British Journal of Neurosurgery, October 2014; 28(5): 616–621 © 2014 The Neurosurgical Foundation ISSN: 0268-8697 print / ISSN 1360-046X online DOI: 10.3109/02688697.2013.872225
ORIGINAL ARTICLE
Transsphenoidal pituitary surgery in the elderly is safe and effective Erlick A. C. Pereira1, Puneet Plaha1, Aswin Chari1, Menaka Paranathala1, Nicholas Haslam1, Angela Rogers3, Tim Korevaar3, Diane Tran2, Remi Olarinde3, Niki Karavitaki3, Ashley B. Grossman3 & Simon A. Cudlip1 1Department of Neurological Surgery, John Radcliffe Hospital, Oxford University Hospitals, Oxford, UK, 2Department of Anaesthetics, John Radcliffe Hospital, Oxford University Hospitals, Oxford, UK, and 3Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, University of Oxford, Oxford, UK
Introduction
Abstract Object. With an increasingly ageing population, the number of elderly people diagnosed with pituitary tumours continues to rise. There is a concern that with increasing age and comorbidities, there is higher anaesthetic risk, as well as peri-operative morbidity and mortality from pituitary surgery. This study aimed to audit the benefits and complications of transsphenoidal surgery performed in a large pituitary centre in elderly patients. Methods. Data on all elderly patients (age: ⱖ 70 years) undergoing transsphenoidal surgery at a large tertiary referral centre between November 2003 and August 2012 were collected retrospectively. Results. A total of 104 operations were performed on 102 patients during 106 months. Median age was 75.2 years (range: 70–94) and 63 (61%) of the patients were male. Median follow-up was 15.2 months (range: 2.3–84.4). The majority presented with either peripheral visual field defects (26.4%) or pituitary hormone deficits (17.9%). A significant number (21.7%) of tumours were incidental radiological findings while investigating other diagnoses like stroke and dementia. 48.1% of operations were undertaken microscopically and the remaining 51.9% were endoscopic. Median hospital stay was 4 days (range: 3–18). Intra-operative complications included hypotension (1.9%) and blood loss requiring transfusion (2.9%). The 30-day complications included transient diabetes insipidus (9.6%), syndrome of inappropriate anti-diuretic hormone secretion (8.7%), delayed cerebrospinal fluid leak requiring lumbar drainage (0.9%) with no patient requiring formal repair. There were no peri-operative deaths. Long-term assessment suggested 79% had improved or stable endocrine function with 7% achieving biochemical cure and 91% showed improved or stable visual fields. Conclusions. Pituitary surgery in the elderly, whether microscopic or endoscopic, has low morbidity and mortality and is a safe and effective intervention for both symptom control and functional outcomes.
Pituitary tumours account for a significant proportion of intracranial neoplasms. Recent cross-sectional studies have suggested that they are more common than previously thought, with a study of the community serving our neurosurgical centre estimating a prevalence of 78 pituitary adenomas per 100,000 people.1,2 Several series have suggested that elderly patients account for some 7–10% of presentations for pituitary surgery.3–6 In particular, the widespread use of increasingly advanced neuroimaging has led to more frequent incidental findings of non-functioning adenomas and an enhanced awareness and suspicion of pituitary dysfunction by primary care physicians over the last two decades. However, the clinical diagnosis in the elderly patient may be obfuscated by a wide differential diagnosis, medical co-morbidities, and polypharmacy, and may potentially be missed more often than in younger adults.7 It is important to make and act on this diagnosis as hormonal replacement therapy in elderly patients with hypopituitarism has demonstrably improved quality of life,8 and transsphenoidal surgery has been increasingly considered.9 Nevertheless, clinicians may be dissuaded from investigation and referral of suspected pituitary disease due to a lack of awareness regarding the continued possibility of surgery and its clinical benefits versus their assumptions regarding frailty, increased adverse outcomes, and reduced life expectancy.10,11 On the contrary, an increasingly ageing society presents a need to fairly ensure elderly patients receive maximum benefit from available treatments, and neurosurgery should be no exception for treatment of these usually benign tumours.12 Most literature establishing transsphenoidal surgery as the gold standard of treatment for most pituitary tumours relates to a general adult rather than older population, with little characterisation of risk-benefit ratios in the latter.13 While several recent studies have suggested that transsphenoidal surgery could be a safe and effective
Keywords: adenoma; elderly; endoscopic; outcomes; pituitary; transsphenoidal adenohypophysectomy, tumour
Correspondence: Mr. Erlick A. C. Pereira, Department of Neurosurgery, Level 3, West Wing, John Radcliffe Hospital, Oxford OX3 9DU, UK. Tel: ⫹ 44-1865741166. Fax: ⫹ 44-1865-231885. E-mail: [email protected] Received for publication 13 May 2013; accepted 1 December 2013
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Pituitary surgery in the elderly treatment in elderly patients, without excess mortality or complications,5,6,9,14–20 others have questioned the findings citing the poorer physiological reserve, frailty and multimorbidity of older patients, leading to lack of consensus and controversy.21,22 As lifespans increase in the Western world, definitions of what constitutes an elderly person have also begun to drift upwards from the seventh decade of life to the eighth. This study therefore sought to evaluate the efficacy and safety of transsphenoidal surgery for pituitary tumours in a consecutive cohort of 102 patients of 70 years and older presenting to a single neurosurgical centre with pituitary expertise over a period of nearly nine years.
Table I. Clinical presentations in 102 patients. Incidental Visual field deficit as presenting symptom Bitemporal hemianopia Other need to define Blindness Hormonal Hypothyroidism Panhypopituitarism Acromegaly Cushing ’s Hypogonadism Other eye symptoms need to define Headache Recurrence (clinical or radiological) Apoplexy Collapse
617
23 26 19 8 1 19 8 4 4 2 1 15 6 5 4 4
Patients and methods A retrospective analysis was performed on consecutive elderly patients aged 70 years or more at the time of surgery, undergoing endonasal transsphenoidal surgery at a large tertiary referral centre (Oxford, UK) over 106 months from November 2003 to August 2012. Both microscopic and endoscopic procedures were undertaken endonasally with a trend towards increasing endoscopic operations over the time period, occasionally augmented by image guidance from Medtronic or Brainlab neuronavigation equipment utilizing CT imaging co-registered to the MRI. Surgical indications included the presence of neurological symptoms or signs related to the tumour mass at presentation including visual field deficits; a demonstrated trend of lesion growth or hormonal dysfunction. All patients were assessed by a multi-disciplinary team including endocrinologists and neurosurgeons implementing proactive care.23 Neurological and endocrine examinations were performed six weeks before surgery, immediately before and after surgery and six weeks after surgery, then at six months after surgery, then at annual follow-up. Gadoliniumenhanced T1-weighted MRI was performed preoperatively and regularly during follow-up according to the departmental protocols. Data were collected on presenting features, pre- and post-operative endocrine profiles and visual fields, comorbidities, American Society of Anesthesiologists (ASA) grade, operative procedure, post-operative course and complications. Clinical and biochemical follow-up data were also reviewed. Ethical approval was obtained by local institutional review board regarding the clinical study of human subjects. Data analysis was performed on Microsoft Excel (Microsoft Corporation, USA).
Results Patient characteristics A total of 104 operations were performed on 102 patients over 106 months: 39 (38.2%) were female and 63 (61.8%) were male. The median age at the time of surgery was 75.2 years (range: 70–94 years). The median clinical follow-up was 15 months (range: 2–84). The clinical presentations for all 104 operations are shown in Table I. Twenty-eight (26.9%) presented with visual field defects, while a further 15 (14.4%) presented
with other visual symptoms such as diplopia, decreased visual acuity and/or ophthalmoplegia. There were four presentations (3.8%) of apoplexy. Nineteen (18.2%) presented with endocrine features of hormonal dysfunction as follows: four (3.8%) with acromegaly, two (1.4%) with Cushing ’s disease, eight (7.6%) with hypothyroidism, one (1%) hypogonadism and four (3.8%) with panhypopituitarism. Twenty-three patients (22.6%) had pituitary tumours identified incidentally during investigation for other presentations such as suspected stroke or dementia assessment for memory loss. Six (5.8%) had headache as their sole presenting symptom.
Pre-operative health state In the 102-patient cohort, 310 co-existing medical problems were identified Significant problems are listed in Table II, the most common being hypertension in 61.2% of patients. The cohort had also received 109 previous operations of all types, although only four had undergone previous transsphenoidal surgery. Thirty-four (33.3%) were receiving aspirin, three (2.9%) dual anti-platelet therapy and two (2.0%) warfarin. ASA grades of patients at time of surgery where available are shown in Table III. The majority had ASA Grade 2 (mild systemic disease, 59.5%) or ASA Grade 3 (severe systemic disease, 34.2%). Regarding mobility, 76.9% were independently mobile and did not require carers, 15.4% mobilised with a walking stick, 6.2% required a frame and one patient could not mobilise at all. Overall, 12% required carers before surgery.
Table II. Frequency of comorbidities in 102 patients. Comorbidity Hypertension Hypercholesterolemia Cancer need details Diabetes mellitus Osteoarthritis Ischemic heart disease Atrial fibrillation Benign prostatic hypertrophy Transient ischaemic attacks/stroke Asthma Congestive cardiac failure
Frequency 63 16 14 14 11 11 10 9 7 6 3
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Table III. American Society of Anaesthesiologists (ASA) grade at first surgery. ASA grade Frequency Per cent 1 2 3 4 5 Data unavailable
3 47 27 2 0 23
3.8 59.5 34.2 2.5 0 n/a
1, healthy patient; 2, mild systemic disease; 3, severe systemic disease; 4, lifethreatening disease; 5, emergency.
Surgery and complications Endonasal approaches were used throughout, occasionally with additional neuronavigation (Medtronic or Brainlab): 50 microscopic (48.1%) and 54 (51.9%) endoscopic procedures were performed. An increasing use of endoscopy from 2003 to 2009 was seen, with all cases from 2009 to 2012 being performed endoscopically. Post-operative packing was with a combination of abdominal fat, Spongistan and either Tisseel or Duraseal. Twenty-six (25.0%) were suspected to have cerebrospinal fluid (CSF) leaks at time of surgery, with 18 receiving intra-operative lumbar drain insertion. There were few other intra-operative complications with two patients having episodes of hypotension and three patients requiring a blood transfusion due to haemorrhage. The median hospital stay was 4 days (range: 3–18 days). Post-operative 30-day complication rates are shown in Table IV: 14 patients (13.5%) required lumbar drains to remain inserted after one week, with one additional drain inserted post-operatively due to CSF rhinorrhoea, although none required formal repair during the 30-day period. Transient diabetes insipidus (DI) occurred in 10 patients (9.6%) and transient syndrome of inappropriate anti-diuretic hormone secretion (SIADH) occurred in nine (8.7%). Other complications were relatively rare and included one pulmonary embolus and one complete cardiac conduction block requiring cardiac pacing, but no deaths occurred.
Table IV. Complications within 30 days of surgery for 104 operations. Complication Frequency Per cent CSF leak either requiring lumbar drain or when intra-operative lumbar drain clamped after surgery Diabetes Insipidus Syndrome of inappropriate anti-diuretic hormone secretion Urinary Retention Rhinorrhoea Headache Epistaxis Confusion Other Infection (UTI/LRTI) ITU Admission Required Sinusitis Sixth cranial nerve palsy Arrhythmia Pulmonary embolus Haemorrhage CSF leak requiring formal repair Death CSF, cerebrospinal fluid
15
14.4
10 9
9.6 8.7
7 6 6 5 4 3 2 2 1 1 1 1 0 0
6.7 5.8 5.8 4.8 3.8 2.9 1.9 1.9 1.0 1.0 1.0 1.0 0 0
Table V. Pathological diagnoses in 96 patients. Diagnosis
Frequency
Non-functioning adenoma (NFA) Gonadotroph tumour Apoplexy from NFA Corticotroph tumour Somatotroph tumour Chordoma Rathke’s cleft cyst Lactotroph tumour Granular cell tumour Adamantinous craniopharyngioma
48 22 12 3 3 3 2 1 1 1
Radiological follow-up was for a median of 15.2 months (range: 2–84 months). Of 49 reported MRI images, 4 (8.2%) were reported as having shown complete clearance, 41 (83.7%) reported as having residual tissue stable over time, while only 4 (8.2%) showed signs of enlarging residual tissue potentially requiring reoperation for mass effect in due course.
Pathological diagnoses, hormonal and visual outcomes Pathological diagnoses are shown in Table V. The large majority (85.4%) were non-functioning and gonadotrophic adenomas of which 12.5% showed radiological evidence of haemorrhage. Other tumours accounted for another 7.3% of lesions. Of the remaining 7.3%, three were chordomas, and the others included adamantinomatous craniopharyngioma, Rathke’s cleft cysts and granular cell tumours. Pre-operative endocrine data were available for 92 patients whereas post-operative data were available for 86 patients. The frequencies of pre- and post-operative hormone deficiencies are shown in Table VI. Most (72.9%) had a hormonal deficit before surgery. Long-term endocrine follow-up at a median of 24 months of 86 patients showed that six (7.0%) achieved complete biochemical cure not requiring post-operative hormonal replacement, 12 (14.0%) improved and were deficient in less hormones than pre-operatively, 50 (58.1%) remained stable and only 18 (20.9%) had more hormonal deficits post-operatively (Fig. 1). Humphrey visual field assessments were identified for all but one patient and are categorized in Table VII. Bitemporal hemianopia was the most common finding in 26.5% of patients, followed by normal visual fields in 23.5%. Many of the so-called complex field deficits tabulated comprised a superior temporal quadrantanopia in one eye and nasal deficit in the other. Post-operatively, 41.2% of patients had visual field improvements, 49.4% remained stable and only 9.4% had a deterioration in their visual fields (Fig. 2). Semi-quantitative analysis, where normal visual fields are Table VI. Frequency of hormone deficiencies where assayed in 92 patients before surgery and 86 patients after surgery. Hormonal problem Before After Normal hormonal profile Hormonal abnormality Secondary hypothyroidism Low ACTH Secondary hypoadrenalism Low IGF-1 Low gonadotrophins Secondary hypogonadism
22 70 36 33 29 61
19 67 36 36 30 54
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Fig. 1. Hormonal changes after transsphenoidal surgery at long-term follow-up.
Fig. 2. Visual field changes after transsphenoidal surgery at long-term follow-up.
assigned a value of 1 and blindness a value of 0, suggested a pre-operative mean of 0.66 (SD: 0.26) improving with surgery to 0.73 (SD: 0.27).
Apoplexy rates have remained low at 4–7%. Nonfunctioning adenomas continue to comprise half the cohort and Cushing ’s disease 3–5%. The proportion of growth hormone secreting tumours was much higher historically (13% vs. 3%), but this most likely reflects almost 30% of patients in the historical case series being medically treated. Consequently, prolactinomas comprise 8% of the historical series but appropriately none of the current surgical study. Other rare conditions such as craniopharyngiomas and chordomas remain rare, each comprising 1–3% of both cohorts. Broadly similar results of surgery are seen between the two cohorts, with DI occurring in 10% of operated upon patients, two haematomas occurring historically and one in the current study, and no deaths within 30 days of surgery in either study. What is striking is the very significant increase at the same centre in the number of elderly patients receiving surgery. This is commented upon between historical cohorts comparing the 1980s and 1990s, and again seen when comparing those to the current study.3 As with other series, the commonest mode of presentation in the current study was visual field impairment, confirming the classically late presentation of non-functioning tumours.3,5,6,14–16 Importantly, this was often misattributed in elderly patients to cataracts or macular degeneration, leading to diagnostic delay and therefore delay to treatment in those found to have concomitant hypopituitarism. Vascular comorbidities such as hypertension may contribute towards the significant proportion of apoplectic presentations in this older patient group. The observations of older adults with predominantly non-functioning adenomas presenting usually with visual field defects and small but significant rates of apoplexy reflect other recent large case series, confirming that in the elderly most pituitary tumours are slow growing, presenting as macroadenomas and potentially amenable to transsphenoidal surgery.6,9,14,16 In agreement with Locatelli et al.’s surgical series of 43 patients over 65 years of age, and Sheehan et al.’s surgical
Discussion The study described here is the largest reported consecutive series of patients over the age of 70 years undergoing transsphenoidal surgery. The results suggest that transsphenoidal pituitary surgery is both safe and effective in the older patient. Both presentation and tumour type can be compared in this 102-patient group presenting from 2003 to 2012 to a historical cohort of 84 patients over 65 years of age from the same centre referred between 1975 and 1996.3 The proportions of elderly patients presenting with visual symptoms and hypopituitarism have remained similar at approximately 40% and 20%, respectively. Predictably, the proportion of incidental radiological diagnoses has doubled from just over 11% to just over 22%. Incidental tumours were discussed with patients at multi-disciplinary pituitary clinics involving endocrinologists and neurosurgeons. Conservative, medical, operative and occasionally radiosurgical options were offered where appropriate. A proportion of patients later had symptom onset or received serial imaging demonstrating tumour growth and were offered surgery. Others chose surgery over other management options.
Table VII. Frequency of visual field deficits when formally assessed in 101 patients before surgery and 85 after surgery. Visual field deficit Before After None Bitemporal hemianopia Bitemporal superior quadrantanopia Bitemporal inferior quadrantanopia Other complex field deficit Blind
24 27 15 1 28 6
31 13 7 1 31 2
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series of 64 patients over 70 years old,14,16 nearly two-thirds of this series were also male, perhaps representing that delayed diagnosis is more likely in older men in comparison to women. The finding is not consistent across series, as Kurosaki et al.’s 32-patient series of patients over 70 years old were almost 1:1 in a male to female ratio.15 Unsurprisingly, comorbid medical conditions dominated the older cohort in this study with nearly 85% having moderate or severe systemic disease, mirroring other large series. Locatelli et al.’s study included slightly younger patients aged 65–69 years and only 70% were ASA Grade 2–3.16 Similarly, in Hong et al.’s 103-patient study of patients over 65 years old, 80% were ASA Grade 2–3.6 Sheehan et al.’s cohort over 70 years old had less comorbidities with only 64% being ASA Grade 2–3,14 but nonetheless such proportions across studies appear significantly higher than they would for the younger general adult population, although the increased co-morbidities appeared not to worsen either complications or mortality. Considering complications, rates of transient DI and SIADH at approximately 10% each were lower than some large elderly series but higher than others who have reported an up to a 40% incidence.16,21,22 Such variability may reflect differences in definitions between studies. We define transient dysfunction as resolving within the inpatient episode (mean five days) with medication and not sustained requiring medication beyond 30 days. Similarly, we consider our CSF leak rate low with only one of 104 operations requiring readmission for a lumbar drain and none requiring formal repair. However, 14 received prophylactic lumbar drains intra-operatively. Locatelli et al. reported no postoperative CSF leaks, Sheehan et al. reported 14 intraoperative CSF leaks in 64 patients – none requiring reoperation, Kurosaki et al. described five reoperations for CSF leak in 32 patients and Hong et al. described five intraoperative CSF leaks, none requiring reoperation.6,14–16 Of note, the current series included pathologies more likely to incur CSF leak such as craniopharyngioma, chordoma and Rathke’s cleft cysts, whereas several of the comparison series discussed include only adenomas. Although 16 patients died from other causes at long-term follow-up in Hong et al.’s 103-patient series,6 none of the large elderly series including ours had any peri-operative or 30-day mortality, thus refuting the dogma that transsphenoidal surgery in elderly patients confers excess mortality.14,16 The 7% biochemical cure rate and 14% improved hormonal function reported in the current study at long-term follow-up is lower than the 54% cure rate that Locatelli et al report.16 However, theirs is a hybrid cure report comprising radiological or endocrinological measures and interestingly other large elderly series do not report hormonal cure rates.6,14 We tentatively conclude that biochemical cure rates are lower in elderly cohorts. The finding may be because surgery here usually aims to remove the growing part of a nonfunctioning adenoma from the adjacent compressed optic chiasm rather than radically remove it. Nonetheless, stable endocrinological function in 58% is reassuring regarding surgical outcome, and the radiological appearances often demonstrate radical removal as a consequence of aiming
to relieve neural compression. The primary indication for surgery in the elderly patient therefore appears to be visual field preservation: the current series reports improvement in visual fields with surgery in 41% of treated patients, with progressive deterioration prevented in a further 49%. These results concur with high rates of visual improvement seen in other elderly series,3,6 some despite established visual field loss for greater than six months.16 The suggestion therefore is that transsphenoidal surgery is the treatment of choice for visual field deterioration due to pituitary tumour in the elderly patient, regardless of duration of symptoms. Surgery often does not improve pituitary function, and in the elderly, recovery of pre-operative hypopituitarism is less frequent than in younger patients.5,6,9 The elderly patients in this study, as elsewhere,16 did not receive any particularly special treatment with regard to pre-operative optimisation or peri-operative care in comparison to younger patients, and nor was their mean inpatient stay longer at five days or their level of independence reduced. We therefore suggest that older patients’ age and comorbidities do not warrant special treatment regimes. This study is limited by its design as a retrospective review of hospital records and a small attrition to follow-up in some outcome measures. In addition, a slight heterogeneity of the cohort in comparison to studies purely focusing upon non-functioning adenomas, for example, limits some direct comparisons. We do, however, consider the heterogeneity useful in documenting the epidemiology of different pathologies requiring surgery in this patient group. Other desirable outcomes include longer-term follow-up, direct comparison to patients under 70 years of age within the same time period, and assessment of whether patients had subsequent revision surgery or adjuvant therapies such as radiotherapy. Radiotherapy has a significant risk of inducing hormone deficiencies and small risk of optic nerve damage when employed in a conventional, fractionated manner, as does radiosurgery. As with most other large centres, we generally restrict its use to patients with recurrent tumours.6,9,24,25
Conclusions The study shows transsphenoidal pituitary surgery in elderly patients over 70 years of age to be safe and effective regardless of pathology, in particular for relieving and preventing progression of visual field deficits. Increased age and comorbidities in this patient group do not appear to confer excess morbidity and mortality. The results should be interpreted with the caveat that they arise from patients operated upon at a single, highly specialised neurosurgical centre with a caseload of 80–100 transsphenoidal pituitary operations per annum managed in collaboration with endocrinologists in an endocrinological centre with dedicated pituitary expertise. Considering reports showing significant morbidity and mortality for pituitary surgery in the elderly nationwide across US hospitals,22 we conclude that such patients should only be managed by dedicated, expert multi-disciplinary teams working in high-volume centres where chronological age should not be a barrier
Pituitary surgery in the elderly to surgery. Within this cohort we have treated a 94-year old and Michael Powell recalls treating a 92-year old with apoplexy with good outcome.26 We agree with him that “quite often in our NHS wards, where we have three or four patients together, we have the older pituitary patients mentoring their more tearful juniors.”27
Declaration of interest: The authors report no declarations of interest. The authors alone are responsible for the content and writing of the paper.
References 1. Daly AF, Rixhon M, Adam C, et al. High prevalence of pituitary adenomas: a cross-sectional study in the province of Liege, Belgium. J Clin Endocrinol Metab 2006;91:4769–75. 2. Fernandez A , Karavitaki N, Wass JA . Prevalence of pituitary adenomas: a community-based, cross-sectional study in Banbury (Oxfordshire, UK). Clin Endocrinol 2010;72:377–82. 3. Turner HE, Adams CB, Wass JA . Pituitary tumours in the elderly: a 20 year experience. Eur J Endocrinol 1999;140:383–9. 4. Barzaghi LR, Losa M, Giovanelli M, Mortini P. Complications of transsphenoidal surgery in patients with pituitary adenoma: experience at a single centre. Acta Neurochir 2007;149:877–85; discussion 85–6. 5. Ferrante L, Trillo G, Ramundo E, et al. Surgical treatment of pituitary tumors in the elderly: clinical outcome and long-term follow-up. J Neurooncol 2002;60:185–91. 6. Hong J, Ding X, Lu Y. Clinical analysis of 103 elderly patients with pituitary adenomas: transsphenoidal surgery and follow-up. J Clin Neurosci 2008;15:1091–5. 7. Cohen DL, Bevan JS, Adams CB. The presentation and management of pituitary tumours in the elderly. Age Ageing 1989;18:247–52. 8. Tayal SC, Bansal SK , Chadha DK . Hypopituitarism: a difficult diagnosis in elderly people but worth a search. Age Ageing 1994;23:320–2. 9. Minniti G, Esposito V, Piccirilli M, et al. Diagnosis and management of pituitary tumours in the elderly: a review based on personal experience and evidence of literature. Eur J Endocrinol 2005;153:723–35. 10. Partridge JS, Harari D, Dhesi JK . Frailty in the older surgical patient: a review. Age Ageing 2012;41:142–7.
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11. Vacanti CJ, VanHouten RJ, Hill RC. A statistical analysis of the relationship of physical status to postoperative mortality in 68,388 cases. Anesth Analg 1970;49:564–6. 12. Department of Health. The Impact of Patient Age on Clinical Decision-making in Oncology. London: Department of Health, 2012. 13. Buchfelder M, Schlaffer S. Surgical treatment of pituitary tumours. Best Pract Res Clin Endocrinol Metab 2009;23:677–92. 14. Sheehan JM, Douds GL, Hill K , Farace E. Transsphenoidal surgery for pituitary adenoma in elderly patients. Acta Neurochir 2008;150:571–4; discussion 4. 15. Kurosaki M, Ludecke DK, Flitsch J, Saeger W. Surgical treatment of clinically nonsecreting pituitary adenomas in elderly patients. Neurosurgery 2000;47:843–8; discussion 8–9. 16. Locatelli M, Bertani G, Carrabba G, et al. The trans-sphenoidal resection of pituitary adenomas in elderly patients and surgical risk. Pituitary 2012;Epub Apr 10. 17. Fraioli B, Pastore FS, Signoretti S, De Caro GM, Giuffre R. The surgical treatment of pituitary adenomas in the eighth decade. Surg Neurol 1999;51:261–6; discussion 6–7. 18. Pospiech J, Stolke D, Pospiech FR. Surgical treatment of pituitary adenomas in elderly patients. Acta Neurochir Suppl 1996;65:35–6. 19. Puchner MJ, Knappe UJ, Ludecke DK. Pituitary surgery in elderly patients with acromegaly. Neurosurgery 1995;36:677–83; discussion 83–4. 20. Ross DA , Wilson CB. Results of transsphenoidal microsurgery for growth hormone-secreting pituitary adenoma in a series of 214 patients. J Neurosurg 1988;68:854–67. 21. Freda PU, Bruce JN. Surgery: risks of pituitary surgery in the elderly. Nat Rev Endocrinol 2010;6:606–8. 22. Grossman R, Mukherjee D, Chaichana KL, et al. Complications and death among elderly patients undergoing pituitary tumour surgery. Clin Endocrinol 2010;73:361–8. 23. Harari D, Hopper A , Dhesi J, et al. Proactive care of older people undergoing surgery (‘POPS’): designing, embedding, evaluating and funding a comprehensive geriatric assessment service for older elective surgical patients. Age Ageing 2007;36:190–6. 24. Becker G, Kocher M, Kortmann RD, et al. Radiation therapy in the multimodal treatment approach of pituitary adenoma. Strahlenther Onkol 2002;178:173–86. 25. Sheehan JP, Niranjan A , Sheehan JM, et al. Stereotactic radiosurgery for pituitary adenomas: an intermediate review of its safety, efficacy, and role in the neurosurgical treatment armamentarium. J Neurosurg 2005;102:678–91. 26. Thompson D, Powell M, Foster O. Atypical presentation of vascular events in pituitary tumours: “non-apoplectic” pituitary apoplexy. J Neurol Neurosurg Psychiatry 1994;57:1441–2. 27. Powell M. Comment on Transsphenoidal surgery for pituitary adenoma in elderly patients. Acta Neurochir 2008;150:574.
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ORIGINAL ARTICLE
Transsphenoidal pituitary surgery in the elderly is safe and effective Erlick A. C. Pereira1, Puneet Plaha1, Aswin Chari1, Menaka Paranathala1, Nicholas Haslam1, Angela Rogers3, Tim Korevaar3, Diane Tran2, Remi Olarinde3, Niki Karavitaki3, Ashley B. Grossman3 & Simon A. Cudlip1 1Department of Neurological Surgery, John Radcliffe Hospital, Oxford University Hospitals, Oxford, UK, 2Department of Anaesthetics, John Radcliffe Hospital, Oxford University Hospitals, Oxford, UK, and 3Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, University of Oxford, Oxford, UK
Introduction
Abstract Object. With an increasingly ageing population, the number of elderly people diagnosed with pituitary tumours continues to rise. There is a concern that with increasing age and comorbidities, there is higher anaesthetic risk, as well as peri-operative morbidity and mortality from pituitary surgery. This study aimed to audit the benefits and complications of transsphenoidal surgery performed in a large pituitary centre in elderly patients. Methods. Data on all elderly patients (age: ⱖ 70 years) undergoing transsphenoidal surgery at a large tertiary referral centre between November 2003 and August 2012 were collected retrospectively. Results. A total of 104 operations were performed on 102 patients during 106 months. Median age was 75.2 years (range: 70–94) and 63 (61%) of the patients were male. Median follow-up was 15.2 months (range: 2.3–84.4). The majority presented with either peripheral visual field defects (26.4%) or pituitary hormone deficits (17.9%). A significant number (21.7%) of tumours were incidental radiological findings while investigating other diagnoses like stroke and dementia. 48.1% of operations were undertaken microscopically and the remaining 51.9% were endoscopic. Median hospital stay was 4 days (range: 3–18). Intra-operative complications included hypotension (1.9%) and blood loss requiring transfusion (2.9%). The 30-day complications included transient diabetes insipidus (9.6%), syndrome of inappropriate anti-diuretic hormone secretion (8.7%), delayed cerebrospinal fluid leak requiring lumbar drainage (0.9%) with no patient requiring formal repair. There were no peri-operative deaths. Long-term assessment suggested 79% had improved or stable endocrine function with 7% achieving biochemical cure and 91% showed improved or stable visual fields. Conclusions. Pituitary surgery in the elderly, whether microscopic or endoscopic, has low morbidity and mortality and is a safe and effective intervention for both symptom control and functional outcomes.
Pituitary tumours account for a significant proportion of intracranial neoplasms. Recent cross-sectional studies have suggested that they are more common than previously thought, with a study of the community serving our neurosurgical centre estimating a prevalence of 78 pituitary adenomas per 100,000 people.1,2 Several series have suggested that elderly patients account for some 7–10% of presentations for pituitary surgery.3–6 In particular, the widespread use of increasingly advanced neuroimaging has led to more frequent incidental findings of non-functioning adenomas and an enhanced awareness and suspicion of pituitary dysfunction by primary care physicians over the last two decades. However, the clinical diagnosis in the elderly patient may be obfuscated by a wide differential diagnosis, medical co-morbidities, and polypharmacy, and may potentially be missed more often than in younger adults.7 It is important to make and act on this diagnosis as hormonal replacement therapy in elderly patients with hypopituitarism has demonstrably improved quality of life,8 and transsphenoidal surgery has been increasingly considered.9 Nevertheless, clinicians may be dissuaded from investigation and referral of suspected pituitary disease due to a lack of awareness regarding the continued possibility of surgery and its clinical benefits versus their assumptions regarding frailty, increased adverse outcomes, and reduced life expectancy.10,11 On the contrary, an increasingly ageing society presents a need to fairly ensure elderly patients receive maximum benefit from available treatments, and neurosurgery should be no exception for treatment of these usually benign tumours.12 Most literature establishing transsphenoidal surgery as the gold standard of treatment for most pituitary tumours relates to a general adult rather than older population, with little characterisation of risk-benefit ratios in the latter.13 While several recent studies have suggested that transsphenoidal surgery could be a safe and effective
Keywords: adenoma; elderly; endoscopic; outcomes; pituitary; transsphenoidal adenohypophysectomy, tumour
Correspondence: Mr. Erlick A. C. Pereira, Department of Neurosurgery, Level 3, West Wing, John Radcliffe Hospital, Oxford OX3 9DU, UK. Tel: ⫹ 44-1865741166. Fax: ⫹ 44-1865-231885. E-mail: [email protected] Received for publication 13 May 2013; accepted 1 December 2013
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Pituitary surgery in the elderly treatment in elderly patients, without excess mortality or complications,5,6,9,14–20 others have questioned the findings citing the poorer physiological reserve, frailty and multimorbidity of older patients, leading to lack of consensus and controversy.21,22 As lifespans increase in the Western world, definitions of what constitutes an elderly person have also begun to drift upwards from the seventh decade of life to the eighth. This study therefore sought to evaluate the efficacy and safety of transsphenoidal surgery for pituitary tumours in a consecutive cohort of 102 patients of 70 years and older presenting to a single neurosurgical centre with pituitary expertise over a period of nearly nine years.
Table I. Clinical presentations in 102 patients. Incidental Visual field deficit as presenting symptom Bitemporal hemianopia Other need to define Blindness Hormonal Hypothyroidism Panhypopituitarism Acromegaly Cushing ’s Hypogonadism Other eye symptoms need to define Headache Recurrence (clinical or radiological) Apoplexy Collapse
617
23 26 19 8 1 19 8 4 4 2 1 15 6 5 4 4
Patients and methods A retrospective analysis was performed on consecutive elderly patients aged 70 years or more at the time of surgery, undergoing endonasal transsphenoidal surgery at a large tertiary referral centre (Oxford, UK) over 106 months from November 2003 to August 2012. Both microscopic and endoscopic procedures were undertaken endonasally with a trend towards increasing endoscopic operations over the time period, occasionally augmented by image guidance from Medtronic or Brainlab neuronavigation equipment utilizing CT imaging co-registered to the MRI. Surgical indications included the presence of neurological symptoms or signs related to the tumour mass at presentation including visual field deficits; a demonstrated trend of lesion growth or hormonal dysfunction. All patients were assessed by a multi-disciplinary team including endocrinologists and neurosurgeons implementing proactive care.23 Neurological and endocrine examinations were performed six weeks before surgery, immediately before and after surgery and six weeks after surgery, then at six months after surgery, then at annual follow-up. Gadoliniumenhanced T1-weighted MRI was performed preoperatively and regularly during follow-up according to the departmental protocols. Data were collected on presenting features, pre- and post-operative endocrine profiles and visual fields, comorbidities, American Society of Anesthesiologists (ASA) grade, operative procedure, post-operative course and complications. Clinical and biochemical follow-up data were also reviewed. Ethical approval was obtained by local institutional review board regarding the clinical study of human subjects. Data analysis was performed on Microsoft Excel (Microsoft Corporation, USA).
Results Patient characteristics A total of 104 operations were performed on 102 patients over 106 months: 39 (38.2%) were female and 63 (61.8%) were male. The median age at the time of surgery was 75.2 years (range: 70–94 years). The median clinical follow-up was 15 months (range: 2–84). The clinical presentations for all 104 operations are shown in Table I. Twenty-eight (26.9%) presented with visual field defects, while a further 15 (14.4%) presented
with other visual symptoms such as diplopia, decreased visual acuity and/or ophthalmoplegia. There were four presentations (3.8%) of apoplexy. Nineteen (18.2%) presented with endocrine features of hormonal dysfunction as follows: four (3.8%) with acromegaly, two (1.4%) with Cushing ’s disease, eight (7.6%) with hypothyroidism, one (1%) hypogonadism and four (3.8%) with panhypopituitarism. Twenty-three patients (22.6%) had pituitary tumours identified incidentally during investigation for other presentations such as suspected stroke or dementia assessment for memory loss. Six (5.8%) had headache as their sole presenting symptom.
Pre-operative health state In the 102-patient cohort, 310 co-existing medical problems were identified Significant problems are listed in Table II, the most common being hypertension in 61.2% of patients. The cohort had also received 109 previous operations of all types, although only four had undergone previous transsphenoidal surgery. Thirty-four (33.3%) were receiving aspirin, three (2.9%) dual anti-platelet therapy and two (2.0%) warfarin. ASA grades of patients at time of surgery where available are shown in Table III. The majority had ASA Grade 2 (mild systemic disease, 59.5%) or ASA Grade 3 (severe systemic disease, 34.2%). Regarding mobility, 76.9% were independently mobile and did not require carers, 15.4% mobilised with a walking stick, 6.2% required a frame and one patient could not mobilise at all. Overall, 12% required carers before surgery.
Table II. Frequency of comorbidities in 102 patients. Comorbidity Hypertension Hypercholesterolemia Cancer need details Diabetes mellitus Osteoarthritis Ischemic heart disease Atrial fibrillation Benign prostatic hypertrophy Transient ischaemic attacks/stroke Asthma Congestive cardiac failure
Frequency 63 16 14 14 11 11 10 9 7 6 3
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Table III. American Society of Anaesthesiologists (ASA) grade at first surgery. ASA grade Frequency Per cent 1 2 3 4 5 Data unavailable
3 47 27 2 0 23
3.8 59.5 34.2 2.5 0 n/a
1, healthy patient; 2, mild systemic disease; 3, severe systemic disease; 4, lifethreatening disease; 5, emergency.
Surgery and complications Endonasal approaches were used throughout, occasionally with additional neuronavigation (Medtronic or Brainlab): 50 microscopic (48.1%) and 54 (51.9%) endoscopic procedures were performed. An increasing use of endoscopy from 2003 to 2009 was seen, with all cases from 2009 to 2012 being performed endoscopically. Post-operative packing was with a combination of abdominal fat, Spongistan and either Tisseel or Duraseal. Twenty-six (25.0%) were suspected to have cerebrospinal fluid (CSF) leaks at time of surgery, with 18 receiving intra-operative lumbar drain insertion. There were few other intra-operative complications with two patients having episodes of hypotension and three patients requiring a blood transfusion due to haemorrhage. The median hospital stay was 4 days (range: 3–18 days). Post-operative 30-day complication rates are shown in Table IV: 14 patients (13.5%) required lumbar drains to remain inserted after one week, with one additional drain inserted post-operatively due to CSF rhinorrhoea, although none required formal repair during the 30-day period. Transient diabetes insipidus (DI) occurred in 10 patients (9.6%) and transient syndrome of inappropriate anti-diuretic hormone secretion (SIADH) occurred in nine (8.7%). Other complications were relatively rare and included one pulmonary embolus and one complete cardiac conduction block requiring cardiac pacing, but no deaths occurred.
Table IV. Complications within 30 days of surgery for 104 operations. Complication Frequency Per cent CSF leak either requiring lumbar drain or when intra-operative lumbar drain clamped after surgery Diabetes Insipidus Syndrome of inappropriate anti-diuretic hormone secretion Urinary Retention Rhinorrhoea Headache Epistaxis Confusion Other Infection (UTI/LRTI) ITU Admission Required Sinusitis Sixth cranial nerve palsy Arrhythmia Pulmonary embolus Haemorrhage CSF leak requiring formal repair Death CSF, cerebrospinal fluid
15
14.4
10 9
9.6 8.7
7 6 6 5 4 3 2 2 1 1 1 1 0 0
6.7 5.8 5.8 4.8 3.8 2.9 1.9 1.9 1.0 1.0 1.0 1.0 0 0
Table V. Pathological diagnoses in 96 patients. Diagnosis
Frequency
Non-functioning adenoma (NFA) Gonadotroph tumour Apoplexy from NFA Corticotroph tumour Somatotroph tumour Chordoma Rathke’s cleft cyst Lactotroph tumour Granular cell tumour Adamantinous craniopharyngioma
48 22 12 3 3 3 2 1 1 1
Radiological follow-up was for a median of 15.2 months (range: 2–84 months). Of 49 reported MRI images, 4 (8.2%) were reported as having shown complete clearance, 41 (83.7%) reported as having residual tissue stable over time, while only 4 (8.2%) showed signs of enlarging residual tissue potentially requiring reoperation for mass effect in due course.
Pathological diagnoses, hormonal and visual outcomes Pathological diagnoses are shown in Table V. The large majority (85.4%) were non-functioning and gonadotrophic adenomas of which 12.5% showed radiological evidence of haemorrhage. Other tumours accounted for another 7.3% of lesions. Of the remaining 7.3%, three were chordomas, and the others included adamantinomatous craniopharyngioma, Rathke’s cleft cysts and granular cell tumours. Pre-operative endocrine data were available for 92 patients whereas post-operative data were available for 86 patients. The frequencies of pre- and post-operative hormone deficiencies are shown in Table VI. Most (72.9%) had a hormonal deficit before surgery. Long-term endocrine follow-up at a median of 24 months of 86 patients showed that six (7.0%) achieved complete biochemical cure not requiring post-operative hormonal replacement, 12 (14.0%) improved and were deficient in less hormones than pre-operatively, 50 (58.1%) remained stable and only 18 (20.9%) had more hormonal deficits post-operatively (Fig. 1). Humphrey visual field assessments were identified for all but one patient and are categorized in Table VII. Bitemporal hemianopia was the most common finding in 26.5% of patients, followed by normal visual fields in 23.5%. Many of the so-called complex field deficits tabulated comprised a superior temporal quadrantanopia in one eye and nasal deficit in the other. Post-operatively, 41.2% of patients had visual field improvements, 49.4% remained stable and only 9.4% had a deterioration in their visual fields (Fig. 2). Semi-quantitative analysis, where normal visual fields are Table VI. Frequency of hormone deficiencies where assayed in 92 patients before surgery and 86 patients after surgery. Hormonal problem Before After Normal hormonal profile Hormonal abnormality Secondary hypothyroidism Low ACTH Secondary hypoadrenalism Low IGF-1 Low gonadotrophins Secondary hypogonadism
22 70 36 33 29 61
19 67 36 36 30 54
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Fig. 1. Hormonal changes after transsphenoidal surgery at long-term follow-up.
Fig. 2. Visual field changes after transsphenoidal surgery at long-term follow-up.
assigned a value of 1 and blindness a value of 0, suggested a pre-operative mean of 0.66 (SD: 0.26) improving with surgery to 0.73 (SD: 0.27).
Apoplexy rates have remained low at 4–7%. Nonfunctioning adenomas continue to comprise half the cohort and Cushing ’s disease 3–5%. The proportion of growth hormone secreting tumours was much higher historically (13% vs. 3%), but this most likely reflects almost 30% of patients in the historical case series being medically treated. Consequently, prolactinomas comprise 8% of the historical series but appropriately none of the current surgical study. Other rare conditions such as craniopharyngiomas and chordomas remain rare, each comprising 1–3% of both cohorts. Broadly similar results of surgery are seen between the two cohorts, with DI occurring in 10% of operated upon patients, two haematomas occurring historically and one in the current study, and no deaths within 30 days of surgery in either study. What is striking is the very significant increase at the same centre in the number of elderly patients receiving surgery. This is commented upon between historical cohorts comparing the 1980s and 1990s, and again seen when comparing those to the current study.3 As with other series, the commonest mode of presentation in the current study was visual field impairment, confirming the classically late presentation of non-functioning tumours.3,5,6,14–16 Importantly, this was often misattributed in elderly patients to cataracts or macular degeneration, leading to diagnostic delay and therefore delay to treatment in those found to have concomitant hypopituitarism. Vascular comorbidities such as hypertension may contribute towards the significant proportion of apoplectic presentations in this older patient group. The observations of older adults with predominantly non-functioning adenomas presenting usually with visual field defects and small but significant rates of apoplexy reflect other recent large case series, confirming that in the elderly most pituitary tumours are slow growing, presenting as macroadenomas and potentially amenable to transsphenoidal surgery.6,9,14,16 In agreement with Locatelli et al.’s surgical series of 43 patients over 65 years of age, and Sheehan et al.’s surgical
Discussion The study described here is the largest reported consecutive series of patients over the age of 70 years undergoing transsphenoidal surgery. The results suggest that transsphenoidal pituitary surgery is both safe and effective in the older patient. Both presentation and tumour type can be compared in this 102-patient group presenting from 2003 to 2012 to a historical cohort of 84 patients over 65 years of age from the same centre referred between 1975 and 1996.3 The proportions of elderly patients presenting with visual symptoms and hypopituitarism have remained similar at approximately 40% and 20%, respectively. Predictably, the proportion of incidental radiological diagnoses has doubled from just over 11% to just over 22%. Incidental tumours were discussed with patients at multi-disciplinary pituitary clinics involving endocrinologists and neurosurgeons. Conservative, medical, operative and occasionally radiosurgical options were offered where appropriate. A proportion of patients later had symptom onset or received serial imaging demonstrating tumour growth and were offered surgery. Others chose surgery over other management options.
Table VII. Frequency of visual field deficits when formally assessed in 101 patients before surgery and 85 after surgery. Visual field deficit Before After None Bitemporal hemianopia Bitemporal superior quadrantanopia Bitemporal inferior quadrantanopia Other complex field deficit Blind
24 27 15 1 28 6
31 13 7 1 31 2
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series of 64 patients over 70 years old,14,16 nearly two-thirds of this series were also male, perhaps representing that delayed diagnosis is more likely in older men in comparison to women. The finding is not consistent across series, as Kurosaki et al.’s 32-patient series of patients over 70 years old were almost 1:1 in a male to female ratio.15 Unsurprisingly, comorbid medical conditions dominated the older cohort in this study with nearly 85% having moderate or severe systemic disease, mirroring other large series. Locatelli et al.’s study included slightly younger patients aged 65–69 years and only 70% were ASA Grade 2–3.16 Similarly, in Hong et al.’s 103-patient study of patients over 65 years old, 80% were ASA Grade 2–3.6 Sheehan et al.’s cohort over 70 years old had less comorbidities with only 64% being ASA Grade 2–3,14 but nonetheless such proportions across studies appear significantly higher than they would for the younger general adult population, although the increased co-morbidities appeared not to worsen either complications or mortality. Considering complications, rates of transient DI and SIADH at approximately 10% each were lower than some large elderly series but higher than others who have reported an up to a 40% incidence.16,21,22 Such variability may reflect differences in definitions between studies. We define transient dysfunction as resolving within the inpatient episode (mean five days) with medication and not sustained requiring medication beyond 30 days. Similarly, we consider our CSF leak rate low with only one of 104 operations requiring readmission for a lumbar drain and none requiring formal repair. However, 14 received prophylactic lumbar drains intra-operatively. Locatelli et al. reported no postoperative CSF leaks, Sheehan et al. reported 14 intraoperative CSF leaks in 64 patients – none requiring reoperation, Kurosaki et al. described five reoperations for CSF leak in 32 patients and Hong et al. described five intraoperative CSF leaks, none requiring reoperation.6,14–16 Of note, the current series included pathologies more likely to incur CSF leak such as craniopharyngioma, chordoma and Rathke’s cleft cysts, whereas several of the comparison series discussed include only adenomas. Although 16 patients died from other causes at long-term follow-up in Hong et al.’s 103-patient series,6 none of the large elderly series including ours had any peri-operative or 30-day mortality, thus refuting the dogma that transsphenoidal surgery in elderly patients confers excess mortality.14,16 The 7% biochemical cure rate and 14% improved hormonal function reported in the current study at long-term follow-up is lower than the 54% cure rate that Locatelli et al report.16 However, theirs is a hybrid cure report comprising radiological or endocrinological measures and interestingly other large elderly series do not report hormonal cure rates.6,14 We tentatively conclude that biochemical cure rates are lower in elderly cohorts. The finding may be because surgery here usually aims to remove the growing part of a nonfunctioning adenoma from the adjacent compressed optic chiasm rather than radically remove it. Nonetheless, stable endocrinological function in 58% is reassuring regarding surgical outcome, and the radiological appearances often demonstrate radical removal as a consequence of aiming
to relieve neural compression. The primary indication for surgery in the elderly patient therefore appears to be visual field preservation: the current series reports improvement in visual fields with surgery in 41% of treated patients, with progressive deterioration prevented in a further 49%. These results concur with high rates of visual improvement seen in other elderly series,3,6 some despite established visual field loss for greater than six months.16 The suggestion therefore is that transsphenoidal surgery is the treatment of choice for visual field deterioration due to pituitary tumour in the elderly patient, regardless of duration of symptoms. Surgery often does not improve pituitary function, and in the elderly, recovery of pre-operative hypopituitarism is less frequent than in younger patients.5,6,9 The elderly patients in this study, as elsewhere,16 did not receive any particularly special treatment with regard to pre-operative optimisation or peri-operative care in comparison to younger patients, and nor was their mean inpatient stay longer at five days or their level of independence reduced. We therefore suggest that older patients’ age and comorbidities do not warrant special treatment regimes. This study is limited by its design as a retrospective review of hospital records and a small attrition to follow-up in some outcome measures. In addition, a slight heterogeneity of the cohort in comparison to studies purely focusing upon non-functioning adenomas, for example, limits some direct comparisons. We do, however, consider the heterogeneity useful in documenting the epidemiology of different pathologies requiring surgery in this patient group. Other desirable outcomes include longer-term follow-up, direct comparison to patients under 70 years of age within the same time period, and assessment of whether patients had subsequent revision surgery or adjuvant therapies such as radiotherapy. Radiotherapy has a significant risk of inducing hormone deficiencies and small risk of optic nerve damage when employed in a conventional, fractionated manner, as does radiosurgery. As with most other large centres, we generally restrict its use to patients with recurrent tumours.6,9,24,25
Conclusions The study shows transsphenoidal pituitary surgery in elderly patients over 70 years of age to be safe and effective regardless of pathology, in particular for relieving and preventing progression of visual field deficits. Increased age and comorbidities in this patient group do not appear to confer excess morbidity and mortality. The results should be interpreted with the caveat that they arise from patients operated upon at a single, highly specialised neurosurgical centre with a caseload of 80–100 transsphenoidal pituitary operations per annum managed in collaboration with endocrinologists in an endocrinological centre with dedicated pituitary expertise. Considering reports showing significant morbidity and mortality for pituitary surgery in the elderly nationwide across US hospitals,22 we conclude that such patients should only be managed by dedicated, expert multi-disciplinary teams working in high-volume centres where chronological age should not be a barrier
Pituitary surgery in the elderly to surgery. Within this cohort we have treated a 94-year old and Michael Powell recalls treating a 92-year old with apoplexy with good outcome.26 We agree with him that “quite often in our NHS wards, where we have three or four patients together, we have the older pituitary patients mentoring their more tearful juniors.”27
Declaration of interest: The authors report no declarations of interest. The authors alone are responsible for the content and writing of the paper.
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