Review ArticleMultidisciplinary protocol of preoperative and surgical management of patients with pituitary tumors candidates to pituitary surgeryProtocole multidisciplinaire de prise en charge préopératoire et chirurgicale des patients atteints de tumeurs hypophysaires candidats à la chirurgie hypophysaire
Introduction
Pituitary tumors (PT) are present in up to 10% of the general population [1]. These heterogeneous but usually benign tumors of the central nervous system do not necessarily result in to symptoms, either due to their small size or because they do not secrete hormones in excess [2]. In symptomatic cases, pituitary surgery (PS) by an expert neurosurgeon is usually the initial treatment of choice, with the exception of prolactinomas in which medical treatment with dopamine agonists is preferred [3]. An accurate diagnosis and careful planning of the most appropriate treatment, based on a complete hormonal, radiological and neuro-ophthalmological preoperative study, are essential for improving short- and long-term surgical outcomes [3].
All patients should undergo complete hormonal study before surgery [4]. This study aims to:
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help to decide if the patient is more suited to medical treatment (prolactinomas);
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whether preoperative glucocorticoid coverage is actually needed, and;
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establish the need of replacement therapy with thyroid hormone, desmopressin or other treatments before PS [5].
The perioperative use of glucocorticoid therapy in PS has been debated for years yet, nowadays. However, since the publication of Inder et al. in 2002, it is known that restricting glucocorticoid therapy to cases with proven secondary adrenal insufficiency is safe and advisable with the purpose of avoiding the risks associated with the indiscriminate use of glucocorticoid [6].
On the other hand, although a CT scan may serve for the initial detection of PT in rare cases, staging and surgical planning requires a high resolution contrast-enhanced MRI and a complete otolaryngology evaluation [7]. Of note, a detailed neuro-ophthalmological study is paramount to decide the optimal timing of surgery because emergency PS may be required in selected cases presenting with rapidly progressing and/or severe visual symptoms or when PT compress the optic chiasma [8].
The decision of whether or not the individual patient should be submitted to PS may be quite complex and should be discussed within a multidisciplinary team. Even though a craniotomy may be necessary in some giant PT or when tumoral invasion of suprasellar structures is extensive, transsphenoidal surgery is the preferred surgical approach in more than 95% of the cases [9]. Moreover the transsphenoidal endoscopic approach (EEA) could be a safe and effective option in extrasellar tumors because this approach offers a better visualization of hidden structures, which are not usually visible under the direct microsurgical light [10], [11], [12], [13].
The cure rate in the hands of expert pituitary surgeons ranges from 80 to 90% for microadenomas and from 40 to 70% for macroadenomas with a rate of major complications below 1% [14]. However, hyponatremia may occur in up to 10%, and hypopituitarism in 7.5% of patients submitted to experience pituitary neurosurgeons [15].
For the reasons outlined above, we truly believe that pre- and post-operative diagnosis and management of PT who are suitable candidates to PS optimally require a multidisciplinary team consisting of endocrinologists, neurosurgeons, ENT, neuro-ophthalmologists, neuroradiologists and endocrine pathologists.
The present review is based on our clinical practice protocol, recently updated according to available scientific evidence and published consensus of experts in pituitary pathology. We here describe in detail the structured protocol on the multidisciplinary management of patients undergoing PS due to PT, focusing on the preoperative study and surgical treatment, with the aim of offering guidance on other multidisciplinary teams working in the field. Our protocol about the postoperative management of pituitary tumors has also been published recently [16].
Section snippets
Material and methods
The physicians involved in the management of patients with PT of Hospital Universitario Ramón y Cajal reviewed systematically current knowledge on the management of PT. The literature review used the online Entrez-PubMed facilities, including only publications in English and Spanish published from 1986 to 2019. The complete search strategy and MEsH terms were: (pituitary incidentaloma [title]); (pituitary surgery [title]); (pituitary tumor [title]); (pituitary adenoma [title]); (pituitary
Preoperative hormonal evaluation
Following consensus and guidelines, we recommend obtaining an endocrine panel as an initial set of laboratory tests [3], [18]. This panel consists of measurement of serum prolactin, insulin-like growth factor 1 (IGF-1), gonadotropins, TSH, free thyroxine (FT4), 8.00 am serum cortisol and ACTH levels, and, only when indicated by clinical presentation, a screening test for hypercortisolism (Table 1).
Conclusions
The optimal planning of the preoperative diagnosis, management and treatment of pituitary tumors (PT) candidates to pituitary surgery (PS) requires a multidisciplinary approach involving a team of endocrinologists, neurosurgeons, ENT, neuro-ophthalmologists and neuroradiologists with experience in pituitary diseases. Such teams optimize the hormonal, ophthalmological and radiological preoperative evaluation, improving surgical results and minimizing the development of complications. Through
Ethical statement
The article “Multidisciplinary protocol of preoperative and surgical management of patients with pituitary tumors candidates to pituitary surgery” does not present personal data of patients or animals, so it is not subject to ethical responsibilities of this type.
Ethical approval
This article does not contain any studies with human participants or animals performed by any of the authors.
Disclosure of interest
The authors declare that they have no competing interest.
Funding
This research did not receive any funding.
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