Cost-Effectiveness Analysis of Microscopic and Endoscopic Transsphenoidal Surgery Versus Medical Therapy in the Management of Microprolactinoma in the United States

Clinical use of [18F]fluoro-ethyl-L-tyrosine PET co-registered with MRI for localizing prolactinoma remnants

PURPOSE

To assess the utility of [18F]fluoroethyl-L-tyrosine PET co-registered with magnetic resonance imaging ([18F]FET-PET/MRICR) in patients with difficult-to-localize prolactinoma to inform clinical decision-making and (surgical) treatment planning.

METHODS

Retrospective cohort study of 17 consecutive patients with prolactinoma undergoing [18F]FET-PET/MRICR between October 2020 and September 2022 for either (1) additional information in case of difficult-to-visualize remnants after prior transsphenoidal surgery (TSS), or pharmacological treatment, or (2) radiological diagnosis in absence of a (clear) adenoma on diagnostic/post-treatment conventional MRI.

RESULTS

[18F]FET-PET/MRICR identified a lesion in 14/17 patients, yet failed to identify active lesions in 2 patients with negative conventional MRI despite prolactin > 7.5 times upper limit of normal. [18F]FET-PET/MRICR results were inconclusive in 1 patient due to diffuse tracer uptake 10 weeks post-surgery. [18F]FET-PET/MRICR was completely concordant with a suspected lesion on conventional MRI in 10/17 patients, and partially concordant in 3/17 patients. New foci were identified in 4/17 patients. The [18F]FET-PET/MRICR conclusions influenced clinical shared decision-making in 15/17 patients, of whom 7 patients underwent TSS and 8 refrained from TSS. One patient underwent TSS despite negative [18F]FET-PET/MRICR, and one patient underwent additional imaging. Intraoperative findings corresponded with [18F]FET-PET/MRICR in 5/8 patients, and immunohistochemistry was positive in 5/8 patients. The treatment goal was achieved in 7/8 patients, and remission was achieved in 5/7 patients in whom total resection was considered feasible.

CONCLUSION

[18F]FET-PET/MRICR can be of added value in the preoperative decision-making process for selected patients with difficult-to-localize prolactinoma (remnants), or patients lacking a substrate on conventional MRI.

Prognostic factors for surgical treatment of prolactin-secreting pituitary adenomas

Introduction

Usually, prolactinomas are treated with dopamine agonists (DA). Surgery is considered an option when the patient cannot bear or does not respond positively to DA therapy.

Aim

This study aims to determine the early and late outcomes of surgery, with particular emphasis on developing prognostic factors for surgical treatment and analyzing risk factors affecting the recurrence of hyperprolactinemia and prolactinoma.

Material and methods

This retrospective study was conducted at the Feofaniya Clinical Hospital of the State Administration of Affairs (Kyiv, Ukraine), evaluating 109 patients' records from 2009 to 2019. The main patients' inclusion criteria were: serum prolactin (PRL) level of more than 100 ng/ml, presence of pituitary adenoma (PA) on MRI, histologically approved PA by microscopy. According to the size of the prolactin-secreting PA (PSPAs) the selected 109 patients were divided into two groups: micro- (≤10 mm, n = 75) and macroadenoma group (10-40 mm, n = 34).

Results

1 month after the operation, PRL levels decreased by 87% (p < 0.001), 12 months-by 93% (p < 0.001). After receiving surgery and DA therapy for 12 months 77.1% of patients achieved biochemical remission. Out of the total number of patients observed, 15.6% (n = 17) had a Knosp score greater than 3. Additionally, in the macroadenoma group, the percentage of patients with a Knosp score greater than 3 was 41,2%, which was significantly higher as compared to the microadenoma group (4%, p < 0.001). In patients with microadenomas a weak reverse correlation between patients' age (r = -0.258, p < 0.026) and positive with tumor size (r = 0.251, p < 0.030) was revealed. In the macroadenoma group significant association was found only between preoperative serum PRL level and tumor size (r = 0.412, p < 0.016). The preoperative PRL can be used as a diagnostic marker for lack of early biochemical remission in patients with PSPAs with diagnostic accuracy 66.9%.

Conclusions

This study found that primary transsphenoidal surgery is an effective treatment in reaching PRL level control in patients with both micro- and macroprolactinomas. The correct and thorough selection of candidates for surgery is crucial to achieve postoperative serum PRL normalization in the vast majority of patients.

A pharmacoeconomic analysis from Italian guidelines for the management of prolactinomas

Background

Prolactinoma, the most common pituitary adenoma, is usually treated with dopamine agonist (DA) therapy like cabergoline. Surgery is second-line therapy, and radiotherapy is used if surgical treatment fails or in relapsing macroprolactinoma.

Objective

This study aimed to provide economic evidence for the management of prolactinoma in Italy, using a cost-of-illness and cost-utility analysis that considered various treatment options, including cabergoline, bromocriptine, temozolomide, radiation therapy, and surgical strategies.

Methods

The researchers conducted a systematic literature review for each research question on scientific databases and surveyed a panel of experts for each therapeutic procedure's specific drivers that contributed to its total cost.

Results

The average cost of the first year of treatment was €2,558.91 and €3,287.40 for subjects with microprolactinoma and macroprolactinoma, respectively. Follow-up costs from the second to the fifth year after initial treatment were €798.13 and €1,084.59 per year in both groups. Cabergoline had an adequate cost-utility profile, with an incremental cost-effectiveness ratio (ICER) of €3,201.15 compared to bromocriptine, based on a willingness-to-pay of €40,000 per quality-adjusted life year (QALY) in the reference economy. Endoscopic surgery was more cost-effective than cabergoline, with an ICER of €44,846.64. Considering a willingness-to-pay of €40,000/QALY, the baseline findings show cabergoline to have high cost utility and endoscopic surgery just a tad above that.

Conclusions

Due to the favorable cost-utility profile and safety of surgical treatment, pituitary surgery should be considered more frequently as the initial therapeutic approach. This management choice could lead to better outcomes and an appropriate allocation of healthcare resources.

Care trajectories of surgically treated patients with a prolactinoma: why did they opt for surgery?

PURPOSE

To describe care trajectories in patients with prolactinoma, aiming to clarify the rationale for surgery.

METHODS

Retrospective observational cohort study of consecutive patients with prolactinoma undergoing surgery from 2017 to 2019 at the referral center (RC), prior to surgery being considered a viable treatment option (i.e. PRolaCT study). Demographics and clinical data (type and duration of pretreatment and surgical indications, goals, and outcomes) were collected from patient records. Care trajectories were divided into three phases: (1) diagnosis and initial treatment, (2) endocrine treatment at the RC, and (3) surgical treatment.

RESULTS

40 patients were included (31 females (77.5%), median age 26.5 (14-63) years. Indications for surgery were dopamine agonist (DA) intolerance (n = 31, 77.5%), resistance (n = 6, 15.0%), and patient/physician preference (n = 3, 7.5%). Patients were pretreated with DA (n = 39 (97.5%)), and surgery (n = 3 (7.5%)). Median disease duration at surgery was 4 (0-27) years. Primary surgical goal was total resection in 38 patients (95.0%), of which biochemical remission was achieved 6 months postoperatively in 23 patients (62.2%), and clinical remission in 6 patients (16.2%), missing data n = 1.

CONCLUSION

Care trajectories were highly individualized based on patient and tumor characteristics, as well as the multidisciplinary team's assessment (need for alternative treatment, surgical chances and risks). Most patients were pretreated pharmacologically and had broad variation in timing of referral, undergoing surgery as last-resort treatment predominantly due to DA intolerance. High quality imaging and multidisciplinary consultations with experienced neurosurgeons and endocrinologists enabling treatment tailored to patients' needs were prerequisites for adequate counseling in treatment of patients with prolactinoma.

Clival Chordomas in the Endoscopic Endonasal Era: Comparison With Management With Open Skull Base Approaches

BACKGROUND

The most significant paradigm shift in surgical management of skull base chordomas has been the adoption of the endoscopic endonasal approach, but the impact on patient outcomes compared with open skull base approaches remains unclear.

OBJECTIVE

To compare a large series of patients treated by a single surgeon using primarily endoscopic endonasal approaches with previously published outcomes by the same surgeon using open skull base approaches.

METHODS

Between 2006 and 2020, 68 patients with skull base chordoma underwent resection using primarily endoscopic endonasal approaches. Outcomes and complications were compared with previously published results of resection of chordomas from 1991 to 2005 using open skull base approaches.

RESULTS

Compared with the prior cohort, the current principally endoscopic cohort demonstrated similar rates of OS ( P = .86) and progression-free survival ( P = .56), but patients undergoing first-time resection had significantly higher rates of radical resection (82.9% compared with 64.3%, P = .05) and required fewer staged surgeries (9.8% compared with 33.3%, P = .01).

CONCLUSION

There was no difference in survival rates for patients treated in the current era, primarily using endoscopic endonasal techniques, compared with previously published results using open skull-base approaches by the same surgeon. Although use of endoscopic endonasal approach resulted in higher rates of radical resection, patients undergoing first-time resection and fewer staged surgeries were required.

Implementation of a Streamlined Care Pathway to Reduce Cost and Length of Stay for Patients Undergoing Endoscopic Transsphenoidal Pituitary Surgery

BACKGROUND

We implemented a streamlined care pathway for patients undergoing endoscopic transsphenoidal (TSA) pituitary surgery. Select patients are recovered in the postanesthesia care unit and transferred to a step-down unit for intermediate neurologic care (INCU), with clinicians trained to manage cerebrospinal fluid leak, diabetes insipidus (DI), and other complications.

METHODS

We evaluated all TSA surgeries performed at 1 academic medical center from 7th January, 2017 to 30th March, 2020, collecting patient factors, tumor characteristics, cost variables, and outcomes. The INCU pathway was implemented on 7th January 2018. Pathway patients were compared with nonpathway patients across the study period. Outcomes were assessed using multivariate regression, adjusting for patient and surgical characteristics, including intraoperative cerebrospinal fluid leak, postoperative DI, and tumor dimensions.

RESULTS

One hundred eighty-seven patients were identified. Seventy-nine were on the INCU pathway. Mean age was 53.5 years. Most patients were male (66%), privately insured (62%), and white (66%). Mean total cost of admission was $27,276. Mean length of stay (LOS) was 3.97 days. Use of the INCU pathway was associated with total cost reduction of $6376.33 (P < 0.001, 95% confidence interval [CI]: $3698.21-$9054.45) and LOS reduction by 1.27 days (P = 0.008, 95% CI: 0.33-2.20). In-hospital costs were reduced across all domains, including $1964.87 in variable direct labor costs (P < 0.001, 95% CI: $1142.08-$2787.64) and $1206.52 in variable direct supply costs (P < 0.001, 95% CI: $762.54-$1650.51). Pathway patients were discharged earlier despite a higher rate of postoperative DI (25% vs. 11%, P = 0.011), with fewer readmissions (0% vs. 6%, P = 0.021).

CONCLUSIONS

A streamlined care pathway following TSA surgery can reduce in-hospital costs and LOS without compromising patient outcomes.

Endoscopic Transnasal Approach for Microprolactinomas with Experience of 105 Cases in a Single Center: Paradigmal Shift for Conventional Medical Therapy

OBJECTIVE

The classically recommended first-line therapy for microprolactinomas is medical therapy. In the presence of drug resistance and intolerance after the use of dopamine agonists or when the patients prefer surgery instead of medication, surgical treatment is considered as second-line treatment. The high hormonal remission and low complication rates after surgery for microprolactinomas suggest that the surgical outcome of endoscopic surgeries may be better than medical therapy in well-selected patients. This study reports a large series of patients with microprolactinoma treated by endoscopic transnasal approach and evaluates the efficiency of surgical treatment.

METHODS

Our study is a retrospective cohort analysis of patients with microprolactinoma operated on by an endoscopic transnasal approach between August 1997 and February 2022 by an experienced pituitary surgeon in a single tertiary center. Inclusion criteria for microprolactinoma were based on increased prolactin levels, microadenoma (<10 mm in diameter) on pituitary magnetic resonance imaging, and histopathologically verified lactotroph adenoma.

RESULTS

The mean follow-up was 74.90 months (range, 6-207). The postoperative day 1 remission rate was 85.7% and the long-term remission rate was 74.3%. The long-term remission rates of the patients in the preference group were significantly higher than those of the patients in the resistant or intolerance group (P = 0.002). Patients who used dopamine agonists for more than 3 years had a lower remission rate compared with patients who used dopamine agonists for a shorter period or who did not use it (P = 0.01). The surgical complication rate was 4.76%.

CONCLUSIONS

According to our findings, endoscopic transnasal surgery performed by an experienced neurosurgeon in well-selected patients with microprolactinoma can be offered with cure rates superior to medical therapy and may be an alternative first-line treatment option to dopamine agonists.

Surgical Technique and Efficacy Analysis of Extra-pseudocapsular Transnasal Transsphenoidal Surgery for Pituitary Microprolactinoma

OBJECTIVE

To elucidate the role of transsphenoidal surgery in the treatment of pituitary microprolactinoma.

METHODS

The clinical data of 107 prolactinoma cases treated by extra-pseudocapsular transnasal transsphenoidal surgery (ETTS) for different indications in our department since 2011 was retrospectively analyzed.

RESULTS

The most common indication was the ineffectiveness of oral medication (41.1%), followed by the personal willingness of the patient (35.5%), and 20.6% of the patients were young women with clear tumor boundaries. The pseudocapsule was not observed in 63 cases (58.9%), incomplete pseudocapsule was observed in 26 cases (24.3%), and complete pseudocapsule in 18 cases (16.8%). A total of 97 patients (90.7%) obtained 1-year post-operation remission. According to the relative location of the adenoma and pituitary gland on the MRI scan, 46 patients were classified into a central type, 59 a lateral type, and 2 a supra-pituitary type. Two patients developed hypogonadism, one patient developed hypocortisolism, and one patient developed post-operative hypothyroidism. Two patients were administrated with hormone replacement treatment, and the treatment was stopped within one week. There was no permanent hypopituitarism. Further investigation demonstrated that the adenoma types could affect the remission rates of hyperprolactinemia and gross total resection rate in microprolactinoma.

CONCLUSION

ETTS was an effective treatment for pituitary microprolactinomas. This could be the first choice for patients who presented enclosed adenoma on the MRI and were potentially curable in a preoperative evaluation. Maximal safe removal of the adenoma by ETTS with the aim to increase the sensitivity of the drugs was also recommended for patients with invasive dopamine agonist resistant prolactinomas and patients with difficulty in childbirth.

Surgery as a first-line option for prolactinomas

INTRODUCTION

Treatment of prolactinomas with dopamine agonists has been the established first-line treatment option for many years, with surgery reserved for refractory cases or medication intolerance. This approach may not be the best option in many cases.

AREAS COVERED

Review of the epidemiology, biology, and treatment options available for prolactinomas, including best available data on outcomes, costs, and morbidities for each therapy. These data are then used to propose a 'surgery-first' treatment approach for a subset of prolactinomas as an alternative to primary medical management.

EXPERT OPINION

Based on the available data, there is a strong rationale that transsphenoidal surgery should be considered a first-line treatment option for both micro- and macro-prolactinomas that do not demonstrate high grade cavernous sinus invasion on MRI imaging, with dopamine agonists administered as a secondary therapy for tumors not in remission following surgery, and for giant tumors. This 'surgery-first' approach assumes the availability of skilled and experienced pituitary surgeons to ensure optimal outcomes. This approach should result in high cure rates and reduced DA requirements for patients not cured from initial surgery. Further, it will reduce medical costs over a patient's lifetime and the chronic morbidities associated with protracted dopamine agonist usage.

11C-methionine PET aids localization of microprolactinomas in patients with intolerance or resistance to dopamine agonist therapy

PURPOSE

To assess the potential for ¹¹C-methionine PET (Met-PET) coregistered with volumetric magnetic resonance imaging (Met-PET/MR^CR) to inform clinical decision making in patients with poorly visualized or occult microprolactinomas and dopamine agonist intolerance or resistance.

PATIENTS AND METHODS

Thirteen patients with pituitary microprolactinomas, and who were intolerant (n = 11) or resistant (n = 2) to dopamine agonist therapy, were referred to our specialist pituitary centre for Met-PET/MR^CR between 2016 and 2020. All patients had persistent hyperprolactinemia and were being considered for surgical intervention, but standard clinical MRI had shown either no visible adenoma or equivocal appearances.

RESULTS

In all 13 patients Met-PET/MR^CR demonstrated a single focus of avid tracer uptake. This was localized either to the right or left side of the sella in 12 subjects. In one patient, who had previously undergone surgery for a left-sided adenoma, recurrent tumor was unexpectedly identified in the left cavernous sinus. Five patients underwent endoscopic transsphenoidal selective adenomectomy, with subsequent complete remission of hyperprolactinaemia and normalization of other pituitary function; three patients are awaiting surgery. In the patient with inoperable cavernous sinus disease PET-guided stereotactic radiosurgery (SRS) was performed with subsequent near-normalization of serum prolactin. Two patients elected for a further trial of medical therapy, while two declined surgery or radiotherapy and chose to remain off medical treatment.

CONCLUSIONS

In patients with dopamine agonist intolerance or resistance, and indeterminate pituitary MRI, molecular (functional) imaging with Met-PET/MR^CR can allow precise localization of a microprolactinoma to facilitate selective surgical adenomectomy or SRS.

Extra-Pseudocapsular Transsphenoidal Surgery for Microprolactinoma in Women

A recall for histological pseudocapsule (PS) and reappraisal of transsphenoidal surgery (TSS) as a viable alternative to dopamine agonists in the treatment algorithm of prolactinomas are getting vibrant. We hope to investigate the effectiveness and risks of extra-pseudocapsular transsphenoidal surgery (EPTSS) for young women with microprolactinoma, and to look into the factors that influenced remission and recurrence, and thus to figure out the possible indication shift for primary TSS. We proposed a new classification method of microprolactinoma based on the relationship between tumor and pituitary position, which can be divided into hypo-pituitary, para-pituitary and supra-pituitary groups. We retrospectively analyzed 133 patients of women (<50 yr) with microprolactinoma (≤10 mm) who underwent EPTSS in a tertiary center. PS were identified in 113 (84.96%) microadenomas intraoperatively. The long-term surgical cure rate was 88.2%, and the comprehensive remission rate was 95.8% in total. There was no severe or permanent complication, and the surgical morbidity rate was 4.5%. The recurrence rate with over 5 years of follow-up was 9.2%, and a lot lower for the tumors in the complete PS group (0) and hypo-pituitary group (2.1%). Use of the extra-pseudocapsule dissection in microprolactinoma resulted in a good chance of increasing the surgical remission without increasing the risk of CSF leakage or endocrine deficits. First-line EPTSS may offer a greater opportunity of long-term cure for young female patients with microprolactinoma of hypo-pituitary located and Knosp grade 0-II.

The role of endoscopic endonasal surgery in the management of prolactinomas based on their invasiveness into the cavernous sinus

PURPOSE

To review our institutional experience with the surgical management of prolactinomas through the endoscopic endonasal approach with specific focus on cavernous sinus invasion.

METHODS

Clinical and radiographic data were collected retrospectively from the electronic medical record of 78 consecutive patients with prolactinomas undergoing endoscopic endonasal resection from 2002 to 2019. Immediate and late post-operative remission were defined as prolactin < 20 ng/mL within 14 days and 1-year of surgery without adjuvant therapy, respectively. Cavernous sinus invasion was quantified by Knosp score.

RESULTS

A total of 78 patients with prolactinoma, 59% being male, underwent surgical resection with a mean age of 37 ± 13 years. Indications for surgery were medication resistance in 38 patients (48.7%), medication intolerance in 11 (14.1%), and patient preference in 29 (37.2%). Patients with Knosp 0-2 achieved higher immediate remission rates (83.8%) compared to patients with Knosp 3 (58.8%) and Knosp 4 (41.7%) patients (p = 0.003). Long-term remission rates were 48.7% and increased to 71.8% when combined with adjuvant treatments. Knosp 4 prolactinomas had significantly higher tumor volumes, higher preoperative prolactin levels, higher recurrence rates, higher rates of adjuvant therapy utilization, and were more likely to have failed dopamine agonist therapy compared to other tumor grades (p < 0.05). We encountered 18 complications in our series, and no cerebrospinal fluid leaks.

CONCLUSION

The endoscopic endonasal approach is a safe and effective modality that can be employed in properly selected patients with invasive prolactinomas. It is associated with improved control and remission rates despite cavernous sinus invasion, though at a lower rate than without invasion.

Italian Association of Clinical Endocrinologists (AME) and International Chapter of Clinical Endocrinology (ICCE). Position statement for clinical practice: prolactin-secreting tumors

Prolactinomas are the most frequent pituitary adenomas. Prolactinoma may occur in different clinical settings and always require an individually tailored approach. This is the reason why a panel of Italian neuroendocrine experts was charged with the task to provide indications for the diagnostic and therapeutic approaches that can be easily applied in different contexts. The document provides 15 recommendations for diagnosis and 54 recommendations for treatment, issued according to the GRADE system. The level of agreement among panel members was formally evaluated by RAND-UCLA methodology. In the last century, prolactinomas represented the paradigm of pituitary tumors for which the development of highly effective drugs obtained the best results, allowing to avoid neurosurgery in most cases. The impressive improvement of neurosurgical endoscopic techniques allows a far better definition of the tumoral tissue during surgery and the remission of endocrine symptoms in many patients with pituitary tumors. Consequently, this refinement of neurosurgery is changing the therapeutic strategy in prolactinomas, allowing the definitive cure of some patients with permanent discontinuation of medical therapy.

Dopamine agonist therapy for prolactinomas: do we need to rethink the place of surgery in prolactinoma management?

The current treatment paradigm for prolactinomas involves dopamine agonist (DA) therapy as the first-line treatment, with surgical resection reserved for cases where there is DA failure due to resistance or intolerance. This review highlights how DA therapy can be optimised to overcome its increasingly recognised pitfalls, whilst also addressing the potential for expanding the use of surgery in the management of prolactinomas. The first part of the review discusses the limitations of DA therapy, namely: DA resistance; common DA side effects; and the rare but serious DA-induced risks of cardiac valvulopathy, impulse control disorders, psychosis, CSF rhinorrhoea and tumour fibrosis. The second part of the review explores the role of surgery in prolactinoma management with reference to its current second-line position and recent calls for surgery to be considered as an alternative first-line treatment alongside DA therapy. Randomised trials comparing medical vs surgical therapy for prolactinomas are currently underway. Pending these results, a low surgical threshold approach is herein proposed, whereby DA therapy remains the default treatment for prolactinomas unless there are specific triggers to consider surgery, including concern regarding DA side effects or risks in vulnerable patients, persistent and bothersome DA side effects, emergence of any serious risks of DA therapy, expected need for long-term DA therapy, as well as the traditional indications for surgery. This approach should optimise the use of DA therapy for those who will most benefit from it, whilst instituting surgery early in others in order to minimise the cumulative burden of prolonged DA therapy.

Costs and Its Determinants in Pituitary Tumour Surgery

PURPOSE

Value-based healthcare (VBHC) provides a framework to improve care by improving patient outcomes and reducing healthcare costs. To support value-based decision making in clinical practice we evaluated healthcare costs and cost drivers in perioperative care for pituitary tumour patients.

METHODS

We retrospectively assessed financial and clinical data for surgical treatment up to the first year after surgery of pituitary tumour patients treated between 2015 and 2018 in a Dutch tertiary referral centre. Multivariable regression analyses were performed to identify determinants of higher costs.

RESULTS

271 patients who underwent surgery were included. Mean total costs (SD) were €16339 (13573) per patient, with the following cost determinants: surgery time (€62 per minute; 95% CI: 50, 74), length of stay (€1331 per day; 95% CI 1139, 1523), admission to higher care unit (€12154 in total; 95% CI 6413, 17895), emergency surgery (€10363 higher than elective surgery; 95% CI: 1422, 19305) and postoperative cerebrospinal fluid leak (€14232; 95% CI 9667, 18797). Intradural (€7128; 95% CI 10421, 23836) and combined transsphenoidal/transcranial surgery (B: 38494; 95% CI 29191, 47797) were associated with higher costs than standard. Further, higher costs were found in these baseline conditions: Rathke's cleft cyst (€9201 higher than non-functioning adenoma; 95% CI 1173, 17230), giant adenoma (€19106 higher than microadenoma; 95% CI 12336, 25877), third ventricle invasion (€14613; 95% CI 7613, 21613) and dependent functional status (€12231; 95% CI 3985, 20477). In patients with uncomplicated course, costs were €8879 (3210) and with complications €17551 (14250).

CONCLUSIONS

Length of hospital stay, and complications are the main drivers of costs in perioperative pituitary tumour healthcare as were some baseline features, e.g. larger tumors, cysts and dependent functional status. Costs analysis may correspond with healthcare resource utilization and guide further individualized care path development and capacity planning.

Postoperative remission of non-invasive lactotroph pituitary tumor: a single-center experience

BACKGROUND

Dopaminergic agonists (DA) are the first-line treatment in lactotroph pituitary tumor but treatment usually needs to be life-long. After surgical transphenoid resection, remission rates range from 60% to 90%, with low morbidity.

OBJECTIVE

The objective was to evaluate outcome of surgical treatment of selected non-invasive prolactinoma, and to identify factors associated with long-term remission.

METHOD

Early postoperative (3 months) and last follow-up data for non-invasive lactotroph tumors operated on in intention-to-cure in our center, between 2008 and 2017 were retrospectively reviewed: prolactin (PRL) level, DA treatment, pituitary function, and MRI data. Remission was defined as PRL plasma level below the upper limit of normal without DA treatment.

RESULTS

Fifty-three of the 60 patients (32 of the 33 microadenomas) were in remission at 3 months and 46 (28/33 microadenomas) at last follow-up 22.7 months (range, 1.1-126.5 months) after surgery. Five-year recurrence-free survival was 77.5% [65.8-91.2]. Male gender, larger tumor size at diagnosis and before surgery and higher plasma PRL level at diagnosis were all significantly associated with lower remission rates on univariate analysis. Transient diabetes insipidus and hyponatremia occurred in 2 and 5 patients respectively. One case of isolated thyrotroph insufficiency was observed. During follow-up, 13 women became pregnant (12 spontaneously).

CONCLUSION

This cohort confirmed the high remission rate of lactotroph tumors after surgery in a selected population, with limited morbidity, and conserved pituitary function in almost all cases.

First-line surgery in prolactinomas: lessons from a long-term follow-up study in a tertiary referral center

CONTEXT

Although consensus guidelines recommend dopamine agonists (DAs) as the first-line approach in prolactinomas, some patients may opt instead for upfront surgery, with the goal of minimizing the need for continuation of DAs over the long term. While this approach can be recommended in selected patients with a microprolactinoma, the indication for upfront surgery in macroprolactinomas remains controversial, with limited long-term data in large cohorts. We aimed at elucidating whether first-line surgery is equally safe and effective for patients with micro- or macroprolactinomas not extending beyond the median carotid line (i.e., Knosp grade ≤ 1).

METHODOLOGY

Retrospective study of patients with prolactinomas Knosp grade ≤ 1 treated with upfront surgery. The primary endpoint was patients' dependence on DAs at last follow-up. The secondary endpoint was postoperative complications. Independent risk factors for long-term dependence on DAs were analyzed.

RESULTS

A microadenoma was noted in 45 patients (52%) and a macroadenoma in 41 (48%), with 17 (20%) harboring a Knosp grade 1 prolactinoma. Median follow-up was 80 months. First-line surgery resulted in long-term remission in 31 patients (72%) with a microprolactinoma and in 18 patients (45%) with a macroprolactinoma (p = 0.02). DA therapy was ultimately required in 11 patients (24%) with microadenomas vs. 20 (49%) with macroadenomas (p = 0.03). As for the latter, DA was required in 13 patients (76%) with Knosp grade 1 macroadenomas vs. 7 patients (29%) with Knosp grade 0 macroadenomas (p = 0.004). There was no mortality, and morbidity was minimal. Knosp grade 1 prolactinomas (OR 7.3, 95% CI 1.4-37.7, p = 0.02) but not adenoma size (i.e., macroprolactinomas) were an independent predictor of long-term dependence on DAs.

CONCLUSIONS

First-line surgery in patients with microprolactinomas or macroprolactinomas Knosp grade 0 resulted in a good chance of non-dependency on DA therapy. However, in patients with prolactinomas Knosp grade 1, first-line surgery cannot be recommended, as adjuvant DA therapy after surgery is required in the majority of them over the long term.

Molecular Pathways in Prolactinomas: Translational and Therapeutic Implications

Prolactinoma has the highest incidence rate among patients with functional pituitary tumours. Although mostly benign, there is a subgroup that can be aggressive. Some clinical, radiological and pathology features have been associated with a poor prognostic. Therefore, it can be considered as a group of heterogeneous tumours. The aim of this paper is to give an overview of the molecular pathways involved in the behaviour of prolactinoma in order to improve our approach and gain deeper insight into the better understanding of tumour development and its management. This is essential for identifying patients harbouring aggressive prolactinoma and to establish personalised therapeutics options.

The PRolaCT studies - a study protocol for a combined randomised clinical trial and observational cohort study design in prolactinoma

Background

First-line treatment for prolactinomas is a medical treatment with dopamine agonists (DAs), which effectively control hyperprolactinaemia in most patients, although post-withdrawal remission rates are approximately 34%. Therefore, many patients require prolonged DA treatment, while side effects negatively impact health-related quality of life (HRQoL). Endoscopic transsphenoidal resection is reserved for patients with severe side effects, or with DA-resistant prolactinoma. Surgery has a good safety profile and high probability of remission and may thus deserve a more prominent place in prolactinoma treatment. The hypothesis for this study is that early or upfront surgical resection is superior to DA treatment both in terms of HRQoL and remission rate in patients with a non-invasive prolactinoma of limited size.

Methods

We present a combined randomised clinical trial and observational cohort study design, which comprises three unblinded randomised controlled trials (RCTs; PRolaCT-1, PRolaCT-2, PRolaCT-3), and an observational study arm (PRolaCT-O) that compare neurosurgical counselling, and potential subsequent endoscopic transsphenoidal adenoma resection, with current standard care. Patients with a non-invasive prolactinoma (< 25 mm) will be eligible for one of three RCTs based on the duration of pre-treatment with DAs: PRolaCT-1: newly diagnosed, treatment-naïve patients; PRolaCT-2: patients with limited duration of DA treatment (4–6 months); and PRolaCT-3: patients with persisting prolactinoma after DA treatment for > 2 years. PRolaCT-O will include patients who decline randomisation, due to e.g. a clear treatment preference. Primary outcomes are disease remission after 36 months and HRQoL after 12 months.

Discussion

Early or upfront surgical resection for patients with a limited-sized prolactinoma may be a reasonable alternative to the current standard practice of DA treatment, which we will investigate in three RCTs and an observational cohort study. Within the three RCTs, patients will be randomised between neurosurgical counselling and standard care. The observational study arm will recruit patients who refuse randomisation and have a pronounced treatment preference. PRolaCT will collect randomised and observational data, which may facilitate a more individually tailored practice of evidence-based medicine.

Trial registration

US National Library of Medicine registry (ClinicalTrials.gov) NCT04107480. Registered on 27 September 2019, registered retrospectively (by 2 months).

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05604-y.

Long-term Outcome of Microscopic Transsphenoidal Surgery for Prolactinomas as an Alternative to Dopamine Agonists

BACKGROUND

Although long-term dopamine agonist (DA) therapy is recommended as a first-line treatment for prolactinoma, some patients may prefer surgical treatment because of the potential adverse effects of long-term medication, or the desire to become pregnant. This study aimed to determine whether surgical treatment of prolactinomas could be an alternative to DA therapy.

METHODS

In this retrospective study, 96 consecutive patients (74 female, 22 male) underwent primary pituitary surgery without long-term DA treatment for prolactinomas at a single institution from 1990 to 2010. All patients underwent primary surgical treatment in the microscopic transsphenoidal approach (TSA).

RESULTS

The median age and median follow-up period were 31 (16-73) years and 139.1 (12.2-319.6) months, respectively. An initial overall remission was accomplished in 47.9% (46 of 96 patients, 33 macroadenomas, and 13 microadenomas) of patients. DA dose reduction was achieved in all patients after TSA. A better remission rate was independently predicted by lower diagnostic prolactin levels and by a greater extent of surgical resection. Overall remission at the last follow-up was 33.3%, and the overall recurrence rate was 30.4%. The permanent complication rate was 3.1%, and there was no mortality.

CONCLUSION

TSA can be considered a safe and potentially curative treatment for selective microprolactinomas as an alternative to treatment with a long-term DA.

Healthcare utilization and costs among prolactinoma patients: a cross-sectional study and analysis of determinants

PURPOSE

Prolactinomas are the most prevalent functioning pituitary adenomas. They affect gonadal function as well as health-related quality of life (HRQoL). This study aimed to report healthcare utilization and costs, including their determinants, for prolactinoma patients.

METHODS

Cross-sectional study of 116 adult prolactinoma patients in chronic care in a Dutch tertiary referral center. Patients completed four validated questionnaires, assessing healthcare utilization and costs over the previous 12 months (Medical Consumption Questionnaire), disease bother and needs (Leiden Bother and Needs Questionnaire Pituitary), HRQoL (Short Form-36), and self-reported health status (EuroQol 5D). Regression analyses were used to assess associations between disease-related characteristics and healthcare utilization and costs.

RESULTS

Mean age was 52.0 years (SD 13.7) and median follow-up was 15.0 years (IQR 7.6-26.1). Patients visited the endocrinologist (86.2%), general practitioner (37.9%), and ophthalmologist (25.0%) most frequently. Psychological care was used by 12.9% of patients and 5% were admitted to hospital. Mean annual healthcare costs were €1928 (SD 3319), mainly for pituitary-specific medication (37.6% of total costs), hospitalization (19.4%) and specialist care (16.1%). Determinants for higher healthcare utilization and costs were greater disease bother and needs for support, lower HRQoL, elevated prolactin, and longer disease duration, while tumor size, hypopituitarism and adrenal insufficiency were not significantly associated with healthcare utilization and costs.

CONCLUSION

Healthcare utilization and costs of prolactinoma patients are related to patient-reported HRQoL, bother by disease and needs for support. Therefore, addressing patients' HRQoL and needs is a way forward to improve efficiency of care and patients' health status.

Drivers of In-Hospital Costs Following Endoscopic Transphenoidal Pituitary Surgery

OBJECTIVE

To characterize the patient and clinical factors that determine variability in hospital costs following endoscopic transphenoidal pituitary surgery.

METHODS

All endoscopic transphenoidal pituitary surgeries performed from January 1, 2015, to October 24, 2017, with complete data were evaluated in this retrospective single-institution study. The electronic medical record was reviewed for patient factors, tumor characteristics, and cost variables during each hospital stay. Multivariate linear regression was performed using Stata software.

RESULTS

The analysis included 190 patients and average length of stay was 4.71 days. Average total in-hospital cost was $28,624 (95% confidence interval $25,094-$32,155) with average total direct cost of $19,444 ($17,136-$21,752) and total indirect cost of $9181 ($7592-$10,409). On multivariate regression, post-operative cerebrospinal fluid (CSF) leak was associated with a significant increase in all cost variables, including a total cost increase of $40,981 ($15,474-$66,489, P = .002). Current smoking status was associated with an increased total cost of $20,189 ($6,638-$33,740, P = .004). Self-reported Caucasian ethnicity was associated with a significant decrease in total cost of $6646 (-$12,760 to -$532, P = .033). Post-operative DI was associated with increased costs across all variables that were not statistically significant.

CONCLUSIONS

Post-operative CSF leak, current smoking status, and non-Caucasian ethnicity were associated with significantly increased costs. Understanding of cost drivers of endoscopic transphenoidal pituitary surgery is critical for future cost control and value creation initiatives.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:760-764, 2021.

Prolactinomas and nonfunctioning adenomas: preoperative diagnosis of tumor type using serum prolactin and tumor size

OBJECTIVE

Prolactinoma and nonfunctioning adenoma (NFA) are the most common sellar pathologies, and both can present with hyperprolactinemia. There are no definitive studies analyzing the relationship between the sizes of prolactinomas and NFAs and the serum prolactin level. Current guidelines for serum prolactin level cutoffs to distinguish between pathologies are suboptimal because they fail to consider the adenoma volume. In this study, the authors attempted to describe the relationship between serum prolactin level and prolactinoma volume. They also examined the predictive value that can be gained by considering tumor volume in differentiating prolactinoma from NFA and provide cutoff values based on a large sample of patients.

METHODS

A retrospective analysis of consecutive patients with prolactinomas (n = 76) and NFAs (n = 217) was performed. Patients were divided into groups based on adenoma volume, and the two pathologies were compared.

RESULTS

A strong correlation was found between prolactinoma volume and serum prolactin level (r = 0.831, p < 0.001). However, there was no significant correlation between NFA volume and serum prolactin level (r = -0.020, p = 0.773). Receiver operating characteristic curve analysis of three different adenoma volume groups was performed and resulted in different serum prolactin level cutoffs for each group. For group 1 (≤ 0.5 cm3), the most accurate cutoff was 43.65 μg/L (area under the curve [AUC] = 0.951); for group 2 (> 0.5 to 4 cm3), 60.05 μg/L (AUC = 0.949); and for group 3 (> 4 cm3), 248.15 μg/L (AUC = 1.0).

CONCLUSIONS

Prolactinoma volume has a significant impact on serum prolactin level, whereas NFA volume does not. This finding indicates that the amount of prolactin-producing tissue is a more important factor regarding serum prolactin level than absolute adenoma volume. Hence, volume should be a determining factor to distinguish between prolactinoma and NFA prior to surgery. Current serum prolactin threshold level guidelines are suboptimal and cannot be generalized across all adenoma volumes.

ICAR: endoscopic skull-base surgery

BACKGROUND

Endoscopic skull-base surgery (ESBS) is employed in the management of diverse skull-base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull-base surgery have produced the International Consensus Statement on Endoscopic Skull-Base Surgery (ICAR:ESBS).

METHODS

Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence-based review or evidence-based review with recommendations format. Subsequently, each topic was written and then reviewed by skull-base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus.

RESULTS

The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull-base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated.

CONCLUSION

A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence-based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull-base community to embrace these opportunities and collaboratively address these shortcomings.

Endoscopic Transsphenoidal Surgery of Microprolactinomas: A Reappraisal of Cure Rate Based on Radiological Criteria

BACKGROUND

Current standard treatment of microprolactinomas is dopamine agonist therapy. As this drug treatment is lifelong in up to 80% of cases, many patients consult pituitary surgeons regarding a surgical alternative.

OBJECTIVE

To identify prognostic criteria for surgical remission, we reviewed outcomes of our series of microprolactinomas treated with endoscopic transsphenoidal surgery, with a special emphasis on magnetic resonance adenoma delineation and position.

METHODS

Our study cohort comprises a single center series of 60 patients operated for histopathologically verified magnetic resonance imaging unequivocally identifiable endosellar microprolactinoma between 2003 and 2017. In 31 patients the adenoma was enclosed by pituitary gland (group ENC), in 29 patients the adenoma was located lateral to the gland adherent to the medial cavernous sinus wall (group LAT).

RESULTS

After a mean follow-up of 37 mo (range 4-143 mo), remission rate was significantly higher in adenomas enclosed by pituitary gland (group ENC) than adenomas located lateral to the gland (group LAT), with 87% vs 45%, P = .01. Intraoperatively, 4 patients showed signs of invasiveness. Preoperative prolactin levels did not differ between the groups (mean 155 and 187 ng/ml in group ENC and LAT, respectively).A binary logistic regression model revealed that only the radiological criteria applied showed a significant correlation (P = .003) with endocrine remission.

CONCLUSION

According to our results, remission rate is significantly higher in microprolactinomas enclosed by the pituitary gland. However, the decision for surgery should take into account surgeons experience and possibility of complications.

Surgery as a Viable Alternative First-Line Treatment for Prolactinoma Patients. A Systematic Review and Meta-Analysis

CONTEXT

The improved remission and complication rates of current transsphenoidal surgery warrant reappraisal of the position of surgery as a viable alternative to dopamine agonists in the treatment algorithm of prolactinomas.

OBJECTIVE

To compare clinical outcomes after dopamine agonist withdrawal and transsphenoidal surgery in prolactinoma patients.

METHODS

Eight databases were searched up to July 13, 2018. Primary outcome was disease remission after drug withdrawal or surgery. Secondary outcomes were biochemical control and side effects during dopamine agonist treatment and postoperative complications. Fixed- or random-effects meta-analysis was performed to estimate pooled proportions. Robustness of results was assessed by sensitivity analyses.

RESULTS

A total of 1469 articles were screened: 55 (10 low risk of bias) on medical treatment (n = 3564 patients) and 25 (12 low risk of bias) on transsphenoidal surgery (n = 1836 patients). Long-term disease remission after dopamine agonist withdrawal was 34% (95% confidence interval [CI], 26-46) and 67% (95% CI, 60-74) after surgery. Subgroup analysis of microprolactinomas showed 36% (95% CI, 21-52) disease remission after dopamine agonist withdrawal, and 83% (95% CI, 76-90) after surgery. Biochemical control was achieved in 81% (95% CI, 75-87) of patients during dopamine agonists with side effects in 26% (95% CI, 13-41). Transsphenoidal surgery resulted in 0% mortality, 2% (95% CI, 0-5) permanent diabetes insipidus, and 3% (95% CI, 2-5) cerebrospinal fluid leakage. Multiple sensitivity analyses yielded similar results.

CONCLUSIONS

In the majority of prolactinoma patients, disease remission can be achieved through surgery, with low risks of long-term surgical complications, and disease remission is less often achieved with dopamine agonists.

Surgery for prolactinomas: a better choice?

PURPOSE

Renewed interest in transsphenoidal surgery (TSS) as a therapeutic option for prolactinomas has emerged.

METHODS

Based on contemporary literature and own experience, the changing role of surgery for treatment of prolactinomas is discussed.

RESULTS

Today, TSS is performed by minimally invasive microscopic or endoscopic techniques. Normoprolactinemia is obtained in 71-100% of patients with microprolactinomas by TSS. Almost equal results are found in circumscribed intrasellar macroprolactinomas. In experienced hands, pituitary function is preserved in TSS. The risk of cardiac valve disease is still a concern with ergot-derived dopamine-agonists (DAs) in patients requiring long-term, high-dose dopamine-agonist (DA) treatment. Cost-utility analysis favors TSS over DA treatment. The possible negative impact of DA treatment on future surgical results is still a controversial and unsettled issue. In patients who wish to become pregnant, the advantages of microprolactinoma removal to avoid DAs and macroprolactinoma debulking to avoid symptomatic enlargement during pregnancy should be discussed with the patients. Young patients' age is an argument for surgery to circumvent the unpredictable sequelae of long-term DA treatment. Surgery should be discussed in male gender because of a higher likelihood of DA resistance and aggressive behavior of prolactinoma.

CONCLUSION

Given excellent results of TSS and concerns about medical treatment, the scale of indications for TSS as an alternative to DAs has increased. The patient's wishes concerning a chance at a cure with TSS instead of a long-term treatment with DAs has become an important and accepted indication. With DA medication and TSS, two effective treatment modalities for prolactinomas are available that can be used in a complementary fashion.

Surgical management considerations in cystic prolactinomas-a single center case series

PURPOSE

The optimal treatment of prolactinomas with a predominantly cystic component remains poorly defined. The cystic tumor component is considered to respond less favorably to medical treatment, thereby advocating surgical management. The purpose of this study was to assess remission rates in surgically treated cystic prolactinomas, and to compare outcomes to similarly treated solid micro- and macroprolactinomas.

METHODS

Clinical and imaging data were retrospectively compiled from 56 patients who underwent transsphenoidal resection, for symptomatic prolactinomas, from 2004 to 2018, at a single academic institution. Pituitary adenomas were subdivided according to tumor size and tumor consistency: cystic prolactinomas (>50% cystic tumor component) n = 17; solid microprolactinomas (<10 mm) n = 10; and solid macroprolactinomas (≥10 mm) n = 29. Remission was defined as a prolactin level of <10 ng/dl either immediately postoperative or at a later time point.

RESULTS

Median tumor size was 15 mm for cystic prolactinomas, 7 mm for solid microprolactinomas, and 25.5 mm for solid macroprolactinomas. Remission was achieved in 76% (n = 13/17) of surgically treated cystic prolactinomas, 100% (n = 10/10) of solid microprolactinomas, and 24% (n = 7/29) of solid macroprolactinomas. More than 44% of solid macroprolactinomas had a Knosp grade > 3, while most cystic prolactinomas (93.8%) and all solid microprolactinomas (100%) had a Knosp grade ≤ 2.

CONCLUSIONS

Despite their large tumor size (≥10 mm), high remission rates can be expected with surgically treated cystic prolactinomas. This case series of cystic prolactinomas demonstrates the successful use of transsphenoidal surgery as a favorable, and a potentially curative alternative to dopaminergic therapy in this patient population.

Evidence-Based Medicine in Otolaryngology Part 10: Cost-Effectiveness Analyses in Otolaryngology

Clinicians seek to pursue the most clinically effective treatment strategies, but costs have also become a key determinant in contemporary health care. Economic analyses have thus emerged as a valuable resource to both quantify and qualify the value of existing and emerging interventions and programs. Cost-effectiveness analyses estimate the benefits gained per monetary unit, providing insights to guide resource allocation. Herein, we delineate the related concepts and considerations to facilitate understanding and appraisal of these analyses, so as to better inform the stakeholders in our otolaryngology community.

The epidemiology, diagnosis and treatment of Prolactinomas: The old and the new

Prevalence and incidence of prolactinomas are approximately 50 per 100,000 and 3-5 new cases/100,000/year. The pathophysiological mechanism of hyperprolactinemia-induced gonadotropic failure involves kisspeptin neurons. Prolactinomas in males are larger, more invasive and less sensitive to dopamine agonists (DAs). Macroprolactin, responsible for pseudohyperprolactinemia is a frequent pitfall of prolactin assay. DAs still represent the primary therapy for most prolactinomas, but neurosurgery has regained interest, due to progress in surgical techniques and a high success rate in microprolactinoma, as well as to some underestimated side effects of long-term DA treatment, such as impulse control disorders or impaired quality of life. Recent data show that the suspected effects of DAs on cardiac valves in patients with prolactinomas are reassuring. Finally, temozolomide has emerged as a valuable treatment for rare cases of aggressive and malignant prolactinomas that do not respond to all other conventional treatments.

Costs and Their Predictors in Transsphenoidal Pituitary Surgery

BACKGROUND

Contemporary surgical approaches to pituitary pathologies include transsphenoidal microsurgical and, more recently, endoscopic techniques. Data reporting direct costs in transsphenoidal pituitary surgery are limited.

OBJECTIVE

To examine direct costs (including overall total, hospital/facility, and physician payments) of microscopic and endoscopic pituitary surgery and evaluate predictors of differential costs in transsphenoidal pituitary surgery using a national database.

METHODS

The Truven MarketScan® database 2010-2014 (IBM, Armonk, New York) was queried and patients undergoing microscopic and/or endoscopic transsphenoidal pituitary surgery identified. Mean costs and predictors of differential costs were analyzed using analysis of variance and generalized linear models. Beta-coefficients (β) assessed relative contributions of independent predictors.

RESULTS

Mean overall total ($34 943.13 [SD ± 19 074.54]) and hospital/facility ($26 505.93 [SD ± 16 819.52]) payments were higher in endoscopic compared to microscopic surgeries (both P < .001). Lengths of hospital stay (LOS) were similar between groups. Predictors of overall total and hospital/facility payments were similar including surgical technique, age, geographical region, comorbidity index, postoperative surgical and medical complications, and LOS with LOS being the most significant predictor (β = 0.27 and β = 0.29, respectively). Mean physician payments ($4549.24 [SD ± 3956.27]) were similar in microscopic and endoscopic cohorts (P = .26). Predictors of physician payments included age, health plan, geographical region, postoperative surgical complications, and LOS with health plan being the most significant predictor (β = –0.21).

CONCLUSION

Higher overall total and hospital/facility costs are associated with endoscopic transsphenoidal pituitary surgery compared to microsurgery. In contrast, physician reimbursements are similar between techniques. Whereas LOS was the strongest predictor of overall total and hospital/facility costs, health plan was the strongest predictor of differential physician reimbursements.

Systematic review of health economic studies in cranial neurosurgery

OBJECTIVE As the cost of health care continues to increase, there is a growing emphasis on evaluating the relative economic value of treatment options to guide resource allocation. The objective of this systematic review was to evaluate the current evidence regarding the cost-effectiveness of cranial neurosurgery procedures. METHODS The authors performed a systematic review of the literature using PubMed, EMBASE, and the Cochrane Library, focusing on themes of economic evaluation and cranial neurosurgery following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Included studies were publications of cost-effectiveness analysis or cost-utility analysis between 1995 and 2017 in which health utility outcomes in life years (LYs), quality-adjusted life years (QALYs), or disability-adjusted life years (DALYs) were used. Three independent reviewers conducted the study appraisal, data abstraction, and quality assessment, with differences resolved by consensus discussion. RESULTS In total, 3485 citations were reviewed, with 53 studies meeting the inclusion criteria. Of those, 34 studies were published in the last 5 years. The most common subspecialty focus was cerebrovascular (32%), followed by neurooncology (26%) and functional neurosurgery (24%). Twenty-eight (53%) studies, using a willingness to pay threshold of US$50,000 per QALY or LY, found a specific surgical treatment to be cost-effective. In addition, there were 11 (21%) studies that found a specific surgical option to be economically dominant (both cost saving and having superior outcome), including endovascular thrombectomy for acute ischemic stroke, epilepsy surgery for drug-refractory epilepsy, and endoscopic pituitary tumor resection. CONCLUSIONS There is an increasing number of cost-effectiveness studies in cranial neurosurgery, especially within the last 5 years. Although there are numerous procedures, such as endovascular thrombectomy for acute ischemic stroke, that have been conclusively proven to be cost-effective, there remain promising interventions in current practice that have yet to meet cost-effectiveness thresholds.

Management of hormone-secreting pituitary adenomas

Pituitary adenomas are one of the most common primary central nervous system tumors and have an estimated prevalence of 17%. Approximately half of pituitary adenomas secrete distinct pituitary hormones (most often prolactin, growth hormone, or adrenocorticotropic hormone). While these tumors are histologically benign, they have potent endocrine effects that lead to significant morbidity and shortened lifespan. Because of their pathophysiologic endocrine secretion and anatomic location near critical neural/vascular structures, hormone-secreting pituitary adenomas require defined management paradigms that can include relief of mass effect and biochemical remission. Management of hormone-secreting pituitary adenomas involves a multidisciplinary approach that can incorporate surgical, medical, and/or radiation therapies. Early and effective treatment of hormone-secreting pituitary adenomas can reduce morbidity and mortality. Consequently, understanding clinical features as well as therapeutic options in the context of the specific biological features of each type of hormone-secreting pituitary adenoma is critical for optimal management.

The posterior nasoseptal flap: A novel technique for closure after endoscopic transsphenoidal resection of pituitary adenomas

Background:

While effective for the repair of large skull base defects, the Hadad-Bassagasteguy nasoseptal flap increases operative time and can result in a several-week period of postoperative crusting during re-mucosalization of the denuded nasal septum. Endoscopic transsphenoidal surgery for pituitary adenoma resection is generally not associated with large dural defects and high-flow cerebrospinal fluid (CSF) leaks requiring extensive reconstruction. Here, we present the posterior nasoseptal flap as a novel technique for closure of skull defects following endoscopic resection of pituitary adenomas. This flap is raised in all surgeries during the transnasal exposure using septal mucoperiosteum that would otherwise be discarded during the posterior septectomy performed in binostril approaches.

Methods:

We present a retrospective, consecutive case series of 43 patients undergoing endoscopic transsphenoidal resection of a pituitary adenoma followed by posterior nasoseptal flap placement and closure. Main outcome measures were extent of resection and postoperative CSF leak.

Results:

The mean extent of resection was 97.16 ± 1.03%. Radiographic measurement showed flap length to be adequate. While a defect in the diaphragma sellae and CSF leak were identified in 21 patients during surgery, postoperative CSF leak occurred in only one patient.

Conclusions:

The posterior nasoseptal flap provides adequate coverage of the surgical defect and is nearly always successful in preventing postoperative CSF leak following endoscopic transsphenoidal resection of pituitary adenomas. The flap is raised from mucoperiosteum lining the posterior nasal septum, which is otherwise resected during posterior septectomy. Because the anterior septal cartilage is not denuded, raising such flaps avoids the postoperative morbidity associated with the larger Hadad-Bassagasteguy nasoseptal flap.

Medical versus surgical treatment of prolactinomas: an analysis of treatment outcomes

INTRODUCTION

Prolactinomas are unique tumors that may go into both hormonal and radiographic remission with dopamine agonist therapy or transsphenoidal surgery. Regardless of modality, the goals of therapy remain the same: (1) biochemical remission, including reduction of prolactin and normalization of sex hormones; (2) radiographic tumor control, with a range including prevention of tumor growth, tumor regression, or complete tumor resolution; (3) resolution of preoperative symptoms, including those that are hormonal or neurologic; and (4) prevention of new hypopituitarism or new neurologic symptoms.

AREAS COVERED

In the following review, we performed a search of the literature using keywords 'prolactinoma,' 'dopamine agonist,' 'surgery,' 'cost-effectiveness,' 'recurrence,' and 'complication' to compare the relative merits of medical versus surgical therapy for prolactinoma, including special circumstances such as cystic tumors, pregnant patients, and the cost-effectiveness of different strategies.

EXPERT COMMENTARY

Medical therapy can offer a cure, but surgery provides an important adjunct to patients with resistance or intolerance to dopamine agonists, and offers excellent outcomes including when combined with continued postoperative medical therapy. Further head to head comparisons will benefit patients and practitioners weighing the relative risks and benefits of medical and surgical intervention, including the issue of their relative cost-effectiveness.

The Chance of Permanent Cure for Micro- and Macroprolactinomas, Medication or Surgery? A Systematic Review and Meta-Analysis

Background: This meta-analysis aims to evaluate the long-term efficacy of medication treatment vs. surgery treatment in patients with prolactinomas. Methods: An electronic literature search was performed using MEDLINE, EMBASE and Web of Science databases for studies dated before July in 2018. Patients with prolactinomas received primary dopamine agonists (DAs) treatment or primary surgical interventions were included in this study. A systematic review and meta-analysis were performed in pertinent studies meeting eligible criteria. The clinical outcome was measured by the long-term remission rate of prolactin (PRL) in each cohort. The pooled data was analyzed according to a random effect model. Results: Thirteen publications with total 809 patients were included in the final meta-analysis. In the overall patients with prolactinomas, long-term remission rate was achieved in 88% patients treated with surgeries and in 52% patients treated with DAs (P = 0.001). The long-term remission rates in surgery cohort were also significantly higher than medication cohort in both microprolactinomas and macroprolactinomas (91 vs. 60%, P = 0.002; 77 vs. 43%, P = 0.003). Conclusions: Patients with prolactinomas, especially microprolactinomas, can consider transsphenoidal surgery as an alternative first-line treatment strategy. After receiving primary surgical intervention, administration of DAs should be considered based on the postoperative PRL level to achieve the best long-term remission rate.

Endoscopic vs. Microscopic Resection of Sellar Lesions-A Matched Analysis of Clinical and Socioeconomic Outcomes

BACKGROUND

Direct comparisons of microscopic and endoscopic resection of sellar lesions are scarce, with conflicting reports of cost and clinical outcome advantages.

OBJECTIVE

To determine if the proposed benefits of endoscopic resection are realized on a population level.

METHODS

We performed a matched cohort study of 9,670 adult patients in the MarketScan database who underwent either endoscopic or microscopic surgery for sellar lesions. Coarsened matching was applied to estimate the effects of surgical approach on complication rates, length of stay (LOS), costs, and likelihood of postoperative radiation.

RESULTS

We found that LOS, readmission, and revision rates did not differ significantly between approaches. The overall complication rate was higher for endoscopy (47% compared to 39%, OR 1.37, 95% CI 1.22-1.53). Endoscopic approach was associated with greater risk of neurological complications (OR 1.32, 95% CI 1.11-1.55), diabetes insipidus (OR 1.65, 95% CI 1.37-2.00), and cerebrospinal fluid rhinorrhea (OR 1.83, 95% CI 1.07-3.13) compared to the microscopic approach. Although the total index payment was higher for patients receiving endoscopic resection ($32,959 compared to $29,977 for microscopic resection), there was no difference in long-term payments. Endoscopic surgery was associated with decreased likelihood of receiving post-resection stereotactic radiosurgery (OR 0.67, 95% CI 0.49-0.90) and intensity-modulated radiation therapy (OR 0.78, 95% CI 0.65-0.93).

CONCLUSION

Our results suggest that the transition from a microscopic to endoscopic approach to sellar lesions must be subject to careful evaluation. Although there are evident advantages to transsphenoidal endoscopy, our analysis suggests that the benefits of the endoscopic approach are yet to be materialized.

Cost-Effectiveness Analysis of Surgical versus Medical Treatment of Prolactinomas

Background Few studies address the cost of treating prolactinomas. We performed a cost-utility analysis of surgical versus medical treatment for prolactinomas. Materials and Methods We determined total hospital costs for surgically and medically treated prolactinoma patients. Decision-tree analysis was performed to determine which treatment produced the highest quality-adjusted life years (QALYs). Outcome data were derived from published studies. Results Average total costs for surgical patients were $19,224 ( ± 18,920). Average cost for the first year of bromocriptine or cabergoline treatment was $3,935 and $6,042, with $2,622 and $4,729 for each additional treatment year. For a patient diagnosed with prolactinoma at 40 years of age, surgery has the lowest lifetime cost ($40,473), followed by bromocriptine ($41,601) and cabergoline ($70,696). Surgery also appears to generate high health state utility and thus more QALYs. In sensitivity analyses, surgery appears to be a cost-effective treatment option for prolactinomas across a range of ages, medical/surgical costs, and medical/surgical response rates, except when surgical cure rates are ≤ 30%. Conclusion Our single institution analysis suggests that surgery may be a more cost-effective treatment for prolactinomas than medical management for a range of patient ages, costs, and response rates. Direct empirical comparison of QALYs for different treatment strategies is needed to confirm these findings.

[Indications for surgical treatment of prolactin-secreting pituitary adenomas]

Prolactinomas account for about 40% of all pituitary adenomas. The main treatment for prolactinomas is undoubtedly therapy with dopamine agonists (DAs). However, prolonged conservative treatment (for many years or even throughout life) that is necessary for permanent control of the disease makes some patients refuse pharmacological treatment for various reasons. In addition, not all prolactinomas respond to DAs therapy. Sometimes, the patient is not able to continue treatment because of the severity of side effects. Along with tumor resistance to therapy and patient intolerance of DAs, complications (liquorrhea, hemorrhage in the tumor) may occur during conservative treatment. In these cases, surgery is necessary. The paper analyzes the modern literature on various treatment options for prolactin-secreting pituitary adenomas and defines the indications for surgical treatment.

THERAPY OF ENDOCRINE DISEASE: Surgery in microprolactinomas: effectiveness and risks based on contemporary literature

Microprolactinomas are the most common pituitary adenomas. In symptomatic patients, dopamine agonists are the first-line treatment of choice; when cabergoline is used, biochemical control rates between 85 and 93% have been reported. Long-term treatment is needed in most of the cases with compliance, patient convenience, and potential adverse effects representing areas requiring attention. Based on the literature published in the past 15 years, transsphenoidal surgery can lead to normal prolactin in the postoperative period in usually 71-100% of the cases with very low postoperative complication rates. Surgical expertise is the major determinant of the outcomes, and it may be a cost-effective option in young patients with life expectancy greater than 10 years (provided it is performed by experienced surgeons at high volume centers with confirmed optimal outcomes). Larger series of patients with adequate follow-up could further validate the place of transsphenoidal surgery (particularly through the endoscopic approach for which long-term results are currently limited) in the management algorithm of patients with microprolactinoma.