Good Morning 12 November 2002. Pituitary Tumor with Acromegaly 麻醉科林子富

Good Morning

12 November 2002

Pituitary Tumor with Pituitary Tumor with AcromegalyAcromegaly

麻醉科林子富麻醉科林子富

Case SummaryCase Summary

A 43-year-old maleA 43-year-old male Schizophrenia under medical control for 20Schizophrenia under medical control for 20++ years years Insidious onset of Insidious onset of enlargement of the jaw, hands, nose enlargement of the jaw, hands, nose

and feet which became prominent in recent 3 yearsand feet which became prominent in recent 3 years Endocrinology work-up and brain MRI revealed pituitary Endocrinology work-up and brain MRI revealed pituitary

tumortumor Called on our OPD for surgical interventionCalled on our OPD for surgical intervention DM, HTN: --DM, HTN: -- Family history: --Family history: --

NE: intactNE: intact VF: hemianopia (L>R)VF: hemianopia (L>R) CBC, coagulation profile, blood chemistry: WNLCBC, coagulation profile, blood chemistry: WNL Endocrinology: Endocrinology:

• T3, T4, TSH, cortisol: WNLT3, T4, TSH, cortisol: WNL• Elevated GHElevated GH

MRI of sella: pituitary microadenomaMRI of sella: pituitary microadenoma Surgical tumor excisionSurgical tumor excision

• Endonasal, transsphenoidEndonasal, transsphenoid

Pituitary Disease and Pituitary Disease and AnesthesiaAnesthesia

M. Smith and N. P. Hirsch. M. Smith and N. P. Hirsch. Br J AnaesthBr J Anaesth 2000; 85: 3–14 2000; 85: 3–14

AnatomyAnatomy

The large anterior lobe or The large anterior lobe or adenohypophysisadenohypophysis and the and the smaller posterior lobe or smaller posterior lobe or neurohypophysisneurohypophysis

The gland averages 6 × 13 × 9 mmThe gland averages 6 × 13 × 9 mm33

Lie within the pituitaryLie within the pituitary fossa or sella turcicafossa or sella turcica Bounded by the roof of the Bounded by the roof of the sphenoid air sinussphenoid air sinus and and

cavernous sinusescavernous sinuses which contain the carotid arteries and which contain the carotid arteries and the third, fourth andthe third, fourth and sixth cranial nervessixth cranial nerves

PhysiologyPhysiology

At least five cellAt least five cell types within the anterior lobe:types within the anterior lobe: • Somatotrophs: Somatotrophs: growth hormonegrowth hormone; 50% ; 50% • ProlactinProlactin-producing-producing lactotrophs; 10–25% lactotrophs; 10–25% • ACTHACTH-producing corticotrophs; 15%.-producing corticotrophs; 15%.• Thyrotrophs: Thyrotrophs: TSHTSH; 5–10% ; 5–10% • Gonadotrophs: Gonadotrophs: FSH and LHFSH and LH; 10% ; 10% • Null cells: non-functioning pituitary adenomasNull cells: non-functioning pituitary adenomas

Growth HormoneGrowth Hormone

• Growth hormone acts on a wide variety ofGrowth hormone acts on a wide variety of

tissues, both directly and through release of tissues, both directly and through release of insulin-like growthinsulin-like growth factor I (IGF-I). factor I (IGF-I).

• In addition toIn addition to stimulating bone and cartilage stimulating bone and cartilage growthgrowth, growth hormone and IGF-I, growth hormone and IGF-I increase increase protein synthesis and lipolysisprotein synthesis and lipolysis whilst decreasing whilst decreasing insulininsulin sensitivity and causing sensitivity and causing NaNa++ retention retention..

Pituitary PathologyPituitary Pathology

Mostly arise from the anterior part of the glandMostly arise from the anterior part of the gland The majority are The majority are benign adenomasbenign adenomas

10–15%10–15% of intracranial neoplasmsof intracranial neoplasms 75% of them secrete inappropriate75% of them secrete inappropriate amounts of pituitary hormonesamounts of pituitary hormones

Malfunction of normal growth-regulating genes, abnormalitiesMalfunction of normal growth-regulating genes, abnormalities of of tumour suppressor genes tumour suppressor genes

Prevalence: 200 perPrevalence: 200 per million of the populationmillion of the population Post-mortem studies: 10–27%. The majority are thereforePost-mortem studies: 10–27%. The majority are therefore

asymptomatic.asymptomatic.

PresentationPresentation

Hormonal hypersecretion syndromesHormonal hypersecretion syndromes hyperprolactinaemia,hyperprolactinaemia, acromegaly and Cushing’s diseaseacromegaly and Cushing’s disease

Mass effectMass effect visual disturbance or raised intracranial pressurevisual disturbance or raised intracranial pressure

Non-specificNon-specific infertility, headache, epilepsyinfertility, headache, epilepsy or pituitary hypofunctionor pituitary hypofunction

IncidentalIncidental detecteddetected during imaging for other conditionsduring imaging for other conditions

GH-secreting tumoursGH-secreting tumours

AcromegalyAcromegaly in the in the adult and adult and gigantismgigantism before epiphyseal before epiphyseal closureclosure

Annual incidenceAnnual incidence of acromegaly is 6-8 cases per millionof acromegaly is 6-8 cases per million Insidious in onset, characterizedInsidious in onset, characterized by by enlargement of the enlargement of the

jaw, hands and feetjaw, hands and feet and and increased softincreased soft tissue growthtissue growth Associated complications of the diseaseAssociated complications of the disease

diabetesdiabetes mellitus and hypertensionmellitus and hypertension

Increase in size of skull and supraorbital ridges; enlarged lower jaw; increase in spacing between teeth/malocclusion

Face

Spade-shaped; carpal tunnel syndromeHands and feet

Macroglossia; thickened pharyngeal and laryngeal soft tissues; obstructive sleep apnoea

Mouth/tongue

Thick skin; doughlike feel to palmSoft tissue

Vertebral enlargement; osteoporosis; kyphosisSkeleton

Hypertension; cardiomegaly; impaired left ventricular functionCardiovascular

Impaired glucose tolerance; diabetesEndocrine

Arthropathy; proximal myopathyOther

Clinical features Affected area

Clinical features of acromegaly

GH-secreting tumoursGH-secreting tumours

Preoperative diagnosis Preoperative diagnosis • A random serum GH concentration of >10 mU litreA random serum GH concentration of >10 mU litre–1 –1 (5 ng ml(5 ng ml–1–1))• Failure of suppression of GHFailure of suppression of GH concentrations to < 2 mU litreconcentrations to < 2 mU litre–1–1

(1 ng ml(1 ng ml–1–1) following) following a 75 g oral glucose load a 75 g oral glucose load • Elevated IGF-IElevated IGF-I

TreatmentTreatment• The primary treatment is The primary treatment is surgerysurgery, with or without subsequent, with or without subsequent

radiotherapyradiotherapy• Dopamine agonists Dopamine agonists • Long-acting analogues of somatostatinLong-acting analogues of somatostatin (such as octreotide)(such as octreotide)

Preoperative AssessmentPreoperative Assessment

VisuaVisual functionl function Signs and symptoms of raised Signs and symptoms of raised intracranialintracranial

pressurepressure Endocrine Endocrine studies; and the effectsstudies; and the effects of hormonal of hormonal

hypersecretion hypersecretion Co-morbiditiesCo-morbidities, particularly in acromegaly or , particularly in acromegaly or

Cushing’sCushing’s syndromesyndrome

AcromegalyAcromegaly

1. 1. Anatomical changesAnatomical changes• prognathismprognathism and macroglossiaand macroglossia• thickening of the pharyngeal and laryngealthickening of the pharyngeal and laryngeal soft soft

tissues and vocal cordstissues and vocal cords• reduction in the size of the laryngealreduction in the size of the laryngeal apertureaperture• hypertrophy of the periepiglottic folds hypertrophy of the periepiglottic folds • recurrentrecurrent laryngeal nerve palsy laryngeal nerve palsy • enlarged thyroid: 25%enlarged thyroid: 25%


2. 2. Sleep apnoeaSleep apnoea • a rare complicatinga rare complicating factor, but is associated with a factor, but is associated with a

high risk of perioperativehigh risk of perioperative airway compromiseairway compromise• upper airway obstruction is the majorupper airway obstruction is the major cause, but cause, but

central depressioncentral depression may also contributemay also contribute• a history of loud snoring and daytime a history of loud snoring and daytime

hypersomnolencehypersomnolence should alert the anaesthetist to the should alert the anaesthetist to the possibility of sleep apnoeapossibility of sleep apnoea


3. 3. HypertensionHypertension• occurs in 30% of patients, but usuallyoccurs in 30% of patients, but usually responds to responds to

therapytherapy• myocardial hypertrophy and interstitialmyocardial hypertrophy and interstitial fibrosis are fibrosis are

common and may be associatedcommon and may be associated with reduced left with reduced left ventricular functionventricular function

4.4. Glucose intoleranceGlucose intolerance• diabetes: 25% diabetes: 25%

Surgical Approach Surgical Approach

The pituitaryThe pituitary fossa can be approached using the fossa can be approached using the transsphenoidaltranssphenoidal, transethmoidal, transethmoidal or transcranial routeor transcranial route

The transsphenoidal route is preferredThe transsphenoidal route is preferred for all but the for all but the largest of tumourslargest of tumours

TranssphenoidalTranssphenoidal access to the pituitary fossa is obtained access to the pituitary fossa is obtained using a sublabialusing a sublabial or or endonasal endonasal approachapproach

Anesthetic Anesthetic Management Management

1. Hormone replacement1. Hormone replacementPreoperative hormone replacement therapy should Preoperative hormone replacement therapy should

be be continuedcontinued into the operative periodinto the operative periodIn general, In general, hydrocortisone 100 mghydrocortisone 100 mg should be should be

administered at induction of anaesthesia in all administered at induction of anaesthesia in all patientspatients undergoing pituitary surgeryundergoing pituitary surgery


2. Airway management2. Airway management Four gradesFour grades of airway involvement: of airway involvement:

• grade 1-- no significant involvementgrade 1-- no significant involvement• grade 2-- nasal and pharyngealgrade 2-- nasal and pharyngeal mucosa hypertrophy but mucosa hypertrophy but

normal cords and glottisnormal cords and glottis• grade 3-- glotticgrade 3-- glottic involvement including glottic stenosis or involvement including glottic stenosis or

vocal cord paresisvocal cord paresis• grade 4-- combination of grades 2 and 3, i.e. glottic andgrade 4-- combination of grades 2 and 3, i.e. glottic and

soft tissue abnormalitiessoft tissue abnormalities

2. Airway management2. Airway management airwayairway management and tracheal intubation proceed management and tracheal intubation proceed

uneventfully in theuneventfully in the majority of patients if majority of patients if large face maskslarge face masks and and long-bladed laryngoscopeslong-bladed laryngoscopes are usedare used

fibreoptic intubationfibreoptic intubation should be considered should be considered in patients in in patients in whom difficult airway management is predictedwhom difficult airway management is predicted

intubating laryngeal mask airwayintubating laryngeal mask airway has also been used has also been used successfullysuccessfully

Equipment for Equipment for tracheostomytracheostomy should should be available if airway be available if airway changes are advanced (recommendedchanges are advanced (recommended for grades 3 and 4)for grades 3 and 4)

2. Airway management2. Airway management the mouth and posterior pharynx shouldthe mouth and posterior pharynx should be be packedpacked

before surgery beginsbefore surgery begins preventprevent bleeding into the glottic region during bleeding into the glottic region during

surgery, but also entrysurgery, but also entry of blood and secretions into of blood and secretions into the stomach which may precipitatethe stomach which may precipitate postoperative postoperative vomitingvomiting


3. Maintenance of anaesthesia3. Maintenance of anaesthesia short-actingshort-acting agentsagents are used to allow rapid recovery at the end are used to allow rapid recovery at the end

of surgeryof surgery During transsphenoidal surgery, ventilation toDuring transsphenoidal surgery, ventilation to normocapnianormocapnia

should be employed. should be employed. (Excessive hyperventilation will(Excessive hyperventilation will result in loss of result in loss of brain bulk and make any suprasellar extensionbrain bulk and make any suprasellar extension of the tumour less of the tumour less accessible from below)accessible from below)

longer-actinglonger-acting opioidsopioids are administered before the end of are administered before the end of surgery so that patientssurgery so that patients do not awaken in pain (IVdo not awaken in pain (IV morphine morphine or IM or IM codeine 20–30 min before the end of surgery)codeine 20–30 min before the end of surgery)


4. Operative complications4. Operative complicationssurgeonsurgeon loses the anatomical landmarks of the fossa loses the anatomical landmarks of the fossa

during transsphenoidalduring transsphenoidal surgery. Deviation laterally surgery. Deviation laterally may result in may result in carotid damagecarotid damage..

risk of developmentrisk of development of a of a false aneurysmfalse aneurysm in the in the postoperative periodpostoperative period

If misses the fossa altogether,If misses the fossa altogether, damage to the damage to the ponspons may occurmay occur


4. Emergence from anaesthesia4. Emergence from anaesthesiaSmooth and rapidSmooth and rapid emergence from anaesthesia is emergence from anaesthesia is

essential to allow early neurological assessment and essential to allow early neurological assessment and maintenancemaintenance of stable respiratory and cardiovascular of stable respiratory and cardiovascular variables.variables.

use of use of short-acting agentsshort-acting agents for maintenance for maintenance of of anaesthesiaanaesthesia

Postoperative Care Postoperative Care

Airway managementAirway management Postoperative analgesiaPostoperative analgesia Hormone replacementHormone replacement Postoperative hormone Postoperative hormone

complicationscomplications

學習心得…學習心得…• 此類病人此類病人 air wayair way 之之 management, management, 雖然雖然

case case 很少…很少…• Keep in mind: endocrine abnormalities Keep in mind: endocrine abnormalities 所造成所造成

的的 co-morbidities.co-morbidities.• Awakening management after neurosurgery…Awakening management after neurosurgery…

Have A Nice Day

Documents

Good Morning 12 November 2002. Pituitary Tumor with Acromegaly 麻醉科 林子富

Good Morning 12 November 2002. Pituitary Tumor with Acromegaly 麻醉科林子富