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Diagnosed Non Functioning Pituitary Macroadenoma. What Is The Next Step? Serious? Surgery?
Question: I have uploaded recent reports from blood work, CT scans, field of vision tests regarding a recently diagnosed non functioning pituitary macroadenoma. Would like an opinion on how and when to proceed and how serious the risks of surgery would be?
Hi XXXXXXX
Thanks for writing in with details of your problem and reports.
While you might have discussed your problem with you doctors, I shall try to answer your specific queries, which you have asked.
I have gone through your reports with diligence and infer that you have had a discussion on the matter with Dr XXXXXXX and are more inclined towards surgery pending a second opinion. It is observed that the tumor presently measures 2.3 x 2.5 x 1.9 cm (earlier measured 1.8 cms way back in 2005). The growth rate of the tumor appears to be slow in the last 8 years and Dr XXXXXXX has made note of this.
It may be essential to consider your heart condition and hypertension, apart from the risk of damage to the structures close to the tumor itself.
Nowadays, the trans sphenoidal approach is the treatment of choice for pituitary macroadenoma. This might have been discussed with you, however it may differ among neurosurgeons and I would be pleased to know the procedure as explained to you. Since it is a non functioning tumor, we really don’t have to worry from the remission rate point of view.
Complications in your surgery can be divided into following:
Problems faced during surgery:
1. Complications due to your heart condition due to your heart rhythm problem and hypertension.
2. Unintentional damage to the carotid arteries within the brain. This is a very rare occurrence, however must be known to your prior to surgery and because on the left side the tumor is slightly closer to the XXXXXXX carotid artery. I am sure that your surgical team will make all efforts and take precautions necessary.
3. Any unintentional damage to the optic tract.
Problems faced after surgery:
1. CSF leak can occur due to a communication between the fluid in the brain and the roof of the nasal cavity, the patient complains of fluid dripping a few days following surgery and this is treatable.
2. Meningitis is an infective condition and is a least likely possibility with the standard of operative procedure and post operative care which are available nowadays.
3. Worsening of endocrinal functions: We do not clearly know the exact amount of functional normalcy post surgery. But considering the number of macroadenomas operated upon, this is not a limitation for surgery.
I would be pleased to carry on this discussion further regarding any more specific areas mentioned above and their occurence after hearing more from you.
Further queries welcome.
Wishing you good health.
Regards
Dr Vivek
Thanks for writing in with details of your problem and reports.
While you might have discussed your problem with you doctors, I shall try to answer your specific queries, which you have asked.
I have gone through your reports with diligence and infer that you have had a discussion on the matter with Dr XXXXXXX and are more inclined towards surgery pending a second opinion. It is observed that the tumor presently measures 2.3 x 2.5 x 1.9 cm (earlier measured 1.8 cms way back in 2005). The growth rate of the tumor appears to be slow in the last 8 years and Dr XXXXXXX has made note of this.
It may be essential to consider your heart condition and hypertension, apart from the risk of damage to the structures close to the tumor itself.
Nowadays, the trans sphenoidal approach is the treatment of choice for pituitary macroadenoma. This might have been discussed with you, however it may differ among neurosurgeons and I would be pleased to know the procedure as explained to you. Since it is a non functioning tumor, we really don’t have to worry from the remission rate point of view.
Complications in your surgery can be divided into following:
Problems faced during surgery:
1. Complications due to your heart condition due to your heart rhythm problem and hypertension.
2. Unintentional damage to the carotid arteries within the brain. This is a very rare occurrence, however must be known to your prior to surgery and because on the left side the tumor is slightly closer to the XXXXXXX carotid artery. I am sure that your surgical team will make all efforts and take precautions necessary.
3. Any unintentional damage to the optic tract.
Problems faced after surgery:
1. CSF leak can occur due to a communication between the fluid in the brain and the roof of the nasal cavity, the patient complains of fluid dripping a few days following surgery and this is treatable.
2. Meningitis is an infective condition and is a least likely possibility with the standard of operative procedure and post operative care which are available nowadays.
3. Worsening of endocrinal functions: We do not clearly know the exact amount of functional normalcy post surgery. But considering the number of macroadenomas operated upon, this is not a limitation for surgery.
I would be pleased to carry on this discussion further regarding any more specific areas mentioned above and their occurence after hearing more from you.
Further queries welcome.
Wishing you good health.
Regards
Dr Vivek
Above answer was peer-reviewed by :
Dr. Shanthi.E
I am considering asking for a second opinion at a larger center considering the various risks involved. If I were to decide against surgery would the risk be greater of my being blind or would it be a gradual deterioration of visual disturbances? There is so much to be considered and I don't know anyone in our area who has had a similar situation.
Hi XXXXXXX
Thanks for writing in again.
Please allow me to elaborate on the treatment and various risks involved in the management of a non functional pituitary tumor as a continuation of our earlier discussion.
Surgical removal of the tumor is effective in most patients who present with symptoms due to the tumor. The extent of surgical removal of the tumor depends on the following:
1. The size of the tumor.
2. Invasion of the tumor into the cavernous sinus.
3. Expansion of the tumor inside the brain cavity (Eg the optic tract involvement).
4. Even in patients with apparent complete tumor removal, cure rate is 70 – 80% approximately.
Overall, surgery improves vision in 75 percent to 90 percent of patients, headache in 80 percent to 90 percent, and suppressed pituitary function in 10 percent to 30 percent.
Role of radiosurgery
• Radiation is generally used as a second line therapy for endocrine-inactive tumors.
• For patients with residual tumor or regrowth after the initial surgery, radiation or repeat transsphenoidal surgery or both are options.
• Stereotactic radiosurgery is relatively effective in controlling growth.
• Stereotactic radiosurgery may also cause loss of pituitary function in some patients.
Regarding visual disturbances, I would like to make you aware that right now your peripheral (side) vision is affected. The worsening of symptoms occurs very slowly and as mentioned above, surgery does restore vision in most patients.
Given the choice of radiosurgery and/ or trans sphenoidal surgery, you may surely discuss your problem at a hospital having best facilities in your country having a specialised team in dealing with such tumors.
Further queries welcome.
Wishing you good health.
Regards
Dr Vivek
Thanks for writing in again.
Please allow me to elaborate on the treatment and various risks involved in the management of a non functional pituitary tumor as a continuation of our earlier discussion.
Surgical removal of the tumor is effective in most patients who present with symptoms due to the tumor. The extent of surgical removal of the tumor depends on the following:
1. The size of the tumor.
2. Invasion of the tumor into the cavernous sinus.
3. Expansion of the tumor inside the brain cavity (Eg the optic tract involvement).
4. Even in patients with apparent complete tumor removal, cure rate is 70 – 80% approximately.
Overall, surgery improves vision in 75 percent to 90 percent of patients, headache in 80 percent to 90 percent, and suppressed pituitary function in 10 percent to 30 percent.
Role of radiosurgery
• Radiation is generally used as a second line therapy for endocrine-inactive tumors.
• For patients with residual tumor or regrowth after the initial surgery, radiation or repeat transsphenoidal surgery or both are options.
• Stereotactic radiosurgery is relatively effective in controlling growth.
• Stereotactic radiosurgery may also cause loss of pituitary function in some patients.
Regarding visual disturbances, I would like to make you aware that right now your peripheral (side) vision is affected. The worsening of symptoms occurs very slowly and as mentioned above, surgery does restore vision in most patients.
Given the choice of radiosurgery and/ or trans sphenoidal surgery, you may surely discuss your problem at a hospital having best facilities in your country having a specialised team in dealing with such tumors.
Further queries welcome.
Wishing you good health.
Regards
Dr Vivek
Above answer was peer-reviewed by :
Dr. Shanthi.E
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