In recent years, with the improvement of socio-economic level and people’s health awareness, the detection rate of pituitary adenoma has been increasing year by year. Since pituitary adenomas not only have various characteristics of tumors, but also can cause abnormal endocrine functions (including infertility and sterility), they bring great adverse effects to patients, families and society. Pituitary adenoma is a benign tumor, and its detection rate has been increasing year by year in recent years. Due to the varying medical standards and differences in medical personnel’s understanding and management of the disease, the prognosis of patients with pituitary adenoma is seriously affected.
In order to improve the level of surgical treatment of pituitary adenoma, the China Pituitary Adenoma Collaborative Group organized experts and scholars related to pituitary adenoma to write the “Expert Consensus on Surgical Treatment of Pituitary Adenoma in China”, hoping to improve the understanding of surgical treatment of pituitary adenoma, standardize the behavior of pituitary surgical treatment, and contribute to the development of pituitary surgery in China through the consensus.
I. Introduction of pituitary adenoma
The incidence of pituitary adenoma ranks 2nd among intracranial tumors, accounting for about 15% of intracranial tumors, with a population incidence of 8.2%-14.7% and an autopsy detection rate of 20%-30%.
1. Classification.
(1) According to the type of hormone secretion: functional pituitary adenoma (including prolactin adenoma, growth hormone adenoma, thyroid hormone adenoma, adrenocorticotropic hormone adenoma, gonadotropin adenoma and mixed pituitary adenoma) and non-functional pituitary adenoma.
(2) According to the size of the tumor, there are microadenoma (<1cm in diameter), macroadenoma (1-3cm in diameter) and giant adenoma (>3cm in diameter).
(3) The tumors are classified into invasive pituitary adenomas and non-invasive pituitary adenomas based on the imaging classification, intraoperative findings and pathology. Atypical pituitary adenoma: Ki-67>3%, P53 staining, and nuclear heterogeneity, 2 of the above 3 points can be diagnosed as atypical pituitary adenoma.
2. Main clinical manifestations.
(1) Headache;
(2) Visual field disorder;
(3) Other corresponding symptoms caused by tumor compression on adjacent tissues;
(4) The corresponding symptoms and signs of functional pituitary adenoma.
3.Diagnosis.
(1) Corresponding clinical manifestations;
(2) Endocrinological examination: Prolactin adenoma: Prolactin > 150 μg/L and exclude other specific causes of hyperprolactinemia. Serum prolactin < 150 μg/L must be diagnosed with caution in the context of the specific case. Growth hormone adenoma: Diagnosis by random growth hormone levels alone is not recommended and a glucose growth hormone suppression test should be performed. Pituitary growth hormone adenoma can be excluded if the post-load serum growth hormone trough value is < 1.0 μg/L.
Serum insulin-like factor (IGF)-1 also needs to be measured. an abnormality is judged when the patient’s serum IGF-1 level is higher than the age- and sex-appropriate range of normal values. Cushing’s disease: loss of circadian rhythm of blood cortisol, normal or mildly elevated ACTH, and elevated 24-h urinary free cortisol (UFC). In patients with Cushing’s disease, the classic low-dose dexamethasone suppression test (LDDST) is not suppressed and the high-dose dexamethasone suppression test (HDDST) is suppressed.
The differential diagnosis of Cushing’s disease and ectopic ACTH syndrome can be improved by measuring ACTH levels in subclavian sinus veins in hospitals where available. Thyrotropin adenoma: Plasma thyroxine levels are elevated and TSH levels are mostly elevated, but a few are in the normal range;
(3) Enhanced MRI or dynamic MRI scan of the saddle area: definite adenoma in the saddle area. MRI may be negative in some patients with Cushing’s disease.
Indications for surgical treatment of pituitary adenoma
The objectives of surgical treatment of pituitary adenoma include removing the tumor to relieve the clinical symptoms caused by long-term pressure on the surrounding structures such as vision loss; correcting endocrine dysfunction; preserving normal pituitary function; and clarifying the histology of the tumor.
1.Surgical indications.
(1) Transnasal butterfly approach surgery.
(1) Symptomatic pituitary adenoma stroke exists.
(2) The occupying effect of pituitary adenoma causes compression symptoms. The symptoms may include compression of the optic nerve, actinic nerve and other adjacent cerebral nerves as well as hypopituitarism caused by pituitary gland compression, and surgery should be preferred after excluding prolactin adenoma.
Prolactin adenomas and other hypersecretory pituitary adenomas (mainly ACTH tumors and CH tumors) that have difficulty tolerating adverse drug reactions or are resistant to drug therapy.
④ Partial pituitary resection and/or biopsy of the lesion. For lesions of pituitary origin with severe endocrine function (especially pituitary ACTH is obviously increased), pituitary exploration or partial resection is feasible; for lesions of pituitary origin whose nature cannot be determined before surgery but need treatment, biopsy is feasible to clarify their nature.
The selection of transnasal butterfly surgery also needs to take into account the following factors: the height of the tumor; the shape of the lesion; the texture and blood supply of the tumor; whether the saddle septal surface is smooth and intact; the size of the intracranial and cavernous sinus invasion; the development of the sinus and the pathology of the nasal cavity; the patient’s general condition and willingness to operate.
(2) Open pituitary adenoma resection: patients who cannot undergo transsphenoidal sinus approach; patients with nasal cavity infection.
(3) Combined approach surgery: the main body of the tumor is located in the saddle, supra-saddle and parasternal development, and is in the shape of “dumbbell”.
2. Contraindications.
(1) Transnasal butterfly approach surgery: the surgery is relatively contraindicated due to pathological hypersecretion of pituitary hormone which leads to severe systemic dysfunction or low pituitary function which leads to poor general condition of the patient, and the surgery should be performed after actively improving the general condition of the patient.
①Active intracranial or nasal cavity or butterfly sinus infections can be operated after the infection is controlled.
②Patients with poor general condition cannot tolerate surgery. The lesion is mainly located in the suprasellar area or in the shape of “dumbbell”. (3) Residual or recurrent tumor without obvious symptoms and difficult to be removed by surgery.
(2) Craniotomy for pituitary adenoma.
①Microadenoma of pituitary gland;
(2) Open pituitary adenoma resection: ①Pituitary microadenoma; ②If there is obvious hypopituitarism, it needs to be corrected first before surgery.
Assessment and management of perioperative conditions
The evaluation and treatment of perioperative patients include.
(1) Indications for surgery, timing of surgery and selection of surgical approach;
(2) Treatment of preoperative and postoperative pituitary hormone abnormalities resulting in comorbidities or pre-existing medical diseases;
(3) Pre- and post-operative evaluation of pituitary function and adjustment and treatment of hormone levels;
(4) Adjustment of water and electrolyte balance before and after surgery;
(5) Publicity and education of perioperative conditions. It is recommended that multidisciplinary teams or groups experienced in the treatment of pituitary adenomas should be involved in the development of treatment plans in tertiary hospitals or above.
Perioperative management should focus on the following areas.
(1) Complicated cardiovascular lesions, including acromegaly cardiomyopathy, cardiac insufficiency and arrhythmias, should be treated preoperatively and postoperatively with cardiovascular medicine consultation, such as cardiac diuresis, angiotensin-converting enzyme inhibitors and B-blocker therapy; if patients with pituitary growth hormone adenoma have been found to have clear heart lesions preoperatively, even if their heart function can tolerate surgery, they can be treated with medium- and long-acting growth inhibitor drugs first to If a patient with pituitary growth hormone adenoma has been found to have a clear heart defect before surgery, even if his heart function can tolerate surgery, he can be treated with medium- and long-acting growth inhibitors first to improve his heart disease before surgery.
For patients with combined hypertension and diabetes mellitus, symptomatic treatment should be given before and after surgery to actively control blood pressure and blood glucose. Patients with pituitary adenoma, especially growth hormone adenoma combined with OSAS, are at high risk of anesthesia, so anesthesiologists and cardiovascular doctors should be consulted before surgery.
(2) Management of postoperative water-electrolytes and uremia: Patients with postoperative pituitary adenoma should routinely record 24-h fluid intake and output, and monitor blood electrolytes and urine specific gravity. If symptoms of uremia appear immediately after surgery, antidiuretic hormone treatment should be given if necessary according to the volume and electrolyte condition.
(3) Perioperative hormone replacement therapy: Patients with pituitary adenoma should undergo preoperative evaluation of adenopituitary function, including measurement of hormone levels of thyroid axis, adrenal axis, gonadal axis, growth hormone, IGF-I, etc. In the presence of secondary hypothyroidism and secondary hypoadrenocorticism, physiological replacement volume therapy is required. Patients with pituitary adenoma are given a stress dose of glucocorticoids on the day of surgery (except for Cushing’s disease), and the dose of glucocorticoids is adjusted postoperatively to maintain the patient’s normal vital signs and water-electrolyte balance, and the dose of glucocorticoids is gradually reduced to a physiologic replacement dose. Patients with pituitary adenoma should be followed up clinically and evaluated for pituitary function to adjust the dose of hormone replacement therapy, and some patients need lifelong adenopituitary hormone replacement therapy.
IV. Operating room conditions and personnel training
1.Microscope, endoscope and instruments: We have a neurosurgical microscope or endoscopic system and a variety of microscopic instruments for transsphenoidal or craniotomy of pituitary adenoma.
2. Monitoring system: intraoperative C-arm or neuronavigation equipment.
3.Personnel training: have the foundation of skull base microscopic operation training and participate in the pituitary adenoma microscopic operation training course, and have done more than 50 cases of similar operations under the guidance of superior doctors. Endoscopic surgery operators should have the anatomical training of neuroendoscopic operation and hold the associate certificate, and have done more than 50 cases of endoscopic operation under the guidance of the superior doctor.
V. Surgical treatment
1. Transnasal pteridian approach surgery.
(1) Surgical principles: Adequate preoperative preparation.
(1) Surgical principles: Adequate preoperative preparation, intraoperative localization;
(2) Remove the tumor and better protect the pituitary function.
(3) Good repair of the saddle base and cerebrospinal fluid leak. Anatomical and physiological reset.
(2) Surgical methods.
①Microscopic transnasal butterfly approach: preoperative preparation: nasal drops of antibiotic solution, trimming nasal hair; position: supine position, adjust the angle of head tilted back appropriately according to the direction of tumor growth; enter along the midline under the mucosa of nasal septum, expose the anterior wall of pterygoid sinus and the opening of pterygoid sinus, open the anterior wall of pterygoid sinus and then deal with the mucosa of pterygoid sinus to expose the bone of saddle base; after high speed grinding drill to open the bone of saddle base, position and then cut the dura of saddle base to expose the tumor The tumor cavity is moderately filled with hemostatic materials, such as gelatin sponge, fluid gelatin, regenerated oxidized cellulose (quick i.e. yarn), etc., and the saddle base is reconstructed with small bone fragments and fibrin adhesive (if necessary, white body fascia, muscle or fat are used for repair), and the nasal septum and mucosa are repositioned and the nasal cavity is moderately filled.
②Neuroendoscopic transsphenoidal approach: a. The endoscope is entered into the selected nostril (routinely via the right side), and the inferior turbinate is visible on the lateral side of the nasal septum. After filling the inferior nasal tract (between inferior turbinate and septum), middle nasal tract and superior nasal tract with a cotton pad soaked with epinephrine dilution (1 mg epinephrine/10 ml physiological saline), the gap between the nasal tract is significantly enlarged and the endoscope is passed along the nasal tract to the pterygoid septal fossa, where the opening of the pterygoid sinus can be found. The opening of the pterygoid sinus can be determined based on the superior margin of the posterior nostril, 0.8-1.5 cm anteriorly along the nasal septum toward the pterygoid septal fossa; b. 1 cm upward at the inferior margin of the root of the middle turbinate.
c. A curved incision is made medially along the anterior edge of the opening of the pterygoid sinus on the anterior wall of the pterygoid sinus and the vertical plate of the septum, and the mucosal flap is turned toward the posterior nostril (there is a branch of the pterygopalatine artery near the root of the middle turbinate) to reveal the anterior wall of the pterygoid sinus. d. The bone of the anterior wall of the pterygoid sinus and the intracavity separation of the pterygoid sinus are removed with a high-speed grinding drill to fully expose the saddle base. The OCR (internal carotid artery-optic nerve crypt), optic canal bulge, internal carotid artery bulge, slope crypt, and pterygoid plateau can be seen. The saddle base bone is fully opened. After puncture, the dura of the saddle base is incised and the tumor can be removed either by separation along the tumor pseudopapillary or by spatula and suction. After removal of the tumor, saddle base reconstruction is performed by reliable methods, and the mucosal flap of the anterior wall of the pterygoid sinus and the turbinate are repositioned and the mirror is withdrawn. e. Post-operative treatment: The other procedures are the same as transnasal microsurgery.
2. Craniotomy.
(1) Surgical methods of transfrontal inferior approach.
① Scalp incision: Mostly adopt coronal incision in the hairline.
(2) Cranial bone flap: Generally do the right frontal bone flap, the front is as close to the front skull base as possible.
③Tumor exposure: stellate incision of the dura mater, with the anterior side flush with the supraorbital area. The arachnoid is sharply incised along the lateral fissure of the pterygoid crest to release the cerebrospinal fluid and reduce the intracranial pressure. The ipsilateral optic nerve and internal carotid artery were explored to reveal the tumor anterior to the optic cross.
④Tumor resection: electrocoagulate and puncture the tumor, incise the pseudo-envelope of the tumor, and first perform intracapsular resection of the tumor in blocks. The periphery of the tumor is freed and the tumor is removed gradually. For recurrent tumor, take care not to damage the penetrating artery and pituitary stalk around the tumor during the operation.
(2) Surgical methods of trans-pterygoid approach.
① Skin flap and bone flap: The skin incision of the pterygoid point approach is as far as possible within the hairline. The bone flap is close to the skull base, and the pterygoid crest is ground away as much as possible in order to reduce the strain on the frontal lobe.
②Tumor disclosure: Sharp incision of the lateral fissure pool to release cerebrospinal fluid. The frontal lobe is retracted to reveal the optic nerve and internal carotid artery. The main body of the tumor is exposed by probing through the anterior and posterior optic cross, the optic nerve and the internal carotid artery and the external space of the internal carotid artery.
(3) Tumor resection method is the same as above.
3.Surgical method of combined approach.
The above approaches are combined with endoscopic or microscopic transnasal butterfly surgery.
Intraoperative special conditions treatment
1.Intraoperative bleeding.
(1) Intercavernous sinus bleeding: Intraoperative encounter with intercavernous sinus bleeding, hemostatic material can be used to stop bleeding. If the bleeding is difficult to control, consider using a special gun-shaped titanium clamp for transsphenoidal sinus surgery to close the hemostasis;
(2) Spongy sinus hemorrhage: After suction to keep the operation field clear and remove the tumor as soon as possible, local filling with appropriate amount of hemostatic material and cotton pad to stop the hemorrhage, but need to avoid damaging the sinus nerve and thrombus formation;
(3) Suprasellar hemorrhage: If the pituitary macroadenoma invades into the suprasellar area and adheres to Willis artery ring, it may cause hemorrhage when pulling and scraping the tumor during the operation;
(4) Bleeding from internal carotid artery and its branches: due to the anatomical variation of internal carotid artery or the growth of tumor around internal carotid artery, the internal carotid artery may be damaged during surgery, causing intraoperative hemorrhage and even endangering the patient’s life. In this case, the coarse suction device should be replaced immediately to keep the operation field clear and find the bleeding point quickly. If the rupture is not large, hemostatic materials, artificial meninges and cotton sheets can be used to compress the bleeding, if the rupture is large, the bleeding can be stopped by local filling and compression and then transferred to interventional treatment. Postoperative angiography is required to rule out pseudoaneurysm in these patients;
(5) Intracerebral hematoma: Intracerebral hematoma can occur during craniotomy due to overstretching of the brain pressure plate and injury to the frontal lobe; when a giant pituitary adenoma can only be partially removed, it is easy to have a residual stroke. In addition, craniotomy is advocated to carry out surgical treatment without cerebral pressure plate.
Intraoperative hemostasis method and material selection. For pituitary adenoma surgery, intraoperative hemostasis is very critical, and incomplete hemostasis can affect the patient’s function and even life. In case of intraoperative venous bleeding, hemostasis can be achieved by cotton pad compression and bipolar electrocoagulation and electrocautery. If the bleeding from the intercavernous sinus or cavernous sinus is difficult to stop completely, hemostatic materials can be used to stop the bleeding, such as gelatin sponge, fluid gelatin, and regenerated oxidized cellulose (quick i.e. yarn). In case of intra-arterial hemorrhage, in addition to compression, digital subtraction cerebral angiography (DSA) should be performed at the same time to clarify the hemorrhagic artery and site, and to stop the hemorrhage by interventional treatment if necessary.
2. Intraoperative cerebrospinal fluid leakage.
(1) Causes of intraoperative saddle compartment rupture.
① Compressed by tumor, saddle septum is often thin and transparent, only a layer of arachnoid membrane remains, when scraping the upper tumor, it is very easy to cause rupture of saddle septum;
②During the process of tumor scraping, the saddle septum descends unevenly and appears to be folded, which is easy to rupture when scraping the tumor in the fold;
③It is easy to damage the attachment point of the skull base of the saddle septum when trying to remove the peripheral tumor;
④The attachment point of the anterior part of the saddle septum is low, and after the saddle septum collapses, the area is prone to leakage of cerebrospinal fluid or the dural incision of the saddle base is too high, and the saddle septum is cut directly when the saddle base is incised;
(5) In patients with pituitary adenoma with empty saddle, the septum is sometimes thin or even absent.
(2) Points to note to reduce the occurrence of cerebrospinal fluid leakage during surgery.
(1) The position of the saddle base window should not be too high, and the upper edge of the saddle base dural incision should be at a certain distance from the septal attachment edge;
(2) The tumor should be scraped as gently as possible, especially when removing the residual tumor in the suprasellar and septal folds;
(3) Intraoperative attention should be paid to the suprasellar arachnoid and its deep gray-blue suprasellar pool.
(3) Cerebrospinal fluid leak repair methods.
①For small rupture and intraoperative cerebrospinal fluid leakage only, fill the saddle with gelatin sponge, and then close the saddle base dura with dry artificial dura or gelatin sponge with fibrin adhesive;
For those with a large rupture, the leak should be filled with white body fascia or muscle, and then the dura mater should be closed with dry artificial dura mater plus fibrin adhesive. The success of intraoperative cerebrospinal fluid leak repair is judged by the criterion that no clear cerebrospinal fluid leakage is found under high magnification microscopy or endoscopy before the saddle base is closed with fibrin adhesive.
3.Frontal lobe contusion: it often occurs in craniotomy with inferior frontal approach, due to excessive pulling of frontal base by cerebral pressure plate. Postoperatively, patients should be observed for changes in the patient’s mental pupil, and CT examination should be performed immediately once the condition deteriorates, so that hematoma and contusion foci can be found in time for timely treatment, and craniotomy can be performed to remove the hematoma and decompress if necessary.
4, optic nerve and internal carotid artery injury: craniotomy to remove tumor in optic cross and optic nerve interval, transsphenoidal sinus access surgery to chisel out the saddle base to damage the optic nerve canal or remove part of the tumor on the saddle with scraper and suction device may damage the optic nerve, especially for patients with weak vision before surgery, vision loss or even blindness may occur after surgery. Prevention can only be achieved by skillful microscopic techniques and gentle surgical operations. Treatment does not require reoperation and can be treated with neurotrophic drugs, vasodilators and hyperbaric oxygen. See above for treatment of internal carotid artery injury.
VII. Treatment of postoperative complications
1. Postoperative hemorrhage: It is manifested as headache with rapid loss of vision, or even hypothalamic disorders such as impaired consciousness, hyperthermia, and uremia within a few hours after surgery. CT should be reviewed immediately, and if bleeding in the saddle area or in the brain is found, an aggressive approach should be taken, and if necessary, the hematoma should be removed by transsphenoidal or craniotomy again.
2, postoperative vision loss: common causes are bleeding in the operative area; too tight intra-saddle filling; acute vacuolation butterfly saddle; acute optic nerve ischemia due to optic nerve vasospasm and other causes can also cause vision loss. After the operation, observe the condition closely, once the visual dysfunction occurs, CT should be reviewed as soon as possible, and the bleeding should be treated by surgery as soon as possible.
3, postoperative infection: mostly secondary to cerebrospinal fluid leakage. Common clinical manifestations include: body temperature over 38℃ or below 36℃. There are clear signs of meningeal irritation, associated symptoms of increased intracranial pressure, or clinical imaging evidence. Lumbar puncture cerebrospinal fluid examination reveals total leukocyte count >500 x 106/L or even 1,000 x 106/L, multinucleation >0.80, sugar <2.8 -4.5 mol/L (or <2>0.45 g/L, positive bacterial smear findings, and positive cerebrospinal fluid bacteriology culture.
Fungal, tumor, tuberculosis, and viral tests were also added for differential diagnosis as appropriate. Empirical medication is used to select antibiotics that can cross the blood-brain barrier. Adjust the treatment plan according to the pathogenic and drug-sensitive results in a timely manner. The intravenous route should be used whenever possible, and intrathecal administration by lumbar puncture is generally not recommended, but the intracerebroventricular route can be added if necessary. Combination of multiple bacterial infections or multisystemic infections may be used. The maximum drug dose in the tolerated drug profile and a long course of treatment (2-8 weeks or longer) are generally recommended.
4. Central uremia: If uremia has not occurred as of discharge, blood sodium levels should be rechecked on postoperative day 7. If the uremia is not resolved at discharge, appropriate medication may be used until the symptoms disappear.
5. Hypopituitarism: endocrinological evaluation should be performed at week 12 postoperatively, and endocrine replacement therapy should be given if any pituitary-target gland insufficiency is found.
VIII. Pathology and molecular marker testing
Clinicopathological classification of pituitary adenomas based on hormonal phenotype and expression of transcription factors by immunohistochemistry (Table 1) is feasible in China and should be promoted.
The vast majority of pituitary adenomas are benign tumors with a single ovoid cell morphology, round or ovoid nuclei, slender chromatin, rare nuclear schistosomes, moderate cytoplasm, and a Ki-67 marker index usually <3%; if the cell morphology is heterogeneous, the nucleus is clear, nuclear schistosomes are easily seen, ki-67 >3%, and p53 protein is positively expressed, the diagnosis is “atypical” pituitary adenoma. “If the pituitary adenoma cells have evidence of invasion of submucosal tissue of the nasal cavity, soft tissue of the skull base or bone tissue, the diagnosis of “invasive” pituitary adenoma can be made; if metastasis occurs (brain, spinal cord or other parts of the body), the diagnosis of pituitary cancer can be made.
Recently, FGF and its receptor FGFR have been found to be strongly associated with the aggressiveness of pituitary adenomas; MMP9 and PTTG are highly expressed in aggressive pituitary adenomas. Molecular genetic studies related to pituitary adenoma revealed that: GADD45 is closely associated with non-functional pituitary adenoma; IGFBP5 and MY05A are overexpressed in aggressive pituitary adenoma, but only MY05A is overexpressed at the protein level; overexpression of ADAMTS6, CRMPI, PTTG, CCNBI, AURKB and CENPE is thought to be associated with recurrence or progression of PRL adenoma. In addition, testing for MENI and AIP genes is recommended for familial patients with a genetic predisposition, giant pituitary adenomas, rare multihormonal adenomas, and young patients with unclassifiable pituitary adenomas.
Evaluation of surgical outcome and follow-up
Cure criteria and follow-up.
(1) Growth hormone adenoma: Random growth hormone level <1μg/L and IGF-I level decreased to normal range according to gender and age are considered as the criteria for cure.
(2) RL adenomas: PRL <20 μg/L in women and <15 μg/L in men without treatment such as dopamine agonists, and PRL <10 μg/L on postoperative day 1 indicates a good prognosis.
(3) ACTH adenoma: blood cortisol <20 μg/L within 2 d after surgery, 24 h urinary free cortisol and ACTH levels in normal range or below normal levels (UFC). Within 3-6 months after surgery, blood cortisol, 24-h urine free cortisol and ACTH were within normal range or below normal levels, and clinical symptoms disappeared or resolved.
(4) TSH, free T3, and free T4 levels are reduced to normal within 2 d after adenoma surgery.
(5) Normal FSH and LH levels within 2 d after surgery for gonadotropin adenoma.
(6) No residual tumor on MRI 3-6 months after surgery for non-functional adenomas. For functional adenoma, normalization of hormone levels for more than 6 months after surgery is the baseline for cure; the first MRI examination will be performed 3-4 months after surgery, followed by 3-6 months as needed by hormone levels and disease.
X. Imaging evaluation
Imaging has an important role in the diagnosis and differential diagnosis of pituitary adenomas, as well as in the evaluation of postoperative residuals, complications and recurrence. Currently, magnetic resonance imaging is the imaging method of choice for pituitary lesions, and CT can be added in some cases where differential diagnosis is needed. In cases of suspected pituitary adenoma, contrast-enhanced pituitary MRI should be performed, and in cases of suspected microadenoma, dynamic-enhanced pituitary MRI should be performed if the technical conditions of the MRI equipment allow.
For postoperative follow-up of pituitary adenoma, a pituitary enhancement MRI should be performed routinely in the early postoperative period (within 1 week) as a baseline judgment. A review should be performed 3 months after surgery, and thereafter the interval between imaging reviews and the duration of observation should be decided according to the clinical situation. For pituitary adenoma, there should be pituitary enhancement MRI examination before and after radiotherapy, and the review interval and observation period after radiotherapy should refer to the basic requirements of tumor radiotherapy.
XI. Adjuvant therapy
1, radiation therapy indications, gamma knife treatment indications: radiation therapy is the adjuvant treatment of pituitary adenoma, including: conventional radiotherapy (RT), stereotactic radiosurgery / radiotherapy (SRS) / Radiotherapy (SRT).
Indications for RT, SRS/SRT for pituitary adenoma.
(1) Those who have residual or recurrence after surgery;
(2) Aggressive growth or malignancy;
(3) Prolactin adenoma drugs are ineffective, or the patient can not tolerate the adverse effects, and at the same time can not or do not want to accept the surgical treatment;
(4) SRS may be preferred for small non-functioning adenomas with a tendency to grow or involve the cavernous sinus;
(5) Those who are not suitable for surgery or drug treatment due to other diseases; large, aggressive, recurrent, or malignant pituitary adenomas are suitable for RT, including intensity-modulated radiotherapy (IMRT), image-guided radiotherapy (IGRT), etc.
Smaller pituitary adenomas that are spaced from the optic nerve or involve the cavernous sinus are more suitable for one-time SRS treatment. For lesions in between, SRT may be considered. If patients need to relieve tumor compression and restore severe clinical symptoms caused by abnormal hormone levels as soon as possible, it is not appropriate to prefer any form of radiation therapy.
2. Indications for drug treatment.
(1) Pathologically confirmed prolactin adenoma or prolactin-dominant mixed adenoma, if the postoperative PRL level is still higher than normal and accompanied by corresponding symptoms, need to receive dopamine agonist 291;
(2) Growth hormone adenomas with postoperative growth hormone or IGF-I levels that are not in remission and MRI suggests residual tumor (especially if the residual tumor is located in the cavernous sinus) may be treated with growth inhibitor analogs, and dopamine agonist therapy may be attempted for mixed adenomas with positive PRL; (3) ACTH adenomas that are not in remission after surgery may be treated with growth inhibitor analogs or drugs for hypercortisolism.
XII. Follow-up
Pituitary hormone tests and other related examinations, such as visual acuity and visual field, should be performed on the first postoperative day and at the time of discharge, and the changes in symptoms and signs should be recorded in detail. Early (1 week after surgery) pituitary gland enhancement MRI is recommended. When patients are discharged from the hospital, health education is emphasized, and the importance of long-term follow-up is instructed to control their disease and improve the quality of survival, and follow-up cards are given to inform the follow-up process. Patients will receive annual follow-up questionnaires and will inform the follow-up physician of any changes in address or telephone number.
Pituitary hormone and related tests will be performed from 6 to 12 weeks after surgery to assess pituitary and target gland function. Patients with pituitary dysfunction were given appropriate hormone replacement therapy, and patients with complications were followed up with the appropriate screening programs. The pituitary MRI was reviewed 3 months after surgery to assess postoperative imaging changes and to record changes in patients’ symptoms and signs. For patients with pituitary dysfunction requiring hormone replacement therapy, monthly follow-up of symptoms, signs and hormone levels should be performed to record the changes and adjust the replacement therapy in a timely manner.
After the patient’s condition stabilizes, pituitary and target gland functions can be evaluated every 3 months, and hormone replacement therapy can be adjusted according to the follow-up results. Some patients require lifelong hormone replacement therapy. Pituitary hormone levels and pituitary MRI are optionally reviewed at 6 months postoperatively based on the 3-month postoperative follow-up results. For patients with good control, pituitary hormones and related tests should be reviewed annually after surgery, and pituitary MRI should be reviewed according to the degree of control of the patient’s disease; patients with complications should be evaluated for complications once a year. The follow-up interval should be extended appropriately after 5 years postoperatively, and lifelong follow-up is recommended.
XIII. Summary
This consensus systematically introduces the principles of diagnosis, treatment and postoperative follow-up of pituitary adenoma, focusing on the indications for surgical treatment, perioperative management, choice of surgical approach and prevention and management of various complications. Due to the complexity and diversity of pituitary adenomas, various problems may still be encountered during treatment. It is hoped that a pituitary consultation center composed of multidisciplinary personnel from neurosurgery, endocrinology, obstetrics and gynecology, radiology and radiotherapy will be established in hospitals with conditions to jointly agree on treatment plans; patients and their families should also go to such pituitary consultation and treatment center hospitals for treatment in order to obtain the best results.