Pituitary neuroendocrine tumor surgery
Indications
Currently, there is no prioritization scale available to distinguish those patients with pituitary tumors who require urgent surgical intervention from those who are candidates for elective treatment.
To develop a classification system that can help primary care physicians, endocrinologists, neurosurgeons, ancillary support staff, and hospital administrators identify high-priority surgical candidates.
An expert international panel of clinicians consisting of endocrinologists and neurosurgeons who are involved in the diagnosis and management of sellar disease was convened. The panel retrospectively reviewed individual experiences, including a cohort of patients operated upon for pituitary related disease at the Brigham and Women's Hospital from January 2008 to November 2015. A risk stratification schema was developed to streamline patient care pathways.
They identified 4 groups of surgical candidates with varying levels of risk, and then assigned treatment timelines and different differential diagnoses to each. The 4 groups were as follows: group A: urgent-immediate; group B: prompt-initiate treatment within 1 to 2 weeks; group C: soon-initiate treatment within 3 months; group D: elective-as soon as indicated. Among 472 patients treated at Brigham and Women's Hospital for pituitary neuroendocrine tumors, each was assigned to 1 of the 4 predetermined subgroups: group A, 6.8%; group B, 30.1%; group C, 31.1%; group D, 32.0%.
They developed a risk stratification schema that may serve as a platform to streamline care to the patients at highest risk. The expert opinions presented provide a basis for future studies regarding the risk prioritization of patients 1).
Medical preparation for surgery
General principles
1. Stress dose steroids: given to all patients during and immediately after surgery
2. Hypothyroidism: Ideally, hypothyroid patients should have > 4 weeks of replacement to reverse hypothyroidism; however:
a) ✖ Do not replace thyroid hormone until the adrenal axis is assessed; giving thyroid replacement to a patient with hypoadrenalism can precipitate an adrenal crisis. If hypoadrenalism, begin cortisol replacement first, may begin thyroid hormone replacement after 24 hours of cortisol
b) Surgery is done frequently on patients with hypothyroid and appears to be tolerated well in the vast majority of cases.
Pre-op orders
1. for transsphenoidal approach: Polysporin® ointment (PSO) applied in both nostrils the night before surgery
2. antibiotics: e.g., Unasyn® 1.5 gm (1 gm ampicillin + 0.5 gm sulbactam) IVPB at MN & 6 AM
3. steroids, either:
a) hydrocortisone sodium succinate (Solu-Cortef®) 50 mg IM at 11 PM & 6 AM. On call to OR: hang 1 L D5LR + 20 mEq KCl/l + 50 mg Solu-Cortef at 75 ml/hr
OR
b) hydrocortisone 100mg POat MN & IV at 6 AM
4. Intra-op: Continue 100 mg hydrocortisone IV q 8 hrs