Quality of life and emotional burden after transnasal and transcranial anterior skull base surgery

Gross-total resection in optic nerve sheath meningiomas: minimally invasive and cosmetic pleasing

PURPOSE

The optic nerve sheath meningioma (ONSM) is one of the most challenging tumors in orbital surgery. From the perspective of mental health and patient needs, we analyzed the necessity and importance of the endoscopic transnasal approach (ETA) combined with optic nerve transection (ONT) in gross-total resection (GTR) in ONSM patients with residual vision and aim to broaden the use of ONT for specific people.

METHODS

The authors included patients with ONSMs who were treated between 2014 and 2022. We divided those cases into two groups named ETA group and lateral orbitotomy approach (LOA) group. We present the application of ETA and analyze the preoperative indication of the ONT and compared the advantages and disadvantages between ETA and LOA. The degree of tumor resection was based on imaging and surgical evaluation.

RESULTS

A total of 23 patients with ONSM were included. Sixteen patients underwent ETA, and seven underwent LOA. Among ETA cases, GTR was achieved in 14 patients with ONT and most patients maintained normal eye movement function (75%) and morphology (93.75%). In the ETA group, 14 patients experienced vision loss, while two other patients saw improvements in vision. And proptosis was alleviated (5.20 ± 2.34 vs 0.27 ± 0.46, p < 0.0001). Six patients with blindness and proptosis of the LOA group resulted in GTR with ONT and ophthalmectomy. Although intracranial extension and recurrence included no cases in the two groups, a significant psychological gap was presented due to cosmetic problems.

CONCLUSIONS

Under the premise of reducing damage and improving aesthetics, the selection of ETA combined with ONT to gross-total resect ONSMs successfully provides a minimally invasive access with acceptable complications. As an important adjunct to GTR in the surgical treatment of ONSM, the scope of ONT application should be expanded to relieve the patient's psychological burden.

Correlation Between Pituitary Adenoma Surgery and Anxiety Disorder: Systematic Review and Meta-Analysis

OBJECTIVE

This study aims to evaluate the impact of surgical intervention on anxiety levels in patients with various types of pituitary adenoma (PA).

METHOD

A systematic review was conducted following PRISMA guidelines until October 2022, searching Embase, PubMed, Web of Sciences, and Scopus.

RESULTS

A total of 32 studies were included, encompassing 2,681 patients with the mean age of 53.33 ± 6.48 years (43.4% male). Among all subtypes, 664 diagnosed with Cushing's disease (25.8%), 612 with acromegaly (23.8%), 282 with prolactinoma (10.9%), and 969 with nonfunctional pituitary adenomas (37.6%). Pituitary insufficiency was the most common complication. Considering therapeutic modalities, 515 patients (29.8%) underwent endoscopic trans-sphenoidal surgery, while 222 (12.9%) underwent microscopic trans-sphenoidal surgery. The type of trans-sphenoidal surgery was not specified in 977 (56.6%) patients. A total of 17 studies including 1510 patients which mostly assessed anxiety using the Hospital Anxiety and Depression Scale (HADS) and Zung Self-Rating Anxiety Scale (SAS) were included in the meta-analysis. Preoperative evaluation using Hospital Anxiety and Depression Scale (HADS) questionnaire showed a pooled score of 8.27 (95%CI 4.54-12.01), while postoperative evaluation yielded a pooled score of 6.49 (95%CI 5.35-7.63), indicating no significant difference. Preoperative SAS assessment resulted in a pooled score of 50.43 (95%CI 37.40-63.45), with postoperative pooled score of 55.91 (95%CI 49.40-62.41), showing no significant difference.

CONCLUSIONS

Our analysis revealed no significant difference in anxiety scores pre- and postoperatively. While our findings suggest stability in anxiety levels following surgical intervention, it is imperative to recognize the limitations of the current evidence base. The observed lack of consensus may be influenced by factors such as the heterogeneous nature of the patient population, variations in the characteristics of pituitary adenomas, diverse therapeutic approaches, and potential confounding variables such as pre-existing mental health conditions and coping mechanisms. Further research is warranted to elucidate the nuanced relationship between surgical intervention for PA and anxiety outcomes, considering these complex interactions and employing rigorous methodologies to address potential sources of bias.

Meningiomas with CNS invasion

CNS invasion has been included as an independent criterion for the diagnosis of a high-grade (WHO and CNS grade 2 and 3) meningioma in the 2016 and more recently in the 2021 WHO classification. However, the prognostic role of brain invasion has recently been questioned. Also, surgical treatment for brain invasive meningiomas may pose specific challenges. We conducted a systematic review of the 2016-2022 literature on brain invasive meningiomas in Pubmed, Scopus, Web of Science and the Cochrane Library. The prognostic relevance of brain invasion as a stand-alone criterion is still unclear. Additional and larger studies using robust definitions of histological brain invasion and addressing the issue of sampling errors are clearly warranted. Although the necessity of molecular profiling in meningioma grading, prognostication and decision making in the future is obvious, specific markers for brain invasion are lacking for the time being. Advanced neuroimaging may predict CNS invasion preoperatively. The extent of resection (e.g., the Simpson grading) is an important predictor of tumor recurrence especially in higher grade meningiomas, but also - although likely to a lesser degree - in benign tumors, and therefore also in brain invasive meningiomas with and without other histological features of atypia or malignancy. Hence, surgery for brain invasive meningiomas should follow the principles of maximal but safe resections. There are some data to suggest that safety and functional outcomes in such cases may benefit from the armamentarium of surgical adjuncts commonly used for surgery of eloquent gliomas such as intraoperative monitoring, awake craniotomy, DTI tractography and further advanced intraoperative brain tumor visualization.

Health-Related Quality of Life in Intracranial Meningioma: Current Evidence and Future Directions

Historically, largely due to the good prognosis for survival, there has been little attention paid to the possible impact of meningiomas and their treatment on health-related quality of life (HRQoL). However, in the last decade there has been increasing evidence that patients with intracranial meningiomas suffer from long-term decreases in their HRQoL. Compared with controls and normative data, meningioma patients have worse HRQoL scores both before and after intervention and continuing long term (even after >4 years of follow-up). Overall, surgery results in improvements in many aspects of HRQoL. The limited available studies investigating the impact of radiotherapy suggest that this type of treatment decreases HRQoL scores, especially in the long term. There is however only limited evidence on additional determinants of HRQoL. Patients with anatomically complex skull base meningiomas and severe comorbidities, including epilepsy, report the lowest HRQoL scores. Other tumor and sociodemographic characteristics have shown weak associations with HRQoL. Furthermore, about one-third of caregivers of meningioma patients report caregiver burden, warranting interventions to improve caregiver HRQoL. As antitumor interventions may not improve HRQoL scores to be comparable to those of the general population, more attention should be paid to the development of integrative rehabilitation and supportive care programs for meningioma patients.

Functional Outcomes and Quality of Life in Patients with Sinonasal, Nasopharyngeal, and Anterior Skull Base Tumors

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.

Depression and mortality after craniotomy for brain tumor removal: A Nationwide cohort study in South Korea

BACKGROUND

We aimed to investigate the prevalence and associated factors of newly developed depression in patients who underwent craniotomy for brain tumor removal, as well as its effect on long-term mortality.

METHODS

Using a nationwide cohort database in South Korea, we included adult patients diagnosed with brain tumors who underwent craniotomy for brain tumor removal from January 1, 2011, to December 31, 2017. We excluded patients with a preoperative history of depression.

RESULTS

Among 4,275 patients, 727 (17.0%) patients were newly diagnosed with depression within one year, postoperatively. Two-year all-cause mortality and mortality due to brain cancer occurred in 1,233 (28.8%) and 1,099 (25.7%) patients, respectively. In the multivariable logistic regression model, older age, living in rural areas, newly acquired brain disability, underlying other psychiatric disorders, and longer length of hospital stay were associated with a higher incidence of newly developed depression. In the multivariable Cox regression model, newly acquired depression was associated with a 1.58-fold higher 2-year all-cause mortality compared with that in other patients (hazard ratio: 1.58, 95% confidence interval: 1.38-1.80; P < 0.001).

LIMITATION

Lack of information regarding severity and pathologic tumor type.

CONCLUSION

Within one follow-up year, 17.0% of patients were newly diagnosed with depression after craniotomy for brain tumor removal. Some factors (old age, living in rural areas, newly acquired brain disability, longer length of hospital stay, and underlying other psychiatric illnesses) could be risk factors for newly diagnosed depression. Furthermore, newly developed depression was associated with an increased 2-year all-cause mortality.

The Suprasellar Meningioma Patient-Reported Outcome Survey: a disease-specific patient-reported outcome measure for resection of suprasellar meningioma

OBJECTIVE

Suprasellar meningioma resection via either the transcranial approach (TCA) or the endoscopic endonasal approach (EEA) is an area of controversy and active evaluation. Skull base surgeons increasingly consider patient-reported outcomes (PROs) when choosing an approach. No PRO measure currently exists to assess quality of life for suprasellar meningiomas.

METHODS

Adult patients undergoing suprasellar meningioma resection between 2013 and 2019 via EEA (n = 14) or TCA (n = 14) underwent semistructured interviews. Transcripts were coded using a grounded theory approach to identify themes as the basis for a PRO measure that includes all uniquely reported symptoms. To assess content validity, 32 patients and 15 surgeons used a Likert scale to rate the relevance of items on the resulting questionnaire and the general Patient-Reported Outcomes Measurement Information System-29 (PROMIS29). The mean scores were calculated for all items and compared for TCA versus EEA patient cohorts by using unpaired t-tests. Items on either questionnaire with mean scores ≥ 2.0 from patients were considered meaningful and were aggregated to form the novel Suprasellar Meningioma Patient-Reported Outcome Survey (SMPRO) instrument.

RESULTS

Qualitative analyses resulted in 55 candidate items. Relative to patients who underwent the EEA, those who underwent the TCA reported significantly worse future outlook before surgery (p = 0.01), tiredness from medications 2 weeks after surgery (p = 0.001), and word-finding and memory difficulties 3 months after surgery (p = 0.05 and < 0.001, respectively). The items that patients who received a TCA were most concerned about included medication-induced lethargy after surgery (2.9 ± 1.3), blurry vision before surgery (2.7 ± 1.5), and difficulty reading due to blurry vision before surgery (2.7 ± 2.7). Items that patients who received an EEA were most concerned about included blurry vision before surgery (3.5 ± 1.3), difficulty reading due to blurry vision before surgery (2.4 ± 1.3), and problems with smell postsurgery (2.9 ± 1.3). Although surgeons overall overestimated how concerned patients were about questionnaire items (p < 0.0005), the greatest discrepancies between patient and surgeon relevance scores were for blurry vision pre- and postoperatively (p < 0.001 and < 0.001, respectively) and problems with taste postoperatively (p < 0.001). Seventeen meningioma-specific items were considered meaningful, supplementing 8 significant PROMIS29 items to create the novel 25-item SMPRO.

CONCLUSIONS

The authors developed a disease- and approach-specific measure for suprasellar meningiomas to compare quality of life by operative approach. If demonstrated to be reliable and valid in future studies, this instrument may assist patients and providers in choosing a personalized surgical approach.

ABBREVIATIONS

EEA = endoscopic endonasal approach; GTR = gross-total resection; PRO = patient-reported outcome; PROMIS29 = Patient-Reported Outcomes Measurement Information System-29; QOL = quality of life; SMPRO = Suprasellar Meningioma Patient-Reported Outcome Survey; TCA = transcranial approach.

Opioid use after endoscopic skull base surgery: A descriptive, prospective, longitudinal cohort study

BACKGROUND

Opioid abuse is a public health crisis and the perioperative period can be a time of first opioid exposure. Little is known about postoperative pain management after endoscopic skull base surgery (ESBS).

METHODS

This investigation was a single-institution, longitudinal, prospective cohort study of adult patients undergoing ESBS between November 2019 and March 2020. Participants completed preoperative questionnaires and were contacted every 48 hours postoperatively to quantify pain and opioid consumption.

RESULTS

A total of 33 patients were enrolled and 28 of 33 patients (85%) underwent ESBS for sellar pathology. Mean total morphine milligram equivalents (MME) consumed was 381.9 ± 476.0. History of a headache disorder (p = 0.025) and previous opioid use within 60 days preoperatively (p < 0.001) were significantly associated with greater opioid use. Mean duration of opioid use was 6.7 ± 5.1 (range, 0-20) days. Headache disorder (p = 0.01), depression (p = 0.03), anxiety (p = 0.03), age ≤46 years (p = 0.029), and previous opioid use (p = 0.008) were all associated with longer mean opioid use. Patients with headache disorder also reported higher mean postoperative pain scores. Fewer than half of the participants required opioids by postoperative day 8. Prescription of nonsteroidal anti-inflammatory drugs at discharge was significantly associated with less outpatient opioid use (p = 0.032). At 2-month follow-up, 37% of patients reported keeping excess opioids.

CONCLUSION

After ESBS, greater total opioid use was significantly associated with history of headaches and previous opioid use within 60 days. Overall, opioid use declined among all patients in the postoperative period, but several factors may contribute to longer duration of use.

Health-related quality of life in meningioma

Background. Meningiomas are the most common primary intracranial tumor in adults. Although frequently histologically benign, the clinical severity of a lesion may range from being asymptomatic to causing severe impairment of global function and well-being. The diversity of intracranial locations and clinical phenotypes poses a challenge when studying functional impairments, however, more recent attention to patient-reported outcomes and health-related quality of life (HRQOL) have helped to improve our understanding of how meningioma may impact a patient’s life.Methods. Treatment strategies such as observation, surgery, radiation, or a combination thereof have been examined to ascertain their contributions to symptoms, physical and cognitive functioning, disability, and general aspects of daily functioning.Results. This review explores the multidimensional nature of HRQOL and how patients may be influenced by meningiomas and their treatment.Conclusion. Overall, treatment of symptomatic meningiomas is associated with improved HRQOL, cognitive functioning, and seizure control while tumor size, location, histologic grade, and epileptic burden are associated with worse HRQOL.

Quality-of-life evaluation for patients submitted to nasal endoscopic surgery for resection of pituitary tumours

PURPOSE

This study aimed to evaluate the pre- and post-operative quality-of-life of patients submitted to the resection of pituitary adenoma via endoscopic transsphenoidal.

METHODS

This was a prospective study on patients submitted to endoscopic transsphenoidal pituitary surgery with the harvest of a nasoseptal flap who responded to the questionnaires FV-36 and SNOT-22 in the pre-operative and in months 1, 3 and 6 following the surgical procedure.

RESULTS

A total of 42 patients submitted to pituitary adenoma resection surgery via endoscopic transsphenoidal with a nasoseptal flap were recruited. In all of the physical and mental domains (SF-36) evaluated, there was an improvement in the long-term evaluation (6 months), compared to the pre-operative, as well as in the site-specific evaluation (SNOT-22).

CONCLUSION

The global and site-specific questionnaires in the 6th post-operative month follow-up presented an important improvement in all the physical and mental domains evaluated, as well as in nasal function in the perception of the patients submitted to pituitary adenoma resection via endoscopic transsphenoidal, demonstrating the safety and efficiency of the procedure.

Rhinological Consequences of Microsurgical Endonasal-Transsphenoidal Surgery for Pituitary Tumors

BACKGROUND

Transsphenoidal surgery for sellar lesions may affect patency and function of the nasal airways, smell and sinonasal quality of life. Below is our report on otorhinolaryngological data garnered from patients undergoing endonasal transsphenoidal pituitary microsurgery.

METHODS

In a prospective study, 68 patients scheduled for transsphenoidal operations (32 female, 36 male, age 17-72 years) underwent otorhinolaryngological evaluation of their nasal morphology, a standardized smell test (sniffin' sticks) and rhinomanometry to analyse nasal breathing function preoperatively, 3-5 days postoperatively (without rhinomanometry), after 3-4 months and after 9 months.

RESULTS

Immediately after surgery, a reduction in smell sensation was detected in almost all patients. Within 3 months, this impairment resolved in all cases except one. In 2 patients (3%) with preoperative anosmia, improvement of smell function to>6 out of 12 sniffin' sticks was observed. At final visit no patient was noted to have new anosmia. Within 3 months, the results of the rhinomanometry revealed that all patients except one, regained their preoperative nasal breathing function. In 6 patients (8.8%) an improvement in their nose breathing abilities compared to the preoperative state was found. Three patients (4.4%) underwent a LASER transection of mucosal synechiae. In one case with persistent nasal obstruction (1.5%), secondary septoplasty had to be performed. There was no case in which perforation of the nasal septum, nasal tip deflection, or saddle nose deformity was observed.

CONCLUSION

Microsurgical resection of pituitary tumors via the endonasal transsphenoidal approach poses an acceptable risk with regards to sinonasal complications. The incidence of secondary rhinosurgical interventions is low. Standardized comparative studies between endoscopic and microsurgical transsphenoidal operations should be undertaken.