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Zdrojowy-Wełna A, Valassi E. Cushing's Syndrome in the Elderly. Exp Clin Endocrinol Diabetes 2024. [PMID: 38698635 DOI: 10.1055/a-2317-8821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/05/2024]
Abstract
Management of Cushing's syndrome (CS) can be particularly challenging in older patients, compared with younger individuals, due to the lack of several clinical features associated with cortisol excess along with a greater burden of associated comorbidities. Moreover, the interpretation of diagnostic tests could be influenced by age-related physiological changes in cortisol secretion. While mortality is higher and quality of life is more impaired in the elderly with CS as compared with the younger, there is currently no agreement on the most effective therapeutic options in aged individuals, and safety data concerning medical treatment are scanty. In this review, we summarize the current knowledge about age-related differences in CS etiology, clinical presentation, treatment, and outcomes and describe the potential underlying mechanisms.
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Affiliation(s)
- Aleksandra Zdrojowy-Wełna
- Department of Endocrinology, Diabetes and Isotope Therapy, Wroclaw Medical University, Wroclaw, Poland
- Endocrinology Department, Wroclaw University Hospital, Wroclaw, Poland
| | - Elena Valassi
- Endocrinology and Nutrition Department, Germans Trias i Pujol Hospital and Research Institute, Badalona, Spain
- School of Medicine, Universitat Internacional de Catalunya (UIC), Barcelona, Spain
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Shah H, Slavin A, Botvinov J, O'Malley GR, Sarwar S, Patel NV. Endoscopic Endonasal Transsphenoidal Surgery for the Resection of Pituitary Adenomas: A Prime Candidate for a Shortened Length of Stay Enhanced Recovery after Surgery Protocol? A Systematic Review. World Neurosurg 2024; 186:145-154. [PMID: 38552787 DOI: 10.1016/j.wneu.2024.03.135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Revised: 03/22/2024] [Accepted: 03/23/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) is a perioperative model of care aimed at optimizing postoperative rehabilitation and reducing hospital length of stay (LOS). Decreasing LOS avoids hospital-acquired complications, reduces cost of care, and improves patient satisfaction. Given the lack of ERAS protocols for endoscopic endonasal transsphenoidal surgery (EETS) resection of pituitary adenomas, a systematic review of EETS was performed to compile patient outcomes and analyze factors that may lead to increased LOS, reoperation, and readmission rates with the intention to contribute to the development of a successful ERAS protocol for EETS. METHODS The authors performed a Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines-based systematic review of the literature. Information was extracted regarding patient LOS, surgery complications, and readmission/reoperation rates. Pearson's correlations to LOS and reoperation/readmission rates were performed with variables normalized to the number of participants. Statistical significance was set at P value <0.05. RESULTS Fourteen studies were included, consisting of 2083 patients. The most common complications were cerebrospinal fluid leaks (37%) and postoperative diabetes insipidus (DI) (9%). Transient DI was significantly correlated with shorter LOS. Functional pituitary adenomas were significantly correlated with lower readmission rates while nonfunctional pituitary adenomas were correlated with higher readmission rates. No other factor was found to be significantly correlated with a change in LOS or reoperation rate. CONCLUSIONS EETS may be an ideal candidate for the development of ERAS cranial protocols. While our data largely supports the safe implementation of shortened LOS protocols in EETS, our findings highlight the importance of transient DI and nonfunctional pituitary adenomas management when formulating ERAS protocols.
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Affiliation(s)
- Harshal Shah
- Department of Neurosurgery, Hackensack Meridian School of Medicine, Nutley, New Jersey, USA.
| | - Avi Slavin
- Department of Neurosurgery, Hackensack Meridian School of Medicine, Nutley, New Jersey, USA
| | - Julia Botvinov
- Department of Neurosurgery, Hackensack Meridian School of Medicine, Nutley, New Jersey, USA
| | - Geoffrey R O'Malley
- Department of Neurosurgery, Hackensack Meridian School of Medicine, Nutley, New Jersey, USA
| | - Syed Sarwar
- Department of Neurosurgery, HMH-Jersey Shore University Medical Center, Neptune, New Jersey, USA
| | - Nitesh V Patel
- Department of Neurosurgery, Hackensack Meridian School of Medicine, Nutley, New Jersey, USA; Department of Neurosurgery, HMH-Jersey Shore University Medical Center, Neptune, New Jersey, USA
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Zhang Z, Li S, Wang Y, Wang Z, Wang X, Wang B, Yang Z, Liu P, Li P. Visual outcomes and optimal timing for repeat surgery in cases of postoperative hematoma following transsphenoidal surgery for pituitary neuroendocrine tumors: A retrospective cohort study. Acta Neurochir (Wien) 2024; 166:127. [PMID: 38460009 DOI: 10.1007/s00701-024-06027-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 03/03/2024] [Indexed: 03/11/2024]
Abstract
OBJECTIVE To investigate the visual outcomes and optimal timing for repeat surgery in cases of postoperative hematoma following transsphenoidal surgery for pituitary neuroendocrine tumors (PitNETs). METHODS A retrospective study was conducted on 28 patients who developed evident postoperative hematoma out of a total of 9,010 patients. The hematomas were classified into three types based on their CT appearance. Type 1a - mild high density with no tension, Type 1b - thin-layer high density; Type 2a - solid high density with large empty cavities, Type 2b - solid high density with small empty cavities; Type 3 -solid high density with no cavity showing high tension. Patient data were collected for analysis. RESULTS The study cohort comprised 10 female and 18 male patients, with a mean age of 51.5±11.9 years. Most patients presented with large adenomas (median diameter 36mm). Postoperative visual sight improved in 12 patients, remained stable in 11 patients, and worsened in 5 patients. Notably, no patients experienced worsened visual sight beyond twenty-four hours after the operation. Among the five patients with visual deterioration, four had CT type 3 hematoma (4/6, 66.7%), and one had CT type 2b hematoma (1/9, 11.1%). Patients in the type 3 CT group were significantly more prone to experience visual deterioration compared to those in the type 2 group (odds ratio [OR] 2.154 [95% CI 1.858-611.014], P=.027). Four patients underwent repeat surgery after visual deterioration, resulting in visual improvement following a prolonged recovery period. Postoperative hematoma had limited impact on pituitary dysfunction and hyponatremia. CONCLUSION Our study reveals a significant association between postoperative hematoma CT types and visual deterioration. For patients with stable visual sight and type 1 or 2a hematoma, conservative strategies may be considered. Conversely, type 2b and 3 patients are at higher risk of visual deterioration, especially within the first 24 hours after the operation. Consequently, early reoperation before vision worsens may be a prudent approach to reduce risks and improve visual outcomes, particularly in type 3 patients.
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Affiliation(s)
- Zhe Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shiwei Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ying Wang
- Neural Reconstruction Department, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Zhenmin Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xingchao Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Bo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhijun Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Pinan Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
| | - Peng Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
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Karsy M, Kshettry V, Gardner P, Chicoine M, Fernandez-Miranda JC, Evans JJ, Barkhoudarian G, Hardesty D, Kim W, Zada G, Crocker T, Torok I, Little A. The RAPID Consortium: A Platform for Clinical and Translational Pituitary Tumor Research. J Neurol Surg B Skull Base 2024; 85:1-8. [PMID: 38274483 PMCID: PMC10807961 DOI: 10.1055/a-1978-9380] [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: 07/10/2022] [Accepted: 09/07/2022] [Indexed: 11/17/2022] Open
Abstract
Objectives Pituitary tumor treatment is hampered by the relative rarity of the disease, absence of a multicenter collaborative platform, and limited translational-clinical research partnerships. Prior studies offer limited insight into the formation of a multicenter consortium. Design The authors describe the establishment of a multicenter research initiative, Registry of Adenomas of the Pituitary and Related Disorders (RAPID), to encourage quality improvement and research, promote scholarship, and apply innovative solutions in outcomes research. Methods The challenges encountered during the formation of other research registries were reviewed with those lessons applied to the development of RAPID. Setting/Participants RAPID was formed by 11 academic U.S. pituitary centers. Results A Steering Committee, bylaws, data coordination center, and leadership team have been established. Clinical modules with standardized data fields for nonfunctioning adenoma, prolactinoma, acromegaly, Cushing's disease, craniopharyngioma, and Rathke's cleft cyst were created using a Health Insurance Portability and Accountability Act-compliant cloud-based platform. Currently, RAPID has received institutional review board approval at all centers, compiled retrospective data and agreements from most centers, and begun prospective data collection at one site. Existing institutional databases are being mapped to one central repository. Conclusion The RAPID consortium has laid the foundation for a multicenter collaboration to facilitate pituitary tumor and surgical research. We sought to share our experiences so that other groups also contemplating this approach may benefit. Future studies may include outcomes benchmarking, clinically annotated biobank tissue, multicenter outcomes studies, prospective intervention studies, translational research, and health economics studies focused on value-based care questions.
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Affiliation(s)
- Michael Karsy
- Department of Neurosurgery, The University of Utah, Salt Lake City, Utah, United States
| | - Varun Kshettry
- Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio, United States
| | - Paul Gardner
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
| | - Michael Chicoine
- Department of Neurosurgery, Washington University in Saint Louis, Saint Louis, Missouri, United States
| | - Juan C. Fernandez-Miranda
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
| | - James J. Evans
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, United States
| | - Garni Barkhoudarian
- Department of Neurosurgery, Pacific Neuroscience Institute, Los Angeles, California, United States
| | - Douglas Hardesty
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, United States
| | - Won Kim
- Department of Neurosurgery, University of California, Los Angeles (UCLA), Los Angeles, California, United States
| | - Gabriel Zada
- Department of Neurosurgery, University of Southern California, Los Angeles, California, United States
| | - Tomiko Crocker
- Barrow Clinical Outcomes Center, Barrow Neurological Institute, Phoenix, Arizona, United States
| | - Ildiko Torok
- Barrow Clinical Outcomes Center, Barrow Neurological Institute, Phoenix, Arizona, United States
| | - Andrew Little
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, United States
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Lu B, Zhang Y, Liu C, Ma X, Liu G, Bie Z, Yang Z, Liu P. Intraoperative cerebrospinal fluid leakage and residual tumors in endoscopic transsphenoidal surgery for pituitary adenoma: risk analysis and nomogram development. Acta Neurochir (Wien) 2023; 165:4131-4142. [PMID: 37966528 DOI: 10.1007/s00701-023-05830-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 09/19/2023] [Indexed: 11/16/2023]
Abstract
BACKGROUND Endoscopic transsphenoidal surgery is the primary method used to treat pituitary adenomas (PAs) at present; however, this technique is associated with certain risks, including cerebrospinal fluid leakage (CFL) and residual tumors (RTs). In this study, we aimed to identify specific risk factors for intraoperative CFL (ioCFL) and postoperative RT in patients with pituitary adenoma and construct a corresponding nomogram for risk assessment. METHODS We collected a range of information from 782 patients who underwent endoscopic transsphenoidal PA resection in the Department of Neurosurgery at Beijing Tiantan Hospital between 2019 and 2021. Patients were then randomly assigned to training and validation groups (in a 8:2 ratio) with R software. Univariate and multivariable logistic regression models were then used to screen variables related to ioCFL and RT. These variables were then used to construct a predictive nomogram. Finally, the accuracy of the nomogram was validated by receiver operating characteristic curve (ROC) analysis, calibration plots, and decision curve analysis (DCA). RESULTS Univariate and multivariable logistic regression models identified four risk factors for ioCFL (Hardy grade, tumor size, position, and consistency) and five risk factors for RT (operation time, tumor size, consistency, Knosp grade, and primary/recurrence type). The area under the ROC curve (AUC) for the ioCFL risk model was 0.666 and 0.697 for the training and validation groups, respectively. For RT, the AUCs for the two groups were 0.788 and 0.754, respectively. The calibration plots for the ioCFL and RT models showed high calibration quality and DCA analysis yielded excellent efficiency with regards to clinical decision making. CONCLUSION Tumor size, growth characteristics, and invasion location were identified as the main factors affecting intraoperative CFL and RT. With our novel nomogram, surgeons can identify high-risk patients according to preoperative and intraoperative tumor performance and reduce the probability of complications.
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Affiliation(s)
- Bin Lu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Yu Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Chenan Liu
- Department of Gastrointestinal Surgery, Beijing Shijitan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Xin Ma
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Gemingtian Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Zhixu Bie
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Zhijun Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Pinan Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China.
- Department of Neural Reconstruction, Beijing Key Laboratory of Central Nervous System Injury, Beijing Neurosurgical Institute, Capital Medical University, Beijing, People's Republic of China.
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Shao C, Wang J, Wang P, Wu N. Endoscopic Transsphenoidal Surgery with a Layered Peel Strategy for Cushing's Disease Treatment: A Case Series. Brain Sci 2023; 13:brainsci13040671. [PMID: 37190636 DOI: 10.3390/brainsci13040671] [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: 02/27/2023] [Revised: 03/27/2023] [Accepted: 04/12/2023] [Indexed: 05/17/2023] Open
Abstract
Patients with Cushing's disease (CD) who underwent endoscopic transsphenoidal surgery (ETS) with a layered peel strategy at our center were retrospectively analyzed. Records on patients' basic characteristics, preoperative and early postoperative evaluations, perioperative complications, and follow-up were collected. A total of 12 unselected, consecutive patients with CD were identified. Ten of the twelve patients were female. All tumors were confirmed by magnetic resonance imaging, with a maximum tumor diameter ranging from 5 mm to 11 mm. A lower rate of surgical complications was identified postoperatively, with no cases of carotid artery injury, epistaxis, hematoma, visual disturbance, or intracranial infection, but with one case of cerebrospinal fluid rhinorrhea. Ten patients experienced immediate remission, and two had delayed remission. No recurrence events were observed during a median follow-up of 51 months. In conclusion, our preliminary experience indicated that ETS with a layered peel strategy provided a perfect remission rate, low complication rate, and no recurrence in a case series of CD patients. Given the limited number of cases, future studies are warranted to confirm its effectiveness and safety.
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Affiliation(s)
- Chuan Shao
- Department of Neurosurgery, Chongqing General Hospital, Chongqing 401147, China
- Graduate Institute, Chongqing Medical University, Chongqing 400016, China
| | - Junwei Wang
- Department of Neurosurgery, Chongqing General Hospital, Chongqing 401147, China
| | - Pan Wang
- Department of Neurosurgery, Chongqing General Hospital, Chongqing 401147, China
| | - Nan Wu
- Department of Neurosurgery, Chongqing General Hospital, Chongqing 401147, China
- Graduate Institute, Chongqing Medical University, Chongqing 400016, China
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Overview of Pituitary Surgery. Otolaryngol Clin North Am 2022; 55:205-221. [DOI: 10.1016/j.otc.2022.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Comparison of Endoscopic and Microscopic Transsphenoidal Approaches for the Resection of Pituitary Adenoma. ARCHIVES OF NEUROSCIENCE 2021. [DOI: 10.5812/ans.117339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: The comparative outcomes between endoscopic and microscopic transsphenoidal approaches (ETSA and MTSA) for pituitary adenomas (PAs) remain controversial; however, the numerous literatures have been investigated for decades. This study evaluated the effectiveness of these two techniques using comprehensive measurements and rigorous statistical methods. Methods: A retrospective review of patients who underwent transsphenoidal surgery for PAs at our institution between January 2010 and December 2019 was performed. We included only cases treated by surgeons who have independently performed more than 30 transsphenoidal surgeries. Patients’ characteristics, surgical outcomes, complications, and recurrence were collected for statistical analysis Results: A total of 210 patients, including 138 ETSA patients, and 72 MTSA patients, were analyzed. The baseline characteristics of the two groups were comparable. ETSA patients showed less intraoperative blood loss (191.9 mL vs. 369.9 mL, P < 0.01), a higher rate of gross total resection (GTR) (84.1% vs. 72.2%, P = 0.04), a higher rate of extent of resection (EOR) (95.1% vs. 87.4%, P < 0.01), and shorter hospital stay (10 days vs. 13.5 days, P < 0.01). These better outcomes of ETSA persisted in multivariable regression analysis. Complications were not significantly different between groups. There was no statistical difference between recurrence-free survival of the two groups (P = 0.06, log-rank test) Conclusions: Our study showed that ETSA provided better outcomes and attained similar complications compared to MTSA for the resection of PAs.
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