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Honavalli Murali S, Nair P, Hariharan Venkat E. Endoscopic Endonasal Transsphenoidal Transcavernous Transoculomotor Triangle Approach for Resection of an Invasive Pituitary Adenoma Extending Into the Parapeduncular Space Through the Cavernous Sinus. Oper Neurosurg (Hagerstown) 2024; 27:233-238. [PMID: 38329366 DOI: 10.1227/ons.0000000000001080] [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: 08/20/2023] [Accepted: 12/19/2023] [Indexed: 02/09/2024] Open
Abstract
BACKGROUND AND IMPORTANCE A subset of invasive pituitary adenomas invade not only the medial wall of the cavernous sinus but can progress superiorly through the cavernous sinus roof at the oculomotor triangle and reach the subarachnoid parapeduncular space. We describe a series of 2 of 3 cases where an endoscopic endonasal approach was used to reach the parapeduncular space through the oculomotor triangle for tumor decompression. Images of the third case are presented. CLINICAL PRESENTATION Case 1: We present a 2-dimensional surgical video of a recurrent corticotroph adenoma post gamma knife radiotherapy which was invading the left cavernous sinus and extending into the left parapeduncular space. Histopathological examination revealed densely granulated corticotrophin adenoma. The patient had reduction in the serum cortisol level postoperatively and was induced into remission medically. Postoperative third nerve palsy recovered partially, and sixth nerve palsy recovered completely at the 3-month follow-up. Case 2 : A case of recurrent silent corticotrophin adenoma invading the right parapeduncular space through the right cavernous sinus was operated through the same approach as case 1. Only a subtotal excision of the tumor in the cisternal space was possible. The patient developed a complete right third cranial palsy in the immediate postoperative period with near total recovery at the 6-month follow-up. CONCLUSION Endoscopic endonasal approach to the parapeduncular space through a transcavernous transoculomotor route is reasonably safe and effective, as long as key anatomic landmarks and structures are identified and preserved while using natural tumor corridors to achieve tumor clearance.
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Affiliation(s)
- Sanjay Honavalli Murali
- Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore , India
| | - Prakash Nair
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum , India
| | - Easwer Hariharan Venkat
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum , India
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Tang OY, Chen JS, Monje S, Kumarapuram S, Eloy JA, Liu JK. Comparison of Surgical Modalities for Giant Pituitary Adenoma: A Systematic Review and Meta-Analysis of 1413 Patients. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01238. [PMID: 38967434 DOI: 10.1227/ons.0000000000001238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 04/22/2024] [Indexed: 07/06/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Giant pituitary adenomas (GPAs) are a challenging clinical entity, composing 5% to 15% of all pituitary adenomas. While the endoscopic endonasal transsphenoidal (EET) approach has surpassed the microsurgical transsphenoidal (MT) and transcranial (TC) approaches as the first-line surgical modality in most institutions, a systematic review comparing the 3 approaches has not been undertaken since 2012. Given growing adoption of EET and development of novel operative techniques over the past decade, an updated comparison of GPA surgical modalities is warranted. METHODS We identified all studies related to the surgical management of GPAs in PubMed, Embase, and Web of Science from inception to December 31, 2021. End points assessed included gross total resection (GTR) rates, postoperative visual improvement, mortality, and perioperative complications. RESULTS After screening of 1701 studies, we identified 45 studies on the surgical management of GPAs for meta-analysis. Thirty-one used the EET approach (n = 1413), 11 studies used the MT approach (n = 601), and 10 used the TC approach (n = 416). The cumulative number of patients treated by EET did not exceed that of patients treated by the TC or MT approaches until 2014 and 2015, respectively. Despite patients undergoing EET having the highest average tumor diameter, pooled rates for GTR were significantly higher for EET (42%) than MT (33%, P < .001) and TC (8%, P < .001) and EET similarly exhibited superior rates of visual improvement (85%) than MT (73%, P < .001) and TC (56%, P < .001). Mortality rates were comparable between EET (0.6%) and MT (1.6%), but EET had significantly lower mortality than TC (2.7%, P < .001). Compared with MT, EET had lower rates of hypopituitarism (8.5% vs 14.9%, P = .012) but higher rates of diabetes insipidus (3.1% vs 0.5%, P = .001). CONCLUSION In an updated meta-analysis of 1413 patients with GPA, EET resection conferred significantly higher rates of visual improvement and GTR, when compared with the MT and TC approaches.
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Affiliation(s)
- Oliver Y Tang
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Jia-Shu Chen
- Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Silas Monje
- Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Siddhant Kumarapuram
- Department of Neurosurgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Jean Anderson Eloy
- Department of Neurosurgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
- Department of Otolaryngology and Facial Plastic Surgery, Cooperman Barnabas Medical Center, RWJ Barnabas Health, Livingston, New Jersey, USA
- Department of Neurosurgery, Cooperman Barnabas Medical Center, RWJ Barnabas Health, Livingston, New Jersey, USA
| | - James K Liu
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
- Department of Otolaryngology and Facial Plastic Surgery, Cooperman Barnabas Medical Center, RWJ Barnabas Health, Livingston, New Jersey, USA
- Department of Neurosurgery, Cooperman Barnabas Medical Center, RWJ Barnabas Health, Livingston, New Jersey, USA
- Department of Neurosurgery, Skull Base Institute of New Jersey, Neurosurgeons of New Jersey, NYU Langone Neurosurgery Network, Livingston, New Jersey, USA
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Sahoo SK, Bethanbhatla MK, Dhandapani S. Suturing and Closure of Diaphragma Sella to Augment Sellar Floor Repair after Endonasal Endoscopic Resection of Large Pituitary Adenoma. Asian J Neurosurg 2024; 19:334-337. [PMID: 38974444 PMCID: PMC11226271 DOI: 10.1055/s-0044-1787088] [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] [Indexed: 07/09/2024] Open
Abstract
Background Large pituitary adenoma often pushes the diaphragma sella and extends to the suprasellar compartment. The thinned out diaphragma may get opened during endonasal endoscopic surgery and pose high risk for cerebrospinal fluid (CSF) leak. Such larger defects are difficult to plug with fat graft that tends to slip in to the subarachnoid space. Here, we describe a unique technique of closure of diaphragma sella that augment repair of the skull base in such cases. Materials and Method The free edge of diaphragma sella was sutured with the anterior tuberculum sella dura in five cases of large pituitary adenoma that needed extra arachnoidal resection. Suturing was done with 6-0 prolene using endoscopic needle holder that converted a large diaphragm defect in to a smaller arachnoid rent and was easily plugged with fat graft. Result None of these patients had postoperative CSF leak. Conclusion Though technically difficult, direct repair of the diaphragma sella is possible. This augments the skull base reconstruct and effectively reduces the chances of postoperative CSF leak.
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Affiliation(s)
- Sushanta K. Sahoo
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Murali K. Bethanbhatla
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sivashanmugam Dhandapani
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Mortini P, Albano L, Barzaghi LR, Spina A, Losa M. The open sella technique for surgical treatment of pituitary macroadenomas: Safety and efficacy in a large clinical series. Br J Neurosurg 2024; 38:674-681. [PMID: 34269154 DOI: 10.1080/02688697.2021.1950629] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 03/12/2021] [Accepted: 06/28/2021] [Indexed: 01/12/2023]
Abstract
PURPOSE To analyse the efficacy and safety of the transsphenoidal microsurgical approach with open sella technique (OST) for the treatment of pituitary adenoma (PA) with suprasellar extension. METHODS We retrospectively reviewed 2305 consecutive patients with PA who underwent their first surgery through the transsphenoidal microsurgical approach at our department between 1990 and 2018. Focusing on tumours with suprasellar extension, in particular, grade B, C and D adenomas according to Wilson-Hardy's classification, 376 patients who received the OST surgery were identified. Outcomes and complications were evaluated and compared with those obtained in patients who underwent a standard transsphenoidal approach (TSM). RESULTS Two-hundred and sixty-four of 376 patients (70.2%) were found to be suffering from a non-functioning pituitary adenoma, whereas 112 of 376 patients (29.8%) from a hormone-secreting PA. The mean craniocaudal diameter of the tumor was 30.6 ± 0.3 mm (range, 21-75 mm) and 151 patients (40.1%) had a cavernous sinus invasion too. An overall surgical remission rate of 50.3% was achieved in the OST group, whereas the recurrence rate was 10.5%. Patients were followed for a mean period of 68 ± 1.4 months (range, 6-96 months). Less postoperative intrasellar haemorrhages have been recorded in the OST group than the TSM one (1.1% vs. 4.6%, p = 0.02). CONCLUSIONS In experienced hands, OST represents an effective and safe treatment strategy for PA with suprasellar extension.
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Affiliation(s)
- Pietro Mortini
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Luigi Albano
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
- Neuroimaging Research Unit, Institute of Experimental Neurology, Division of Neuroscience, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Lina Raffaella Barzaghi
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Alfio Spina
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Marco Losa
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
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Pascual-Corrales E, Acitores Cancela A, Baonza G, Madrid Egusquiza I, Rodríguez Berrocal V, Araujo-Castro M. Clinical presentation and surgical outcomes of very large and giant pituitary adenomas: 80 cases in a cohort study of 306 patients with pituitary adenomas. Acta Neurochir (Wien) 2024; 166:225. [PMID: 38772927 DOI: 10.1007/s00701-024-06107-w] [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: 02/23/2024] [Accepted: 04/28/2024] [Indexed: 05/23/2024]
Abstract
PURPOSE To identify differences in the presentation and surgical outcomes between very large (30-39 mm) and giant (≥ 40 mm) (LARGE group) pituitary adenomas (PAs) compared to the smaller group (< 30 mm) (non-LARGE group). METHODS Eighty patients with very large (n = 44) or giant (n = 36) PAs and 226 patients in the non-LARGE group who underwent tumor resection by pituitary surgery between 2008 and 2023 were studied. Hormonal, radiological, ophthalmological, and pathological data, and surgical outcomes were evaluated. RESULTS Preoperatively, patients of the LARGE group presented more frequently with visual impairment (82.5% vs. 22.1%, P < 0.001) and with pituitary apoplexy (15.0% vs. 2.7%, P < 0.001) than the non-LARGE group. Moreover, the LARGE group were more commonly associated with preoperative panhypopituitarism (28.8% vs. 6.2%, P < 0.001). This group presented cavernous sinus invasion more frequently (71.3% vs. 23.9%, P < 0.001). The non-LARGE group achieved surgical cure more often than the LARGE group (79.7% vs. 50.0%, P < 0.001), and the rate of major complications was higher in the latest (8.8% vs. 1.3%, P < 0.004). CONCLUSIONS PAs ≥ 30 mm are most frequently accompanied by hormonal dysfunction, cavernous sinus invasion, and visual impairment. All this implies lower resection rates and higher postoperative complications than the smaller adenomas, posing a real surgical challenge.
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Affiliation(s)
- Eider Pascual-Corrales
- Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, Instituto de Investigación Biomédica Ramón y Cajal (IRYCIS), Colmenar Viejo Street Km 9. PC: 28034, Madrid, Spain.
| | - Alberto Acitores Cancela
- Department of Neurosurgery, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Department of Neurosurgery, Hospital Universitario HM Puerta del Sur, Madrid, Spain
| | - Gonzalo Baonza
- Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, Instituto de Investigación Biomédica Ramón y Cajal (IRYCIS), Colmenar Viejo Street Km 9. PC: 28034, Madrid, Spain
| | - Imanol Madrid Egusquiza
- Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, Instituto de Investigación Biomédica Ramón y Cajal (IRYCIS), Colmenar Viejo Street Km 9. PC: 28034, Madrid, Spain
| | - Víctor Rodríguez Berrocal
- Department of Neurosurgery, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Department of Neurosurgery, Hospital Universitario HM Puerta del Sur, Madrid, Spain
| | - Marta Araujo-Castro
- Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, Instituto de Investigación Biomédica Ramón y Cajal (IRYCIS), Colmenar Viejo Street Km 9. PC: 28034, Madrid, Spain.
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Deng S, Morisako H, Beniwal M, Sasaki T, Ikegami M, Ikeda S, Teranishi Y, Goto T. Usefulness of Opening the Diaphragma Sellae Before Transecting Interclinoidal Ligament for Endoscopic Endonasal Transoculomotor Triangle Approach: Technical Nuances and Surgical Outcomes. World Neurosurg 2024; 185:e731-e740. [PMID: 38428812 DOI: 10.1016/j.wneu.2024.02.120] [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: 12/29/2023] [Revised: 02/20/2024] [Accepted: 02/21/2024] [Indexed: 03/03/2024]
Abstract
OBJECTIVE Opening the oculomotor triangle (OT) and removing the posterior fossa lesion by endoscopic endonasal approach (EEA) is challenging for even an experienced endoscopic neurosurgeon. We summarize the treatment experience and technical nuances with EEA for resection of pituitary neuroendocrine tumors and cavernous sinus (CS) meningiomas invading through the OT. METHODS Between 2018 and 2022, 8 patients, comprising 5 with pituitary neuroendocrine tumors (3 with nonfunctioning and 2 with somatotroph tumors with increased levels of growth hormone) and 3 CS meningiomas, were treated using an endoscopic endonasal transoculomotor triangle approach. The critical surgical technique is continuously opening the diaphragma sellae from medial to lateral toward the interclinoidal ligament and transecting it to enlarge the OT. We evaluated preoperative tumor size, previous surgical history, preoperative symptoms, extent of tumor resection, histopathology, and postoperative complications for all patients. RESULTS The gross total resection (defined as complete removal) in 3 patients (38%), near-total resection (defined as >95% removal) in 4 patients (50%), and subtotal resection (defined as ≤90% removal) in 1 patient (12%) and gross total resection of tumor invading through the OT was achieved in all patients through pure EEA. Two of 3 patients with visual deficits in nonfunctioning pituitary neuroendocrine tumors improved, and the other remained stable postoperatively. One patient showed transient oculomotor nerve palsy. The growth hormone level of the 2 patients with somatotroph tumors declined to normal. For 3 patients with CS meningiomas, cranial nerve palsy improved in 2 patients, whereas the other patient developed increased facial numbness after surgery. CONCLUSIONS The endoscopic endonasal transoculomotor triangle approach is an efficient surgical option for tumors with CS invasion and OT penetration.
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Affiliation(s)
- Shengze Deng
- Department of Neurosurgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan; Department of Neurosurgery, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China
| | - Hiroki Morisako
- Department of Neurosurgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan.
| | - Manish Beniwal
- Department of Neurosurgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan; Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, India
| | - Tsuyoshi Sasaki
- Department of Neurosurgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Masaki Ikegami
- Department of Neurosurgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Shohei Ikeda
- Department of Neurosurgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Yuichi Teranishi
- Department of Otolaryngology and Head and Neck Surgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Takeo Goto
- Department of Neurosurgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
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Nakase K, Nishimura F, Yokoyama S, Kakutani M, Kim T, Matsuda R, Takeshima Y, Yamada S, Park YS, Nakagawa I. Management Approaches and Patient Outcomes for Giant Pituitary Neuroendocrine Tumors Classified as Knosp Grade 3 and 4. Cureus 2024; 16:e57498. [PMID: 38707178 PMCID: PMC11066726 DOI: 10.7759/cureus.57498] [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] [Accepted: 04/02/2024] [Indexed: 05/07/2024] Open
Abstract
Background Treatment of patients with a giant pituitary neuroendocrine tumor (GPitNET) is challenging. Here, we present the methods used for the clinical management of patients who underwent GPitNET resection mainly via endoscopic endonasal surgery along with multimodal support to avoid surgical complications, which can affect the outcomes. Methodology The medical records of 25 patients with a GPitNET who underwent endonasal endoscopic surgery were retrospectively reviewed. Complications were analyzed and factors affecting the extent of resection were evaluated. Results Gross total resection was achieved in six (24%), near-total resection (>90%) in nine (36%), and partial resection in 10 (40%) patients. Multivariate analyses revealed that tumors invading the middle fossa had negative effects on the extent of resection (odds ratio = 0.092, p = 0.047). Postoperative vision improved or normalized in 16 (64%), remained stable in eight (32%), and worsened in one (4%), while a new hormonal deficit was noted in seven (28%) patients. Complications included permanent oculomotor nerve palsy in one (4%) and transient oculomotor palsy in one (4%), apoplexy of the residual tumor resulting in ischemic stroke in one (4%), postoperative cerebrospinal fluid leakage in one (4%), and permanent diabetes insipidus in six (24%) patients. Conclusions For GPitNETs that extend into the middle fossa, our study underscored the difficulties in surgical extraction and the necessity for tailored treatment approaches. To ensure the safest and most complete removal possible, the surgical strategy must be specifically adapted to each case. Additionally, employing a comprehensive support approach is essential to reduce the chance of complications in patients impacted by this condition.
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Affiliation(s)
- Kenta Nakase
- Department of Neurosurgery, Nara Medical University, Kashihara, JPN
| | | | - Shohei Yokoyama
- Department of Neurosurgery, Nara Medical University, Kashihara, JPN
| | - Miho Kakutani
- Department of Neurosurgery, Nara Medical University, Kashihara, JPN
| | - Taekyun Kim
- Department of Neurosurgery, Nara Medical University, Kashihara, JPN
| | - Ryosuke Matsuda
- Department of Neurosurgery, Nara Medical University, Kashihara, JPN
| | | | - Shuichi Yamada
- Department of Neurosurgery, Nara Medical University, Kashihara, JPN
| | - Young-Soo Park
- Department of Neurosurgery, Nara Medical University, Kashihara, JPN
| | - Ichiro Nakagawa
- Department of Neurosurgery, Nara Medical University, Kashihara, JPN
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Eguiluz-Melendez A, Sangrador-Deitos MV, Calderón-Yrigoyen PJ, Rodríguez-Hernández AL, Guinto-Nishimura YG, Alcazar-Felix JR, Caballero-Delgado S, Portocarrero-Ortiz AL, Valencia-Ramos C, Gómez-Amador LJ. Clinical and Surgical Outcomes of Endoscopic Endonasal Approach for Giant Pituitary Adenomas: Analysis of Predictive Factors. World Neurosurg 2024; 184:e659-e673. [PMID: 38342172 DOI: 10.1016/j.wneu.2024.02.009] [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: 12/27/2023] [Revised: 02/01/2024] [Accepted: 02/02/2024] [Indexed: 02/13/2024]
Abstract
BACKGROUND Giant pituitary adenomas (GPAs) are defined as tumors with ≥40 mm in any maximum diameter, and these tend to invade multiple intracranial compartments. Hence, treatment remains a surgical challenge. OBJECTIVE To describe the clinical and surgical outcomes of the endoscopic endonasal approach (EEA) for GPA in a pituitary referral center in Latin America and to analyze associated predictive factors. METHODS 37 patients with histologically-confirmed GPA treated solely through the EEA between a 2-year period were included. Preoperative and postoperative clinical and neuroimaging findings; surgical morbidity and mortality; and binary logistic regression analysis to assess predictive factors were analyzed. RESULTS Preoperative visual impairment prevalence was 97.3%. Mean tumor volume was 32 cc and gross total resection rate was 40.5%. Favorable visual acuity and visual fields outcome rate was 75% and 82.9%, respectively. In the multivariate analysis, bilateral cavernous sinus invasion (P = 0.018) and postoperative cerebrospinal fluid (CSF) leak (P = 0.036) were associated with an unfavorable visual acuity outcome, while radiation therapy (P = 0.035) was for visual fields. Similarly, intraoperative CSF leak was a predictive factor for postoperative CSF leak (10.8%) (P = 0.042) and vascular injury (13.5%) (P = 0.048). CONCLUSIONS In this first Mexican clinical series, we demonstrated that the EEA is a safe and effective technique for GPA, although early diagnosis and prompt intervention may promote further visual function preservation without significant endocrine morbidity.
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Affiliation(s)
- Aldo Eguiluz-Melendez
- Department of Neurological Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico; Department of Neurological Surgery, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico
| | | | - P Juan Calderón-Yrigoyen
- Department of Neurological Surgery, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico
| | - A Luis Rodríguez-Hernández
- Department of Neurological Surgery, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico
| | - Y Gerardo Guinto-Nishimura
- Department of Neurological Surgery, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico
| | | | - Silvia Caballero-Delgado
- Department of Neurological Surgery, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico
| | - A Lesly Portocarrero-Ortiz
- Department of Neuroendocrinology, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico
| | - Cristopher Valencia-Ramos
- Department of Neurological Surgery, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico
| | - L Juan Gómez-Amador
- Department of Neurological Surgery, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico
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Jotanovic J, Tebani A, Hekmati N, Sivertsson Å, Lindskog C, Uhlèn M, Gudjonsson O, Tsatsaris E, Engström BE, Wikström J, Pontén F, Casar-Borota O. Transcriptome Analysis Reveals Distinct Patterns Between the Invasive and Noninvasive Pituitary Neuroendocrine Tumors. J Endocr Soc 2024; 8:bvae040. [PMID: 38505563 PMCID: PMC10949357 DOI: 10.1210/jendso/bvae040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Indexed: 03/21/2024] Open
Abstract
Although most pituitary neuroendocrine tumors (PitNETs)/pituitary adenomas remain intrasellar, a significant proportion of tumors show parasellar invasive growth and 6% to 8% infiltrate the bone structures, thus affecting the prognosis. There is an unmet need to identify novel markers that can predict the parasellar growth of PitNETs. Furthermore, mechanisms that regulate bone invasiveness of PitNETs and factors related to tumor vascularization are largely unknown. We used genome-wide mRNA analysis in a cohort of 77 patients with PitNETs of different types to explore the differences in gene expression patterns between invasive and noninvasive tumors with respect to the parasellar growth and regarding the rare phenomenon of bone invasiveness. Additionally, we studied the genes correlated to the contrast enhancement quotient, a novel radiological parameter of tumor vascularization. Most of the genes differentially expressed related to the parasellar growth were genes involved in tumor invasiveness. Differentially expressed genes associated with bone invasiveness are involved in NF-κB pathway and antitumoral immune response. Lack of clear clustering regarding the parasellar and bone invasiveness may be explained by the influence of the cell lineage-related genes in this heterogeneous cohort of PitNETs. Our transcriptomics analysis revealed differences in the molecular fingerprints between invasive, including bone invasive, and noninvasive PitNETs, although without clear clustering. The contrast enhancement quotient emerged as a radiological parameter of tumor vascularization, correlating with several angiogenesis-related genes. Several of the top genes related to the PitNET invasiveness and vascularization have potential prognostic and therapeutic application requiring further research.
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Affiliation(s)
- Jelena Jotanovic
- Department of Immunology, Genetics and Pathology, Rudbeck Laboratory, Uppsala University, 75185 Uppsala, Sweden
- Department of Clinical Pathology, Uppsala University Hospital, 75185 Uppsala, Sweden
| | - Abdellah Tebani
- Science for Life Laboratory, Department of Protein Science, KTH-Royal Institute of Technology, 17121 Solna, Stockholm, Sweden
- Department of Metabolic Biochemistry, UNIROUEN, INSERM U1245, CHU Rouen, Normandie University, 76000 Rouen, France
| | - Neda Hekmati
- Department of Immunology, Genetics and Pathology, Rudbeck Laboratory, Uppsala University, 75185 Uppsala, Sweden
| | - Åsa Sivertsson
- Science for Life Laboratory, Department of Protein Science, KTH-Royal Institute of Technology, 17121 Solna, Stockholm, Sweden
| | - Cecilia Lindskog
- Department of Immunology, Genetics and Pathology, Rudbeck Laboratory, Uppsala University, 75185 Uppsala, Sweden
| | - Mathias Uhlèn
- Science for Life Laboratory, Department of Protein Science, KTH-Royal Institute of Technology, 17121 Solna, Stockholm, Sweden
| | - Olafur Gudjonsson
- Department of Neuroscience, Uppsala University, 75185 Uppsala, Sweden
| | - Erika Tsatsaris
- Endocrinology and Mineral Metabolism, Department of Medical Sciences, Uppsala University, 75185 Uppsala, Sweden
| | - Britt Edén Engström
- Endocrinology and Mineral Metabolism, Department of Medical Sciences, Uppsala University, 75185 Uppsala, Sweden
| | - Johan Wikström
- Neuroradiology, Department of Surgical Sciences, Uppsala University, 75185 Uppsala, Sweden
| | - Fredrik Pontén
- Department of Immunology, Genetics and Pathology, Rudbeck Laboratory, Uppsala University, 75185 Uppsala, Sweden
| | - Olivera Casar-Borota
- Department of Immunology, Genetics and Pathology, Rudbeck Laboratory, Uppsala University, 75185 Uppsala, Sweden
- Department of Clinical Pathology, Uppsala University Hospital, 75185 Uppsala, Sweden
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Goel A. Letter to the editor - pituitary tumors and diaphragma sellaeRe: Sharifi G, Akbari Dilmaghani N, Sadrhosseini SM, Arastou S. Arachnoid prolapse in endoscopic transsphenoidal surgery of pituitary adenoma, technical note. Br J Neurosurg 2023;37(3):258-64. Br J Neurosurg 2024; 38:149. [PMID: 37885417 DOI: 10.1080/02688697.2023.2273854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 10/17/2023] [Indexed: 10/28/2023]
Affiliation(s)
- Atul Goel
- Department of Neurosurgery, Lilavati Hospital and Research Center, Bandra, Mumbai, India
- Department of Neurosurgery, R.N Cooper Hospital and Medical College, Mumbai, India
- Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, Mumbai, India
- K.J. Somaiya Medical College and Hospital, Mumbai, India
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11
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Joshi KC, Kolb B, Khalili BF, Munich SA, Byrne RW. Surgical Strategies in the Treatment of Giant Pituitary Adenomas. Oper Neurosurg (Hagerstown) 2024; 26:4-15. [PMID: 37655871 DOI: 10.1227/ons.0000000000000896] [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: 04/17/2023] [Accepted: 07/12/2023] [Indexed: 09/02/2023] Open
Abstract
BACKGROUND AND OBJECTIVES The management of giant pituitary adenomas (GPAs) is challenging due to associated endocrinopathies and the close proximity of these tumors to critical structures, such as the optic nerves, structures of the cavernous sinus, and hypothalamus. The objective of this review article was to summarize the current management strategies for giant pituitary adenomas, including the role of open and endoscopic surgical approaches and the role of medical and radiation therapy in conjunction with surgery. METHODS We conducted a retrospective review of GPAs operated at our institute between January 2010 and March 2023. Surgical approaches, extent of resection, and associated complications were documented. Furthermore, we conducted a thorough literature review to identify relevant studies published in the past decade, which were incorporated along with insights gained from our institutional case series of GPAs to analyze and integrate both the existing knowledge base and our institution's firsthand experience in the management of GPAs. RESULTS A total of 46 giant pituitary adenomas (GPAs) were operated on, using various surgical approaches. Transsphenoidal approach was used in 25 cases and a staged approach using transsphenoidal and pterional was used in 15 cases. Other approaches included transcortical-transventricular, transcallosal, pterional/orbitozygomatic, and subfrontal approaches. Complications and technical nuances were reported. CONCLUSION The management of giant pituitary adenomas remains complex, often involving several modalities-open or endoscopic resection, radiosurgery, and medical management of both the tumor and associated endocrinopathies. Surgical resections are often challenging procedures that require careful consideration of several factors, including patient characteristics, tumor location, and size, and the experience and skill of the surgical team.
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Affiliation(s)
- Krishna C Joshi
- Department of Neurosurgery, Rush University Medical Center, Chicago , Illinois , USA
| | - Bradley Kolb
- Department of Neurosurgery, Rush University Medical Center, Chicago , Illinois , USA
| | | | - Stephan A Munich
- Department of Neurosurgery, Rush University Medical Center, Chicago , Illinois , USA
| | - Richard W Byrne
- Department of Neurosurgery, Rush University Medical Center, Chicago , Illinois , USA
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Sarkar S, Corrales CE, Laws ER, Smith TR. Morphological Classification of Pituitary Tumors With Suprasellar Extension. Neurosurgery 2023:00006123-990000000-00981. [PMID: 38047633 DOI: 10.1227/neu.0000000000002786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 10/13/2023] [Indexed: 12/05/2023] Open
Abstract
BACKGROUND AND OBJECTIVES The objective of this study was to study the association among various morphological parameters and surgical outcomes in pituitary macroadenomas with suprasellar extension. METHODS MRI studies of 160 patients undergoing endoscopic transsphenoidal resection of pituitary macroadenomas with suprasellar extension were reviewed. In the coronal plane, tumors were classified into Type 1 (dome-shaped, no constriction at the level of diaphragma sellae) and Type 2 (dumbbell-shaped, with constriction at the level of diaphragma sellae). Based on the dome-to-neck ratio (D/Nr), Type 2 tumors were further classified as Type 2A (wide neck; D/Nr >1 and <1.3) and Type 2B (narrow neck; D/Nr ≥1.3). Surgical outcomes and complications were analyzed using a logistic regression model. Overall extent of resection (EOR) and presence of residual sellar-suprasellar tumor was separately assessed in all patients with available postoperative MRI (n = 149). RESULTS There were 108 Type 1 tumors and 26 patients each in the Type 2A and Type 2B subgroups. Tumor subtype was significantly associated with tumor size (P < .001), intraoperative cerebrospinal fluid leak (P < .001), EOR (P < .001), postoperative suprasellar residual tumor (P < .001), and postoperative complications, including diabetes insipidus (P = .005) and visual worsening (P = .003). On multivariate analysis, after adjusting for confounders, Type 2B tumors were negatively associated with EOR (odds ratio [OR] 0.22; 95% CI 0.07-0.68; P = .008) and associated with the presence of postoperative suprasellar residual tumor (OR 18.08; 95% CI 5.20-62.89; P < .001), intraoperative cerebrospinal fluid leak (OR 5.33; 95% CI 1.89-14.99; P = .002), and postoperative diabetes insipidus (OR 4.89; 95% CI 1.67-14.35; P < .001). CONCLUSION Preoperative tumor classification based on D/Nr is clinically and surgically relevant, and Type 2B macroadenomas are significantly associated with lower rates of gross total resection and higher rates of postoperative complications after endoscopic transsphenoidal resection.
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Affiliation(s)
- Sauradeep Sarkar
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Computatonal Neuroscience Outcomes Center, Harvard Medical School, Boston, Massachusetts, USA
| | - C Eduardo Corrales
- Department of Otolaryngology, Head and Neck Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Edward R Laws
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Timothy R Smith
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Computatonal Neuroscience Outcomes Center, Harvard Medical School, Boston, Massachusetts, USA
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13
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Serioli S, Plou P, Leonel LCPC, Graepel S, Buffoli B, Rezzani R, Fontanella MM, Poliani PL, Doglietto F, Link MJ, Pinheiro-Neto CD, Peris-Celda M. The "candy wrapper" of the pituitary gland: a road map to the parasellar ligaments and the medial wall of the cavernous sinus. Acta Neurochir (Wien) 2023; 165:3431-3444. [PMID: 37594638 DOI: 10.1007/s00701-023-05736-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 07/24/2023] [Indexed: 08/19/2023]
Abstract
PURPOSE The anatomy of the medial wall of the cavernous sinus (MWCS) and parasellar ligaments (PLs) has acquired increasing importance in endoscopic endonasal (EE) surgery of the cavernous sinus (CS), including resection of the MWCS in functioning pituitary adenomas (FPAs). Although anatomical studies have been published, it represents a debated topic due to their complex morphology. The aim is to offer a description of the PLs that originate from the MWCS and reach the lateral wall of the cavernous sinus (LWCS), proposing the "candy wrapper" model. The relationships between the neurovascular structures and histomorphological aspects were investigated. METHODS Forty-two CSs from twenty-one human heads were studied. Eleven specimens were used for EE dissection; five underwent a microscopic dissection. Five specimens were used for histomorphological analysis. RESULTS Two groups of PLs with a fan-shaped appearance were encountered. The anterior group included the periosteal ligament (55% sides) and the carotico-clinoid complex (100% sides), formed by the anterior horizontal and the carotico-clinoid ligaments. The posterior group was formed by the posterior horizontal (78% sides), and the inferior hypophyseal ligament (34% sides). The periosteal ligament originated inferiorly from the MWCS, reaching the periosteal dura. The anterior horizontal ligament was divided in a superior and inferior branch. The superior one continued as the carotid-oculomotor membrane, and the inferior branch reached the CN VI. The carotico-clinoid ligament between the middle and anterior clinoid was ossified in 3 sides. The posterior horizontal ligament was related to the posterior genu and ended at the LWCS. The inferior hypophyseal ligament followed the homonym artery. The ligaments related to the ICA form part of the adventitia. CONCLUSION The "candy wrapper" model adds further details to the previous descriptions of the PLs. Understanding this complex anatomy is essential for safe CS surgery, including MWCS resection for FPAs.
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Affiliation(s)
- Simona Serioli
- Division of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, MN, USA
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Pedro Plou
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, MN, USA
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
- Neurosurgery Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Luciano C P C Leonel
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, MN, USA
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Stephen Graepel
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Barbara Buffoli
- Section of Anatomy and Physiopathology, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Rita Rezzani
- Section of Anatomy and Physiopathology, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Marco Maria Fontanella
- Division of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Pietro Luigi Poliani
- Vita-Salute San Raffaele University and Pathology Unit, IRCCS San Raffaele, Milan, Italy
| | - Francesco Doglietto
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Catholic University School of Medicine, Rome, Italy
| | - Michael J Link
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
- Department of Otolaryngology/Head and Neck Surgery, Mayo Clinic, Rochester, MN, USA
| | - Carlos D Pinheiro-Neto
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
- Department of Otolaryngology/Head and Neck Surgery, Mayo Clinic, Rochester, MN, USA
| | - Maria Peris-Celda
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, MN, USA.
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA.
- Department of Otolaryngology/Head and Neck Surgery, Mayo Clinic, Rochester, MN, USA.
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Bove I, Solari D. Endoscopic endonasal pituitary surgery: How we do it. Consensus statement on behalf of the EANS skull base section. BRAIN & SPINE 2023; 3:102687. [PMID: 38021006 PMCID: PMC10668107 DOI: 10.1016/j.bas.2023.102687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 09/25/2023] [Accepted: 10/04/2023] [Indexed: 12/01/2023]
Abstract
Introduction and research question The use of an endoscope in skull base surgery provides a panoramic close-up view over the intracranial structures from multiple angles with excellent illumination, thus permitting greater extent of resection of tumors arising at sellar area, mostly represented by PitNet - Pituitary neuroendocrine tumors, with higher likelihood of preserving vital/intact gland tissue. For this refined specialty of neurosurgery, unique skills need to be acquired along a steep learning curve. Material and methods EANS (European Association of Neurosurgical Societies) skull base section panelists were enrolled and 11 completed the survey: the goal was to provide a consensus statement of the endoscopic endonasal approach for pituitary adenoma surgery. Results The survey consisted of 44 questions covering demographics data (i.e., academic/non-academic center, case load, years of experience), surgical techniques (i.e., use of neuronavigation, preoperative imaging), and follow-up management. Discussion and conclusions In this paper we identified a series of tips and tricks at different phases of an endoscopic endonasal pituitary surgery procedure to underline the crucial steps to perform successful surgery and reduce complications: we took in consideration the principles of the surgical technique, the knowledge of the anatomy and its variations, and finally the importance of adjoining specialties experts.
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Affiliation(s)
- Ilaria Bove
- Department of Neurosurgery, University of Naples Federico II, Naples, Italy
| | - Domenico Solari
- Department of Neurosurgery, University of Naples Federico II, Naples, Italy
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Wu X, Liang L, Wu BW, Xie SH, Wu J, Wan XC, Din H, Zhan J, Xiao LM, Tang B, Hong T. Pituitary adenoma with oculomotor cistern extension: membranous anatomy and clinical application. Acta Neurochir (Wien) 2023; 165:2985-2993. [PMID: 37672094 DOI: 10.1007/s00701-023-05784-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 08/25/2023] [Indexed: 09/07/2023]
Abstract
BACKGROUND The anatomical basis of pituitary adenomas (PAs) with oculomotor cistern (OC) extension as a growth corridor is overlooked in the literature. In this paper, the authors use the technique of epoxy sheet plastination to study the membranous structure of the OC and validate the results by retrospective analysis of patients with OC extension. METHODS Eighteen specimens were used to study the membranous anatomy surrounding the OC using the epoxy sheet plastination technique. Thirty-four patients with OC extension were retrospectively reviewed. RESULTS The OC consisted of two thin membranous layers. The inner layer was extended by the arachnoid layer from the posterior fossa, and the lateral layer consisted of the dura mater sinking from the roof of the cavernous sinus. The oculomotor nerve is more likely to displace with a superolateral trajectory due to the weakness of the posterior dura and the relatively large space in the medial and posterior trajectories, which is consistent with the intraoperative observations. Among the anatomical factors that affect the PA by OC extension, we found that the relative position of the internal carotid artery (ICA) and posterior clinoid process may lead to the narrowing of the OC. Of 34 cases, 28 patients achieved total resection. Among 24 preoperative patients with oculomotor nerve palsy, 16 cases were relieved to varying degrees postoperatively. There was no ICA injury or severe intracranial infection found in any of the patients. CONCLUSIONS Extension into the OC is influenced by two anatomical factors: a weak point in the dura in the posterior OC and a potential space beyond this region of the dura. Meticulous knowledge of the membranous anatomy in endoscopic endonasal surgery is required to safely and effectively resect PA with OC extension.
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Affiliation(s)
- Xiao Wu
- Department of Neurosurgery, the First Affiliated Hospital of Nanchang University, 17 Yong Wai Zheng Street, Nanchang, China
| | - Liang Liang
- Department of Anatomy, Anhui Medical University, NO. 81, Meishan Road, Shushan District, Hefei, Anhui, China
| | - Bo Wen Wu
- Department of Neurosurgery, the First Affiliated Hospital of Nanchang University, 17 Yong Wai Zheng Street, Nanchang, China
| | - Shen Hao Xie
- Department of Neurosurgery, the First Affiliated Hospital of Nanchang University, 17 Yong Wai Zheng Street, Nanchang, China
| | - Jie Wu
- Department of Neurosurgery, the First Affiliated Hospital of Nanchang University, 17 Yong Wai Zheng Street, Nanchang, China
| | - Xi Chen Wan
- Department of Neurosurgery, the First Affiliated Hospital of Nanchang University, 17 Yong Wai Zheng Street, Nanchang, China
| | - Han Din
- Department of Neurosurgery, the First Affiliated Hospital of Nanchang University, 17 Yong Wai Zheng Street, Nanchang, China
| | - Jie Zhan
- Department of Radiology, the First Affiliated Hospital of Nanchang University, 17 Yong Wai Zheng Street, Nanchang, China
| | - Li Min Xiao
- Department of Neurosurgery, the First Affiliated Hospital of Nanchang University, 17 Yong Wai Zheng Street, Nanchang, China
| | - Bin Tang
- Department of Neurosurgery, the First Affiliated Hospital of Nanchang University, 17 Yong Wai Zheng Street, Nanchang, China.
| | - Tao Hong
- Department of Neurosurgery, the First Affiliated Hospital of Nanchang University, 17 Yong Wai Zheng Street, Nanchang, China.
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Chhabra R, Singh A, Salunke P, Virk R. Controlled arachnoid opening to aid endoscopic trans-sphenoidal extrarachnoidal dissection of pituitary macroadenoma. Br J Neurosurg 2023; 37:1414-1418. [PMID: 33103937 DOI: 10.1080/02688697.2020.1836327] [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: 06/16/2020] [Accepted: 10/08/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES The arachnoid often bulges prematurely during surgical excision of large pituitary tumors obscuring the deeper regions and crevices preventing total excision. Pushing the arachnoid may not be helpful and may tear it inadvertently and extensively leading to complications. We have described controlled arachnoid opening in large pituitary macroadenomas during the final stages of excision to gain access to the hidden portions and compared our results to the conventional technique. PATIENTS AND METHODS Patients with pituitary macroadenoma of Hardy's III and KNOSP II in whom arachnoid had bulged prematurely were considered for study. They were grouped temporally. In first group (n = 12), the arachnoid was pushed to retrieve the tumor and in the second group (n = 10) it was punctured to aid resection. The extent of resection was assessed on postoperative scans, and complications in both groups, were noted. RESULTS In the first group where arachnoid was pushed to retrieve tumor, Gross Total Resection (GTR) could be achieved in 5 patients. Inadvertent large arachnoid tear occurred in 3 patients of which, 2 developed CSF Rhinorrhoea. No patient had neurovascular injury.In the second group, GTR could be achieved in all without any added complications. CONCLUSION Deliberate needle puncture and controlled drainage of CSF from arachnoid that bulges prematurely while endoscopic Transsphenoidal surgery for large pituitary tumors is a safe and effective method to gain access to the hidden portions of tumor to achieve GTR.
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Vassilyeva N, Mena N, Kirov K, Diatlova E. Comparative effectiveness of endoscopic and microscopic adenoma removal in acromegaly. Front Endocrinol (Lausanne) 2023; 14:1128345. [PMID: 37766690 PMCID: PMC10519786 DOI: 10.3389/fendo.2023.1128345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 08/16/2023] [Indexed: 09/29/2023] Open
Abstract
Introduction Somatotropinomas are the main cause of acromegaly. Surgery is the primary and most efficient method of treatment. The study aimed to compare the radicality of small-sized and medium (<30 mm) somatotropinoma removal and the incidence of postoperative complications in patients with acromegaly when using microscopic and endoscopic techniques. Methods In this randomized controlled trial, a total of 83 patients with acromegaly underwent transspheroidal endoscopy or microscopic surgery. Somatotropinoma was the cause of acromegaly in all cases. Patients were randomly divided into two comparison groups depending on the applied surgical technique. Group 1 (n = 40) consisted of patients who underwent adenomectomy with transnasal transsphenoidal access by a microscope. Group 2 (n = 43) included patients who underwent the same surgical procedure with an endoscope. The following indicators were assessed: radicality of tumor removal, treatment effectiveness, postoperative complications, and remission rate. Results The study has shown that removal of somatotropinoma in patients with acromegaly using endoscopic technique increases the radicality of tumor removal in comparison with microscopic technique. Total removal of somatotropinoma was successful in 88.4% of cases when using the endoscopic technique. Secondly, the segmentation of patients according to their tumor characteristics poses challenges, primarily owing to the rarity of acromegaly as a disease. The difference between groups was not statistically significant (p=1.02). There were no statistically significant differences in basal GH level and IGF-1 level between groups (p=0.546 and p=0.784, respectively). Discussion Endonasal transsphenoidal endoscopic adenomectomy is proven efficacy, a less traumatic degree, and higher somatotropinoma removal radicality. Both surgical methods lead to disease remission.
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Affiliation(s)
- Natalya Vassilyeva
- Department Emergency Medicine, Anesthesiology and Resuscitation, Karaganda Medical University, Karaganda, Kazakhstan
| | - Natmir Mena
- Department of General Surgery, Medical University Pleven, Pleven, Bulgaria
| | - Kiril Kirov
- Research Institute, Medical University Pleven, Pleven, Bulgaria
| | - Ekaterina Diatlova
- Department of Nursing Management and Social Work, Sechenov First Moscow State Medical University, Moscow, Russia
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Moreno Jiménez S, Vargas-Olmos I, Ceballos-Arana A, Miranda-Fernández KA, Morgenstern-Kaplan D, Flores-Vázquez F, Bedoya-Gómez Á, Contreras-Núñez PA. Non-functional Pituitary Adenomas: Analysis of Delayed Diagnosis in Mexico. Cureus 2023; 15:e45645. [PMID: 37868458 PMCID: PMC10589391 DOI: 10.7759/cureus.45645] [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] [Accepted: 09/20/2023] [Indexed: 10/24/2023] Open
Abstract
BACKGROUND Although tumors of the central nervous system (CNS) are rare, they can cause significant morbidity and mortality. The clinical presentation of patients with non-functional pituitary adenomas (NFPA) ranges from being completely asymptomatic to causing pituitary, hypothalamic, or visual dysfunction due to their large size. Patients usually arrive with large tumors at the time of diagnosis. Objectives: Try to describe the characteristics of NFPA and explain the causes of delayed diagnosis. Methods: We carried out a retrospective study including 58 patients with NFPA and analyzed the tumor volume at the time of diagnosis and its relationship with sociodemographic and health sector variables. Results: Low socioeconomic status (SES) was associated with high tumor volume (SES 1-2 of 17.4 cm3 vs 3-6 of 11.7 cm3, p=0.018), and the time between first consultation and diagnosis was longer in the public sector than in the private sector (13.5 months vs 5.1 months). The time between the first symptom and the first consultation was shorter when they had visual impairment than when they did not (4.1 vs 18.4 months, p=0.006). CONCLUSIONS On the one hand, citizens should be made aware that a visual deficit should make them go to a medical check-up, and on the other hand, strengthen the health system so that they have the NFPA as a differential diagnosis in patients with some visual alteration. Socioeconomic inequality in our country undoubtedly puts the underprivileged at greater risk.
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Affiliation(s)
- Sergio Moreno Jiménez
- Neurological Center, American British Cowdray (ABC) Medical Center, Mexico, MEX
- Neurosurgery, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico, MEX
| | - Issac Vargas-Olmos
- Internal Medicine, American British Cowdray (ABC) Medical Center, Mexico, MEX
| | | | - Karen A Miranda-Fernández
- Radiosurgery Unit, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico, MEX
| | - Dan Morgenstern-Kaplan
- Internal Medicine, Jackson Memorial Hospital, Miami, USA
- Medicine, Universidad Anáhuac Mexico, Mexico, MEX
| | | | | | - Paula A Contreras-Núñez
- Radiosurgery, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico, MEX
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Edelbach B, Lopez-Gonzalez MA. Staged Strategies to Deal with Complex, Giant, Multi-Fossa Skull Base Tumors. Brain Sci 2023; 13:916. [PMID: 37371394 DOI: 10.3390/brainsci13060916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 05/30/2023] [Accepted: 06/04/2023] [Indexed: 06/29/2023] Open
Abstract
Given the complex and multifaceted nature of resecting giant tumors in the anterior, middle, and, to a lesser extent, the posterior fossa, we present two example strategies for navigating the intricacies of such tumors. The foundational premise of these two approaches is based on a two-stage method that aims to improve the visualization and excision of the tumor. In the first case, we utilized a combined endoscopic endonasal approach and a staged modified pterional, pretemporal, with extradural clinoidectomy, and transcavernous approach to successfully remove a giant pituitary adenoma. In the second case, we performed a modified right-sided pterional approach with pretemporal access and extradural clinoidectomy. This was followed by a transcortical, transventricular approach to excise a giant anterior clinoid meningioma. These cases demonstrate the importance of performing staged operations to address the challenges posed by these giant tumors.
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Affiliation(s)
- Brandon Edelbach
- School of Medicine, Loma Linda University, Loma Linda, CA 92354, USA
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20
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Yang F, Bi Y, Zhou Q, Li H, Xue Y, Zhu Q, Yin J, Wang Z, Lou M. Pituitary adenoma with cavernous sinus compartment penetration and intracranial extension: surgical anatomy, approach, and outcomes. Front Oncol 2023; 13:1169224. [PMID: 37274295 PMCID: PMC10232909 DOI: 10.3389/fonc.2023.1169224] [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: 02/19/2023] [Accepted: 04/27/2023] [Indexed: 06/06/2023] Open
Abstract
Objectives To understand the different characteristics and growth corridors of knosp grade 4 pituitary adenomas (Knosp4PA) with cavernous sinus (CS) compartments penetration and intracranial extension, aiming to improve the safety, effectiveness, and total resection rate of surgery. Methods A case series of 120 Knosp4PA patients with 187 invaded compartments were retrospectively reviewed. A novel surgery-relevant grading system was proposed according to the CS penetrating features. The details of approach drafting, risk prediction, and complication avoidance were analyzed and integrated through illustrated cases. Results All enrolled tumor was Knosp4PA which was derived from Knosp subgrades 3A(62.5%) and 3B(37.5%). Based on the tumor growth pathway and its relevant features, five subclassifications of intracranial extension(n=98,81.7%) were classified, which derived from the superior (Dolenc's and Oculomotor subtype, 5% and 24.2%), lateral (Parkinson's subtype,18.3%), and posterior (cerebral peduncle and Dorello's subtype, 5.8% and 1.7%) CS compartment penetration. The size of intracranial extension is assessed by Lou's scale proposed here based on preoperative MRI characteristics. Under Lou's scale, the gross total rate (GTR) decreased (82%, 53%, 22%, and 19%) with grades increased (grade 0,1,2,3, respectively), and presents significant difference between the four groups (p=0.000), as well as between single and multiple compartments involved (p=0.001). Preoperative cranial nerve deficits included the optic nerve (53%), oculomotor nerve (24.2%), and abducent nerve (4.2%), with an overall rate of visual function improvement in 68.1%. Postoperative complications of transient diabetes insipidus, cerebrospinal fluid (CSF) leakage, and cranial nerve deficits were 6.7%, 0.8%, and 0%. No new cranial nerve deficits occurred. The mortality rate was 0.8%. Conclusion The concept of "penetration" refines the extracavernous growth pattern, and the five intracranial subclassifications help to understand the potential extension corridors, enhancing adequate exposure and targeted resection of Knosp4PA. This grading system may benefit from its predictive and prognostic value, from which a higher GTR rate can be achieved.
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Affiliation(s)
- FuMing Yang
- Department of Neurosurgery, Shanghai General Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - YunKe Bi
- Department of Neurosurgery, Shanghai General Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - QiangYi Zhou
- Department of Neurosurgery, Shanghai General Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - HongChan Li
- Department of Neurosurgery, Shanghai General Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - YaJun Xue
- Department of Neurosurgery, Shanghai General Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - QingWei Zhu
- Department of Neurosurgery, Shanghai General Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Jian Yin
- Department of Neurosurgery, Shanghai General Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - ZhiYu Wang
- Department of Radiology, Shanghai General Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - MeiQing Lou
- Department of Neurosurgery, Shanghai General Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
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Goel A. Letter to the Editor Regarding "The Oculomotor Cistern and its Role in the Management of Pituitary Lesions: An Anatomical, Radiographic, and Clinical Scoping Review". World Neurosurg 2023; 173:285. [PMID: 37189310 DOI: 10.1016/j.wneu.2023.01.102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 01/27/2023] [Indexed: 05/17/2023]
Affiliation(s)
- Atul Goel
- Department of Neurosurgery, Lilavati Hospital and Research Center, Bandra, Mumbai, India; Department of Neurosurgery, R. N. Cooper Hospital and Medical College, Mumbai, India; Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, Mumbai, India; K. J. Somaiya Medical College and Hospital, Mumbai, India.
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Luzzi S, Giotta Lucifero A, Rabski J, Kadri PAS, Al-Mefty O. The Party Wall: Redefining the Indications of Transcranial Approaches for Giant Pituitary Adenomas in Endoscopic Era. Cancers (Basel) 2023; 15:cancers15082235. [PMID: 37190164 DOI: 10.3390/cancers15082235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 03/14/2023] [Accepted: 03/29/2023] [Indexed: 05/17/2023] Open
Abstract
The evolution of endoscopic trans-sphenoidal surgery raises the question of the role of transcranial surgery for pituitary tumors, particularly with the effectiveness of adjunct irradiation. This narrative review aims to redefine the current indications for the transcranial approaches for giant pituitary adenomas in the endoscopic era. A critical appraisal of the personal series of the senior author (O.A.-M.) was performed to characterize the patient factors and the tumor's pathological anatomy features that endorse a cranial approach. Traditional indications for transcranial approaches include the absent pneumatization of the sphenoid sinus; kissing/ectatic internal carotid arteries; reduced dimensions of the sella; lateral invasion of the cavernous sinus lateral to the carotid artery; dumbbell-shaped tumors caused by severe diaphragm constriction; fibrous/calcified tumor consistency; wide supra-, para-, and retrosellar extension; arterial encasement; brain invasion; coexisting cerebral aneurysms; and separate coexisting pathologies of the sphenoid sinus, especially infections. Residual/recurrent tumors and postoperative pituitary apoplexy after trans-sphenoidal surgery require individualized considerations. Transcranial approaches still have a critical role in giant and complex pituitary adenomas with wide intracranial extension, brain parenchymal involvement, and the encasement of neurovascular structures.
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Affiliation(s)
- Sabino Luzzi
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy
- Neurosurgery Unit, Department of Surgical Sciences, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Alice Giotta Lucifero
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy
- Department of Brain and Behavioral Sciences, University of Pavia, 27100 Pavia, Italy
| | - Jessica Rabski
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Paulo A S Kadri
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
- Medical School, Federal University of Mato Grosso do Sul, Campo Grande 79070-900, Brazil
| | - Ossama Al-Mefty
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
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Tang C, Wang JW, Wang P, Zou DW, Wu N. Staged surgery for irregular giant pituitary adenomas: A report of two cases. Oncol Lett 2023; 25:118. [PMID: 36874057 PMCID: PMC9978295 DOI: 10.3892/ol.2023.13704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 01/23/2023] [Indexed: 03/07/2023] Open
Abstract
The resection of giant pituitary adenomas is one of the most challenging brain surgeries, especially when the giant pituitary adenomas have an irregular shape or irregular growth position. The purpose of the present study is to propose staged surgery for irregular giant pituitary adenomas through a retrospective analysis of two cases. The cases of two patients with irregular giant pituitary adenomas who underwent staged surgery are retrospectively analyzed. In one case, a 51-year-old male was hospitalized after 2 months of memory loss. Brain MRI showed that the pituitary adenoma was paginated and located in the sellar and right suprasellar regions, with a size of ~6.15×6.11×5.69 cm. In the second case, a 60-year-old male had a history of intermittent vertigo for 10 years and paroxysmal amaurosis for 1 year. Brain MRI showed that the pituitary adenoma grew laterally and eccentrically, and was located in the sellar region, with a size of ~4.35×3.96×3.07 cm. Both patients underwent staged surgery; more specifically, the tumors were totally removed through two-stage surgery. In the first-stage operation, most of the tumor was removed by the microscopic transcranial approach, while in the second-stage operation, the residual tumor was removed by the endoscopic transsphenoidal approach. Both patients recovered well without obvious postoperative complications after staged surgery. There was no recurrence during the follow-up. Staged surgery is characterized by only treating tumors in the visual field and achieving a total tumor resection, which has the advantages of a high tumor resection rate, high safety and fewer postoperative complications. Staged surgery is especially suitable for irregular giant pituitary adenomas with an irregular shape or irregular growth position.
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Affiliation(s)
- Chao Tang
- Department of Neurosurgery, Chongqing General Hospital, Chongqing 401147, P.R. China
| | - Jun Wei Wang
- Department of Neurosurgery, Chongqing General Hospital, Chongqing 401147, P.R. China
| | - Pan Wang
- Department of Neurosurgery, Chongqing General Hospital, Chongqing 401147, P.R. China
| | - De Wei Zou
- Department of Neurosurgery, Chongqing General Hospital, Chongqing 401147, P.R. China
| | - Nan Wu
- Department of Neurosurgery, Chongqing General Hospital, Chongqing 401147, P.R. China
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Martorell-Llobregat C, Abarca-Olivas J, González-López P, Sánchez-Payá J, Picó-Alfonso A, Moreno-López P. Predictive model of resection in endoscopic endonasal approach for pituitary adenomas based on anatomical limits. NEUROCIRUGIA (ENGLISH EDITION) 2023; 34:112-121. [PMID: 36774259 DOI: 10.1016/j.neucie.2022.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 02/22/2022] [Indexed: 02/11/2023]
Abstract
INTRODUCTION The aim of this project is to study several anatomical-radiological features of pituitary adenomas obtained from preoperative radiological images and to analyze their relationship with the extent of resection achieved through the endoscopic endonasal approach. The second objective was to create a prediction model of the extent of resection. MATERIAL AND METHODS We retrospectively evaluated 105 patients. Tumor volume, Knosp grade, suprasellar-diaphragm coefficient and invasion of the posterior compartment have been analyzed. The extent of resection was assessed by analyzing the postoperative magnetic resonance. We created the predictive scale using statistically independent variables. RESULTS When each of the variables has been studied individually, a statistically significant value of all of them is appreciated to obtain a complete resection. However, only the Knosp grade and the suprasellar-diaphragm coefficient had a statistically significant value as independent variables. The sum of the Odds Ratio obtained from the Knosp scale, and the suprasellar-diaphragm coefficient gives the probability of complete resection. A new set of cases was employed to validate the scale. CONCLUSIONS The cavernous sinus invasion and the newly designed suprasellar diaphragm coefficient are directly related to the extent of resection in pituitary adenoma surgery performed by a transellar endoscopic approach. Moreover, based on both radiologic factors, a predictive scale may predict the probability of complete resection in a series of patients.
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Affiliation(s)
- Carlos Martorell-Llobregat
- Department of Neurosurgery, Hospital General Universitario de Alicante, Miguel Hernández University, Alicante, Spain.
| | - Javier Abarca-Olivas
- Department of Neurosurgery, Hospital General Universitario de Alicante, Miguel Hernández University, Alicante, Spain
| | - Pablo González-López
- Department of Neurosurgery, Hospital General Universitario de Alicante, Miguel Hernández University, Alicante, Spain
| | - José Sánchez-Payá
- Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain; Preventive Medicine Service, Hospital General Universitario de Alicante, Alicante, Spain
| | - Antonio Picó-Alfonso
- Endocrinology Department, Hospital General Universitario de Alicante - ISABIAL-FISABIO, Alicante, Spain
| | - Pedro Moreno-López
- Department of Neurosurgery, Hospital General Universitario de Alicante, Miguel Hernández University, Alicante, Spain
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Wu X, Bao Z, Tian W, Wang J, Miao Z, Wang Q, Lu X. Endoscopic transcranial transdiaphragmatic approach in a single-stage surgery for giant pituitary adenomas. Front Oncol 2023; 13:1133861. [PMID: 36816938 PMCID: PMC9930905 DOI: 10.3389/fonc.2023.1133861] [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: 12/29/2022] [Accepted: 01/16/2023] [Indexed: 02/04/2023] Open
Abstract
Background The treatment for giant pituitary adenomas (GPAs, maximal diameter >4 cm) remains challenging, with remarkable mortality and morbidity, and there is no consensus on the optimal surgical approach. Gross total resection (GTR) for GPAs is difficult to achieve through a single transsphenoidal or transcranial approach. Any residual tumor is at risk for postoperative apoplexy. In this study, we propose a new surgical technique for resecting the GPAs in a sing-stage transcranial surgery. Methods A retrospective review of 4 patients with complicated GPAs, who had been treated via an endoscopic transcranial transdiaphragmatic approach in a single-stage surgery after routine transcranial resection, was performed. The following data was analyzed: clinical characteristics, preoperative imaging studies, resection rate, perioperative morbidity and mortality, as well as postoperative outcomes. Results All patients had nonfunctioning GPAs and preoperative visual disturbances. In three patients, GTR was achieved, and in one patient, near-total resection (90%-100% of the tumor) was achieved. Three patients attained improved postoperative visual function, while one patient's vision remained unchanged. One patient suffered a deficiency in adrenocorticotropic hormone along with thyroid-stimulating hormone, and one patient developed diabetes insipidus. Notably, none of the patients suffered cerebrospinal fluid leakage. However, one patient developed an epidural hematoma and underwent decompressive craniectomy. Conclusions The endoscopic transcranial transdiaphragmatic approach in a single-stage surgery can be efficiently and safely performed for maximal excision of GPAs with extensive suprasellar extension. Furthermore, relative to the conventional combined or staged approaches, this innovative surgical strategy provides neurosurgeons with a clear operative field with reduced invasiveness.
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Affiliation(s)
- Xuechao Wu
- Department of Neurosurgery, Jiangnan University Medical Center, Wuxi, China,Wuxi Neurosurgical Institute, Wuxi, China,Department of Neurosurgery, Wuxi No.2 People’s Hospital, Affiliated Wuxi Clinical College of Nantong University, Wuxi, China
| | - Zhongyuan Bao
- Department of Neurosurgery, Jiangnan University Medical Center, Wuxi, China
| | - Wei Tian
- Department of Neurosurgery, Jiangnan University Medical Center, Wuxi, China
| | - Jing Wang
- Department of Neurosurgery, Jiangnan University Medical Center, Wuxi, China
| | - Zengli Miao
- Department of Neurosurgery, Jiangnan University Medical Center, Wuxi, China,Wuxi Neurosurgical Institute, Wuxi, China,Department of Neurosurgery, Wuxi No.2 People’s Hospital, Affiliated Wuxi Clinical College of Nantong University, Wuxi, China
| | - Qing Wang
- Department of Neurosurgery, Jiangnan University Medical Center, Wuxi, China,Wuxi Neurosurgical Institute, Wuxi, China,Department of Neurosurgery, Wuxi No.2 People’s Hospital, Affiliated Wuxi Clinical College of Nantong University, Wuxi, China,*Correspondence: Qing Wang,
| | - Xiaojie Lu
- Department of Neurosurgery, Jiangnan University Medical Center, Wuxi, China,Wuxi Neurosurgical Institute, Wuxi, China,Department of Neurosurgery, Wuxi No.2 People’s Hospital, Affiliated Wuxi Clinical College of Nantong University, Wuxi, China
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26
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Castle-Kirszbaum M, Wang YY, King J, Kam J, Goldschlager T. The HACKD Score-Predicting Extent of Resection of Pituitary Macroadenomas Through an Endoscopic Endonasal Transsphenoidal Approach. Oper Neurosurg (Hagerstown) 2023; 24:154-161. [PMID: 36354325 DOI: 10.1227/ons.0000000000000488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 08/26/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Predicting extent of resection before pituitary surgery is imperative for operative planning and patient counseling. In the era of endoscopic endonasal transsphenoidal surgery (EEA), a specific, reliable tool for predicting resection of macroadenomas would have widespread applications. OBJECTIVE To identify factors that predict resection of pituitary macroadenomas through the EEA. METHODS A prospectively maintained, multicenter database of 277 consecutive macroadenomas resected through the EEA was analyzed. Multivariate logistic regression identified predictors of gross total resection (GTR). A simple scoring system, the Hardy, Age, Clival, Knosp, Depth (HACKD) Score, was developed and tested. RESULTS GTR was achieved in 82.3% (228/277) of cases. Older than 50 years (odds ratio [OR] 2.96, P = .01), clival extension (OR 5.87, P < .01), Hardy grade C or D suprasellar extension (OR 3.91, P = .01), Knosp grade 3 or 4 cavernous sinus invasion (OR 7.62, P < .01), and tumor depth >20 mm (OR 5.14, P < .01) were all associated with subtotal resection. The HACKD score, awarding 1 point each for Hardy grade C or D, and older than 50 years, and 2 points each for clival extension, Knosp grades 3 or 4, and tumor depth >20 mm, demonstrated excellent discriminative ability (AUROC 0.887, 95% CI: 0.839-0.934). The rate of GTR progressively decreased with a higher HACKD score. Rates of GTR were 95.8% (182/190) for low (HACKD ≤2), 59.5% (44/74) for moderate (HACKD 3-5), and 15.4% (2/13) for high (HACKD 6+) HACKD scores. CONCLUSION The HACKD score is a simple and accurate tool based on the largest study analyzing predictors of GTR in pituitary macroadenomas operated through the EEA.
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Affiliation(s)
- Mendel Castle-Kirszbaum
- Department of Neurosurgery, Monash Health, Melbourne, Australia.,Department of Surgery, Monash University, Melbourne, Australia
| | - Yi Yuen Wang
- Department of Neurosurgery, St Vincent's Health, Melbourne, Australia
| | - James King
- Department of Neurosurgery, Royal Melbourne Hospital, Melbourne, Australia
| | - Jeremy Kam
- Department of Neurosurgery, Monash Health, Melbourne, Australia.,Department of Neurosurgery, Royal Melbourne Hospital, Melbourne, Australia
| | - Tony Goldschlager
- Department of Neurosurgery, Monash Health, Melbourne, Australia.,Department of Surgery, Monash University, Melbourne, Australia
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Garcia Redmond J, Maclachlan LR, Barber J, Ayvaz F, Amato D, Jayalath R, Ananthababu P, Olson S. A retrospective cohort study assessing geometrical parameters related to visual deterioration in pituitary macroadenoma. J Clin Neurosci 2023; 107:1-7. [PMID: 36442337 DOI: 10.1016/j.jocn.2022.11.002] [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: 08/09/2022] [Revised: 10/29/2022] [Accepted: 11/05/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE We aim to identify specific parameters that will allow identification of those patients at greater risk of vision loss, specifically variables such as geometry, volume and size of the pituitary tumour. METHODOLOGY Volume measurements were made with both manual (using the formula width × height × length × 0.5) and video size, sub-voxel interpolation using Brainlab software. The shape of the tumour was divided into four categories, ovoid, dumbbell, pyramidal and other. Chiasmal compression was divided into central and lateral compression and the chiasm location was classified based on pre/post and normal fixed chiasm in relation to the tuberculum sella. We used a visual impairment score ranging from (0-100), which was then further subdivided in to four grades: Grade I - 0-25 (mild); Grade II - 26-50 (moderate); Grade III - 51-75 (severe); Grade IV - 76-100 (subtotal or complete). RESULTS Univariate analysis of variables related to vision loss found tumour volume, suprasellar growth and lateral chiasmal compression related to pre-operative vision loss. On multivariate regression analysis tumour volume and lateral chiasmal compression remained significant (p < 0.008). In relation to post-operative vision, univariate analysis indicated that variables such as giant macroadenoma, pre-operative visual impairment score and suprasellar growth were significant. Multivariate analysis showed pre-operative visual impairment and suprasellar growth as the only statistically significant variables. CONCLUSION Our ROC analysis suggests tumours with suprasellar extension 16 mm (sensitivity 85 %, specificity 67 %) in sagittal plane are more likely to result in moderate to severe grade vision loss (VIS grade ≥ 2).
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Affiliation(s)
- Joseph Garcia Redmond
- The Department of Neurosurgery, Princess Alexandra Hospital, Brisbane, Australia; The Kenneth G Jamieson Department of Neurosurgery, Royal Brisbane and Women's Hospital, Brisbane, Australia.
| | - Liam R Maclachlan
- The Kenneth G Jamieson Department of Neurosurgery, Royal Brisbane and Women's Hospital, Brisbane, Australia; The School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
| | - James Barber
- The Department of Neurosurgery, Princess Alexandra Hospital, Brisbane, Australia
| | - Faruk Ayvaz
- The Department of Neurosurgery, Princess Alexandra Hospital, Brisbane, Australia
| | - Damian Amato
- The Department of Neurosurgery, Princess Alexandra Hospital, Brisbane, Australia
| | - Rumal Jayalath
- The Department of Neurosurgery, Princess Alexandra Hospital, Brisbane, Australia.
| | | | - Sarah Olson
- The Department of Neurosurgery, Princess Alexandra Hospital, Brisbane, Australia.
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Xue L, Wu J, Chen J, Yang Y. Change in the pituitary stalk deviation angle after transsphenoidal surgery can predict the development of diabetes insipidus for pituitary adenomas. Endocr Connect 2022; 11:e220187. [PMID: 36103145 PMCID: PMC9641766 DOI: 10.1530/ec-22-0187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 09/14/2022] [Indexed: 11/08/2022]
Abstract
Purpose We aimed to assess the factors influencing the development of diabetes insipidus after transsphenoidal surgery for pituitary adenomas. Methods A retrospective analysis was conducted on the clinical data of patients with pituitary adenomas who underwent transsphenoidal surgery. The predictors of postoperative diabetes insipidus were determined using statistical analysis. Results Of the 415 patients who underwent microscopic transsphenoidal surgery for pituitary adenomas, 196 experienced postoperative diabetes insipidus. The sinking depth of the diaphragma sellae and the difference between the preoperative and postoperative pituitary stalk deviation angles in the diabetes insipidus group were greater than those in the non-diabetes insipidus group. Logistic regression analysis showed that the risk of diabetes insipidus after transsphenoidal surgery was higher in patients with a larger difference in their pituitary stalk deviation angles (odds ratio = 2.407, 95% CI = 1.335-4.342; P = 0.004). Conclusion The difference in the pituitary stalk deviation angle could predict the onset of diabetes insipidus after transsphenoidal surgery for pituitary adenomas.
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Affiliation(s)
- Liang Xue
- Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, China
- Department of Neurosurgery, 900TH Hospital of the Joint Logistics Support Force, Fuzhou, Fujian, China
| | - Jianwu Wu
- Department of Neurosurgery, 900TH Hospital of the Joint Logistics Support Force, Fuzhou, Fujian, China
| | - Jie Chen
- Department of Radiology, 900TH Hospital of the Joint Logistics Support Force, Fuzhou, Fujian, China
| | - Yongkai Yang
- Department of Neurosurgery, Affiliated Fuzhou First Hospital of Fujian Medical University, Fuzhou, Fujian, China
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Raghib MF, Salim A, Angez M, Ghazi SM, Hashmi S, Tariq MB, Hashmi F, Anis SB, Shamim MS, Tanwir A, Enam SA. Prognostic implication of size on outcomes of pituitary macroadenoma: a comparative analysis of giant adenoma with non-giant macroadenoma. J Neurooncol 2022; 160:491-496. [DOI: 10.1007/s11060-022-04168-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 10/10/2022] [Accepted: 10/12/2022] [Indexed: 11/07/2022]
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Enam SA, Ghazi SM, Raghib MF, Salim A, Hashmi S, Hashmi F, Anis SB, Tariq MB, Angez M, Shamim S, Khan AA. AKU Giant Pituitary Adenoma Score: A Novel Scoring System to Predict the Outcomes of Surgery for Giant Pituitary Adenomas. Cureus 2022; 14:e29232. [PMID: 36258942 PMCID: PMC9573772 DOI: 10.7759/cureus.29232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2022] [Indexed: 11/05/2022] Open
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Giant Non-Functioning Pituitary Adenomas: Treatment Considerations. Brain Sci 2022; 12:brainsci12091256. [PMID: 36138992 PMCID: PMC9497296 DOI: 10.3390/brainsci12091256] [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: 08/01/2022] [Revised: 09/07/2022] [Accepted: 09/13/2022] [Indexed: 11/23/2022] Open
Abstract
Giant pituitary adenomas are a subgroup of pituitary adenomas defined by a diameter greater than 4 cm, and they account for 5–14% of adenomas in surgical series. Because of their growth patterns and locations, often involving critical neurovascular structures, they represent a true surgical challenge, and gross total resection is difficult to achieve. There is no consensus on the optimal surgical strategy for giant pituitary adenomas, and, often, integrated multi-staged treatment strategies have been considered. Transcranial or transsphenoidal approaches, alone or combined, according to tumor and patient features are the two main routes. Each of these strategies has pros and cons. The conventional transcranial approach has for a long time been considered the first choice for the removal of giant pituitary adenomas. Currently, with endoscopic techniques, it is also possible to remove lesions that involve the intradural compartment and the adjacent neurovascular structures with the use of extended approaches. Our policy for the management of these lesions is to adopt the endoscopic endonasal approach as the first choice unless the tumor presents significant intracranial extension that results in it being outside the visibility and maneuverability of the endoscopic endonasal route. In these latter cases, we agree that the transcranial approach is more appropriate. However, accurate preoperative evaluation and refined treatment plans for each patient are mandatory to define a proper strategy in order to achieve the most effective long-term result.
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Ahmadi S, Dayyani M, Etemadrezaie H, Bateni F, Mohabbati H, Pooyan A, Zabihyan S. Diaphragma sellae orifice ratio, is it an applicable anatomical index to determine the direction of the growth of pituitary macroadenomas? INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2022.101547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Goel A. Letter to the Editor. Dumbbell-shaped pituitary adenomas. J Neurosurg 2022; 137:898-899. [PMID: 35303695 DOI: 10.3171/2022.1.jns212952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Harel E, Cossu G, Daniel RT, Messerer M. Relationship with the diaphragm to predict the surgical outcome in large and giant pituitary adenomas. Front Surg 2022; 9:962709. [PMID: 36211275 PMCID: PMC9534030 DOI: 10.3389/fsurg.2022.962709] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 07/25/2022] [Indexed: 11/23/2022] Open
Abstract
Objective Large and giant pituitary adenomas (L- and G-PAs) continue to remain a surgical challenge. The diaphragm may have a role in determining the shape of the tumor and therefore influencing the extent of resection. Our study aims to analyze our surgical series of L- and G-PAs according to their relationship with the diaphragm and invasion of cavernous sinus (CS). Material and methods We performed a retrospective analysis of our surgical series of patients operated for L- and G-PAs. We categorized the tumors into four grades according to their relationship with the diaphragm: grade 1 (supradiaphragmatic component with a wide incompetent diaphragm), grade 2 (purely infra-diaphragmatic tumor with a competent diaphragm), grade 3 (dumbbell-shape tumors), and grade 4 (multilobulated tumor with invasion of the subarachnoid space). Results A total of 37 patients were included in our analysis. According to our classification, 43.3% of patients had grade 1 tumors, 27% had grade 2, 5.4% had grade 3, and 24.3% had grade 4 tumors. CS invasion was confirmed intraoperatively in 17 out of 37 patients (46%). The gross total resection (GTR) was obtained in 19% of the cases, near-total resection in 46%, and subtotal resection in 35%. All the patients who achieved GTR had grade 1 tumors and the lowest rate of CS invasion (p < 0.01). Conclusion Radiological evaluation of the tumor relationship with the diaphragm, invasion of CS, and invasion of the subarachnoid space are crucial to plan the surgical strategy and maximize the possibilities of achieving GTR in L- and G-PAs.
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Makarenko S, Alzahrani I, Karsy M, Deopujari C, Couldwell WT. Outcomes and surgical nuances in management of giant pituitary adenomas: a review of 108 cases in the endoscopic era. J Neurosurg 2022; 137:635-646. [PMID: 35061979 DOI: 10.3171/2021.10.jns21659] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 10/16/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Giant (maximum diameter ≥ 4 cm) pituitary macroadenomas are complex tumors that require resection for decompression of optic nerves, relief of mass effect, and symptom improvement. Given the lack of surgical accessibility, the lateral extent of the lesions, and the invasion of the cavernous sinus, management presents a significant challenge. Transsphenoidal, transcranial, and combined approaches have been viable options for resection. The authors present their findings from a large series of patients to characterize giant pituitary adenomas, document outcomes, and outline surgical nuances in resection of these tumors. METHODS The authors reviewed 887 consecutive patients who underwent resection of pituitary adenomas at a single institution. From this group, 108 patients with giant pituitary adenomas who underwent resection between January 1, 2002, and December 31, 2020, were identified for inclusion in the study. The patient demographics, clinical presentation, tumor imaging characteristics, surgical approaches, and postoperative outcomes were analyzed using descriptive statistics. RESULTS The mean preoperative tumor diameter in this cohort was 4.6 ± 0.8 cm, with a mean volume of 25.9 ± 19.2 cm3. Ninety-seven patients underwent transsphenoidal approaches only, 3 underwent transcranial resection, and 8 patients underwent a combined approach. Gross-total resection was achieved in 42 patients. Tumor stability without a need for additional therapy was achieved in 77 patients, with 26 patients undergoing subsequent adjuvant radiotherapy. Among 100 patients with sufficient follow-up, 14 underwent adjuvant therapy-repeat operation and/or adjuvant radiation therapy-because of recurrence or tumor progression. Six patients with recurrence were observed without additional treatment. Overall, the morbidity associated with removal of these lesions was 11.1%; the most common morbidities were cerebrospinal fluid leak (5 patients, 4.6%) and hydrocephalus (4 patients, 3.7%). One death due to postoperative pituitary apoplexy of the residual tumor and malignant cerebral edema occurred in this cohort. CONCLUSIONS Giant pituitary tumors still represent a surgical challenge, with significant morbidity. Gross-total resection occurs in a minority of patients. Surgical goals for removal of giant pituitary tumors should include attempts at removal of most tumor tissue to minimize the risk of residual tumor apoplexy by tailoring the approach along the major axis of the tumor. Experience with both transsphenoidal and multiple transcranial techniques is necessary for minimizing complications and improving outcomes.
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Affiliation(s)
- Serge Makarenko
- 1Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Ibrahim Alzahrani
- 2Division of Neurological Surgery, Neurosciences Department, King Faisal University Hospital and Research Center, Riyadh, Saudi Arabia; and
| | - Michael Karsy
- 1Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Chandrasekhar Deopujari
- 3Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences (BHIMS), Mumbai, India
| | - William T Couldwell
- 1Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
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Chalif EJ, Couldwell WT, Aghi MK. Effect of facility volume on giant pituitary adenoma neurosurgical outcomes. J Neurosurg 2022; 137:658-667. [PMID: 35171824 DOI: 10.3171/2021.11.jns211936] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 11/08/2021] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Giant pituitary adenomas (PAs), defined as 4 cm or greater at their maximum diameter, are commonly treated with neurosurgical intervention as the first-line therapy. However, existing studies are from high-volume institutions whose outcomes may not be representative of many cancer centers. In the present study, the authors use a large cancer registry to evaluate demographics, national treatment trends, and outcomes by facility volume to address knowledge gaps for this uncommon tumor. METHODS The National Cancer Database was queried for adult patients with PAs who had undergone resection from 2004 to 2016. Univariate and multivariate logistic regression modeling was used to evaluate the prognostic impact of covariates on short-term outcomes including 30-day readmission (30R), 30-day mortality (30M), 90-day mortality (90M), and prolonged length of inpatient hospital stay (LOS). Propensity score matching was used for validation. RESULTS Among the 39,030 patients who met the study inclusion criteria, 3696 giant PAs were identified. These tumors had higher rates of subtotal resection (55% vs 24%, p < 0.001), adjunctive radiotherapy (15% vs 5%, p < 0.001), and hormonal therapy (8% vs 4%, p < 0.001) than nongiant PAs. The giant PAs also had worse 30M (0.6% vs 3.1%, p < 0.001), 90M (1.0% vs 5.0%, p < 0.001), 30R (4.0% vs 6.3%, p < 0.001), and LOS (22.2% vs 42.1%, p < 0.001). On multivariate analysis for giant PA, decreased tumor size, younger age, race other than African American, lower comorbidity score, and high-volume facility (HVF; defined as ≥ 2.5 giant PA cases per year) were statistically significant predictors of favorable outcomes. Specifically, 30M, 90M, 30R, and LOS were decreased by 50%, 43%, 55%, and 32%, respectively, when giant PAs were treated at HVFs (each p < 0.05). HVFs more often used the endoscopic approach (71% vs 46%, p < 0.001) and less adjuvant radiotherapy (11% vs 16%, p < 0.001). Propensity score matching validated 30M, 30R, and LOS outcome differences in a cohort of 1056 patients. CONCLUSIONS This study provides evidence of superior outcomes when giant PAs are treated at HVFs. These results likely reflect the relation between physician experience and outcomes for these uncommon tumors, which suggests the need for institutional collaboration as a potential goal in their surgical management.
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Affiliation(s)
- Eric J Chalif
- 1Department of Neurological Surgery, University of California, San Francisco, California; and
| | | | - Manish K Aghi
- 1Department of Neurological Surgery, University of California, San Francisco, California; and
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Xu Y, Mohyeldin A, Asmaro KP, Nunez MA, Doniz-Gonzalez A, Vigo V, Cohen-Gadol AA, Fernandez-Miranda JC. Intracranial Breakthrough Through Cavernous Sinus Compartments: Anatomic Study and Implications for Pituitary Adenoma Surgery. Oper Neurosurg (Hagerstown) 2022; 23:115-124. [PMID: 35838451 DOI: 10.1227/ons.0000000000000291] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 02/16/2022] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Pituitary adenomas (PAs) with cavernous sinus (CS) invasion can extend into the intradural space by breaking through the CS walls. OBJECTIVE To elaborate on the potential breakthrough route through CS compartments for invasive PAs and describe relevant surgical anatomy and technical nuances, with an aim to improve resection rates. METHODS Twelve colored silicon-injected human head specimens were used for endonasal and transcranial dissection of the CS walls; ligaments, dural folds, and cranial nerves on each compartment were inspected. Two illustrative cases of invasive PA are also presented. RESULTS The potential breakthrough routes through the CS compartments had unique anatomic features. The superior compartment breakthrough was delimited by the anterior petroclinoidal ligament laterally, posterior petroclinoidal ligament posteriorly, and interclinoidal ligament medially; tumor extended into the parapeduncular space with an intimate spatial relationship with the oculomotor nerve and posterior communicating artery. The lateral compartment breakthrough was limited by the anterior petroclinoidal ligament superiorly and ophthalmic nerve inferiorly; tumor extended into the middle fossa, displacing the trochlear nerve and inferolateral trunk to reach the medial temporal lobe. The posterior compartment breakthrough delineated by the Gruber ligament, petrosal process of the sphenoid bone, and petrous apex inferiorly, posterior petroclinoidal ligament superiorly, and dorsum sellae medially; tumor displaced or encased the abducens nerve and inferior hypophyseal artery and compressed the cerebral peduncle. CONCLUSION The superior lateral and posterior components of the CS are potential routes for invasion by PAs. Better identification of CS breakthrough patterns is crucial for achieving higher gross total resection and remission rates.
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Affiliation(s)
- Yuanzhi Xu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China.,Department of Neurosurgery, Stanford Hospital, Stanford, California, USA
| | - Ahmed Mohyeldin
- Department of Neurosurgery, Stanford Hospital, Stanford, California, USA
| | - Karam P Asmaro
- Department of Neurosurgery, Stanford Hospital, Stanford, California, USA
| | | | | | - Vera Vigo
- Department of Neurosurgery, Stanford Hospital, Stanford, California, USA
| | - Aaron A Cohen-Gadol
- The Neurosurgical Atlas , Carmel, Indiana, USA.,Department of Neurological Surgery, Indiana University, Indianapolis, Indiana, USA
| | - Juan C Fernandez-Miranda
- Department of Neurosurgery, Stanford Hospital, Stanford, California, USA.,The Neurosurgical Atlas , Carmel, Indiana, USA
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Pei Z, Wang J, Mu S, Feng T, Wang M, Yu S, Wei L, Fang Y, Wang S. Microscopic Transsphenoidal Resection of Giant Pituitary Adenomas: Analysis of the Factors Limiting the Degree of Resection in 73 Cases. Front Neurol 2022; 13:880732. [PMID: 35711254 PMCID: PMC9195514 DOI: 10.3389/fneur.2022.880732] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 05/10/2022] [Indexed: 11/22/2022] Open
Abstract
Purpose To analyze the risk factors affecting the gross-total resection of giant pituitary adenomas using a transsphenoidal approach under a microscope to provide a reference basis for formulating an appropriate surgical strategy. Methods The clinical data of patients who underwent microscopic transsphenoidal resection of giant pituitary adenomas in a single center from January 2011 to December 2020 were retrospectively analyzed. Based on magnetic resonance imaging and surgical records, the predictive factors affecting the gross-total resection of giant pituitary adenomas under microscopy were determined through univariate and multivariate analyses. Results A total of 73 patients with giant pituitary adenomas underwent transsphenoidal microsurgery. Gross-total resection was performed in 19 cases (26%), subtotal resection in 31 cases (42%), partial resection in 21 cases (29%), and the degree of resection was <50% in only two cases (3%). After binary logistic analysis, it was found that it was more difficult to completely remove giant pituitary adenomas with a Knosp grade 3–4 [odds ratio (OR) = 0.214, 95% confidence interval (CI): 0.05–0.917; P = 0.038], greater proportion of tumor suprasellar volume (odds ratio = 0.937, 95% confidence interval: 0.898–0.978; P = 0.003), and intraoperative evidence of invasion of the cavernous sinus (odds ratio = 0.187, 95% CI: 0.039–0.898; P = 0.036). Conclusion It is difficult to remove a giant pituitary adenoma invading the cavernous sinus completely with a higher degree of invasion of the suprasellar region using microscopic transsphenoidal surgery. The combined application of multiple surgical methods can help to improve the degree of resection during a single operation.
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Affiliation(s)
- Zhijie Pei
- Department of Neurosurgery, Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, China
| | - Jiaxing Wang
- Department of Neurosurgery, The First Hospital of Yichang, The People's Hospital of China Three Gorges University, Yichang, China
| | - Shuwen Mu
- Department of Neurosurgery, Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, China
| | - Tianshun Feng
- Department of Neurosurgery, Oriental Hospital Affiliated to Xiamen University, Fuzhou, China
| | - Meina Wang
- Department of Neurosurgery, Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, China
| | - Shentong Yu
- Department of Pathology, The 900th Hospital, Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, China
| | - Liangfeng Wei
- Department of Neurosurgery, The 900th Hospital, Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, China
| | - Yi Fang
- Department of Neurosurgery, The 900th Hospital, Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, China
| | - Shousen Wang
- Department of Neurosurgery, The 900th Hospital, Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, China
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Butterfield JT, Araki T, Guillaume D, Tummala R, Caicedo-Granados E, Tyler MA, Venteicher AS. Estimating Risk of Pituitary Apoplexy after Resection of Giant Pituitary Adenomas. Skull Base Surg 2022; 83:e152-e159. [DOI: 10.1055/s-0041-1722993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 12/03/2020] [Indexed: 10/22/2022]
Abstract
Abstract
Background Pituitary apoplexy after resection of giant pituitary adenomas is a rare but often cited morbidity associated with devastating outcomes. It presents as hemorrhage and/or infarction of residual tumor in the postoperative period. Because of its rarity, its incidence and consequences remain ill defined.
Objective The aim of this study is to estimate the rate of postoperative pituitary apoplexy after resection of giant pituitary adenomas and assess the morbidity and mortality associated with apoplexy.
Methods A systematic review of literature was performed to examine extent of resection in giant pituitary adenomas based on surgical approach, rate of postoperative apoplexy, morbidities, and mortality. Advantages and disadvantages of each approach were compared.
Results Seventeen studies were included in quantitative analysis describing 1,031 cases of resection of giant pituitary adenomas. The overall rate of subtotal resection (<90%) for all surgical approaches combined was 35.6% (95% confidence interval: 28.0–43.1). Postoperative pituitary apoplexy developed in 5.65% (n = 19) of subtotal resections, often within 24 hours and with a mortality of 42.1% (n = 8). Resulting morbidities included visual deficits, altered consciousness, cranial nerve palsies, and convulsions.
Conclusion Postoperative pituitary apoplexy is uncommon but is associated with high rates of morbidity and mortality in subtotal resection cases. These findings highlight the importance in achieving a maximal resection in a time sensitive fashion to mitigate the severe consequences of postoperative apoplexy.
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Affiliation(s)
- John T. Butterfield
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, United States
| | - Takako Araki
- Department of Medicine, Division of Diabetes, Endocrinology and Metabolism, University of Minnesota, Minneapolis, Minnesota, United States
- Center for Skull Base and Pituitary Surgery, University of Minnesota, Minneapolis, Minnesota, United States
| | - Daniel Guillaume
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, United States
- Center for Skull Base and Pituitary Surgery, University of Minnesota, Minneapolis, Minnesota, United States
| | - Ramachandra Tummala
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, United States
- Center for Skull Base and Pituitary Surgery, University of Minnesota, Minneapolis, Minnesota, United States
| | - Emiro Caicedo-Granados
- Department of Otolaryngology, University of Minnesota, Minneapolis, Minnesota, United States
- Center for Skull Base and Pituitary Surgery, University of Minnesota, Minneapolis, Minnesota, United States
| | - Matthew A. Tyler
- Department of Otolaryngology, University of Minnesota, Minneapolis, Minnesota, United States
- Center for Skull Base and Pituitary Surgery, University of Minnesota, Minneapolis, Minnesota, United States
| | - Andrew S. Venteicher
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, United States
- Center for Skull Base and Pituitary Surgery, University of Minnesota, Minneapolis, Minnesota, United States
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Simultaneous combined endoscopic endonasal and transcranial surgery for giant pituitary adenomas: tips and traps in operative indication and procedure. Clin Neurol Neurosurg 2022; 218:107281. [DOI: 10.1016/j.clineuro.2022.107281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 05/02/2022] [Accepted: 05/02/2022] [Indexed: 11/20/2022]
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41
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Predictive model of resection in endoscopic endonasal approach for pituitary adenomas based on anatomical limits. Neurocirugia (Astur) 2022. [DOI: 10.1016/j.neucir.2022.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Shukla D, Konar S, Kulkarni A, Bhat DI, Sadashiva N, Devi BI, Dikshit P, Mehta S, Jain C. A new comprehensive grading for giant pituitary adenomas: SLAP grading. Br J Neurosurg 2022; 36:377-384. [PMID: 35361030 DOI: 10.1080/02688697.2022.2057432] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
AimGiant pituitary adenomas are difficult to resect due to multicompartmental extension. We developed a new grading system for giant pituitary adenomas (GPAs) considering possible extension in superior, lateral, anterior, and posterior (SLAP) directions. We also related the degree of resection to the SLAP grading.MethodsA review of case files and radiological images of patients with the GPAs defined as pituitary adenomas with a size of more than 4 cm in any dimension was done. The extent of the tumour was noted and scored as per the SLAP system. The maximum total score is 10 and represents a large tumour with maximum extensions in all directions. The subtotal resection (STR) was defined as a residual tumour volume of more than 10%. The association between individual and total score on the degree of resection was determined.ResultsA total of 103 cases of GPAs were analyzed. All patients had a suprasellar (S) extension. The lateral (L) extension was seen in 97.3% of cases. The anterior (A) extension was seen in 28 (27.2%) cases. The posterior (P) extension was seen in 45 (43.7%). Forty-eight (46.6%) had a total score of 5 or more. The STR was achieved in 64 (62.2%) cases. On regression analysis, a total score of ≥5 was associated with odds of 5.02 (1.69-14.93), p-value 0.004 for STR.ConclusionThe SLAP grading is a comprehensive grading system that can be applied easily to the GPAs and gives a complete picture of the extension of the tumour.
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Affiliation(s)
- Dhaval Shukla
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| | - Subhas Konar
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| | - Akshay Kulkarni
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| | - Dhananjaya I Bhat
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India.,Department of Neurosurgery, RV Aster Hospital, Bangalore, India
| | - Nishanth Sadashiva
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| | - Bhagavatula Indira Devi
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| | - Priyadarshi Dikshit
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India.,Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute, Lucknow, India
| | - Sarthak Mehta
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| | - Chirag Jain
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
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Ceylan S, Sen HE, Çabuk B, Anik I. Choice of the surgical approach and capsule dissection in giant pituitary adenomas. World Neurosurg 2022; 163:85-86. [DOI: 10.1016/j.wneu.2022.04.077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Tang OY, Hsueh WD, Eloy JA, Liu JK. Giant Pituitary Adenoma – Special Considerations. Otolaryngol Clin North Am 2022; 55:351-379. [DOI: 10.1016/j.otc.2021.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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45
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Overview of Pituitary Surgery. Otolaryngol Clin North Am 2022; 55:205-221. [DOI: 10.1016/j.otc.2022.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Puglisi V, Morini E, Biasini F, Vinciguerra L, Lanza G, Bramanti P. Neurological Presentation of Giant Pituitary Tumour Apoplexy: Case Report and Literature Review of a Rare but Life-Threatening Condition. J Clin Med 2022; 11:jcm11061581. [PMID: 35329907 PMCID: PMC8953299 DOI: 10.3390/jcm11061581] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 02/24/2022] [Accepted: 03/11/2022] [Indexed: 02/07/2023] Open
Abstract
Background: Giant pituitary adenomas are benign intracranial tumours with a diameter ≥4 cm. Even if hormonally non-functional, they may still cause local extension, leading to symptoms that include mostly gland dysfunction, mass effects, and, much less frequently, apoplexy due to haemorrhage or infarction. Neurological presentation of giant pituitary tumour apoplexy is even more rare and has not been systematically reviewed. Case Presentation: An 81-year-old woman was admitted to the Emergency Department because of acute onset headache, bilateral visual deficit, and altered consciousness. Computed tomography showed a giant mass lesion (>5.5 cm diameter) expanding upward to the suprasellar cistern, optic chiasm, and third ventricle, over-running the sphenoid sinus, and with lateral invasion of the cavernous sinus. Laboratory investigations revealed central adrenal and hypothyroidism insufficiency, while magnetic resonance imaging confirmed a voluminous suprasellar tumour (~6 cm diameter), with signs of pituitary tumour apoplexy. Neurological manifestations and gland-related deficits improved after hormonal replacement therapy with a high dose of intravenous hydrocortisone, followed by oral hydrocortisone and levo-thyroxine. The patient declined surgical treatment and follow-up visit. Conclusions: Giant pituitary tumour apoplexy is a rare but potentially life-threatening condition. Prompt diagnosis and multidisciplinary management may allow a remarkable clinical improvement, as seen in this case.
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Affiliation(s)
- Valentina Puglisi
- Department of Neurology and Stroke Unit, Istituti Ospitalieri, ASST Cremona, Viale Concordia 1, 26100 Cremona, Italy; (V.P.); (L.V.)
| | - Elisabetta Morini
- IRCCS Centro Neurolesi “Bonino-Pulejo”, Via Provinciale Palermo, Contrada Casazza, 98124 Messina, Italy; (E.M.); (P.B.)
| | - Fiammetta Biasini
- Unit of Neurology and Neuromuscular Diseases, Policlinico University Hospital “G. Martino”, Via Consolare Valeria 1-2, 98124 Messina, Italy;
| | - Luisa Vinciguerra
- Department of Neurology and Stroke Unit, Istituti Ospitalieri, ASST Cremona, Viale Concordia 1, 26100 Cremona, Italy; (V.P.); (L.V.)
| | - Giuseppe Lanza
- Department of Surgery and Medical-Surgical Specialties, University of Catania, Via Santa Sofia 78, 95123 Catania, Italy
- Clinical Neurophysiology Research Unit, Oasi Research Institute-IRCCS, Via Conte Ruggero 73, 94018 Troina, Italy
- Correspondence: ; Tel.: +39-095-3782448
| | - Placido Bramanti
- IRCCS Centro Neurolesi “Bonino-Pulejo”, Via Provinciale Palermo, Contrada Casazza, 98124 Messina, Italy; (E.M.); (P.B.)
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Hacisahinogullari H, Canturk S, Dogansen S, Yarman S. Dopamine agonist for the rapid improvement of visual field defects in giant and macro-prolactinomas. J Fr Ophtalmol 2022; 45:511-518. [PMID: 35272874 DOI: 10.1016/j.jfo.2022.01.002] [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: 10/19/2021] [Accepted: 01/10/2022] [Indexed: 11/19/2022]
Abstract
PURPOSE To evaluate effect of first-line dopamine agonist (DA) therapy as an alternative to surgery for visual field defect (VFD) recovery in giant and macro-prolactinoma. METHODS In this retrospective study, 125 patients with giant and macro-prolactinoma, except those with a history of previous surgery or radiotherapy, were evaluated. Those who underwent visual field examinations using the Humphrey Visual Field analyser upon initial assessment and after treatment were included for analysis. Twelve patients with VFD were included. The effects of DA therapy on both VFD and tumor size were evaluated within the first three months. RESULTS There were twelve patients analysed: three females and nine males, five giant and seven macroprolactinomas; eight patients received cabergoline (CAB) and four patients received bromocriptine (BRC). The mean adenoma diameter was 35±13mm (range 15-60), and the mean PRL level was 3,523ng/dL (range 312-11,703). Eight patients (67%) complained of blurred vision, while four patients (33%) reported no visual symptoms. After a median duration of three weeks, the VFD completely resolved in ten patients (83%) but only partially improved in two (17%). The mean initial doses of CAB and BRC that provided VFD improvement were 0.5±0.2mg/week and 6.3±1.4mg/day, respectively. After a mean duration of 2.2±0.9months, the mean decrease in adenoma size was 43.6±24.5% (range 10-95%). CONCLUSION The use of DA as a first-line treatment for at least one month before deciding on surgery is recommended in giant and macro-prolactinomas with VFD. Surgery should be considered only in cases with DA resistance or persistent visual impairment despite medical therapy.
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Affiliation(s)
- H Hacisahinogullari
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Istanbul University, Istanbul Faculty of Medicine, Çapa, Istanbul, Turkey.
| | - S Canturk
- Department of Ophthalmology, Istanbul University, Istanbul Faculty of Medicine, Çapa, Istanbul, Turkey
| | - S Dogansen
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Bakırkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - S Yarman
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Istanbul University, Istanbul Faculty of Medicine, Çapa, Istanbul, Turkey
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Cavernous Hemangioma of Cavernous Sinus: An Outcome Report of 45 Surgically Treated Patients. World Neurosurg 2022; 159:381-389. [PMID: 35255637 DOI: 10.1016/j.wneu.2021.09.120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 09/26/2021] [Accepted: 09/27/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To report an outcome analysis following surgical treatment of 45 patients with cavernous hemangiomas involving cavernous sinus. METHODS From 1992 to 2020, 45 cases of cavernous hemangiomas involving the cavernous sinus were surgically treated. These patients were retrospectively analyzed. RESULTS Patients included 12 males and 33 females; the average age was 34 years (age range, 15-61 years). Two patients had only headache as presenting symptom, and 43 patients had headache and diplopia as presenting symptoms. Investigations showed characteristic radiological imaging and encasement of internal carotid artery (35 cases), extension toward the sella, and displacement of cranial nerves III-V. An entirely extradural surgical approach was adopted in 39 cases. Cranial nerves III-V had a discrete dural covering and were always displaced over the dome of the tumor. The sixth cranial nerve was displaced on the dome of the tumor adjacent to the floor of the cavernous sinus. Three patients died in the early postoperative period, all related to excessive bleeding. In 36 patients, ocular movement dysfunction did not recover or worsened. During an average follow-up period of 110 months (range, 6 months to 27 years), 3 patients had tumor recurrence after postoperative imaging had shown complete tumor resection. CONCLUSIONS Surgery on cavernous hemangiomas of cavernous sinus can be a challenge owing to the vascular profile and complex anatomical location. An extradural approach provides satisfactory exposure for radical tumor resection.
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Matsumoto T, Ono T, Onodera T, Oda M, Takahashi M, Omae T, Shimizu H. Transventricular Preforniceal Approach Combined with Endoscopic Transnasal Surgery for a Giant Pituitary Adenoma: A Case Report and Literature Review. NMC Case Rep J 2022; 8:827-833. [PMID: 35079555 PMCID: PMC8769444 DOI: 10.2176/nmccrj.cr.2021-0274] [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: 08/18/2021] [Accepted: 10/20/2021] [Indexed: 11/20/2022] Open
Abstract
Giant pituitary adenomas carry significant surgical risks when treated with transsphenoidal approaches or the transcranial approach alone. Combined transsphenoidal and transcranial approaches have been reported; however, removing adenomas extending into the third ventricle may still be challenging. We report a case of giant pituitary adenoma expanding into the third ventricle, which was removed using a combined transventricular preforniceal approach and an endoscopic endonasal transsphenoidal surgery (ETSS). A 41-year-old man with headache, nausea, and a 1-week history of a visual field defect was transferred to our hospital. He had a disturbed left visual acuity, right homonymous hemianopia, and choked disc in both eyes. Preoperative magnetic resonance imaging revealed a giant pituitary adenoma with a maximum diameter of 55 mm extending from the intrasellar to the suprasellar region, thus occupying the entire third ventricle and causing hydrocephalus. The space between the anterior commissure and the fornix was expanded. The foramen of Monro was shifted backward due to compression by the tumor. He underwent maximum surgical resection using a combined transventricular preforniceal approach and ETSS. Considering technical demands and reliability, the intra- to suprasellar parts were removed by ETSS while the intraventricular part was removed through the preforniceal approach. The residual tumor in the right cavernous sinus and behind the anterior communicating artery was treated with stereotactic radiotherapy. One year after the operation, the patient leads an independent life. The combined technique of the preforniceal approach and ETSS provided a direct view of the entire third ventricle and hemostasis in the present case.
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Affiliation(s)
- Tomohiro Matsumoto
- Department of Neurosurgery, Akita University Graduate School of Medicine, Akita, Akita, Japan
| | - Takahiro Ono
- Department of Neurosurgery, Akita University Graduate School of Medicine, Akita, Akita, Japan
| | - Tomo Onodera
- Department of Neurosurgery, Akita University Graduate School of Medicine, Akita, Akita, Japan
| | - Masaya Oda
- Department of Neurosurgery, Akita University Graduate School of Medicine, Akita, Akita, Japan
| | - Masataka Takahashi
- Department of Neurosurgery, Akita University Graduate School of Medicine, Akita, Akita, Japan
| | - Tomoya Omae
- Department of Neurosurgery, Omagari Kosei Medical Center, Daisen, Akita, Japan
| | - Hiroaki Shimizu
- Department of Neurosurgery, Akita University Graduate School of Medicine, Akita, Akita, Japan
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Lin K, Lu L, Pei Z, Mu S, Huang S, Wang S. Predictive factors for delayed hyponatremia after transsphenoidal surgery in patients with pituitary adenomas. Endocr Connect 2022; 11:e210497. [PMID: 34860173 PMCID: PMC8789016 DOI: 10.1530/ec-21-0497] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 12/03/2021] [Indexed: 11/08/2022]
Abstract
Objective The aim of this study was to evaluate the incidence and duration of delayed hyponatremia and to assess the factors influencing the development of delayed hyponatremia after transsphenoidal surgery (TSS) in pituitary adenomas. Methods We retrospectively analyzed the clinical data of patients with pituitary adenoma who underwent TSS. Univariable and multivariable statistics were carried out to identify factors independently associated with the occurrence of delayed hyponatremia. Results Of the 285 patients with pituitary adenoma who underwent microscopic TSS, 44 (15.4%) developed postoperative-delayed hyponatremia and 241 (84.6%) did not. The onset of delayed hyponatremia occurred an average of 5.84 days post-surgery and persisted for an average of 5.36 days. Logistic regression analysis showed the highest risk of delayed hyponatremia in patients with significant change in tumor cavity height (odds ratio (OR), 1.158; 95% CI, 1.062, 1.262; P = 0.001), preoperative hypothalamus-pituitary-thyroid axis hypofunction (OR, 3.112; 95% CI, 1.481, 6.539; P = 0.003), and significant difference in blood sodium levels before and 2 days after TSS (OR, 1.101; 95% CI, 1.005, 1.206; P = 0.039). Conclusions Preoperative hypothyroidism, difference in blood sodium levels before and 2 days after TSS, and the change in tumor cavity height after TSS played important roles in predicting postoperative-delayed hyponatremia onset in patients with pituitary adenomas.
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Affiliation(s)
- Kunzhe Lin
- Department of Neurosurgery, Affiliated Fuzhou First Hospital of Fujian Medical University, Fuzhou, China
- Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, China
| | - Lingling Lu
- Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, China
| | - Zhijie Pei
- Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, China
| | - Shuwen Mu
- Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, China
| | - Shaokuan Huang
- Department of Neurosurgery, Guiqian International General Hospital, Guiyang, China
| | - Shousen Wang
- Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, China
- Department of Neurosurgery, 900th Hospital, Fuzhou, China
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