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Extra-pseudocapsular Transnasal Transsphenoidal Resection of Pituitary Macroadenoma: Technique Note and Evaluation of Endocrine Function. Curr Med Sci 2022; 42:1148-1156. [PMID: 36542323 DOI: 10.1007/s11596-022-2674-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 11/11/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE In this study, we investigated the surgical technique and endocrine assessment of pituitary function of patients with macroadenoma treated by extra-pseudocapsular transnasal transsphenoidal surgery (ETTS). METHODS Clinical data of 144 patients with pituitary macroadenomas in the same surgical group at the Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology were retrospectively analyzed from January 2019 to June 2021. Based on the results of the endocrinological evaluation and MRI examinations before and after surgery, the fluctuation of pituitary function and the extent of resection were analyzed. Multiple Logistic regression analysis was used to determine the predictors affecting postoperative tumor residual. RESULTS Among the 144 patients with pituitary macroadenomas, 72 (50.0%) were female and 72 (50.0%) were male, the median age was 50 years, 26 (18.1%) had invasiveness grade 0, 46 (31.9%) had grade I, 57 (39.6%) had grade II, and 15 (10.4%) had grade III according to Lu's classification method. Based on observation during surgery, 37 cases (25.7%) had no pseudocapsule, 54 cases (37.5%) had incomplete pseudocapsule, and 53 cases (36.8%) had intact pseudocapsule. In addition, 91 (63.2%) patients had total resection, 39 (27.1%) had subtotal resection, and 14 (9.7%) had partial resection. As for anterior pituitary function, 13 of 19 hypothyroid patients had recovery after surgery, with a remission rate of 68.4%. Eighteen of the 26 decreased cortisol patients got back to normal, with a remission rate of 69.2%. A total of 27 of 51 patients with hypogonadism improved, with a remission rate of 52.9%. Univariate and multivariate analyses indicated that gender, tumor size, and invasiveness were predictors of postoperative residual in patients (P<0.05). CONCLUSION The results showed that ETTS is an effective treatment modality for restoring the function of pituitary gland of the patients with macroadenomas. Tumor size and invasiveness are predictors of the extent of surgical resection and postoperative residual of macroadenomas.
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Scherer M, Zerweck P, Becker D, Kihm L, Jesser J, Beynon C, Unterberg A. The value of intraoperative MRI for resection of functional pituitary adenomas-a critical assessment of a consecutive single-center series of 114 cases. Neurosurg Rev 2022; 45:2895-2907. [PMID: 35567728 PMCID: PMC9349072 DOI: 10.1007/s10143-022-01810-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 03/25/2022] [Accepted: 05/06/2022] [Indexed: 11/29/2022]
Abstract
This series sought to evaluate the role of intraoperative MRI (iMRI) for resection of functional pituitary adenomas (FPAs). We retrospectively reviewed clinical data of 114 consecutive FPAs with excessive hormone secretion treated with transsphenoidal surgery and iMRI during 01/2010-12/2017. We focused on iMRI findings, extend of resection and postoperative hormonal remission. Variables of incomplete resections and persistent hormone excess were evaluated by binary regression. Patients with FPAs presented with hypercortisolism (n = 23, 20%), acromegaly (n = 56, 49%), and as prolactinomas (n = 35, 31%) resistant to medical treatment. Preoperative MRI showed 81 macroadenomas (71%) and optic system involvement in 41 cases (36%). IMRI was suggestive for residual tumor in 51 cases (45%). Re-inspection of the cavity cleared equivocal findings in 16 cases (14%). Additional tumor was removed in 22 cases (19%). Complete resection was achieved in 95 cases (83%). Postoperative morbidity was low (1.7% revision surgeries, 0.8% permanent diabetes insipidus). Overall hormonal remission-rate was 59% (hypercortisolism 78%, acromegaly 52%, prolactinoma 57%). Supra- and parasellar invasion and preoperative visual impairment were significant predictors for incomplete resections despite use of iMRI. Risk for persistent hormone excess was increased sevenfold after incomplete resections. IMRI enabled reliable identification of tumor remnants during surgery and triggered further resection in a considerable proportion of cases. Nevertheless, tumor size and invasiveness set persistent boundaries to the completeness of resections. The low rate of surgical complications could point at a less invasive iMRI-guided surgical approach while achieving a complete tumor resection was a crucial determinant for hormonal outcome.
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Affiliation(s)
- Moritz Scherer
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.
| | - Paul Zerweck
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Daniela Becker
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Lars Kihm
- Department of Endocrinology, Heidelberg University Hospital, Heidelberg, Germany
| | - Jessica Jesser
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Christopher Beynon
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Andreas Unterberg
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
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Chen J, Liu H, Man S, Liu G, Li Q, Zuo Q, Huo L, Li W, Deng W. Endoscopic vs. Microscopic Transsphenoidal Surgery for the Treatment of Pituitary Adenoma: A Meta-Analysis. Front Surg 2022; 8:806855. [PMID: 35187049 PMCID: PMC8847202 DOI: 10.3389/fsurg.2021.806855] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 12/20/2021] [Indexed: 11/13/2022] Open
Abstract
PurposeCurrently, endoscopic transsphenoidal surgery (ETS) and microscopic transsphenoidal surgery (MTS) are commonly applied treatments for patients with pituitary adenomas. This meta-analysis was conducted to evaluate the efficacy and safety of ETS and MTS for these patients.MethodsA computer search of Pubmed, Embase, Cochrane library, Web of Science, and Google Scholar databases was conducted for studies investigating ETS and MTS for patients with pituitary adenomas. The deadline is March 01, 2021. RevMan5.1 software was used to complete this meta-analysis after literature screening, data extraction, and literature quality evaluation.ResultsA total of 37 studies including 5,591 patients were included. There was no significant difference in gross tumor removal (GTR) and hormone-excess secretion remission (HES remission) between two groups [RR = 1.10, 95% CI (0.99–1.22), P = 0.07; RR = 1.09, 95% CI (1.00–1.20), P = 0.05]. ETS was associated with lower incidence of diabetes insipidus (DI) [RR = 0.71, 95% CI (0.58–0.87), P = 0.0008], hypothyroidism [RR = 0.64, 95% CI (0.47–0.89), P = 0.007], and septal perforation [RR = 0.32, 95% CI (0.13–0.79), P = 0.01] than those with MTS.ConclusionThis meta-analysis indicated that ETS cannot significantly improve GTR and HES remission. However, ETS could reduce the incidence of DI, hypothyroidism, and septal perforation without increasing the rate of other complications.Systematic Review Registrationhttps://www.crd.york.ac.uk/prospero/#myprospero, identifier: CRD42021241217.
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Affiliation(s)
- Jia Chen
- Department of Endocrinology, Beijing Jishuitan Hospital, Beijing, China
| | - Hongyan Liu
- Department of Endocrinology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Siliang Man
- Department of Rheumatology, Beijing Jishuitan Hospital, Beijing, China
| | - Geng Liu
- Department of Endocrinology, Beijing Jishuitan Hospital, Beijing, China
- Department of Emergency, Beijing Jishuitan Hospital, Beijing, China
| | - Quan Li
- Department of Endocrinology, Beijing Jishuitan Hospital, Beijing, China
| | - Qingyao Zuo
- Department of Endocrinology, Beijing Jishuitan Hospital, Beijing, China
| | - Lili Huo
- Department of Endocrinology, Beijing Jishuitan Hospital, Beijing, China
| | - Wei Li
- Department of Endocrinology, Beijing Jishuitan Hospital, Beijing, China
| | - Wei Deng
- Department of Endocrinology, Beijing Jishuitan Hospital, Beijing, China
- *Correspondence: Wei Deng
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Voellger B, Zhang Z, Benzel J, Wang J, Lei T, Nimsky C, Bartsch JW. Targeting Aggressive Pituitary Adenomas at the Molecular Level-A Review. J Clin Med 2021; 11:jcm11010124. [PMID: 35011868 PMCID: PMC8745122 DOI: 10.3390/jcm11010124] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 12/11/2021] [Accepted: 12/21/2021] [Indexed: 12/14/2022] Open
Abstract
Pituitary adenomas (PAs) are mostly benign endocrine tumors that can be treated by resection or medication. However, up to 10% of PAs show an aggressive behavior with invasion of adjacent tissue, rapid proliferation, or recurrence. Here, we provide an overview of target structures in aggressive PAs and summarize current clinical trials including, but not limited to, PAs. Mainly, drug targets in PAs are based on general features of tumor cells such as immune checkpoints, so that programmed cell death 1 (ligand 1) (PD-1/PD-L1) targeting may bear potential to cure aggressive PAs. In addition, epidermal growth factor receptor (EGFR), mammalian target of rapamycin (mTOR), vascular endothelial growth factor (VEGF), fibroblast growth factor (FGF) and their downstream pathways are triggered in PAs, thereby modulating tumor cell proliferation, migration and/or tumor angiogenesis. Temozolomide (TMZ) can be an effective treatment of aggressive PAs. Combination of TMZ with 5-Fluorouracil (5-FU) or with radiotherapy could strengthen the therapeutic effects as compared to TMZ alone. Dopamine agonists (DAs) are the first line treatment for prolactinomas. Dopamine receptors are also expressed in other subtypes of PAs which renders DAs potentially suitable to treat other subtypes of PAs. Furthermore, targeting the invasive behavior of PAs could improve therapy. In this regard, human matrix metalloproteinase (MMP) family members and estrogens receptors (ERs) are highly expressed in aggressive PAs, and numerous studies demonstrated the role of these proteins to modulate invasiveness of PAs. This leaves a number of treatment options for aggressive PAs as reviewed here.
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Affiliation(s)
- Benjamin Voellger
- Department of Neurosurgery, University Hospital Marburg, Baldingerstr., 35033 Marburg, Germany; (Z.Z.); (J.B.); (J.W.); (C.N.); (J.-W.B.)
- Correspondence: ; Tel.: +49-6421-58-66447
| | - Zhuo Zhang
- Department of Neurosurgery, University Hospital Marburg, Baldingerstr., 35033 Marburg, Germany; (Z.Z.); (J.B.); (J.W.); (C.N.); (J.-W.B.)
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan 430030, China;
| | - Julia Benzel
- Department of Neurosurgery, University Hospital Marburg, Baldingerstr., 35033 Marburg, Germany; (Z.Z.); (J.B.); (J.W.); (C.N.); (J.-W.B.)
- Deutsches Krebsforschungszentrum (DKFZ) Heidelberg, Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
| | - Junwen Wang
- Department of Neurosurgery, University Hospital Marburg, Baldingerstr., 35033 Marburg, Germany; (Z.Z.); (J.B.); (J.W.); (C.N.); (J.-W.B.)
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan 430030, China;
| | - Ting Lei
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan 430030, China;
| | - Christopher Nimsky
- Department of Neurosurgery, University Hospital Marburg, Baldingerstr., 35033 Marburg, Germany; (Z.Z.); (J.B.); (J.W.); (C.N.); (J.-W.B.)
| | - Jörg-Walter Bartsch
- Department of Neurosurgery, University Hospital Marburg, Baldingerstr., 35033 Marburg, Germany; (Z.Z.); (J.B.); (J.W.); (C.N.); (J.-W.B.)
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Staartjes VE, Togni-Pogliorini A, Stumpo V, Serra C, Regli L. Impact of intraoperative magnetic resonance imaging on gross total resection, extent of resection, and residual tumor volume in pituitary surgery: systematic review and meta-analysis. Pituitary 2021; 24:644-656. [PMID: 33945115 PMCID: PMC8270798 DOI: 10.1007/s11102-021-01147-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/15/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Residual tumor tissue after pituitary adenoma surgery, is linked with additional morbidity and mortality. Intraoperative magnetic resonance imaging (ioMRI) could improve resection. We aim to assess the improvement in gross total resection (GTR), extent of resection (EOR), and residual tumor volume (RV) achieved using ioMRI. METHODS A systematic review was carried out on PubMed/MEDLINE to identify any studies reporting intra- and postoperative (1) GTR, (2) EOR, or (3) RV in patients who underwent resection of pituitary adenomas with ioMRI. Random effects meta-analysis of the rate of improvement after ioMRI for these three surgical outcomes was intended. RESULTS Among 34 included studies (2130 patients), the proportion of patients with conversion to GTR (∆GTR) after ioMRI was 0.19 (95% CI 0.15-0.23). Mean ∆EOR was + 9.07% after ioMRI. Mean ∆RV was 0.784 cm3. For endoscopically treated patients, ∆GTR was 0.17 (95% CI 0.09-0.25), while microscopic ∆GTR was 0.19 (95% CI 0.15-0.23). Low-field ioMRI studies demonstrated a ∆GTR of 0.19 (95% CI 0.11-0.28), while high-field and ultra-high-field ioMRI demonstrated a ∆GTR of 0.19 (95% CI 0.15-0.24) and 0.20 (95% CI 0.13-0.28), respectively. CONCLUSIONS Our meta-analysis demonstrates that around one fifth of patients undergoing pituitary adenoma resection convert from non-GTR to GTR after the use of ioMRI. EOR and RV can also be improved to a certain extent using ioMRI. Endoscopic versus microscopic technique or field strength does not appear to alter the impact of ioMRI. Statistical heterogeneity was high, indicating that the improvement in surgical results due to ioMRI varies considerably by center.
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Affiliation(s)
- Victor E Staartjes
- Machine Intelligence in Clinical Neuroscience (MICN) Laboratory, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Alex Togni-Pogliorini
- Machine Intelligence in Clinical Neuroscience (MICN) Laboratory, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Vittorio Stumpo
- Machine Intelligence in Clinical Neuroscience (MICN) Laboratory, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Carlo Serra
- Machine Intelligence in Clinical Neuroscience (MICN) Laboratory, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland.
| | - Luca Regli
- Machine Intelligence in Clinical Neuroscience (MICN) Laboratory, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
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Utility of intraoperative ultrasonography for resection of pituitary adenomas: a comparative retrospective study. Acta Neurochir (Wien) 2021; 163:1725-1734. [PMID: 33403430 DOI: 10.1007/s00701-020-04674-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 12/04/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND The evolution of pituitary surgery has made it a safe and effective form of treatment; however, risks of inadequate tumor resection, cerebrospinal fluid (CSF) leak, pituitary dysfunction, and vascular injury still exist. The use of intraoperative ultrasonography (IOUS) in pituitary surgery has been well described. Recent advancements in ultrasound technology have allowed for expanded utility as described here. METHODS A retrospective review was performed between January 2016 and December 2019. One hundred thirty-eight patients (mean age 53.7 years, 47% females) were identified undergoing transsphenoidal surgery for pituitary tumors. Thirty-four patients had IOUS performed using a side-firing ultrasound probe, while 104 did not. Data was analyzed for preoperative (demographics, clinical, and radiographic features), perioperative (blood loss, operative time), and postoperative (complications, length of stay, hormone remission, and extent of resection) outcomes. RESULTS There were no significant differences in patient age, gender, tumor volume, Knosp grade, and hormone-secreting status between the two groups. Patients treated using IOUS had significantly higher rates of gross total resection (79% vs. 44%, p = 0.0008), shorter operative times (74 vs. 146 min, p < 0.0001), lower blood loss (119 vs. 284 cc, p < 0.0001), and hospital stays (2.9 vs. 4.2 days, p = 0.001). Overall complication rates were lower in the IOUS group compared to standard pituitary surgery but did not reach significance. CONCLUSIONS Recent improvements in ultrasound technology have allowed for miniaturization of probes capable of delivering high-resolution images. The use of IOUS in transsphenoidal pituitary surgery may significantly increase rates of gross total resection, while decreasing blood loss, hospital LOS, and operative time.
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Perosevic M, Jones PS, Tritos NA. Magnetic resonance imaging of the hypothalamo-pituitary region. HANDBOOK OF CLINICAL NEUROLOGY 2021; 179:95-112. [PMID: 34225987 DOI: 10.1016/b978-0-12-819975-6.00004-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The diagnosis and management of mass lesions in the sellar and parasellar areas remain challenging. When approaching patients with possible sellar or hypothalamic masses, it is important not only to focus on imaging but also detect possible pituitary hormone deficits or excess, in order to establish an appropriate diagnosis and initiate treatment. The imaging modalities used to characterize hypothalamic and pituitary lesions have significantly evolved over the course of the past several years. Computed tomography (CT) and CT angiography play a major role in detecting various sellar lesions, especially in patients who have contraindications to magnetic resonance imaging (MRI) and can also yield important information for surgical planning. However, MRI has become the gold standard for the detection and characterization of hypothalamic and pituitary tumors, infections, cystic, or vascular lesions. Indeed, the imaging characteristics of hypothalamic and sellar lesions can help narrow down the differential diagnosis preoperatively. In addition, MRI can help establish the relationship of mass lesions to surrounding structures. A pituitary MRI examination should be obtained if there is concern for mass effect (including visual loss, ophthalmoplegia, headache) or if there is clinical suspicion and laboratory evidence of either hypopituitarism or pituitary hormone excess. The information obtained from MRI images also provides us with assistance in planning surgery. Using intraoperative MRI can be very helpful in assessing the adequacy of tumor resection. In addition, MRI images yield reliable data that allow for noninvasive monitoring of patients postoperatively.
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Affiliation(s)
- Milica Perosevic
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States.
| | - Pamela S Jones
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Nicholas A Tritos
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
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Garcia-Garcia S, García-Lorenzo B, Ramos PR, Gonzalez-Sanchez JJ, Culebras D, Restovic G, Alcover E, Pons I, Torales J, Reyes L, Sampietro-Colom L, Enseñat J. Cost-Effectiveness of Low-Field Intraoperative Magnetic Resonance in Glioma Surgery. Front Oncol 2020; 10:586679. [PMID: 33224884 PMCID: PMC7667256 DOI: 10.3389/fonc.2020.586679] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 10/09/2020] [Indexed: 12/01/2022] Open
Abstract
Object Low-field intraoperative magnetic resonance (LF-iMR) has demonstrated a slight increase in the extent of resection of intra-axial tumors while preserving patient`s neurological outcomes. However, whether this improvement is cost-effective or not is still matter of controversy. In this clinical investigation we sought to evaluate the cost-effectiveness of the implementation of a LF-iMR in glioma surgery. Methods Patients undergoing LF-iMR guided glioma surgery with gross total resection (GTR) intention were prospectively collected and compared to an historical cohort operated without this technology. Socio-demographic and clinical variables (pre and postoperative KPS; histopathological classification; Extent of resection; postoperative complications; need of re-intervention within the first year and 1-year postoperative survival) were collected and analyzed. Effectiveness variables were assessed in both groups: Postoperative Karnofsky performance status scale (pKPS); overall survival (OS); Progression-free survival (PFS); and a variable accounting for the number of patients with a greater than subtotal resection and same or higher postoperative KPS (R-KPS). All preoperative, procedural and postoperative costs linked to the treatment were considered for the cost-effectiveness analysis (diagnostic procedures, prosthesis, operating time, hospitalization, consumables, LF-iMR device, etc). Deterministic and probabilistic simulations were conducted to evaluate the consistency of our analysis. Results 50 patients were operated with LF-iMR assistance, while 146 belonged to the control group. GTR rate, pKPS, R-KPS, PFS, and 1-year OS were respectively 13,8% (not significative), 7 points (p < 0.05), 17% (p < 0.05), 38 days (p < 0.05), and 3.7% (not significative) higher in the intervention group. Cost-effectiveness analysis showed a mean incremental cost per patient of 789 € in the intervention group. Incremental cost-effectiveness ratios were 111 € per additional point of pKPS, 21 € per additional day free of progression, and 46 € per additional percentage point of R-KPS. Conclusion Glioma patients operated under LF-iMR guidance experience a better functional outcome, higher resection rates, less complications, better PFS rates but similar life expectancy compared to conventional techniques. In terms of efficiency, LF-iMR is very close to be a dominant technology in terms of R-KPS, PFS and pKPS.
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Affiliation(s)
| | - Borja García-Lorenzo
- Assessment of Innovations and New Technologies Unit, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | | | | | - Diego Culebras
- Department of Neurological Surgery, Hospital Clinic, Barcelona, Spain
| | - Gabriela Restovic
- Assessment of Innovations and New Technologies Unit, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Estanis Alcover
- Economic and Financial Management Department, Hospital Clinic, Barcelona, Spain
| | - Imma Pons
- Economic and Financial Management Department, Hospital Clinic, Barcelona, Spain
| | - Jorge Torales
- Department of Neurological Surgery, Hospital Clinic, Barcelona, Spain
| | - Luis Reyes
- Department of Neurological Surgery, Hospital Clinic, Barcelona, Spain
| | - Laura Sampietro-Colom
- Assessment of Innovations and New Technologies Unit, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Joaquim Enseñat
- Department of Neurological Surgery, Hospital Clinic, Barcelona, Spain
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Peto I, Abou-Al-Shaar H, White TG, Abunimer AM, Kwan K, Zavadskiy G, Wagner K, Black K, Eisenberg M, Bruni M, Dehdashti AR. Sources of residuals after endoscopic transsphenoidal surgery for large and giant pituitary adenomas. Acta Neurochir (Wien) 2020; 162:2341-2351. [PMID: 32700080 DOI: 10.1007/s00701-020-04497-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 07/14/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Giant and large pituitary adenomas (PA) constitute a specific subset of PAs, with gross total resection (GTR) rates frequently not exceeding 50%. Both an anatomical inaccessibility and an inadequate tumor visualization are thought to play a role. This study analyzes risk factors for postoperative residuals after endoscopic transsphenoidal pituitary surgery for large and giant pituitary adenomas. METHODS A retrospective analysis of patients with giant and large PA operated between 2015 and 2018 was performed. RESULTS Forty patients (13 females, 27 males) were included in the analysis (30 large and 10 giant PAs). The mean MRI follow-up time was 5.9 ± 6.54 months. Overall, GTR was achieved in 29 patients (72.5%), subtotal resection in 9 (22.5%), and the inconclusive result was in 2 (5%). Unexpected residuals represented 7 (77.7%) of all 9 residual tumors. The most frequent intraoperative factor associated with unexpected residual tumors was improper identification of residual tumor due to obstruction of view in 2 (28.5%) cases and inability to distinguish normal tissue from tumor in the other two (28.5%). Sub-analysis based on tumor size revealed that with large PAs, GTR was achieved in 25 (83.3%), STR in 4 (13.3%), and inconclusive in 1 (3.3%) patient. In patients with giant PAs, GTR was achieved in 4 (40%), STR in 5 (50%), and inconclusive in 1 (10%). Analysis of preoperative factors showed a significant association of residual tumors with larger suprasellar AP distance (p = 0.041), retrosellar extension (p = 0.007), and higher Zurich Score (p = 0.029). CONCLUSION Large and giant PAs are challenging lesions with high subtotal resection rates. Suprasellar AP distance, retrosellar extension, and higher Zurich Score seem to be significant predictors of degree of resection in these tumors. Improving the intraoperative ability to distinguish tumor from a normal tissue might further decrease the number of unexpected residuals.
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Affiliation(s)
- Ivo Peto
- Department of Neurosurgery, Hofstra Northwell School of Medicine, Manhasset, NY, 11030, USA.
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL, 33606, USA.
| | - Hussam Abou-Al-Shaar
- Department of Neurosurgery, Hofstra Northwell School of Medicine, Manhasset, NY, 11030, USA
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Timothy G White
- Department of Neurosurgery, Hofstra Northwell School of Medicine, Manhasset, NY, 11030, USA
| | - Abdullah M Abunimer
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kevin Kwan
- Department of Neurosurgery, Hofstra Northwell School of Medicine, Manhasset, NY, 11030, USA
| | | | - Katherine Wagner
- Department of Neurosurgery, Hofstra Northwell School of Medicine, Manhasset, NY, 11030, USA
| | - Karen Black
- Department of Neuroradiology, North Shore University Hospital, Hofstra Northwell School of Medicine, Manhasset, NY, USA
| | - Mark Eisenberg
- Department of Neurosurgery, Hofstra Northwell School of Medicine, Manhasset, NY, 11030, USA
| | - Margherita Bruni
- Department of Otolaryngology, New York Head & Neck Institute, New York, NY, USA
| | - Amir R Dehdashti
- Department of Neurosurgery, Hofstra Northwell School of Medicine, Manhasset, NY, 11030, USA.
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10
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Schmale IL, Vandelaar LJ, Luong AU, Citardi MJ, Yao WC. Image-Guided Surgery and Intraoperative Imaging in Rhinology: Clinical Update and Current State of the Art. EAR, NOSE & THROAT JOURNAL 2020; 100:NP475-NP486. [PMID: 32453646 DOI: 10.1177/0145561320928202] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Image-guided surgery (IGS) has gained widespread acceptance in otorhinolaryngology for its applications in sinus and skull base surgery. Although the core concepts of IGS have not changed, advances in image guidance technology, including the incorporation of intraoperative imaging, have the potential to enhance surgical education, allow for more rigorous preoperative planning, and aid in more complete surgery with improved outcomes. OBJECTIVES Provide a clinical update regarding the use of image guidance and intraoperative imaging in the field of rhinology and endoscopic skull base surgery with a focus on current state of the art technologies. METHODS English-language studies published in PubMed, Cochrane, and Embase were searched for articles relating to image-guided sinus surgery, skull base surgery, and intraoperative imaging. Relevant studies were reviewed and critical appraisals were included in this clinical update, highlighting current state of the art advances. CONCLUSIONS As image guidance and intraoperative imaging systems have advanced, their applications in sinus and skull base surgery have expanded. Both technologies offer invaluable real-time feedback on the status and progress of surgery, and thus may help to improve the completeness of surgery and overall outcomes. Recent advances such as augmented and virtual reality offer a window into the future of IGS. Future advancements should aim to enhance the surgeon's operative experience by improving user satisfaction and ultimately lead to better surgical results.
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Affiliation(s)
- Isaac L Schmale
- Department of Otorhinolaryngology-Head & Neck Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, TX, USA
| | - Laura J Vandelaar
- Department of Otorhinolaryngology-Head & Neck Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, TX, USA
| | - Amber U Luong
- Department of Otorhinolaryngology-Head & Neck Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, TX, USA
| | - Martin J Citardi
- Department of Otorhinolaryngology-Head & Neck Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, TX, USA
| | - William C Yao
- Department of Otorhinolaryngology-Head & Neck Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, TX, USA
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Wang EW, Zanation AM, Gardner PA, Schwartz TH, Eloy JA, Adappa ND, Bettag M, Bleier BS, Cappabianca P, Carrau RL, Casiano RR, Cavallo LM, Ebert CS, El-Sayed IH, Evans JJ, Fernandez-Miranda JC, Folbe AJ, Froelich S, Gentili F, Harvey RJ, Hwang PH, Jane JA, Kelly DF, Kennedy D, Knosp E, Lal D, Lee JYK, Liu JK, Lund VJ, Palmer JN, Prevedello DM, Schlosser RJ, Sindwani R, Solares CA, Tabaee A, Teo C, Thirumala PD, Thorp BD, de Arnaldo Silva Vellutini E, Witterick I, Woodworth BA, Wormald PJ, Snyderman CH. ICAR: endoscopic skull-base surgery. Int Forum Allergy Rhinol 2020; 9:S145-S365. [PMID: 31329374 DOI: 10.1002/alr.22326] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 02/12/2019] [Accepted: 02/15/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Endoscopic skull-base surgery (ESBS) is employed in the management of diverse skull-base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull-base surgery have produced the International Consensus Statement on Endoscopic Skull-Base Surgery (ICAR:ESBS). METHODS Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence-based review or evidence-based review with recommendations format. Subsequently, each topic was written and then reviewed by skull-base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus. RESULTS The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull-base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated. CONCLUSION A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence-based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull-base community to embrace these opportunities and collaboratively address these shortcomings.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Adam J Folbe
- Michigan Sinus and Skull Base Institute, Royal Oak, MI
| | | | | | - Richard J Harvey
- University of Toronto, Toronto, Canada.,University of New South Wales, Sydney, Australia
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Charles Teo
- Prince of Wales Hospital, Randwick, Australia
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12
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Strange F, Remonda L, Schütz P, Fandino J, Berkmann S. 10 Years' Experience of Using Low-Field Intraoperative MRI in Transsphenoidal Surgery for Pituitary Adenoma: Results of the Swiss Pituitary Registry (SwissPit). World Neurosurg 2019; 136:e284-e293. [PMID: 31899402 DOI: 10.1016/j.wneu.2019.12.146] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 12/21/2019] [Accepted: 12/23/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND For 20 years, several studies have reported intraoperative magnetic resonance imaging (iMRI) utility to achieve gross total resections in transsphenoidal pituitary adenoma surgery. Although few studies on low-field iMRI included >100 patients, data on hormonally active tumors remain scarce and follow-up times are <3 years. This is not sufficient to judge the long-term efficiency of the use of low-field iMRI. The aim of this retrospective study is to report the detailed outcome of iMRI-controlled transsphenoidal surgery in >200 patients during a follow-up exceeding 5 years. METHODS Patients undergoing surgery for pituitary adenoma by iMRI-controlled, endoscopically assisted transsphenoidal surgery at the authors' institution between 2006 and 2016 were eligible for inclusion. Data were collected in the Swiss Pituitary Registry. A Polestar 0.15T-scanner was used. RESULTS A total of 231 patients had surgery for 160 nonfunctioning adenomas; 28 hGH-, 27 PRL-, 10 ACTH-secreting and 6 mixed adenomas and were followed for 62 months (9-178). Additional iMRI-guided resections were possible in 54% and increased the gross total resection rate by 4% (P = 0.004). Remission rates were as follows: nonfunctioning adenoma, 53%; acromegaly, 61%; prolactinoma, 50%; Cushing disease, 90%. Tumor regrowth and recurrence was detected at a mean time of 24 and 63 months, respectively. Recovery of deficient hormone axes was detected in 22% to 27%. The risk for new postoperative hormonal deficiencies was 15%. Postoperative relieve of visual field and visual acuity deficiencies was seen in 94 (86%) and 73 (81%) patients, respectively. CONCLUSION Judged by long-term follow-ups of >200 nonfunctioning/functioning pituitary adenomas, the use of low-field iMRI in transsphenoidal surgery increases resection rates and sustainably influences outcomes.
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Affiliation(s)
- Fabio Strange
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| | - Luca Remonda
- Division of Neuroradiology, Department of Radiology, Kantonsspital Aarau, Aarau, Switzerland
| | - Philipp Schütz
- Division of Endocrinology, University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Javier Fandino
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| | - Sven Berkmann
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland.
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13
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Identification of tumor residuals in pituitary adenoma surgery with intraoperative MRI: do we need gadolinium? Neurosurg Rev 2019; 43:1623-1629. [PMID: 31728847 DOI: 10.1007/s10143-019-01202-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 10/19/2019] [Accepted: 10/28/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To evaluate the diagnostic accuracy of high-resolution T2w intraoperative magnetic resonance imaging (iMRI) for detecting pituitary adenoma remnants compared to contrast-enhanced T1-weighted images. METHODS 42 patients underwent iMRI-guided resection of large pituitary macroadenomas and fulfilled the inclusion criteria for this retrospective analysis. Intraoperative and postoperative imaging evaluation of tumor residuals and localization were assessed by two experienced neuroradiologists in a blinded fashion. The diagnostic accuracy of T2w and contrast-enhanced T1w images were evaluated. RESULTS The diagnostic accuracy for detecting tumor residuals of high-resolution T2w images showed highly significant association to contrast-enhanced T1w images (p < 0.0001). Furthermore, identification rate of tumor remnants in different compartments, e.g., cavernous sinus, was comparable. In total, coronal T2w images provided a diagnostic sensitivity of 97.7% and specificity of 100% compared to the gold standard of contrast-enhanced T1w images. The postoperatively expected extent of resection proved to be true in 97.6% according to MRI 3 months after resection. CONCLUSIONS High-resolution T2w intraoperative MR images provide excellent diagnostic accuracy for detecting tumor remnants in macroadenoma surgery with highly significant association compared to T1w images with gadolinium. The routine-use and need of gadolinium in these patients should be questioned critically in each case in the future.
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14
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The Zurich Pituitary Score predicts utility of intraoperative high-field magnetic resonance imaging in transsphenoidal pituitary adenoma surgery. Acta Neurochir (Wien) 2019; 161:2107-2115. [PMID: 31392567 DOI: 10.1007/s00701-019-04018-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 07/18/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND It is currently unclear if there are subsets of patients undergoing transsphenoidal surgery (TSS) in which intraoperative high-field magnetic resonance imaging (3T-iMRI) is particularly advantageous. We aimed to investigate whether a radiological grading scale predicts the utility of 3T-iMRI in pituitary adenoma (PA) TSS. METHODS From a prospective registry, patients who underwent endoscopic TSS for PA using 3T-iMRI were identified. Adenomas were graded using the Zurich Pituitary Score (ZPS). We assessed improvement after 3T-iMRI in terms of gross total resection (GTR), residual volume (RV), and extent of resection (EOR). RESULTS Among 95 patients, rates of conversion to GTR after 3T-iMRI decreased steadily from 33% for grade I to 0% for grade IV adenomas, with a statistically significant conversion rate only for grade I (p = 0.008) and grade II (p < 0.001). All grade I adenomas were completely resected after 3T-iMRI. Median RV change was statistically significant for grades I to III, but not for grade IV (p = 0.625). EOR improvement ranged from a median change of 0.0% (IQR 0.0-4.5%) for grade I to 4.4% (IQR 0.0-9.0%) for grade IV, with a significant improvement only for grades I to III (p < 0.05). CONCLUSIONS Interestingly, this study shows that clinical utility of 3T-iMRI is highest in the more "simple" adenomas (ZPS grades I-II) than for the more "complex" ones (ZPS grade III-IV). Grade I adenomas are amenable to GTR if 3T-iMRI is implemented. In grade III adenomas, EOR and RV can be improved to clinically relevant levels. Conversely, in grade IV adenomas, 3T-iMRI may be of limited use.
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16
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Can Intraoperative Magnetic Resonance Imaging Be Helpful in the Surgical Resection of Parasellar Meningiomas? A Case Series. World Neurosurg 2019; 132:e577-e584. [PMID: 31442639 DOI: 10.1016/j.wneu.2019.08.070] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 08/08/2019] [Accepted: 08/09/2019] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The surgery of parasellar meningiomas is crucial. There are only a few reports of the use of intraoperative magnetic resonance imaging (iMRI) for resection of these lesions. We discuss the safety and usefulness of this technique in achieving the planned surgical goal and analyze patients' outcomes. METHODS Nineteen cases of parasellar meningioma were treated in our institution using iMRI. We classified the tumors according to their primary location: tuberculum sellae, clinoidal, and cavernous sinus meningiomas. We evaluated the history of previous surgery, outcome, residual (if present) tumor volume, degree of resection, achievement of the surgical goal, and number of iMRI scans. RESULTS The preoperative surgical goal was achieved in all patients. In 7 of 19 patients, (37%) further tumor resection was performed after the first iMRI scan. Regarding the cavernous sinus group, the surgical resection was continued after the first iMRI in 56% of patients, obtaining substantial additional volume reduction. No complications were found related to the use of iMRI scan. CONCLUSIONS iMRI has been effective in safely increasing the extent of parasellar meningioma resection mainly for recurrent and invasive tumors. Its usefulness has been seen mostly in cavernous sinus lesions, in which it allowed the further safe resection in 56% of cases. Moreover, this tool was particularly useful in recurrent or residual meningiomas with extension in extracranial compartments.
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Metwali H, Samii A, Gerganov V, Giordano M, Fahlbusch R, Samii M. The Significance of Intraoperative Magnetic Resonance Imaging in Resection of Skull Base Chordomas. World Neurosurg 2019; 128:e185-e194. [DOI: 10.1016/j.wneu.2019.04.086] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Revised: 04/08/2019] [Accepted: 04/09/2019] [Indexed: 11/26/2022]
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Little AS, Chicoine MR, Kelly DF, Sarris CE, Mooney MA, White WL, Gardner PA, Fernandez-Miranda JC, Barkhoudarian G, Chandler JP, Prevedello DM, Liebelt BD, Sfondouris J, Mayberg MR. Evaluation of Surgical Resection Goal and Its Relationship to Extent of Resection and Patient Outcomes in a Multicenter Prospective Study of Patients With Surgically Treated, Nonfunctioning Pituitary Adenomas: A Case Series. Oper Neurosurg (Hagerstown) 2019; 18:26-33. [DOI: 10.1093/ons/opz085] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 12/25/2018] [Indexed: 02/02/2023] Open
Abstract
Abstract
BACKGROUND
The influence of the surgeon's preoperative goal regarding the extent of tumor resection on patient outcomes has not been carefully studied among patients with nonfunctioning pituitary adenomas.
OBJECTIVE
To analyze the relationship between surgical tumor removal goal and patient outcomes in a prospective multicenter study.
METHODS
Centrally adjudicated extent of tumor resection (gross total resection [GTR] and subtotal resection [STR]) data were analyzed using standard univariate and multivariable analyses.
RESULTS
GTR was accomplished in 148 of 171 (86.5%) patients with planned GTR and 32 of 50 (64.0%) patients with planned STR (P = .001). Sensitivity, specificity, positive predictive value, and negative predictive value of GTR goal were 82.2, 43.9, 86.5, and 36.0%, respectively. Knosp grade 0-2, first surgery, and being an experienced surgeon were associated with surgeons choosing GTR as the goal (P < .01). There was no association between surgical goal and presence of pituitary deficiency at 6 mo (P = .31). Tumor Knosp grade (P = .004) and size (P = .001) were stronger predictors of GTR than was surgical goal (P = .014). The most common site of residual tumor was the cavernous sinus (29 of 41 patients; 70.1%).
CONCLUSION
This is the first pituitary surgery study to examine surgical goal regarding extent of tumor resection and associated patient outcomes. Surgical goal is a poor predictor of actual tumor resection. A more aggressive surgical goal does not correlate with pituitary gland dysfunction. A better understanding of the ability of surgeons to meet their expectations and of the factors associated with surgical result should improve prognostication and preoperative counseling.
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Affiliation(s)
- Andrew S Little
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Michael R Chicoine
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Daniel F Kelly
- Pacific Brain Tumor Center and Pituitary Disorders Program, John Wayne Cancer Institute at Providence Saint John's Health Center, Santa Monica, California
| | - Christina E Sarris
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Michael A Mooney
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - William L White
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Paul A Gardner
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Garni Barkhoudarian
- Pacific Brain Tumor Center and Pituitary Disorders Program, John Wayne Cancer Institute at Providence Saint John's Health Center, Santa Monica, California
| | - James P Chandler
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Daniel M Prevedello
- Department of Neurological Surgery, The Ohio State University, Columbus, Ohio
| | - Brandon D Liebelt
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - John Sfondouris
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Marc R Mayberg
- Department of Neurological Surgery, University of Washington, Seattle, Washington
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Zhang Z, Yang K, Xia Y, Meng X, Yu X. High-Field Intraoperative Magnetic Resonance Imaging Increases Extent of Resection and Progression-Free Survival for Nonfunctioning Pituitary Adenomas. World Neurosurg 2019; 127:e925-e931. [PMID: 30974275 DOI: 10.1016/j.wneu.2019.04.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Revised: 03/30/2019] [Accepted: 04/01/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND The effect of intraoperative magnetic resonance imaging (iMRI) on tumor control during endoscopic transsphenoidal surgery (TSS) for nonfunctioning pituitary adenomas (NFPAs) has not yet been completely characterized. The present study assessed the effect of the iMRI findings on gross total resection (GTR) and progression-free survival at a mean follow-up of 62 ± 9.4 months. METHODS Retrospective analyses were performed on the data from 133 consecutive patients with NFPA who had undergone endoscopic TSS with iMRI using a 1.5T scanner. RESULTS Compared with the first and final iMRI scans, the GTR rate increased from 42.9% to 63.9%. Multivariate logistic regression analysis revealed that a lower GTR rate was associated with a higher Knosp score (odds ratio [OR], 3.612; 95% confidence interval [CI], 1.568-8.321; P = 0.003), an increased tumor volume (OR, 0.926; 95% CI, 0.866-0.991; P = 0.025), and a history of surgery (OR, 0.376; 95% CI, 0.155-0.917; P = 0.031). During follow-up, 8 tumors (9.4%) recurred, and 29 remnants (60.4%) regenerated. The recurrence and regeneration rates were 0.019 and 0.121 patient/year, respectively. Kaplan-Meier analysis revealed that the tumor recurrence rates were lower for patients who had undergone GTR (P < 0.01) compared with those who had not. Univariate Cox regression analysis suggested that the presence of tumor remnants (hazard ratio, 1.546; 95% CI, 1.071-2.232; P = 0.02) was the influencing factor associated with tumor progression. CONCLUSIONS High-field iMRI can increase the GTR rate in endoscopic TSS for NPFAs. The increased GTR rate was associated with longer progression-free survival. Cavernous sinus invasion, tumor size, and surgical history were important predictors of GTR in patients with NFPA.
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Affiliation(s)
- Zhibin Zhang
- School of Medcine, Nankai University, Tianjin, China; Department of Neurosurgery, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Kai Yang
- Department of Neurosurgery, Dongying People's Hospital, Shandong Province, China
| | - Yirong Xia
- Department of Neurosurgery, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Xianghui Meng
- Department of Neurosurgery, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Xinguang Yu
- School of Medcine, Nankai University, Tianjin, China; Department of Neurosurgery, Chinese People's Liberation Army General Hospital, Beijing, China.
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Abstract
In this paper, the currently used and well evaluated techniques for the surgery of pituitary tumors will be reviewed. Since the first surgical approaches to pituitary tumors more than 100 years have elapsed. Various surgical techniques have been developed, refined and standardized. Most of these tumors are to date treated via transsphenoidal approaches. Many pituitary adenomas, particularly, smaller, enclosed ones, can be completely excised and a selective adenomectomy is usually attempted. It leads to remission of hormonal oversecretion and also to recovery of pituitary function in many patients. The resection of pseudocapsule around the adenoma seems to improve the operative results further. Transcranial approaches, employing craniotomies, are still needed in some patients with pituitary adenomas and in many of those harbouring craniopharyngiomas. The operative techniques will be described and briefly commented. Moreover, the application and usefulness of several technical developments will be reviewed, such as the use of the endoscope, magnetic resonance imaging, fluorenscent dyes and neuronavigation. The use of the intraoperative Doppler probe, ultrasound and the value of intraoperative hormonal measurements will be briefly discussed. There is sufficient evidence that the best and optimal outcome in terms of tumor resection and correction of hormonal oversecretion as well as the lowest rate of complications are obtained in centers of excellence with sufficiently experienced, specialized surgeons and a high patient load.
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Affiliation(s)
- M Buchfelder
- Department of Neurosurgery, University Hospital Erlangen, Erlangen, Germany.
| | - S M Schlaffer
- Department of Neurosurgery, University Hospital Erlangen, Erlangen, Germany
| | - Y Zhao
- Department of Neurosurgery, University Hospital Erlangen, Erlangen, Germany
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Feigl GC, Heckl S, Kullmann M, Filip Z, Decker K, Klein J, Ernemann U, Tatagiba M, Velnar T, Ritz R. Review of first clinical experiences with a 1.5 Tesla ceiling-mounted moveable intraoperative MRI system in Europe. Bosn J Basic Med Sci 2019; 19:24-30. [PMID: 30589401 PMCID: PMC6387677 DOI: 10.17305/bjbms.2018.3777] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Accepted: 07/29/2018] [Indexed: 11/16/2022] Open
Abstract
High-field intraoperative MRI (iMRI) systems provide excellent imaging quality and are used for resection control and update of image guidance systems in a number of centers. A ceiling-mounted intraoperative MRI system has several advantages compared to a conventional iMRI system. In this article, we report on first clinical experience with using such a state-of-the-art, the 1.5T iMRI system, in Europe. A total of 50 consecutive patients with intracranial tumors and vascular lesions were operated in the iMRI unit. We analyzed the patients' data, surgery preparation times, intraoperative scans, surgical time, and radicality of tumor removal. Patients' mean age was 46 years (range 8 to 77 years) and the median surgical procedure time was 5 hours (range 1 to 11 hours). The lesions included 6 low-grade gliomas, 8 grade III astrocytomas, 10 glioblastomas, 7 metastases, 7 pituitary adenomas, 2 cavernomas, 2 lymphomas, 1 cortical dysplasia, 3 aneurysms, 1 arterio-venous malformation and 1 extracranial-intracranial bypass, 1 clival chordoma, and 1 Chiari malformation. In the surgical treatment of tumor lesions, intraoperative imaging depicted tumor remnant in 29.7% of the cases, which led to a change in the intraoperative strategy. The mobile 1.5T iMRI system proved to be safe and allowed an optimal workflow in the iMRI unit. Due to the fact that the MRI scanner is moved into the operating room only for imaging, the working environment is comparable to a regular operating room.
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Affiliation(s)
- Guenther C Feigl
- Department of Neurosurgery, University of Tuebingen Medical Center, Germany.
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22
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Alomari A, Jaspers C, Reinbold WD, Feldkamp J, Knappe UJ. Use of intraoperative intracavitary (direct-contact) ultrasound for resection control in transsphenoidal surgery for pituitary tumors: evaluation of a microsurgical series. Acta Neurochir (Wien) 2019; 161:109-117. [PMID: 30483982 DOI: 10.1007/s00701-018-3747-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 11/21/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Perisellar infiltration may be responsible for incomplete removal of pituitary tumors. Since intraoperative visualization of parasellar structures is difficult during transsphenoidal surgery, we are describing the use of intraoperative direct contact ultrasound (IOUS). METHODS Within 5 years, in 113 transsphenoidal operations (58 male, 55 female, age 14-81 years, 110 pituitary adenomas (mean diameter 26.6 mm, 69 non-secreting adenomas, 41 secreting adenomas), and 1 of each Rathke's cleft cyst, craniopharyngioma, and xanthogranuloma), IOUS was applied. After wide opening of the sellar floor and removal of the intrasellar tumor portions, a commercially available side fire ultrasound probe is introduced, and in direct contact to the sellar envelope, the perisellar space is scanned perpendicular to the axis of the working channel. We compared the results of IOUS to postoperative MRI after 3-6 months. RESULTS Identification of the intracavernous ICA, the anterior optic pathway, and the ACA, was possible, it was safe to operate close to them. In 65 operations (58%), further resection of tumor remnants was performed after IOUS. In this selected series, complete resection of tumors (stated by postoperative MRI after 3-6 months) was achieved in 75 operations (66%) and remission was achieved in 18 operations of secreting adenomas (44%). Compared to MRI after 3 to 6 months, the sensitivity of IOUS was 0.568 and the specificity was 0.907. No complications related to IOUS were seen. CONCLUSIONS Visualization of the perisellar compartments by IOUS is easy and fast to perform. It allows the surgeon to identify resectable tumor remnants intraoperatively, which otherwise could be missed.
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Affiliation(s)
- Ali Alomari
- Department of Neurosurgery, Johannes Wesling Klinikum, University Hospital of Ruhr-Universität Bochum, Hans Nolte Str. 1, 32429, Minden, Germany
| | - Christian Jaspers
- Department of Endocrinology, Johannes Wesling Klinikum, University Hospital of Ruhr-Universität Bochum, Hans Nolte Str. 1, 32429, Minden, Germany
| | - Wolf-Dieter Reinbold
- Institute of Radiology and Neuroradiology, Johannes Wesling Klinikum, University Hospital of Ruhr-Universität Bochum, Hans Nolte Str. 1, 32429, Minden, Germany
| | - Joachim Feldkamp
- Department of Endocrinology, Klinikum Bielefeld, Bielefeld, Germany
| | - Ulrich J Knappe
- Department of Neurosurgery, Johannes Wesling Klinikum, University Hospital of Ruhr-Universität Bochum, Hans Nolte Str. 1, 32429, Minden, Germany.
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Intraoperative computed tomography as reliable navigation registration device in 200 cranial procedures. Acta Neurochir (Wien) 2018; 160:1681-1689. [PMID: 30051160 DOI: 10.1007/s00701-018-3641-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 07/20/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Registration accuracy is a main factor influencing overall navigation accuracy. Standard fiducial- or landmark-based patient registration is user dependent and error-prone. Intraoperative imaging offers the possibility for user-independent patient registration. The aim of this paper is to evaluate our initial experience applying intraoperative computed tomography (CT) for navigation registration in cranial neurosurgery, with a special focus on registration accuracy and effective radiation dose. METHODS A total of 200 patients (141 craniotomy, 19 transsphenoidal, and 40 stereotactic burr hole procedures) were investigated by intraoperative CT applying a 32-slice movable CT scanner, which was used for automatic navigation registration. Registration accuracy was measured by at least three skin fiducials that were not part of the registration process. RESULTS Automatic registration resulted in high registration accuracy (mean registration error: 0.93 ± 0.41 mm). Implementation of low-dose scanning protocols did not impede registration accuracy (registration error applying the full dose head protocol: 0.87 ± 0.36 mm vs. the low dose sinus protocol 0.72 ± 0.43 mm) while a reduction of the effective radiation dose by a factor of 8 could be achieved (mean effective radiation dose head protocol: 2.73 mSv vs. sinus protocol: 0.34 mSv). CONCLUSION Intraoperative CT allows highly reliable navigation registration with low radiation exposure.
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Intraoperative 3 tesla magnetic resonance imaging: Our experience in tumors. RADIOLOGIA 2018. [DOI: 10.1016/j.rxeng.2018.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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García-Baizán A, Tomás-Biosca A, Bartolomé Leal P, Domínguez P, García de Eulate Ruiz R, Tejada S, Zubieta J. Resonancia magnética intraoperatoria de 3 teslas: Nuestra experiencia en patología tumoral. RADIOLOGIA 2018; 60:136-142. [DOI: 10.1016/j.rx.2017.12.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 11/01/2017] [Accepted: 12/03/2017] [Indexed: 10/18/2022]
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Abstract
A variety of intraoperative MRI (iMRI) systems are in use during transsphenoidal surgery (TSS). The variations in iMRI systems include field strengths, magnet configurations, and room configurations. Most studies report that the primary utility of iMRI during TSS lies in detecting resectable tumor residuals following maximal resection with conventional technique. Stereotaxis, neuronavigation, and complication avoidance/detection are enhanced by iMRI use during TSS. The use of iMRI during TSS can lead to increased extent of resection for large tumors. Improved remission rates from hormone-secreting tumors have also been reported with iMRI use. This article discusses the history, indications, and future directions for iMRI during TSS.
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Affiliation(s)
- Prashant Chittiboina
- Neurosurgery Unit for Pituitary and Inheritable Diseases, National Institute of Neurological Diseases and Stroke, National Institutes of Health, 10 Center Drive, Room 3D20, Bethesda, MD 20892-1414, USA.
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Zhang H, Wang F, Zhou T, Wang P, Chen X, Zhang J, Zhou D. Analysis of 137 Patients Who Underwent Endoscopic Transsphenoidal Pituitary Adenoma Resection Under High-Field Intraoperative Magnetic Resonance Imaging Navigation. World Neurosurg 2017; 104:802-815. [DOI: 10.1016/j.wneu.2017.04.056] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 04/07/2017] [Accepted: 04/09/2017] [Indexed: 12/17/2022]
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Marcus HJ, Vercauteren T, Ourselin S, Dorward NL. Intraoperative Ultrasound in Patients Undergoing Transsphenoidal Surgery for Pituitary Adenoma: Systematic Review [corrected]. World Neurosurg 2017; 106:680-685. [PMID: 28736351 DOI: 10.1016/j.wneu.2017.07.054] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Revised: 07/07/2017] [Accepted: 07/11/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Transsphenoidal surgery is the gold standard for pituitary adenoma resection. However, despite advances in microsurgical and endoscopic techniques, some pituitary adenomas can be challenging to cure. OBJECTIVE We sought to determine whether, in patients undergoing transsphenoidal surgery for pituitary adenoma, intraoperative ultrasound is a safe and effective technologic adjunct. METHODS The PubMed database was searched between January 1996 and January 2016 to identify relevant publications that 1) featured patients undergoing transsphenoidal surgery for pituitary adenoma, 2) used intraoperative ultrasound, and 3) reported on safety or effectiveness. Reference lists were also checked, and expert opinions were sought to identify further publications. RESULTS Ultimately, 10 studies were included, comprising 1 cohort study, 7 case series, and 2 case reports. One study reported their prototype probe malfunctioned, leading to false-positive results in 2 cases, and another study' prototype probe was too large to safely enter the sphenoid sinus in 2 cases. Otherwise, no safety issues directly related to use of intraoperative ultrasound were reported. In the only comparative study, remission occurred in 89.7% (61/68) of patients with Cushing disease in whom intraoperative ultrasound was used, compared with 83.8% (57/68) in whom it was not. All studies reported that surgeons anecdotally found intraoperative ultrasound helpful. CONCLUSIONS Although there is limited and low-quality evidence available, the use of intraoperative ultrasound appears to be a safe and effective technologic adjunct to transsphenoidal surgery for pituitary adenoma. Advances in ultrasound technology may allow for more widespread use of such devices.
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Affiliation(s)
- Hani J Marcus
- Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, London, UK; Translational Imaging Group, CMIC, Department of Medical Physics and Biomedical Engineering, University College London, London, UK.
| | - Tom Vercauteren
- Translational Imaging Group, CMIC, Department of Medical Physics and Biomedical Engineering, University College London, London, UK
| | - Sebastien Ourselin
- Translational Imaging Group, CMIC, Department of Medical Physics and Biomedical Engineering, University College London, London, UK
| | - Neil L Dorward
- Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, London, UK
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Does Low-Field Intraoperative Magnetic Resonance Improve the Results of Endoscopic Pituitary Surgery? Experience of the Implementation of a New Device in a Referral Center. World Neurosurg 2017; 102:102-110. [DOI: 10.1016/j.wneu.2017.02.094] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 02/18/2017] [Accepted: 02/20/2017] [Indexed: 11/21/2022]
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Giordano M, Samii A, Lawson McLean AC, Bertalanffy H, Fahlbusch R, Samii M, Di Rocco C. Intraoperative magnetic resonance imaging in pediatric neurosurgery: safety and utility. J Neurosurg Pediatr 2017; 19:77-84. [PMID: 27791707 DOI: 10.3171/2016.8.peds15708] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The use of high-field intraoperative MRI has been largely studied for the treatment of intracranial tumors in adult patients. In this study, the authors investigated the safety, advantages, and limitations of high-field iMRI for cranial neurosurgical procedures in pediatric patients, with particular attention to craniopharyngiomas and gliomas. METHODS The authors performed 82 surgical procedures in patients under 16 years of age (range 0.8-15 years) over an 8-year period (2007-2014) using iMRI. The population was divided into 3 groups based on the condition treated: sellar region tumors (Group 1), gliomas (Group 2), and other pathological entities (Group 3). The patients' pre- and postoperative neurological status, the presence of residual tumor, the number of intraoperative scans, and complications were evaluated. RESULTS In Group 1, gross-total resection (GTR) was performed in 22 (88%) of the procedures and subtotal resection (STR) in 3 (12%). In Group 2, GTR, STR, and partial resection (PR) were performed, respectively, in 15 (56%), 7 (26%), and 5 (18%) of the procedures. In Group 3, GTR was performed in 28 (93%) and STR in 2 (7%) of the procedures. In cases of craniopharyngioma (Group 1) and glioma (Group 2) in which a complete removal was planned, iMRI allowed localization of residual lesions and attainment of the surgical goal through further resection, respectively, in 18% and 27% of the procedures. Moreover, in gliomas the resection could be extended from partial to subtotal in 50% of the cases. In 17% of the patients in Group 3, iMRI enabled the identification and further removal of tumor remnants. There was no intra- or postoperative complication related to the use of iMRI despite special technical difficulties in smaller children. CONCLUSIONS In this study, the use of iMRI in children proved to be safe. It was most effective in increasing the extent of tumor resection, especially in patients with low-grade gliomas and craniopharyngiomas. The most prominent disadvantage of high-field iMRI was the limitation with respect to operative positioning due to the configuration of the surgical table.
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Affiliation(s)
- Mario Giordano
- Department of Neurosurgery, International Neuroscience Institute, Hannover; and
| | - Amir Samii
- Department of Neurosurgery, International Neuroscience Institute, Hannover; and.,Leibniz Institute for Neurobiology, Magdeburg, Germany
| | | | - Helmut Bertalanffy
- Department of Neurosurgery, International Neuroscience Institute, Hannover; and
| | - Rudolf Fahlbusch
- Department of Neurosurgery, International Neuroscience Institute, Hannover; and
| | - Madjid Samii
- Department of Neurosurgery, International Neuroscience Institute, Hannover; and
| | - Concezio Di Rocco
- Department of Neurosurgery, International Neuroscience Institute, Hannover; and
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31
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Kuo JS, Barkhoudarian G, Farrell CJ, Bodach ME, Tumialan LM, Oyesiku NM, Litvack Z, Zada G, Patil CG, Aghi MK. Congress of Neurological Surgeons Systematic Review and Evidence-Based Guideline on Surgical Techniques and Technologies for the Management of Patients With Nonfunctioning Pituitary Adenomas. Neurosurgery 2016; 79:E536-8. [DOI: 10.1227/neu.0000000000001390] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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32
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33
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Netuka D, Májovský M, Masopust V, Belšán T, Marek J, Kršek M, Hána V, Ježková J, Hána V, Beneš V. Intraoperative Magnetic Resonance Imaging During Endoscopic Transsphenoidal Surgery of Growth Hormone-Secreting Pituitary Adenomas. World Neurosurg 2016; 91:490-6. [DOI: 10.1016/j.wneu.2016.04.094] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 04/20/2016] [Accepted: 04/21/2016] [Indexed: 10/21/2022]
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34
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Patel KS, Yao Y, Wang R, Carter BS, Chen CC. Intraoperative magnetic resonance imaging assessment of non-functioning pituitary adenomas during transsphenoidal surgery. Pituitary 2016; 19:222-31. [PMID: 26323592 DOI: 10.1007/s11102-015-0679-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE To review the utility of intraoperative imaging in facilitating maximal resection of non-functioning pituitary adenomas (NFAs). METHODS We performed an exhaustive MEDLINE search, which yielded 5598 articles. Upon careful review of these studies, 31 were pertinent to the issue of interest. RESULTS Nine studies examined whether intraoperative MRI (iMRI) findings correlated with the presence of residual tumor on MRI taken 3 months after surgical resection. All studies using iMRI of >0.15T showed a ≥90% concordance between iMRI and 3-month post-operative MRI findings. 24 studies (22 iMRI and 2 intraoperative CT) examined whether intraoperative imaging improved the surgeon's ability to achieve a more complete resection. The resections were carried out under microscopic magnification in 17 studies and under endoscopic visualization in 7 studies. All studies support the value of intraoperative imaging in this regard, with improved resection in 15-83% of patients. Two studies examined whether iMRI (≥0.3T) improved visualization of residual NFA when compared to endoscopic visualization. Both studies demonstrated the value of iMRI in this regard, particularly when the tumor is located lateral of the sella, in the cavernous sinus, and in the suprasellar space. CONCLUSION The currently available literature supports the utility of intraoperative imaging in facilitating increased NFA resection, without compromising safety.
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Affiliation(s)
- Kunal S Patel
- Center for Theoretic and Applied Neuro-Oncology, Division of Neurosurgery, Moores Cancer Center, University of California, San Diego, 3855 Health Science Drive #0987, La Jolla, CA, 92093-0987, USA
| | - Yong Yao
- Department of Neurosurgery, Peking Union Medical College Hospital, Beijing, China
| | - Renzhi Wang
- Department of Neurosurgery, Peking Union Medical College Hospital, Beijing, China
| | - Bob S Carter
- Center for Theoretic and Applied Neuro-Oncology, Division of Neurosurgery, Moores Cancer Center, University of California, San Diego, 3855 Health Science Drive #0987, La Jolla, CA, 92093-0987, USA
| | - Clark C Chen
- Center for Theoretic and Applied Neuro-Oncology, Division of Neurosurgery, Moores Cancer Center, University of California, San Diego, 3855 Health Science Drive #0987, La Jolla, CA, 92093-0987, USA.
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35
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Serra C, Burkhardt JK, Esposito G, Bozinov O, Pangalu A, Valavanis A, Holzmann D, Schmid C, Regli L. Pituitary surgery and volumetric assessment of extent of resection: a paradigm shift in the use of intraoperative magnetic resonance imaging. Neurosurg Focus 2016; 40:E17. [DOI: 10.3171/2015.12.focus15564] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
The aim of this study was to quantitatively assess the role of intraoperative high-field 3-T MRI (3T-iMRI) in improving the gross-total resection (GTR) rate and the extent of resection (EOR) in endoscopic transsphenoidal surgery (TSS) for pituitary adenomas.
METHODS
Radiological and clinical data from a prospective database were retrospectively analyzed. Volumetric measurements of adenoma volumes pre-, intraoperatively, and 3 months postoperatively were performed in a consecutive series of patients who had undergone endoscopic TSS. The quantitative contribution of 3T-iMRI was measured as a percentage of the additional rate of GTR and of the EOR achieved after 3T-iMRI.
RESULTS
The cohort consisted of 50 patients (51 operations) harboring 33 nonfunctioning and 18 functioning pituitary adenomas. Mean adenoma diameter and volume were 21.1 mm (range 5–47 mm) and 5.23 cm3 (range 0.09–22.14 cm3), respectively. According to Knosp's classification, 10 cases were Grade 0; 8, Grade 1; 17, Grade 2; 12, Grade 3; and 4, Grade 4. Gross-total resection was the surgical goal (targeted [t]GTR) in 34 of 51 operations and was initially achieved in 16 (47%) of 34 at 3T-iMRI and in 30 (88%) of 34 cases after further resection. In this subgroup, the EOR increased from 91% at 3T-iMRI to 99% at the 3-month MRI (p < 0.05). In the 17 cases in which subtotal resection (STR) had been planned (tSTR), the EOR increased from 79% to 86% (p < 0.05) and GTR could be achieved in 1 case. Intrasellar remnants were present in 20 of 51 procedures at 3T-iMRI and in only 5 (10%) of 51 procedures after further resection (median volume 0.15 cm3). Overall, the use of 3T-iMRI led to further resection in 27 (53%) of 51 procedures and permitted GTR in 15 (56%) of these 27 procedures; thus, the GTR rate in the entire cohort increased from 31% (16 of 51) to 61% (31 of 51) and the EOR increased from 87% to 95% (p < 0.05).
CONCLUSIONS
The use of high-definition 3T-iMRI allowed precise visualization and quantification of adenoma remnant volume. It helped to increase GTR and EOR rates in both tGTR and tSTR patient groups. Moreover, it helped to achieve low rates of intrasellar remnants. These data support the use of 3T-iMRI to achieve maximal, safe adenoma resection.
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Affiliation(s)
| | | | | | | | | | | | | | - Christoph Schmid
- 4Endocrinology and Diabetes, University Hospital of Zürich, University of Zürich, Switzerland
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36
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Abstract
Stepwise improvements in the imaging of pituitary adenomas in the last 100 years have had a tremendous impact on patient care. Pituitary tumors are now diagnosed earlier in the time course of the disease, improving chances of endocrine and visual recovery. There is improved pre-surgical planning due to a better understanding of the investment of the tumor around important surrounding parasellar structures. Approaches to tumors are now safer due to stereotactic navigation and residual disease can be radiographically followed for a lifetime and treated prior to irreversible neurological damage. Furthermore, adjuvant radiotherapy can be more precisely delivered to the tumor bed with the aid of higher resolution images. Thanks to these incremental improvements previously formidable macroadenomas, which carried a high risk for morbidity and residual disease, can now be treated safely and effectively. Here, we review modern imaging modalities used to diagnose pituitary adenomas, and identify areas for further improvement.
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Affiliation(s)
- Hasan A Zaidi
- a Department of Neurosurgery , Brigham and Women's Hospital, Harvard Medical School , Boston , MA , USA
| | - David J Cote
- a Department of Neurosurgery , Brigham and Women's Hospital, Harvard Medical School , Boston , MA , USA
| | - Edward R Laws
- a Department of Neurosurgery , Brigham and Women's Hospital, Harvard Medical School , Boston , MA , USA
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37
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Bao X, Deng K, Liu X, Feng M, Chen CC, Lian W, Xing B, Yao Y, Wang R. Extended transsphenoidal approach for pituitary adenomas invading the cavernous sinus using multiple complementary techniques. Pituitary 2016; 19:1-10. [PMID: 26267303 DOI: 10.1007/s11102-015-0675-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE Transsphenoidal surgery is the treatment of choice for most pituitary adenomas (PA), except prolactinomas. Difficulties achieving radical resection with this method are encountered in patients with PAs invading the cavernous sinus (CS), due to the inability of the standard transsphenoidal approach to expose all tumors adequately. This study analyzed methods to resect PAs invading the CS and factors influencing the degree of tumor resection and occurrence of complications. METHODS Outcomes were retrospectively analyzed in 52 patients with PA invading the CS who underwent surgery via the extended transsphenoidal approach utilizing multiple techniques, including microscopy, endoscopy, neuronavigation, and intraoperative Doppler ultrasonography. RESULTS Gross-total resection (GTR) was achieved in 33 patients (63.5 %). GTR rate was significantly higher in patients with Knosp Grade 3 than Knosp Grade 4 (92.3 vs. 53.8 %) and in patients undergoing initial surgery than reoperation (77.1 vs. 35.3 %). One patient (2.9 %) undergoing initial surgery experienced transient cranial nerve palsy, without other postoperative complications. Postoperative complications were significantly higher after reoperation. Firm tumor consistency was significantly more frequent in patients undergoing reoperation than initial surgery (52.9 vs. 8.6 %). CONCLUSION Extended transsphenoidal surgery incorporating multiple complementary techniques was highly effective for PAs invading the CS. Postoperative complications rates were relatively low, especially for patients undergoing initial surgery and those with Knosp Grade 3 tumors. Total resection of PAs invading the CS remains challenging, especially in patients undergoing reoperation or having firm tumors.
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Affiliation(s)
- Xinjie Bao
- Department of Neurosurgery, Pituitary Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Kan Deng
- Department of Neurosurgery, Pituitary Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaohai Liu
- Department of Neurosurgery, Pituitary Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ming Feng
- Department of Neurosurgery, Pituitary Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Clark C Chen
- Division of Neurosurgery, Center for Theoretic and Applied Neuro-Oncology, University of California, San Diego, CA, USA
| | - Wei Lian
- Department of Neurosurgery, Pituitary Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bing Xing
- Department of Neurosurgery, Pituitary Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yong Yao
- Department of Neurosurgery, Pituitary Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Renzhi Wang
- Department of Neurosurgery, Pituitary Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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Buchfelder M, Schlaffer SM. Novel Techniques in the Surgical Treatment of Acromegaly: Applications and Efficacy. Neuroendocrinology 2016; 103:32-41. [PMID: 26536097 DOI: 10.1159/000441980] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2015] [Accepted: 10/27/2015] [Indexed: 11/19/2022]
Abstract
Since the establishment of transsphenoidal microsurgery as the operative treatment of choice in most patients with acromegaly 40 years ago, a few novel technical developments have evolved. Their application, utility and efficacy will be briefly discussed in this review article, based on an analysis of published results and the authors' personal experience. The endoscope was additionally used to search for residual tumours in locations which could not be visualised with the operating microscope. In many centres it has by now fully replaced the operating microscope. Extended endoscopic operations hardly have limits in respect to accessible pathology. Overall, the results and complications reported from microsurgical and endoscopic series are comparable. Intraoperative magnetic resonance imaging allows depicting the completeness of a tumour resection. While in many patients additional tumour resections are performed on the basis of intraoperative imaging, the improvements in hormonal remission rates reported are less impressive. Neuronavigation uses imaging data to improve the surgeon's orientation, and it is certainly a major asset to the inexperienced. In high-caseload centres it is mainly appreciated in anatomical variants and reoperations. While the Doppler probe is a valuable and easily affordable gadget to avoid vascular arterial injury, intraoperative ultrasound imaging of tumour extension has a much poorer resolution than magnetic resonance imaging and is thus not widely implemented. The clinical value of intraoperative growth hormone measurements is controversially discussed. In summary, the application of modern technology has only led to a minor improvement of results, but it has widened the spectrum of accessible pathologies and increased the safety of the procedures for the patient. It is expected that outcomes will continue to improve as novel techniques and concepts are being developed.
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Affiliation(s)
- Michael Buchfelder
- Department of Neurosurgery, Friedrich-Alexander-Universitx00E4;t Erlangen-Nx00FC;rnberg, Erlangen, Germany
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39
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Solheim O, Johansen TF, Cappelen J, Unsgård G, Selbekk T. Transsellar Ultrasound in Pituitary Surgery With a Designated Probe: Early Experiences. Oper Neurosurg (Hagerstown) 2015; 12:128-134. [PMID: 29506091 DOI: 10.1227/neu.0000000000001108] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Accepted: 09/20/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Anatomic orientation in transsphenoidal surgery can be difficult, and residual tumors are common. A major limitation of both direct microscopy and endoscopic visualization is the inability to see below the surface of the surgical field to confirm the location of vessels, nerves, tumor remnants, and normal pituitary tissue. OBJECTIVE To present our initial experience with a new forward-looking, custom-designed ultrasound probe for transsellar imaging. METHODS The center frequency of the prototype tightly curved linear array, bayonet-shaped probe is 12 MHz. Twenty-four patients with pituitary adenomas were included after informed consent. RESULTS With the use of transsellar ultrasound, we could confirm the location of important neurovascular structures and improve the extent of resection in 4 of 24 cases, as rated subjectively by the operating surgeons. Image quality was good. In 17 patients (71%), biochemical cures and/or complete resections were confirmed at 3 months. CONCLUSION We found the images from our custom-designed ultrasound probe to be clinically helpful for anatomic orientation during surgery, and the technology is potentially helpful for improving the extent of resection during transsphenoidal surgery. This quick and flexible form of intraoperative imaging in transsphenoidal surgery could be of great support for surgeons in both routine use and difficult cases. The concept of transsellar intraoperative ultrasound imaging can be further refined and developed.
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Affiliation(s)
- Ole Solheim
- Department of Neurosurgery, St. Olav's University Hospital, Trondheim, Norway.,Department of Neuroscience, Norwegian University of Science and Technology, Trondheim, Norway.,National Competence Centre for Ultrasound and Image-Guided Therapy, St. Olav's University Hospital, Trondheim, Norway
| | | | - Johan Cappelen
- Department of Neurosurgery, St. Olav's University Hospital, Trondheim, Norway
| | - Geirmund Unsgård
- Department of Neurosurgery, St. Olav's University Hospital, Trondheim, Norway.,Department of Neuroscience, Norwegian University of Science and Technology, Trondheim, Norway.,National Competence Centre for Ultrasound and Image-Guided Therapy, St. Olav's University Hospital, Trondheim, Norway
| | - Tormod Selbekk
- National Competence Centre for Ultrasound and Image-Guided Therapy, St. Olav's University Hospital, Trondheim, Norway.,Department of Medical Technology, SINTEF Technology and Society, Trondheim, Norway
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40
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Tosaka M, Nagaki T, Honda F, Takahashi K, Yoshimoto Y. Multi-slice computed tomography-assisted endoscopic transsphenoidal surgery for pituitary macroadenoma: a comparison with conventional microscopic transsphenoidal surgery. Neurol Res 2015; 37:951-8. [DOI: 10.1179/1743132815y.0000000078] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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41
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[Advances in the surgical treatment of tumors of the pituitary region : rhino-neurosurgical transnasal endoscopic surgery]. HNO 2015; 62:793-9. [PMID: 25270836 DOI: 10.1007/s00106-014-2908-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Conventional microscopic surgery of pituitary adenomas offers excellent results with regard to local tumour control and endocrine function. Overall patient morbidity and mortality is low. However, recent studies demonstrate further improvements in tumour resection control and more favourable endocrine/ophthalmologic results when endoscopic techniques are applied, as well as an overall reduction in peri-interventional morbidity. Additionally, use of endoscopic techniques in rhino-neurosurgical cooperation achieved better specifically rhinologic results and improved subjective comfort for patients. The cooperative rhino-neurosurgical approach not only allows for optimal treatment of the primary pituitary pathology, but also treatment of additional nasal and paranasal pathologies, such as a deviated septum or disturbed drainage of the paranasal sinus.
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42
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Abstract
Diagnosis of Cushing's disease frequently remains a challenge. In this review we critically appraise the clinical features, biochemical tests, and imaging modalities used for this purpose. We outline recommendations for approaches to clinical investigation, with a particular focus on developments made within the last two years.
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Affiliation(s)
- Eleni Daniel
- Academic Unit of Endocrinology, University of Sheffield, Beech Hill Road, Sheffield, S10 2RX, UK
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43
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Mert A, Micko A, Donat M, Maringer M, Buehler K, Sutherland GR, Knosp E, Wolfsberger S. An advanced navigation protocol for endoscopic transsphenoidal surgery. World Neurosurg 2015; 82:S95-105. [PMID: 25496642 DOI: 10.1016/j.wneu.2014.07.032] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Accepted: 07/25/2014] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To report our clinical experience with an advanced navigation protocol that provides seamless integration into the operating workflow of endoscopic transsphenoidal surgery. PATIENTS AND METHODS From 32 consecutive cases of endoscopic transsphenoidal surgery, an optimal setup of continuous electromagnetic instrument navigation was created. Additionally, our standard multimodality image navigation of T1-weighted magnetic resonance (MR) images for soft tissue, MR angiogram for vascular structures, and computed tomography (CT) for solid bone was advanced by the addition of a CT surface rendering for fine paranasal sinus structures. The anatomic structures visualized and their clinical impacts were compared between standard and advanced visualization protocol. Bone-windowed CT images served as reference. The accuracy of the navigation setup was assessed by intraoperative landmark tests. Potential tissue shift was calculated by comparing pre- and postoperative MR angiograms of 20 macroadenomas. RESULTS After a learning curve of 2 cases (1 ferromagnetic interference and 1 dislocation of the patient reference tracker), the advanced navigation protocol was feasible in 30 cases. Advanced multimodality imaging was able to visualize significantly finer paranasal sinus structures than multimodality image navigation without CT surface rendering, equal to bone-windowed CT images (P < 0.001, McNemar test). This was found helpful for orientation in cases of complex sphenoid sinus anatomy. The accuracy of the advanced navigation setup corresponded to standard optic navigation with skull fixation. A tissue shift of median 2 mm (range 0-9 mm) was observed in the posterior genu of the internal carotid arteries after tumor resection. CONCLUSIONS The advanced navigation protocol permits continuous suction-tracked navigation guidance during endoscopic transsphenoidal surgery and optimal visualization of solid bone, fine paranasal sinus structures, soft-tissue and vascular structures. This may add to the safety of the procedure especially in cases of anatomical variations and in cases of recurrent adenomas with distorted anatomy.
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Affiliation(s)
- Ayguel Mert
- Department of Neurosurgery, Medical University Vienna, Austria
| | - Alexander Micko
- Department of Neurosurgery, Medical University Vienna, Austria
| | - Markus Donat
- Department of Neurosurgery, Medical University Vienna, Austria
| | | | - Katja Buehler
- VRVis Research Centre for Virtual Reality and Visualization GmbH, Vienna, Austria
| | - Garnette R Sutherland
- Department of Clinical Neurosciences, Division of Neurosurgery, University of Calgary, Canada
| | - Engelbert Knosp
- Department of Neurosurgery, Medical University Vienna, Austria
| | - Stefan Wolfsberger
- Department of Neurosurgery, Medical University Vienna, Austria; Department of Clinical Neurosciences, Division of Neurosurgery, University of Calgary, Canada.
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Fathalla H, Cusimano MD, Di Ieva A, Lee J, Alsharif O, Goguen J, Zhang S, Smyth H. Endoscopic versus microscopic approach for surgical treatment of acromegaly. Neurosurg Rev 2015; 38:541-8; discussion 548-9. [PMID: 25666392 DOI: 10.1007/s10143-015-0613-7] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Revised: 10/10/2014] [Accepted: 11/16/2014] [Indexed: 11/30/2022]
Abstract
Transsphenoidal surgery in the setting of acromegaly is quite challenging due to increased soft tissue mass, bony overgrowth, and bleeding. There is a debate on the endoscopic versus microscopic approach for these patients. The purpose of our study is to compare the outcomes for acromegaly after transsphenoidal surgery using both techniques. Retrospective review of 65 acromegalic patients who underwent transsphenoidal surgery in our department. Clinical remission was defined as resolution of typical acromegalic symptoms. Radiological resection was defined by volumetric criteria, and biochemical remission was defined as by the 2010 consensus on the criteria for remission of acromegaly. There was no significant difference in age, preoperative endocrine status, percent of macro adenomas, suprasellar, or infrasellar extension between both groups. Patients were assigned to both groups based on our existing referral pattern. Endoscopic approach was performed in 42 patients, while the microscopic approach was performed in 23 patients. No significant difference in remission rates was found between both groups (45.2 vs. 34.7 %, p = 0.40). The endoscopic group, however, had a significantly higher rate of gross total resections (61 vs. 42 %, p = 0.05). There was also a trend towards higher rates of gross total resections when cavernous sinus was present (48 vs. 14.2 %, p = 0.09). Postoperative diabetes insipidus occurred more in microscopic patients (34.7 vs. 17 %, p = 0.05), otherwise there was no significant difference in rates of complications. The median follow-up period was 56.6 months (range 6-156, mean 66.1). There is no significant difference in the rates of biochemical remission between the endoscopic and microscopic techniques. The endoscope technique, however, seems to be superior in achieving gross total resection especially with tumors invading the cavernous sinus.
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Affiliation(s)
- Hussein Fathalla
- Division of Neurosurgery, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada,
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Sylvester PT, Evans JA, Zipfel GJ, Chole RA, Uppaluri R, Haughey BH, Getz AE, Silverstein J, Rich KM, Kim AH, Dacey RG, Chicoine MR. Combined high-field intraoperative magnetic resonance imaging and endoscopy increase extent of resection and progression-free survival for pituitary adenomas. Pituitary 2015; 18:72-85. [PMID: 24599833 PMCID: PMC4161669 DOI: 10.1007/s11102-014-0560-2] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE The clinical benefit of combined intraoperative magnetic resonance imaging (iMRI) and endoscopy for transsphenoidal pituitary adenoma resection has not been completely characterized. This study assessed the impact of microscopy, endoscopy, and/or iMRI on progression-free survival, extent of resection status (gross-, near-, and sub-total resection), and operative complications. METHODS Retrospective analyses were performed on 446 transsphenoidal pituitary adenoma surgeries at a single institution between 1998 and 2012. Multivariate analyses were used to control for baseline characteristics, differences during extent of resection status, and progression-free survival analysis. RESULTS Additional surgery was performed after iMRI in 56/156 cases (35.9%), which led to increased extent of resection status in 15/156 cases (9.6%). Multivariate ordinal logistic regression revealed no increase in extent of resection status following iMRI or endoscopy alone; however, combining these modalities increased extent of resection status (odds ratio 2.05, 95% CI 1.21-3.46) compared to conventional transsphenoidal microsurgery. Multivariate Cox regression revealed that reduced extent of resection status shortened progression-free survival for near- versus gross-total resection [hazard ratio (HR) 2.87, 95% CI 1.24-6.65] and sub- versus near-total resection (HR 2.10; 95% CI 1.00-4.40). Complication comparisons between microscopy, endoscopy, and iMRI revealed increased perioperative deaths for endoscopy versus microscopy (4/209 and 0/237, respectively), but this difference was non-significant considering multiple post hoc comparisons (Fisher exact, p = 0.24). CONCLUSIONS Combined use of endoscopy and iMRI increased pituitary adenoma extent of resection status compared to conventional transsphenoidal microsurgery, and increased extent of resection status was associated with longer progression-free survival. Treatment modality combination did not significantly impact complication rate.
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Affiliation(s)
- Peter T. Sylvester
- Department of Neurosurgery, Washington University School of Medicine, 660 S Euclid Ave, Campus Box 8057, St. Louis, MO, USA
| | - John A. Evans
- Department of Neurosurgery, Washington University School of Medicine, 660 S Euclid Ave, Campus Box 8057, St. Louis, MO, USA
| | - Gregory J. Zipfel
- Department of Neurosurgery, Washington University School of Medicine, 660 S Euclid Ave, Campus Box 8057, St. Louis, MO, USA
| | - Richard A. Chole
- Getz Department of Otolaryngology, Head and Neck Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Ravindra Uppaluri
- Getz Department of Otolaryngology, Head and Neck Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Bruce H. Haughey
- Getz Department of Otolaryngology, Head and Neck Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Anne E. Getz
- Getz Department of Otolaryngology, Head and Neck Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Julie Silverstein
- Department of Neurosurgery, Washington University School of Medicine, 660 S Euclid Ave, Campus Box 8057, St. Louis, MO, USA
- Department of Internal Medicine/Endocrinology, Metabolism and Lipid Research, Washington University School of Medicine, St. Louis, MO, USA
| | - Keith M. Rich
- Department of Neurosurgery, Washington University School of Medicine, 660 S Euclid Ave, Campus Box 8057, St. Louis, MO, USA
| | - Albert H. Kim
- Department of Neurosurgery, Washington University School of Medicine, 660 S Euclid Ave, Campus Box 8057, St. Louis, MO, USA
| | - Ralph G. Dacey
- Department of Neurosurgery, Washington University School of Medicine, 660 S Euclid Ave, Campus Box 8057, St. Louis, MO, USA
| | - Michael R. Chicoine
- Department of Neurosurgery, Washington University School of Medicine, 660 S Euclid Ave, Campus Box 8057, St. Louis, MO, USA
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Berkmann S, Schlaffer S, Nimsky C, Fahlbusch R, Buchfelder M. Follow-up and long-term outcome of nonfunctioning pituitary adenoma operated by transsphenoidal surgery with intraoperative high-field magnetic resonance imaging. Acta Neurochir (Wien) 2014; 156:2233-43; discussion 2243. [PMID: 25174805 DOI: 10.1007/s00701-014-2210-x] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Accepted: 08/15/2014] [Indexed: 01/17/2023]
Abstract
BACKGROUND Intraoperative MRI (iMRI) increases gross total resection (GTR) rates in transsphenoidal surgery; however, long-term follow-up data is lacking. The objective is to assess the outcome of patients with nonfunctioning pituitary adenomas (NFA) at a mean follow-up of > 5 years. METHODS Patients with NFA operated in a single institution with resection control by a 1.5 T intraoperative magnetic resonance imaging (iMRI) scanner and no previous pituitary surgery were included. Microscopical transsphenoidal approaches with optional endoscopy were used. The iMRI was chosen for spacious suprasellar or retrosellar and/or invasive tumours. IMRI-scans were made if GTR or if nonresectable remnants were presumed. The patients had a full neuroradiological, endocrinological and ophthalmological follow-up at the institution. RESULTS Eighty-five patients (67 % male;55 ± 14 years) with a follow-up of 5.6 ± 1.9 years were included. The initial GTR rate on iMRI was 44 %. In 83 %, further resections were possible, resulting in a final GTR rate of 66 %. In invasive tumours, the GTR rate was increased by 29 %. The detection of remnants by iMRI had high sensitivity and specificity (100 %), as opposed to endoscopy (21 %;78 %). During follow-up, four (7 %) tumours recurred and 14 (64 %) remnants grew. The recurrence and regrowth rate were 0.013 and 0.114 patients/years, respectively. Seventy-nine percent of the growing remnants were seen < 5 years postoperatively. CONCLUSIONS The use of iMRI for transsphenoidal resection leads to low recurrence rates. Even in case of invasive tumours, distinctly more patients show long tumour-free follow-ups. Tumour remnants detected by iMRI are at high risk to grow within 5 years after surgery.
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Affiliation(s)
- Sven Berkmann
- Department of Neurosurgery, University Hospital of Erlangen, Schwabachanlage 6, 91054, Erlangen, Germany,
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Livne O, Harel R, Hadani M, Spiegelmann R, Feldman Z, Cohen ZR. Intraoperative Magnetic Resonance Imaging for Resection of Intra-Axial Brain Lesions: A Decade of Experience Using Low-Field Magnetic Resonance Imaging, Polestar N-10, 20, 30 Systems. World Neurosurg 2014; 82:770-6. [DOI: 10.1016/j.wneu.2014.02.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2013] [Revised: 11/07/2013] [Accepted: 02/06/2014] [Indexed: 11/30/2022]
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Fomekong E, Duprez T, Docquier MA, Ntsambi G, Maiter D, Raftopoulos C. Intraoperative 3T MRI for pituitary macroadenoma resection: Initial experience in 73 consecutive patients. Clin Neurol Neurosurg 2014; 126:143-9. [PMID: 25255158 DOI: 10.1016/j.clineuro.2014.09.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2014] [Accepted: 09/06/2014] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To report a single-center experience with a 3T intraoperative magnetic resonance imaging (iMRI) to assess transsphenoidal microsurgery on pituitary macroadenomas. METHODS In a dual, independent operating room (OR) magnetic resonance imaging (MRI) suite, the operating table with the anesthetized patient was moved on rail tracks once a supposed maximized resection was reached to the MRI room for intraoperative image acquisition and interpretation. After the assessment of the iMRI images, the neurosurgeon evaluated whether additional resection was still possible. The resection rates were assessed on iMRI and postoperative MRI at 3 months. RESULTS A total of 73 macroadenomas benefited from an iMRI from March 2006 to October 2011. The gross total resection (GTR) rate at the time of the first iMRI was 58.9% (n=43). Based on the iMRI, eight patients (10.9%) underwent a second surgical resection. In 3 cases, the intraoperative imaging results were suspicious for a minor residue but not convincing enough for further surgery. Fortunately, the 3 months postoperative MRI control did not disclose any residual tumor in these cases. Finally, the GTR rate at the 3-month postoperative MRI increased to 72.6% (n=53). CONCLUSIONS 3T intraoperative MRI offered excellent quality images. Its use during transsphenoidal microsurgery on pituitary macroadenomas led to an increase not only in the extent of tumor resection (in 8 patients) but also in the rate of radical resections (69% instead of 60%). No complications due to the iMRI procedure were observed.
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Affiliation(s)
- Edward Fomekong
- Department of Neurosurgery, Cliniques Universitaires St-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Thierry Duprez
- Department of Radiology, Cliniques Universitaires St-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Marie-Agnès Docquier
- Department of Anesthesiology, Cliniques Universitaires St-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Glennie Ntsambi
- Department of Neurosurgery, Cliniques Universitaires St-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Dominique Maiter
- Department of Internal Medicine, Cliniques Universitaires St-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Christian Raftopoulos
- Department of Neurosurgery, Cliniques Universitaires St-Luc, Université Catholique de Louvain, Brussels, Belgium.
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Berkmann S, Schlaffer S, Nimsky C, Fahlbusch R, Buchfelder M. Intraoperative high-field MRI for transsphenoidal reoperations of nonfunctioning pituitary adenoma. J Neurosurg 2014; 121:1166-75. [PMID: 25127413 DOI: 10.3171/2014.6.jns131994] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The loss of anatomical landmarks, frequently invasive tumor growth, and tissue changes make transsphenoidal reoperation of nonfunctioning pituitary adenomas (NFAs) challenging. The use of intraoperative MRI (iMRI) may lead to improved results. The goal of this retrospective study was to evaluate the impact of iMRI on transsphenoidal reoperations for NFA. METHODS Between September 2002 and July 2012, 109 patients underwent reoperations in which 111 transsphenoidal procedures were performed and are represented in this study. A 1.5-T Magnetom Sonata Maestro Class scanner (Siemens) was used for iMRI. Follow-up iMRI scans were acquired if gross-total resection (GTR) was suspected or if no further removal seemed possible. RESULTS Surgery was performed for tumor persistence and regrowth in 26 (23%) and 85 (77%) patients, respectively. On the initial iMRI scans, GTR was confirmed in 19 (17%) patients. Remnants were located as follows: 65 in the cavernous sinus (71%), 35 in the suprasellar space (38%), 9 in the retrosellar space (10%). Additional resection was possible in 62 (67%) patients, resulting in a significant volume reduction and increased GTR rate (49%). The GTR rates of invasive tumors on initial iMRI and postoperative MRI (poMRI) were 7% and 25%, respectively. Additional remnant resection was possible in 64% of the patients. Noninvasive tumors were shown to be totally resected on the initial iMRI in 31% of cases. After additional resection for 69% of the procedures, the GTR rate on poMRI was 75%. Transcranial surgery to resect tumor remnants was indicated in 5 (5%), and radiotherapy was performed in 29 (27%) patients. After GTR, no recurrence was detected during a mean follow-up of 2.2 ± 2.1 years. CONCLUSIONS The use of iMRI in transsphenoidal reoperations for NFA leads to significantly higher GTR rates. It thus prevents additional operations and reduces the number of tumor remnants. The complication rates do not exceed the incidences reported in the literature for primary transsphenoidal surgery. If complete tumor resection is not possible, iMRI guidance can facilitate tumor volume reduction.
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Affiliation(s)
- Sven Berkmann
- Department of Neurosurgery, University Hospital Erlangen, Erlangen
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D'Amico RS, Kennedy BC, Bruce JN. Neurosurgical oncology: advances in operative technologies and adjuncts. J Neurooncol 2014; 119:451-63. [PMID: 24969924 DOI: 10.1007/s11060-014-1493-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Accepted: 05/22/2014] [Indexed: 12/31/2022]
Abstract
Modern glioma surgery has evolved around the central tenet of safely maximizing resection. Recent surgical adjuncts have focused on increasing the maximum extent of resection while minimizing risk to functional brain. Technologies such as cortical and subcortical stimulation mapping, intraoperative magnetic resonance imaging, functional neuronavigation, navigable intraoperative ultrasound, neuroendoscopy, and fluorescence-guided resection have been developed to augment the identification of tumor while preserving brain anatomy and function. However, whether these technologies offer additional long-term benefits to glioma patients remains to be determined. Here we review advances over the past decade in operative technologies that have offered the most promising benefits for glioblastoma patients.
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Affiliation(s)
- Randy S D'Amico
- Department of Neurological Surgery, Neurological Institute, Columbia University Medical Center, 4th Floor, 710 West 168th Street, New York, NY, 10032, USA,
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