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Transection of the Pituitary Stalk in Man: Anatomical Changes in the Pituitary Glands of 21 Patients

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Transection of the Pituitary Stalk in Man: Anatomical Changes in the Pituitary Glands of 21 Patients J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.29.6.545 on 1 December 1966. Downloaded from J. Neurol. Neurosurg. Psychiat., 1966, 29, 545 Transection of the pituitary stalk in man: anatomical changes in the pituitary glands of 21 patients J. HUME ADAMS, PETER M. DANIEL, AND MARJORIE M. L. PRICHARD From the Department ofPathology, The University and Western Infirmary, Glasgow, the Department of Neuropathology, Institute ofPsychiatry, Maudsley Hospital, London, and the Nuffield Institute for Medical Research, University of Oxford In recent years hypophysectomy (Luft and Olive- MATERIAL AND METHODS crona, 1953) and adrenalectomy (which is nearly The pituitary glands from 21 patients were available for always combined with ovariectomy) have been used study. In 20 cases the operation was undertaken for the as methods of treating cases of advanced cancer of relief of carcinoma of the breast or prostate but in one the breast (Atkins, Falconer, Hayward, MacLean, (case 4 in Table I) the indication was a rapidly advancing and Schurr, 1966) and the results of comparative diabetic retinopathy. Fourteen of the patients were trials suggest that hypophysectomy is slightly the females and seven were males. The age range was from guest. Protected by copyright. two (Atkins, Fal- 36 to 67 years. The pituitary stalk was approached by more effective of these operations way of a frontal craniotomy, and in some cases the coner, Hayward, MacLean, Schurr, and Armitage, pituitary stalk was clipped before it was transected at as 1960). As an alternative to hypophysectomy neuro- low a level as was technically possible. In the majority surgeons have sometimes used the operation of pitui- of cases an inert and impermeable barrier or 'plate' tary stalk section for relieving such cases and also for (composed usually of dental acrylic resin or tantalum) treating patients with cancer of the prostate (see was placed between the cut ends of the stalk to prevent Schurr, 1966). In addition pituitary stalk section has the re-establishment of the hypothalamo-hypophysial been used for patients with advancing diabetic retino- portal circulation. pathy (Field, Schepens, Sweet, and Appels, 1962; The period of survival after stalk section ranged from 30 hours to 11 months (see Table I). The necropsies on Cullen, Harris, Munro, and Duncan, 1965; Fager, the majority of the cases were undertaken by P.M.D.or Rees, and Bradley, 1966). In assessing the merits J.H.A. but in a few cases the pituitary glands were sent of this particular operation as a means of depressing to us, and in these less detailed information is available. pituitary function, it is important to know the extent At necropsy care was taken to ensure that the plate did to which the structure of the gland is altered and its not become displaced during the removal of the brain, functions impaired. There are few reports in the and a check was made that there was no vascular con- literature on the effects of stalk section on the human nexion between the hypothalamus and the pituitary pituitary (Dandy and Goetsch, 1911; Russell, 1956; gland and that the position of the plate was satisfactory. Daniel, Prichard, and Schurr, 1958; Le Beau and The gland was then carefully dissected from the pituitary Foncin, 1960; Nicolaidis, 1962; Adams, Daniel, fossa. The pituitaries were fixed whole, either in 10 % formol http://jnnp.bmj.com/ Prichard, and Schurr, 1963), although much saline or in mercuric formol. After fixation two of the information has now been obtained on the effects glands were cut sagittally into five blocks which were then of the operation on several species of animal (Harris, embedded in paraffin wax. Sections (7 ,t or 4 u) were 1950; Barrnett and Greep, 1951; Greep and taken from each block (Fig. la), mounted and stained Barrnett, 1951; Benoit and Assenmacher, 1953; with haematoxylin and eosin, or with iron haematoxylin Campbell and Harris, 1957; Daniel and Prichard, and Van Gieson's mixture, P.A.S., and a few other 1958; Holmes, 1961, 1962; Laszlo, David, and special stains. The remaining 19 glands were bisected Kovics, 1962; Adams, Daniel, and Prichard, in the horizontal plane and after embedding in paraffin 1963a, b, c; 1964a, b, c; 1966a, b; Jacobsohn, 1966). wax were cut serially. The serial sections (usually at on October 1, 2021 by 7 p or 4 jp) were all mounted, and selected sections at We have now had the opportunity of examining various levels were stained as above (Figs. lb and 2-7). the glands of 21 human patients surviving for For technical reasons the two pituitaries which were cut various periods of time after stalk section and in sagittally and two of those cut horizontally were un- this paper we report our findings in these pituitary suitable for measurement, but in the other 17 glands the glands. volumes of the anterior lobe, the infarct or the col- 545 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.29.6.545 on 1 December 1966. Downloaded from 546 J. Hume Adams, Peter M. Daniel, and Marjorie M. L. Prichard TABLE I MEASUREMENTS OF THE ANTERIOR AND POSTERIOR LOBES OF THE PITUITARY GLANDS OF PATIENTS AFTER TRANSECTION OF THE PITUITARY STALK Volumes in mm.3 Anterior Lobe Posterior Lobe Case No. Age Sex Survival after Plate' Whole Surviving Infarct Percentage of Stalk Section Lobe Parenchyma or Scar Lobe Occupied by Infarct or Scar 1 (M.L.) 47 F 30 hours + 216-2 21-8 194-4 90 29-9 2 (J.T.) 57 M 2 days + 127-7 25-4 102 3 80 9.5 3 (A.L.) 61 F 6 days 188-5 40 7 147-8 78 32-2 4 (T.McN) 36 M 7 days + 95-8 83-3 12-5 13 39-4 5 (M.K.) 61 F 11 days - 199-5 102-0 97-5 49 24-1 6 (V.B.) 49 F 15 days + Pituitary gland not measured 7 (R.B.) 37 F 19 days + Pituitary gland not measured 8 (S.) F 3 weeks Pituitary gland not measured 9 (B.L.) 45 F 3j weeks + Pituitary gland not measured 10 (J.McK) 57 M 4 weeks + 116-9 33-6 83-3 71 6-8 11 (G.B.) 52 F 6 weeks - 138-3 99-2 39-1 28 23-3 12 (J.H.) 53 M 21 months + 43-7 17-1 26-6 70 17-6 13 (M.W.) 62 F 3 months + 68-3 52 3 16-0 23 18-1 14 (A.W.) 40 M 3 months + 111-1 31-8 79-3 71 19-9 15 (R.A.) 63 M 3i months + 140-8 108-4 32-4 23 18-3 16 (C.H.) 67 M 4 months + 46-1 39-8 6-3 14 15-2 17 (A.D.) 49 F 4 months + 113-1 91-7 21-4 19 11-0 18 (J.V.) 45 F 6 months + 103-9 67-9 36-0 35 19-5 guest. Protected by copyright. 19 (J.McE) 52 F 11 months + 89-0 87-3 1-7 2 13-3 20 (E.J.) 45 F 11 months - 167-3 164-0 3-3 2 15-9 21 (M.H.) 57 F 11 months + 157-3 79-6 77-7 49 27-2 I+means that an impermeable plate had been inserted at operation between the cut ends of the stalk. -means no plate: a blank means no information available. lagenous scar within the lobe, and the posterior lobe scopical appearances varied according to the length were measured by a method in which Simpson's rule is of survival. First the cytoplasm of the epithelial applied to serial paraffin sections (Adams, Daniel, cells became swollen and homogeneous and the Prichard, and Venables, 1963). Using a projection nuclei became pyknotic. Then the cell boundaries microscope, the requisite areas were measured on disappeared and the nuclei became fragmented. graph paper, and from these the volumes of the various within the infarct contained parts of the gland could be calculated. Many of the sinusoids It would have been of interest to have been able to red blood cells. Immediate reactive changes were compare the volumes of the anterior and posterior lobes restricted to a mild peripheral infiltration of poly- of the pituitary in these stalk-sectioned patients with the morphonuclear leucocytes, but within about a week volumes of these lobes in the normal subject. However, macrophages could be seen within the infarct and the difficulty in obtaining absolutely normal glands from there was an early mild peripheral fibroblastic patients of the various age groups and the great labour reaction. In the three cases that survived for less and time needed to process and measure such glands has than a week the infarct occupied from 78 % to 90 % http://jnnp.bmj.com/ of the work. deterred us from this extension present of the lobe (cases 1-3). In case 4 (survival seven days) there was a very broad band of surviving parenchyma FINDINGS IN THE PITUITARY GLANDS adjacent to the posterior lobe with the result that the anteriorly placed infarct was unusually small, The anterior lobe (pars distalis) of the pituitary gland occupying only 13 % of the lobe. In case 5 (survival was abnormal in every case. In the patients of short 11 days), where there was also an unusually broad survival (cases 1-5 in Table I) the typical finding was band of surviving epithelial cells posteriorly (Fig. a large infarct occupying the greater part of the 2c), the infarct occupied 49 % of the anterior lobe. on October 1, 2021 by lobe. The necrotic tissue was always much paler than In the cases of longer survival there was a col- the surviving epithelial cells (Fig.
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