Current imaging techniques for the diagnosis of pituitary adenoma

Pituitary Incidentalomas: Best Practices and Looking Ahead

Pituitary Incidentalomas (PI) are pituitary lesions serendipitously identified on imaging. PIs have become common in clinical practice because of increased use of imaging and radiologic advances. The most frequently incidentally detected lesions in adults are pituitary adenomas, followed by cystic lesions, and rarely other types of tumors and infiltrative and inflammatory disorders. Biochemical screening for hyperprolactinemia and acromegaly is needed in all patients with PI, whereas testing for hyposecretion is recommended for lesions larger than 6.0 mm. Most PIs are small nonfunctioning adenomas or cysts, which can be conservatively managed. For larger lesions, a multidisciplinary approach including endocrinology, neurosurgery, and neuro-ophthalmology is required. For incidentally detected lactotroph, somatotroph, and corticotroph adenomas, disease-specific management guidelines apply. Prospective studies are needed to enhance our understanding of the long-term course and response to treatment.

Transnasal Transsphenoidal Approach for Pituitary Tumors: An ENT Perspective

Endoscopic transnasal transsphenoidal (ETNTS) approach was first described in 1992 and is standard approach for the resection of benign pituitary adenomas. This prospective study aims in incidence and preoperative assessment of extent of the pituitary adenoma, peroperative findings of transnasal transsphenoidal excision, techniques of skull base repair, complications and its management in a tertiary centre. A prospective analysis from Jan 2017 to May 2019, of patients undergoing ETNTS approach of pituitary adenomas was made in terms of incidence in various age-groups, type of adenoma, operative findings including CSF leak, repair of the skull base defect, complications encountered and its management was done in a tertiary care centre and compared with the present literature. A total of 141 patients underwent ETNTS, with highest number of cases found in 41-50 years age-group with mean age of 42.6 years. Male: Female ratio was 1.6. Macroadenoma was in 123 patients while 18 had microadenoma, of these 63.74% were functional adenoma, highest of GH secreting, while 36.26% were non-functional. Mean surgical time was 98.4 min ± 21.2 min. Peroperative CSF leak was in 30.5% cases in various grades. Closure techniques included use of fat, multilayer techniques, Hadad's flap and gasket technique as per the type of CSF leak. Neurological and rhinological complications were 6.38% each. This study is focused on the ENT perspective of the endoscopic transnasal trans-sphenoidal approach for pituitary adenomas. The reduced rate of morbidity and complications is encouraging. The endoscopic skull base defect closure is challenging and requires skill, meticulous approach and synchronised team work in order to achieve a favourable outcome. The incidence of CSF leak can be minimised and if encountered has to be dealt in an organised manner, thus contributing to a reduced rate of complications. The complications encountered must be foreseen and managed with a proficient approach.