PitNET/Adenomas—Surgical Management, Outcome, and Recurrence Management Flashcards
Surgery for pituitary adenomas require medical management just before and after surgery. Which of the following statements regarding medical management of pituitary adenomas undergoing surgery is incorrect?
● A. A hypothyroid patient cannot tolerate surgery until thyroid replacement is done for at least 4 weeks before surgery
● B. For transsphenoidal surgery, polysporin ointment should be applied in both nostrils a night before surgery
● C. 1 g ampicillin + 0.5 g sulbactam should be given IV at midnight and 6 a.m. before surgery
● D. Hydrocortisone sodium succinate (Solu-Cortef) should be given 50 mg IM at 11 p.m. and 6 a.m. before surgery
● E. On call to OR a drip of dextrose 5% lactated ringer with 20 mEq KCL/L plus 50 mg of Solu-Cortef at 75 mL/h is hung and intraoperative 100 mg hydrocortisone IV every 8 hours is given
A. A hypothyroid patient cannot tolerate surgery until thyroid replacement is done for at least 4 weeks before surgery
What are the indications of transcranial approaches for the surgery of pituitary adenomas?
● A. Minimal enlargement of the sella with a large suprasellar mass, especially if the diaphragma sellae is tightly constricting the tumor (producing a cottage loaf tumor), and the suprasellar component is causing chiasmal compression
● B. Extrasellar extension into the middle fossa that is larger than the intrasellar component
● C. Unrelated pathology that may complicate a transsphenoidal approach, for example, a parasellar aneurysm
● D. Usually fibrous tumor that could not be completely removed on a previous transsphenoidal approach or a recurrent tumor following a previous transsphenoidal surgery
● E. All of the above
E. All of the above
Which of the following statements are correct regarding surgical approaches for pituitary adenomas?
● A. Transsphenoidal approach is indicated for microadenomas, macroadenomas without significant extension laterally beyond the confines of sella turcica, patients with CSF rhinorrhea, and tumors with extension into sphenoid air sinus
● B. Subfrontal approach provides access to both the optic nerves and it may be more difficult in patients with prefixed chiasma
● C. Frontotemporal (pterional) approach places optic nerve and sometimes carotid artery in line of vision of tumor.
There is also limited access to intrasellar components using this approach while it provides good access to tumors with significant unilateral extrasellar extension
● D. Subtemporal approach is usually not a viable choice with poor visualization of optic nerve, chiasma, and carotid artery. It also does not allow total removal of intrasellar component
● E. All of the above
E. All of the above
Transsphenoidal surgery can lead to intraoperative disasters which include injury to carotid artery in the lateral aspect of opening. It needs to be packed with fat, fascia, and woven surgical, which can lead to pseudoaneurysm and needs postoperative detection through CT angiography. This pseudoaneurysm is treated endoscopically or with surgical application of clips above and below the pseudoaneurysm. Other intraoperative disaster is injury to the pons which can occur through which of
the following?
● A. Opening through the floor of the frontal fossa
● B. Opening through the clivus
● C. By reaching deep through the sella and rongeuring blindly
● D. Opening the floor of sella to extreme laterally
● E. Opening through the inferior clinoid
B. Opening through the clivus
Following are the steps in the transsphenoidal surgery to remove pituitary tumor except?
● A. Endoscope is used to locate the middle concha and it is followed posteriorly to identify sphenoid ostium, which is located slightly above the posterior extent of middle concha
● B. Posterior part of the septum is broken and the sphenoid sinus is reached by breaking through the vomer bone
● C. Floor of the sella is opened in the middle using the nasal septum as the midline, using bayoneted chisel or high-speed diamond burr
● D. Dura is opened in plus pattern using bipolar cautery
● E. Tumor is brought into the field using ring curettes and removed with pituitary rongeurs or aspirated with suction
D. Dura is opened in plus pattern using bipolar cautery
What is the most common complication after removal of pituitary adenoma?
● A. Transient alteration in ADH levels with diabetes insipidus
● B. Secondary empty sella syndrome
● C. Hydrocephalus with coma
● D. Pituitary abscess or meningitis
● E. CSF rhinorrhea
A. Transient alteration in ADH levels with diabetes insipidus
In using frontotemporal (pterional) approach for removal of pituitary tumor, right-sided approach is usually employed because of less risk to dominant hemisphere with the exception of which of the following?
● A. When the left eye is the side of worsening
● B. If there is dominant left-sided tumor extension
● C. If there is another pathology on the left side (aneurysm)
● D. If there is some other pathology at that side
● E. All of the above
E. All of the above
Diagnostic criteria for diabetes insipidus is urine output of more than 250 mL/h for 2 hours and urine specific gravity of less than 1.005. Patients after pituitary tumor surgery are placed on DI watch which includes strict intake, output monitoring every 1 hour, urine specific gravity every 4 hour or any
time urine output is more than 250 mL/h, and serum electrolytes every 6 hours. Which statement is incorrect regarding postoperative management of these patients?
● A. Basal IV fluid is 5% dextrose with ½ normal saline plus 20 mEq KCL/L at appropriate rate of 75 to 100 mL/h
● B. If urine output is above the basal, then excess is replaced mL to mL with ½ normal saline
● C. If the urine output is too high (more than 300 mL/h for 4 hours or more than 500 mL/h for 2 hours) and urine specific gravity is also less than 1.005, then vasopressin is started with 5 u aqueous vasopressin IV/IM every 6 hours or desmopressin injection SQ or IV in 0.5 to 1 mL (2–4 μg) in two div-
ided doses
● D. Electrolytes with osmolarity every 6 hours are done
● E. Nasal packing is removed on the second postoperative day
E. Nasal packing is removed on the second postoperative day
After pituitary surgery, hydrocortisone is tapered in 24 to 48 hours postoperatively. 6 a.m. cortisol level is checked after discontinuing hydrocortisone. Which level of cortisol indicates continuation of hydrocortisone?
● A. Less than 12 μg/dL
● B. Less than 15 μg/dL
● C. Less than 9 μg/dL
● D. Less than 18 μg/dL
● E. Less than 21 μg/dL
C. Less than 9 μg/dL
What are the biochemical cure criteria for acromegalic patients after surgery?
● A. IGF 1 levels within age-matched reference range
● B. Basal (morning) serum GH level less than 5 ng/mL
● C. Growth hormone nadir less than 1 ng/mL in OGST
● D. No detectable growth hormone after OGST
● E. A, B, and C
E. A, B, and C
A 40-year-old male presented with features of hypothyroidism. Thyroid function tests showed decreased TSH and T4 levels while MRI showed a pituitary adenoma. Hormone replacement to correct hypothyroidism usually takes how long?
● A. 3 days
● B. 7 days
● C. 10 days
● D. 4 weeks
● E. 3 months
D. 4 weeks
Which of the following transcranial approaches is usually not a viable choice due to poor visualization of optic nerve/chiasm and carotids?
● A. Unifrontal
● B. Subfrontal
● C. Bifrotal
● D. Frontotemporal
● E. Subtemporal
E. Subtemporal
What is the recommended dural opening in endonasal transsphenoidal surgery?
● A. C shaped
● B. Z shaped
● C. Horseshoe shaped
● D. X shaped
● E. + Shaped
D. X shaped
After endonasal transsphenoidal excision of pituitary adenoma, what is the recommended duration for antibiotic cover?
● A. Till nasal pack is removed
● B. Till DI is managed
● C. 24 hours
● D. 7 days
● E. 10 days
A. Till nasal pack is removed
Regarding diagnostic criteria for diabetes insipidus, urinary
specific gravity is which of the following?
● A. > 1.030
● B. > 1.020
● C. > 1.010
● D. < 1.030
● E. < 1.005
E. < 1.005
