Treatment modalities and outcomes of patients with pituitary adenoma at Inkhosi Albert Luthuli Central Hospital at Kwazulu Natal province South Africa

Abstract

Introduction: Pituitary tumours are common, estimated to constitute about 10 to 15 % of brain tumours. They have been studied extensively in developed world than developing and underdeveloped countries. Little is known in KwaZulu Natal province on what are outcomes of different treatment modalities of pituitary adenomas. Objective: The study objective was to assess the treatment modalities and their outcome in patients presented with pituitary adenoma. Materials and Methods: A descriptive cross-sectional retrospective study on patients who presented with pituitary adenomas at IALCH at Durban, KZN province in South Africa from January 2007 to December 2012. Patients were treated, medically, surgically and adjuvant medical and radiotherapy done. Treatment outcomes were assessed versus treatment modalities. Outcomes were considered as improved or not improved in patient preoperative symptoms, residual or no residual tumour. Complications of each treatment modality were assessed. Outcomes were computed and association were determined using Chi- square test and p-values. Results: Out of 42 patients reviewed, 67.5% were female and 33% were males with a male to female ratio of 1:2. Fifty percent of patient had age above 40 years, mean age was 43 years ,with a range of 19 to 76years, median of 40 years ( p-value <0.15). The main clinical presentations were, 48.4% of patient presented with symptoms related to visual disturbances, and 30.6% had headache. Laboratory results were reviewed , Out of 42 patients 6 had prolactinoma,8 had GH secreting tumours, 2 had ACTH secreting tumours. In those prolactinoma patients 66.6% had serum prolactin levels 5000 to 1000001ng/ml, when bromocriptine or carbergoline instituted and patients were followed up for 3 to 6months.It was found that they had both clinical ,visual, biochemical and radiological improvement and this was statistical significance ( p-value <0.04). Eight patients had GH secreting tumours , GH and IGF-1 levels compared preoperative and post operatives, it was found a significant decrease in serum levels in 48hrs and at 3 to six weeks,( p-value <0.0067) this shows a possibility of good outcomes after surgery. A follow up of six month was not adequate for objective conclusion. Among 42 patients who were reviewed, 59.5% had Hardys Classification grade II, 35 patients were treated surgically and 6patients with prolactinomas were treated medically, and one patient died while waiting operation with pituitary apoplexy. Sixty four percent of patients who had transphenoidal surgery had improvement, 4(80%) who had transcranial route, had improvement and there was statistical significant (p-value< 0.060). Considering all surgical modality used in all 35 patients who only 25.7% had no residual tumours and 74.3% had residual tumours. As far as surgical approach is concern, there was no statistical significance among surgical treatment approach used (p-values <0.27). Every surgical treatment had complications post operatively, however the patient who were operated transphenoidally had more complication than other group and this could be due the fact that 67% of patient who were operated had transphenoidal surgery, overall complications were CSF leak s(14.3%),DI (14.3%), Meningitis (8%)and permanent hypopituitarism (29.6%.)Other patients who had residual tumours were either reoperated, treated medically with adjuvant therapy or stereotactic radiotherapy. Conclusion: Medical treatment for prolactin secreting tumours, and Surgical treatment for GH, ACTH, and TSH secreting tumours remain the known modalities of treatment of choice for pituitary adenomas. However sample size was small and findings of this size merit further research. Recommendations: Education is needed to avoid late hospital presentation to prevent avoidable irreversible visual disturbances. There is a need of the IALCH to improve its record keeping. Standardized criteria are of importance in managing patients with residual tumours