In almost all cases, neurosurgery is the initial treatment of choice for nonfunctioning pituitary tumors. The surgery is usually performed via the transsphenoidal route, which avoids a craniotomy. The goal in most cases of large tumors is to debulk the tumor, rather than to completely remove it. In the case of smaller tumors, complete cure is a reasonable goal.

The single most important factor in achieving optimal surgical results with large pituitary tumors (good debulking, few or no side effects, no damage to the normal pituitary gland and other structures) is an experienced surgeon with a good track record. Transsphenoidal surgery is best done by surgeons who perform many such operations every year and have documented good results with low complication rates.

Surgical success rates and complication rates are critically dependent on tumor size (1,15; and see Chapter 8). In the most experienced centers, initial gross total tumor resection for nonfunctioning tumors is as high as 90%, although these numbers probably underestimate the presence of residual tumor. Improvement in vision and/or visual field defects are seen in 60% to >80% of patients in published surgical series. However, worsening of vision can also be seen in 3% to 11% of these patients.

Recurrence rates after surgery without irradiation for nonfunctioning pituitary tumors is reported to be between 10% and 75%, usually after many months or years of follow-up. However, these data include many studies that used cranial, rather than transsphenoidal, surgery and included tumors of heterogeneous size, invasiveness, and completeness of resection. In one study of patients who had apparently complete transsphenoidal resection without evidence of tumor invasion or rapid growth, the recurrence rate without irradiation was 10% (16). These data suggest that many patients with nonaggressive tumors can be followed after complete resection without adjuvant therapy. New surgical techniques, such as endoscopic surgery, hold promise for improved cure rates with fewer complications and are currently under study (see Chapter 10).

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