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Toader C, Eva L, Tataru CI, Covache-Busuioc RA, Bratu BG, Dumitrascu DI, Costin HP, Glavan LA, Ciurea AV. Frontiers of Cranial Base Surgery: Integrating Technique, Technology, and Teamwork for the Future of Neurosurgery. Brain Sci 2023; 13:1495. [PMID: 37891862 PMCID: PMC10605159 DOI: 10.3390/brainsci13101495] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 10/10/2023] [Accepted: 10/18/2023] [Indexed: 10/29/2023] Open
Abstract
The landscape of cranial base surgery has undergone monumental transformations over the past several decades. This article serves as a comprehensive survey, detailing both the historical and current techniques and technologies that have propelled this field into an era of unprecedented capabilities and sophistication. In the prologue, we traverse the historical evolution from rudimentary interventions to the state-of-the-art neurosurgical methodologies that define today's practice. Subsequent sections delve into the anatomical complexities of the anterior, middle, and posterior cranial fossa, shedding light on the intricacies that dictate surgical approaches. In a section dedicated to advanced techniques and modalities, we explore cutting-edge evolutions in minimally invasive procedures, pituitary surgery, and cranial base reconstruction. Here, we highlight the seamless integration of endocrinology, biomaterial science, and engineering into neurosurgical craftsmanship. The article emphasizes the paradigm shift towards "Functionally" Guided Surgery facilitated by intraoperative neuromonitoring. We explore its historical origins, current technologies, and its invaluable role in tailoring surgical interventions across diverse pathologies. Additionally, the digital era's contributions to cranial base surgery are examined. This includes breakthroughs in endoscopic technology, robotics, augmented reality, and the potential of machine learning and AI-assisted diagnostic and surgical planning. The discussion extends to radiosurgery and radiotherapy, focusing on the harmonization of precision and efficacy through advanced modalities such as Gamma Knife and CyberKnife. The article also evaluates newer protocols that optimize tumor control while preserving neural structures. In acknowledging the holistic nature of cranial base surgery, we advocate for an interdisciplinary approach. The ecosystem of this surgical field is presented as an amalgamation of various medical disciplines, including neurology, radiology, oncology, and rehabilitation, and is further enriched by insights from patient narratives and quality-of-life metrics. The epilogue contemplates future challenges and opportunities, pinpointing potential breakthroughs in stem cell research, regenerative medicine, and genomic tailoring. Ultimately, the article reaffirms the ethos of continuous learning, global collaboration, and patient-first principles, projecting an optimistic trajectory for the field of cranial base surgery in the coming decade.
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Affiliation(s)
- Corneliu Toader
- Department of Neurosurgery, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (C.T.); (R.-A.C.-B.); (D.-I.D.); (H.P.C.); (L.-A.G.); (A.V.C.)
- Department of Vascular Neurosurgery, National Institute of Neurology and Neurovascular Diseases, 077160 Bucharest, Romania
| | - Lucian Eva
- Department of Neurosurgery, Dunarea de Jos University, 800010 Galati, Romania
- Department of Neurosurgery, Clinical Emergency Hospital “Prof. Dr. Nicolae Oblu”, 700309 Iasi, Romania
| | - Catalina-Ioana Tataru
- Department of Ophthalmology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Clinical Hospital of Ophthalmological Emergencies, 010464 Bucharest, Romania
| | - Razvan-Adrian Covache-Busuioc
- Department of Neurosurgery, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (C.T.); (R.-A.C.-B.); (D.-I.D.); (H.P.C.); (L.-A.G.); (A.V.C.)
| | - Bogdan-Gabriel Bratu
- Department of Neurosurgery, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (C.T.); (R.-A.C.-B.); (D.-I.D.); (H.P.C.); (L.-A.G.); (A.V.C.)
| | - David-Ioan Dumitrascu
- Department of Neurosurgery, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (C.T.); (R.-A.C.-B.); (D.-I.D.); (H.P.C.); (L.-A.G.); (A.V.C.)
| | - Horia Petre Costin
- Department of Neurosurgery, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (C.T.); (R.-A.C.-B.); (D.-I.D.); (H.P.C.); (L.-A.G.); (A.V.C.)
| | - Luca-Andrei Glavan
- Department of Neurosurgery, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (C.T.); (R.-A.C.-B.); (D.-I.D.); (H.P.C.); (L.-A.G.); (A.V.C.)
| | - Alexandru Vlad Ciurea
- Department of Neurosurgery, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (C.T.); (R.-A.C.-B.); (D.-I.D.); (H.P.C.); (L.-A.G.); (A.V.C.)
- Neurosurgery Department, Sanador Clinical Hospital, 010991 Bucharest, Romania
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Khan DZ, Hanrahan JG, Baldeweg SE, Dorward NL, Stoyanov D, Marcus HJ. Current and Future Advances in Surgical Therapy for Pituitary Adenoma. Endocr Rev 2023; 44:947-959. [PMID: 37207359 PMCID: PMC10502574 DOI: 10.1210/endrev/bnad014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 03/14/2023] [Accepted: 05/17/2023] [Indexed: 05/21/2023]
Abstract
The vital physiological role of the pituitary gland, alongside its proximity to critical neurovascular structures, means that pituitary adenomas can cause significant morbidity or mortality. While enormous advancements have been made in the surgical care of pituitary adenomas, numerous challenges remain, such as treatment failure and recurrence. To meet these clinical challenges, there has been an enormous expansion of novel medical technologies (eg, endoscopy, advanced imaging, artificial intelligence). These innovations have the potential to benefit each step of the patient's journey, and ultimately, drive improved outcomes. Earlier and more accurate diagnosis addresses this in part. Analysis of novel patient data sets, such as automated facial analysis or natural language processing of medical records holds potential in achieving an earlier diagnosis. After diagnosis, treatment decision-making and planning will benefit from radiomics and multimodal machine learning models. Surgical safety and effectiveness will be transformed by smart simulation methods for trainees. Next-generation imaging techniques and augmented reality will enhance surgical planning and intraoperative navigation. Similarly, surgical abilities will be augmented by the future operative armamentarium, including advanced optical devices, smart instruments, and surgical robotics. Intraoperative support to surgical team members will benefit from a data science approach, utilizing machine learning analysis of operative videos to improve patient safety and orientate team members to a common workflow. Postoperatively, neural networks leveraging multimodal datasets will allow early detection of individuals at risk of complications and assist in the prediction of treatment failure, thus supporting patient-specific discharge and monitoring protocols. While these advancements in pituitary surgery hold promise to enhance the quality of care, clinicians must be the gatekeepers of the translation of such technologies, ensuring systematic assessment of risk and benefit prior to clinical implementation. In doing so, the synergy between these innovations can be leveraged to drive improved outcomes for patients of the future.
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Affiliation(s)
- Danyal Z Khan
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London WC1N 3BG, UK
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London W1W 7TY, UK
| | - John G Hanrahan
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London WC1N 3BG, UK
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London W1W 7TY, UK
| | - Stephanie E Baldeweg
- Department of Diabetes & Endocrinology, University College London Hospitals NHS Foundation Trust, London NW1 2BU, UK
- Centre for Obesity and Metabolism, Department of Experimental and Translational Medicine, Division of Medicine, University College London, London WC1E 6BT, UK
| | - Neil L Dorward
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London WC1N 3BG, UK
| | - Danail Stoyanov
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London W1W 7TY, UK
- Digital Surgery Ltd, Medtronic, London WD18 8WW, UK
| | - Hani J Marcus
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London WC1N 3BG, UK
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London W1W 7TY, UK
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Jozaghi Y, Phan J, Hanna EY, Kupferman ME, Su SY. Functional Outcomes and Quality of Life in Patients with Sinonasal, Nasopharyngeal, and Anterior Skull Base Tumors. Curr Oncol Rep 2022; 24:775-781. [PMID: 35290597 DOI: 10.1007/s11912-022-01214-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/01/2021] [Indexed: 01/18/2023]
Abstract
PURPOSE OF REVIEW This article will review functional and QOL outcomes among patients treated predominantly for sinonasal and nasopharyngeal malignancies. RECENT FINDINGS Treatment advances and interdisciplinary supportive care help to lessen the functional impairments and the reduction in quality of life (QOL) that were once accepted as inevitable tradeoffs for cure. Recent progress in QOL and Patient-Reported Outcome (PRO) instruments for this population will be covered. Sinonasal and nasopharyngeal tumors affect patients' quality of life, appearance, and critical functions. Tumors arise in proximity of vital structures including the orbit, cranial nerves, carotid artery, brain, cervical spine, and pituitary gland. Surgical morbidity, along with acute and late effects of systemic therapy and radiotherapy on normal tissues in this functionally critical region, may result in wide-ranging symptoms. Patients with skull base tumors report a high symptom burden at presentation, prior to treatment, relative to other malignancies in the head and neck region.
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Affiliation(s)
- Yelda Jozaghi
- Department of Head and Neck Surgery, The University of Texas, M. D. Anderson Cancer Center, 1515 Holcombe Blvd, Suite 1445, Houston, TX, 77030, USA
| | - Jack Phan
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ehab Y Hanna
- Department of Head and Neck Surgery, The University of Texas, M. D. Anderson Cancer Center, 1515 Holcombe Blvd, Suite 1445, Houston, TX, 77030, USA
| | - Michael E Kupferman
- Department of Head and Neck Surgery, The University of Texas, M. D. Anderson Cancer Center, 1515 Holcombe Blvd, Suite 1445, Houston, TX, 77030, USA
| | - Shirley Y Su
- Department of Head and Neck Surgery, The University of Texas, M. D. Anderson Cancer Center, 1515 Holcombe Blvd, Suite 1445, Houston, TX, 77030, USA.
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Castle-Kirszbaum M, Wang YY, King J, Goldschlager T. Quality of Life After Endoscopic Surgical Management of Pituitary Adenomas. Neurosurgery 2022; 90:81-91. [PMID: 34982874 DOI: 10.1227/neu.0000000000001740] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 08/21/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Patient-reported quality of life (QOL) is a vital metric for surgical success. OBJECTIVE To assess the effect of surgery on QOL in the largest prospectively collected, longitudinal cohort of surgically managed pituitary adenomas. METHODS A consecutive surgical adenoma cohort (n = 304) between late 2016 and mid-2020 underwent a scheduled overall (Anterior Skull Base Questionnaire-35) and sinonasal-specific (Sinonasal Outcome Test-22) QOL assessment. Scores were stratified by adenoma subtype and analyzed for clinical predictors of QOL changes. RESULTS The average age was 53.8 ± 16 yr, and 53% of participants were female. 60.9% of adenomas were nonfunctioning while adrenocorticotropic hormone adenomas (16.4%), growth hormone adenomas (14.1%), and prolactinomas (5.9%) were the most prevalent secreting adenomas. Baseline overall QOL differed between tumor types (P = .006), with adrenocorticotropic hormone adenomas worse than growth hormone adenomas (P = .03) and nonfunctioning pituitary adenomas (NFPA) (P < .001). Sinonasal QOL worsened in the 3 wk after surgery but returned to baseline by 6 wk and beyond. Overall QOL worsened at 3 wk after surgery (P < .001) but significantly improved from baseline by 3 mo (P = .009) and beyond (P < .001). Emotional functioning improved soon after surgery, followed by performance and pain, and then, by 6 mo, physical function and vitality. Predictors of improved QOL were sellar/suprasellar lesions (P = .01), prolactinomas (P = .003), and NFPA (P = .04). Conversely, new postoperative hypopituitarism (P = .04) and larger adenoma volume (P = .04) predicted QOL worsening. CONCLUSION QOL is worsened after surgery at early time points. Prolactinomas and NFPA enjoy significant QOL improvements from surgery as early as 3 mo postoperatively. Other functional tumors may experience early benefits in younger patients without hypopituitarism and when isolated to the sellar/suprasellar region. These findings provide valuable information for counseling patients and setting expectations for surgery.
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Affiliation(s)
| | - Yi Yuen Wang
- Department of Neurosurgery, St Vincent's Health, Melbourne, Australia
| | - James King
- Department of Neurosurgery, Royal Melbourne Hospital, Melbourne, Australia
| | - Tony Goldschlager
- Department of Neurosurgery, Monash Health, Melbourne, Australia.,Department of Surgery, Monash University, Melbourne, Australia
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Keandoungchun P, Tirakotai W, Phinthusophon A, Wattanasen Y, Masayaanon P, Takathaweephon S. Pituitary Hormonal Status after Endoscopic Endonasal Transphenoidal Removal of Nonfunctioning Pituitary Adenoma: 5 years' Experience in a Single Center. Asian J Neurosurg 2021; 16:62-66. [PMID: 34211868 PMCID: PMC8202392 DOI: 10.4103/ajns.ajns_386_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 09/22/2020] [Accepted: 10/15/2020] [Indexed: 11/04/2022] Open
Abstract
Background This study focuses on hormonal disorder and medical complications postoperative endoscopic endonasal transsphenoidal approach of nonfunctioning adenoma at Prasat Neurological Institute, Bangkok, between January 2013 and December 2017. Methods and Material Baseline characteristics, clinical complications, and hormonal status data were collected from the patients' medical records and analyzed using the descriptive statistics. Results There were four surgeons who operated 126 cases, 17 of them were reoperation. The average age of the patients was 49 years old. The average length of stay was 13 days, and average operating time was 134 min. Visual field defect was the most common presenting symptom. Almost all the tumors were classified as pituitary macroadenoma which invaded one or two sellar walls. Total or near total tumor removal was the most extend of resection. There were 61 cases developed early diabetes insipidus (DI), but only 12 cases continue to long-term DI. Seven cases were meningitis. Three cases were death. Out of 83 patients who had preoperative intact hypothalamic-pituitary-adrenal (HPA) axis and hypothalamic pituitary thyroidal (HPT) axis, 2 and 3 of them developed postoperative impair HPA and HPT axis in that order. In addition, among 45 patients who had preoperative impair HPA and HPT axis, 6 of them achieved postoperative endocrinological normalization. Conclusion In preoperative intact pituitary hormone patients, the total or near total tumor removal of non functioning pituitary adenoma may have hypopituitarism during early postoperative period but gradually returned to normal during 4-6 month postoperative period.
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Affiliation(s)
| | - Wuttipong Tirakotai
- Department of Neurosurgery, Prasat Neurological Institute, Bangkok, Thailand
| | - Ampai Phinthusophon
- Department of Internal Medicine, Prasat Neurological Institute, Bangkok, Thailand
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Hasegawa H, Jentoft ME, Young WF, Lakomkin N, Van Gompel JJ, Link MJ, Atkinson JL, Meyer FB. Collision of Craniopharyngioma and Pituitary Adenoma: Comprehensive Review of an Extremely Rare Sellar Condition. World Neurosurg 2021; 149:e51-e62. [PMID: 33647491 DOI: 10.1016/j.wneu.2021.02.091] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 02/18/2021] [Accepted: 02/19/2021] [Indexed: 01/18/2023]
Abstract
OBJECTIVE The collision of pituitary adenoma and craniopharyngioma is extremely rare and thus there remains a paucity of data. METHODS We described a patient from our institution. We also performed a systematic review and subsequent quantitative synthesis of the literature (n = 21) and our institutional case to yield an integrated cohort, and a descriptive analysis was carried out. RESULTS Twenty-two patients (15 males and 7 females) were included in the integrated cohort. The median age was 47.0 years (range, 8-75 years). The tumor subtypes were 5 somatotropic, 5 lactotropic, 4 nonfunctioning, 3 gonadotropic, 2 corticotropic, 1 plurihormonal, and 1 silent subtype 3 for pituitary adenomas, and 19 adamantinomatous, 2 papillary, and 1 unknown subtype for craniopharyngiomas. Three different radiographic patterns were observed: solid mass with cystic component (n = 5), coexistence of two distinct solid components (n = 3), and a mixed-intensity solid mass (n = 5). The first 2 were consistent with histologically separate collision, whereas the third was consistent with histologically admixed collision. Among 19 patients in whom the postoperative course was recorded, a secondary intervention was required in 14 (73.7%) because of tumor progression or residual. The recurrence rate after gross total resection was 33.3%. Postoperative hormone replacement was required in 33.3%. The 10-year cumulative overall survival was 73.1%. CONCLUSIONS Most craniopharyngiomas were adamantinomatous. There are 2 types of collisions: separated and admixed. Tumor control, overall survival, and endocrinologic remission are more challenging to achieve than for solitary tumors, but gross total resection of both tumors is important for satisfactory tumor control.
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Affiliation(s)
- Hirotaka Hasegawa
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA; Department of Neurosurgery, University of Tokyo Hospital, Tokyo, Japan
| | - Mark E Jentoft
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Jacksonville, Florida, USA
| | - William F Young
- Division of Endocrinology, Diabetes, Metabolism, Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Nikita Lakomkin
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Jamie J Van Gompel
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael J Link
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - John L Atkinson
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Fredric B Meyer
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA.
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Pérez-López C, Álvarez-Escolá C, Isla Guerrero A. Therapeutic approach to non-functioning pituitary adenomas. Med Clin (Barc) 2021; 156:284-289. [PMID: 33454125 DOI: 10.1016/j.medcli.2020.08.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 08/03/2020] [Accepted: 08/04/2020] [Indexed: 10/22/2022]
Abstract
The treatment of non-functioning pituitary adenomas raises two questions: when should they be treated and what role does each available treatment play. We review the usefulness of the different treatments and propose a therapeutic scheme based on the existing literature. Active treatment of pituitary adenomas should be performed when they produce symptoms, have contact with the optic tract, or have grown on imaging tests. The treatment is surgical, using radiotherapy for cases with significant non-removable postsurgical tumour remnants and for those in which histopathology studies show aggressive features. Medical treatment is reserved for situations in which surgical and radiotherapy treatments have been exhausted. The most advisable surgical treatment is endoscopic, although experienced neurosurgeons achieve results with microsurgery that are only slightly inferior.
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Affiliation(s)
- Carlos Pérez-López
- Servicio de Neurocirugía. Hospital Universitario La Paz, Madrid, España.
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Abstract
Acromegaly is a systemic disease associated with increased morbidity and mortality. Most of these comorbidities can be prevented or delayed with adequate disease treatment. Although three modalities of treatment (surgery, medical treatment, and radiotherapy) are available and new drugs were approved in the last decades, there are still some patients that maintain disease activity despite treatment. Therefore, there is a need for novel therapies for acromegaly and for that purpose new formulations of currently used drugs and also new drugs are currently under study. In this review, we summarize the novel therapies for acromegaly.
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Affiliation(s)
- Bernardo Maia
- Neuroendocrinology Research Center/Endocrinology Division – Medical School and Hospital Universitário Clementino Fraga Filho – Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Leandro Kasuki
- Neuroendocrinology Research Center/Endocrinology Division – Medical School and Hospital Universitário Clementino Fraga Filho – Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
- Neuroendocrinology Division – Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
- Endocrinology Division – Hospital Federal de Bonsucesso, Rio de Janeiro Brazil
| | - Mônica R Gadelha
- Neuroendocrinology Research Center/Endocrinology Division – Medical School and Hospital Universitário Clementino Fraga Filho – Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
- Neuroendocrinology Division – Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
- Neuropatology and Molecular Genetics Laboratory – Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
- Correspondence should be addressed to M R Gadelha:
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Störmann S, Schopohl J. Drug treatment strategies for secondary diabetes in patients with acromegaly. Expert Opin Pharmacother 2020; 21:1883-1895. [PMID: 32633582 DOI: 10.1080/14656566.2020.1789098] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Acromegaly is a rare disease due to oversecretion of growth hormone (GH). Even though the disease is often portrayed by its most apparent clinical features, given the abundance of GH receptors throughout the body, it truly is a systemic disease leading to numerous complications and comorbidities. A distinct medical issue in the context of acromegaly is diabetes: It can be a complication as a consequence of GH excess and its mediators, but it can also result from treatment of acromegaly. AREAS COVERED This review provides an overview of the effects of acromegaly pathophysiology on glucose homeostasis. Furthermore, it devotes an extensive section on the influence that acromegaly treatment has on glucose metabolism, including approved as well as currently investigated drugs. It also summarizes observations from the use of anti-diabetic medication in patients with acromegaly. EXPERT OPINION Glucose imbalance is an important aspect of acromegaly comorbidity and deserves more attention. Even though numerous studies have investigated glucose homeostasis in acromegaly, there is still a clear need for more basic, translational, and also clinical research to advance the understanding of the underlying mechanisms and how to best address them.
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Affiliation(s)
- Sylvère Störmann
- Klinikum der Universität München, Medizinische Klinik und Poliklinik IV , München, Germany
| | - Jochen Schopohl
- Klinikum der Universität München, Medizinische Klinik und Poliklinik IV , München, Germany
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Baudracco I, Ekanayake J, Warner E, Grieve JP, Dorward NL. Olfactory outcomes after transsphenoidal endonasal surgery. Br J Neurosurg 2019; 34:35-39. [PMID: 31709822 DOI: 10.1080/02688697.2019.1680798] [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] [Indexed: 10/25/2022]
Abstract
Background: The endonasal approach is the gold standard for the resection of pituitary tumours, with either microscopic endonasal transsphenoidal (MET) or endoscopic endonasal transsphenoidal (EET) technique. Advantages and disadvantages of both techniques have been widely described in the literature, although limited attention has been paid to its impact on the sense of smell.Objective: The present study aims to quantify the effect of transnasal surgery on pituitary patients and examine olfactory outcomes.Methods: A prospective cohort study assessing the sense of smell of 20 patients (10 MET and 10 EET) pre-operatively. Olfactory function was re-assessed 6 months after surgery, using the University of Pennsylvania Smell Identification Test (Sensonics Inc., Haddon Heights, NJ).Results: The UPSIT (Sensonics Inc.) results showed a median pre-operative score of 33 (IQR 31-37.5) (normosmia). The median post-operative result was 25 (IQR 19.5-32), consistent with moderate microsmia. Twenty percent of the patients had normal olfactory function post-operatively, all of whom were from the EET group. Twenty percent had mild microsmia, equally divided in MET and EET subgroups. Seven patients had severe microsmia. Four patients were completely anosmic at 6 months follow-up.Conclusions: Patients undergoing a transsphenoidal procedure are at risk of olfactory disturbance post-operatively, which may include loss of the sense of smell. This information is relevant to the patients' perioperative experience, and should be incorporated into counselling with regards to outcomes and expectations. Although the study size is small, the study results suggest the ETS technique may be less traumatic for the olfactory function. A larger study powered to fully examine potential differences in olfactory outcomes following ETS and MTS is warranted.
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Affiliation(s)
- Irene Baudracco
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
| | - Jinendra Ekanayake
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
| | - Elinor Warner
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
| | - Joan P Grieve
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
| | - Neil L Dorward
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
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Ding ZQ, Zhang SF, Wang QH. Neuroendoscopic and microscopic transsphenoidal approach for resection of nonfunctional pituitary adenomas. World J Clin Cases 2019; 7:1591-1598. [PMID: 31367618 PMCID: PMC6658379 DOI: 10.12998/wjcc.v7.i13.1591] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Revised: 04/29/2019] [Accepted: 05/01/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Nonfunctional pituitary adenoma is a common type of pituitary adenoma, which can lead to headache, visual field disturbance, and cranial nerve damage due to increased tumor volume. Neuroendoscopic and microscopic transsphenoidal approaches have been widely used in the resection of nonfunctional pituitary adenomas. However, the clinical efficacy in neuroendoscopic and microscopic surgery is still controversial.
AIM To explore the clinical efficacy of neuroendoscopic and microscopic transsphenoidal approach for resection of nonfunctional pituitary adenomas.
METHODS We retrospectively analyzed 251 patients with nonfunctional pituitary adenomas; 138 underwent neuroendoscopic surgery via transsphenoidal approach, and 113 underwent microscopic surgery via transsphenoidal approach between July 2010 and September 2015. All patients were followed up for > 6 mo. Gender, age, course of disease, tumor diameter, tumor location, and percentage of patients with headache, visual impairment, sexual dysfunction, and menstrual disorders were contrasted between the two groups to compare the difference of preoperative data. Cure rate, symptom improvement rate, recurrence rate, the postoperative hospital stay, operating time, intraoperative blood loss, and the incidence of postoperative complications were compared in order to evaluate the advantages and disadvantages of neuroendoscopic and microscopic surgery.
RESULTS There was no significant difference in cure rate, symptom improvement rate, and recurrence rate between neuroendoscopy group and microscopy group (82.6% vs 85.8%, P > 0.05; 90.6% vs 93.8%, P > 0.05; 5.1% vs 9.7%, P > 0.05). In the neuroendoscopy group, the postoperative hospital stay was 8.4 ± 0.6 d; operating time was 167.2 ± 9.6 min; intraoperative blood loss was 83.4 ± 9.3 mL, and the rates of diabetes insipidus and electrolyte imbalance were 4.3% and 8.0%, respectively. The corresponding results in the microscopic group were 11.2 ± 0.6 d, 199.7 ± 9.3 min, 138.8 ± 13.6 mL, and 32.7% and 20.4%, respectively. There were significant differences in postoperative hospital stay, operating time, intraoperative blood loss, and the rates of diabetes insipidus and electrolyte imbalance between the two groups (P < 0.05).
CONCLUSION Neuroendoscopic and microscopic transsphenoidal approaches have similar clinical efficacy for the resection of nonfunctional pituitary adenomas. Neuroendoscopic surgery reduces operating time, intraoperative bleeding, postoperative recovery, and complications.
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Affiliation(s)
- Zhi-Quan Ding
- Department of Neurosurgery, Zhujiang Hospital, Southern Medical University, The National Key Clinical Specialty, The Engineering Technology Research Center of Education Ministry of China, Guangdong Provincial Key Laboratory on Brain Function Repair and Regeneration, Guangzhou 510282, Guangdong Province, China
| | - Sheng-Fan Zhang
- Department of Neurosurgery, Zhujiang Hospital, Southern Medical University, The National Key Clinical Specialty, The Engineering Technology Research Center of Education Ministry of China, Guangdong Provincial Key Laboratory on Brain Function Repair and Regeneration, Guangzhou 510282, Guangdong Province, China
| | - Qing-Hua Wang
- Department of Neurosurgery, Zhujiang Hospital, Southern Medical University, The National Key Clinical Specialty, The Engineering Technology Research Center of Education Ministry of China, Guangdong Provincial Key Laboratory on Brain Function Repair and Regeneration, Guangzhou 510282, Guangdong Province, China
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Rutkowski MJ, Aghi MK. Medical versus surgical treatment of prolactinomas: an analysis of treatment outcomes. Expert Rev Endocrinol Metab 2018; 13:25-33. [PMID: 30063440 DOI: 10.1080/17446651.2018.1411798] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Prolactinomas are unique tumors that may go into both hormonal and radiographic remission with dopamine agonist therapy or transsphenoidal surgery. Regardless of modality, the goals of therapy remain the same: (1) biochemical remission, including reduction of prolactin and normalization of sex hormones; (2) radiographic tumor control, with a range including prevention of tumor growth, tumor regression, or complete tumor resolution; (3) resolution of preoperative symptoms, including those that are hormonal or neurologic; and (4) prevention of new hypopituitarism or new neurologic symptoms. AREAS COVERED In the following review, we performed a search of the literature using keywords 'prolactinoma,' 'dopamine agonist,' 'surgery,' 'cost-effectiveness,' 'recurrence,' and 'complication' to compare the relative merits of medical versus surgical therapy for prolactinoma, including special circumstances such as cystic tumors, pregnant patients, and the cost-effectiveness of different strategies. EXPERT COMMENTARY Medical therapy can offer a cure, but surgery provides an important adjunct to patients with resistance or intolerance to dopamine agonists, and offers excellent outcomes including when combined with continued postoperative medical therapy. Further head to head comparisons will benefit patients and practitioners weighing the relative risks and benefits of medical and surgical intervention, including the issue of their relative cost-effectiveness.
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Affiliation(s)
- Martin J Rutkowski
- a California Center for Pituitary Disorders, Department of Neurological Surgery , University of California , San Francisco , CA , USA
| | - Manish K Aghi
- a California Center for Pituitary Disorders, Department of Neurological Surgery , University of California , San Francisco , CA , USA
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13
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Ekanayake J, Baudracco I, Quereshi A, Vercauteren T, Dorward NL. The conversational position in endoscopic pituitary surgery. Br J Neurosurg 2017; 32:44-46. [DOI: 10.1080/02688697.2017.1406058] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
| | - Irene Baudracco
- National Hospital for Neurology and Neurosurgery, London, UK
| | - Anjum Quereshi
- National Hospital for Neurology and Neurosurgery, London, UK
| | - Tom Vercauteren
- Wellcome Trust/EPSRC Centre for Interventional and Surgical Sciences, London, UK
| | - Neil L. Dorward
- National Hospital for Neurology and Neurosurgery, London, UK
- Wellcome Trust/EPSRC Centre for Interventional and Surgical Sciences, London, UK
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Nishioka H. Recent Evolution of Endoscopic Endonasal Surgery for Treatment of Pituitary Adenomas. Neurol Med Chir (Tokyo) 2017; 57:151-158. [PMID: 28239067 PMCID: PMC5409268 DOI: 10.2176/nmc.ra.2016-0276] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
For the treatment of pituitary tumors, microscopic transsphenoidal surgery has been considered the "gold standard" since the late 1960s. Over the last two decades, however, a worldwide shift towards endoscopic endonasal surgery is in progress for many reasons. These include a wide panoramic view, improved illumination, an ability to look around anatomical corners using angled tip and, in addition, application to the extended approaches for parasellar tumors. Both endoscopic and microscopic approaches appear equally effective for nonfunctioning adenomas without significant suprasellar or lateral extensions, whereas the endoscopic approach may improve outcomes associated with the extent of resection and postoperative complications for larger tumors. Despite many theoretical benefits in the endoscopic surgery, remission rates of functioning adenomas do not substantially differ between the approaches in experienced hands. The endoscopic approach is a valid alternative to the microscopic approach for adenomas. The benefits will be more appreciated in the extended surgery for parasellar tumors.
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Affiliation(s)
- Hiroshi Nishioka
- Department of Hypothalamic and Pituitary Surgery, Toranomon Hospital.,Okinaka Memorial Institute for Medical Research
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15
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Endoscopic Endonasal versus Microsurgical Transsphenoidal Approach for Growth Hormone–Secreting Pituitary Adenomas—Systematic Review and Meta-Analysis. World Neurosurg 2017; 97:398-406. [DOI: 10.1016/j.wneu.2016.10.029] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Revised: 10/01/2016] [Accepted: 10/04/2016] [Indexed: 12/26/2022]
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Magro E, Graillon T, Lassave J, Castinetti F, Boissonneau S, Tabouret E, Fuentes S, Velly L, Gras R, Dufour H. Complications Related to the Endoscopic Endonasal Transsphenoidal Approach for Nonfunctioning Pituitary Macroadenomas in 300 Consecutive Patients. World Neurosurg 2016; 89:442-53. [PMID: 26902781 DOI: 10.1016/j.wneu.2016.02.059] [Citation(s) in RCA: 88] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2015] [Revised: 02/09/2016] [Accepted: 02/11/2016] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To analyze complications of endoscopic transsphenoidal surgery (ETS) for nonfunctioning pituitary macroadenomas (NFPAs). METHODS A retrospective study of 300 NFPAs was performed. Complications and factors that could influence these complications were analyzed. RESULTS Visual and pituitary functions worsened in 2.4% and 13.7% of cases, respectively. Postoperative diabetes insipidus was permanent in 6.2% of cases. Postoperative meningitis occurred in 3.3% of patients. Meningitis was strongly associated with intraoperative cerebrospinal fluid (CSF) leaks (P = 0.01), postoperative CSF leaks (P = 0.0001), and operation times longer than 1 hour (P = 0.023). Detection of Staphylococcus aureus and preoperative treatment with mupirocin in the nostrils did not impact the occurrence of meningitis. Two patients with meningitis died (unique causes of death). Postoperative CSF leaks occurred in 2.7% of cases and were associated with intraoperative CSF leaks (P = 0.007) and permanent diabetes insipidus (P = 0.028). The rate of CSF leak decreased from 4% to 0.8% (P = 0.048) after we moved from a soft to hard reconstruction of the sella. The rate of postoperative epistaxis decreased from 6.7% to 1.25% after we stopped using monopolar coagulation (P = 0.013). CONCLUSIONS ETS permits a wide view, allowing good conditions for a satisfactory resection in the majority of NFPAs. Some pitfalls of endoscopy can lead to complications that improve with modification of the operative technique (i.e., CSF leak and postoperative epistaxis). This study confirms an acceptable rate of complications associated with ETS.
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Affiliation(s)
- Elsa Magro
- Department of Neurosurgery, CHU de la Timone, Université de la méditérannée, Marseille, France
| | - Thomas Graillon
- Department of Neurosurgery, CHU de la Timone, Université de la méditérannée, Marseille, France
| | - Jerome Lassave
- Department of Neurosurgery, CHU de la Timone, Université de la méditérannée, Marseille, France
| | - Frederic Castinetti
- Department of Endocrinology, CHU de la Conception, Université de la méditérannée, Marseille, France
| | - Sebastien Boissonneau
- Department of Neurosurgery, CHU de la Timone, Université de la méditérannée, Marseille, France
| | - Emline Tabouret
- Department of Neuro-oncology, CHU de la Timone, Université de la méditérannée, Marseille, France
| | - Stéphane Fuentes
- Department of Neurosurgery, CHU de la Timone, Université de la méditérannée, Marseille, France
| | - Lionel Velly
- Intensive Care Unit, CHU de la Timone, Université de la méditérannée, Marseille, France
| | - Regis Gras
- Department of Neurosurgery, CHU de la Timone, Université de la méditérannée, Marseille, France
| | - Henry Dufour
- Department of Neurosurgery, CHU de la Timone, Université de la méditérannée, Marseille, France.
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Abstract
Acromegaly (ACM) is a chronic, progressive disorder caused by the persistent hypersecretion of GH, in the vast majority of cases secreted by a pituitary adenoma. The consequent increase in IGF1 (a GH-induced liver protein) is responsible for most clinical features and for the systemic complications associated with increased mortality. The clinical diagnosis, based on symptoms related to GH excess or the presence of a pituitary mass, is often delayed many years because of the slow progression of the disease. Initial testing relies on measuring the serum IGF1 concentration. The oral glucose tolerance test with concomitant GH measurement is the gold-standard diagnostic test. The therapeutic options for ACM are surgery, medical treatment, and radiotherapy (RT). The outcome of surgery is very good for microadenomas (80-90% cure rate), but at least half of the macroadenomas (most frequently encountered in ACM patients) are not cured surgically. Somatostatin analogs are mainly indicated after surgical failure. Currently their routine use as primary therapy is not recommended. Dopamine agonists are useful in a minority of cases. Pegvisomant is indicated for patients refractory to surgery and other medical treatments. RT is employed sparingly, in cases of persistent disease activity despite other treatments, due to its long-term side effects. With complex, combined treatment, at least three-quarters of the cases are controlled according to current criteria. With proper control of the disease, the specific complications are partially improved and the mortality rate is close to that of the background population.
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Affiliation(s)
- Cristina Capatina
- Department of EndocrinologyCarol Davila University of Medicine and Pharmacy, Bucharest, RomaniaCI Parhon National Institute of EndocrinologyBucharest, RomaniaDepartment of EndocrinologyOxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Old Road, Headington, Oxford OX3 7LE, UK Department of EndocrinologyCarol Davila University of Medicine and Pharmacy, Bucharest, RomaniaCI Parhon National Institute of EndocrinologyBucharest, RomaniaDepartment of EndocrinologyOxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Old Road, Headington, Oxford OX3 7LE, UK
| | - John A H Wass
- Department of EndocrinologyCarol Davila University of Medicine and Pharmacy, Bucharest, RomaniaCI Parhon National Institute of EndocrinologyBucharest, RomaniaDepartment of EndocrinologyOxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Old Road, Headington, Oxford OX3 7LE, UK
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Storr HL, Drake WM, Evanson J, Matson M, Berney DM, Grossman AB, Akker SA, Monson JP, Alusi G, Savage MO, Sabin I. Endonasal endoscopic transsphenoidal pituitary surgery: early experience and outcome in paediatric Cushing's disease. Clin Endocrinol (Oxf) 2014; 80:270-6. [PMID: 23800132 DOI: 10.1111/cen.12275] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Revised: 06/14/2013] [Accepted: 06/20/2013] [Indexed: 12/27/2022]
Abstract
BACKGROUND Selective adenomectomy remains the first-line treatment for Cushing's disease (CD), until recently by microscopic transsphenoidal pituitary surgery. Endonasal transsphenoidal endoscopic surgery (ETES) is emerging as a novel, less invasive treatment for pituitary adenomas and has become the optimal surgical approach. OBJECTIVE There are no published series for the treatment of paediatric CD by ETES, and we report our centre's preliminary results. DESIGN Retrospective analysis. PATIENTS Six paediatric patients (median age 15·8 years; range 11·7-17·0 years) fulfilled standard diagnostic criteria for CD. Preoperatively, no abnormality was identified on pituitary MR scanning in 3 (50%) patients, one had a macroadenoma. Bilateral petrosal sinus sampling demonstrated central ACTH secretion (IPS/P ACTH ratio ≥3·0, post-CRH) in 3/6 (50%) patients. The same neurosurgeon and endoscopic nasal surgeon undertook all the operations. OUTCOME MEASURES Therapeutic outcome and rate of complications. RESULTS Clinical recovery and biochemical 'cure' were achieved in 5 (83%) patients, and a corticotroph adenoma was confirmed histologically in all cured cases. One case developed post-operative CSF leak requiring lumbar drain insertion and patching. At a mean interval of 4·7 years (0·1-10·8 years) post-operatively, cured patients have shown no recurrence. One patient, with a large diffuse adenoma requiring more extensive surgery, has panhypopituitarism, and another patient has GH and gonadotrophin deficiencies. CONCLUSIONS Our experience shows that ETES for removing corticotroph adenomas in children, in most cases not visualized on MRI, is minimally invasive and gave excellent post-operative recovery/results. In skilled hands, this technique provides an alternative to conventional transsphenoidal microscopic surgery in managing paediatric CD.
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Affiliation(s)
- Helen L Storr
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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Abstract
INTRODUCTION Acromegaly is a rare disease that severely impacts patients' health all the while, being a slowly progressing illness. In the past decades, advancements in treatment modalities, especially development of new drugs, as well as focused guidelines has improved management of acromegaly. Still, many patients are considered not sufficiently treated and there remains an ongoing need for further development. AREAS COVERED This article reviews new medical treatments currently under clinical investigation (such as pasireotide, oral octreotide and somatoprim) and under experimental development (such as octreotide implants, CAM2029 and ATL-1103). EXPERT OPINION As it seems unlikely that one single agent may achieve cure in 100% of cases, there is an urgent need for new agents that help patients where current medication fails. Imperatively, this means we have to improve our understanding of the underlying pathogenetic and molecular mechanisms.
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Affiliation(s)
- Sylvère Störmann
- Klinikum der Universität München, Medizinische Klinik und Poliklinik IV , Ziemssenstr. 1, 80336 München , Germany +49 0 89 5160 2111 ; +49 0 89 5160 2194 ;
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20
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Abstract
The endoscopic transsphenoidal approach to the sella turcica has been developed and refined for the treatment of pituitary lesions. Studies comparing endoscopic transsphenoidal surgery with the traditional microscopic transsphenoidal technique have found equivalent or improved rates of tumor resection and hormonal remission, and equal or lower rates of complications. This procedure affords improved panoramic visualization, illumination, surgical freedom, and mobility. This approach facilitates two-handed microdissection and the ability to look around corners using angled lenses, promoting maximal tumor resection and preservation of the pituitary gland. Experience, technologic advancements, and improved instrumentation are likely to contribute to improved surgical outcomes.
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Affiliation(s)
- Joshua W Lucas
- Department of Neurosurgery, University of Southern California, Los Angeles, CA 90033, USA.
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21
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Hill J. Changing trends in pituitary surgery. Br J Hosp Med (Lond) 2012; 73:486-7. [PMID: 23124398 DOI: 10.12968/hmed.2012.73.9.486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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22
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de Almeida JR, Witterick IJ, Gullane PJ, Gentili F, Lohfeld L, Ringash J, Thoma A, Vescan AD. Physical morbidity by surgical approach and tumor location in skull base surgery. Head Neck 2012; 35:493-9. [DOI: 10.1002/hed.23006] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2012] [Indexed: 11/08/2022] Open
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Paluzzi A, Gardner P, Fernandez-Miranda JC, Snyderman C. The expanding role of endoscopic skull base surgery. Br J Neurosurg 2012; 26:649-61. [DOI: 10.3109/02688697.2012.673649] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Honegger J, Schmalisch K, Beuschlein F, Kaufmann S, Schnauder G, Naegele T, Psaras T. Contemporary microsurgical concept for the treatment of Cushing's disease: endocrine outcome in 83 consecutive patients. Clin Endocrinol (Oxf) 2012; 76:560-7. [PMID: 22026553 DOI: 10.1111/j.1365-2265.2011.04268.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Evidence suggests that occult adenoma remnants are responsible for persistent Cushing's disease (CD) following transsphenoidal surgery (TSS). To optimize the outcome, we have adapted our microsurgical concept. The influence of our surgical strategy on remission rate and pituitary function is presented. DESIGN AND PATIENTS 83 patients undergoing TSS for newly diagnosed CD. An enlarged resection was performed in 36 patients. A modified exploration technique with radial incisions was performed in 19 patients in whom an adenoma was not readily detectable. RESULTS The overall remission rate of primary surgery was 84·3% (70/83). A remission rate of 87·5% (63/72) was achieved in microadenomas. Six patients with microadenomas were re-operated for persistence, and hypercortisolism was corrected in five of them. With re-operation included, the overall remission rate for microadenomas was 94·4%. No procedure-related complications occurred in primary surgery. Of the patients in remission, 72·5% had early postoperative random cortisol levels below 2 μg/dl, 17·4% had cortisol levels between 2 and 5 μg/dl, and 10·1% had cortisol levels >5 μg/dl. 15·2% of the patients with microadenomas developed postoperative partial hypopituitarism and 3% diabetes insipidus. No increased rate of hypopituitarism was found with enlarged adenomectomy compared to selective adenomectomy. Only a slightly higher rate of partial hypopituitarism (23·1%) was found if extensive exploration was required. CONCLUSION With our microsurgical concept, a high initial cure rate is achievable with minimal surgical morbidity. Enlarged adenomectomy has no adverse effect on the rate of postoperative hypopituitarism. Early repeat surgery is a successful option if CD persists.
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Affiliation(s)
- Juergen Honegger
- Department of Neurosurgery, University of Tuebingen, Tuebingen, Germany.
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25
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Cheng RX, Tian HL, Gao WW, Li ZQ. A comparison between endoscopic trans-sphenoidal surgery and traditional trans-sphenoidal microsurgery for functioning pituitary adenomas. J Int Med Res 2012; 39:1985-93. [PMID: 22118003 DOI: 10.1177/147323001103900545] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
This retrospective study reviewed and compared the efficacy and safety outcomes following trans-sphenoidal endoscopy or microsurgery approaches in patients with functioning pituitary adenomas: 68 patients underwent endoscopic trans-sphenoidal resections and 59 patients had microsurgical resections. Tumours were classified according to diameter and clinical outcomes were evaluated. Overall disease control rates were 70.6% following endoscopy and 49.2% following microsurgery. The most obvious between-group difference was observed in macroadenomas: disease control rates were 63.9% following endoscopy and 27.3% following microsurgery. Cerebrospinal fluid leaks, diabetes insipidus and syndrome of inappropriate antidiuretic hormone secretion were observed postoperatively in both groups. The complication rate was lower following endoscopy compared with microsurgery (this difference was not statistically significant). Trans-sphenoidal endoscopy resection achieved good results in pituitary tumours, particularly for the complete removal of macroadenomas, and was an effective alternative to microsurgery.
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Affiliation(s)
- R-X Cheng
- Department of Neurosurgery, Fengxian Branch of Shanghai Sixth People's Hospital, Shanghai, China
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Roelfsema F, Biermasz NR, Pereira AM. Clinical factors involved in the recurrence of pituitary adenomas after surgical remission: a structured review and meta-analysis. Pituitary 2012; 15:71-83. [PMID: 21918830 PMCID: PMC3296023 DOI: 10.1007/s11102-011-0347-7] [Citation(s) in RCA: 232] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
To study the currently available data of recurrence rates of functioning and nonfunctioning pituitary adenomas following surgical cure and to analyze associated predisposing factors, which are not well established. A systematic literature search was conducted using Medline, Embase, Web of Science and the Cochran Library for studies reporting data on recurrence of pituitary adenoma after surgery, in nonfunctioning adenoma (NF), prolactinoma (PRL) acromegaly (ACRO) and Cushing's disease (CUSH). Of 557 initially retrieved potential relevant studies 143 were selected. Recurrence in NFA was defined as reappearance of tumor on MRI or CT. Increase of hormone levels above normal limits as set by the authors after initial remission was used to indicate recurrence in the functioning tumor types. Remission percentage was lowest in NFA compared with other tumor types (P < 0.001). Surgery-related hypopituitarism was more frequent in CUSH than in the other tumors (P < 0.001). Recurrence, expressed as percentage of the cured population or as ratio of recurrence and total patient years of follow-up was highest in PRL (P < 0.001). The remission percentage did not improve over 3 decades of publications, but there was a modest decrease in recurrence rate (P = 0.04). Recurrences peaked between 1 and 5 years after surgery. Most of the studies with a sufficient number of recurrences did not apply multivariate statistics, and mentioned at best associated factors. Age, gender, tumor size and invasion were generally unrelated to recurrence. For functioning adenomas a low postoperative hormone concentration was a prognostically favorable factor. In NFA no specific factor predicted recurrence. Recurrence rate differs between pituitary adenomas, being highest in patients with prolactinoma, with the highest incidence of recurrence between 1 and 5 years after surgery in all adenomas. Patients with NFA have a lower chance of remission than patients with functioning adenomas. The postoperative basal hormone level is the most important predictor for recurrence in functioning adenomas, while in NFA no single convincing factor could be identified.
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Affiliation(s)
- Ferdinand Roelfsema
- Department of Endocrinology and Metabolic Diseases, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands.
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Wang YY, Higham C, Kearney T, Davis JRE, Trainer P, Gnanalingham KK. Acromegaly surgery in Manchester revisited--the impact of reducing surgeon numbers and the 2010 consensus guidelines for disease remission. Clin Endocrinol (Oxf) 2012; 76:399-406. [PMID: 21824170 DOI: 10.1111/j.1365-2265.2011.04193.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Surgical remission rates for acromegaly vary and are dependent on the tumour morphology, biochemical definition of disease remission and surgical expertise. A previous report from the Manchester region in 1998 reported an overall surgical remission rate of 27% using accepted criteria for biochemical remission at the time. The establishment of the 2010 Consensus guidelines further tightens biochemical criteria for remission. This report aims to assess the impact of establishing a specialist pituitary surgery service in Manchester in 2005, with reduced surgeon numbers on the remission rates for acromegaly surgery. METHODS Patients with acromegaly undergoing first time endoscopic transsphenoidal surgery between 2005 and 2010 were studied. Surgery was performed by a single surgeon. Review of a prospectively collected acromegaly surgery database was performed with documentation of pre- and postoperative biochemical tests [oral glucose tolerance test (oGTT) and IGF-1], as well as clinical, pathological and radiological data. Definition of disease remission was according to the 2010 Consensus criteria (GH nadir <0·4 μg/l following an oGTT and normalized population matched IGF-1). RESULTS There were 43 consecutive patients with acromegaly, with 13 (30%) microadenomas and 12 (28%) invasive adenomas. Overall, surgical remission was achieved in 29 (67%) patients. The remission rates were similar between micro (77%), macro (63%) and giant (67%) adenomas. There were nonsignificant trends towards higher remission rates for noninvasive tumours compared with invasive tumours (74%vs 50%) and for patients with a preoperative GH nadir <10 μg/l (73%vs 54%) and IGF-1 standard deviation score <15 (72%vs 54%). CONCLUSIONS Remission rates for acromegaly surgery have improved following establishment of a specialist surgical service, with a reduction in surgeon numbers. Endoscopic trans-sphenoidal surgery remains an effective first-line treatment for achieving biochemical remission in acromegaly, despite the introduction of the more stringent 2010 consensus guidelines.
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Affiliation(s)
- Yi Yuen Wang
- Departments of Neurosurgery Endocrinology, Greater Manchester Neurosciences Centre, Salford Royal Foundation Trust, Stott Lane, Salford, UK.
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Rizk A, Honegger J, Milian M, Psaras T. Treatment Options in Cushing's Disease. CLINICAL MEDICINE INSIGHTS-ONCOLOGY 2012; 6:75-84. [PMID: 22346367 PMCID: PMC3273924 DOI: 10.4137/cmo.s6198] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Endogenous Cushing’s syndrome is a grave disease that requires a multidisciplinary and individualized treatment approach for each patient. Approximately 80% of all patients harbour a corticotroph pituitary adenoma (Cushing’s disease) with excessive secretion of adrenocorticotropin-hormone (ACTH) and, consecutively, cortisol. The goals of treatment include normalization of hormone excess, long-term disease control and the reversal of comorbidities caused by the underlying pathology. The treatment of choice is neurosurgical tumour removal of the pituitary adenoma. Second-line treatments include medical therapy, bilateral adrenalectomy and radiation therapy. Drug treatment modalities target at the hypothalamic/pituitary level, the adrenal gland and at the glucocorticoid receptor level and are commonly used in patients in whom surgery has failed. Bilateral adrenalectomy is the second-line treatment for persistent hypercortisolism that offers immediate control of hypercortisolism. However, this treatment option requires a careful individualized evaluation, since it has the disadvantage of permanent hypoadrenalism which requires lifelong glucocorticoid and mineralocorticoid replacement therapy and bears the risk of developing Nelson’s syndrome. Although there are some very promising medical therapy options it clearly remains a second-line treatment option. However, there are numerous circumstances where medical management of CD is indicated. Medical therapy is frequently used in cases with severe hypercortisolism before surgery in order to control the metabolic effects and help reduce the anestesiological risk. Additionally, it can help to bridge the time gap until radiotherapy takes effect. The aim of this review is to analyze and present current treatment options in Cushing’s disease.
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Affiliation(s)
- Ahmed Rizk
- Department of Neurosurgery, University of Tuebingen, Germany
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de Almeida JR, Witterick IJ, Vescan AD. Functional Outcomes for Endoscopic and Open Skull Base Surgery: An Evidence-Based Review. Otolaryngol Clin North Am 2011; 44:1185-200. [DOI: 10.1016/j.otc.2011.06.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Dhepnorrarat RC, Ang BT, Sethi DS. Endoscopic surgery of pituitary tumors. Otolaryngol Clin North Am 2011; 44:923-35, viii. [PMID: 21819880 DOI: 10.1016/j.otc.2011.06.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Endoscopic pituitary surgery has been gaining wide acceptance as the first-line treatment of most functional pituitary adenomas. This technique has many advantages over traditional procedures, and growing evidence supports its use for endocrine control of functioning tumors. This article reviews data on the different modalities of treatment of functioning pituitary adenomas and compares the results. Endoscopic pituitary surgery controls tumor growth and endocrinopathy as well as or better than other treatment modalities. Complication rates are low and patient recovery is fast. Furthermore, surgery provides a means of achieving prompt decompression of neurologic structures and endocrine remission.
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Wang YY, Srirathan V, Tirr E, Kearney T, Gnanalingham KK. Nasal symptoms following endoscopic transsphenoidal pituitary surgery: assessment using the General Nasal Patient Inventory. Neurosurg Focus 2011; 30:E12. [PMID: 21456923 DOI: 10.3171/2011.1.focus10319] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The endoscopic approach for pituitary tumors is a recent innovation and is said to reduce the nasal trauma associated with transnasal transsphenoidal surgery. The authors assessed the temporal changes in the rhinological symptoms following endoscopic transsphenoidal surgery for pituitary lesions, using the General Nasal Patient Inventory (GNPI). METHODS The GNPI was administered to 88 consecutive patients undergoing endoscopic transsphenoidal surgery at 3 time points (presurgery, 3-6 months postsurgery, and at final follow-up). The total GNPI score and the scores for the individual GNPI questions were calculated and differences between groups were assessed once before surgery, several months after surgery, and at final follow-up. RESULTS Of a maximum possible score of 135, the mean GNPI score at 3-6 months postsurgery was only 12.9 ± 12 and was not significantly different from the preoperative score (10.4 ± 13) or final follow-up score (10.3 ± 10). Patients with functioning tumors had higher GNPI scores than those with nonfunctioning tumors for each of these time points (p < 0.05). Individually, a mild increase in symptom severity was seen for symptoms attributable to the nasal trauma of surgery, with partial recovery (nasal sores and bleeding) or complete recovery (nasal blockage, painful sinuses, and unpleasant nasal smell) by final follow-up (p < 0.05). Progressive improvements in symptom severity were seen for symptoms more attributable to tumor mass preoperatively (for example, headaches and painkiller use [p < 0.05]). In total, by final follow-up 8 patients (9%) required further treatment or advice for ongoing nasal symptoms. CONCLUSIONS Endoscopic transsphenoidal surgery is a well-tolerated minimally invasive procedure for pituitary fossa lesions. Overall patient-assessed nasal symptoms do not change, but some individual symptoms may show a mild worsening or overall improvement.
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Affiliation(s)
- Yi Yuen Wang
- Department of Neurosurgery, Greater Manchester Neuroscience Centre, Salford Royal Foundation Trust, Salford, United Kingdom.
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