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Pituitary Surgery

A pituitary tumour is an abnormal growth of cells in the pituitary gland, which is the main hormone-producing gland in the body. About the size of a pea, the pituitary gland is located in the center of the brain behind the nose and eyes.

Hospital Stay: Hospital Stay: 5 days
Duration: Duration: 3 hrs
Cost Estimate: Cost Estimate: 5000 USD - 7500 USD These are indicative prices in Indian Hospitals

There is no obvious cause of pituitary tumours. Some pituitary tumours might be caused by stimulation from the hypothalamus — a part of the brain that signals the pituitary gland to make hormones.

People who have the rare inherited conditions such as multiple endocrine neoplasia type 1 (MEN-1) — a disorder that causes tumours in the endocrine glands (which secrete hormones into the bloodstream and include the pituitary gland) and the first part of the small intestine — or Carney complex — a disorder that causes several types of tumours, including in the pituitary gland — have a higher risk of pituitary tumours. About 1-5% of pituitary tumours occur within families.

Types of Pituitary Tumours

Almost all pituitary tumours are benign. How serious a pituitary tumour is depends on whether it is:

  • Causing health problems by pressing on the pituitary gland or other parts of the nervous system
  • Producing (secreting) excess hormones

Types

  • Adenomas – They are common benign tumours of the pituitary gland. It is said that up to 10% of people will have a pituitary adenoma (which might never have caused a problem) by the time of their death. Some tumours secrete one or more hormones in excess. Such so-called secretory pituitary adenomas are usually found due to hormonal imbalances that affect bodily functions. They may be relatively small when detected. People can develop pituitary adenomas at any age. Most pituitary adenomas are in the front part (anterior lobe) of the pituitary gland.
  • Craniopharyngiomas – They are benign tumours that grow near the pituitary gland. They can be solid tumours or cysts. Approximately 10-15% of pituitary tumours are craniopharyngiomas. They are most commonly found in children, teenagers, and adults older than 50. Craniopharyngiomas often press on nerves, blood vessels or parts of the brain around the pituitary gland.
  • Rathke’s cleft cysts – RCC’s are benign cysts — fluid-filled growths — in the pituitary gland. They develop in the space between the front (anterior) and back (posterior) parts of the pituitary gland.

Signs and symptoms of pituitary tumours:

A pituitary tumour causes symptoms by pushing on brain tissue surrounding the tumour or through excessive or impaired hormone production. Some pituitary tumours may not cause any symptoms.
The most common symptoms include:

  • Headaches
  • Vision problems that cannot be easily explained
  • Menstrual cycle changes in women
  • Mood swings or behavior changes
  • Erectile dysfunction
  • Weight change

Other symptoms include:

  • Production of breast milk by a woman who has not given birth
  • Accelerated or stunted growth in a child or teenager
  • Growth of the hands, feet, forehead and jaw in adults
  • Development of a round face, a hump between the shoulders or both
  • Feeling very tired

Pituitary tumours are not usually diagnosed until symptoms appear.

The treatment for a pituitary tumour will depend on many factors, including:

  • The location of the tumour
  • Whether the pituitary tumour produces excessive amounts of a specific hormone
  • The patient’s general health and preferences regarding potential treatment options

Because having a pituitary tumour can affect many different organs and systems in the body, doctors from several medical specialties will work together to develop a customized treatment plan for the patient.

  • Medication
  • Observation
  • Radiation therapy
  • Surgery

Surgery

Surgery is the most common treatment for pituitary tumours. If the pituitary tumour is benign and in a part of the brain where neurosurgeons can safely completely remove it, surgery might be the only treatment needed. The patient will probably need surgery if the tumour:

  • Is producing hormones that medication cannot control
  • Is causing health problems by pressing on the pituitary gland or other parts of the nervous system.
  • Is still growing despite previous treatment with medication or surgery

The most common types of surgery for pituitary tumours are:

  • Endonasal endoscopic surgery
  • Neuroendoscopic surgery
  • Craniotomy

Endoscopic pituitary surgery

Endoscopic pituitary surgery, also called transsphenoidal endoscopic surgery, is the most common surgery used to remove pituitary tumours. The pituitary gland is located at the bottom of your brain and above the inside of your nose. It is responsible for regulating most of your body’s hormones, the chemical messengers that travel through your blood.

Endoscopic pituitary surgery is done with an instrument called an endoscope. An endoscope is a thin, rigid tube that has a microscope, light, and camera built into it, and it’s usually inserted through the nose. The camera lets your surgeon watch on a television screen while inserting other special instruments through the scope to remove the tumour.

Reasons for endoscopic pituitary surgery

Endoscopic pituitary surgery is done to remove certain types of tumours that start to grow in your pituitary gland:

  • Hormone-secreting tumours. These growths secrete chemical messengers that travel through the blood.
  • Nonhormone-secreting tumours. These growths, also called endocrine inactive pituitary adenomas, are removed by surgery because as they increase in size they may cause headache and visual disturbances.
  • Cancerous tumours. These growths may be treated with a combination of surgery, cancer drugs, and X-ray treatment.

Before endoscopic pituitary surgery

  • You may need to see an endocrinology specialist for an evaluation before surgery. Endocrinologists are the medical specialists that deal with glands and hormones.
  • You may also have your vision checked before surgery.
  • Endoscopic pituitary surgery is usually done under general anesthesia, so you will be asked to stop eating and drinking after midnight on the night before surgery.
  • You may need to stop taking some types of medications that may increase bleeding during surgery.
  • Don’t take any over-the-counter medications before surgery without telling your doctor.
  • You may have several blood tests, a heart rhythm test, and a chest X-ray. These will all be checked before surgery and you will need to be examined by the doctor who gives anesthesia (Pre anesthetic check).

During endoscopic pituitary surgery

The actual surgery may take a few hours. These steps may take place:

  • The surgeon usually places the endoscope through the nose. In some cases, the endoscope may be inserted through an incision under the upper lip.
  • The endoscope is advanced until the bony wall of the sphenoid sinus is found at the back of the nose.
  • The sphenoid sinus is opened and the scope is passed through to the back wall of the sinus.
  • A small opening is made in the back wall of the sinus.
  • Magnetic resonance imagining (MRI) may be used to make images of the pituitary area using a computer and magnets during the surgery to help guide the surgeons.
  • When the pituitary area is entered, the neurosurgeon removes the pituitary tumour in small pieces.
  • When all parts of the tumour that can be reached have been removed, the endoscope is removed. Some packing may be placed in the nose to complete the operation.

After endoscopic surgery

You may need to stay in the hospital for a day or two. During this time, nurses will help you with any dressings and bathroom needs. You will be able to return to a normal diet as long as you are taking fluids well. You will be encouraged to get out of bed and walk as soon as you are able. Aftercare at home may include:

  • Pain medication to control headaches, the most common complaint after surgery
  • Restricted activities – no lifting or straining until cleared by your surgeons
  • Follow-up visits with your endocrinologist and surgeons
  • Repeat MRI
  • Visual testing

It is important to let your surgeons know about:

  • Any headache that doesn’t go away with medication
  • Nausea and vomiting
  • Fever
  • Bleeding from the nose
  • Watery discharge from the nose
  • Increased urination

Craniotomy:

For larger or more complicated pituitary tumours, a craniotomy may be needed. In this approach the surgeon operates through an opening in the front and side of the skull. The surgeon has to work carefully beneath and between the lobes of the brain to reach the tumour. Although the craniotomy has a higher chance of brain injury than transsphenoidal surgery for small lesions, it’s actually safer for large and complex lesions because the surgeon is better able to see and reach the tumour and nearby nerves and blood vessels.
For both transsphenoidal surgery and craniotomies, the doctor may use image-guidance with MRI or CT scans before surgery to help plan the best surgical approach. Some centers also use intraoperative MRI, where MRI scans are done in the operating room one or more times during the surgery. As a general rule, smaller pituitary tumours are easier to treat with surgery. The larger and more invasive the tumour, the less likely the tumour can be cured by surgery.

No, in over 99% of patients, this is not a cancer; it is benign. Although the tumour is benign, it can cause problems because of its size, causing loss of vision, loss of normal pituitary function (hypopituitarism) and/or headache or because of excessive hormone production by the tumour.

The risk of many types of cancer can be reduced with certain lifestyle changes (such as staying at a healthy weight or quitting smoking). But pituitary tumours have not been linked with any known outside risk factors. As a result, there is no known way to prevent these tumours at this time. Still, for people at high risk of pituitary tumours due to certain inherited syndromes, there may be ways to find and treat them early, before they cause problems.

Transsphenoidal literally means “through the sphenoid sinus.” It is a surgical procedure performed through the nose and sphenoid sinus to remove pituitary tumours. Transsphenoidal surgery can be performed with a microscope, endoscope, or both. The procedure is often a team effort between neurosurgeons and ENT surgeons.
A traditional microscopic technique uses a skin incision under the lip and removal of a large portion of the nasal septum so that the surgeon can directly see the area. A minimally invasive technique, called endoscopic endonasal surgery, uses a small incision at the back of the nasal cavity and causes little disruption of the nasal tissues. The ENT surgeon works through the nostrils with a tiny camera and light called an endoscope. In both techniques, bony openings are made in the nasal septum, sphenoid sinus, and sella to reach the pituitary. Once the pituitary is exposed, the neurosurgeon removes the tumour.

You may be a candidate for transsphenoidal surgery if you have a:

  • Pituitary adenoma: a tumour that grows from the pituitary gland; may be hormone-secreting or not.
  • Craniopharyngioma: a benign tumour that grows from cells near the pituitary stalk; may invade the third ventricle.
  • Rathke’s cleft cyst: a benign cyst, or fluid-filled sac, between the anterior and posterior lobes of the pituitary gland.
  • Meningioma: a tumour that grows from the meninges (dura), the membrane that surrounds the brain and spinal cord.
  • Chordoma: a malignant bone tumour that grows from embryonic notochord remnants located at the base of the skull.

If you have a prolactinoma or a small (<10mm) non-secretory tumour, surgery may not be required. These types of tumours respond well to medication or may be observed with periodic MRIs to watch for tumour growth.
Some tumours extend beyond the limits of the transsphenoidal approach. For these tumours, a more extensive operation that uses a craniotomy combined with skull base approaches may be needed

No surgery is without risks. General complications of any surgery include bleeding, infection, blood clots, and reactions to anesthesia. Specific complications related to pituitary surgery include:

  • Vision loss: the optic chiasm can be damaged during surgery. If vision problems were present before surgery, decompression may not restore normal visual function. The nerve may have been permanently damaged by the tumour.
  • Damage to normal pituitary gland: can occur 5 to 10% of the time for macroadenomas. Hormone replacement may be required after surgery, such as cortisol, thyroid hormone, growth hormone, estrogen, or testosterone.
  • Diabetes insipidus (DI): caused by damage to the posterior lobe of the pituitary gland. DI leads to frequent urination and excessive thirst, because the kidneys inadequately concentrate the urine. This effect is usually temporary, lasting 1 to 3 days. DI can be controlled with medication called desmopressin acetate (DDAVP) in nasal spray or pill form. Permanent DI is rare and controlled with medication.
  • Cerebrospinal fluid (CSF) leak: the fluid surrounding the brain can escape through a hole in the dura lining the skull. In 1% of transsphenoidal cases, a clear watery discharge from the nose, postnasal drip, or excessive swallowing occurs; may require surgery to patch the leak.
  • Meningitis: an infection of the meninges often caused by CSF leak.
  • Sinus congestion: small adhesions can stick together and form scars that block air flow through the nose.
  • Nasal deformity: caused by bone removal or adhesions; may be corrected by surgery.
  • Nasal bleeding: continued bleeding from the nose after surgery occurs in less than 1% of patients. May require surgery to correct.
  • Stroke: the carotid arteries and cavernous sinuses located on either side of the pituitary may be damaged during surgery causing an interruption of blood supply to the brain.

If the tumour is hormone secreting, the endocrinologist will follow your hormone levels after surgery to determine whether you are cured.
Patients with Cushing’s disease usually have small tumours (microadenomas) and are surgically cured about 90% of the time.

Patients with acromegaly often have larger, more invasive tumours. The success rate is about 60% with growth-hormone secreting macroadenomas.

Some pituitary tumours remain surgically incurable due to invasion of the cavernous sinuses and other important structures. Radiosurgery can be used to treat unresectable tumour remnants with very good long-term control rates. If there is residual tumour after surgery for acromegaly, Cushing’s disease, or prolactinomas, medical treatments are available to control the excess hormone secretion.

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