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Lefevre E, Chasseloup F, Hage M, Chanson P, Buchfelder M, Kamenický P. Clinical and therapeutic implications of cavernous sinus invasion in pituitary adenomas. Endocrine 2024:10.1007/s12020-024-03877-2. [PMID: 38761347 DOI: 10.1007/s12020-024-03877-2] [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] [Received: 03/25/2024] [Accepted: 05/12/2024] [Indexed: 05/20/2024]
Abstract
Invasion of the cavernous sinus by pituitary adenomas impedes complete surgical resection, compromises biochemical remission, and increases the risk of further tumor recurrence. Accurate preoperative MRI-based diagnosis or intraoperative direct inspection of cavernous sinus invasion are essential for optimal surgical planning and for tailoring postoperative therapeutic strategies, depending on whether a total resection has been achieved, or tumoral tissue has been left in surgically inaccessible locations. The molecular mechanisms underlying the invasive behavior of pituitary adenomas remain poorly understood, hindering the development of targeted therapies. Some studies have identified genes overexpressed in pituitary adenomas invading the cavernous sinus, offering insights into the acquisition of invasive behavior. Their main limitation however lies in comparing purely intrasellar specimens obtained from invasive and non-invasive adenomas. Further, precise anatomical knowledge of the medial wall of the cavernous sinus is crucial for grasping the mechanisms of invasion. Recently, alongside the standard intrasellar surgery, extended endoscopic intracavernous surgical procedures with systematic selective resection of the medial wall of the cavernous sinus have shown promising results for invasive secreting pituitary adenomas. The first- and second-generation somatostatin agonist ligands and cabergoline are used with variable efficacy to control secretory activity and/or growth of intracavernous remnants. Tumor regrowth usually requires surgical reintervention, sometimes combined with radiotherapy or radiosurgery which is applied despite their benign nature. Unraveling the molecular pathways driving invasive behavior of pituitary adenomas and their tropism to the cavernous sinuses is the key for developing efficient innovative treatment modalities that could reduce the need for repeated surgery or radiotherapy.
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Affiliation(s)
- Etienne Lefevre
- INSERM U1185, Physiologie et Physiopathologie Endocriniennes, Université Paris-Saclay, 94276, Le Kremlin-Bicêtre, France.
- Service de Neurochirurgie, AP-HP, Hôpital Pitié-Salpêtrière, 75013, Paris, France.
| | - Fanny Chasseloup
- INSERM U1185, Physiologie et Physiopathologie Endocriniennes, Université Paris-Saclay, 94276, Le Kremlin-Bicêtre, France
- Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des maladies Rares de l'Hypophyse, AP-HP, Hôpital Bicêtre, 94276, Le Kremlin-Bicêtre, France
| | - Mirella Hage
- INSERM U1185, Physiologie et Physiopathologie Endocriniennes, Université Paris-Saclay, 94276, Le Kremlin-Bicêtre, France
| | - Philippe Chanson
- INSERM U1185, Physiologie et Physiopathologie Endocriniennes, Université Paris-Saclay, 94276, Le Kremlin-Bicêtre, France
- Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des maladies Rares de l'Hypophyse, AP-HP, Hôpital Bicêtre, 94276, Le Kremlin-Bicêtre, France
| | - Michael Buchfelder
- Department of Neurosurgery, University Hospital Erlangen, 91054, Erlangen, Germany
| | - Peter Kamenický
- INSERM U1185, Physiologie et Physiopathologie Endocriniennes, Université Paris-Saclay, 94276, Le Kremlin-Bicêtre, France
- Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des maladies Rares de l'Hypophyse, AP-HP, Hôpital Bicêtre, 94276, Le Kremlin-Bicêtre, France
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Castle-Kirszbaum M, Amukotuwa S, Fuller P, Goldschlager T, Gonzalvo A, Kam J, Kow CY, Shi MD, Stuckey S. MRI for Cushing Disease: A Systematic Review. AJNR Am J Neuroradiol 2023; 44:311-316. [PMID: 36759141 PMCID: PMC10187804 DOI: 10.3174/ajnr.a7789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 10/11/2022] [Indexed: 02/11/2023]
Abstract
BACKGROUND MR imaging is key in the diagnostic work-up of Cushing disease. The sensitivity of MR imaging in Cushing disease is not known nor is the prognostic significance of "MR imaging-negative" disease. PURPOSE Our aim was to determine the overall sensitivity and prognostic significance of MR imaging localization of Cushing disease. DATA SOURCES We performed a systematic review of the MEDLINE and PubMed databases for cohort studies reporting the sensitivity of MR imaging for the detection of adenomas in Cushing disease. STUDY SELECTION This study included 57 studies, comprising 5651 patients. DATA ANALYSIS Risk of bias was assessed using the methodological index for non-randomized studies criteria. Meta-analysis of proportions and pooled subgroup analysis were performed. DATA SYNTHESIS Overall sensitivity was 73.4% (95% CI, 68.8%-77.7%), and the sensitivity for microadenomas was 70.6% (66.2%-74.6%). There was a trend toward greater sensitivity in more recent studies and with the use of higher-field-strength scanners. Thinner-section acquisitions and gadolinium-enhanced imaging, particularly dynamic sequences, also increased the sensitivity. The use of FLAIR and newer 3D spoiled gradient-echo and FSE sequences, such as spoiled gradient-echo sequences and sampling perfection with application-optimized contrasts by using different flip angle evolutions, may further increase the sensitivity but appear complementary to standard 2D spin-echo sequences. MR imaging detection conferred a 2.63-fold (95% CI, 2.06-3.35-fold) increase in remission for microadenomas compared with MR imaging-negative Cushing disease. LIMITATIONS Pooled analysis is limited by heterogeneity among studies. We could not account for variation in image interpretation and tumor characteristics. CONCLUSIONS Detection on MR imaging improves the chances of curative resection of adenomas in Cushing disease. The evolution of MR imaging technology has improved the sensitivity for adenoma detection. Given the prognostic importance of MR imaging localization, further effort should be made to improve MR imaging protocols for Cushing disease.
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Affiliation(s)
- M Castle-Kirszbaum
- From the Departments of Neurosurgery (M.C.-K., T.G., J.K., C.Y.K.)
- Surgery (M.C.-K., T.G.), Monash Health, Melbourne, Australia
| | | | - P Fuller
- Endocrinology (P.F.)
- Hudson Institute (P.F.), Melbourne, Australia
| | - T Goldschlager
- From the Departments of Neurosurgery (M.C.-K., T.G., J.K., C.Y.K.)
- Surgery (M.C.-K., T.G.), Monash Health, Melbourne, Australia
| | - A Gonzalvo
- Department of Neurosurgery (A.G., J.K.), Austin Hospital, Melbourne, Australia
| | - J Kam
- From the Departments of Neurosurgery (M.C.-K., T.G., J.K., C.Y.K.)
- Department of Neurosurgery (A.G., J.K.), Austin Hospital, Melbourne, Australia
| | - C Y Kow
- From the Departments of Neurosurgery (M.C.-K., T.G., J.K., C.Y.K.)
| | - M D Shi
- Barwon Health (M.D.S.), Geelong, Australia
| | - S Stuckey
- Department of Radiology (S.S.), Peter MacCallum Cancer Centre, Melbourne, Australia
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Becerra V, Hinojosa J, Candela S, Culebras D, Alamar M, Armero G, Echaniz G, Artés D, Munuera J, Muchart J. The impact of 1.5-T intraoperative magnetic resonance imaging in pediatric tumor surgery: Safety, utility, and challenges. Front Oncol 2023; 12:1021335. [PMID: 36686826 PMCID: PMC9846736 DOI: 10.3389/fonc.2022.1021335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 12/05/2022] [Indexed: 01/06/2023] Open
Abstract
Objective In this study, we present our experience with 1.5-T high-field intraoperative magnetic resonance imaging (ioMRI) for different neuro-oncological procedures in a pediatric population, and we discuss the safety, utility, and challenges of this intraoperative imaging technology. Methods A pediatric consecutive-case series of neuro-oncological surgeries performed between February 2020 and May 2022 was analyzed from a prospective ioMRI registry. Patients were divided into four groups according to the surgical procedure: intracranial tumors (group 1), intraspinal tumors (group 2), stereotactic biopsy for unresectable tumors (group 3), and catheter placement for cystic tumors (group 4). The goal of surgery, the volume of residual tumor, preoperative and discharge neurological status, and postoperative complications related to ioMRI were evaluated. Results A total of 146 procedures with ioMRI were performed during this period. Of these, 62 were oncology surgeries: 45 in group 1, two in group 2, 10 in group 3, and five in group 4. The mean age of our patients was 8.91 years, with the youngest being 12 months. ioMRI identified residual tumors and prompted further resection in 14% of the cases. The mean time for intraoperative image processing was 54 ± 6 min. There were no intra- or postoperative security incidents related to the use of ioMRI. The reoperation rate in the early postoperative period was 0%. Conclusion ioMRI in pediatric neuro-oncology surgery is a safe and reliable tool. Its routine use maximized the extent of tumor resection and did not result in increased neurological deficits or complications in our series. The main limitations included the need for strict safety protocols in a highly complex surgical environment as well as the inherent limitations on certain patient positions with available MR-compatible headrests.
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Affiliation(s)
- Victoria Becerra
- Department of Neurosurgery, Hospital Sant Joan de Déu, Esplugues de Llobregat (Cataluña), Spain,*Correspondence: Victoria Becerra,
| | - José Hinojosa
- Department of Neurosurgery, Hospital Sant Joan de Déu, Esplugues de Llobregat (Cataluña), Spain
| | - Santiago Candela
- Department of Neurosurgery, Hospital Sant Joan de Déu, Esplugues de Llobregat (Cataluña), Spain
| | - Diego Culebras
- Department of Neurosurgery, Hospital Sant Joan de Déu, Esplugues de Llobregat (Cataluña), Spain
| | - Mariana Alamar
- Department of Neurosurgery, Hospital Sant Joan de Déu, Esplugues de Llobregat (Cataluña), Spain
| | - Georgina Armero
- Department of Pediatrics, Hospital Sant Joan de Déu, Esplugues de Llobregat (Cataluña), Spain
| | - Gastón Echaniz
- Department of Anesthesiology, Hospital Sant Joan de Déu, Esplugues de Llobregat (Cataluña), Spain
| | - David Artés
- Department of Anesthesiology, Hospital Sant Joan de Déu, Esplugues de Llobregat (Cataluña), Spain
| | - Josep Munuera
- Diagnostic Imaging Department, Hospital Sant Joan de Déu, Esplugues de Llobregat (Cataluña), Spain,Diagnostic and Therapeutic Imaging, Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat (Cataluña), Spain
| | - Jordi Muchart
- Diagnostic Imaging Department, Hospital Sant Joan de Déu, Esplugues de Llobregat (Cataluña), Spain,Diagnostic and Therapeutic Imaging, Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat (Cataluña), Spain
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Yu S, Taghvaei M, Collopy S, Piper K, Karsy M, Lavergne P, Barton B, Chitguppi C, D'Souza G, Rosen MR, Nyquist GG, Rabinowitz M, Farrell CJ, Evans JJ. Evaluation of early postoperative day 1 discharge after endoscopic endonasal pituitary adenoma resection. J Neurosurg 2022; 136:1337-1346. [PMID: 34653980 DOI: 10.3171/2021.5.jns2185] [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: 01/11/2021] [Accepted: 05/17/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE While multiple studies have evaluated the length of stay after endonasal transsphenoidal surgery (ETS) for pituitary adenoma, the potential for early discharge on postoperative day 1 (POD 1) remains unclear. The authors compared patients discharged on POD 1 with patients discharged on POD > 1 to better characterize factors that facilitate early discharge after ETS. METHODS A retrospective chart review was performed for patients undergoing ETS for pituitary adenoma at a single tertiary care academic center from February 2005 to February 2020. Discharge on POD 1 was defined as a discharge within 24 hours of surgery. RESULTS A total of 726 patients (mean age 55 years, 52% male) were identified, of whom 178 (24.5%) patients were discharged on POD 1. These patients were more likely to have pituitary incidentaloma (p = 0.001), require dural substitutes and DuraSeal (p = 0.0001), have fewer intraoperative CSF leaks (p = 0.02), and have lower postoperative complication rates (p = 0.006) compared with patients discharged on POD > 1. POD 1 patients also showed higher rates of macroadenomas (96.1% vs 91.4%, p = 0.03) and lower rates of functional tumors (p = 0.02). POD > 1 patients were more likely to have readmission within 30 days (p = 0.002), readmission after 30 days (p = 0.0001), nasal synechiae on follow-up (p = 0.003), diabetes insipidus (DI; 1.7% vs 9.8%, p = 0.0001), postoperative hypocortisolism (21.8% vs 12.1%, p = 0.01), and postoperative steroid usage (44.6% vs 59.7%, p = 0.003). The number of patients discharged on POD 1 significantly increased during each subsequent time epoch: 2005-2010, 2011-2015, and 2016-2020 (p = 0.0001). On multivariate analysis, DI (OR 7.02, 95% CI 2.01-24.57; p = 0.002) and intraoperative leak (OR 2.02, 95% CI 1.25-3.28; p = 0.004) were associated with increased risk for POD > 1 discharge, while operation epoch (OR 0.46, 95% CI 0.3-0.71; p = 0.0001) was associated with POD 1 discharge. CONCLUSIONS This study demonstrates that discharge on POD 1 after ETS for pituitary adenomas was safe and feasible and without increased risk of 30-day readmission. On multivariate analysis, surgical epoch was associated with decreased risk of prolonged length of stay, while factors associated with increased risk of prolonged length of stay included DI and intraoperative CSF leak. These findings may help in selecting patients who are deemed reasonable for safe, early discharge after pituitary adenoma resection.
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Affiliation(s)
- Siyuan Yu
- 1Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia; and
| | - Mohammad Taghvaei
- 1Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia; and
| | - Sarah Collopy
- 1Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia; and
| | - Keenan Piper
- 1Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia; and
| | - Michael Karsy
- 1Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia; and
| | - Pascal Lavergne
- 1Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia; and
| | - Blair Barton
- 2Department of Otolaryngology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Chandala Chitguppi
- 2Department of Otolaryngology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Glen D'Souza
- 2Department of Otolaryngology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Marc R Rosen
- 2Department of Otolaryngology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Gurston G Nyquist
- 2Department of Otolaryngology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Mindy Rabinowitz
- 2Department of Otolaryngology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Christopher J Farrell
- 1Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia; and
| | - James J Evans
- 1Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia; and
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Acitores Cancela A, Rodríguez Berrocal V, Pian H, Martínez San Millán JS, Díez JJ, Iglesias P. Clinical relevance of tumor consistency in pituitary adenoma. Hormones (Athens) 2021; 20:463-473. [PMID: 34148222 DOI: 10.1007/s42000-021-00302-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 05/13/2021] [Indexed: 12/30/2022]
Abstract
PURPOSE To review the clinical relevance of pituitary adenoma (PA) consistency and its relationship to clinical presentation, radiologic and histopathological characteristics, and surgical outcomes. BACKGROUND PA consistency is a critical factor influencing operative planning, surgical outcomes, and patient counseling. There is no validated classification of PA consistency in the literature, and there are no current preoperative variables capable of predicting it. REVIEW We conducted a thorough literature review of the Medline, Embase, Web of Science, and Cochrane Library databases. The inclusion criteria were all articles that described PA consistency and correlated it with preoperative aspects, radiological, pathological, and operative findings, or clinical outcomes. DISCUSSION Although most authors differentiate easily aspirated (soft) tumors from those that are not (fibrous, might require prior fragmentation), there is no universally accepted PA consistency classification. Fibrous PA tends to be hypointense on T2WI and has lower apparent diffusion coefficient (ADC) values. Fibrous tumors seemed to present higher invasion into neighboring structures, including the cavernous sinus. Several articles suggest that dopamine agonists could increase PA consistency and that prior surgery and radiotherapy also make PA more fibrous. The anatomopathological studies identify collagen as being mainly responsible for fibrous consistency of adenomas. CONCLUSIONS Preoperative knowledge of PA consistency affords the neurosurgeon substantial benefit, which clearly appears to be relevant to surgical planning, risks, and surgery outcomes. It could also encourage the centralization of these high complexity tumors in reference centers. Further studies may be enhanced by applying standard consistency classification of the PA and analyzing a more extensive and prospective series of fibrous PA.
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Affiliation(s)
- Alberto Acitores Cancela
- Department of Neurosurgery, Hospital Universitario Ramón Y Cajal, Ctra. de Colmenar Viejo km. 9, 100, 28034, Madrid, Spain.
| | - Víctor Rodríguez Berrocal
- Department of Neurosurgery, Hospital Universitario Ramón Y Cajal, Ctra. de Colmenar Viejo km. 9, 100, 28034, Madrid, Spain
| | - Héctor Pian
- Departments of Neurosurgery and Pathology, Hospital Universitario Ramón Y Cajal, Madrid, Spain
| | | | - Juan José Díez
- Department of Endocrinology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
| | - Pedro Iglesias
- Department of Endocrinology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
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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: 0] [Impact Index Per Article: 0] [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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Hunsaker JC, Khan M, Gamblin A, Karsy M, Couldwell WT. Use of a Surgical Stepdown Protocol for Cost Reduction After Transsphenoidal Pituitary Adenoma Resection: A Case Series. World Neurosurg 2021; 152:e476-e483. [PMID: 34098141 DOI: 10.1016/j.wneu.2021.05.126] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 05/26/2021] [Accepted: 05/27/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVE No established standard of care currently exists for the postoperative management of patients with surgically resected pituitary adenomas. Our objective was to quantify the efficacy of a postoperative stepdown unit protocol for reducing patient cost. METHODS In 2018-2020, consecutive patients undergoing transsphenoidal microsurgical resection of sellar lesions were managed postoperatively in the full intensive care unit (ICU) or an ICU-based surgical stepdown unit based on preset criteria. Demographic variables, surgical outcomes, and patient costs were evaluated. RESULTS Fifty-four patients (27 stepdown, 27 full ICU; no difference in age or sex) were identified. Stepdown patients were also compared with 634 historical control patients. The total hospital length of stay was no different among stepdown, ICU, and historical patients (4.8 ± 1.0 vs. 5.9 ± 2.8 vs. 4.4 ± 4.3 days, respectively, P = 0.1). Overall costs were 12.5% less for stepdown patients (P = 0.01), a difference mainly driven by reduced facility utilization costs of -8.9% (P = 0.02). The morbidity and complication rates were similar in the stepdown and full ICU groups. Extrapolation of findings to historical patients suggested that ∼$225,000 could have been saved from 2011 to 2016. CONCLUSIONS These results suggest that use of a postoperative stepdown unit could result in a 12.5% savings for eligible patients undergoing treatment of pituitary tumors by shifting patients to a less acute unit without worsened surgical outcomes. Historical controls indicate that over half of all pituitary patients would be eligible. Further refinement of patient selection for less costly perioperative management may reduce cost burden for the health care system and patients.
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Affiliation(s)
| | - Majid Khan
- Reno School of Medicine, University of Nevada, Reno, NV, USA
| | - Austin Gamblin
- School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Michael Karsy
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA; Department of Neurosurgery, University of Utah, Salt Lake City, UT, USA
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Perosevic M, Jones PS, Tritos NA. Magnetic resonance imaging of the hypothalamo-pituitary region. HANDBOOK OF CLINICAL NEUROLOGY 2021; 179:95-112. [PMID: 34225987 DOI: 10.1016/b978-0-12-819975-6.00004-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The diagnosis and management of mass lesions in the sellar and parasellar areas remain challenging. When approaching patients with possible sellar or hypothalamic masses, it is important not only to focus on imaging but also detect possible pituitary hormone deficits or excess, in order to establish an appropriate diagnosis and initiate treatment. The imaging modalities used to characterize hypothalamic and pituitary lesions have significantly evolved over the course of the past several years. Computed tomography (CT) and CT angiography play a major role in detecting various sellar lesions, especially in patients who have contraindications to magnetic resonance imaging (MRI) and can also yield important information for surgical planning. However, MRI has become the gold standard for the detection and characterization of hypothalamic and pituitary tumors, infections, cystic, or vascular lesions. Indeed, the imaging characteristics of hypothalamic and sellar lesions can help narrow down the differential diagnosis preoperatively. In addition, MRI can help establish the relationship of mass lesions to surrounding structures. A pituitary MRI examination should be obtained if there is concern for mass effect (including visual loss, ophthalmoplegia, headache) or if there is clinical suspicion and laboratory evidence of either hypopituitarism or pituitary hormone excess. The information obtained from MRI images also provides us with assistance in planning surgery. Using intraoperative MRI can be very helpful in assessing the adequacy of tumor resection. In addition, MRI images yield reliable data that allow for noninvasive monitoring of patients postoperatively.
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Affiliation(s)
- Milica Perosevic
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States.
| | - Pamela S Jones
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Nicholas A Tritos
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
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Abstract
This article discusses intraoperative imaging techniques used during high-grade glioma surgery. Gliomas can be difficult to differentiate from surrounding tissue during surgery. Intraoperative imaging helps to alleviate problems encountered during glioma surgery, such as brain shift and residual tumor. There are a variety of modalities available all of which aim to give the surgeon more information, address brain shift, identify residual tumor, and increase the extent of surgical resection. The article starts with a brief introduction followed by a review of with the latest advances in intraoperative ultrasound, intraoperative MRI, and intraoperative computed tomography.
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Affiliation(s)
- Thomas Noh
- Department of Neurosurgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA; Hawaii Pacific Health, John A Burns School of Medicine, Honolulu, Hawaii, USA
| | - Martina Mustroph
- Department of Neurosurgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA; Harvard Medical School, Boston, Massachusetts, USA
| | - Alexandra J Golby
- Department of Neurosurgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA; Department of Radiology, Harvard Medical School, Boston, Massachusetts, USA.
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Schmale IL, Vandelaar LJ, Luong AU, Citardi MJ, Yao WC. Image-Guided Surgery and Intraoperative Imaging in Rhinology: Clinical Update and Current State of the Art. EAR, NOSE & THROAT JOURNAL 2020; 100:NP475-NP486. [PMID: 32453646 DOI: 10.1177/0145561320928202] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Image-guided surgery (IGS) has gained widespread acceptance in otorhinolaryngology for its applications in sinus and skull base surgery. Although the core concepts of IGS have not changed, advances in image guidance technology, including the incorporation of intraoperative imaging, have the potential to enhance surgical education, allow for more rigorous preoperative planning, and aid in more complete surgery with improved outcomes. OBJECTIVES Provide a clinical update regarding the use of image guidance and intraoperative imaging in the field of rhinology and endoscopic skull base surgery with a focus on current state of the art technologies. METHODS English-language studies published in PubMed, Cochrane, and Embase were searched for articles relating to image-guided sinus surgery, skull base surgery, and intraoperative imaging. Relevant studies were reviewed and critical appraisals were included in this clinical update, highlighting current state of the art advances. CONCLUSIONS As image guidance and intraoperative imaging systems have advanced, their applications in sinus and skull base surgery have expanded. Both technologies offer invaluable real-time feedback on the status and progress of surgery, and thus may help to improve the completeness of surgery and overall outcomes. Recent advances such as augmented and virtual reality offer a window into the future of IGS. Future advancements should aim to enhance the surgeon's operative experience by improving user satisfaction and ultimately lead to better surgical results.
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Affiliation(s)
- Isaac L Schmale
- Department of Otorhinolaryngology-Head & Neck Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, TX, USA
| | - Laura J Vandelaar
- Department of Otorhinolaryngology-Head & Neck Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, TX, USA
| | - Amber U Luong
- Department of Otorhinolaryngology-Head & Neck Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, TX, USA
| | - Martin J Citardi
- Department of Otorhinolaryngology-Head & Neck Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, TX, USA
| | - William C Yao
- Department of Otorhinolaryngology-Head & Neck Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, TX, USA
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