibrutinib due to its platelet dysfunction effects.A thorough assessment is required to assess the risks and benefits of using ibrutinib in patients with pituitary macroadenoma to avoid serious complications.