In order to investigate the problems faced by patients with pituitary disease, we have reviewed the long-term morbidity and mortality after transsphenoidal surgery in 349 patients who underwent surgery at MGH between 1978 and 1985. Follow-up data were obtained by telephone interview and written questionnaire, and cause of death confirmed by hospital record, family contact, or death certificate. We were specifically interested in:
the relative mortality rate
as compared with controls, and
the overall morbidity as shown
by complications, disability and need for hormone replacement.
We obtained follow-up on 299 of 349 patients (86 %) operated on between 1978-85. Of those lost to follow-up, about 2/3 appear to be foreign nationals. The average age at operation was 41, and mean follow-up was 13 years.
The majority of tumors were either nonfunctioning, includuing alpha secreting tumors, or prolactinornas (recalling that bromocriptine was only coming into wide-spread usage during this period).
Thirty nine deaths were documented over the 13 year follow-up; average age at death was 72 years. The primary cause of death was cardiovascular, at 27.5% followed by non -pituitary neoplasm (20%) and pituitary-related deaths (20%). When compared to the population at large (not age matched), the primary cause of death was also cardiovascular (40%), followed by neoplastic (at 24%).
Do patients with pituitary tumors have a higher mortality rate than the population as a whole? Using age matched historical controls, the expected mortality over the period of follow-up calculated on a per patient per year at risk basis is 44 deaths, as opposed to our actual 39. The validity of this in part depends upon the assumption that those patients lost to follow-up die at the same expected rate.
When calculating expected mortality by tumor type we see that in our group only the Cushing's patients died at a higher than expected rate; those with non-functioning tumors actually lived slightly longer than expected.
Mortality by Tumor Type
- Cushing's -
- Acromegaly -
- NFA -
- Prolactinoma -
- Total -
actual
6
6
22
5
39
predicted
3
5.9
30
5.3
44.2
How did the pituitary related (total=8) deaths occur?
one patient died of metastatic
Cushing's
one died of meningitis after
a craniotomy elsewhere
four patients had giant macroadenomas
refractory to therapy; two patients had pituitary tumors listed
as the cause of death but no other information is available.
The perioperative mortality in this group was zero.
What were the major surgical complications?
three cases of worsening vision
two cases of meningitis
two cases of CSF rhinorrhea
requiring repair
one case of severe epistaxis
requiring embolization
The requirement for long-term homone replacement was clearly a function of whether the patient received radiation treatment; 50% of radiated patients were receiving replacement in at least one axis, while 10% of non-radiated patients did so. The incidence of permanent diabetes insipidus was 3%, in both groups.
Were the patients disabled by surgery for their pituitary tumor? In general, the vast majonty of patients returned to work, with only 4% disabled by their disease.
Overall, then, with modern transsphenoidal surgery and medical management, pituitary disease is well tolerated over long periods of time. The surgery itself carries a low morbidity and mortality, and most patients are able to continue to lead productive lives.
