What Is Involved in Pituitary Gland Surgery?

Pituitary tumors are a group of tumors that develop from residual cells in the anterior and posterior pituitary and craniopharyngeal epithelium. Approximately 10% of patients with clinically significant symptoms account for intracranial tumors. Slightly more men than women, pituitary tumors usually occur in young adults and often affect the patient's growth and development, reproductive function, learning and work ability. Clinical manifestations include abnormal hormone secretion, tumor compression of pituitary tissue, pituitary stroke, and other anterior pituitary dysfunction.

Basic Information

English name: pituitarytumor
English alias: hypophysoma
Visiting department: Oncology
Multiple groups: Young male

Common locations: pituitary
Common symptoms: Abnormal hormone secretion, tumors compress the surrounding pituitary tissue, pituitary stroke, other anterior pituitary dysfunction
Contagious: no

Clinical manifestations of pituitary tumors

1. hormone secretion syndrome

Hyperhormone secretion group, such as excessive growth hormone causing acromegaly; hormonal hyposecretion group. When non-functional tumors increase and normal pituitary tissue is damaged, amenorrhea is caused by reduced gonadotropin secretion. Infertility or impotence often occur first and are more common.

2. Symptoms of tumors compressing tissues around the pituitary

(1) Nerve fiber irritation showed persistent headache.

(2) Optic nerve, optic cross, and optic nerve bundle compression Patients with vision loss, visual field defects, and fundus changes; other compression groups.

3. Pituitary stroke.

4. Other anterior pituitary dysfunction.

Pituitary tumor examination

Cranial radiograph

The front and side radiographs show that the saddle is enlarged, deformed, the bottom of the saddle is depressed, there are double bottoms, the back of the saddle is thinned and erected backwards, and the bone is often absorbed and damaged;

2.CT scan

Pituitary density is higher than brain tissue;

3. Magnetic resonance imaging (MRI)

The resolution of pituitary soft tissue is better than CT, which can make up for the deficiency of CT;

4. Qi brain and cerebral angiography.

Pituitary tumor diagnosis

Clinical manifestation

Patient age, gender, discomfort after illness, physical changes.

2. Endocrine examination

Because most pituitary tumors have the function of secreting hormones, their clinical manifestations are not obvious, and imaging has not yet shown that when there is a tumor, the pituitary tumor hormones have changed. Some pituitary tumor cases can be diagnosed simply by endocrine tests.

3. Imaging

(1) Plain X-ray film of the skull This is a relatively primitive diagnostic method. Judging the presence of tumors and differential diagnosis based on changes in the sphenoid bone and calcification in the saddle area.

(2) CT scan has diagnostic value only for large pituitary tumors, and small pituitary tumors are easy to miss. Cannot be used as the main tool for the diagnosis of pituitary tumors.

(3) MRI is the most important tool for diagnosing pituitary tumors. It can clearly show the size, morphology, location of tumors, and the relationship with surrounding structures. Even tumors with a diameter of 2 to 3 mm can be displayed. However, some tumor signals are similar to the surrounding normal pituitary tissues, which are difficult to distinguish. The diagnosis needs to be combined with clinical manifestations and endocrine tests.

4. Pathological examination

This is the most reliable diagnostic method with a low misdiagnosis rate. The pathological diagnosis was observed by light microscopy with ordinary HE staining. It can only be used as a general diagnosis, and the tumor type cannot be separated. Immunohistochemical staining, diagnosis based on hormones contained in tumor cells, has high sensitivity, but also has a high misdiagnosis rate. Observation by electron perspective microscope, the tumor type is distinguished according to the different characteristics of tumor cells, which is rarely used clinically.

Differential diagnosis of pituitary tumors

Clinically, the pathogenesis of pituitary tumors is mainly benign tumors on the pituitary gland, also known as pituitary adenomas. It is one of the common neuroendocrine tumors, accounting for 10% to 15% of central nervous system tumors. Most pituitary adenomas are benign tumors.

Tumor

(1) Craniopharyngioma occurs mostly in young children and young people, and the pathological changes are slow. In addition to vision and visual field disturbances, there are also developmental cessation, sexual organ failure, obesity, diabetes insipidus and other hypothalamic functions. , Large tumors show symptoms of increased intracranial pressure. In most cases of clinical imaging, tumors have cystic changes and calcification. Most tumors are located on the saddle, with pituitary tissue at the bottom of the saddle.

(2) Saddle nodular meningiomas occur mostly in middle-aged people, and the disease progresses slowly. The first symptoms are progressive vision loss with irregular visual field defects, headache, and less obvious endocrine symptoms.

The clinical imaging manifestations of tumor morphology, enhanced comprehensive treatment has obvious curative effect, the tumor is located on the saddle, and the pituitary tissue is on the inner bottom of the saddle.

(3) Lagrange cysts are young, and there are no obvious pathological changes, and a small part of them show endocrine disorders and vision loss. Clinical imaging shows that small cysts are located between the anterior and posterior lobes of the pituitary gland, similar to a "sandwich". The pituitary tissue of the large cyst is pushed to the lower, front, and upper sides of the cyst. The disease is most likely to be misdiagnosed as a pituitary tumor.

(4) Germ cell tumor, also known as ectopic pineal tumor, mostly occurs in young children, the condition develops quickly, drinking more urine, precocious puberty, weight loss, obvious clinical symptoms. Most clinical imaging pathological changes are located on the saddle, and the effect of enhanced comprehensive treatment is obvious.

(5) Optic gliomas mostly occur in young children and young people. Headache and vision loss are the main clinical manifestations. The pathological changes in clinical imaging are mostly located on the saddle, and the boundaries of pathological changes are unclear. It is a mixed danger signal and strengthens comprehensive treatment The effect is less obvious.

(6) Epithelial cysts are more common in young people, with slow pathological changes, clinical manifestations of visual impairment, and clinical imaging manifestations of low-risk signal pathological changes.

2. inflammation

(1) Pituitary abscess Repeated occurrence of metastatic fever, headache, visual loss, and other cranial nerve damage, usually the condition develops rapidly. The volume of clinical imaging pathological changes is usually not large and is not consistent with clinical symptoms. The soft tissue structure around the saddle was strengthened obviously.

(2) Eosinophilic granulomatous symptoms are similar to pituitary abscesses, and they develop faster. In addition to headaches and vision loss, multiple groups of cranial nerves are often damaged, and most of them are accompanied by hypopituitarism. Pathological changes cover a wide range of areas, such as within the saddle, within the sphenoid sinus, above the saddle, anterior, middle, and posterior skulls. Peripheral dural enhancement was evident in clinical imaging pathological changes.

(3) Lymphocytic pituitary inflammation Diabetes insipidus is the main clinical manifestation. Some are accompanied by hypopituitarism. Clinical imaging showed that the pituitary stalk was significantly thickened, and the pituitary tissue was enlarged to varying degrees.

(4) The symptoms of fungal inflammation are similar to pituitary abscesses, and there is a long history of long-term use of hormones and antibiotics. In some cases, other cranial nerves were damaged.

(5) Tuberculous meningitis. Youth or young children develop symptoms, headache, fever, history of meningitis, and clinical imaging shows adhesion hydrocephalus.

Pituitary tumor complications

Postoperative diabetes insipidus, sphenoid sinusitis, water and electrolyte disorders, cerebrospinal fluid leakage, increased visual impairment, cerebral palsy, meningitis, vascular damage, and central nervous system damage can occur.

Pituitary tumor treatment

Comprehensive treatment

The treatment of pituitary tumors mainly includes surgery, drugs and radiation therapy. It is precisely because there is no one method to achieve a complete cure. Therefore, various treatment methods have advantages and disadvantages. They should be based on the patient's pituitary tumor size, hormone secretion, complications and comorbidities, the patient's age, There are fertility requirements and the patient's financial situation to develop an individualized treatment plan.

The treatment of pituitary tumors is a comprehensive multidisciplinary process.

2. Radiotherapy

Because pituitary tumors are adenomas, they are less sensitive to radiotherapy. 70% to 80% of patients have reduced pituitary function after radiotherapy, which reduces the quality of life of patients. Therefore, radiotherapy is only suitable for residual surgery, intolerance of surgery, Patients who are not sensitive to the drug and who have comorbid conditions cannot undergo surgery or medication.

3. Drug treatment

For pituitary prolactin-secreting tumors, dopamine agonists (short-acting bromocriptine and long-acting cabergoline) can be used to control PRL levels in more than 90% of patients (whether micro-adenomas or large adenomas). The size of the tumor shrinks. Only those patients with prolactinoma who are allergic or intolerant to this class of drugs, who have acute symptoms due to tumor compression that require emergency surgical decompression, or who are unwilling to undergo surgery, should choose surgery. During the treatment with bromocriptine, the dose of bromocriptine should be gradually increased until the serum PRL level drops to normal levels, and the dose is adjusted for long-term maintenance treatment.

Regardless of the treatment, patients with growth hormone-secreting tumors should achieve the following treatment goals: eliminate tumors, reduce tumor recurrence, achieve GH compliance, alleviate clinical symptoms, preserve pituitary function as much as possible, improve patients' quality of life, and prolong patients Life.

For somatostatin-secreting pituitary tumors, the main advance in the past 20 years has been the application of somatostatin analogs. The clinical application of the drug has significantly improved the cure rate of GH-secreting tumors. In recent years, long-acting somatostatin analogues such as long-acting octreotide and somadolin have been used in clinical practice, which has greatly improved patient compliance. Application of this kind of drugs before surgery can quickly reduce the serum GH level of patients, reduce the symptoms of patients, reduce the size of tumors, and create good preoperative conditions for complete tumor resection. Additional indications for the use of somatostatin analogues in GH-secreting tumors include: postoperative residual patients, transitional treatment of patients whose GH has not decreased to normal after radiotherapy. After the application of growth hormone analogues, for patients with heart failure, apnea, poorly controlled hyperglycemia, and hypertension, patients who cannot tolerate anesthesia provide an opportunity to prepare for surgery before surgery. Somatostatin analogs have also achieved satisfactory therapeutic effects in thyroid-stimulating hormone-producing tumors.

4. Surgery

At present, the treatment of pituitary tumors is mainly surgery, supplemented by drug therapy and radiation therapy. The position of the pituitary tumor is in the saddle area, and there are important nerve structures such as the optic nerve, internal carotid artery, and hypothalamus, so the operation is still risky. The current surgical methods include transsphenoidal sinus, craniotomy and gamma knife. Tumors with a diameter greater than 3 cm and adhesions to the optic nerve or visually impaired can be treated with surgery first. The surgery must achieve sufficient decompression of the optic nerve, followed by gamma knife surgery, but there may still be recurrence after surgery, so regular review is required.

Pituitary tumor prevention

Postoperative complications

Pituitary tumor surgery will affect the posterior pituitary lobe, which may cause insufficient post-pituitrin secretion, which may lead to increased urine output and even diabetes insipidus. Other complications include hypothalamic response, optic nerve damage, and cerebrospinal fluid leakage.

2. Review

Some aggressive pituitary tumors are very easy to relapse. The patient needs to be reviewed three days, one month, three months, half a year, and one year after the operation to observe the dynamic changes of the operation area and evaluate the effect of the operation.

3. Postoperative radiotherapy

Generally, pituitary tumors do not require postoperative radiotherapy. There are only some invasive pituitary tumors that have residual or recurring postoperative conditions. They must be treated with radiotherapy or gamma knife.

Pituitary tumor prognosis

According to the different needs of patients, personalized treatment plans are formulated. Finally, the patient's tumor can be resected. During the lifelong follow-up, avoid recurrence of the tumor, try to preserve the patient's pituitary function, reduce the elevated secreted hormones to the normal range, and replace the reduced pituitary hormones with normal ones that match the age Range, improve patient's quality of life, and extend patient's life.