Indications For Surgery

Although there are significant developments in the medical treatment of pituitary tumors, the only unquestionably successful therapy is that applied to prolactinomas. The majority of other symptomatic pituitary lesions are managed surgically. The classic surgical indications for sellar lesions include the following:

From: Management of Pituitary Tumors: The Clinician's Practical Guide, Second Edition Edited by: M. P. Powell, S. L. Lightman, and E. R. Laws, Jr. © Humana Press Inc., Totowa, NJ

1. The most urgent indication for surgical intervention relates to instances of pituitary apoplexy (1). Patients may present with either hemorrhage into an existing pituitary tumor or with acute necrosis of the tumor with subsequent swelling (Fig. 1). In the most florid of examples, the presentation includes sudden headache, visual loss, ophthalmoplegia, altered level of consciousness, and collapse from adrenal insufficiency. This is discussed in Chapter 7.

2. A second clear indication for surgery is progressive mass effect (usually visual loss) from a large macroadenoma or other sellar mass (Fig. 1). These patients should always have a serum prolactin (PRL) determination because prompt and dramatic shrinkage of prolactinomas can occur with appropriate pharmacologic management. More often, the PRL level is only modestly elevated and the patient has a clinically nonfunctioning pituitary tumor or other sellar mass. Such patients are in need of surgical decompression.

3. Among the hyperfunctioning pituitary adenomas, surgery is the treatment of choice for Cushing's disease (CD), acromegaly, and secondary hyperthyroidism. In CD, medical management is invariably suboptimal and surgery provides the best means of obtaining prompt and lasting remission. In somatotroph and thyrotroph adenomas, some latitude exists for the use of somatostatin analogs as the initial intervention; however, surgery remains the preferred, primary, and definitive treatment for these conditions. For prolactinomas, however, medical therapy is the preferred initial option in most instances.

4. Failure of previous therapy is an increasingly common indication for surgical intervention and usually occurs in one of several situations. The most straightforward are those patients with symptomatic recurrence in whom previous therapy resulted in a satisfactory remission. Other patients will have been treated with radiotherapy and, after a favorable initial response, now present with recurrence of symptoms, in the form of either mass effect or recurrent hormonal hypersecretion. Others will have been treated with medical therapy, with suboptimal response.

5. A final occasional surgical indication is the need for a tissue diagnosis. Although seldom required in the case of functioning pituitary adenomas, this indication may be important when the surgeon is confronted with a nonfunc-tioning sellar mass whose pathologic identity cannot be confirmed without histologic examination (2).

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