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NCI CANCERLIT^® Search: Pituitary Tumor - September 2002

National Cancer Institute^®

Pituitary carcinoma: report of an exceptional case and review of the literature.
[Two faces of gonadotroph adenoma]
[Pituitary apoplexy: retrospective study of 9 patients with hypophyseal adenoma]
Gender-related differences in prolactin secretion in pituitary prolactinomas.
(99m)Technetium pentavalent dimercaptosuccinic acid scintigraphy in the follow-up of clinically nonfunctioning pituitary adenomas after
Dysregulation of iodothyronine deiodinase enzyme expression and function in human pituitary tumours.
Pituitary tumours are multiclonal from the outset: evidence from a case with dural metastases.
A critical reappraisal of MIB-1 labelling index significance in a large series of pituitary tumours: secreting versus non-secreting adenomas.
Transnasal surgery for prolactin-secreting pituitary adenomas in childhood and adolescence.
Combined transsphenoidal and pterional craniotomy approach to giant pituitary tumors.
Surgical complications associated with the endoscopic endonasal transsphenoidal approach for pituitary adenomas.
Giant prolactinomas: clinical management and long-term follow up.
Predictive value of serum prolactin levels measured immediately after transsphenoidal surgery.
Galanin in human pituitary adenomas: frequency and clinical significance.
Granular cell tumor of the pituitary fossa.
Severe hyponatremia as the presenting feature of clinically non-functional pituitary adenoma with hypopituitarism.
Hypopituitarsim is associated with triglyceride enrichment of very low-density lipoprotein.
The history and evolution of transsphenoidal surgery.
Pioneers in the development of transsphenoidal surgery: Theodor Kocher, Oskar Hirsch, and Norman Dott.
Pitfalls in pituitary diagnosis: peculiarities of three cases.
MR and CT findings of craniopharyngioma during and after radiation therapy.
Astrocytoma of the pituitary gland (pituicytoma): case report.
Simultaneous treatment of a pituitary adenoma and an internal carotid artery aneurysm through a supraorbital keyhole approach.
Endoscopic transnasal approach to the pituitary lesions using a navigation system (InstaTrak system): technical note.
Usefulness of silicone plate for sellar floor reconstruction.
[Hypophyseal incidentaloma in a patient with autosomal dominant polycystic kidney disease]
Collagen sponge repair of small cerebrospinal fluid leaks obviates tissue grafts and cerebrospinal fluid diversion after pituitary surgery.
Double pituitary adenomas: a series of three patients.
Very delayed hyponatremia after surgery and radiotherapy for a pituitary macroadenoma.
Macroprolactinoma associated with Cushing's disease, successfully treated with cabergoline.
[A 46-year-old woman with clinical characteristics of growth hormone excess]
Orbital invasion with prolactinoma: a clinical review of four patients.
Magnetic resonance imaging after transsphenoidal surgery of clinically non-functional pituitary macroadenomas and its impact on detecting
Endocrinological outcome following first time transsphenoidal surgery for GH-, ACTH-, and PRL-secreting pituitary adenomas.
Expression of 5'-deiodinase enzymes in normal pituitaries and in various human pituitary adenomas.
[Diagnostic image (72). An adult woman with coarsening of the face. Acromegaly]
[Detection of serum epidermal growth factor receptor in the diagnosis of proliferation of pituitary adenomas]
Giant cystic craniopharyngioma with posterior fossa extension.
Evaluation of the optimum dose of growth hormone (GH) for restoring bone mass in adult-onset GH deficiency: results from two 12-month randomized
[New full length cDNA cloned from normal pituitary and pituitary tumors]
Outcome of postoperative intratumoral bleomycin injection for cystic craniopharyngioma.
Expression of cyclin kinase inhibitor p21/WAF1 protein in pituitary adenomas: correlations with endocrine activity, but not cell
Vascular endothelial growth factor, its receptor KDR/Flk-1, and pituitary tumor transforming gene in pituitary tumors.

1
UI - 11883868
AU - Pichard C; Gerber S; Laloi M; Kujas M; Clemenceau S; Ponvert D; Bruckert
TI - E; Turpin G Pituitary carcinoma: report of an exceptional case and review of the literature.
SO - J Endocrinol Invest 2002 Jan;25(1):65-72
AD - Department of Endocrinology, Groupe Hospitalier La Pitie Salpetriere, Paris, France. caroline.pichard@psl.ap-hop-paris.fr
Pituitary carcinomas are exceptional tumors and constitute 0.1 to 0.2% of pituitary tumors. Their definition includes well-established criteria but distant metastasis is the hallmark required for diagnosis. We report the fourth case of gonadotropic pituitary carcinoma described in the literature. This case illustrates the dramatic outcome of these tumors. The most interesting feature of our case was the loss of differentiation with time, established by retrospective analysis of the primary tumor surgically treated 15 years earlier. Most of the previously reported cases exhibited a majority of adrenocoticotropin and non-functioning pituitary tumors. However, the frequency of non-functioning tumors seems smaller than previously believed. In the discussion, we stress the need to detect these very aggressive tumors as early as possible and identify treatments to improve the dramatic course of these carcinomas.

2
UI - 12116715
AU - Sane T; Tiitinen A; Paetau A; Alfthan H; Poranen A; Valimaki M
TI - [Two faces of gonadotroph adenoma]
SO - Duodecim 2001;117(11):1160-4
AD - HYKS, Meilahden sairaala, endokrinologian klinikka PL 340, 00029 HUS. timo.sane@hus.fi

3
UI - 11862769
AU - Carral San Laureano F; Gavilan Villarejo I; Olveira Fuster G; Ortego
TI - Rojo J; Aguilar Diosdado M [Pituitary apoplexy: retrospective study of 9 patients with hypophyseal adenoma]
SO - An Med Interna 2001 Nov;18(11):582-6
AD - Seccion de Endocrinologia, Hospital Universitario Puerta del Mar, Cadiz.
Pituitary apoplexy is an acute hemorrhage or ischemia infarction of the pituitary gland, almost invariably occurring in the presence of an pituitary adenoma. Although intratumoral bleeding occur in about 9.5 to 25% of pituitary adenomas, various series suggest that clinical apoplexy may be diagnosed in about 2% to 10% of the adenomas. In a retrospective study from 1988 to 1998 of 110 patients with hypophyseal adenomas, there were 9 cases with pituitary apoplexy, yielding an incidence of 8.2%. Their mean age was 52.4 +/- 12.8 anos years, with a male to female ratio of 7:2. Symptoms observed were headache (89%), sudden visual deterioration (78%), vomiting (78%) and oculomotor nerves paresis (33%). The diagnosis of pituitary apoplexy was established by computerized tomographic scans, and hypophyseal macroadenoma with intratumoral bleeding was observed in every patient. Five patients underwent transphenoidal surgery. Improvement of visual deficit was observed in 3/4 (75%) and ocular paresis in 3/3 (100%) of affected patients. Four patients were treated conservatively with steroids. Two patients who had visual deficit recovered it completely without surgery. Two hypophyseal adenomas were resolved spontaneously after bleeding, one stayed unchanged and another presented recurrence of bleeding at six years of follow-up. Steroid and thyroid hormone replacement therapy was required in 62.5% of patients.

4
UI - 12012125
AU - Nishioka H; Haraoka J; Akada K; Azuma S
TI - Gender-related differences in prolactin secretion in pituitary prolactinomas.
SO - Neuroradiology 2002 May;44(5):407-10
AD - Department of Neurosurgery, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Japan. nishioka@tokyo-med.ac.jp
In pituitary prolactinomas, serum prolactin (PRL) levels usually parallel the tumor size. We conducted a retrospective study to determine differences in PRL production between men and women with prolactinomas. A total of 51 patients, 16 men and 35 women, was studied. We investigated clinical, endocrinological, radiological and histological findings, and estimated the tumor volume (TV) by high-resolution magnetic resonance imaging (MRI). Correlation between PRL level and TV was low in men (R=0.458), in contrast to women (R=0.953), c. Men with prolactinomas showed predominance of large tumors (P=0.0009) with high PRL levels (P=0.0009) and had greater tendencies for cyst formation (P=0.0047). Large prolactinomas tended to be accompanied by cyst(s) (P=0.0051) and hemorrhage ( P=0.0015), both of which were associated with reduced PRL secretion (P=0.0004 and P<0.0001, respectively). When the volume of the cysts and hemorrhage was subtracted from the total TV, correlation between PRL level and TV became greater (R=0.905) with no gender difference. Histological examination demonstrated a sparsely granulated type of lactotroph adenoma with occasional fibrosis, particularly in tumors with hemorrhage and cysts. Although a significant discrepancy between PRL level and TV may exist in prolactinomas when intratumoral hemorrhage and/or cysts are present, there is no essential difference in PRL secretion between the sexes.

5
UI - 12072040
AU - Colao A; Ferone D; Lombardi G; Lastoria S
TI - (99m)Technetium pentavalent dimercaptosuccinic acid scintigraphy in the follow-up of clinically nonfunctioning pituitary adenomas after radiotherapy.
SO - Clin Endocrinol (Oxf) 2002 Jun;56(6):713-21
AD - Department of Clinical and Molecular Endocrinology and Oncology, University Federico II of Naples, Italy. colao@unina.it
BACKGROUND: It is still difficult to differentiate pituitary adenoma remnants from postradiotherapy fibrosis by computed tomography (CT) or magnetic resonance imaging (MRI), especially in patients with clinically nonfunctioning pituitary adenomas (NFA), lacking circulating markers to follow disease progression or cure. OBJECTIVE: We investigated the usefulness of scintigraphy with technetium-99m pentavalent dimercaptosuccinic acid [(99m)Tc(V)DMSA], shown previously to detect most pituitary GH- and PRL-secreting adenomas and NFA, with tumour-to-background ratios (T/B) as high as 25-fold. PATIENTS: Eighteen patients with NFA (study group), 10 patients with GH- and three patients with PRL-secreting adenomas (control group), all of whom had undergone previous surgery. DESIGN: The study was an open longitudinal design. Pituitary CT/MRI and (99m)Tc(V)DMSA scintigraphy was performed before and 1, 3 and 5 years after conventional radiotherapy. Tumour size was measured as maximal diameter of the residual lesion, while uptake of (99m)Tc(V)DMSA was measured as a T/B ratio. RESULTS: At study entry, pituitary (99m)Tc(V)DMSA uptake was found in 13 NFA (72.2%), seven GH-secreting (70%) and all PRL-secreting adenomas; remnant tumour was documented by CT/MRI in all 31 patients. Maximal remnant diameter was significantly higher in patients with positive (13.3 +/- 0.9 mm) than in those with negative scintigraphy (7.0 +/- 0.3 mm, P < 0.001). During the 5-year follow-up postradiotherapy, a significant decrease in (99m)Tc(V)DMSA uptake (9.7 +/- 0.8 vs. 3.2 +/- 0.5, P < 0.0001) occurred in all but three patients. Two NFA patients died of tumour invasion 19 and 36 months after radiotherapy and one acromegalic patient had no change in his hormone levels. In the eight negative patients (five NFA and three GH), scintigraphy remained negative throughout follow-up. A remarkable shrinkage of the remnant tumour was observed in both the patients with negative (from 7.0 +/- 0.3 to 1.9 +/- 0.6 mm, P < 0.001) and in those with positive scintigraphy (from 13.3 +/- 0.9 to 7.3 +/- 0.6 mm, P < 0.001). At the end of the study, CT/MRI showed evident remnant tumour in 13 of 16 NFA (81.2%), nine GH-secreting (90%) and all three prolactinomas (100%), while the scintigraphy was negative (T/B < 1) or faintly positive (T/B 1-2) in eight of 16 NFA (50%), five GH-secreting (50%) and one prolactinoma (33.3%). CONCLUSIONS: Functional imaging of pituitary remnant adenomas (> 10 mm in size) by (99m)Tc(V)DMSA depicts viable pituitary adenoma remnants. This approach may be of clinical value in patients with clinically nonfunctioning adenomas to monitor the effects of radiotherapy.

6
UI - 12072042
AU - Tannahill LA; Visser TJ; McCabe CJ; Kachilele S; Boelaert K; Sheppard
TI - MC; Franklyn JA; Gittoes NJ Dysregulation of iodothyronine deiodinase enzyme expression and function in human pituitary tumours.
SO - Clin Endocrinol (Oxf) 2002 Jun;56(6):735-43
AD - Division of Medical Sciences, University of Birmingham, Queen Elizabeth Hospital, Edgbaston, UK.
OBJECTIVE: Thyroid hormones (THs) perform essential roles in pituitary function. They regulate anterior pituitary hormone secretion and are also key determinants of pituitary cell proliferation and differentiation. The critical role of deiodinase enzymes, which serve as prereceptor regulators of TH action, remains largely unexplored. Three deiodinase enzymes metabolize active and inactive THs and thereby determine tissue concentrations of the biologically active ligand, tri-iodothyronine (T3). We hypothesized that aberrant expression of deiodinase enzymes and/or altered enzyme activity in pituitary tumours may change tissue concentrations of THs and influence their growth and secretory characteristics. STUDY DESIGN AND PATIENTS: We studied 105 pituitary tumours and 10 normal pituitaries for expression of deiodinase enzyme mRNAs encoding types 1 (D1), 2 (D2) and 3 (D3) using real-time RT-PCR. Enzyme activity data from 20 pituitary samples were also obtained. RESULTS: Pituitary tumours expressed significantly increased D3 mRNA (6.5-fold, P < 0.0005) compared with normal pituitaries. D2 mRNA was also increased 2.6-fold (P = 0.005) in pituitary tumours compared with normals. The rare TSH-secreting pituitary tumour subtype expressed a 13.1-fold excess of D3 mRNA and reduced D2 mRNA (0.1-fold of normal pituitaries). D2 mRNA expression in ACTH-secreting tumours was similarly reduced to 0.1-fold that in normal pituitaries. CONCLUSIONS: Pituitary adenomas express abnormal levels of deiodinase enzymes compared to normal pituitaries. These abnormalities may have functional consequences on pituitary tumour growth. In the case of TSH-secreting pituitary adenomas, the observed pattern of deiodinase mRNA expression may explain the 'resistance' of this tumour type to TH feedback.

7
UI - 12072054
AU - Buch H; El-Hadd T; Bicknell J; Simpson DJ; Farrell WE; Clayton RN
TI - Pituitary tumours are multiclonal from the outset: evidence from a case with dural metastases.
SO - Clin Endocrinol (Oxf) 2002 Jun;56(6):817-22
AD - Department of Medicine, School of Post-Graduate Medicine, Keele University, Stoke-on-Trent, Staffordshire, UK.
In 1992 a 54-year-old man underwent transsphenoidal adenomectomy to remove a clinically nonfunctioning pituitary adenoma during which there was a transient cerebrospinal fluid (CSF) leak. He received radiotherapy to a small residual remnant. Follow-up magnetic resonance imaging (MRI) scan in 1997 showed an increase in the tumour in the pituitary stalk region and an additional intradural lesion at C1 level. In the absence of neurological symptoms and signs, an observational policy was followed. By 1999 the cervical dural lesion had enlarged and laminectomy was performed, during which three intradural lesions were removed. Histology and immunohistochemistry of the metastases were identical to those of the initial pituitary adenoma. Follow-up MRI scan showed extension of the pituitary remnant above the chiasma, requiring transfrontal surgery. Operation was complicated by secondary brain haemorrhage from which the patient died. Autopsy revealed a small amount of residual tumour at the top of the stalk and several small intradural tumour nodules at the level of the foramen magnum. Genetic analysis of the initial pituitary tumour identified significant allelic losses in keeping with its invasive nature, while that of the metastases indicated a separate clone as shown by retention of alleles lost in the primary tumour. The regrown pituitary tumour also appeared to be of a different clone to the initial tumour and the same as two of three of the first metastases (C1 level). The foramen magnum metastasis showed the same loss of heterozygosity (LOH) pattern as one of the original C1 metastases and the pituitary tumour tissue obtained at autopsy. We speculate that at the initial pituitary surgery, cells seeded into the CSF and grew in the dura. These cells were from a different clone, implying that the original pituitary tumour contained at least two clones, possibly three, providing evidence for the contemporaneous oligoclonality of the original pituitary tumour.

8
UI - 12121834
AU - Jaffrain-Rea ML; Di Stefano D; Minniti G; Esposito V; Bultrini A;
TI - Ferretti E; Santoro A; Faticanti Scucchi L; Gulino A; Cantore G A critical reappraisal of MIB-1 labelling index significance in a large series of pituitary tumours: secreting versus non-secreting adenomas.
SO - Endocr Relat Cancer 2002 Jun;9(2):103-13
AD - Department of Experimental Medicine, Universita degli Studi di L'Aquila, Via Vetoio, Coppito 2, 67100 L'Aquila (AQ), Italy. jaffrain.ml.rea@katamail.com
Pituitary tumours are usually benign neoplasia, but may have a locally aggressive or malignant evolution. This study aimed to identify factors which mostly influence their proliferative activity, in order to clarify its value for clinical and research purposes. The proliferative index was determined in a prospective series of 132 pituitary tumours as the percentage of monoclonal antibody MIB-1-immunopositive cells and referred to as the MIB-1 labelling index (LI). Its distribution was analysed according to both univariate and multivariate models. A life-threatening pituitary tumour is presented separately. The mean LI was 1.24+/-1.59%, with significant differences between clinically secreting (CS) and clinically non-secreting (CNS) adenomas. In CS adenomas (n=65), LI was highly variable and markedly influenced by pre-operative pharmacological treatment (0.80+/-1.03 vs 2.06+/-2.39% in treated vs untreated cases, P=0.009); it decreased with patient's age (P=0.025, r=0.28) and increased with tumour volume and invasiveness. The influence of pre-operative treatment and macroscopic features on LI in this group was confirmed by multivariate analysis. In CNS adenomas (n=67), LI distribution was less variable than in CS adenomas (P<0.0001), it was age-independent and correlations with tumour volume, invasiveness or recurrence did not reach significance. In a rapidly growing parasellar tumour, the mean LI was 24% at first surgery and exceeded 50% at second surgery performed 4 months later. LI should be interpreted according to hormone secretion and pre-operative treatment. Unusually high LI values deserve particular attention.

9
UI - 12176193
AU - Abe T; Ludecke DK
TI - Transnasal surgery for prolactin-secreting pituitary adenomas in childhood and adolescence.
SO - Surg Neurol 2002 Jun;57(6):369-78; discussion 378-9
AD - Department of Neurosurgery, Showa University School of Medicine, Tokyo, Japan.
BACKGROUND: Prolactin (PRL)-secreting pituitary adenomas (prolactinomas) are rare in childhood and adolescence; there are only a few published series of patients who were surgically treated. We discuss the gender-dependent differences, and the surgical indications and results for 14 patients with prolactinomas under 18 years of age at surgery. METHODS: We reviewed the data for 14 patients (10 girls and 4 boys) treated surgically for prolactinomas between 1980 and 1996. Surgery was chosen because of intolerance and/or resistance to dopamine agonist (DA) in 9 patients, the patient's decision in 3, rhinorrhea in 1, and pituitary apoplexy in 1 during DA therapy. All patients underwent direct transnasal explorations. Since 1988, intraoperative PRL measurements were performed. The follow-up period was at least 6 years. RESULTS: Nine of the 10 girls had primary or secondary amenorrhea, and 3 of the 4 boys had visual field defects. The boys and girls were the same age at the onset of symptoms and had the same preoperative duration of symptoms. Boys had larger, more invasive tumors and higher preoperative and postoperative plasma PRL levels than girls. Two boys demonstrated significant extrasellar extension at the time of diagnosis. Two patients required drilling of the incompletely pneumatized sphenoid sinus to reach the sella. Radical tumor resection was achieved in seven girls and in none of the four boys. In 12 of the 14 patients, normal pituitary function was preserved by transnasal surgery. There was no severe surgical morbidity or mortality. Endocrinological remission by surgery alone was achieved for seven girls, and was achieved in 4 of the 5 patients (80%) with microadenomas. In patients with preoperative mean PRL levels of less than 200 microg/L, the surgical cure rate was 75%. CONCLUSIONS: Prolactinomas in childhood and adolescence differ in their biology in boys and girls. Transnasal surgery is as safe in childhood patients as it is in adult patients, and it may be an effective alternative to long-term medical therapy for selected patients with prolactinomas. Successful surgical outcomes were achieved in patients with microadenomas and preoperative serum PRL levels of less than 200 microg/L.

10
UI - 12176196
AU - Alleyne CH Jr; Barrow DL; Oyesiku NM
TI - Combined transsphenoidal and pterional craniotomy approach to giant pituitary tumors.
SO - Surg Neurol 2002 Jun;57(6):380-90; discussion 390
AD - Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia 30322, USA.
OBJECTIVE: We describe a combined simultaneous approach to giant pituitary tumors and present a review of 10 patients undergoing this procedure with emphasis on patient selection, surgical technique, and results. METHODS: A retrospective review was performed of patients who had undergone a combined, simultaneous transsphenoidal and pterional craniotomy approach to a giant pituitary adenoma. Visual findings, endocrine presentation, and tumor type were compiled. Tumor stage and grade (Hardy classification) were based on MRI and intraoperative findings. RESULTS: Gross total resection of tumor was achieved in 4 of 10 patients, near total (>90%) in 2 of 10, and subtotal (80-90%) in 4. At the time of follow-up (average, 29.7 months; range, 17-44 months), stereotactic radiosurgery had been performed in 2 patients. Of the 9 patients who presented with visual field loss, all had improvement at 1-month follow-up. At 6 months follow-up, resolution was complete in 5 patients and partial in 4. No patient had worsening of vision. Hypopituitarism persisted in all 5 patients who presented with it preoperatively. CONCLUSION: The combined, simultaneous transsphenoidal and pterional approach described is indicated for a small subset of patients with giant (>3 cm) clinically nonfunctional pituitary tumors who meet the criteria of tumor configuration outlined where the surgeon cannot achieve complete resection by a single approach. We propose adding a new Hardy's scheme subtype, Stage B-a, to describe giant pituitary tumors with a dumbbell configuration. Combining both craniotomy and transsphenoidal approaches may achieve the goal of tumor resection with less need for multiple sequential operations.

11
UI - 12186456
AU - Cappabianca P; Cavallo LM; Colao A; de Divitiis E
TI - Surgical complications associated with the endoscopic endonasal transsphenoidal approach for pituitary adenomas.
SO - J Neurosurg 2002 Aug;97(2):293-8
AD - Department of Neurological Sciences, Federico II University, Naples, Italy. cappabia@unina.it
OBJECT: To assess postoperative complications related to the surgical procedure, a retrospective analysis was conducted in a series of 146 consecutively treated patients who underwent an endoscopic endonasal transsphenoidal approach to the sellar region for resection of pituitary divided into groups (nasofacial, sphenoid sinus, sella turcica, supra or parasellar, and endocrine complications) according to the anatomical structures and the systems involved. Overall, a decreased incidence of complications has been observed, compared with large historical series of the traditional microsurgical transsphenoidal approach, likely because of the overview inside the anatomy facilitated by the endoscope, and the decreased surgical trauma. CONCLUSIONS: Transsphenoidal surgery, either microscopic or endoscopic, is a safe procedure in experienced hands, but serious complications still occur and must be reduced as much as possible. Additional improvement can be expected with greater experience and new technical developments. A coordinated team effort with other dedicated colleagues from different specialties is advised.

12
UI - 12186457
AU - Shrivastava RK; Arginteanu MS; King WA; Post KD
TI - Giant prolactinomas: clinical management and long-term follow up.
SO - J Neurosurg 2002 Aug;97(2):299-306
AD - Department of Neurosurgery, Mount Sinai Medical Center, New York, New York 10029, USA. rkshrivastava@aol.com
OBJECT: Giant prolactinomas are rare tumors whose treatment and outcome has only been addressed in isolated case reports. The authors document the long-term follow-up findings and clinical outcome in a group of patients with giant prolactinomas. METHODS: This study is a retrospective chart and clinical review of more than 2000 cases of pituitary tumors treated at the authors' institution, of which 10 met the criteria for inclusion (prolactin level > 1000 ng/ml, diameter > 4 cm on neuroimaging studies, and clinical signs of hyperprolactinemia/mass effect). The average follow-up duration was 6.7 years after initial treatment with either bromocriptine or transsphenoidal resection. In more than 90% of the patients in this series the disease was controlled by medical treatment with bromocriptine alone; the other 10% required early surgery via transsphenoidal resection. All patients had improvement in visual symptoms. All tumors had extrasellar components, five of which exhibited frank invasion of the cavernous sinus. Tumor volume on magnetic resonance imaging was decreased on average by 69%; this occurred at a faster rate and in larger amounts when treated with bromocriptine than has been reported in the literature for macroprolactinomas. CONCLUSIONS: According to long-term follow-up findings, giant prolactinomas are exquisitely responsive to dopamine agonist therapy. In giant prolactinomas the prolactin level does not correlate with size. The main indication for early surgery is intratumoral hematoma, whereas our main indications for late surgery are cerebrospinal fluid leakage caused by medical treatment, or an increasing prolactin level despite medical therapy. Checking prolactin levels in suspicious sellar and/or suprasellar lesions may be diagnostic and prevent unnecessary surgery.

13
UI - 12186458
AU - Amar AP; Couldwell WT; Chen JC; Weiss MH
TI - Predictive value of serum prolactin levels measured immediately after transsphenoidal surgery.
SO - J Neurosurg 2002 Aug;97(2):307-14
AD - Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, USA. amar@aya.yale.edu
OBJECT: Prolactin-secreting pituitary adenomas may be managed by surgery, medication, radiotherapy, or observation. The authors reviewed a consecutive series of patients who were followed for at least 5 years after surgery to assess the prognostic significance of preoperative factors (tumor size and prolactin level) and an immediate postoperative factor (prolactin level obtained the morning after surgery) on long-term hormonal outcome, thereby clarifying the indications for surgical removal of tumor, the definition of successful treatment outcomes, and the nature of "recurrent" tumors. METHODS: Between 1979 and 1991, 241 patients with prolactinomas underwent transsphenoidal resection. Nineteen patients were lost to follow-up review, whereas the remaining 222 patients underwent measurement of their prolactin levels on postoperative Day 1 (POD 1), at 6 and 12 weeks, and every 6 months thereafter for a minimum of 5 years. On POD 1, prolactin levels in 133 patients (Group 1) were lower than 10 ng/ml, in 43 patients (Group 2) between 10 and 20 ng/ml, and in 46 patients (Group 3) higher than 20 ng/ml. At 6 and 12 weeks, normal prolactin levels (< or = 20 ng/ml) were measured in 132 (99%) of the 133 patients in Group 1 but only in 32 (74%) of the 43 patients in Group 2. By 5 years postoperatively, normal levels of prolactin were still measured in 130 patients (98%) in Group 1 compared with only five patients (12%) in Group 2. No patient with a prolactin level lower than 3 ng/ml on POD 1 was found to have an elevated hormone level at 5 years. The likelihood of a long-term chemical cure was greater for patients with microadenomas (91% cure rate) than for those with macroadenomas (33%). Preoperative prolactin levels also correlated with hormonal outcome. CONCLUSIONS: Prolactin levels lower than 10 ng/ml on POD 1 predict a long-term chemical cure in patients with microadenomas (100% cure rate) and those with macroadenomas (93% cure rate). In contrast, a cure is not likely to be obtained in patients with normal levels ranging between 10 and 20 ng/ml on POD 1 if they harbor macroadenomas (0% cure rate). A recurrence reported several years after surgery probably represents the presence of persistent tumor that was not originally removed. If the initial operation was performed by an experienced surgeon, however, reoperation is not likely to yield a chemical cure.

14
UI - 11940053
AU - Leung B; Iisma TP; Leung KC; Hort YJ; Turner J; Sheehy JP; Ho KK; Lismaa
TI - TP Galanin in human pituitary adenomas: frequency and clinical significance.
SO - Clin Endocrinol (Oxf) 2002 Mar;56(3):397-403
AD - Department of Anatomical Pathology, St Vincent's Hospital, Sydney, Australia.
OBJECTIVES: Galanin (GAL) is a neuropeptide widely expressed in the central and peripheral nervous system and in neuroendocrine tissue, including the adenohypophysis where, in humans, it is expressed in corticotrophs and in ACTH-producing adenomas. Previous analyses of human tissue have used antiserum against porcine GAL for detection of GAL immunoreactivity (GAL-IR) and no pathophysiological correlates have been reported. Given significant differences between the sequence of porcine and human GAL peptides, the aim of this study was to use antiserum raised against synthetic human GAL to investigate GAL-IR in non tumorous pituitaries and in pituitary adenomas, and to correlate GAL-IR with the clinical and hormonal characteristics of patients with Cushing's disease. PATIENTS: Six nontumorous pituitaries were obtained from autopsy and 151 pituitary adenomas, comprising 62 functioning (16 corticotroph, 26 somatotroph, 19 lactotroph and one thyrotroph) and 89 nonfunctioning adenomas, were obtained by surgery. RESULTS: All non tumorous pituitary glands showed GAL-IR in corticotrophs, in basophil cells within the neurohypophysis and in nerve fibres of the neurohypophysis. GAL-IR was found in a subset (10 of 16) of patients with ACTH-secreting tumours causing Cushing's syndrome. GAL-IR was rarely expressed in somatotroph adenomas and prolactinomas, but was expressed in approximately one-third of nonfunctioning tumours. GAL-IR was found in almost 90% of nonfunctioning tumours that were positive for ACTH. There were no significant differences in sex ratio, age at presentation or 24-h urinary free cortisol secretion in the subset of patients with Cushing's disease positive (n = 10) or negative (n = 6) for GAL-IR. However, Cushing's patients positive for GAL-IR tended to have smaller tumours and achieved a higher cure rate than those without (100 vs. 50%, P = 0.017). CONCLUSIONS: Galanin is present in normal and tumorous human pituitaries. In addition, GAL colocalizes exclusively in corticotrophs of normal pituitaries and is coexpressed almost exclusively in corticotrophs from functioning and nonfunctioning tumours. The finding that corticotroph adenomas can function irrespective of the presence of GAL suggests that GAL may not play a pathophysiological role in Cushing's disease. However, the better surgical outcome observed in patients with Cushing's disease who had tumours positive for GAL-IR suggests that the expression of GAL confers a less aggressive tumour phenotype.

15
UI - 12184601
AU - Rhee JS; Wackym PA; Hague K; Wolfe D; King WA
TI - Granular cell tumor of the pituitary fossa.
SO - Ann Otol Rhinol Laryngol 2002 Aug;111(8):754-8
AD - Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, 53226, USA.
Although granular cell tumors are relatively common in the head and neck, symptomatic granular cell tumors of the neurohypophysis are extremely rare. Ophthalmologic symptoms are most common, followed by endocrinologic manifestations. We report a case of a granular cell tumor of the pituitary fossa that was surgically treated. The clinical manifestations, radiographic appearance, and surgical management of granular cell tumors of the pituitary fossa are reviewed, as well as the unique histopathology and electron microscopy of this uncommon neoplasm.

16
UI - 11837807
AU - Lin SH; Hung YH; Lin YF
TI - Severe hyponatremia as the presenting feature of clinically non-functional pituitary adenoma with hypopituitarism.
SO - Clin Nephrol 2002 Jan;57(1):85-8
AD - Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC. 521116@ndmctsgh.edu.tw
Hyponatremia can result from a wide range of causes. While hyponatremia is known to occur in patients with hypopituitarism, severe hyponatremia occurring as the presenting feature of hypopituitarism is very rare. We present two cases in which severe hyponatremia developed with weakness, light-headedness and seizure. The hyponatremia in these 2 cases mimicked the laboratory diagnostic criteria of a syndrome of inappropriate secretion of antidiuretic hormone (SIADH). However, the hormone studies displayed hypopituitarism. Hyponatremia was completely corrected after administering a supplement of prednisolone and L-thyroxine. Computerized tomography of the brain revealed an adenoma of the pituitary gland. These two cases illustrate that severe hyponatremia may be the presenting feature of clinically non-functional pituitary adenoma with hypopituitarism, which should be kept in mind in the differential diagnosis of hyponatremia mimicking SIADH.

18
UI - 11765830
AU - Liu JK; Das K; Weiss MH; Laws ER Jr; Couldwell WT
TI - The history and evolution of transsphenoidal surgery.
SO - J Neurosurg 2001 Dec;95(6):1083-96
AD - Department of Neurosurgery, New York Medical College, Valhalla, New York 10595, USA.
Initial attempts at transcranial approaches to the pituitary gland in the late 1800s and early 1900s resulted in a mortality rate that was generally considered prohibitive. Schloffer suggested the use of a transsphenoidal route as a safer, alternative approach to the sella turcica. He reported the first successful removal of a pituitary tumor via the transsphenoidal approach in 1906. His procedure underwent a number of modifications by interested surgeons, the culmination of which was A. E. Halstead's description in 1910 of a sublabial gingival incision for the initial stage of exposure. From 1910 to 1925, Cushing, combining a number of suggestions made by previous authors, refined the transsphenoidal approach and used it to operate on 231 pituitary tumors, with a mortality rate of 5.6%. As he developed increasing expertise with transcranial surgery, however, Cushing reduced his mortality rate to 4.5%. With the transcranial approach, he was able to verify suprasellar tumors and achieve better decompression of the optic apparatus, resulting in better recovery of vision and a lower recurrence rate. As a result he and most other neurosurgeons at the time abandoned the transnasal in favor of the transcranial approaches. Norman Dott, a visiting scholar who studied with Cushing in 1923, returned to Edinburgh, Scotland, and continued to use the transsphenoidal procedure while others pursued transcranial approaches. Dott introduced the procedure to Gerard Guiot, who published excellent results with the transsphenoidal approach and revived the interest of many physicians throughout Europe in the early 1960s. Jules Hardy, who used intraoperative fluoroscopy while learning the transsphenoidal approach from Guiot, then introduced the operating microscope to further refine the procedure; he thereby significantly improved its efficacy and decreased surgical morbidity. With the development of antibiotic drugs and modern microinstrumentation, the transsphenoidal approach became the preferred route for the removal of lesions that were confined to the sella turcica. The evolution of the transsphenoidal approaches and their current applications and modifications are discussed.

19
UI - 11765831
AU - Lanzino G; Laws ER Jr
TI - Pioneers in the development of transsphenoidal surgery: Theodor Kocher, Oskar Hirsch, and Norman Dott.
SO - J Neurosurg 2001 Dec;95(6):1097-103
AD - Department of Neurological Surgery, University of Virginia Health Sciences Center, Charlottesville, Virginia, USA.
The development of new scientific concepts and techniques is usually the result of a progressive evolution. The transsphenoidal approach to pituitary lesions is no exception. Several pioneers contributed to its development and its eventual and nearly unconditional acceptance. In this historical vignette, the contributions of three master surgeons. Theodor Kocher, Oskar Hirsch, and Norman Dott, are reviewed.

20
UI - 12100082
AU - Glezer A; D'Alva CB; Salgado LR; Musolino NR; Serafini P; Vieira JG;
TI - Bronstein MD Pitfalls in pituitary diagnosis: peculiarities of three cases.
SO - Clin Endocrinol (Oxf) 2002 Jul;57(1):135-9
AD - Neuroendocrine Unit, Hospital das Clinicas, University of Sao Paulo Medical School, Brazil.
Due to the increasing availability and sensitivity of diagnostic methods, biochemical and imaging abnormalities of pituitary function and anatomy are becoming more frequent. Hyperprolactinaemia was found in three women without any prolactin (PRL) related clinical features. All three patients had normal libido, regular menses with evidence of ovulation, no galactorrhoea, and normal FSH, LH, TSH and free T4 serum levels. Magnetic resonance imaging (MRI) of the sellar region showed images that were compatible with pituitary microadenomas in all three cases. Due to the discordance between laboratory and clinical features, we searched for the presence of PRL aggregates with high molecular weight and low biological activity (macroprolactinaemia). Initially, we screened with a polyethylene glycol precipitation method, and then confirmed the presence of macroprolactinaemia by chromatography. All three cases screened positive for the presence of macroprolactinaemia. MRI alterations, compatible with pituitary microadenomas, may be due to true microincidentalomas, normal anatomical variations or imaging artefacts. In conclusion, we have described the presence of double diagnostic pitfalls that might lead to unnecessary medical or surgical intervention.

21
UI - 11942362
AU - Hamamoto Y; Niino K; Adachi M; Hosoya T
TI - MR and CT findings of craniopharyngioma during and after radiation therapy.
SO - Neuroradiology 2002 Feb;44(2):118-22
AD - Department of Radiology, Yamagata University School of Medicine, Iidanishi, Japan. hamamoto@med.id.yamagata-u.ac.jp
Long-term changes in craniopharyngioma treated with radiation therapy (RT) were investigated by computed tomography (CT) and/ or magnetic resonance (MR) imaging. Eight patients with craniopharyngioma were treated with incomplete resection or conservative surgical intervention followed by postoperative RT. The periods of tumor shrinkage were often long and varied (range: 6-68 months, mean: 29.1 months). Temporary enlargement of the solid component of a tumor usually occurs during RT and does not represent tumor progression. Cystic enlargement also occurs sometimes comparatively early after RT, and enlarged cysts often shrink with no treatment or with conservative treatment. These changes should be differentiated from tumor recurrence, with careful follow-up. After shrinkage, small solid or cystic nodules enhanced with contrast medium often remain. Long-term follow-up is necessary to differentiate uncontrolled tumors from controlled tumors with imaging modalities.

22
UI - 11942363
AU - Uesaka T; Miyazono M; Nishio S; Iwaki T
TI - Astrocytoma of the pituitary gland (pituicytoma): case report.
SO - Neuroradiology 2002 Feb;44(2):123-5
AD - Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
A 34-year-old man presented with a 4-month history of visual obscuration. Magnetic resonance imaging showed a solid, discrete, contrast-enhancing pituitary mass with suprasellar extension. Surgery, which was performed via a transsphenoidal approach, disclosed the pituitary tumor to be a fibrillary astrocytoma (pituicytoma). This case report contains the clinical and neuroimaging features of this rare tumor of the neurohypophysis, which masqueraded as a pituitary adenoma.

23
UI - 12087510
AU - Revuelta R; Arriada-Mendicoa N; Ramirez-Alba J; Soto-Hernandez JL
TI - Simultaneous treatment of a pituitary adenoma and an internal carotid artery aneurysm through a supraorbital keyhole approach.
SO - Minim Invasive Neurosurg 2002 Jun;45(2):109-11
AD - Department of Neurosurgery, National Institute of Neurology and Neurosurgery, Mexico City, Mexico. rogelio_revuelta@hotmail.com
We describe a case in which an incidental left carotid aneurysm was found during the preoperative evaluation of a pituitary adenoma. After magnetic resonance imaging (MRI) and angiography delineated their characteristics, we chose to treat both lesions simultaneously through a left supraorbital keyhole approach. The aneurysm clipping was followed by intracapsular resection of the tumor that was identified later as a non-secretory adenoma. The postoperative course was uneventful. This case shows that in carefully selected patients it is possible to treat successfully concurrent conditions through a minimally invasive approach, with the well known advantages of low morbidity and a short hospital stay.

24
UI - 12087513
AU - Ohhashi G; Kamio M; Abe T; Otori N; Haruna S
TI - Endoscopic transnasal approach to the pituitary lesions using a navigation system (InstaTrak system): technical note.
SO - Minim Invasive Neurosurg 2002 Jun;45(2):120-3
AD - Department of Neurological Surgery, Jikei University, Tokyo, Japan. n-ikyoku@po.iijnet.or.jp
The endoscopic transnasal approach has become a procedure of choice for the surgical management of pituitary lesions. However, in conventional endoscopic transnasal surgery, the surgeon may become disorientated to the actual operating position. In our series, 31 patients have undergone an endoscopic transnasal approach to the pituitary lesions with the use of the navigation system InstaTrak for real-time imaging. This image guidance system proved valuable for anatomic localization during pituitary surgery. We have reduced the average surgical time, and improved patient outcome. As consequence, complications during surgery should decrease and safety should increase. Intraoperative image guidance is expected to have major advantageous effects on pituitary surgery by allowing the surgeon to remove pathology more efficiently. As this system is improved technically and surgeons become more proficient in its use, there should be better postoperative outcomes.

25
UI - 12087514
AU - Kim J; Cheong J; Yi H; Bak K; Kim C; Lee S
TI - Usefulness of silicone plate for sellar floor reconstruction.
SO - Minim Invasive Neurosurg 2002 Jun;45(2):124-7
AD - Department of Neurosurgery, Hanyang University Kuri Hospital, Kuri, Kyunggi-do, South Korea. kjm@hanyang.ac.kr
During the transsphenoidal approach (TSA), the proper sellar floor reconstruction plays an important role in the surgical results. The authors have evaluated the usefulness of a silicone as a substitute for bone splint in sellar floor reconstruction. Silicone plates were used in 10 patients who had 7 pituitary adenomas, 2 Rathke's cleft cysts, and 1 metastatic tumor. Among the ten cases, seven underwent standard TSAs and three received extended TSAs. The silicone plate was cut to a size slightly larger than that of bone window, inserted with a three-pronged fork, and then adjusted precisely. In nine patients, complications that related to surgical repair did not occur. A postoperative cerebrospinal fluid (CSF) rhinorrhea occurred in one pituitary macroadenoma, and no infection was observed in any case. From the authors' experience, advantages of the silicone plate are its simplicity to shape for any size of defects, and the easy detectability of the previous bone window at reoperation.

26
UI - 12109276
AU - Fajfr R; Muller B; Diem P
TI - [Hypophyseal incidentaloma in a patient with autosomal dominant polycystic kidney disease]
SO - Schweiz Rundsch Med Prax 2002 Jun 19;91(25-26):1123-6
AD - Abteilung fur Endokrinologie und Diabetologie, Inselspital, Bern.
The prevalence of incidentally discovered lesions within the pituitary (pituitary incidentalomas) is about 10%. The most common form of sellar mass are clinically nonfunctioning adenomas (less than 10 mm); functioning adenomas, however, are rare. Incidentally discovered pituitary microadenomas causing growth hormone hypersecretion are uncommon. In addition, the association of autosomal dominant polycystic kidney disease with acromegaly is exceptional and has not yet been reported to our knowledge.

27
UI - 11564250
AU - Kelly DF; Oskouian RJ; Fineman I
TI - Collagen sponge repair of small cerebrospinal fluid leaks obviates tissue grafts and cerebrospinal fluid diversion after pituitary surgery.
SO - Neurosurgery 2001 Oct;49(4):885-9; discussion 889-90
AD - Division of Neurosurgery, University of California at Los Angeles Medical Center, Los Angeles, CA 90095-7039, USA. dkelly@mednet.ucla.edu
OBJECTIVE: Repair of a cerebrospinal fluid (CSF) leak created at the time of transsphenoidal surgery typically involves placement of a fat, fascial, or muscle graft and sellar floor reconstruction. In this report, a simplified repair for small, "weeping" CSF leaks using collagen sponge is described. METHODS: All patients underwent an endonasal transsphenoidal procedure using the operating microscope. At the completion of tumor removal, if a small CSF leak was noted but no obvious large arachnoidal defect was present, a piece of collagen sponge was fashioned to cover the exposed diaphragma sellae. Titanium mesh was then wedged into the intrasellar, extradural space and a larger piece of collagen was placed over the reconstructed sellar floor. Nasal packing was removed within 24 hours. RESULTS: During an 18-month period, 62 consecutive transsphenoidal procedures were performed for tumor removal. Of 20 patients with a small CSF leak (18 pituitary adenomas, 1 Rathke's cleft cyst, and 1 chordoma), all had successful repair with collagen sponge. At follow-up examinations at 1 to 18 months, no patient had required a lumbar drain or had developed meningitis. One other patient had a large intraoperative arachnoidal defect that was unsuccessfully repaired with the collagen sponge technique; in this patient, a second operation was required with a fat graft, sellar floor reconstruction, and lumbar drainage. CONCLUSION: A simplified repair of small CSF leaks after transsphenoidal surgery using a two-layered collagen sponge technique with sellar floor reinforcement is thought to be safe and effective and obviates the need for tissue grafts, fibrin glue, or lumbar

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