Neurosurgical Techniques

EBEN ALEXANDER, JR., M.D., EDITOR Intracranial Hypophysectomy

BRONSON S. RAY, M.D. Clinical Professor of (), and Director of Neurological Surgery, The New York Hospital- Cornell Medical Center. New York, New York

OTAL removal of the pituitary in man tion, intracranial metastases, and advanced became feasible when the resulting states of debility or other systemic disease. T hypoadrenalism could be controlled by Progressive diabetic retinopathy, uncon- ACTH or cortisone that was made available trolled by medical management, which threat- in the early 1950's. Since then, hypophysec- ens vision can be improved or arrested in its tomy has come to have a valuable place as an progress by surgical hypophysectomy in about elective palliative procedure in selected cases 75 % of selected cases. The best results occur of mammary cancer, prostatic cancer, and in patients under 40 years of age who retain diabetic retinopathy. It has a useful place some useful vision and have not developed also in the treatment of uncontrolled acro- retinitis proliferans or a significant degree of megaly, recurrent chromophobe adenoma, cardiovascular or renal disease. and Cushing's disease. Acromegaly when found to be an active Although there are alternate methods of disease with excessive growth hormone should removing or ablating the pituitary, the trans- be treated by some method designed to ablate frontal intracranial operation has the ad- the tumor. Hypophysectomy by the intra- vantage of providing direct visualization of cranial approach is considered to be appro- the variable anatomy and pathology in and priate at any stage of the disease but particu- about the seUa turcica and is attended by a larly if there is evidence of extrasellar exten- relatively low morbidity and mortality. The sion of the tumor. The risk attending hypo- operation described is the outgrowth of the physectomy may be increased if the operation author's experience with approximately 900 follows unsuccessful transphenoidal proce- hypophysectomies performed for a variety dures that disrupt the floor of the sella. of diseases, among which metastatic breast Contraindications to the operation include cancer has been the commonest. old age, severe cardiovascular disease, and debilitating systemic disease. Selection of Cases Patients who have recurring chromophobe Patients with cancer of the breast or pros- adenoma not controlled by subtotal surgical tate are potential candidates for hypophysec- removal and radiation therapy should be con- tomy when metastases first become evident. sidered for total hypophysectomy if it is be- The beneficial effects of removing the pituitary lieved that the tumor has not invaded adjacent are believed to result from terminating hor- structures. monal influence on the hormone-dependent The presence of Cushing's disease accom- tumor; the earlier this is accomplished the panied by a recognized , better the chance for controlling growth of the particularly if there are visual defects or extra- tumor before it develops autonomy of growth ocular palsies, is an indication for hypophy- independent of hormonal influence. Unfor- sectomy. The operation is appropriate also as tunately, no tests have been developed that an alternative to in the absence will reliably predict the influence of hypo- of a recognized pituitary adenoma or as a physectomy on these two types of cancer but secondary procedure if adrenalectomy proves the rate of objective remission is in the neigh- to be inadequate to control the disease. borhood of 35 to 40% of all cases; the rate is much higher in premenopausal women or in Operative Procedure men when these patients have had temporary Cortisone replacement therapy is started on remission of disease by castration. Specific the afternoon before surgery by administering contraindications for hypophysectomy in- 300 mg of cortisone acetate intramuscularly in clude pulmonary disease with respiratory limi- divided doses. On the day of operation, 50 mg tation, liver disease with reduced hepatic rune- are given intramuscularly every 4 hours; 180