Endoscopic Endonasal Surgery in Recurrent and Residual Pituitary Adenomas After Microscopic Resection

Recurrent Cushing Disease: An Extensive Review on Pros and Cons of Different Therapeutic Approaches

OBJECTIVE

Recurrent Cushing disease (CD) is characterized by the reappearance of clinical and hormonal aspects of hypercortisolism that occur more than 6 months after an initial post-treatment remission.

METHODS

We performed a systematic review and meta-analysis to synthesize the evidence about remission and complication rates after transsphenoidal surgery (TSS) radiotherapy (RT) and medical therapy (MT) in recurrent CD patients. A quantitative systematic review was performed. Article selection was performed by searching MEDLINE (using PubMed), and Cochrane electronic bibliographic databases through 2020.

RESULTS

We noted 61 articles described therapeutic management of recurrent CD patients with representative outcome. A total of 723 patients received different therapeutic modality for their recurrent CD. The remission rates were 0.65 (95% confidence interval [CI] 0.60-0.70), 0.57 (95% CI 0.51-0.63), and 0.75 (95% CI 0.60-0.86) in the TSS, RT, and MT subgroups, respectively. The total remission rate after therapeutic approaches on recurrent CD patients was 0.64 (95% CI 0.60-0.68). A test for subgroup differences revealed there was a statistically significant difference between different subgroups (P = 0.01). The post hoc test showed that in comparison with RT, TSS (P = 0.0344) and MT (P = 0.0149) had a higher rate of remission. However, there was no statistically significant difference between separate therapeutic modalities in terms of complications including diabetes insipidus (P = 1.0) and hypopituitarism (P = 0.28).

CONCLUSIONS

Compared MT and TSS, RT has a statistically lower rate of remission. Although there is robust superiority of surgery over RT, interpretation of MT data must considered with caution due to the small number of included cases and wide CI range.

Outcome of Endoscopic Transsphenoidal Surgery for Recurrent or Residual Pituitary Adenomas and Comparison to Non-Recurrent or Residual Cohort by Propensity Score Analysis

OBJECTIVE

To evaluate the long-term outcomes and safety of endoscopic transsphenoidal surgery (ETS) in recurrent and residual pituitary adenomas (rrPAs), as well as the predictors of gross total resection (GTR) and intraoperative CSF leakage. Furthermore, to compare outcomes and complications with non-rrPAs cohort.

METHODS

Clinical and radiological characteristics of patients with rrPAs who underwent ETS were collected between 2017 and 2020. Data of patients with non-rrPAs were collected from 2019 to 2020. Logistic regression analyses were performed to investigate the factors influencing gross total resection (GTR) and intraoperative CSF leakage. Between-group comparisons of outcomes and complications were performed through propensity score analysis.

RESULTS

We enrolled 73 patients with rrPAs. GTR was achieved in 41 (56.1%) cases; further, GTR or near-total resection was achieved in 93.2% of patients. The mean tumor volumes for GTR and non-GTR cases were 6.2 ±7.2 cm³ and 11.1 ±9.1 cm³, respectively. Multivariate regression analysis of the GTR rate in patients with rrPAs revealed that Knosp grade was an independent factor (odds ratio [OR] = 0.324; p=0.005). Moreover, previous transcranial surgery and non-functional pituitary adenomas were risk factors for intraoperative CSF leakage in patients with rrPAs (OR=6.450, p=0.019 and OR=7.472, p=0.012, respectively). After propensity score matching, There was no significant difference in the GTR rate between patients with rrPAs and patients with non-rrPAs. Contrastingly, patients with rrPAs had a higher rate of intraoperative CSF leakage and longer postoperative hospital stay than patients with non-rrPAs. During the follow-up, vision improved in 9 (22.0%) and 24 (62.5%) patients with rrPAs and non-rrPAs, respectively. Although there was a trend that reoperation of rrPAs involved a lower hypopituitarism recovery rate and biochemical remission rate, as well as a higher hypopituitarism rate, there was no statistically significant between-group difference.

CONCLUSIONS

Knosp grade was an independent factor for GTR in endoscopic transsphenoidal surgery in patients with rrPAs. Previous transcranial surgery and non-functional PAs were risk factors for intraoperative CSF leakage. Although associated with longer hospital stay, rrPAs did not associate with lower GTR rate or more frequent postoperative complications than non-rrPAs cohort.

Carotid Artery-Cavernous Segment Injury during an Endoscopic Endonasal Surgery: A Case Report and Literature Review of the Overlooked Option for Surgical Trapping in the Hyperacute Phase

Internal carotid artery (ICA) injury is a catastrophic complication of endoscopic endonasal surgery (EES). However, its standard management, emergent endovascular treatment, may not always be available, and the transnasal approach may be insufficient to achieve hemostasis. A 44-year-old woman with pituitary adenoma underwent EES complicated with the ICA cavernous segment injury (CSI). In urgent intraoperative angiogram, a good collateral flow from the contralateral carotid circulation was observed. Due to the unavailability of intraoperative embolization, emergent surgical trapping was performed by combined transcranial and cervical approach. The patient recovered but later developed a giant cavernous pseudoaneurysm. During the pseudoaneurysm embolization, ICA was directly accessed via a 1.7-F puncture hole using a bare microcatheter technique. Then, both the aneurysm and parent artery were obliterated with coils. At the 4-year follow-up, the patient was asymptomatic without a residual tumor. To our knowledge, this is the first case of ICA-CSI during EES successfully treated with ICA trapping as a lifesaving urgent surgery that achieved a complete recovery after a pseudoaneurysm embolization. Although several studies reported that EES-related ICA-CSIs with percutaneous carotid artery access, neither our surgical salvage technique nor our carotid access and tract embolization techniques were previously described.

Guidelines in the management of CNS tumors

INTRODUCTION

Evidence-based, clinical practice guidelines in the management of central nervous system tumors (CNS) continue to be developed and updated through the work of the Joint Section on Tumors of the Congress of Neurological Surgeons (CNS) and the American Association of Neurological Surgeons (AANS).

METHODS

The guidelines are created using the most current and clinically relevant evidence using systematic methodologies, which classify available data and provide recommendations for clinical practice.

CONCLUSION

This update summarizes the Tumor Section Guidelines developed over the last five years for non-functioning pituitary adenomas, low grade gliomas, vestibular schwannomas, and metastatic brain tumors.

Surgical Outcomes Following Repeat Transsphenoidal Surgery for Nonfunctional Pituitary Adenomas: A Retrospective Comparative Study

BACKGROUND

Endonasal transsphenoidal surgery (ETSS) remains the preferred treatment for recurrent or residual nonfunctional pituitary adenomas (NFPAs). However, surgical complications and outcomes with repeat ETSS are unclear.

OBJECTIVE

To compare outcomes from primary and repeat ETSS in patients with NFPAs.

METHODS

Retrospective review of ETSS for NFPAs at USC University Hospital and LAC + USC Medical Center between 2000 and 2015. Patients with ≥3-mo follow-up data were included. Patients were categorized as primary or repeat ETSS. Patient and tumor characteristics were compared preoperatively, and postoperative outcomes were analyzed.

RESULTS

Two hundred sixty-eight patients (89%) met the inclusion criteria (primary ETSS = 211 and repeat ETSS = 57) with a mean follow-up time of 38 mo (range 3-235 mo). Both groups had similar demographics, endocrine function, and tumor characteristics. Surgical complication rates were similar and no mortalities were observed. Repeat ETSS patients had a higher rate of new postoperative panhypopituitarism (primary ETSS: 0.5% vs repeat ETSS: 7.1%, P = .011), lower rates of gross total resection (GTR; primary ETSS: 59.2% vs repeat ETSS: 26.3%, P = .001), and greater rates of postoperative radiosurgery (36.8% vs 24.2%, P = .009). At 2-yr follow-up, progression-free survival on MRI was similar in both groups (primary ETSS: 97.9% vs repeat ETSS: 95.4%, log-rank test P = .807).

CONCLUSION

At experienced tertiary pituitary centers, repeat ETSS for NFPAs was associated with a similar incidence of surgical complications as primary ETSS. However, repeat ETSS carried a higher rate for worsening endocrine dysfunction and a lower rate of GTR.

An advanced protocol for intraoperative visualization of sinunasal structures: experiences from pituitary surgery

OBJECTIVE

The transsphenoidal route to pituitary adenomas challenges surgeons because of the highly variable sinunasal anatomy. Orientation may be improved if the appropriate information is provided intraoperatively by image guidance. The authors developed an advanced image guidance protocol dedicated to sinunasal surgery that extracts information from multiple modalities and forms it into a single image that includes fine sinunasal structures and arteries.The aim of this study was to compare the advantages of this novel image guidance protocol with the authors' previous series, with emphasis on anatomical structures visualized and complication rate.

METHODS

This retrospective analysis comprised 200 patients who underwent surgery for pituitary adenoma via a transnasal transsphenoidal endoscopic approach. The authors' standard image guidance protocol consisting of CT for solid bone, T1CEMRI for soft tissues, and MRA for the carotid artery was applied in 100 consecutive cases. The advanced image guidance protocol added a first-hit ray casting of the CT scan for visualization of fine sinunasal structures, and adjustments to the MRA to visualize the sphenopalatine artery (SPA) were applied in a subsequent 100 consecutive cases.

RESULTS

A patent sphenoid ostium-i.e., an ostium not covered by a mucosal layer-was visualized significantly more often by the advanced protocol than the standard protocol (89% vs 40%, p < 0.001) in primary surgeries. The SPA and its branches were only visualized by the advanced protocol (87% and 91% of cases in primary surgeries and reoperations, respectively) and not once by the standard protocol. The number of visualized complete and incomplete sphenoid septations matched significantly more commonly with the surgical view when using the advanced protocol than the standard protocol at primary operation (mean 1.9 vs 1.6, p < 0.001). However, in 25% of all cases a complex and not a simple sinus anatomy was present. In comparison with the intraoperative results, a complex sphenoid sinus anatomy was always detected by the advanced but not by the standard protocol (25% vs 8.5%, p = 0.001).Furthermore, application of the advanced protocol reduced the cumulative rate of complications (25% vs 18% [standard vs advanced group]). Although an overall significant difference could not be determined (p = 0.228), a subgroup analysis of reoperations (35/200) revealed a significantly lower rate of complications in the advanced group (5% vs 30%, p = 0.028).

CONCLUSIONS

The data show that the advanced image guidance protocol could intraoperatively visualize the fine sinunasal sinus structures and small arteries with a high degree of detail. By improving intraoperative orientation, this may help to reduce the rate of complications in endoscopic transsphenoidal surgery, especially in reoperations.

Application of the Three Points and Three Lines Method to Accurately Open the Sellar Floor in Microscopic Transsphenoidal Surgery of Pituitary Adenomas

OBJECTIVE

In this study, the sellar floor morphology of patients with pituitary adenoma is analyzed and a simple yet reliable method is identified to determine the location of bone window opening.

METHODS

Clinical information of 144 consecutively admitted patients was retrospectively analyzed. Enhanced magnetic resonance imaging of the midsagittal plane was selected as the reference for classifying the sellar floor. Intraoperative tumor location, extent of tumor resection, and follow-up results were analyzed for different types of sellar floor. The tuberculum sellae, lowest point of the sphenoid sinus, and the lowest point of the sellar floor and 3 lines related to them were used to classify the sellar floor. This is referred to as the "three points and three lines" method.

RESULTS

Based on its location in the sphenoid sinus, the sellar floor can be classified into 4 types: 12 patients (8.3%) with high sellar, 70 (48.6%) with medium sellar, 30 (20.8%) with low sellar, and 32 (22.8%) with steep sellar. The maximum tumor diameter, maximum sellar floor diameter, and the intercarotid distance were all significantly different among patients with different types of sellar floor (P < 0.001). For all patients, quick intraoperative location of the sellar floor opening was achieved. A total of 104 patients (72.2%) had total tumor resection, 28 (19.40%) had subtotal tumor resection, and 4 (2.8%) had partial tumor resection. Twenty patients (13.9%) experienced cerebrospinal fluid leak, and there was no significant difference in cerebrospinal fluid leak rate among groups.

CONCLUSIONS

Presurgical classification and location of the sellar floor are critical for understanding and assessing the transsphenoidal approach. Different types of sellar floor appeared in the surgery with different morphologic features. The three points and three lines method helps the surgeon to predetermine the location of the sellar floor opening and to shorten surgical time.

Postsurgical Salvage Radiosurgery for Nonfunctioning Pituitary Adenomas Touching/Compressing the Optic Chiasm: Median 13-Year Postirradiation Imaging Follow-up Results

BACKGROUND

There is little information on long-term outcomes after salvage treatment by either surgery or stereotactic radiosurgery (SRS) for patients with recurrent/residual nonfunctioning pituitary adenomas (NFPAs).

OBJECTIVE

To reappraise the efficacy and safety of SRS for patients with NFPAs touching/compressing the optic apparatus (OA).

METHODS

We studied 27 patients (14 females, 13 males; mean age: 61 [range, 19-85] yr) who underwent SRS between 1998 and 2008 for NFPAs with such condition. The median tumor volume was 4.9 (range, 1.8-50.8) cc. To avoid excess irradiation to the OA, the lower part of the tumor was covered with a 50% or a 60% isodose gradient, ie 49% to 98% (mean, 84%; median, 88%) of the entire tumor received the selected doses. Median doses at the tumor periphery/OA were 7.6/11.0 (interquartile range [IQR], 5.8-9.1/10.1-11.8) Gy.

RESULTS

Seven patients (26%) were confirmed to be deceased due to unrelated diseases at a median post-SRS period of 149 (IQR, 83-158) mo. Follow-up magnetic resonance imaging (MRI) showed tumor growth in 2 patients (7%) at the 11th and 134th post-SRS month; the former underwent surgery and the other SRS. Excluding these 2 patients, the latest follow-up MRI examinations, performed 13 to 238 (median: 168, IQR: 120-180) mo after SRS, showed no size changes in 5 (19%) and shrinkage in 20 (74%) patients. Cumulative incidences of tumor growth control were 96.3% and 91.8% at the 120th and 180th post-SRS month. None of our patients developed subjective symptoms suggesting SRS-induced optic neuropathy or endocrinological impairment.

CONCLUSION

In patients with NFPAs touching/compressing the OA, SRS achieves good long-term results.

Successful application of stereotactic radiosurgery for multiply recurrent Rathke's cleft cysts

OBJECTIVE

Rathke's cleft cysts (RCCs) are benign lesions of the sella turcica that usually come to neurosurgical attention due to compression of the optic apparatus (OA) and headaches. Treatment options for these lesions include observation, aspiration of cyst contents, or open resection of the cyst with the cyst wall. All of these options involve the potential for cyst recurrence or enlargement. In this study the authors report on a potential new therapeutic option for RCCs, i.e., stereotactic radiosurgery (SRS).

METHODS

A retrospective review was conducted of 5 patients with histologically confirmed, multiply recurrent RCCs who were treated with single-fraction SRS at a tertiary referral academic medical center.

RESULTS

The total cohort consisted of 5 female patients with an average age of 31.8 years. The most common presenting symptom was headache followed by blurry vision. The symptoms were present on average for 7 months before intervention. The median number of surgeries prior to radiosurgery was 2. The average volume of lesion treated was 0.34 cm3. The median SRS dose was 12.5 Gy prescribed to the 50% isodose line with an average prescription coverage of 96.6%. The median dose to the OA was 5 Gy. At last follow-up, 3 of 5 cysts had completely regressed, 1 had regressed by more than 50% but was still present, and 1 was stable, with an overall mean follow-up duration of 34.2 months. There were no neurological, endocrinological, or visual complications attributable to SRS during the follow-up period.

CONCLUSIONS

RCCs can be a challenging clinical entity to treat, especially when they are multiply recurrent. In patients with an average of 2 previous surgeries for resection, a single SRS session prevented recurrence universally, with an average follow-up of almost 3 years. These results indicate that further investigation of the treatment of RCCs with SRS is indicated.

Current perspectives on recurrent pituitary adenoma: The role and timing of surgery vs adjuvant treatment

The clinical course of pituitary adenoma can be highly variable. Aggressive pituitary tumours may require multimodal therapy with multiple operations. Even standard pituitary adenomas exhibit relatively high long-term recurrence rates and delayed intervention is often required. The indications for revision surgery in the endoscopic era are expanding for both functioning and nonfunctioning tumours, including access to the cavernous sinus and intracranial compartments. Although revision surgery can be challenging, it has been demonstrated to be both safe and effective. The question of the use of early radiotherapy in pituitary adenoma remains controversial. Our increasing understanding of pituitary tumour biology facilitates individualized treatment and surveillance protocols, with early intervention in high-risk adenoma subtypes. In this review, we discuss the treatment options for recurring pituitary tumours and focus on the role of revision surgery.

A systematic review of effects and complications after transsphenoidal pituitary surgery: endoscopic versus microscopic approach

Background: Microscopic transsphenoidal surgery (MTS) has been considered as the gold standard for transsphenoidal pituitary surgery, but nowadays endoscopic transsphenoidal surgery (ETS) has become popular due to its wide view and improved lighting.Material and methods: The electronic databases were systematically searched, and the meta-analyses of the eligible studies that evaluated endoscopic versus microscopic methods in patients with pituitary surgery were conducted with Review Manager 5.0. The primary outcomes included visual improvement, gross tumor removal (GTR), cerebrospinal fluid (CFS) leak, diabetes insipidus (DI), other complications, and length of hospital stay. The Egger's test was conducted to estimate possible publication bias.Results: In total, 13 articles eventually met the inclusion criteria. The meta-analyses suggested that the differences with regard to visual improvement, overall complication rate, GTR, CSF leak, diabetes insipidus (DI), meningitis, visual impairment, syndrome of inappropriate antidiuretic hormone secretion (SIADH), new onset hypopituitarism, and hypothyroidism between the endoscopic and microscopic groups were not statistically significant. The length of hospital stay was much longer with the microscopic approach when compared with the endoscopic method.Conclusion: The endoscopic and microscopic approaches show similar effects and complication rates. The endoscopic technique could be adopted as a reasonable alternative in pituitary surgery.

Management of Nonfunctioning Recurrent Pituitary Adenomas

Pituitary adenomas are typically slow-growing benign tumors. However, 50% to 60% of tumors progress following subtotal resection and up to 30% recur after apparent complete resection. Options for treatment of recurrent pituitary adenomas include repeat surgical resection, radiation therapy, and systemic therapies. There is no consensus approach for the management of recurrent pituitary adenomas. This article reviews the natural history of recurrent adenomas and emerging biomarkers predictive of clinical behavior as well as the outcomes associated with the various treatment modalities for these challenging tumors, with an emphasis on the surgical treatment.

Superiority of constructive interference in steady-state MRI sequencing over T1-weighted MRI sequencing for evaluating cavernous sinus invasion by pituitary macroadenomas

OBJECTIVE

Preoperatively determining the extent of parasellar invasion of pituitary macroadenomas is useful for surgical planning and patient counseling. Here, the authors compared constructive interference in steady state (CISS), a T2-weighted gradient-echo MRI sequence, to volume-interpolated breath-hold examination (VIBE), a T1-weighted gradient-echo MRI sequence, for evaluation of cavernous sinus invasion (CSI) by pituitary macroadenomas.

METHODS

VIBE and CISS images of 98 patients with pituitary macroadenoma were retrospectively analyzed and graded using the modified Knosp classification. The Knosp grades were correlated to surgical findings of CSI, which were determined intraoperatively using 0° and 30° endoscopes. The predictive accuracies for CSI according to the Knosp grades derived from the CISS and VIBE images were compared using receiver operating characteristic (ROC) curves. Postoperative MRI was used to evaluate the gross-total resection (GTR) rates.

RESULTS

The CSI rate by pituitary macroadenomas was 27.6% (27 of 98 cases). Of 196 assessments (left and right sides of 98 macroadenomas), 45 (23.0%) had different Knosp grades when scored using VIBE versus CISS images. For the VIBE images, 0% of Knosp grade 0, 4.5% of grade 1, 23.8% of grade 2, 42.1% of grade 3A, 100% of grade 3B, and 83.3% of grade 4 macroadenomas were found to have CSI intraoperatively. For the CISS images, 0% of Knosp grade 0, 2.1% of grade 1, 31.3% of grade 2, 56.3% of grade 3A, 100% of grade 3B, and 100% of grade 4 macroadenomas were found to have CSI intraoperatively. Two pituitary macroadenomas were classified as grade 4 on VIBE sequences but grades 3A and 2 on CISS sequences; CSI was not observed intraoperatively in both cases. The GTR rate was 64.3% and 60.0% for high-grade (3A, 3B, and 4) macroadenomas classified using VIBE and CISS sequences, respectively. The areas under the ROC curves were 0.94 and 0.97 for VIBE- and CISS-derived Knosp grades (p = 0.007), respectively.

CONCLUSIONS

Knosp grades determined using CISS sequence images are better correlated with intraoperative CSI than those determined using VIBE sequence images. CISS sequences may be valuable for the preoperative assessment of pituitary macroadenomas.

Association of TGF-β1 and WIF1 Expression with 36 Paired Primary/Recurrent Nonfunctioning Pituitary Adenomas: A High-Throughput Tissue Microarrays Immunohistochemical Study

OBJECTIVE

This study was undertaken primarily to research transforming growth factor β1 (TGF-β1) and Wnt inhibitory factor 1 (WIF1) for the prediction of nonfunctioning pituitary adenoma (NFPAs) invasion and recurrence of tumor samples and the relations between quantitatively determined markers and clinical characters.

METHODS

We studied 104 patients, including 59 patients without recurrence and 45 patients with recurrence (9 patients with one surgery and 36 patients operated twice, both tumors being studied). All tissues were immunostained for TGF-β1 and WIF1 using tissue microarrays and confirmed with real-time quantitative reverse transcription polymerase chain reaction (qRT-PCR) and Western blot.

RESULTS

We found that invasion, TGF-β1, and WIF1 were significantly associated with recurrence and that age was associated with low expression of TGF-β1 and WIF1 (P < 0.001). There were no statistically significant differences in the expression of the 2 proteins between the noninvasive and the invasive groups. The expression of TGF-β1 and WIF1 in primary tumors in the recurrence group was lower than in the nonrecurrence group (P < 0.001). In the 36 paired primary or recurrent tumors, the expression of TGF-β1 and WIF1 in recurrent tumors was higher than the expression of primary tumors, which was confirmed with qRT-PCR and Western blot. Therefore, TGF-β1 and WIF1 seem to be related to recurrence or progression of pituitary adenomas.

CONCLUSIONS

The expression of TGF-β1 and WIF1 in NFPAs correlated with cell proliferation and recurrence potential. They may be good markers of progressive behavior in NFPAs; however, the biologic mechanism needs further study.

Imaging Evaluation of the Location and Fenestration of Sellar Floor During Endonasal Transsphenoidal Surgery in Patients with Pituitary Adenomas

OBJECTIVE

To evaluate clinical value of three-dimensional (3D) computed tomography (CT) reconstruction of the sphenoid sinus separation in localizing sellar floor during endonasal transsphenoidal surgery and determine size and location of sellar floor fenestration.

METHODS

There were 51 patients eligible for study inclusion. Preoperative CT scan of the paranasal sinus and CT scan and magnetic resonance imaging of the pituitary gland were obtained. Sphenoid sinus separation was reconstructed using Mimics 15.0 software, and quantity, shape, and orientation were observed and compared with intraoperative data to guide the localization of sellar floor. Anatomic variation of the sphenoid sinus and adjacent structures, tumor and sella turcica morphology, minimal distance between the cavernous segment of the internal carotid artery bilaterally, and shortest distance from the midline were measured.

RESULTS

Based on the shape of the sphenoid sinus separation, sellar floor was accurately localized in all cases. Intraoperative sphenoid sinus separation was consistent with preoperative three-dimensional CT reconstruction images. The sellar floor was extremely small in 2 patients, and insufficient fenestration of sellar floor negatively affected tumor resection. Preoperative three-dimensional CT reconstruction is helpful for accurate and rapid localization of sellar floor.

CONCLUSIONS

Anatomic variation of sphenoid sinus and adjacent structures, characteristics of tumor and sella, minimum distance between bilateral cavernous segment of the internal carotid artery, and shortest distance from midline are helpful for establishment of individualized sellar floor fenestration.

Endoscopic Endonasal Surgery Treatment Strategies for Invasive Pituitary Adenoma: Analysis of Four Approaches

OBJECTIVE

To explore the surgical methods and clinical effect of endoscopic endonasal approaches for the treatment of invasive pituitary adenomas (IPAs).

METHODS

A retrospective analysis was made of the clinical data of 74 patients (75 procedures) with IPAs treated by different endoscopic endonasal approaches at the Department of Neurosurgery, The First Affiliated Hospital of Shenzhen University from May 2014 to August 2017. The data include clinical manifestation, imaging features, surgical methods and complications, resection rate, cure rate, prognosis, and complications in different Knosp classifications and Hardy stages. The transcavernous approach was used in 47 patients, the lateral-cavernous approach was used in 14 patients, the tuberculum sella planum approach was used in 8 patients, and the diaphragma sellae open or dorsum sellae cut approach was used in 6 patients.

RESULTS

The gross total resection (GTR) rate was 70.7% (53 patients) and tumor residue rate was 29.3% (22 patients). GTR rate for pituitary adenoma according to Knosp classification was 89.3% in grade 3 and 28.6% in grade 4. The biology cure rate was 75.0% and 23.8%, respectively. There was significance between them (P < 0.05). In addition, the GTR rate of Hardy stage was 90.5% in stage C, 90.0% in stage D, 26.1% in stage E, and the biology cure rate was 80.1%, 75.0%, and 13.0%, respectively. There was significance among them (P < 0.05) Postoperative severe complications included 9 patients (12.0%) with cerebrospinal fluid leaks, 26 patients (34.7%)with electrolyte imbalance, 36 patients (48.0%) with transient diabetes insipidus, 22 patients (29.3%) with hypopituitarism, 2 patients (2.7%) with permanent hypopituitarism, and 2 patients (2.7%)with epistaxis. The follow-up lasted 2-41 months (average, 19.3 months). No patient experienced recurrence after GTR, 1 patient undergoing subtotal experienced recurrence and underwent reoperation, 3 patients underwent postoperative Gamma Knife treatment, and 2 patients with refractory IPA were given temozolomide and metformin chemotherapy.

CONCLUSIONS

According to the invasiveness of IPA, choosing the appropriate endoscopic surgical approach is helpful in removing tumors and reducing complications.

Clinical outcomes of endoscopic versus microscopic trans-sphenoidal surgery for large pituitary adenoma

OBJECTIVE

To compare clinical outcomes of large pituitary adenomas (≥3 cm in maximum diameter), operated on by Endoscopic Transsphenoidal Surgery (ETS), versus Microscopic Transsphenoidal Surgery (MTS).

METHODS

Medical records and MRI Scans of patients with a diagnosis of pituitary adenoma for whom transphenoidal surgery was done were reviewed. Complete pre and post-operative data were available for 121 patients. Thirty five patients had large pituitary adenoma and were enrolled in this study. ETS was done in 16 patients, and 19 underwent MTS. All patients were followed for at least six months. Clinical and imaging characteristics were reported in details. Post-operative clinical outcomes were defined as clinical outcomes persisted 6 months after surgery.

RESULTS

The average tumor size was 36.3 ± 4.4 mm in ETS group, and 34.0 ± 4.6 mm in MTS group, (p = .46). Six months after surgery, tumor size was 4.6 ± 6.6 mm in ETS and 17.7 ± 12.2 mm in MTS group, (p = .002). Gross total resection (GTR) was observed in the 81.2% of the patient in the ETS group. In the MTS group, GTR was observed in 15.8%. Post-operative clinical outcomes including new onset hypopituitarism, visual impairment, and permanent diabetes insipidus (DI) were comparable between the two groups.

CONCLUSION

ETS is superior to MTS in treatment of large pituitary adenomas with comparable post-operative complications.

Modular Classification of Endoscopic Endonasal Transsphenoidal Approaches to Sellar Region: Anatomic Quantitative Study

BACKGROUND

Endoscopic visualization does not necessarily correspond to an adequate working space. The need for balancing invasiveness and adequacy of sellar tumor exposure has recently led to the description of multiple endoscopic endonasal transsphenoidal approaches. Comparative anatomic data on these variants are lacking.

OBJECT

We sought to quantitatively compare endoscopic endonasal transsphenoidal approaches to the sella and parasellar region, using the concept of "surgical pyramid."

METHODS

Four endoscopic transsphenoidal approaches were performed in 10 injected specimens: 1) hemisphenoidotomy; 2) transrostral; 3) extended transrostral (with superior turbinectomy); and 4) extended transrostral with posterior ethmoidectomy. ApproachViewer software (part of GTx-Eyes II, University Health Network, Toronto, Canada) with a dedicated navigation system was used to quantify the surgical pyramid volume, as well as exposure of sellar and parasellar areas. Statistical analyses were performed with Friedman's tests and Nemenyi's procedure.

RESULTS

Hemisphenoidotomy provided limited exposure of the sellar area and a small working volume. A transrostral approach was necessary to expose the entire sella. Exposure of lateral parasellar areas required superior turbinectomy or posterior ethmoidectomy. The differences between each of the modules was statistically significant.

CONCLUSION

The present study validates, from an anatomic point of view, a modular classification of endoscopic endonasal transsphenoidal approaches to the sellar region.

Reoperation for growth hormone-secreting pituitary adenomas: report on an endonasal endoscopic series with a systematic review and meta-analysis of the literature

OBJECTIVE Surgery is generally the first-line therapy for acromegaly. For patients with residual or recurrent tumors, several treatment options exist, including repeat surgery, medical therapy, and radiation. Reoperation for recurrent acromegaly has been associated with poor results, with hormonal control usually achieved in fewer than 50% of cases. Extended endonasal endoscopic approaches (EEAs) may potentially improve the results of reoperation for acromegaly by providing increased visibility and maneuverability in parasellar areas. METHODS A database of all patients treated in the authors' center between July 2004 and February 2016 was reviewed. Cases involving patients with acromegaly secondary to growth hormone (GH)-secreting adenomas who underwent EEA were selected for chart review and divided into 2 groups: first-time surgery and reoperation. Disease control was defined by 2010 guidelines. Clinical and radiological characteristics and outcome data were extracted. A systematic review was done through a MEDLINE database search (2000-2016) to identify studies on the surgical treatment of acromegaly. Using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, the included studies were reviewed for surgical approach, tumor size, cavernous sinus invasion, disease control, and complications. Cases were divided into reoperation or first-time surgery for comparative analysis. RESULTS A total of 44 patients from the authors' institution were included in this study. Of these patients, 2 underwent both first-time surgery and reoperation during the study period and were therefore included in both groups. Thus data from 46 surgical cases were analyzed (35 first-time operations and 11 reoperations). The mean length of follow-up was 70 months (range 6-150 months). The mean size of the reoperated tumors was 14.8 ± 10.0 mm (5 micro- and 6 macroadenomas). The patients' mean age at the time of surgery was younger in the reoperation group than in the first-time surgery group (34.3 ± 12.8 years vs 49.1 ± 15.7 years, p = 0.007) and the mean preoperative GH level was also lower (7.7 ± 13.1 μg/L vs 25.6 ± 36.8 μg/L, p = 0.04). There was no statistically significant difference in disease control rates between the reoperation (7 [63.6%] of 11) and first-time surgery (25 [71.4%] of 33) groups (p = 0.71). Univariate analysis showed that older age, smaller tumor size, lower preoperative GH level, lower preoperative IGF-I level, and absence of cavernous sinus invasion were associated with higher chances of disease control in the first-time surgery group, whereas only absence of cavernous sinus invasion was associated with disease control in the reoperation group (p = 0.01). There was 1 case (9%) of transient diabetes insipidus and hypogonadism and 1 (9%) postoperative nasal infection after reoperation. The systematic review retrieved 29 papers with 161 reoperation and 2189 first-time surgery cases. Overall disease control for reoperation was 46.8% (95% CI 20%-74%) versus 56.4% (95% CI 49%-63%) for first-time operation. Reoperation and first-time surgery had similar control rates for microadenomas (73.6% [95% CI 32%-98%] vs 77.6% [95% CI 68%-85%]); however, reoperation was associated with substantially lower control rates for macroadenomas (27.5% [95% CI 5%-57%] vs 54.3% [95% CI 45%-62%]) and tumors invading the cavernous sinus (14.7% [95% CI 4%-29%] vs 38.5% [95% CI 27%-50%]). CONCLUSIONS Reoperative EEA for acromegaly had results similar to those for first-time surgery and rates of control for macroadenomas that were better than historical rates. Cavernous sinus invasion continues to be a negative prognostic indicator for disease control; however, results with EEA show improvement compared with results reported in the prior literature.

Reoperative endoscopic endonasal surgery for residual or recurrent pituitary adenomas

OBJECTIVE

Regrowth of the lesion after surgical removal of pituitary adenomas is uncommon unless subtotal resection was originally achieved in the first surgery. Treatment for recurrent tumor can involve surgery or radiotherapy. Locations of residual tumor may vary based on the original approach. The authors evaluated the specific sites of residual or recurrent tumor after different transsphenoidal approaches and describe the surgical outcome of endoscopic endonasal transsphenoidal reoperation.

METHODS

The authors analyzed a prospectively collected database of a consecutive series of patients who had undergone endoscopic endonasal surgeries for residual or recurrent pituitary adenomas after an original transsphenoidal microscopic or endoscopic surgery. The site of the recurrent tumor and outcome after reoperation were noted and correlated with the primary surgical approach. The chi-square or Fisher exact test was used to compare categorical variables, and the Mann-Whitney U-test was used to compare continuous variables between surgical groups.

RESULTS

Forty-one patients underwent surgery for residual/recurrent pituitary adenoma from 2004 to 2015 at Weill Cornell Medical College. The previous treatment was a transsphenoidal microscopic (n = 22) and endoscopic endonasal (n = 19) surgery. In 83.3% patients (n = 30/36) there was postoperative residual tumor after the initial surgery. A residual tumor following endonasal endoscopic surgery was less common in the sphenoid sinus (10.5%; 2/19) than it was after microscopic transsphenoidal surgery (72.7%; n =16/22; p = 0.004). Gross-total resection (GTR) was achieved in 58.5%, and either GTR or near-total resection was achieved in 92.7%. Across all cases, the average extent of resection was 93.7%. The rate of GTR was lower in patients with Knosp-Steiner Grade 3–4 invasion (p < 0.0005). Postoperative CSF leak was seen in only one case (2.4%), which stopped with lumbar drainage. Visual fields improved in 52.9% (n = 9/17) of patients and were stable in 47% (n = 8/17). Endocrine remission was achieved in 77.8% (n = 14/18) of cases, 12 by surgery alone and 2 by adjuvant medical (n = 1) and radiation (n = 1) therapy. New diabetes insipidus occurred in 4.9% (n = 2/41) of patients—in one of whom an additional single anterior hormonal axis was compromised—and 9.7% (n = 4/41) of patients had a new anterior pituitary hormonal insufficiency.

CONCLUSIONS

Endonasal endoscopic reoperation is extremely effective at removing recurrent or residual pituitary adenomas that remain after a prior surgery, and it may be preferable to radiation therapy particularly in symptomatic patients. Achievement of GTR is less common when lateral cavernous sinus invasion is present. The locations of residual/recurrent tumor were more likely sphenoidal and parasellar following a prior microscopic transsphenoidal surgery and sellar following a prior endonasal endoscopic surgery.

Efficacy of sellar opening in the pituitary adenoma resection of transsphenoidal surgery influences the degree of tumor resection

Background

Endonasal transsphenoidal microsurgery is often adopted in the resection of pituitary adenoma, and has showed satisfactory treatment and minor injuries. It is important to accurately localize sellar floor and properly incise the bone and dura matter.

Methods

Fifty-one patients with pituitary adenoma undergoing endonasal transsphenoidal microsurgery were included in the present study. To identify the scope of sellar floor opening, CT scan of the paranasal sinus and MRI scan of the pituitary gland were performed for each subject. Intraoperatively, internal carotid artery injury, leakage of cerebrospinal fluid, and tumor texture were recorded, and postoperative complications and residual tumors were identified.

Result

The relative size of sellar floor opening significantly differed among the pituitary micro-, macro- and giant adenoma groups, and between the total and partial tumor resection groups. The ratio of sellar floor opening area to maximal tumor area was significantly different between the total and partial resection groups. Logistic regression analysis revealed that the ratio of sellar floor opening area to the largest tumor area, tumor texture, tumor invasion and age were independent prognostic factors. The vertical distance between the top point of sellar floor opening and planum sphenoidale significantly differed between the patients with and without leakage of cerebrospinal fluid.

Conclusion

These results together indicated that relatively insufficient sellar floor opening is a cause of leading to residual tumor, and the higher position of the opening and closer to the planum sphenoidale are likely to induce the occurrence of leakage of cerebrospinal fluid.

Extent of Resection, Visual, and Endocrinologic Outcomes for Endoscopic Endonasal Surgery for Recurrent Pituitary Adenomas

OBJECTIVE

To assess outcomes after endoscopic endonasal surgery for recurrent or residual pituitary adenomas.

METHODS

We retrospectively analyzed 61 patients from 2009 to 2016 who underwent endoscopic endonasal surgery for recurrent or residual pituitary adenomas after previous microscopic or endoscopic transsphenoidal operation.

RESULTS

The previous surgical approach was endoscopic endonasal in 55.7% and microscopic in 44.2% of patients. The mean preoperative maximal tumor diameter was 2.3 cm. Tumor commonly invaded the suprasellar cistern (63.9%). Gross total resection (GTR) was achieved in 31 patients (51.7%). GTR rate was 68.4% and 21.7% for Knosp grade 0-2 and grade 3-4 tumors, respectively (P < 0.001). GTR was 73.1% and 35.3% for patients with previous microscopic and endoscopic transsphenoidal surgery, respectively (P = 0.002). On multivariate analysis, smaller tumor size (odds ratio [OR], 1.1 per cm; P = 0.007), Knosp grade 0-2 (OR, 9.7; P = 0.002), and previous microscopic approach (OR, 12.7; P = 0.007) were independent predictors of GTR. Preoperative visual deficit outcome was improved in 32.5%, unchanged in 62.5%, and worse in 5.0%. New postoperative endocrinopathies included adrenal insufficiency (6.5%), hypothyroidism (8.1%), hypogonadism (6.5%), and diabetes insipidus (4.9%). Complications included postoperative cerebrospinal fluid leak (4.9%), meningitis (1.6%), medical complications (4.9%), and postoperative hematoma requiring re-exploration (3.2%).

CONCLUSIONS

The endoscopic endonasal approach provides a safe and effective option for recurrent pituitary adenomas. Smaller tumor size, absence of cavernous sinus invasion, and previous microscopic approach were independent predictors of GTR. This finding might suggest that inadequate exposure or limited viewing angle may adversely affect extent of resection in primary microscopic surgeries.

Recent Evolution of Endoscopic Endonasal Surgery for Treatment of Pituitary Adenomas

For the treatment of pituitary tumors, microscopic transsphenoidal surgery has been considered the "gold standard" since the late 1960s. Over the last two decades, however, a worldwide shift towards endoscopic endonasal surgery is in progress for many reasons. These include a wide panoramic view, improved illumination, an ability to look around anatomical corners using angled tip and, in addition, application to the extended approaches for parasellar tumors. Both endoscopic and microscopic approaches appear equally effective for nonfunctioning adenomas without significant suprasellar or lateral extensions, whereas the endoscopic approach may improve outcomes associated with the extent of resection and postoperative complications for larger tumors. Despite many theoretical benefits in the endoscopic surgery, remission rates of functioning adenomas do not substantially differ between the approaches in experienced hands. The endoscopic approach is a valid alternative to the microscopic approach for adenomas. The benefits will be more appreciated in the extended surgery for parasellar tumors.

Endoscopic Endonasal Versus Microscopic Transsphenoidal Surgery for Recurrent and/or Residual Pituitary Adenomas

OBJECTIVE

Surgery for recurrent/residual pituitary adenomas is increasingly being performed through endoscopic surgery. Whether this new technology has altered the indications and outcomes of surgery is unknown. We conducted a systematic review and meta-analysis of published studies to compare the indications and outcomes between microscopic and endoscopic approaches.

METHODS

A PubMed search was conducted (1985-2015) to identify surgical series of endoscopic endonasal and microscopic transsphenoidal resection of residual or recurrent pituitary adenomas. Data were extracted regarding tumor characteristics, surgical treatment, extent of resection, endocrine remission, visual outcome, and complications.

RESULTS

Twenty-one studies met inclusion criteria. A total of 292 patients were in the endoscopic group, and 648 patients were in the microscopic group. Endoscopic cases were more likely nonfunctional (P < 0.001) macroadenomas (P < 0.001) with higher rates of cavernous sinus invasion (P = 0.012). The pooled rate of gross total tumor resection was 53.5% for the endoscopic group and 46.6% for the microscopic group. Endocrine remission was achieved in 53.0% and 46.7% of patients, and visual improvement occurred in 73.2% and 49.6% for the endoscopic and microscopic groups. Cerebrospinal fluid leak and pituitary insufficiency were higher in the endoscopic group.

CONCLUSION

This meta-analysis indicates that the use of the endoscope to reoperate on residual or recurrent adenomas has only led to modest increases in resection rates. However, larger more complex cases are being tackled, so direct comparisons are misleading. The most dramatic change has been in visual improvement along with modest increases in risk. Reoperation for recurrent or residual adenomas is a safe and effective treatment option.

Endoscopic endonasal control of the paraclival internal carotid artery by Fogarty balloon catheter inflation: an anatomical study

OBJECTIVE Neurosurgical management of many vascular and neoplastic lesions necessitates control of the internal carotid artery (ICA). The aim of this study was to investigate the feasibility of achieving control of the ICA through the endoscopic endonasal approach by temporary occlusion with a Fogarty balloon catheter. METHODS Ten endoscopic endonasal paraseptal approaches were performed on cadaveric specimens. A Fogarty balloon catheter was inserted through a sellar bony opening and pushed laterally and posteriorly extraarterially along the paraclival carotid artery. The balloon was then inflated, thus achieving temporary occlusion of the vessel. The position of the catheter was confirmed with CT scans, and occlusion of the ICA was demonstrated with angiography. The technique was performed in 2 surgical cases of pituitary macroadenoma with cavernous sinus invasion. RESULTS Positioning the Fogarty balloon catheter at the level of the paraclival ICA was achieved in all cadaveric dissections and surgical cases through a minimally invasive, quick, and safe approach. Inflation of the Fogarty balloon caused interruption of blood flow in 100% of cases. CONCLUSIONS Temporary occlusion of the paraclival ICA performed through the endoscopic endonasal route with the aid of a Fogarty balloon catheter may be another maneuver for dealing with intraoperative ICA control. Further clinical studies are required to prove the efficacy of this method.

Repeated transsphenoidal surgery for resection of pituitary adenoma

To investigate the surgical strategy of repeated microscopic transsphenoidal surgery (TSS) for treatment of pituitary adenoma, surgical techniques and treatment outcomes for 29 patients with pituitary adenoma were reviewed and analyzed. There were 17 patients who underwent TSS 18 times and 12 patients who underwent TSS 13 times. The interval between each TSS ranged from 3 months to 18 years, with a median time of 4 years. The tumor height was 15 to 45 mm on the last surgery. Among the 29 patients, 16 patients underwent total tumor resection, 11 patients underwent subtotal resection, and 2 patients underwent partial resection. Cerebrospinal fluid leak occurred in 10 patients. Among 24 patients who were followed up effectively, 1 patient developed abducens paralysis after surgery, 1 patient had chronic diabetes insipidus, and 1 patient received steroid-dependent alternative treatment. The repeated TSS may present satisfied outcomes in experienced hands. The upper edge of the posterior choanae should be identified to ensure the right orientation. The openings of the anterior wall of the sphenoid sinus and the sellar floor should be appropriately expanded to improve tumor exposure. The artificial materials should be identified and removed carefully. Intraoperative cerebrospinal fluid leakage should be managed well.

Endoscopic endonasal approach for pituitary adenomas: a series of 555 patients

PURPOSE

To report the results of a consecutive series of patients who underwent an endoscopic endonasal approach (EEA) for resection of a pituitary adenoma and compare them to previous series of microscopic and endoscopic approaches.

METHODS

A retrospective review of clinical and radiographic outcomes of a consecutive series of patients operated at our center between 2002 and 2011 was performed.

RESULTS

555 patients underwent an EEA for removal of a pituitary adenoma. The mean follow up was 3.1 years (range 3 months to 9.5 years); 36 were lost to follow up. Ninety-one (17.5%) harbored recurrent adenomas. An expanded approach to reach the supra-, para- and infra-sellar spaces was employed in 290 patients (55.9%). Reconstruction with a nasal septal flap was used in 238 cases (65.6%). The rate of gross total resection was 65.3% in the 359 patients with non-functioning adenomas. The remission rates with EEA alone were 82.5% in the 57 ACTH-secreting adenomas, 65.3% in the 49 GH-secreting adenomas and 54.7% in the 53 prolactinomas. Of the 237 patients presenting with visual loss, 190 (80.2%) improved or normalized, 41 (17.3%) remained unchanged and 4 (1.7%) experienced transient visual deterioration due to postoperative apoplexy. In addition, no patient without preexisting visual loss suffered new visual decline. The overall post-operative CSF leak rate was 5% and this decreased to 2.9% after the introduction of reconstruction with the naso-septal flap. Two patients (0.3%) had an ICA injury.

CONCLUSIONS

The EEA is a safe and effective way to surgically approach pituitary adenomas, particularly in recurrent tumors, those with supra-sellar extension or cavernous sinus invasion. The remission and complication rates are comparable or favorable compared with those reported in previous series of microscopic and endoscopic approaches.

Carotid artery injury during endoscopic endonasal skull base surgery: incidence and outcomes

BACKGROUND

Injury to the internal carotid artery (ICA) during endoscopic endonasal skull base surgery is a feared complication that is not well studied or reported.

OBJECTIVE

To evaluate the incidence, to identify potential risk factors, and to present management strategies and outcomes of ICA injury during endonasal skull base surgery at our institution.

METHODS

We performed a retrospective review of all endoscopic endonasal operations performed at our institution between 1998 and 2011 to examine potential factors predisposing to ICA injury. We also documented the perioperative management and outcomes after injury.

RESULTS

There were 7 ICA injuries encountered in 2015 endonasal skull base surgeries, giving an incidence of 0.3%. Most injuries (5 of 7) involved the left ICA, and the most common diagnosis was chondroid neoplasm (chordoma, chondrosarcoma; 3 of 7 [2% of 142 cases]). Two injuries occurred during 660 pituitary adenoma resections (0.3%). The paraclival ICA segment was the most commonly injured site (5 of 7), and transclival and transpterygoid approaches had a higher incidence of injury, although neither factor reached statistical significance. Four of 7 injured ICAs were sacrificed either intraoperatively or postoperatively. No patient suffered a stroke or neurological deficit. There were no intraoperative mortalities; 1 patient died postoperatively of cardiac ischemia. One of the 3 preserved ICAs developed a pseudoaneurysm over a mean follow-up period of 5 months that was treated endovascularly.

CONCLUSION

ICA injury during endonasal skull base surgery is an infrequent and manageable complication. Preservation of the vessel remains difficult. Chondroid tumors represent a higher risk and should be resected by surgical teams with significant experience.

Endoscopic endonasal transsphenoidal approach to large and giant pituitary adenomas: institutional experience and predictors of extent of resection

Object

While the use of endoscopic approaches has become increasingly accepted in the resection of pituitary adenomas, limited evidence exists regarding the success of this technique for patients with large and giant pituitary adenomas. This study reviews the outcomes of a large cohort of patients with large and giant pituitary adenomas who underwent endoscopic endonasal transsphenoidal surgery at the authors' institution and focuses on identifying factors that can predict extent of resection and hence aid in developing guidelines and indications for the use of endoscopic endonasal transsphenoidal surgery versus open craniotomy approaches to large and giant pituitary adenomas.

Methods

The authors reviewed 487 patients who underwent endoscopic endonasal transsphenoidal resection of sellar masses. From this group, 73 consecutive patients with large and giant pituitary adenomas (defined as maximum diameter ≥ 3 cm and tumor volume ≥ 10 cm3) who underwent endoscopic endonasal transsphenoidal surgery between January 1, 2006, and June 6, 2012, were included in the study. Clinical presentation, radiological studies, laboratory investigations, tumor pathology data, clinical outcomes, extent of resection measured by volumetric analysis, and complications were analyzed.

Results

The mean preoperative tumor diameter in this series was 4.1 cm and the volume was 18 cm3. The average resection rate was 82.9%, corresponding with a mean residual volume of 3 cm3. Gross-total resection was achieved in 16 patients (24%), near-total in 11 (17%), subtotal in 24 (36%), and partial in 15 (23%). Seventy-three percent of patients experienced improvement in visual acuity, while 24% were unchanged. Visual fields were improved in 61.8% and unchanged in 5.5%. Overall, 27 patients (37%) experienced a total of 32 complications. The most common complications were sinusitis (14%) and CSF leak (10%). Six patients underwent subsequent radiation therapy because of aggressive tumor histopathology. No deaths occurred in this cohort of patients. Statistically significant predictors of extent of resection included highest Knosp grade (p = 0.001), preoperative tumor volume (p = 0.025), preoperative maximum tumor diameter (p = 0.002), hemorrhagic component (p = 0.027), posterior extension (p = 0.001), and sphenoid sinus invasion (p = 0.005).

Conclusions

Endoscopic endonasal transsphenoidal surgery is an effective treatment method for patients with large and giant pituitary adenomas, which results in high (> 80%) rates of resection and improvement in visual function. It is not associated with high rates of major complications and is safe when performed by experienced surgeons. The preoperative Knosp grade, tumor volume, tumor diameter, hemorrhagic components on MRI, posterior extension, and sphenoid sinus invasion may allow a prediction of extent of resection and in these patients a staged operation may be required to maximize extent of resection.

Growth patterns of pituitary adenomas and histopathological correlates

CONTEXT

The factors associated with pituitary adenoma (PA) growth rate remain unclear.

OBJECTIVE

The objective of the study was to establish whether the preoperative growth and extension pattern of PA can predict postoperative growth rate and recurrence in addition to whether the PA growth rate correlates with proliferation and growth factor expression.

PATIENTS

One hundred fifty-three consecutive patients who underwent surgery for pituitary adenoma from 1999 to 2011 at Toronto Western Hospital were identified.

MAIN OUTCOME MEASURES

The PA growth rate was measured both pre- and postoperatively, and its association with patient demographics, magnetic resonance imaging, and histolopathological parameters was determined.

RESULTS

The preoperative growth rate was associated with age (P = .0001), suprasellar growth (P = .003), the presence of a cyst/hemorrhage (P = .004), the mindbomb homolog-1 (P = .005), fibroblast growth factor receptor-4 positivity (P = .047), and p27 negativity (P = .007). After surgery, there were 34.6% residual volumes, which were associated with older age (P = .038) and also with growth patterns including anterior, posterior, suprasellar, and cavernous sinus extension (P = .001); 43.3% of these residuals grew and postoperative growth rate was calculated. Pre- and postoperative growth rates were correlated (r = 0.497, P = .026). Postoperative growth rate was associated with age (P = .015) and gender (P = .017).

CONCLUSIONS

Our data suggest that the growth rate of PAs are influenced by various patient- and tumor-specific characteristics including the age and sex of the patient, the specific subtype of PA, its hormonal activity, its immunohistochemical profile including the mindbomb homolog 1 labeling index status, and its preponderance for different growth directions relative to the pituitary fossa. Furthermore, the pre- and postoperative PA growth rates were correlated, suggesting that postoperative PA growth rates can be predicted, in part, by preoperative growth rates, thus better informing postoperative outcome.

Lateral transorbital neuroendoscopic approach to the lateral cavernous sinus

Objective To design and assess the quality of a novel lateral retrocanthal endoscopic approach to the lateral cavernous sinus. Design Computer modeling software was used to optimize the geometry of the surgical pathway, which was confirmed on cadaver specimens. We calculated trajectories and surgically accessible areas to the middle fossa while applying a constraint on the amount of soft tissue retraction. Setting Virtual computer model to simulate the surgical approach and cadaver laboratory. Participants The authors. Main Outcome Measures Adequate surgical access to the lateral cavernous sinus and adjacent regions as determined by operations on the cadaver specimens. Additionally, geometric limitations were imposed as determined by the model so that retraction on soft tissue structures was maintained at a clinically safe distance. Results Our calculations revealed adequate access to the lateral cavernous sinus, Meckel cave, orbital apex, and middle fossa floor. Cadaveric testing revealed sufficient access to these areas using <10 mm of orbital retraction. Conclusions Our study validates not only the use of computer simulation to plan operative approaches but the feasibility of the lateral retrocanthal approach to the lateral cavernous sinus.

Management options for persistent postoperative acromegaly

This article presents management options for the patient with acromegaly after noncurative surgery. The current evidence for repeat surgery, adjuvant medical therapy with somatostatin analogues, dopamine agonists, the growth hormone receptor antagonist pegvisomant, combination medical therapy, and radiotherapy in the context of persistent postoperative disease are summarized. The relative advantages and disadvantages of each of these treatment modalities are explored, and a general treatment algorithm that integrates these modalities is proposed.