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Fulltext The transcolumellar transsphenoidal approach to pituitary tumours: advantanges and limitations

Gendeh BS, Sakina MS, Selladurai BM, Jegan T, Misiran K

Med J Malaysia, 2006 Aug;61(3):349-54.
PMID: 17240588

A retrospective review was performed on 11 patients who had undergone the transcolumellar transsphenoidal hypophysectomy in our center. There were eight females and three males with age ranging from 17 to 72 years (mean 50 years). Ten patients had pituitary macroadenomas and one had suprasellar cyst. The mean follow up duration for these 11 patients post surgery was 7.2 months. Complications included two cerebrospinal leaks, one postoperative sphenopalatine bleed, one septal perforation and one patient developed numbness of the tip of the nose. We found that this approach is a preferred alternative technique especially in smaller Oriental noses with lower complication rate and better aesthetic result.

Matched MeSH terms: Pituitary Neoplasms/surgery*
Fulltext The role of endoscopic endonasal approach to pituitary tumours: HUKM experience

Gendeh BS, Doi M, Selladurai BM, Khalid BA, Jegan T, Misiran K

Med J Malaysia, 2006 Aug;61(3):343-8.
PMID: 17240587

Surgery for pituitary tumours at our institution was performed by rhinosurgical route by combined procedure by otolaryngologist and neurosurgeons. A retrospective review of case records of patients who had endonasal endoscopic transphenoidal approach for pituitary tumours from September 1998 to December 2004 was performed. A total of 81 trans-sphenoidal surgeries were performed during this study period. Only 68 case records with adequate information were available for review, 56 patients were included in the study and 12 were excluded. There were 24 males (42%) and 32 females (58%). The ethnic distribution, were 29 Malays, 24 Chinese, 2 Indian and 1 others. The age ranged from 16 years to 76 years, with a mean of 46 years. The majority of our patients presented with visual symptoms (38), headache (28), menstrual cycle disturbance or impotence (14) and acromegalic features (16). Forty patients had macroadenoma (71%) and 16 had microadenomas (29%). Thirty-six patients out of 40 macro-adenomas had suprasellar extensions (90%). Only eleven patients had lumbar drain inserted prior to commencement of the surgery and the majority of these were macroadenomas. The common complications encountered were diabetes insipidus (4), cerebrospinal fluid leak (2), meningitis (3), epistaxis (2), septal perforation (2), intercavernous sinus haemorrhage (3) and anterior pituitary insufficiency (2). Our study reveals that endonasal trans-sphenoidal approach is a safe and effective method of management of pituitary adenomas.

Matched MeSH terms: Pituitary Neoplasms/surgery
Fulltext Giant aneurysm or pituitary macroadenoma: a diagnostical misconstrue

Pany A, Sobri M, Valarmathi S, Nazihah M, Latif AZ, Adnan JS

Med J Malaysia, 2004 Mar;59(1):123-5.
PMID: 15535350

We describe a case of a giant thrombosed intrasellar internal carotid artery aneurysm initially diagnosed as pituitary macroadenoma. The differentiating neuroimaging features were discussed.

Matched MeSH terms: Pituitary Neoplasms/diagnosis*
A new modified speculum guided single nostril technique for endoscopic transnasal transsphenoidal surgery: an analysis of nasal complications

Waran V, Tang IP, Karuppiah R, Abd Kadir KA, Chandran H, Muthusamy KA, et al.

Br J Neurosurg, 2013 Dec;27(6):742-6.
PMID: 23647078 DOI: 10.3109/02688697.2013.791667

Abstract The endoscopic transnasal, transsphenoidal surgical technique for pituitary tumour excision has generally been regarded as a less invasive technique, ranging from single nostril to dual nostril techniques. We propose a single nostril technique using a modified nasal speculum as a preferred technique. We initially reviewed 25 patients who underwent pituitary tumour excision, via endoscopic transnasal transsphenoidal surgery, using this new modified speculum-guided single nostril technique. The results show shorter operation time with reduced intra- and post-operative nasal soft tissue injuries and complications.

Matched MeSH terms: Pituitary Neoplasms/pathology; Pituitary Neoplasms/surgery
Fulltext Burkitt's lymphoma presenting with hypopituitarism: a case report and review of literature

Foo SH, Sobah SA

Endocrinol Diabetes Metab Case Rep, 2014;2014:140029.
PMID: 25045522 DOI: 10.1530/EDM-14-0029

Hypopituitarism is a rare presentation of Burkitt's lymphoma (BL). The purpose of this report is to present a case of BL presenting with panhypopituitarism and to review other case reports of lymphoma presenting with pituitary dysfunction to highlight the distinguishing features of these cases from other benign aetiologies of pituitary dysfunction such as non-functioning pituitary adenomas. We reviewed a total of 11 cases of lymphoma presenting with pituitary dysfunction published from 1998 to 2013 including the present case. The demographics, clinical presentations, laboratory features, radiological findings, histological diagnosis, treatment administered and outcomes were described. Of the total number of patients, 45.5% of the cases had diffuse large B-cell lymphoma while 27.3% had BL. Anterior pituitary dysfunction was more common than posterior pituitary dysfunction at presentation. The other common associated presenting symptoms were painful ophthalmoplegia, cranial nerve palsies and constitutional symptoms. Hypothalamic-pituitary abnormalities were often demonstrated radiologically to be associated with cavernous sinus and/or stalk involvement. All patients who completed immunochemotherapy responded haematologically. Pituitary dysfunction also improved in most cases although the recovery tended to be partial. In conclusion, a high index of suspicion of underlying malignancy, such as lymphoma, should be present in patients presenting with acute pituitary dysfunction associated with painful ophthalmoplegia, rapidly evolving neurological features, radiological features atypical of a pituitary adenoma and constitutional symptoms. An early diagnosis is essential as prompt initiation of definitive therapy will induce disease remission and recovery of pituitary dysfunction.

Matched MeSH terms: Pituitary Neoplasms
Fulltext Experience with sublabial transseptal transsphenoidal hypophysectomy at the Universiti Kebangsaan Malaysia

Said H, Cheah F, Mohamed AS, Hadi AR

Med J Malaysia, 1993 Jun;48(2):222-4.
PMID: 8350800

The transseptal transsphenoidal hypophysectomy has become a relatively frequent procedure in recent years. We performed 20 such procedures between January 1984 and December 1987 for various pituitary disorders. Significant complications such as CSF rhinorrhea, meningitis, diabetes insipidus, haemorrhage and septal perforation are discussed. The mortality rate for the series was 5%. In analysing the data, we feel that this technique of hypophysectomy is a safe procedure.

Matched MeSH terms: Pituitary Neoplasms/surgery*
Intracranial neoplasms in Malaysia

Selby R, Pereira N

Int Surg, 1973 Aug;58(8):536-41.
PMID: 4738062
Matched MeSH terms: Pituitary Neoplasms/epidemiology
Fulltext Syndrome of inappropriate antidiuretic hormone caused by continuous lumbar spinal fluid drainage after transphenoidal surgery

Norlela S, Azmi KN, Khalid BA

Singapore Med J, 2006 Jan;47(1):75-6.
PMID: 16397727

A 53-year-old acromegalic woman had cerebrospinal fluid rhinorrhoea following transphenoidal surgery for a pituitary microadenoma. A continuous lumbar spinal fluid drainage catheter was inserted and on the sixth postoperative day, she developed hyponatremia with features of syndrome of inappropriate antidiuretic hormone (SIADH) requiring hypertonic saline administration. Over-drainage is potentially hazardous and close biochemical monitoring is required. To our knowledge, this is the first reported case of SIADH caused by continuous lumbar drainage in an adult.

Matched MeSH terms: Pituitary Neoplasms/surgery
Fulltext Endoscopic transnasal approach to anterior and middle cranial base lesions

Tan SH, Brand Y, Prepageran N, Waran V

Neurol India, 2015 Sep-Oct;63(5):673-80.
PMID: 26448224 DOI: 10.4103/0028-3886.166539

We present our experience in managing pathologies involving the anterior and middle cranial base using an endoscopic transnasal approach, highlighting the surgical technique, indications, and complications. The different types of endoscopic approaches used include the transtuberculum/transplanum, transcribiform, transsellar, and cavernous sinus approaches. The common indications include repair of cerebrospinal fluid leaks (both spontaneous and post traumatic) and excision of pituitary adenomas, meningiomas, craniopharyngiomas, esthesioneuroblastomas, and other malignancies of the anterior cranial base. Careful reconstruction is performed with the multilayer technique utilizing fat, fascia lata, and fibrin sealant. The endoscopic transnasal approach, coupled with the present-day sophisticated neuronavigation systems, allows access to lesions in the midline extending from the cribriform plate to the craniovertebral junction. However, preoperative planning and careful selection of cases with evaluation of each case on an individual basis with regard to the lateral extension of the lesion are imperative.

Matched MeSH terms: Pituitary Neoplasms
Fulltext Estrogen Receptors in Nonfunctioning Pituitary Neuroendocrine Tumors: Review on Expression and Gonadotroph Functions

Haydar Ali Tajuddin A, Kamaruddin N, Sukor N, Azizan EA, Omar AM

J Endocr Soc, 2020 Dec 01;4(12):bvaa157.
PMID: 33241169 DOI: 10.1210/jendso/bvaa157

Estrogen (17β-estradiol or E2) is a crucial regulator of the synthesis and secretion of pituitary reproductive hormones luteinizing hormone, follicle-stimulating hormone, and prolactin. In this review, we summarize the role of estrogen receptors in nonfunctioning pituitary neuroendocrine tumors (NF-Pitnets), focusing on immunoexpression and gonadotroph cell proliferation and apoptosis. Gonadotroph tumors are the most common subtype of NF-Pitnets. Two major estrogen receptor (ER) isoforms expressed in the pituitary are estrogen receptor alpha (ERα) and estrogen receptor beta (ERβ). Overall, estrogen actions are mostly exerted through the ERα isoform on the pituitary. The G protein-coupled estrogen receptor (GPER) located at the plasma membrane may contribute to nongenomic effects of estrogen. Nuclear immunoreactivity for ERα and ERβ was highest among gonadotroph and null cell tumors. Silent corticotroph tumors are the least immunoreactive for both receptors. A significantly elevated ERα expression was observed in macroadenomas compared with microadenomas. ERα and ERβ may act in opposite directions to regulate the Slug-E-cadherin pathway and to affect invasiveness of NF-Pitnets. In the cellular pathway, ERs regulate estrogen-induced proliferation and differentiation and impact several signaling pathways including the MAPK and PI3K/Akt pathway. Estrogen was the first-discovered inducer of pituitary tumor transforming gene 1 that was abundantly expressed in NF-Pitnets. ERα can be a potential biomarker for predicting tumor size and invasiveness as well as therapeutic target for NF-Pitnets. Selective estrogen receptor modulators or antiestrogen may represent as an alternative choice for the treatment of NF-Pitnets.

Matched MeSH terms: Pituitary Neoplasms
Visual Presentation and Factors Affecting Visual Outcome in Children with Craniopharyngioma in East Coast States of Peninsular Malaysia: A Five-year Review

Mohd-Ilham IM, Ahmad-Kamal GR, Wan Hitam WH, Shatriah I

Cureus, 2019 Apr 08;11(4):e4407.
PMID: 31205829 DOI: 10.7759/cureus.4407

Purpose To describe the visual presentation and factors affecting visual outcome in pediatric patients treated for craniopharyngioma at a referral center in the East Coast states of Peninsular Malaysia. Methodology A retrospective review of medical records of children aged 17 years and below who had been treated for craniopharyngioma in Hospital Universiti Sains Malaysia from January 2014 to December 2018. The data collected included age, gender, presenting symptoms and duration, visual acuity, visual fields, color vision, light brightness, relative afferent pupillary defects, fundus examination and cranial nerves examination. The best corrected visual acuity during presentation, and after a one-year post-operative period, was documented. Records on investigations, surgical procedures, therapeutic modalities and recurrences were also reviewed. Results A total of 11 pediatric patients (22 eyes) were recruited. Fifty percent presented with optic atrophy. The mean duration of the onset of symptoms before consultation was 22.3 (24.5) months. A final best corrected visual acuity of 6/12 (20/40) or better was observed in 50% of the patients. There was a statistically significant association between presenting visual acuity, optic nerve function and visual field defects, and the final visual outcome. Conclusions Visual presentations in our study were fairly similar to previous reported studies. One-third presented late with permanent visual loss. Almost half had significant visual impairment after one-year post-operative period. Significant associations were observed between presenting visual acuity, duration of symptoms, impairment of optic nerve function tests, and visual field defects during presentation, and final visual acuity at one year after treatment.

Matched MeSH terms: Pituitary Neoplasms
Evolving Strategies for Resection of Sellar/Parasellar Synchronous Tumors via Endoscopic Endonasal Approach: A Technical Case Report and Systematic Review of the Literature

Roethlisberger M, Jayapalan RR, Hostettler IC, Bin Abd Kadir KA, Mun KS, Brand Y, et al.

World Neurosurg, 2020 Jan;133:381-391.e2.
PMID: 31476461 DOI: 10.1016/j.wneu.2019.08.102

BACKGROUND: Data on the endonasal endoscopic approach (EEA) to treat sellar/parasellar synchronous tumors remain sparse. This work aims to describe a minimally invasive approach with intraoperative magnetic resonance imaging (MRI) to remove a large sellar/parasellar synchronous tumor, and presents a systematic literature review.
METHODS: The preoperative MRI of a 54-year-old woman revealed a sellar lesion (28 × 19 × 16 mm), presumably a pituitary macroadenoma, and a second extra-axial lesion (22 × 36 × 20 mm) expanding from the tuberculum sellae to the planum sphenoidale with encasement of the anterior communicating complex, presumably a meningioma. We used intraoperative MRI to assess the extent of the resection before reconstructing the large skull base defect. Furthermore, we systematically reviewed pertinent articles retrieved by a PubMed/Embase database search between 1961 and December 2018.
RESULTS: Out of 63 patients with synchronous tumors reported in 43 publications, we found 3 patients in which the tumor was removed by EEA. In these 3 patients and the presented case, the resection of both lesions was successful, without major approach-related morbidity or mortality. More extensive removal of endonasal structures to gain an adequate tumor exposure was not necessary. We did not find any previous reports describing the benefits of intraoperative MRI in the presented setting.
CONCLUSIONS: In the rare case of a synchronous meningioma and pituitary adenoma of the sellar region, intraoperative MRI might be beneficial in confirming residual disease before skull base reconstruction, and therefore radiologic follow-up.

Matched MeSH terms: Pituitary Neoplasms
Fulltext Successful Primary Medical Therapy with Somatostatin Receptor Ligand in Acromegaly with Thyroid Cancer

Dharan SS, Kamaruddin NA

J ASEAN Fed Endocr Soc, 2017;32(2):169-172.
PMID: 33442102 DOI: 10.15605/jafes.032.02.12

Acromegaly is a rare disease with an annual incidence of 3 to 4 cases in a million.1 Diagnosis is often delayed due to the slow progression of the disease. Persistent elevation of growth hormone (GH) in acromegaly causes a reduction in life expectancy by 10 years. Aside from multiple cardiovascular, respiratory and metabolic co-morbidities, it has also been proven to cause an increased incidence of cancer. The main treatment of acromegaly is surgical excision of the functioning pituitary adenoma. Multiple comorbidities, including obstructive sleep apnea (OSA), left ventricular hypertrophy (LVH) and soft tissue swelling, make surgery complicated, if not impossible. Medical therapy to reduce comorbidities may be indicated in certain situations. Somatostatin receptor ligands (SRL) are able to reduce, and possibly normalize, IGF-1 levels.2 Reduction of insulin-like growth factor-1 (IGF-1), the main mediator of GH, is able to resolve headache, sweating, fatigue and soft tissue swelling, and also reduce ventricular hypertrophy. This case report illustrates the successful use of the SRL octreotide LAR in treating acromegaly. It also confirms the observation from several case series that thyroid cancer is the most common malignancy in acromegaly.

Matched MeSH terms: Pituitary Neoplasms
Fulltext Factors Affecting Visual Field Outcome Post-Surgery in Sellar Region Tumors: Retrospective Study

Sriram PR, Sellamuthu P, Ghani ARI

Malays J Med Sci, 2017 Dec;24(6):58-67.
PMID: 29379387 DOI: 10.21315/mjms2017.24.6.7

Background: Despite the broad category of differentials for sellar region, most of them present with similar clinical signs and symptoms. Headache and visual disturbance are among the frequently seen as presenting symptom. Visual field (VF) assessment is one of the crucial component of neuroophtalmologic assessment and mean deviation (MD) value from automated perimetry allows quantification of the visual field defect. We formulated a study to look into the factors that affect the visual field outcome after surgery.
Methods: All patients with sellar region tumor who has underwent surgery in Queen Elizabeth Hospital from July 2010 to July 2016 were retrospectively analysed through hospital notes. VF assessment via Humphrey visual assessment for these patient pre and post-surgery were reviewed for MD value.
Results: Eighty four patients were recruited and out of them, 151 eyes were taken into analysis after excluding eyes with missing data. Mean age of patients were 45.4 years with 70.2% of them were male. Visual disturbance is the commonest presenting symptom with mean duration of symptom prior to surgery is 9.7 months. Majority of them were pituitary adenomas (75%) followed by sellar meningioma (19%), craniopharyngioma (4.8%), and rathke cleft cyst (1.2%). 70.9% of patients showed improvement in VF based on MD outcome. Mean MD for pre surgery and post-surgery were -14.0 dB and -12.4 dB, respectively. Univariate analysis reveals younger age, female sex, shorter duration of symptom, pituitary adenoma, transsphenoidal approach, and transcranial approach favours improvement in VF. Multivariate analysis shows only shorter symptom duration, transphenoidal approach, and transcranial approach are significant for favourable VF outcome when other factors adjusted.
Conclusion: Symptom duration and surgical approach were independent factors that affects the visual field after surgery in patients with sellar region tumors.

Matched MeSH terms: Pituitary Neoplasms

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