Sellarsuprasellar tumours pituitary adenoma

MANAGEMENT

A variety of different forms of treatment are available: Drug therapy

Bromocriptine: a dopamine agonist which lowers abnormal circulating hormone concentrations, especially prolactin. In two-thirds of patients with prolactinomas, the prolactin levels fall and the tumour shrinks. These patients require long-term therapy as the source of the hyperprolactinaemia persists. Cessation of treatment can result in rapid tumour re-expansion.

Somatostatin analogues: e.g. octreotide, inhibit growth hormone production and cause some tumour shrinkage in a proportion of patients. It is no longer used as long-term therapy unless a specific contraindication to surgery exists.

Operative approach From BELOW.

1. Transsphenoidal

Through an incision in the upper gum the nasal mucosa is stripped from the septum and the pituitary fossa approached through the sphenoid sinus.

2. Transethmoidal

An incision is made on the medial orbital wall and the pituitary fossa approached through the ethmoid and sphenoid sinuses.

With the transethmoidal and trans-sphenoidal routes the pituitary gland can be directly visualised and explored for microadenoma. Even large tumours with suprasellar extensions may be removed from below, avoiding the need for craniotomy.

From ABOVE

3. Transfrontal

Through a craniotomy flap the frontal lobe is retracted to provide direct access to the pituitary tumour. This approach is usually reserved for tumours with large frontal or lateral extensions.

n.b. All patients require steroid cover before any anaesthetic or operative procedure.

Radiotherapy

Pituitary adenomas are radiosensitive and external irradiation is commonly employed. Occasionally, radioactive seeds of yttrium or gold are implanted into the pituitary fossa, either via a trans-sphenoidal approach or stereotactically through a frontal burr hole.

Several months elapse before hormone levels begin to fall. Pituitary function gradually declines over a 5-10 year period after treatment and most patients eventually require replacement hormone therapy to prevent symptoms of hypopituitarism developing.

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