RESUMO
BACKGROUND: Resection of the medial wall of the cavernous sinus (MWCSR) is a growing surgical maneuver for the radical removal of pituitary adenomas. METHOD: We present a simple modification of the technique following the two dural layers of the floor of the sella turcica, allowing for early identification of the medial wall and simplifying dissection. We support this technique with an anatomical analysis on cadaveric specimens and clarifying dissection images. CONCLUSION: Recognition and dissection of the dural unfolding of the floor of the sella turcica are "key points" that lower the risk and facilitate the MWCSR.
Assuntos
Seio Cavernoso , Neoplasias Hipofisárias , Sela Túrcica , Seio Cavernoso/cirurgia , Humanos , Neoplasias Hipofisárias/cirurgia , Neoplasias Hipofisárias/patologia , Neoplasias Hipofisárias/diagnóstico por imagem , Sela Túrcica/cirurgia , Adenoma/cirurgia , Adenoma/patologia , Cadáver , Procedimentos Neurocirúrgicos/métodos , Neuroendoscopia/métodos , Endoscopia/métodos , Dissecação/métodosRESUMO
Nowadays, neither imaging nor pathology evaluation can accurately predict the aggressiveness or treatment resistance of pituitary tumors at diagnosis. However, histological examination can provide useful information that might alert clinicians about the nature of pituitary tumors. Here, we describe our experience with a silent corticothoph tumor with unusual pathology, aggressive local invasion and metastatic dissemination during follow-up. We present a 61-year-old man with third cranial nerve palsy at presentation due to invasive pituitary tumor. Subtotal surgical approach was performed with a diagnosis of silent corticotroph tumor but with unusual histological features (nuclear atypia, frequent multinucleation and mitotic figures, and Ki-67 labeling index up to 70%). After a rapid regrowth, a second surgical intervention achieved successful debulking. Temozolomide treatment followed by stereotactic fractionated radiotherapy associated with temozolomide successfully managed the primary tumor. However, sacral metastasis showed up 6 months after radiotherapy treatment. Due to aggressive distant behavior, a carboplatine-etoposide scheme was decided but the patient died of urinary sepsis 31 months after the first symptoms. Our case report shows how the presentation of a pituitary tumor with aggressive features should raise a suspicion of malignancy and the need of follow up by multidisciplinary team with experience in its management. Metastases may occur even if the primary tumor is well controlled.
Assuntos
Adenoma/diagnóstico por imagem , Adenoma/cirurgia , Corticotrofos/patologia , Neoplasias Hipofisárias/diagnóstico por imagem , Neoplasias Hipofisárias/cirurgia , Evolução Fatal , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
OBJECTIVE: Cushing disease (CD) is a rare, poorly understood entity. Our aim was to add our clinical experience of >30 years in a multidisciplinary specialized unit to the global knowledge of CD. METHODS: This descriptive retrospective study included all patients admitted to the Endocrinology and Nutrition Department of the Virgen del Rocío University Hospital, Seville, Spain, from January 1980 to May 2016. All patients had a definitive diagnosis of CD. RESULTS: Total sample included 119 patients; 100 (84%) were female. Median age at diagnosis was 37.97 years (interquartile range [IQR]: 25.89-45.07 years). Median follow-up was 88 months (IQR: 45.50-157.00 months). Most tumors were microadenomas (62/95) (5.1 mm [IQR: 4.0-7.0 mm]) without sinus invasion. Surgical procedures were conventional transsphenoidal surgery (CTSS) (101/108; cured 70 after first attempt) and expanded endoscopic transsphenoidal surgery (EETSS) (7/108; cured 5 after first attempt); 11 patients did not receive surgical treatment. Fourteen patients received radiotherapy after a first surgery and 5 patients after a second surgical removal attempt. In 13 patients (12.04%), CD relapse was demonstrated after initial CTSS (median disease-free period 65 months [IQR: 45-120 months]). Ten patients developed panhypopituitarism owing to the surgical procedure (CTSS); 8 patients developed panhypopituitarism after adjuvant radiotherapy. CONCLUSIONS: We observed slightly inferior cure rate after first surgery compared with moderately better relapse rates and time to relapse. Radiotherapy after surgery failure seemed to be more effective than CTSS; however, EETSS may be a valid alternative. Postoperative panhypopituitarism rate after first surgery was lower than expected; after radiotherapy, our results were comparable to other series.
Assuntos
Endoscopia/métodos , Hipersecreção Hipofisária de ACTH/cirurgia , Adenoma Hipofisário Secretor de ACT/complicações , Adenoma Hipofisário Secretor de ACT/cirurgia , Adenoma/complicações , Adenoma/cirurgia , Adulto , Feminino , Humanos , Hipopituitarismo/etiologia , Masculino , Pessoa de Meia-Idade , Hipersecreção Hipofisária de ACTH/radioterapia , Complicações Pós-Operatórias/etiologia , Radioterapia Adjuvante/efeitos adversos , Estudos Retrospectivos , Resultado do TratamentoRESUMO
OBJECTIVE: Thyrotropin (TSH)-secreting pituitary tumors are rare and typically present with hyperthyroidism. Here we report the diagnosis, treatment, and surgical outcomes in a series of patients with TSH-secreting pituitary tumors in a tertiary referral center. METHODS: Descriptive retrospective study that included all patients with TSH-secreting pituitary tumors who underwent transsphenoidal surgery in the endocrinology and nutrition unit of the Virgen del Rocío University Hospital (Seville, Spain) between 2004 and 2016. RESULTS: The mean age at diagnosis was 42.8 ± 17 years. The mean time from onset of symptoms to diagnosis was 13 ± 10 months. Four patients displayed symptoms indicating hyperthyroidism (1 suffered from tachycardia); 3 patients showed symptoms because of mass effect (visual impairment and headache) and 3 patients were diagnosed based on incidental findings after routine blood tests (high free thyroxine levels). Eight patients had macroadenomas, and 2 patients had microadenomas. Five patients underwent conventional pituitary surgery, and 5 patients underwent expanded endoscopic transsphenoidal surgery. Six patients achieved cure after surgery. The other patients received radiotherapy and/or treatment with somatostatin analogs. Analysis of somatostatin receptor (SSTR) expression by immunohistochemistry could be performed in 6 tumors. CONCLUSIONS: Our results confirm the clinical and hormonal heterogeneity caused by TSH-secreting pituitary adenomas. Surgery is considered the first choice of treatment for these tumors. We observed surgical cure rates similar to those reported in recent published series. SSTR2 and SSTR3 are highly expressed in TSH-secreting pituitary adenomas. Our results suggest that somatostatin analog treatment may be also helpful in the treatment of TSH-secreting pituitary adenomas.
Assuntos
Adenoma/cirurgia , Hipertireoidismo/cirurgia , Procedimentos Neurocirúrgicos/métodos , Neoplasias Hipofisárias/cirurgia , Tireotrofos/patologia , Tireotropina/metabolismo , Adenoma/complicações , Adenoma/metabolismo , Adenoma/patologia , Adolescente , Adulto , Idoso , Feminino , Humanos , Hipertireoidismo/etiologia , Hipertireoidismo/metabolismo , Hipertireoidismo/patologia , Masculino , Pessoa de Meia-Idade , Neoplasias Hipofisárias/complicações , Neoplasias Hipofisárias/metabolismo , Neoplasias Hipofisárias/patologia , Estudos Retrospectivos , Centros de Atenção Terciária , Resultado do Tratamento , Adulto JovemRESUMO
Objective When the use of the nasoseptal flap for endoscopic skull base reconstruction has been precluded, the posterior pedicle inferior turbinate flap is a viable option for small midclival defects. Limitations of the inferior turbinate flap include its small surface area and limited arc of rotation. We describe a novel extended inferior turbinate flap that expands the reconstructive applications of this flap. Design Cadaveric anatomical study. Participants Cadaveric specimens. Main Outcome Measures Flap size, arc of rotation, and reconstructive applications were assessed. Results The average width of the flap was 5.46 ± 0.58 cm (7.32 ± 0.59 cm with septal mucosa). The average length of the flap was 5.01 ± 0.58 cm (5.28 ± 0.37 cm with septal mucosa). The average surface area of the flap was â¼ 27.26 ± 3.65 cm(2) (40.53 ± 6.45 cm(2) with septal mucosa). The extended inferior turbinate flap was sufficient to cover clival defects extending between the paraclival internal carotid arteries. The use of the flap in 22 cadavers and 5 clinical patients is described. Conclusion The extended inferior turbinate flap presents an additional option for reconstruction of skull base defects when the nasoseptal flap is unavailable.