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Gordon AJ, Dastagirzada Y, Schlacter J, Mehta S, Agrawal N, Golfinos JG, Lebowitz R, Pacione D, Lieberman S. Health Care Disparities in Transsphenoidal Surgery for Pituitary Tumors: An Experience from Neighboring Urban Public and Private Hospitals. J Neurol Surg B Skull Base 2023; 84:560-566. [PMID: 37854536 PMCID: PMC10581820 DOI: 10.1055/s-0042-1757613] [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: 05/03/2022] [Accepted: 08/29/2022] [Indexed: 10/17/2022] Open
Abstract
Objectives Few studies have assessed the role of socioeconomic health care disparities in skull base pathologies. We compared the clinical history and outcomes of pituitary tumors at private and public hospitals to delineate whether health care disparities exist in pituitary tumor surgery. Methods We reviewed the records of patients who underwent transsphenoidal pituitary tumor resection at NYU Langone Health and Bellevue Hospital. Seventy-two consecutive patients were identified from each hospital. The primary outcome was time-to-surgery from initial recommendation. Secondary outcomes included postoperative diabetes insipidus, cerebrospinal fluid (CSF) leak, and gross total resection. Results Of 144 patients, 23 (32%) public hospital patients and 24 (33%) private hospital patients had functional adenomas ( p = 0.29). Mean ages for public and private hospital patients were 46.5 and 51.1 years, respectively ( p = 0.06). Private hospital patients more often identified as white ( p < 0.001), spoke English ( p < 0.001), and had private insurance ( p < 0.001). The average time-to-surgery for public and private hospital patients were 46.2 and 34.8 days, respectively ( p = 0.39). No statistically significant differences were found in symptom duration, tumor size, reoperation, CSF leak, or postoperative length of stay; however, public hospital patients more frequently required emergency surgery ( p = 0.03), developed transient diabetes insipidus ( p = 0.02), and underwent subtotal resection ( p = 0.04). Conclusion Significant socioeconomic differences exist among patients undergoing pituitary surgery at our institution's hospitals. Public hospital patients more often required emergency surgery, developed diabetes insipidus, and underwent subtotal tumor resection. Identifying these differences is an imperative initial step in improving the care of our patients.
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Affiliation(s)
- Alex J. Gordon
- NYU Grossman School of Medicine, NYU Langone Health, New York, New York, United States
| | - Yosef Dastagirzada
- Department of Neurosurgery, NYU Langone Health, New York, New York, United States
| | - Jamie Schlacter
- NYU Grossman School of Medicine, NYU Langone Health, New York, New York, United States
| | - Sonal Mehta
- Division of Endocrinology, Department of Medicine, NYU Langone Health, New York, New York, United States
| | - Nidhi Agrawal
- Division of Endocrinology, Department of Medicine, NYU Langone Health, New York, New York, United States
| | - John G. Golfinos
- Department of Neurosurgery, NYU Langone Health, New York, New York, United States
| | - Richard Lebowitz
- Department of Otolaryngology-Head and Neck Surgery, NYU Langone Health, New York, New York, United States
| | - Donato Pacione
- Department of Neurosurgery, NYU Langone Health, New York, New York, United States
| | - Seth Lieberman
- Department of Otolaryngology-Head and Neck Surgery, NYU Langone Health, New York, New York, United States
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Altaf A, Baqai MWS, Urooj F, Alam MS, Aziz HF, Mubarak F, Knopp E, Siddiqui K, Enam SA. Intraoperative use of ultra-low-field, portable magnetic resonance imaging - first report. Surg Neurol Int 2023; 14:212. [PMID: 37404510 PMCID: PMC10316138 DOI: 10.25259/sni_124_2023] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 05/04/2023] [Indexed: 07/06/2023] Open
Abstract
Background Intraoperative use of portable magnetic resonance imaging (pMRI) has become a valuable tool in a surgeon's arsenal since its inception. It allows intraoperative localization of tumor extent and identification of residual disease, hence maximizing tumor resection. Its utility has been widespread in high-income countries for the past 20 years, but in lower-middle-income countries (LMIC), it is still not widely available due to several reasons, including cost constraints. The use of intraoperative pMRI may be a cost-effective and efficient substitute for conventional MRI machines. The authors present a case where a pMRI device was used intraoperatively in an LMIC setting. Case Description The authors performed a microscopic transsphenoidal resection of a sellar lesion with intraoperative imaging using the pMRI system on a 45-year-old man with a nonfunctioning pituitary macroadenoma. Without the need for an MRI suite or other MRI-compatible equipment, the scan was conducted within the confinements of a standard operating room. Low-field MRI showed some residual disease and postsurgical changes, comparable to postoperative high-field MRI. Conclusion To the best of our knowledge, our report provides the first documented successful intraoperative transsphenoidal resection of a pituitary adenoma using an ultra-low-field pMRI device. The device can potentially enhance neurosurgical capacity in resource-constrained settings and improve patient outcomes in developing country.
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Affiliation(s)
- Ahmed Altaf
- Department of Neurosurgery, Aga Khan University Hospital, Karachi, Sindh, Pakistan
| | | | - Faiza Urooj
- Department of Neurosurgery, Aga Khan University Hospital, Karachi, Sindh, Pakistan
| | - Muhammad Sami Alam
- Department of Radiology, National Medical Centre, Karachi, Sindh, Pakistan
| | - Hafiza Fatima Aziz
- Department of Neurosurgery, Aga Khan University Hospital, Karachi, Sindh, Pakistan
| | - Fatima Mubarak
- Department of Radiology, Aga Khan University Hospital, Karachi, Sindh, Pakistan
| | - Edmond Knopp
- Department of Radiology, Hyperfine, Guilford, Connecticut, United States
| | - Khan Siddiqui
- Department of Radiology, Hyperfine, Guilford, Connecticut, United States
| | - Syed Ather Enam
- Department of Neurosurgery, Aga Khan University Hospital, Karachi, Sindh, Pakistan
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Bunyaratavej K, Siwanuwatn R, Tuchinda L, Wangsawatwong P. Impact of Intraoperative Magnetic Resonance Imaging (i-MRI) on Surgeon Decision Making and Clinical Outcomes in Cranial Tumor Surgery. Asian J Neurosurg 2022; 17:218-226. [PMID: 36120606 PMCID: PMC9473858 DOI: 10.1055/s-0042-1751008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background
Although intraoperative magnetic resonance imaging (iMRI) has an established role in guiding intraoperative extent of resection (EOR) in cranial tumor surgery, the details of how iMRI data are used by the surgeon in the real-time decision-making process is lacking.
Materials and Methods
The authors retrospectively reviewed 40 consecutive patients who underwent cranial tumor resection with the guidance of iMRI. The tumor volumes were measured by volumetric software. Intraoperative and postoperative EOR were calculated and compared. Surgeon preoperative EOR intention, intraoperative EOR assessment, and how iMRI data impacted surgeon decisions were analyzed.
Results
The pathology consisted of 29 gliomas, 8 pituitary tumors, and 3 other tumors. Preoperative surgeon intention called for gross total resection (GTR) in 28 (70%) cases. After resection and before iMRI scanning, GTR was 20 (50.0%) cases based on the surgeon's perception. After iMRI scanning, the results helped identify 19 (47.5%) cases with unexpected results consisting of 5 (12.5%) with unexpected locations of residual tumors and 14 (35%) with unexpected EOR. Additional resection was performed in 24 (60%) cases after iMRI review, including 6 (15%) cases with expected iMRI results. Among 34 cases with postoperative MRI results, iMRI helped improve EOR in 12 (35.3%) cases.
Conclusion
In cranial tumor surgery, the surgeon's preoperative and intraoperative assessment is frequently imprecise. iMRI data serve several purposes, including identifying the presence of residual tumors, providing residual tumor locations, giving spatial relation data of the tumor with nearby eloquent structures, and updating the neuro-navigation system for the final stage of tumor resection.
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Affiliation(s)
- Krishnapundha Bunyaratavej
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Pathumwan, Bangkok, Thailand
| | - Rungsak Siwanuwatn
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Pathumwan, Bangkok, Thailand
| | - Lawan Tuchinda
- Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Pathumwan, Bangkok, Thailand
| | - Piyanat Wangsawatwong
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Pathumwan, Bangkok, Thailand
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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] [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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Mortini P, Albano L, Barzaghi LR, Losa M. Pituitary Surgery. Presse Med 2021; 50:104079. [PMID: 34687913 DOI: 10.1016/j.lpm.2021.104079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 09/08/2021] [Accepted: 10/12/2021] [Indexed: 01/13/2023] Open
Abstract
Surgery, more specifically transsphenoidal approach, remains the primary treatment chosen for the majority of pituitary tumors (except for prolactinomas where medical treatment is indicated) allowing for pathologic analysis and complete or partial tumor removal. Transcranial approaches, employing craniotomies, are still needed in some patients with giant pituitary adenomas and in many of those harboring craniopharyngiomas. However, the surgical treatment of pituitary tumors is challenging because of their complex anatomical location and their heterogenous histology. Due to the proximity of critical structures, a successful surgical procedure may often not be achievable due to the high risks related to the procedure itself. Therefore, the treatment of pituitary tumors in 2020 commonly requires a multimodal approach, including surgery, radiosurgery, radiation therapy, and medical therapy. Recently, efforts have been made to develop intraoperative imaging, by increasing the diffusion of radiosurgery. Furthermore, the development of Pituitary Tumor Centers of Excellence (PTCOE) is becoming crucial to provide the optimal treatment for a single patient. There is in fact sufficient evidence that the best and optimal outcome in terms of tumor resection and correction of hormonal over secretion as well as the lowest rate of complications are obtained in centers of excellence with sufficiently experienced, specialized surgeons and a high patient load. Technological developments will probably even gain increasing importance in the future.
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Affiliation(s)
- Pietro Mortini
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Via Olgettina 60, 20132 Milan, Italy.
| | - Luigi Albano
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Via Olgettina 60, 20132 Milan, Italy; Neuroimaging Research Unit, Division of Neuroscience, IRCCS Ospedale San Raffaele, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Lina Raffaella Barzaghi
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Via Olgettina 60, 20132 Milan, Italy
| | - Marco Losa
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Via Olgettina 60, 20132 Milan, Italy
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Ashraf M, Kamboh UA, Raza MA, Haq NU, Choudhary N, Sultan KA, Hussain SS, Ashraf N. Usefulness of Intraoperative Computed Tomography on Extent of Resection of Large and Giant Pituitary Adenomas. Experience from a Developing Country. World Neurosurg 2021; 157:13-20. [PMID: 34619403 DOI: 10.1016/j.wneu.2021.09.114] [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: 08/18/2021] [Revised: 09/25/2021] [Accepted: 09/27/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND AND OBJECTIVE The literature on the use of intraoperative computed tomography (iCT) is sparse. We provide our experience of the usefulness of iCT in extent of resection in large and giant pituitary adenomas. METHODS A retrospective review was performed of cases using the endonasal endoscopic technique in which iCT was used. Demographic factors, number of scans, and impact on the extent of resection are reported, with visual acuity and field changes. Tumors were graded according to the Hardy classification. Patients with cavernous sinus invasion were excluded. RESULTS All patients received a perioperative computed tomography scan with our iCT scanner. Thirty patients are reported, including 14 large and 16 giant pituitary adenomas, including 14 nonfunctional and 16 growth hormone-secreting tumors. The overall gross total resection (GTR), near-total resection, and subtotal resection rates were 83.3%, 16.7%, and 3.3%, respectively. iCT scanning detected residual in 13 of 30 patients, including 4 with 14 large (29%) and 9 with 16 (56.3%) giant adenomas promoting further surgery. iCT use improved GTR from 43.8% to 81.3% in giant adenomas and from 71% to 86% in large adenomas. Of the 13 patients in whom iCT detected residual disease, none required >2 iCT scans. No intraoperative complications were observed. CONCLUSIONS iCT can improve extent of resection in large and giant pituitary adenomas and facilitate maximum safe resection such as GTR or near-total resection in patients where such should be attempted. iCT use may reduce iatrogenic complications and has select financial benefits in our patients' socioeconomic demographics. However, further prospective controlled studies are required to affirm our conclusions.
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Affiliation(s)
- Mohammad Ashraf
- Wolfson School of Medicine, University of Glasgow, Glasgow, United Kingdom; Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital Lahore, Pakistan.
| | - Usman Ahmad Kamboh
- Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital Lahore, Pakistan
| | - Muhammad Asif Raza
- Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital Lahore, Pakistan
| | - Naseer Ul Haq
- Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital Lahore, Pakistan
| | - Nabeel Choudhary
- Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital Lahore, Pakistan
| | - Kashif Ali Sultan
- Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital Lahore, Pakistan
| | - Syed Shahzad Hussain
- Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital Lahore, Pakistan
| | - Naveed Ashraf
- Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital Lahore, Pakistan
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Domino JS, Gattozzi DA, Jack M, Carroll M, Harn N, Beahm DD, Chamoun R. Outcomes of intraoperative ultrasound for endoscopic endonasal transsphenoidal pituitary surgery in adenomas with parasellar extension. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Májovský M, Grotenhuis A, Foroglou N, Zenga F, Froehlich S, Ringel F, Sampron N, Thomas N, Komarc M, Netuka D. What is the current clinical practice in pituitary adenoma surgery in Europe? European Pituitary Adenoma Surgery Survey (EU-PASS) results-technical part. Neurosurg Rev 2021; 45:831-841. [PMID: 34337683 DOI: 10.1007/s10143-021-01614-1] [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: 04/13/2021] [Revised: 07/15/2021] [Accepted: 07/20/2021] [Indexed: 10/20/2022]
Abstract
Pituitary adenoma surgery has evolved rapidly in recent decades, changing clinical practice markedly and raising new challenges. There is no current consensus or guidelines for perioperative care that includes possible complication management. This study aims to determine current practice across European neurosurgical centres. We created a list of eligible departments performing pituitary adenoma surgery based on cooperation with EANS, national neurosurgical societies, and personal communication with local neurosurgeons. We contacted the chairpersons from each department and asked them (or another responsible neurosurgeon) to fill out the survey. The survey consisted of 58 questions. For further analysis, departments were divided into subgroups: "academic"/ "non-academic centre", "high-volume"/"low-volume", "mainly endoscopic"/ "mainly microscopic"/ "mixed practise", and by geographical regions. Data from 254 departments from 34 countries were obtained. The average time to complete the survey was 18 min. Notably, the endoscopic approach is the predominant surgical approach in Europe, used in 56.8% of the centres. In routine cases without intraoperative cerebrospinal fluid leak, high-volume centres are less pedantic with sellar closure when compared with low-volume centres (p < 0.001). On the other hand, when a postoperative cerebrospinal fluid leak occurs, high-volume centres are more active and indicate early reoperation (p = 0.013). Less than 15% of the participating centres perform early postoperative MRI scans. Marked variation was noted among different groups of respondents and some contentious issues are discussed. Such information can encourage useful debate about the reasons for the variations seen and perhaps help develop standardised protocols to improve patient outcomes. A future research focus is to compare European results with other regions.
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Affiliation(s)
- Martin Májovský
- Department of Neurosurgery and Neurooncology, First Faculty of Medicine, Charles University and Military University Hospital, Prague, Czech Republic.
| | - Andre Grotenhuis
- Neurosurgery Department, Radboud University Medical Center, Nijmegen, Netherlands
| | - Nicolas Foroglou
- 1St Department of Neurosurgery, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Francesco Zenga
- Neurosurgery Unit, Department of Neuroscience "Rita Levi Montalcini", University of Turin, Turin, Italy
| | | | - Florian Ringel
- Department of Neurosurgery, Johannes Gutenberg-Universität Mainz, Mainz, Germany
| | - Nicolas Sampron
- Neurosurgery Department, University Hospital Donostia, San Sebastian, Spain
| | - Nick Thomas
- Department of Neurosurgery, King's College, London, UK
| | - Martin Komarc
- Institute of Biophysics and Informatics, First Faculty of Medicine, Charles University, Prague, Czech Republic.,Department of Methodology, Faculty of Physical Education and Sport, Charles University, Prague, Czech Republic
| | - David Netuka
- Department of Neurosurgery and Neurooncology, First Faculty of Medicine, Charles University and Military University Hospital, Prague, Czech Republic
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9
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Alhilali LM, Little AS, Yuen KCJ, Lee J, Ho TK, Fakhran S, White WL. Early postoperative MRI and detection of residual adenoma after transsphenoidal pituitary surgery. J Neurosurg 2021; 134:761-770. [DOI: 10.3171/2019.11.jns191845] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 11/11/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVECurrent practice guidelines recommend delayed (≥ 3 months after operation) postoperative MRI after transsphenoidal surgery for pituitary adenomas, although this practice defers obtaining important information, such as the presence of a residual adenoma, that might influence patient management during the perioperative period. In this study, the authors compared detection of residual adenomas by means of early postoperative (EPO) MRI (< 48 hours postsurgery) with both surgeon intraoperative assessment and late postoperative (LPO) MRI at 3 months.METHODSAdult patients who underwent microscopic transsphenoidal surgery for pituitary adenomas with MRI preoperatively, < 48 hours after the operation, 3 months postoperatively, and yearly for 4 years were included. The presence or absence of residual tumor was assessed intraoperatively by a single surgeon and postoperatively by 2 neuroradiologists blinded to the intraoperative assessment and other postoperative imaging studies. The presence of residual tumor was confirmed by reresection, tumor growth on imaging, or hormonal evidence. Interreader reliability was calculated at each imaging time point. Specificity, sensitivity, positive predictive value, and negative predictive value for EPO and LPO imaging and intraoperative assessment were determined.RESULTSIn total, 102 consecutive patients who underwent microscopic transsphenoidal resection of a pituitary adenoma were included. Eighteen patients (18%) had confirmed residual tumors (12 confirmed by tumor growth, 5 by surgery, and 1 by biochemical evidence of persistent disease). Interreader reliability for detecting residual tumor on EPO MRI was almost perfect (κ = 0.88) and significantly higher than that for LPO MRI (κ = 0.69, p = 0.03). EPO MRI was highly specific for residual tumor (98%), a finding similar to that for intraoperative assessment (99%, p = 0.60) and significantly higher than that for LPO MRI (81%, p < 0.001). Notably, EPO MRI was significantly more sensitive for residual tumor (100%) than both intraoperative assessment (78%, p = 0.04) and LPO MRI (78%, p = 0.04). EPO MRI had a 100% negative predictive value and was used to find 4 residual tumors that were not identified intraoperatively. Residual tumors found on EPO MRI allowed for reresection during the same hospitalization for 3 patients.CONCLUSIONSEPO MRI after transsphenoidal pituitary surgery can be reliably interpreted and has greater sensitivity for detecting residual tumor than intraoperative assessment and LPO MRI. This result challenges current guidelines stating that delayed postoperative imaging is preferable to early imaging. Pituitary surgeons should consider performing EPO MRI either in addition to or instead of delayed imaging.
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Affiliation(s)
| | | | - Kevin C. J. Yuen
- 3Neurology and Barrow Neuroendocrinology Clinic, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona; and
| | - Jae Lee
- Departments of 1Neuroradiology,
| | | | - Saeed Fakhran
- 4Department of Radiology, Radiology Partners, Banner Health and Hospital System, Phoenix, Arizona
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Redjal N, Venteicher AS, Dang D, Sloan A, Kessler RA, Baron RR, Hadjipanayis CG, Chen CC, Ziu M, Olson JJ, Nahed BV. Guidelines in the management of CNS tumors. J Neurooncol 2021; 151:345-359. [PMID: 33611702 DOI: 10.1007/s11060-020-03530-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Accepted: 05/05/2020] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Evidence-based, clinical practice guidelines in the management of central nervous system tumors (CNS) continue to be developed and updated through the work of the Joint Section on Tumors of the Congress of Neurological Surgeons (CNS) and the American Association of Neurological Surgeons (AANS). METHODS The guidelines are created using the most current and clinically relevant evidence using systematic methodologies, which classify available data and provide recommendations for clinical practice. CONCLUSION This update summarizes the Tumor Section Guidelines developed over the last five years for non-functioning pituitary adenomas, low grade gliomas, vestibular schwannomas, and metastatic brain tumors.
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Affiliation(s)
- Navid Redjal
- Department of Neurosurgery, Capital Institute for Neurosciences, Two Capital Way, Pennington, NJ, 08534, USA.
| | - Andrew S Venteicher
- Center for Pituitary and Skull Base Surgery, Department of Neurosurgery, University of Minnesota, Minneapolis, MN, 55455, USA
| | - Danielle Dang
- Inova Neuroscience and Spine Institute, 3300 Gallows Rd, Falls Church, VA, 22042, USA
| | - Andrew Sloan
- Department of Neurosurgery, Case Western Reserve University, Cleveland, OH, USA
| | - Remi A Kessler
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rebecca R Baron
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Clark C Chen
- Center for Pituitary and Skull Base Surgery, Department of Neurosurgery, University of Minnesota, Minneapolis, MN, 55455, USA
| | - Mateo Ziu
- Inova Neuroscience and Spine Institute, 3300 Gallows Rd, Falls Church, VA, 22042, USA
| | - Jeffrey J Olson
- Department of Neurosurgery, Emory University, Atlanta, GA, USA
| | - Brian V Nahed
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA
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11
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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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12
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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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Abstract
Despite characteristic symptoms the diagnosis of clinically relevant pituitary adenomas is often delayed until an advanced stage due to the rarity of the disease. The typical clinical manifestations are presented in this review article. The recent discovery of the USP8 mutation in Cushing's disease and of X‑linked acrogigantism (X-LAG) syndrome in early onset gigantism were milestones in the search for the molecular etiology of pituitary adenomas. The triad of endocrinological, radiological and ophthalmological diagnostics are the main pillars for the diagnostic work-up of pituitary adenomas. The standard treatment modalities, which include surgery, medical treatment and irradiation, have been further developed and refined. For transsphenoidal excision of pituitary adenomas, microsurgery and endoscopy are two equivalent surgical techniques with relatively few complications. Surgery represents the first-line treatment of pituitary adenomas. Prolactinomas are an exception as the medical treatment with dopamine agonists is highly efficient. Nowadays, new medical treatment options are available for acromegaly and Cushing's disease and are used for second-line treatment. The alkylating chemotherapeutic agent temozolomide is used for the first-line chemotherapy of rare aggressively growing pituitary adenomas. Irradiation is indicated if surgical and medical treatment options are insufficiently successful. Stereotactic one-stage irradiation (radiosurgery) is especially suitable for well-demarcated invasive residual or recurrent adenomas in the cavernous sinus. A new development is hypofractionated radiosurgery for protection of structures at risk. Fractionated irradiation is necessary with large radiation volumes and for pituitary adenomas with a close proximity to the optic tract.
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Affiliation(s)
- Jürgen Honegger
- Klinik für Neurochirurgie, Universitätsklinikum Tübingen, Hoppe-Seyler-Straße 3, 72076, Tübingen, Deutschland.
| | - Isabella Nasi-Kordhishti
- Klinik für Neurochirurgie, Universitätsklinikum Tübingen, Hoppe-Seyler-Straße 3, 72076, Tübingen, Deutschland
| | - Sabrina Giese
- Klinik für Neurochirurgie, Universitätsklinikum Tübingen, Hoppe-Seyler-Straße 3, 72076, Tübingen, Deutschland
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15
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Stammes MA, Bugby SL, Porta T, Pierzchalski K, Devling T, Otto C, Dijkstra J, Vahrmeijer AL, de Geus-Oei LF, Mieog JSD. Modalities for image- and molecular-guided cancer surgery. Br J Surg 2018; 105:e69-e83. [PMID: 29341161 DOI: 10.1002/bjs.10789] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 10/25/2017] [Accepted: 11/05/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND Surgery is the cornerstone of treatment for many solid tumours. A wide variety of imaging modalities are available before surgery for staging, although surgeons still rely primarily on visual and haptic cues in the operating environment. Image and molecular guidance might improve the adequacy of resection through enhanced tumour definition and detection of aberrant deposits. Intraoperative modalities available for image- and molecular-guided cancer surgery are reviewed here. METHODS Intraoperative cancer detection techniques were identified through a systematic literature search, with selection of peer-reviewed publications from January 2012 to January 2017. Modalities were reviewed, described and compared according to 25 predefined characteristics. To summarize the data in a comparable way, a three-point rating scale was applied to quantitative characteristics. RESULTS The search identified ten image- and molecular-guided surgery techniques, which can be divided into four groups: conventional, optical, nuclear and endogenous reflectance modalities. Conventional techniques are the most well known imaging modalities, but unfortunately have the drawback of a defined resolution and long acquisition time. Optical imaging is a real-time modality; however, the penetration depth is limited. Nuclear modalities have excellent penetration depth, but their intraoperative use is limited by the use of radioactivity. Endogenous reflectance modalities provide high resolution, although with a narrow field of view. CONCLUSION Each modality has its strengths and weaknesses; no single technique will be suitable for all surgical procedures. Strict selection of modalities per cancer type and surgical requirements is required as well as combining techniques to find the optimal balance.
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Affiliation(s)
- M A Stammes
- Department of Radiology, Leiden University Medical Centre, Leiden, The Netherlands.,Percuros, Enschede, The Netherlands
| | - S L Bugby
- Space Research Centre, Department of Physics and Astronomy, University of Leicester, Leicester, UK
| | - T Porta
- Maastricht MultiModal Molecular Imaging Institute (M4I), Division of Imaging Mass Spectrometry, Maastricht University, Maastricht, The Netherlands
| | - K Pierzchalski
- Maastricht MultiModal Molecular Imaging Institute (M4I), Division of Imaging Mass Spectrometry, Maastricht University, Maastricht, The Netherlands
| | | | - C Otto
- Medical Cell Bio Physics, University of Twente, Enschede, The Netherlands
| | - J Dijkstra
- Department of Radiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - A L Vahrmeijer
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - L-F de Geus-Oei
- Department of Radiology, Leiden University Medical Centre, Leiden, The Netherlands.,Biomedical Photonic Imaging Group, MIRA Institute, University of Twente, Enschede, The Netherlands
| | - J S D Mieog
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
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16
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Maldaner N, Serra C, Tschopp O, Schmid C, Bozinov O, Regli L. [Modern Management of Pituitary Adenomas - Current State of Diagnosis, Treatment and Follow-Up]. PRAXIS 2018; 107:825-835. [PMID: 30043702 DOI: 10.1024/1661-8157/a003035] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Modern Management of Pituitary Adenomas - Current State of Diagnosis, Treatment and Follow-Up Abstract. Pituitary adenomas (PA) are benign neoplasms originating from parenchymal cells of the anterior pituitary. Tumor mass effect can cause headaches, visual deficits by compression of the optic chiasm, and partial or complete hypopituitarism. Hormone secreting PA can cause several forms of specific syndromes such as Cushing's disease or acromegaly depending on the type of hormone. Endoscopic transsphenoidal resection is the preferred treatment option for most symptomatic or growing PA. Nowadays techniques like high definition intraoperative MRI can assist the surgeon in his goal of maximal safe resection. An exception are prolactinomas which can usually be treated medically with dopamine agonists. Therapy of PA is complex and should be managed in a high-volume center with an interdisciplinary team approach including neurosurgeons and endocrinologists.
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Affiliation(s)
- Nicolai Maldaner
- 1 Klinik für Neurochirurgie, Klinisches Neurozentrum, Universitätsspital Zürich
| | - Carlo Serra
- 1 Klinik für Neurochirurgie, Klinisches Neurozentrum, Universitätsspital Zürich
| | - Oliver Tschopp
- 2 Klinik für Endokrinologie, Diabetologie und klinische Ernährung, Universitätsspital Zürich
| | - Christoph Schmid
- 2 Klinik für Endokrinologie, Diabetologie und klinische Ernährung, Universitätsspital Zürich
| | - Oliver Bozinov
- 1 Klinik für Neurochirurgie, Klinisches Neurozentrum, Universitätsspital Zürich
| | - Luca Regli
- 1 Klinik für Neurochirurgie, Klinisches Neurozentrum, Universitätsspital Zürich
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Møller MW, Andersen MS, Pedersen CB, Kristensen BW, Poulsen FR. Intraoperative low field MRI in transsphenoidal pituitary surgery. Endocr Connect 2018; 7:897-906. [PMID: 29967186 PMCID: PMC6063879 DOI: 10.1530/ec-18-0140] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 06/28/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Intraoperative low field MRI (iMRI, 0.15 T) during transsphenoidal surgery on pituitary adenomas (PAs) may significantly improve tumor removal. However, extensive surgery can lead to pituitary hormone deficiency. Furthermore, introduction of iMRI will prolong duration of surgery, which may elevate risk of postoperative infections. METHODS Overall, 180 transsphenoidal surgeries for PAs from 2007 to 2015 were included. IMRI was available from 2011 to 2015, during this period 67/78 (86%) surgeries were with iMRI (iMRI, n = 67). A total of 113 surgeries were performed without iMRI (controls). All surgical procedures were performed by microscopic technique. Tumor size, hormonal status and vision were assessed before surgery and 3-5 months postoperatively. RESULTS Gross total resection (GTR), mean tumor remnant volume and ∆-volumes were comparable between iMRI and controls: 15% (10/66) vs 23% (26/109) (P = 0.17), 2.97 cm3 (0.9-5) vs 2.1 cm3 (1.6-2.6) (P = 0.3) and 4.5 cm3 (3.6-5.5) vs 5.1 cm3 (4.2-6) (P = 0.4), respectively. Duration of surgery was significantly longer during iMRI vs controls: 126 min (117-135) vs 98 min (92-103) (P < 0.001). New pituitary-adrenal deficiency in iMRI vs controls was seen in 35% (17/48) and 35% (23/66) of surgeries, respectively (P = 0.95). New thyroid deficiency was found in 33% (13/29) and 41% (28/69) and visual field deficiencies improved in 44% (19/43) and 38% (23/60) in iMRI vs controls, respectively (P > 0.1). CONCLUSION Tumor remnant after pituitary surgery was not significantly reduced using intraoperative low field MRI. Duration of surgery was increased in iMRI, but was not associated with increased infection rate. Pituitary hormonal function and vision were comparable between iMRI and controls.
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Affiliation(s)
- Morten Winkler Møller
- Department of NeurosurgeryOdense University Hospital, Odense C, Denmark
- Clinical InstituteUniversity of Southern Denmark, Odense C, Denmark
| | - Marianne Skovsager Andersen
- Clinical InstituteUniversity of Southern Denmark, Odense C, Denmark
- Department of EndocrinologyOdense University Hospital, Odense C, Denmark
| | - Christian Bonde Pedersen
- Department of NeurosurgeryOdense University Hospital, Odense C, Denmark
- Clinical InstituteUniversity of Southern Denmark, Odense C, Denmark
| | - Bjarne Winther Kristensen
- Clinical InstituteUniversity of Southern Denmark, Odense C, Denmark
- Department of PathologyOdense University Hospital, Odense C, Denmark
| | - Frantz Rom Poulsen
- Department of NeurosurgeryOdense University Hospital, Odense C, Denmark
- Clinical InstituteUniversity of Southern Denmark, Odense C, Denmark
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18
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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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19
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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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Sadik ZHA, Voormolen EHJ, Depauw PRAM, Burhani B, Nieuwlaat WA, Verheul J, Leenstra S, Fleischeuer R, Hanssens PEJ. Treatment of Nonfunctional Pituitary Adenoma Postoperative Remnants: Adjuvant or Delayed Gamma Knife Radiosurgery? World Neurosurg 2017; 100:361-368. [PMID: 28108427 DOI: 10.1016/j.wneu.2017.01.028] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2016] [Revised: 01/06/2017] [Accepted: 01/09/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVE It is still not clear whether Gamma Knife radiosurgery (GKRS) for nonfunctional pituitary adenomas should be used as a standard adjuvant postoperative therapy or applied when there is documented progression of the remnant on follow-up magnetic resonance imaging. METHODS We performed a retrospective study of patients with nonfunctional pituitary adenomas who underwent primary surgery and GKRS between 2002 and 2015. Patients were divided into 2 groups on the basis of the GKRS indication: adjuvant treatment (GKRS ≤6 months postoperatively) or delayed treatment (GKRS if documented progression occurred on the follow-up magnetic resonance imaging). RESULTS Fifty patients were included and grouped based on adjuvant (n = 13) or delayed (n = 37) GKRS following primary surgery. The adjuvant and delayed groups had 10-year actuarial tumor control rates of 92% and 96% (P = 0.408), respectively. The 10-year actuarial endocrinologic control rate was 82% for the adjuvant group and 49% for the delayed group (P = 0.597). None of the patients developed any new neurologic deficit post-GKRS. GKRS-induced complications (intratumoral bleeding and tumoral tissue inflammation) occurred in 6% of the patients, of whom 4% were in the delayed group and 2% in the adjuvant group. CONCLUSION Adjuvant treatment with GKRS yields the same high long-term tumor control as delayed GKRS. Neither adjuvant nor delayed GKRS induced additional neurologic complications. There is a trend that adjuvant GKRS induces less additional endocrinologic deficits compared with delayed GKRS.
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Affiliation(s)
- Z H A Sadik
- Gamma Knife Center, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands; Department of Neurosurgery, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands; Department of Neurosurgery, Utrecht University Medical Center, Utrecht, The Netherlands.
| | - E H J Voormolen
- Department of Neurosurgery, Utrecht University Medical Center, Utrecht, The Netherlands
| | - P R A M Depauw
- Department of Neurosurgery, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - B Burhani
- Department of Neurosurgery, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - W A Nieuwlaat
- Department of Internal Medicine, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - J Verheul
- Gamma Knife Center, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands; Department of Neurosurgery, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - S Leenstra
- Gamma Knife Center, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands; Department of Neurosurgery, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - R Fleischeuer
- Department of Pathology, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - P E J Hanssens
- Gamma Knife Center, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
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