The aim of the work is to analyze preoperative predictors and their effect on
results and outcomes following endoscopic endonasal transsphenoidal surgery
(EETSS) for functioning pituitary adenomas, for this purpose; 99 patients were
studied.
All these patients were subjected to:
Full data collection (personal history, history of present illness, past
history)
Clinical examination included general, neurological, and
endocrinological examinations.
Complete general examination including; vital signs (pulse, blood
pressure, temperature), head, neck, chest, and abdominal examination.
Neurological examination at admission included: cranial nerve palsy
(3rd, 4th, and 6th), altered level of consciousness, visual impairments
(decreased visual acuity, visual field defects).
Visual Examination (within 24 to 48 hours after admission): all patients
proceeded to have formal visual field charting by an ophthalmologist.
Laboratory investigations: routine laboratory work & hormonal assays
preoperative (basal) and postoperative as serum prolactin (PRL), growth
hormone (GH), insulin-like growth factor (IGF-1), thyroid stimulating
hormone (TSH), adrenocorticotropic hormone (ACTH), luteinizing
hormone (LH), follicle stimulating hormone (FSH), free thyroxine
(FT4), free triiodothyronine (FT3), serum cortisol and urinary free
cortisol.
Neuroimaging studies: computerized tomography (CT) with and without
contrast was performed on both brain and paranasal sinuses and MRI
brain without & with contrast was performed
Management: In patients with prolactinoma, treatment started with
medical therapy in the form of dopamine agonist e.g. Parlodel or
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dostinex and the endoscopic endonasal trans-sphenoidal surgical
approach was used for tumor removal in all patients.
Histopathological examination, including immunohistochemical
staining, was conducted.
Follow up protocol: all patients underwent CT brain immediately
postoperatively and an MRI three months later to evaluate the extent of
resection; this was then repeated annually.
Post-surgical ophthalmological examination and assessment of
endocrine function were performed 3 months post-surgery, and then
every 6 months thereafter.
Our study reveals the following:
Males are affected more than females with mean age 42.5 years.
Irregular menstruation was the most common presenting symptoms
among the study population in 22 patients (22.2%), followed visual
disturbance in 17 patients (17.2%), acromegaly and increased
intracranial pressure (inform of combination of headache, nausea,
vomiting & visual disturbance) were in third place with each one 14
patients (14.1%), then headache with 11 patients (11.1%), 8 cases
(8.1%) were accidentally discovered, 5 cases (5.1%) had Cushing
disease, also 5 cases (5.1%) had sexual dysfunction, finally 3 cases (3%)
were recurrent pituitary adenomas.
41 cases (41.4 %) were macrooadenoma (> 1cm), while 38 cases (38.8
%) were microadenoma (4cm).
55 patients (55.6%) were prolactiomas, while 17 patients (17.2%) were
GH - secreting adenomas, 11 patients (11.1%) were Gonadotropin
hormone - secreting adenomas, 6 patients (6.1%) were ACTH -
secreting adenomas, 2 patients (2%) were thyrotropin (TSH) -secreting
adenomas and 8 patients (8.1%) were multiple hormones secreting
adenomas.
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79 patients (79.8%) underwent gross total resection of the tumor, while
20 patients (20.2%) underwent subtotal resection of the tumor.
The mean KI 67 labeling index was 2.5±2.2 %
The mean follow up duration was 12.9±7.6 months.
93 patients (93.9%) were clinically improved while 6 patients (6.1%)
were not improved. Also, we found that 60 patients (60.6%) were
improved hormonally while 39 patients (39.4%) were not improved.
64 patients (64.6%) passed without complications but 35 patients
(35.4%) had complication inform of 14 patients (14.1%) had
hypopituitarism, 5 patients (5.1%) had transient diabetes insipidus, 5
patients (5.1%) had csf leak, 4 patients (4%) had hyponatremia, 4
patients (4%) developed anosmia, 2 patients (2%) had epistaxis and one
patient (1%) died due to acute hydrocehallus and cerebral haemorrhage.
After neuroimaging (MRI) follow up; 79 patients (79.8%) were totally
removed and 20 patients (20.2%) had residual of the tumor.
There was no significant relation between age of the studied patients and
hormonal improvement, post-operative complication & MRI follow up.
There was highly statistically significant relation between tumor sizes,
hormonal improvement and MRI follow up but no significant relation
between tumor size and postoperative complications. As 94.7% of
patients with microadenoma showed hormonal improvement (p=0.000)
and 73.7% of patients with microadenoma showed no residual mass on
MRI follow up (p =0.000).
No significant relation between hormonal typing of the studied patients
and hormonal improvement, post-operative complication & MRI follow
up.
There was highly statistically significant relation between extent of
resection of the tumor, hormonal improvement & MRI follow up and
statistically significant relation between extent of resection of the tumor
& postoperative complications. As 62% of patients with totally resected
tumors showed hormonal improvement (p=0.000), 100% of patients
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with totally resected tumors showed no residual mass on MRI follow up
(p =0.000) and 69.6% of totally resected tumors didn't have postoperative complication (p=0.04).
There was no significant relation between Ki-67 Labeling Index of the
studied patients and hormonal improvement, post-operative
complication & MRI follow up |
