Elsevier

World Neurosurgery

Volume 106, October 2017, Pages 315-321
World Neurosurgery

Original Article
Risks and Benefits of Endoscopic Transsphenoidal Surgery for Nonfunctioning Pituitary Adenomas in Patients of the Ninth Decade

https://doi.org/10.1016/j.wneu.2017.06.151Get rights and content

Background

The population older than 80 years of age (very elderly) is increasing, and the management of these patients with pituitary surgery is controversial.

Objective

To determine the prevalence of pituitary tumors in elderly patients and to determine the safety of endoscopic transsphenoidal pituitary surgery for nonfunctioning pituitary adenomas in patients aged older than 80 years.

Methods

This retrospective study included elderly (65–75 years old) and very elderly consecutive patients operated between 2007 and 2015 for nonfunctioning pituitary adenomas. Tumor characteristics, comorbidities, pre- and postoperative visual and endocrinologic status, and postoperative complications were compared.

Results

Of the total 623 operated patients, 307 had nonfunctioning pituitary adenomas. Twenty-three percent (n = 143) of all patients were aged older than 65 years, whereas 2.56% (n = 16) were aged older than 80 years. Gonadotroph and nonimmunoreactive tumors occurred in 81% of patients aged older than 65 years. The study groups were Group A, comprising 15 patients aged older than 80 years, and Group B, comprising 49 patients aged 65–75 years. No presurgical statistical differences were noted between the 2 groups.

Complete tumor resection was achieved in 53.3% of Group A and 73.5% of Group B. Postsurgical visual status improved significantly in Group A than in Group B (P = 0.0012). No deaths occurred, and no group differences were noted in the postoperative complications.

Conclusions

Age exceeding 80 years is not by itself a predictor of worse clinical outcome of endoscopic transsphenoidal pituitary surgery for nonfunctioning adenomas. Emphasis should be placed on visual pathway decompression for the quality of life in very old people.

Introduction

Patients older than the age of 65 years are considered elderly, whereas those older than the age of 80 years are considered very elderly.1 The increase in the quality of life and the access to advanced health care services in developed countries has led to a significant increase in life expectancy and in the number of persons living past 80 years of age.2, 3, 4

For this reason and also as the result of improved investigation techniques,5 the overall incidence of brain tumors as well as the prevalence of pituitary tumors, formerly referred as adenomas,6 lately has seen an increase among elderly patients,7, 8 but the prevalence of these latter tumors is not known. However, the high incidence (13%) of pituitary tumors in necropsies of the very elderly has been shown for more than 35 years,9 and the number of patients older than 80 years presenting with pituitary tumors recently has been found to be increased significantly in clinical practice.3

The management of patients with pituitary tumors at such an extreme age is an ongoing controversial issue. Indeed, an exponential increase in the rate of postsurgical mortality in this age group has been in favor of a more conservative approach, represented by nonsurgical management.4, 10

The aims of this study were the following: 1) to determine the prevalence of pituitary tumors in elderly patients older than 65 years of age and 2) to determine the safety of the transsphenoidal endoscopic approach for nonfunctioning pituitary tumors in very elderly patients, aged older than 80 years. To these ends, we conducted a retrospective and comparative study of 2 groups of patients operated on for gonadotrophic or nonimmunoreactive/null cell pituitary tumors who were older than 80 years of age and between 65 and 75 years of age.

Section snippets

Patients

This retrospective study was performed by comparing 2 concomitant and consecutive series of elderly patients operated between 2007 and 2015 for nonfunctioning pituitary adenomas in the Skull Base and Pituitary Surgical Department of the Groupement Hospitalier Est, Lyon, France. Because a clear delineation between elderly and very elderly individuals is practically impossible, we considered a 5-year gap to accurately delineate the elderly patients from the very elderly patients.

The patients were

Prevalence of Pituitary Tumors in Elderly Patients Older 65 Years

Of all the 623 patients operated from 2007 to 2015, including those who underwent the transsphenoidal, cranial approaches, and second surgeries, 23% (n = 143) of the patients were aged older than 65 years, including those aged older than 80 years and 2.56% (n = 16) of the patients were aged older than 80 years. Gonadotroph and null cell tumors represented 81% (116 of 143) of all tumors (Figure 2).

Comparative Study

A consecutive series of very elderly patients, aged older than 80 years, was compared with a series

Discussion

Individuals older than 80 years of age (very elderly patients) constitute a larger proportion of the population and account for an overall prevalence of approximately 2.5% in our study; there is still a debate about the role of pituitary surgery in this patient population.3, 4, 10

Transsphenoidal surgery, especially with the endoscopic technique, has a low mortality (0–0.4%)18 and rare postoperative morbidity, with an especially small rate of CSF leaks (2.2%–3.5%).13, 18 However, studies on very

Conclusions

Age older than 80 years is not in itself a predictor of a worse outcome in patients with pituitary nonfunctioning tumors treated via an endoscopic transsphenoidal approach, which is performed to improve the visual function after complete tumor resection. The significant improvement of the visual status together with the good clinical status and the quick discharge from the hospital are of utmost importance, allowing this extreme age group to benefit from a better quality of life.

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  • Cited by (14)

    • Characteristics of Preoperative Visual Disturbance and Visual Outcome After Endoscopic Endonasal Transsphenoidal Surgery for Nonfunctioning Pituitary Adenoma in Elderly Patients

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      The aim of surgery for NFPA is mainly improvement of visual function affected by compression of the optic chiasm and anterior visual pathways. Although the risk of perioperative morbidity and mortality is higher in elderly patients compared with younger patients undergoing microscopic and endoscopic transsphenoidal surgery for pituitary adenomas,3,10-12 surgical treatment is considered to be well tolerated and feasible in most elderly patients.4-6,9 However, few objective data are available regarding the surgical benefits for visual outcome in elderly patients to justify such surgical indications.

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      These complications can include greater rates of cerebrospinal fluid (CSF) leak, postoperative hormone dysfunction, and visual deficits. Previous studies have aimed to evaluate the role of microsurgical (MS) resection6-20 and endoscopic, endonasal (EE) resection21-25 of pituitary adenomas. One study showed equivalent outcome and safety in elderly patients after MS and EE resection.26

    • Nonfunctioning pituitary adenomas in elderly patients

      2018, Journal of Clinical Neuroscience
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      NFPAs are the most common type of tumor in elderly patients with pituitary adenomas [3,6,7,9–13]. Symptoms of visual impairment were reported to be common among elderly patients, due to the high incidence of NFPAs [4,6,12,14–16]; however, the tumor size of NFPAs in elderly and younger patients did not differ to a statistically significant extent [4,14]. Robenshtok et al. showed that the tumor size of younger patients (<45 years of age) was larger than that of elderly patients (≥65 years of age) [17].

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    Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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