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TRANSSPHENOIDAL SURGERY IN THE ELDERLY

2003; Wiley; Volume: 51; Issue: 5 Linguagem: Inglês

10.1034/j.1600-0579.2003.00229.x

1532-5415

Franck Letournel, Philippe Meneï, Gilles Guy, Jean‐Paul Saint‐André,

Adrenal and Paraganglionic Tumors

Journal of the American Geriatrics SocietyVolume 51, Issue 5 p. 729-730 Free Access TRANSSPHENOIDAL SURGERY IN THE ELDERLY First published: 29 April 2003 https://doi.org/10.1034/j.1600-0579.2003.00229.xCitations: 6AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinked InRedditWechat To the Editor: There are few published clinical series of elderly patients with pituitary tumors regarding management and outcome. However, the proportion of elderly in the population is increasing,1-3 and the medical conditions in this age group will therefore be important. We studied patients aged 65 and older who underwent a transsphenoidal surgery in the department of neurosurgery at the Angers' University Hospital. The aim of the study was to quantify the outcome of this surgery in this age group. Fifty-nine patients (median age 70.6) had transsphenoidal surgery between 1981 and 1998. The most-common presenting feature was of mass effect (35 cases), including headache, evidence of visual impairment, and progressive ophthalmoplegia. A pituitary apoplexia was the mode of presentation in six cases. Twelve patients were diagnosed with pituitary tumors on the basis of clinical endocrinological features: six with acromegalia, five with hypopituitarism, and one with Cushing disease. Two patients had a sudden cerebrospinal fluid (CSF) leak. The last four cases were known to have a pituitary adenoma. Transsphenoidal surgery was performed for a chiasmatic syndrome (n = 34), ophthalmoplegia (n = 8), pituitary apoplexia (n = 6), acromegalia (n = 6), CSF leak (n = 2), suspected abscess (n = 2), and Cushing disease (n = 1). Forty-nine patients had a pituitary adenoma; 25 of these were of gonadotrope type. In two cases, an empty sella was the diagnosis, presenting as sudden rhinorrhea. Two had pituitary abscess, two a pituitary carcinoma, and four a pituitary tumor of other histological type (two craniopharyngiomas, one pituitary metastasis, one lymphocytic hypophysitis). Of the major specific complications, two patients developed meningitis, two a sellar hematoma, and one a persistent CSF leak that required re-operation. Of the nonspecific complications, one patient had shock during anesthesia, and three had phlebitis, of which one died from a pulmonary embolism 11 days after surgery. Thus, mortality was 1.7% and morbidity 13%. For most of the patients, the outcome was favorable (Table 1). The median follow-up period was 33.5 months. The majority (39 cases) showed improvement in vision. Twenty patients had no treatment. Thirty-six required at least hydrocortisone and one gonadotrophins. Diabetes insipidus was definitive in six patients. One patient, with documented increase in tumor size, received bromocriptine therapy. Three patients died during follow-up, one from unexplained shock 4 years after transsphenoidal surgery and two from their pituitary carcinoma. Table 1. Outcome from Transphenoidal Surgery in the Elderly Outcome n Death 3 Visual outcome Improvement 39 Stabilized 17 Impairment 2 Endocrinological outcome No treatment 20 Hydrocortisone 36 Androgen 1 Bromocriptine 1 Magnetic resonance imaging or computed tomography scan Normal 23 Stabilized residue 24 Recurrence 3 Unknown 8 This study is one of the largest reported series in the elderly (see 3 for review) that shows the safety4 of transsphenoidal surgery in patients aged 65 and older. As with another study,3 our review shows that nonfunctioning adenomas are the most common tumors detected in this age group. Gonadotropic adenomas are the most common type (25 cases in our study). In accordance with literature data,1, 3, 5 our most common mode of presentation was visual impairment. Pospiech et al.6 have shown that 62% of elderly patients with pituitary tumors had visual impairment at diagnosis, so it is important in this age group to pay attention to these signs and to differentiate “pituitary visual impairment” from other causes of vision disturbance, most often cataracts. Pituitary tumors are a difficult diagnosis in elderly because endocrinological signs or tests are modified,2, 7, 8 as in our study (12 patients). Mortality in the elderly is less than 1%9 when transsphenoidal surgery is performed, the same as in younger patients. This result is similar to ours, 1.7%. Postoperative complications are rare (2– 5%)4, 10 and are most often transient and benign.10 Diabetes insipidus (Table 1) was permanent in six cases. Thirty-six patients needed at least hydrocortisone, without increase in cardiovascular complications, as described in one report.1 The majority of our patients (Table 1) had visual improvement, which is similar to other series.1, 3, 4, 7, 10 No patient had radiotherapy. In conclusion, transsphenoidal surgery is a well-tolerated treatment in elderly patients with few life-threatening complications even though there is a high incidence of other medical conditions in patients aged 65 and older. Age alone should not be a deterrent to this surgery. Because of age, visual impairment could be misattributed to cataract. We think that visual examination is important in this age group, looking for a chiasmatic syndrome; the majority of patients show visual improvement after transsphenoidal surgery. Franck Letournel, MD Cellular Biology Laboratory Philippe Menei, MD, PhD Gilles Guy, MD Department of Neurosurgery Jean-Paul Saint-Andre, MD Pathological Anatomy Laboratory Center Hospitalier Universitaire D'Angers Cedex, France REFERENCES 1 Benbow SJ, Foy P, Jones B et al. Pituitary tumours presenting in the elderly: Management and outcome. Clin Endocrinol 1997; 46: 657– 660. Wiley Online LibraryPubMedWeb of Science®Google Scholar 2 Turner HE, Wass JA. Pituitary tumours in the elderly. Bailliers Clin Endocrinol Metab 1997; 11: 407– 422. CrossrefCASPubMedWeb of Science®Google Scholar 3 Turner HE, Adams CB, Wass JA. Pituitary tumors in the elderly: A 20 year experience. Eur J Endocrinol 1999; 140: 383– 389.CrossrefCASPubMedWeb of Science®Google Scholar 4 Kurosaki M, Lüdecke DK, Flitsch J et al. Surgical treatment of clinically nonsecreting pituitary adenomas in elderly patients. 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