Tumours vary in size and activity. If surgery is recommended it may be for one of three reasons:
to remove hormone-producing tissue (typically in Acromegaly or Cushing’s disease)
to reduce the volume of a tumour that is compressing the optic chiasm or other structures
to reduce the volume of, or excise, non hormone-producing tissue that is likely to threaten surrounding structures in the future; for example, in a relatively young patient, in whom continued growth of the tumour is suspected or has been proven by sequential scans.
Transsphenoidal surgery is the most usual method but transcranial surgery is required in some tumours with major intracranial extension. The transsphenoidal approach allows the surgeon a clear, direct view of the tumour (through an operating microscope) and avoids a craniotomy (making a hole in the skull) with its associated slight risks of damage to the brain and epilepsy.
Recently an endoscopic approach has been introduced in some centres. Fine tubes (endoscopes) are pushed through the back of the nose. MRI and/or CT scans will give the surgeon information on the size and position of the tumour.
Successful outcome of this surgery is very dependent on the experience of the surgeon.
PRIOR TO SURGERY
The Pituitary Foundation recommends that the initial point of referral is an Endocrinologist who will arrange for essential preliminary tests (including blood tests, MRI and visual fields) to be performed before surgery.
The patient will be referred to an endocrinologist for post-operative pituitary function assessment at about 5-8 weeks and back to the surgeon at about 12 weeks (for MRI and visual field assessment). In some cases additional replacement pituitary hormones will be needed. These appointments should, ideally, be combined to cause minimal inconvenience to the patient.
Diabetes Insipidus (factsheet 9)
If the patient suffers from new onset polyuria and nocturia after surgery, it is likely that they have developed a degree of diabetes insipidus (DI). This is unusual after transsphenoidal surgery, but in all cases is highly amenable to treatment. In most cases DI is temporary and disappears within a few months, but in 1-2% of patients, especially after removal of Prolactinoma and Cushing’s tumours, it may be permanent but remain treatable.
Cerebrospinal fluid LEAK
It is possible to develop a CSF leak from the nose in the post-operative period (this is rare). This is associated with a risk of meningitis, and is an inconvenience for the patient. Any flulike symptoms or discharge of water-like fluid from the nose should be treated with a view to this possibility. Patients need to be referred back to the surgeon for treatment urgently.
This is not uncommon after this operation, particularly for patients with acromegaly. Symptoms usually clear given time, but occasionally need further treatment or an ENT referral.
Depending on the surgical technique, stitches are inserted in the upper gum or in the nostril. They are usually soluble. The wound itself will be completely healed in 3 weeks. Complete absorption of stitches can take 3 months and loose ends may need to be removed/snipped away. There may be some numbness around the front teeth; this may occasionally be permanent.
A major problem for many patients is weight gain. These patients are likely to need some encouragement to follow a suitable diet and take regular exercise. This may be particularly difficult after a period of illness and hospitalisation. However, including more exercise into their lifestyle should also improve the patient’s general feeling of well-being.
Surgical treatment which involves the head has a strong emotional impact for some patients.
Please see ‘Psychological Issues’ (factsheet 14).
QUESTIONS PATIENTS MAY ASK
Why do I need an operation?
A Benign tumour of the Pituitary gland may be compressing the optic nerve (which lies just above it) and affecting your sight or you may have a tumour that is producing excessive amounts of hormone which could cause you problems.
Is it cancer?
No, the vast majority of tumours are benign.
Will my eyesight improve after the operation?
Once the optic nerve is no longer compressed most patients will notice an improvement, this will carry on improving for 6 months after the operation. However, if your eyesight was very poor before the operation, it may not recover so much.
How long will I be in hospital?
This varies between treatment centres, but may be 3-9 days.
When will I be able to go back to work?
Depending on the job and circumstances, it is usually wise to plan for about 4-6 weeks off and reassess after that time. Some patients may take longer to recover (factsheet 14).
Have I inherited this, will my children get it?
In all but very exceptional circumstances there is no hereditary link.
RESOURCES FOR PATIENTS
MORE SPECIALIST RESOURCES
Management of Pituitary Tumors: The Clinician’s Practical Guide (2003) (Second Edition), Editors and authors Michael P. Powell, Stafford L. Lightman and Edward R. Laws. Humana Press, Totowa, New Jersey
Pituitary Tumours. Recommendations for service provision and guidelines for management of patients. Consensus statement of a working party (1997) RN Clayton & JAH Wass (Eds) London: Royal College of Physicians
The Diagnosis and Treatment of Pituitary Insufficiency (1997) Lamberts SWJ (Ed) Bristol, UK: BioScientifica
Endocrinology (1997) Levy A & Lightman SL New York: Oxford University Press
The Epidemiology, Pathogenesis and Management of Pituitary Tumours (1998) Webb SM (Ed) Bristol, UK: BioScientifica
©2011 Version 3 (To be reviewed by 2013)