Pituitary apoplexy: pathophysiology, diagnosis and management

Pituitary apoplexy is characterized by sudden increase in pituitary gland volume secondary to ischemia and/or necrosis, usually in a pituitary adenoma. Most cases occur during the 5th decade of life, predominantly in males and in previously unknown clinically non-functioning pituitary adenomas. There are some predisposing factors as arterial hypertension, anticoagulant therapy and major surgery. Clinical picture comprises headache, visual impairment, cranial nerve palsies and hypopituitarism. Most cases improve with both surgical and expectant management and the best approach in the acute phase is still controversial. Surgery, usually by transsphenoidal route, is indicated if consciousness and/or vision are impaired, despite glucocorticoid replacement and electrolyte support. Pituitary function is impaired in most patients before apoplexy and ACTH deficiency is common, which makes glucocorticoid replacement needed in most cases. Pituitary deficiencies, once established, usually do not recover, regardless the treatment. Sellar imaging and endocrinological function must be periodic reevaluated. Arch Endocrinol Metab. 2015;59(3):259-64.

Organ preservation protocols in developing countries.

PURPOSE OF REVIEW: Conservative surgical procedures, radiotherapy and chemoradiotherapy can all be considered in organ preservation strategies for patients with head and neck squamous cell carcinoma. In spite of the contribution of well designed clinical trials, in clinical practice, especially in developing countries, results are related to variables that were usually not considered in such trials. RECENT FINDINGS: The results of most organ preservation studies are focused on survival and larynx preservation, but an evaluation of quality of life and function of the organ is still lacking. We performed a systematic search on the MEDLINE database and could not find any such studies conducted in developing countries. In the present review we consider the possible problems associated with the application of organ preservation strategies in developing countries in some critical areas: advanced stage, comorbidities, nutritional status, long distance to travel, availability of chemotherapy and radiotherapy facilities, tolerance, adherence to protocol standards and expertize in performing salvage surgery. Recent publications strongly suggest that chemoradiation should not be indicated in all patients with advanced laryngeal and hypopharyngeal cancer, but that an individualized treatment strategy should be recommended. SUMMARY: Organ preservation treatments depend on factors related to the physician and the institutions providing healthcare, and also on patients and health systems and socioeconomic factors that make it impossible to extrapolate these results. Only after a meticulous evaluation of the final results of the application of these protocols in each specific environment can they be recommended for carefully selected patients.