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Korbonits M, Blair JC, Boguslawska A, Ayuk J, Davies JH, Druce MR, Evanson J, Flanagan D, Glynn N, Higham CE, Jacques TS, Sinha S, Simmons I, Thorp N, Swords FM, Storr HL, Spoudeas HA. Consensus guideline for the diagnosis and management of pituitary adenomas in childhood and adolescence: Part 1, general recommendations. Nat Rev Endocrinol 2024; 20:278-289. [PMID: 38336897 DOI: 10.1038/s41574-023-00948-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/19/2023] [Indexed: 02/12/2024]
Abstract
Tumours of the anterior part of the pituitary gland represent just 1% of all childhood (aged <15 years) intracranial neoplasms, yet they can confer high morbidity and little evidence and guidance is in place for their management. Between 2014 and 2022, a multidisciplinary expert group systematically developed the first comprehensive clinical practice consensus guideline for children and young people under the age 19 years (hereafter referred to as CYP) presenting with a suspected pituitary adenoma to inform specialist care and improve health outcomes. Through robust literature searches and a Delphi consensus exercise with an international Delphi consensus panel of experts, the available scientific evidence and expert opinions were consolidated into 74 recommendations. Part 1 of this consensus guideline includes 17 pragmatic management recommendations related to clinical care, neuroimaging, visual assessment, histopathology, genetics, pituitary surgery and radiotherapy. While in many aspects the care for CYP is similar to that of adults, key differences exist, particularly in aetiology and presentation. CYP with suspected pituitary adenomas require careful clinical examination, appropriate hormonal work-up, dedicated pituitary imaging and visual assessment. Consideration should be given to the potential for syndromic disease and genetic assessment. Multidisciplinary discussion at both the local and national levels can be key for management. Surgery should be performed in specialist centres. The collection of outcome data on novel modalities of medical treatment, surgical intervention and radiotherapy is essential for optimal future treatment.
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Affiliation(s)
- Márta Korbonits
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK.
| | | | - Anna Boguslawska
- Department of Endocrinology, Jagiellonian University Medical College, Krakow, Poland
| | - John Ayuk
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Justin H Davies
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Maralyn R Druce
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Jane Evanson
- Neuroradiology, Barts Health NHS Trust, London, UK
| | | | - Nigel Glynn
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | | | - Thomas S Jacques
- Great Ormond Street Institute of Child Health, University College London, London, UK
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Saurabh Sinha
- Sheffield Children's and Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Ian Simmons
- The Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Nicky Thorp
- The Christie NHS Foundation Trust, Manchester, UK
| | | | - Helen L Storr
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Helen A Spoudeas
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- University College London Hospitals NHS Foundation Trust, London, UK
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Mosallami Aghili SM, Maroufi SF, Sabahi M, Esmaeilzadeh M, Dabecco R, Adada B, Borghei-Razavi H. Intraoperative Ultrasonography in Pituitary Surgery Revisited: An Institutional Experience and Systematic Review on Applications and Considerations. World Neurosurg 2023; 176:149-158. [PMID: 37164206 DOI: 10.1016/j.wneu.2023.04.126] [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: 03/23/2023] [Revised: 04/28/2023] [Accepted: 04/29/2023] [Indexed: 05/12/2023]
Abstract
OBJECTIVE The primary objective of this systematic review is to evaluate the effectiveness of intraoperative ultrasound (IOUS) in improving outcomes in patients undergoing pituitary surgery. METHODS A systematic review was performed by searching MEDLINE (PubMed), Web of Science, Scopus, and Embase electronic bibliographic databases from conception to 2022. RESULTS The included studies yielded a total of 660 patients, with 488 patients undergoing IOUS. Outcome were available for 341 patients treated with IOUS and 157 patients who were treated without the IOUS application, and the remission rates following surgery were 76% and 59%, respectively. Only 2 studies reported remission rates for both groups, and meta-analysis for these studies showed significant superiority of intraoperative ultrasonography (Random effect, odds ratio 4.99, P < 0.01). Regarding extent of resection, IOUS resulted in 71% gross total resection, while absence of IOUS yielded a gross total resection rate of 44%. Among studies with available follow-up on IOUS, the recurrence rate was 3%. Pituitary dysfunction (34%), cerebrospinal fluid leak (31%), and central nervous system infection (8%) were the most common complications in the IOUS group. The mean follow-up was 19.97 months in studies reporting follow-up time. CONCLUSIONS The application of the IOUS is both safe and effective and could improve the outcome of pituitary surgeries. IOUS can assist surgeons in the identification of pituitary tumors and their surrounding anatomy and can help minimize the risk of complications associated with this complex surgical procedure.
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Affiliation(s)
| | - Seyed Farzad Maroufi
- Neurosurgery Research Network (NRN), Universal Scientific Education and Research Network (USERN), Tehran, Iran; Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammadmahdi Sabahi
- Department of Neurological Surgery, Pauline Braathen Neurological Center, Cleveland Clinic Florida, Weston, Florida, USA
| | - Mahla Esmaeilzadeh
- Student Research Committee, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Rocco Dabecco
- Department of Neurological Surgery, Pauline Braathen Neurological Center, Cleveland Clinic Florida, Weston, Florida, USA
| | - Badih Adada
- Department of Neurological Surgery, Pauline Braathen Neurological Center, Cleveland Clinic Florida, Weston, Florida, USA
| | - Hamid Borghei-Razavi
- Department of Neurological Surgery, Pauline Braathen Neurological Center, Cleveland Clinic Florida, Weston, Florida, USA.
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Zhang JJY, Lim JX, Lee KS, Kirollos RW, Rao JP. Impact of Intraoperative Magnetic Resonance Imaging on Short-Term and Long-Term Outcomes After Transsphenoidal Resection of Pituitary Adenoma: A Systematic Review and Meta-Analysis. World Neurosurg 2022; 167:184-194.e16. [PMID: 35977684 DOI: 10.1016/j.wneu.2022.08.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 08/08/2022] [Accepted: 08/09/2022] [Indexed: 10/31/2022]
Abstract
BACKGROUND Intraoperative magnetic resonance imaging (iMRI) allows for greater tumor visualization and extent of resection. It is increasingly used in transsphenoidal surgeries but its role is not yet established. OBJECTIVE We aimed to clarify the usefulness of iMRI in transsphenoidal surgery using direct statistical comparisons, with additional subgroup and regression analyses to investigate which patients benefit the most from iMRI use. METHODS Systematic searches of PubMed, Embase, and Cochrane Central were undertaken from database inception to May 2020 for published studies reporting the outcomes of iMRI use in transsphenoidal resection of pituitary adenoma. RESULTS Thirty-three studies reporting 2106 transsphenoidal surgeries in 2099 patients were included. Of these surgeries, 1487 (70.6%) were for nonfunctioning pituitary adenomas, whereas 619 (29.4%) were for functioning adenomas. Pooled gross total resection (GTR) was 47.6% without iMRI and 66.8% with iMRI (risk ratio [RR], 1.32; P < 0.001). Subgroup and meta-regression analyses demonstrated comparable increases in GTR between microscopic (RR, 1.35; P < 0.001) and endoscopic (RR, 1.31; P < 0.001) approaches as well as functioning and nonfunctioning adenomas (P = 0.584). The pooled rate of hypersecretion normalization was 73.0% within 3 months and 51.7% beyond 3 months postoperatively. The pooled rate of short-term and long-term improvement in visual symptoms was 96.5% and 84.9%, respectively. The incidence of postoperative surgical complications was low. The pooled reoperation rate was 3.8% across 1106 patients. CONCLUSIONS The use of iMRI as an adjunct significantly increases GTR for both microscopic and endoscopic resection of pituitary adenomas, with comparable benefits for both functioning and nonfunctioning adenomas. Satisfactory endocrinologic and visual outcomes were achieved.
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Affiliation(s)
- John J Y Zhang
- Department of Neurosurgery, National Neuroscience Institute, Singapore.
| | - Jia Xu Lim
- Department of Neurosurgery, National Neuroscience Institute, Singapore
| | - Keng Siang Lee
- Bristol Medical School, Faculty of Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Ramez W Kirollos
- Department of Neurosurgery, National Neuroscience Institute, Singapore; Duke-NUS Medical School, Singapore
| | - Jai Prashanth Rao
- Department of Neurosurgery, National Neuroscience Institute, Singapore; Duke-NUS Medical School, Singapore
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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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Multani KM, Balasubramaniam A, Rajesh BJ, Kumar K, Manohar N, Kumar A. Adjunctive Benefit of High-Field 3 Tesla MRI Guidance in Endoscopic Transsphenoidal Resection of Pituitary Adenoma. INDIAN JOURNAL OF NEUROSURGERY 2022. [DOI: 10.1055/s-0042-1743267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Abstract
Introduction Pituitary adenomas (PAs) although benign, are difficult to resect intracranial tumors and their residues are associated with morbidity and reduced quality of life. Thus, gross total resection (GTR) is the goal for all PAs. Role of various modalities for better intraoperative visualization and thus improve resection of adenoma have been tested and each have their pros and cons. The aim of this paper is to analyze adjunctive benefit of high-field 3 Tesla intraoperative magnetic resonance imaging (iMRI) in PAs resection by endoscopic transnasal transsphenoidal surgery (eTSS).
Materials and Methods A total of 50 patients who underwent iMRI-guided eTSS were included. MRI findings in preoperative, intraoperative, and 3 months postoperative stage were compared. Adjunctive value of iMRI in improving resection rates of adenoma, postoperative endocrinological outcomes, need for adjuvant radiotherapy, and postoperative cerebrospinal fluid leak rates was assessed.
Results High-field 3 Tesla iMRI helped us to detect residues in 24 (48%) patients and iMRI-guided second look surgery increased our GTR rates from initial 52 to 80% and also helped us to identify and achieve 100% GTR in intrasellar residues and parasellar residues that were medial to medial carotid tangential line. With better resection rates, need for adjuvant radiotherapy was also reduced and only 2% received adjuvant radiotherapy. Average increase in surgical time with the use of iMRI was 38.78 minutes without any side effects pertaining to prolonged surgery.
Conclusion High-field iMRI is a useful adjunct in assessment and improvement in extent of resection of PA by endoscopic transsphenoidal surgery. Also, it was found beneficial in preserving normal anatomical gland and, thus, reducing the need for postoperative adjuvant hormonal and radiation therapy.
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Affiliation(s)
| | | | | | - Krishna Kumar
- Department of Neurosurgery, Yashoda Hospital, Secunderabad, Telangana, India
| | - Nitin Manohar
- Department of Anesthesia, Yashoda Hospital, Secunderabad, Telangana, India
| | - Anjani Kumar
- Department of Radiodiagnosis, Yashoda Hospital, Secunderabad, Telangana, India
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Matsumae M, Nishiyama J, Kuroda K. Intraoperative MR Imaging during Glioma Resection. Magn Reson Med Sci 2022; 21:148-167. [PMID: 34880193 PMCID: PMC9199972 DOI: 10.2463/mrms.rev.2021-0116] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 10/11/2021] [Indexed: 11/09/2022] Open
Abstract
One of the major issues in the surgical treatment of gliomas is the concern about maximizing the extent of resection while minimizing neurological impairment. Thus, surgical planning by carefully observing the relationship between the glioma infiltration area and eloquent area of the connecting fibers is crucial. Neurosurgeons usually detect an eloquent area by functional MRI and identify a connecting fiber by diffusion tensor imaging. However, during surgery, the accuracy of neuronavigation can be decreased due to brain shift, but the positional information may be updated by intraoperative MRI and the next steps can be planned accordingly. In addition, various intraoperative modalities may be used to guide surgery, including neurophysiological monitoring that provides real-time information (e.g., awake surgery, motor-evoked potentials, and sensory evoked potential); photodynamic diagnosis, which can identify high-grade glioma cells; and other imaging techniques that provide anatomical information during the surgery. In this review, we present the historical and current context of the intraoperative MRI and some related approaches for an audience active in the technical, clinical, and research areas of radiology, as well as mention important aspects regarding safety and types of devices.
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Affiliation(s)
- Mitsunori Matsumae
- Department of Neurosurgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Jun Nishiyama
- Department of Neurosurgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Kagayaki Kuroda
- Department of Human and Information Sciences, School of Information Science and Technology, Tokai University, Hiratsuka, Kanagawa, Japan
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Celtikci E, Sahin MM, Sahin MC, Cindil E, Demirtaş Z, Emmez H. Do We Need Intraoperative Magnetic Resonance Imaging in All Endoscopic Endonasal Pituitary Adenoma Surgery Cases? A Retrospective Study. Front Oncol 2021; 11:733838. [PMID: 34660296 PMCID: PMC8517430 DOI: 10.3389/fonc.2021.733838] [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: 06/30/2021] [Accepted: 09/07/2021] [Indexed: 11/23/2022] Open
Abstract
There are previous reports investigating effectiveness of intraoperative magnetic resonance imaging (IO-MRI) in pituitary adenoma surgery but there is no clear data in the literature recommending when there is no need of intraoperative scan. This retrospective analysis was based on determining which patients does not need any IO-MRI scan following endoscopic endonasal pituitary adenoma surgery. Patients with functional or non-functional pituitary adenomas that were operated via endoscopic endonasal approach (EEA) between June 2017 and May 2019 were enrolled. Patients younger than 18 years old, patients who did not underwent IO-MRI procedure or not operated via EEA were excluded from the study. Hence, this study is designed to clarify if IO-MRI is useful in both functional and non-functional pituitary adenomas, functional adenomas did not split into subgroups. A total of 200 patients treated with pituitary adenoma were included. In Knosp Grade 0 – 2 group, primary surgeon’s opinion and IO-MRI findings were compatible in 150 patients (98.6%). In Knosp Grade 3 – 4 correct prediction were performed in 32 (66.6%) patients. When incorrectly predicted Knosp Grade 3 – 4 patients (n = 16) was analyzed, in 13 patients there were still residual tumor in cavernous sinus and in 3 patients there were no residual tumor. Fisher’s exact test showed there is a statistically significant difference of correct prediction between two different Knosp Grade groups (two-tailed P < 0.0001). Eighteen patients had a residual tumor extending to the suprasellar and parasellar regions which second most common site for residual tumor. Our findings demonstrate that there is no need of IO-MRI scan while operating adenomas limited in the sellae and not invading the cavernous sinus. However, we strongly recommend IO-MRI if there is any suprasellar and parasellar extension and/or cavernous sinus invasion.
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Affiliation(s)
- Emrah Celtikci
- Department of Neurosurgery, Gazi University Medical School, Ankara, Turkey
| | - Muammer Melih Sahin
- Department of Otorhinolaryngology, Gazi University Medical School, Ankara, Turkey
| | | | - Emetullah Cindil
- Department of Radiology, Gazi University Medical School, Ankara, Turkey
| | - Zuhal Demirtaş
- Department of Neurosurgery, Gazi University Medical School, Ankara, Turkey
| | - Hakan Emmez
- Department of Neurosurgery, Gazi University Medical School, Ankara, Turkey
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Staartjes VE, Togni-Pogliorini A, Stumpo V, Serra C, Regli L. Impact of intraoperative magnetic resonance imaging on gross total resection, extent of resection, and residual tumor volume in pituitary surgery: systematic review and meta-analysis. Pituitary 2021; 24:644-656. [PMID: 33945115 PMCID: PMC8270798 DOI: 10.1007/s11102-021-01147-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/15/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Residual tumor tissue after pituitary adenoma surgery, is linked with additional morbidity and mortality. Intraoperative magnetic resonance imaging (ioMRI) could improve resection. We aim to assess the improvement in gross total resection (GTR), extent of resection (EOR), and residual tumor volume (RV) achieved using ioMRI. METHODS A systematic review was carried out on PubMed/MEDLINE to identify any studies reporting intra- and postoperative (1) GTR, (2) EOR, or (3) RV in patients who underwent resection of pituitary adenomas with ioMRI. Random effects meta-analysis of the rate of improvement after ioMRI for these three surgical outcomes was intended. RESULTS Among 34 included studies (2130 patients), the proportion of patients with conversion to GTR (∆GTR) after ioMRI was 0.19 (95% CI 0.15-0.23). Mean ∆EOR was + 9.07% after ioMRI. Mean ∆RV was 0.784 cm3. For endoscopically treated patients, ∆GTR was 0.17 (95% CI 0.09-0.25), while microscopic ∆GTR was 0.19 (95% CI 0.15-0.23). Low-field ioMRI studies demonstrated a ∆GTR of 0.19 (95% CI 0.11-0.28), while high-field and ultra-high-field ioMRI demonstrated a ∆GTR of 0.19 (95% CI 0.15-0.24) and 0.20 (95% CI 0.13-0.28), respectively. CONCLUSIONS Our meta-analysis demonstrates that around one fifth of patients undergoing pituitary adenoma resection convert from non-GTR to GTR after the use of ioMRI. EOR and RV can also be improved to a certain extent using ioMRI. Endoscopic versus microscopic technique or field strength does not appear to alter the impact of ioMRI. Statistical heterogeneity was high, indicating that the improvement in surgical results due to ioMRI varies considerably by center.
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Affiliation(s)
- Victor E Staartjes
- Machine Intelligence in Clinical Neuroscience (MICN) Laboratory, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Alex Togni-Pogliorini
- Machine Intelligence in Clinical Neuroscience (MICN) Laboratory, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Vittorio Stumpo
- Machine Intelligence in Clinical Neuroscience (MICN) Laboratory, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Carlo Serra
- Machine Intelligence in Clinical Neuroscience (MICN) Laboratory, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland.
| | - Luca Regli
- Machine Intelligence in Clinical Neuroscience (MICN) Laboratory, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
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Utility of intraoperative ultrasonography for resection of pituitary adenomas: a comparative retrospective study. Acta Neurochir (Wien) 2021; 163:1725-1734. [PMID: 33403430 DOI: 10.1007/s00701-020-04674-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 12/04/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND The evolution of pituitary surgery has made it a safe and effective form of treatment; however, risks of inadequate tumor resection, cerebrospinal fluid (CSF) leak, pituitary dysfunction, and vascular injury still exist. The use of intraoperative ultrasonography (IOUS) in pituitary surgery has been well described. Recent advancements in ultrasound technology have allowed for expanded utility as described here. METHODS A retrospective review was performed between January 2016 and December 2019. One hundred thirty-eight patients (mean age 53.7 years, 47% females) were identified undergoing transsphenoidal surgery for pituitary tumors. Thirty-four patients had IOUS performed using a side-firing ultrasound probe, while 104 did not. Data was analyzed for preoperative (demographics, clinical, and radiographic features), perioperative (blood loss, operative time), and postoperative (complications, length of stay, hormone remission, and extent of resection) outcomes. RESULTS There were no significant differences in patient age, gender, tumor volume, Knosp grade, and hormone-secreting status between the two groups. Patients treated using IOUS had significantly higher rates of gross total resection (79% vs. 44%, p = 0.0008), shorter operative times (74 vs. 146 min, p < 0.0001), lower blood loss (119 vs. 284 cc, p < 0.0001), and hospital stays (2.9 vs. 4.2 days, p = 0.001). Overall complication rates were lower in the IOUS group compared to standard pituitary surgery but did not reach significance. CONCLUSIONS Recent improvements in ultrasound technology have allowed for miniaturization of probes capable of delivering high-resolution images. The use of IOUS in transsphenoidal pituitary surgery may significantly increase rates of gross total resection, while decreasing blood loss, hospital LOS, and operative time.
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Stanton M, Antony J, Withers T. Intraoperative MRI in trans-sphenoidal surgery using frameless stereotaxis. Surg Neurol Int 2021; 12:179. [PMID: 34084607 PMCID: PMC8168648 DOI: 10.25259/sni_842_2020] [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: 11/23/2020] [Accepted: 03/13/2021] [Indexed: 11/04/2022] Open
Abstract
Background Intraoperative magnetic resonance imaging (iMRI) has been used for pituitary surgery for approximately 20 years. The introduction of frameless stereotaxis allows efficient navigation for both the ENT and neurosurgeon. This allows flexibility in placement of the patients head to facilitate resection, efficient use of theater time and improves the safety profile of the operation. This is the first study to describe and investigate the use of frameless stereotaxis in conjunction with iMRI. Methods Consecutive patients who underwent iMRI guided trans-sphenoidal debulking using frameless stereotaxis over a 3-year period, from January 2016 to June 2019, were included in this case series and reviewed retrospectively. The use of AxiEM (Medtronic, USA) tracker facilitated frameless stereotaxis in conjunction with iMRI for trans-sphenoidal debulking of sellar lesions based on the "twin-operating" model. Results The cohort of 47 patients had a mean age of 55 years with a slight female predilection. The average lesion size measured 20 mm (3-46 mm) in maximal diameter with objective evidence of visual deterioration being the most common indication to consider surgery. The use of iMRI identified two patients with suboptimal decompression facilitating further resection in the same anesthetic and one hemorrhagic complication requiring evacuation and hemostasis to reduce postoperative morbidity. Conclusion This study describes the procedural nuances in the use of frameless stereotaxis for iMRI in transsphenoidal surgery to further reduce morbidity and improve outcomes, as well as improving theater utilization and reducing cost.
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Affiliation(s)
- Mitchell Stanton
- Department of Neurosurgery, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Joyce Antony
- Department of Neurosurgery, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Teresa Withers
- Department of Neurosurgery, Gold Coast University Hospital, Southport, Queensland, Australia
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Micko A, Placzek F, Fonollà R, Winklehner M, Sentosa R, Krause A, Vila G, Höftberger R, Andreana M, Drexler W, Leitgeb RA, Unterhuber A, Wolfsberger S. Diagnosis of Pituitary Adenoma Biopsies by Ultrahigh Resolution Optical Coherence Tomography Using Neuronal Networks. Front Endocrinol (Lausanne) 2021; 12:730100. [PMID: 34733239 PMCID: PMC8560084 DOI: 10.3389/fendo.2021.730100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 09/29/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Despite advancements of intraoperative visualization, the difficulty to visually distinguish adenoma from adjacent pituitary gland due to textural similarities may lead to incomplete adenoma resection or impairment of pituitary function. The aim of this study was to investigate optical coherence tomography (OCT) imaging in combination with a convolutional neural network (CNN) for objectively identify pituitary adenoma tissue in an ex vivo setting. METHODS A prospective study was conducted to train and test a CNN algorithm to identify pituitary adenoma tissue in OCT images of adenoma and adjacent pituitary gland samples. From each sample, 500 slices of adjacent cross-sectional OCT images were used for CNN classification. RESULTS OCT data acquisition was feasible in 19/20 (95%) patients. The 16.000 OCT slices of 16/19 of cases were employed for creating a trained CNN algorithm (70% for training, 15% for validating the classifier). Thereafter, the classifier was tested on the paired samples of three patients (3.000 slices). The CNN correctly predicted adenoma in the 3 adenoma samples (98%, 100% and 84% respectively), and correctly predicted gland and transition zone in the 3 samples from the adjacent pituitary gland. CONCLUSION Trained convolutional neural network computing has the potential for fast and objective identification of pituitary adenoma tissue in OCT images with high sensitivity ex vivo. However, further investigation with larger number of samples is required.
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Affiliation(s)
- Alexander Micko
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Fabian Placzek
- Center for Medical Physics and Biomedical Engineering, Medical University Vienna, Vienna, Austria
| | - Roger Fonollà
- Department of Electrical Engineering, Video Coding and Architectures, Eindhoven University of Technology, Eindhoven, Netherlands
| | - Michael Winklehner
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Ryan Sentosa
- Center for Medical Physics and Biomedical Engineering, Medical University Vienna, Vienna, Austria
| | - Arno Krause
- Center for Medical Physics and Biomedical Engineering, Medical University Vienna, Vienna, Austria
| | - Greisa Vila
- Division of Endocrinology and Metabolism of the Department of Internal Medicine III, Vienna, Austria
| | - Romana Höftberger
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Marco Andreana
- Center for Medical Physics and Biomedical Engineering, Medical University Vienna, Vienna, Austria
| | - Wolfgang Drexler
- Center for Medical Physics and Biomedical Engineering, Medical University Vienna, Vienna, Austria
| | - Rainer A. Leitgeb
- Center for Medical Physics and Biomedical Engineering, Medical University Vienna, Vienna, Austria
- Christian Doppler Laboratory Innovative Optical Imaging and its Translation for “Innovative Optical Imaging and its Translation into Medicine” (OPTRAMED), Medical University of Vienna, Vienna, Austria
| | - Angelika Unterhuber
- Center for Medical Physics and Biomedical Engineering, Medical University Vienna, Vienna, Austria
| | - Stefan Wolfsberger
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
- *Correspondence: Stefan Wolfsberger,
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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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The Zurich Pituitary Score predicts utility of intraoperative high-field magnetic resonance imaging in transsphenoidal pituitary adenoma surgery. Acta Neurochir (Wien) 2019; 161:2107-2115. [PMID: 31392567 DOI: 10.1007/s00701-019-04018-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 07/18/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND It is currently unclear if there are subsets of patients undergoing transsphenoidal surgery (TSS) in which intraoperative high-field magnetic resonance imaging (3T-iMRI) is particularly advantageous. We aimed to investigate whether a radiological grading scale predicts the utility of 3T-iMRI in pituitary adenoma (PA) TSS. METHODS From a prospective registry, patients who underwent endoscopic TSS for PA using 3T-iMRI were identified. Adenomas were graded using the Zurich Pituitary Score (ZPS). We assessed improvement after 3T-iMRI in terms of gross total resection (GTR), residual volume (RV), and extent of resection (EOR). RESULTS Among 95 patients, rates of conversion to GTR after 3T-iMRI decreased steadily from 33% for grade I to 0% for grade IV adenomas, with a statistically significant conversion rate only for grade I (p = 0.008) and grade II (p < 0.001). All grade I adenomas were completely resected after 3T-iMRI. Median RV change was statistically significant for grades I to III, but not for grade IV (p = 0.625). EOR improvement ranged from a median change of 0.0% (IQR 0.0-4.5%) for grade I to 4.4% (IQR 0.0-9.0%) for grade IV, with a significant improvement only for grades I to III (p < 0.05). CONCLUSIONS Interestingly, this study shows that clinical utility of 3T-iMRI is highest in the more "simple" adenomas (ZPS grades I-II) than for the more "complex" ones (ZPS grade III-IV). Grade I adenomas are amenable to GTR if 3T-iMRI is implemented. In grade III adenomas, EOR and RV can be improved to clinically relevant levels. Conversely, in grade IV adenomas, 3T-iMRI may be of limited use.
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Soneru CP, Riley CA, Hoffman K, Tabaee A, Schwartz TH. Intra-operative MRI vs endoscopy in achieving gross total resection of pituitary adenomas: a systematic review. Acta Neurochir (Wien) 2019; 161:1683-1698. [PMID: 31139934 DOI: 10.1007/s00701-019-03955-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 05/16/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Intraoperative magnetic resonance imaging (iMRI) is a technology that may improve rates of gross total resection (GTR) for pituitary adenomas. The endoscope is another less expensive technology, which also may maximize resection rates. A direct comparison of these approaches and their additive benefit has never been performed. METHODS A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) standard. PubMed and Embase databases were searched for studies that examined GTR for pituitary adenoma resection with either endoscopic transsphenoidal surgery (eTSS), microscopic transsphenoidal surgery with iMRI (mTSS + iMRI), or endoscopic transsphenoidal surgery with iMRI (eTSS + iMRI). RESULTS Eighty-five studies that reported GTR rates in 7124 pituitary adenoma patients were identified. For all pituitary adenomas, eTSS had a pooled proportion of GTR of 68.9% (95% CI 64.7-73.0%) which was similar to that of mTSS + iMRI (GTR 68.3%; 95% CI = 59.4-76.5%) and eTSS + iMRI (GTR 70.7%; 95% CI = 56.9-89.6%). For the subgroup of pituitary macroadenomas, pooled proportions for GTR were similar between eTSS and mTSS + iMRI (eTSS: GTR 59.4%; 95% CI = 49.6-68.7% vs mTSS + iMRI: GTR 68.8%; 95% CI = 57.3-79.3%), and higher for eTSS + iMRI (81.1%; 95% CI = 75.5-86.2%). The post-operative CSF leak proportion for eTSS (4.7%; 95% CI = 3.6-5.9%) was similar to that for eTSS + iMRI (3.7%; 95% CI = 1.6-6.5%) and mTSS + iMRI (4.6%; 95% CI = 2.0-8.3%). No direct statistical comparisons could be performed. CONCLUSION Final GTR proportions are similar whether the surgeon uses a microscope supplemented with iMRI or endoscope with or without iMRI. The benefit of the two technologies may be complementary for macroadenomas. These findings are important to consider when comparing the efficacy of different technical strategies in the management of pituitary adenomas.
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Abstract
In this paper, the currently used and well evaluated techniques for the surgery of pituitary tumors will be reviewed. Since the first surgical approaches to pituitary tumors more than 100 years have elapsed. Various surgical techniques have been developed, refined and standardized. Most of these tumors are to date treated via transsphenoidal approaches. Many pituitary adenomas, particularly, smaller, enclosed ones, can be completely excised and a selective adenomectomy is usually attempted. It leads to remission of hormonal oversecretion and also to recovery of pituitary function in many patients. The resection of pseudocapsule around the adenoma seems to improve the operative results further. Transcranial approaches, employing craniotomies, are still needed in some patients with pituitary adenomas and in many of those harbouring craniopharyngiomas. The operative techniques will be described and briefly commented. Moreover, the application and usefulness of several technical developments will be reviewed, such as the use of the endoscope, magnetic resonance imaging, fluorenscent dyes and neuronavigation. The use of the intraoperative Doppler probe, ultrasound and the value of intraoperative hormonal measurements will be briefly discussed. There is sufficient evidence that the best and optimal outcome in terms of tumor resection and correction of hormonal oversecretion as well as the lowest rate of complications are obtained in centers of excellence with sufficiently experienced, specialized surgeons and a high patient load.
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Affiliation(s)
- M Buchfelder
- Department of Neurosurgery, University Hospital Erlangen, Erlangen, Germany.
| | - S M Schlaffer
- Department of Neurosurgery, University Hospital Erlangen, Erlangen, Germany
| | - Y Zhao
- Department of Neurosurgery, University Hospital Erlangen, Erlangen, Germany
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Chang SW, Donoho DA, Zada G. Use of optical fluorescence agents during surgery for pituitary adenomas: current state of the field. J Neurooncol 2018; 141:585-593. [PMID: 30523607 DOI: 10.1007/s11060-018-03062-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 11/24/2018] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Differentiation of normal pituitary from abnormal tumor tissue remains a surgical challenge despite improvements in optical visualization technology for pituitary adenoma (PA) surgery. During neurosurgical procedures for other tumor types, 5-aminolevulinic acid (5-ALA) has become a focus of investigation based on its high specificity in differentiating tumor tissue. However, the role of 5-ALA and other optical fluorescent agents in PA surgery remains less clear. OBJECTIVE To perform a systematic review on the use of various optical fluorescent agents in PA surgery. METHOD Using PRISMA guidelines, a systematic literature review to identify reports describing 5-ALA and other optical agents for fluorescence-guided surgery for PA was performed. Eleven research studies met inclusion criteria and were reviewed. RESULTS In two studies, 5-ALA was not shown to be effective in aiding PA resection using standard neurosurgical endoscopic/microscopic approaches. 5-ALA photodynamic therapy was evaluated in two in-vitro models with inconsistent results. Intraoperative use of indocyanine green (ICG) concluded with varying results, but showed a tendency towards improved differentiation of functional PA. OTL38 showed potential for intraoperative identification of nonfunctioning PA, particularly in tumors with high folate receptor expression. One study reported clinically useful fluorescence following sodium fluorescein administration. CONCLUSION We conclude that selected optical fluorescent agents, including ICG and folate receptors, are most likely to hold promise for clinical use in differentiating PA from normal tissue.
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Affiliation(s)
- Stephanie W Chang
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Daniel A Donoho
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Gabriel Zada
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
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Schroeck H, Welch TL, Rovner MS, Johnson HA, Schroeck FR. Anesthetic challenges and outcomes for procedures in the intraoperative magnetic resonance imaging suite: A systematic review. J Clin Anesth 2018; 54:89-101. [PMID: 30415150 DOI: 10.1016/j.jclinane.2018.10.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Revised: 09/28/2018] [Accepted: 10/28/2018] [Indexed: 01/25/2023]
Abstract
BACKGROUND AND OBJECTIVE Hybrid operating room suites with intraoperative magnetic resonance imaging enable image guided surgery in a fully functional operating room environment. While this environment creates challenges to anesthetic care, the effects on anesthetic adverse events and outcomes are largely unknown. This systematic scoping review aims to map the existing knowledge about anesthetic care in advanced imaging hybrid operating rooms. METHODS A broad-based literature search was performed using the PubMed (Medline), Embase, Cochrane Library, Web of Science, and Google Scholar databases. References published in English between January 1994 and August 2017 were included. Quality of evidence was assessed using the GRADE guidelines. RESULTS Forty-seven manuscripts were eligible for data collection. Adverse events were heterogeneously defined across 17 manuscripts and occurred in 0 to 100% (quality of evidence mostly very low). Monitoring difficulty was reported in 4 manuscripts of very low data quality. Interference between the magnet and the electrocardiogram was investigated in 2 manuscripts (quality of evidence low and very low, respectively). None of the reported events appeared to result in long-term patient harm. Author recommendations or a narrative review of the literature were provided in 40 manuscripts. Common safety concerns included lower equipment reliability, inaccessibility of the patient and airway, and the relative isolation of the suite (in relationship to other anesthesia care areas). Most authors also emphasized the importance of safety checklists, protocols, and provider training. DISCUSSION While intraoperative magnetic resonance imaging hybrid operating rooms are increasingly utilized, the existing literature does not allow estimating adverse event rates in this location. Prospective studies quantifying the effect of the environment on anesthesia outcomes are lacking. Despite this, there is a broad consensus regarding the anesthetic and safety concerns. More research is needed to inform practice standards and training requirements for this challenging environment.
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Affiliation(s)
- Hedwig Schroeck
- Geisel School of Medicine at Dartmouth College, 1 Rope Ferry Road, Hanover, NH 03755, USA; Department of Anesthesiology, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03756, USA.
| | - Tasha L Welch
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
| | - Michelle S Rovner
- Department of Anesthesia & Perioperative Medicine, Medical University of South Carolina, 165 Ashley Avenue, Suite 525CH, Charleston, SC 29425, USA.
| | - Heather A Johnson
- Biomedical Libraries, Dartmouth College, 1 Medical Center Drive, Lebanon, NH 03756, USA
| | - Florian R Schroeck
- Geisel School of Medicine at Dartmouth College, 1 Rope Ferry Road, Hanover, NH 03755, USA; White River Junction VA Medical Center, 215 N Main Street, White River Junction, VT 05009, USA; The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, USA.
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Almutairi RD, Muskens IS, Cote DJ, Dijkman MD, Kavouridis VK, Crocker E, Ghazawi K, Broekman MLD, Smith TR, Mekary RA, Zaidi HA. Gross total resection of pituitary adenomas after endoscopic vs. microscopic transsphenoidal surgery: a meta-analysis. Acta Neurochir (Wien) 2018; 160:1005-1021. [PMID: 29307020 DOI: 10.1007/s00701-017-3438-z] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 12/14/2017] [Indexed: 01/08/2023]
Abstract
BACKGROUND Microscopic transsphenoidal surgery (mTSS) is a well-established method to address adenomas of the pituitary gland. Endoscopic transsphenoidal surgery (eTSS) has become a viable alternative, however. Advocates suggest that the greater illumination, panoramic visualization, and angled endoscopic views afforded by eTSS may allow for higher rates of gross total tumor resection (GTR). The aim of this meta-analysis was to determine the rate of GTR using mTSS and eTSS. METHODS A meta-analysis of the literature was conducted using PubMed, EMBASE, and Cochrane databases through July 2017 in accordance with PRISMA guidelines. RESULTS Seventy case series that reported GTR rate in 8257 pituitary adenoma patients were identified. For all pituitary adenomas, eTSS (GTR=74.0%; I2 = 92.1%) was associated with higher GTR as compared to mTSS (GTR=66.4%; I2 = 84.0%) in a fixed-effect model (P-interaction < 0.01). For functioning pituitary adenomas (FPAs) (n = 1170 patients), there was no significant difference in GTR rate between eTSS (GTR=75.8%; I2 = 63.9%) and mTSS (GTR=75.5%; I2 = 79.0%); (P-interaction = 0.92). For nonfunctioning pituitary adenomas (NFPAs) (n = 2655 patients), eTSS (GTR=71.0%; I2 = 86.4%) was associated with higher GTR as compared to mTSS (GTR=60.7%; I2 = 87.5%) in a fixed-effect model (P-interaction < 0.01). None of the associations were significant in a random-effect model (all P-interaction > 0.05). No significant publication bias was identified for any of the outcomes. CONCLUSION Among patients who were not randomly allocated to either approach, eTSS resulted in a higher rate of GTR as compared to mTSS for all patients and for NFPA patients alone, but only in a fixed-effect model. For FPA, however, eTSS did not seem to offer a significantly higher rate of GTR. These conclusions should be interpreted with caution because of the nature of the included non-comparative studies.
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Affiliation(s)
- Reem D Almutairi
- Department of Pharmaceutical Business and Administrative Sciences, MCPHS University, Boston, MA, USA
- School of Pharmacy, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Ivo S Muskens
- Brain Center Rudolf Magnus, Utrecht University Medical Center, Utrecht, The Netherlands
- Cushing Neurosurgical Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - David J Cote
- Cushing Neurosurgical Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA.
| | - Mark D Dijkman
- Brain Center Rudolf Magnus, Utrecht University Medical Center, Utrecht, The Netherlands
| | - Vasileios K Kavouridis
- Cushing Neurosurgical Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Erin Crocker
- Cushing Neurosurgical Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Kholoud Ghazawi
- Department of Pharmaceutical Business and Administrative Sciences, MCPHS University, Boston, MA, USA
| | - Marike L D Broekman
- Brain Center Rudolf Magnus, Utrecht University Medical Center, Utrecht, The Netherlands
- Cushing Neurosurgical Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Timothy R Smith
- Cushing Neurosurgical Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Rania A Mekary
- Department of Pharmaceutical Business and Administrative Sciences, MCPHS University, Boston, MA, USA
- Cushing Neurosurgical Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Hasan A Zaidi
- Cushing Neurosurgical Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
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Gao HB, Wang LQ, Zhou JY, Sun W. Investigating the application of diving endoscopic technique in determining the extent of pituitary adenoma resection via the trans-nasal-sphenoidal approach. Exp Ther Med 2018; 15:3815-3819. [PMID: 29581739 PMCID: PMC5863581 DOI: 10.3892/etm.2018.5922] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Accepted: 06/15/2017] [Indexed: 11/26/2022] Open
Abstract
The aim of the present study was to investigate the advantages and disadvantages of the diving endoscopic technique in pituitary adenoma surgery, and the application value in determining the extent of tumor resection. A total of 37 patients with pituitary adenoma initially underwent tumor resection under an endoscope-assisted microscope via standard trans-nasal-sphenoidal approach, and tumor cavity structure was observed by applying the diving endoscopic technique. Surgery was subsequently performed again under a microscope or endoscope. The diving endoscopic technique allowed surgeons to directly observe the structure inside a tumor cavity in high-definition. In the present study, 24 patients had pituitary macroadenomas or microadenomas that did not invade the cavernous sinus, and were considered to have undergone successful total resection. Among these patients, no tumor residues were observed through the diving endoscopic technique. Some white lichenoid or fibrous cord-like tissues in the tumor cavity were considered to be remnants of tumors. However, pathology confirmed that these were not tumor tissues. For tumors that invaded the cavernous sinus in 13 patients, observation could only be conducted under the angulation endoscope of the diving endoscope; i.e., the operation could not be conducted under an endoscope. The present study suggests that the diving endoscopic technique may be used to directly observe the resection extent of tumors within the tumor cavity, especially the structure of the tumor cavity inside the sella turcica. The present study also directly validates the reliability of pituitary adenoma resection under endoscope-assisted microscope. In addition, the diving endoscopic technique also allows the surgeon to observe the underwater environment within the sella turcica.
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Affiliation(s)
- Hai-Bin Gao
- Department of Neurosurgery, Beijing Boai Hospital, China Rehabilitation Research Centre, Beijing 100068, P.R. China.,College of Rehabilitation, Capital Medical University, Beijing 100068, P.R. China.,Institute of Nerve Injury and Repair, Beijing Institute for Brain Disorders, Beijing 100069, P.R. China
| | - Li-Qing Wang
- Department of Neurosurgery, Beijing Boai Hospital, China Rehabilitation Research Centre, Beijing 100068, P.R. China
| | - Jian-Yun Zhou
- Department of Neurosurgery, Beijing Boai Hospital, China Rehabilitation Research Centre, Beijing 100068, P.R. China
| | - Wei Sun
- Department of Neurosurgery, Beijing Boai Hospital, China Rehabilitation Research Centre, Beijing 100068, P.R. China.,College of Rehabilitation, Capital Medical University, Beijing 100068, P.R. China.,Institute of Nerve Injury and Repair, Beijing Institute for Brain Disorders, Beijing 100069, P.R. China
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21
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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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Using 3 Tesla magnetic resonance imaging in the pre-operative evaluation of tongue carcinoma. J Laryngol Otol 2017; 131:793-800. [PMID: 28683842 DOI: 10.1017/s0022215117001360] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE This study aimed to evaluate the role of 3 Tesla magnetic resonance imaging in predicting tongue tumour thickness via direct and reconstructed measures, and their correlations with corresponding histological measures, nodal metastasis and extracapsular spread. METHODS A prospective study was conducted of 25 patients with histologically proven squamous cell carcinoma of the tongue and pre-operative 3 Tesla magnetic resonance imaging from 2009 to 2012. RESULTS Correlations between 3 Tesla magnetic resonance imaging and histological measures of tongue tumour thickness were assessed using the Pearson correlation coefficient: r values were 0.84 (p < 0.0001) and 0.81 (p < 0.0001) for direct and reconstructed measurements, respectively. For magnetic resonance imaging, direct measures of tumour thickness (mean ± standard deviation, 18.2 ± 7.3 mm) did not significantly differ from the reconstructed measures (mean ± standard deviation, 17.9 ± 7.2 mm; r = 0.879). Moreover, 3 Tesla magnetic resonance imaging had 83 per cent sensitivity, 82 per cent specificity, 82 per cent accuracy and a 90 per cent negative predictive value for detecting cervical lymph node metastasis. CONCLUSION In this cohort, 3 Tesla magnetic resonance imaging measures of tumour thickness correlated highly with the corresponding histological measures. Further, 3 Tesla magnetic resonance imaging was an effective method of detecting malignant adenopathy with extracapsular spread.
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Mesko NW, Joyce DM, Ilaslan H, Joyce MJ. Creating an Intraoperative MRI Suite for the Musculoskeletal Tumor Center. Clin Orthop Relat Res 2016; 474:1516-22. [PMID: 26183844 PMCID: PMC4868174 DOI: 10.1007/s11999-015-4412-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Accepted: 06/10/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND Altered anatomy in a previously irradiated surgical bed can make accurate localization of anatomic landmarks and local recurrence nearly impossible. The use of intraoperative MRI (iMRI) has been described in neurosurgical settings, but to our knowledge, no such description has been made regarding its utility for local recurrence localization in sarcoma surgery. CASE DESCRIPTION A 58-year-old female presented after previously undergoing two previous resection and reresection procedures of a myxoid liposarcoma located adjacent to her proximal femoral vasculature. After postoperative radiation therapy, she was referred to our institution where she underwent two additional reexcisions of local recurrences during a 3-year span, eventually undergoing a regional rotational muscle flap for coverage. Two years after her third reexcision procedure, she presented with two additional, nonpalpable surgical-bed local recurrences. After converting an MRI bed and scanner to allow for proximal thigh imaging in an iMRI surgical suite, the patient underwent a successful resection that achieved negative margins. To date, she remains without evidence of disease at 37 months. LITERATURE REVIEW Real-time iMRI in neurosurgical studies has shown a high rate of residual disease leading to immediate subsequent reexcision, thus lending to improved rates of negative margin resection. To our knowledge, this is the first example using iMRI technology to remove a recurrent soft tissue sarcoma that otherwise was clinically nonlocalizable. CLINICAL RELEVANCE The use of an iMRI surgical suite can aid with identification of soft tissue nodules in conditions such as an altered tumor bed from prior resection and radiotherapy, which otherwise make recurrences difficult to localize. A team approach between administration, surgeons, and engineers is required to design and pragmatically implement the use of an MRI-compatible table extension to enhance existing iMRI surgical suite technology for extremity sarcoma resection procedures.
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Affiliation(s)
- Nathan W. Mesko
- Department of Orthopaedic Surgery, Cleveland Clinic, 9500 Euclid Ave. Crile Building, A-41, Cleveland, OH 44195 USA
| | - David M. Joyce
- Department of Orthopaedic Surgery, Cleveland Clinic, 9500 Euclid Ave. Crile Building, A-41, Cleveland, OH 44195 USA
| | - Hakan Ilaslan
- Department of Diagnostic Radiology, Cleveland Clinic, Cleveland, OH USA
| | - Michael J. Joyce
- Department of Orthopaedic Surgery, Cleveland Clinic, 9500 Euclid Ave. Crile Building, A-41, Cleveland, OH 44195 USA
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Abstract
Stepwise improvements in the imaging of pituitary adenomas in the last 100 years have had a tremendous impact on patient care. Pituitary tumors are now diagnosed earlier in the time course of the disease, improving chances of endocrine and visual recovery. There is improved pre-surgical planning due to a better understanding of the investment of the tumor around important surrounding parasellar structures. Approaches to tumors are now safer due to stereotactic navigation and residual disease can be radiographically followed for a lifetime and treated prior to irreversible neurological damage. Furthermore, adjuvant radiotherapy can be more precisely delivered to the tumor bed with the aid of higher resolution images. Thanks to these incremental improvements previously formidable macroadenomas, which carried a high risk for morbidity and residual disease, can now be treated safely and effectively. Here, we review modern imaging modalities used to diagnose pituitary adenomas, and identify areas for further improvement.
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Affiliation(s)
- Hasan A Zaidi
- a Department of Neurosurgery , Brigham and Women's Hospital, Harvard Medical School , Boston , MA , USA
| | - David J Cote
- a Department of Neurosurgery , Brigham and Women's Hospital, Harvard Medical School , Boston , MA , USA
| | - Edward R Laws
- a Department of Neurosurgery , Brigham and Women's Hospital, Harvard Medical School , Boston , MA , USA
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