Jules Hardy

Long-term outcome and mortality after transsphenoidal adenomectomy for acromegaly

objective Acromegaly has long been associated with increased mortality but few long‐term follow‐up data are available in patients treated for this disease. We therefore studied a group of 103 patients who underwent transsphenoidal adenomectomy for acromegaly between 1970 and 1999 and were followed for one to 30 years.

Recurrence of Hyperprolactinemia after Selective Transsphenoidal Adenomectomy in Women with Prolactinoma

To assess the long-term prognosis for women with prolactinoma after selective transsphenoidal adenomectomy, we followed 44 patients for 6.2 +/- 1.5 years. Group 1 (28 patients) had microprolactinomas, and Group 2 (16 patients) had macroprolactinomas. After surgery, normal plasma prolactin levels, resumption of menses, and cessation of galactorrhea were observed in 24 Group 1 patients (85 per cent) and 5 Group 2 patients (31 per cent). Hyperprolactinemia recurred in 12 of the 24 Group 1 patients and in 4 of the 5 Group 2 patients after 4 +/- 1.3 and 2.5 +/- 1.6 years of remission, respectively. There was no radiologic evidence of tumor recurrence in any patient, and no relation was found between the occurrence of pregnancy after surgery and the recurrence of hyperprolactinemia. Clinical and biologic features before surgery could not predict the long-term outcome. However, the immediate postoperative level of plasma prolactin was significantly lower in patients in whom normal prolactinemia (6.4 +/- 1.1 ng per milliliter) was maintained than in those who relapsed (11.7 +/- 1.5 ng per milliliter) (P less than 0.02). We conclude that recurrence of hyperprolactinemia after successful surgery is frequent but delayed. The immediate postoperative level of plasma prolactin may be a predictive risk factor.

Hemorrhage, necrosis, and apoplexy in pituitary adenomas

Abstract The records of 664 patients who underwent operations for pituitary adenomas have been reviewed. Sixty-four of the adenomas were hemorrhagic or had necrotic degeneration and were prolactin-secreting, nonsecreting, growth-hormone-secreting, or ACTH-LPH-secreting. The clinical signs and symptoms, etiology, pathophysiology, and diagnostic and therapeutic implications are discussed.

The clinical and endocrine outcome to trans-sphenoidal microsurgery of nonsecreting pituitary adenomas

From 1962 to 1987, 126 patients underwent trans‐sphenoidal surgery for primary treatment of pituitary adenomas unassociated with clinical or biochemical evidence of hormonal overproduction. There were 73 male and 53 female patients (mean age, 50 ± 12 years). Before surgery, 56% of the patients (70 of 124) had headaches, 74% (94 of 126) had deterioration of vision, and 12% (15 of 126) had ophthalmoplegia. Endocrine evaluation revealed the presence of hypogonadism in 75% (87 of 115), adrenal insufficiency in 36% (46 of 126), and hypothyroidism in 18% (21 of 122). Plasma prolactin was increased in 65% (56 of 86) with a mean level of 39 ± 14 μg/l (normal, 3 to 20 μg/l). Radiologic enlargement of the sella turcica was documented in all cases: 67% (84 of 126) had enclosed and 33% (42 of 126) had invasive adenomas. After surgery, vision was normalized or improved in 75% (71 of 94) of the patients. Thyroid, adrenal, and gonadal functions were improved in 14% (three of 22), 41% (19 of 46), 11% (ten of 87), were unchanged in 82% (100 of 122), 77% (97 of 126), 89% (102 of 115), and worsened in 15% (19 of 22), 8% (ten of 126), 3% (102 of 115), respectively. Permanent diabetes insipidus occurred in 5% (seven of 126). Two patients died during the immediate postoperative period. The recurrence rate in patients with a mean follow‐up of 6.4 ± 4.2 years was 21% (15 of 71). These data indicate that trans‐sphenoidal microsurgery is an effective and safe initial treatment for patients with nonsecreting pituitary adenoma and may reverse hypopituitarism.

Surgical management of giant pituitary adenomas.

During the past 25 years, 77 giant pituitary adenomas have been treated surgically, including suprasellar extensions of type C in 66 cases and of type D in 11 cases. Non-secreting adenomas were present in 53 and secreting adenomas in 24 cases. All patients except 3 presented with significant visual field defects; including bitemporal hemianopia, superior quadranopia or unilateral temporal hemianopia, contralateral blindness in 73% of the cases, and one case with sudden bilateral blindness due to acute pituitary apoplexy. A single transsphenoidal procedure was carried out in 74% of the patients while 11 patients (7%) required re-operations for recurrent or residual tumor. Only 3 patients required a subsequent transcranial procedure. Complications included 1 CSF-leak, 1 empty-sella syndrome and 4 fatal post-operative hematomas. We prefer the transsphenoidal route even in very large or giant pituitary adenomas, since it allows rapid and adequate decompression of the optic nerves and chiasm, avoids major pituitary insufficiency in 60% of the cases and is associated with low morbidity-mortality rates.

Microadenomas of the human pituitary and their vascularization.

During 100 autopsies of patients who had no previous endocrinological problem, selective injections of the pituitary arterial systems were performed. Pituitary glands were examined from 60 male and 40 female patients with an average age of 68 years. Detailed histological and immunocytological studies using peroxidase-antiperoxidase techniques for prolactin (PRL), adrenocorticocotropic hormone (ACTH), follicle-stimulating hormone, thyroid-stimulating hormone, and growth hormone were used. Thirty-three microadenomas were found in 27 patients; 22 were single, 4 were double, and 1 was triple. Fourteen were nonreactive to immunostaining, 10 were reactive to PRL, and 9 were reactive to ACTH. Their diameters ranged between 0.5 and 5.0 mm, and they were located mainly in the lateral wings and the peripheral zone of the anterior pituitary gland. Microvascular study revealed that 22 microadenomas (66%) had direct extraportal arterial supplies. Because the hypothalamic factors are transported to the anterior lobe through the portal vessels, this study suggests that the formation of microadenomas occurs most frequently outside the hypothalamic-hypophyseal portal system and further supports the hypothesis that pituitary adenomas may arise de novo without the influence of hypothalamic factors.

Presidential address: XVII Canadian Congress of Neurological Sciences. Cushing's disease: 50 years later.

The recent improvements in transsphenoidal microsurgery have once again placed the emphasis on the basophilic adenoma of the pituitary as the etiology of the disease originally described by Harvey Cushing fifty years ago. In 75 operated cases, tumors were found in 60 cases: 52 were microadenomas, 4 were larger adenomas and 4 were invasive. In 15 cases, no tumor was found at surgery; a selective partial central hypophysectomy was performed in 11 cases and a total hypophysectomy in 4. Among the latter, 3 additional microadenomas were found at pathology. The majority of the microadenomas were located in the center of the gland most often near or within the neural lobe. In 59 patients with a non invasive tumor, initial cure was obtained in 52 (88%); only 1 of the 4 patients with an invasive tumor was cured. In the 12 cases without surgical or pathological tumor, partial or total hypophysectomy resulted in 10 cures (83%).

Arterial supply of the human anterior pituitary gland.

The vascular anatomy of the anterior lobe (AL) of 182 previously injected human pituitary glands was examined. Three different techniques of injection using India ink and acrylic paints were performed to establish a direct arterial supply to the AL. In 81% of the cases, end-arteries were found in the AL. Their participation in the vascularization of the adenohypophysis is variable from a small subcapsular area to almost the entire lateral parts of the AL. Arteries playing some role in the perfusion of the AL are subdivided into infra- and supradiaphragmatic, according to their topography in relation to the diaphragma sellae. Evidence of the presence of end-arteries in the AL is in disagreement with the generally accepted concept of a purely portal supply to this part of the pituitary gland.

Transsphenoidal adenomectomy for microprolactinomas: 10 to 20 years of follow-up

BACKGROUND Transsphenoidal adenomectomy is an effective treatment fo r microprolactinomas. However, postoperative recurrence of hyperprolactinemia is not rare. This study was designed to evaluate the long-term outcome of women with microprolactinomas operated on by transsphenoidal approach. METHODS We retrospectively studied 64 women with microprolactinomas who underwent transsphenoidal adenomectomy and were followed for 10 to 20 years. RESULTS Postoperatively, 58 women (90%) had normal plasma prolactin concentrations (<20 microg/L). After a mean of 3.3 years, during which the women were asymptomatic with normoprolactinemia, 25 (43%) had a relapse of hyperprolactinemia (> or = 20 microg/L). However, their evolution varied. Fifteen women had symptomatic hyperprolactinemia. Computed tomography (CT) scans showed recurrent microadenomas in 2 women. The other 10 women had only hyperprolactinemia. Of these women, 5 had transient hyperprolactinemia (29 +/- 4 microg/L) for 5 years, after which prolactin declined to normal 13 +/- 3 microg/L). The remaining five patients had elevated prolactin (31 +/- 3 microg/L) throughout the follow-up period (10 to 20 years). CT scan did not show recurrent adenomas in these women. Thirty-three women remained normoprolactinemic and asymptomatic for a mean period of 12 years (range, 10 to 20 years). CONCLUSIONS In conclusion, most of the patients with late relapse of hyperprolactinemia have slight functional hyperprolactinemia and remain asymptomatic with no evidence of tumor recurrence.

Chiasmal apoplexy due to ruptured cavernous hemangioma of the optic chiasm

A 30-year-old obese patient with a rapidly progressing chiasmal syndrome presented with acute bitemporal hemianopia, severe bilateral amblyopia, mental confusion, and lethargy. X-ray films of the skull showed a normal sella turcica and computed tomography scan as well as angiography revealed a vascular mass within the chiasmatic cistern. At operation, via left subfrontal approach, an intrachiasmal hematoma was evacuated and biopsies of the hematoma cavity revealed a cavernous hemangioma. Visual symptoms improved markedly postoperatively. This rare association of chiasmal apoplexy and intrachiasmal cavernoma is discussed.