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Advances in Surgery for Pituitary Tumors
review the literature and provide a current consensus statement on tumors, based on serum TSH levels, were present in 14 of the 21
the diagnosis and management of adrenocorticotrophic hormone patients. Ten presented with clinical hyperthyroidism and seven of these
(ACTH)-dependent Cushing’s syndrome.
28
Their recommendations patients had undergone ablative procedures of the thyroid prior to
support many practices in effect in major endocrine surgery centers. diagnosis of the pituitary adenoma. Macroadenomas accounted for 85%
Direct, surgical removal of the ACTH-producing tumor is the preferred of these tumors. Tumor remission rate after initial surgery was 50%.
initial mode of therapy and carries the highest chances of cure. They Immunohistochemical staining for a second pituitary hormone was
recommend early post-operative cortisol levels (<2ng/dl is desired) to relatively common, although the second hormone was clinically active
help predict the chances of long-term remission after pituitary surgery. in only one patient with acromegaly. This report highlights the rarity of
Management options for recurrent tumors include repeat direct surgery these tumors and a relative delay to diagnosis (based on tumor size)
on the tumor, hypophysectomy, radiation therapy, and adrenalectomy. compared with other endocrine-active tumors.
Patients must be treated for secondary adrenal insufficiency after
curative pituitary surgery in most cases. Successful management of Summary
these complex tumors demands an individualized, multidisciplinary Surgical treatment for pituitary tumors continues to evolve based on
approach led by the endocrinologist and surgeon involved. improved diagnostic techniques, refinements in surgical technique
and technologies, better understanding of tumor behavior, better
Hoffman and colleagues
29
reported on a large series of 426 primary documentation of treatment outcomes, and improved guidelines for
surgeries for Cushing’s disease performed by a single surgeon from peri-operative management and long-term follow-up. All of these
1971 to 2004. The median follow-up on the patients was 66 months. developments move physicians further toward their ultimate goal of
After surgery alone, the authors found an early remission rate of 68.5%. permanent cure with minimal side effects in all patients. n
After repeat surgeries were included, the long-term remission rate was
62.4% for surgical therapy alone. Patients with microadenomas fared
Steven N Roper, MD, is the Edward Shedd Wells Professor
better than those with macroadenomas and cases where adenomas
of Neurosurgery at the University of Florida. He specializes
were found did better than those where no adenoma was identified. in surgeries for intractable epilepsy and pituitary tumors.
These data highlight the utility of surgery in the hands of an experienced
He also directs a neurophysiology laboratory that studies
the cellular basis of epilepsy. Dr Roper assumed the role
pituitary surgeon but also the need for additional forms of therapy in
of Surgical Director for the University of Florida Pituitary
cases that cannot be cured by surgery alone. Tumor Program from Dr Albert Rhoton, Jr. His clinical
research interests include minimally invasive techniques
for pituitary tumors and outcomes studies from pituitary
Among pituitary adenomas, those that produce thyroid-stimulating
and epilepsy surgery. He received his MD from the University of Texas Medical Branch
hormone (TSH) are the least common, representing <2% in most series. and his neurosurgical training at the University of California, Los Angeles (UCLA). He
Clarke et al.
30
reported on 21 patients with known TSH-immunoreactive
completed a neurophysiology fellowship under Dr FE Dudek at UCLA.
adenomas that were treated between 1987 and 2003. Endocrine-active
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8. Yoneoka Y, Watanabe N, Matsuzawa H, et al., J Neurosurg, 18, Zhang X, Fei Z, Zhang W, et al., J Clin Neurosci, 2008;15:241–5. 28. Biller BMK, Grossman AB, Stewart PM, et al., J Clin Endcrinol
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US ENDOCRINOLOGY 103
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