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Hanalioglu S, Gurses ME, Gecici NN, Baylarov B, Isikay I, Gürlek A, Berker M. Repeat endoscopic endonasal transsphenoidal surgery for residual or recurrent Cushing's disease: safety, feasibility, and success. Pituitary 2024; 27:259-268. [PMID: 38748309 PMCID: PMC11150181 DOI: 10.1007/s11102-024-01396-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/25/2024] [Indexed: 06/05/2024]
Abstract
PURPOSE The success and outcomes of repeat endoscopic transsphenoidal surgery (ETS) for residual or recurrent Cushing's disease (CD) are underreported in the literature. This study aims to address this gap by assessing the safety, feasibility, and efficacy of repeat ETS in these patients. METHODS A retrospective analysis was conducted on 56 patients who underwent a total of 65 repeat ETS performed by a single neurosurgeon between January 2006 and December 2020. Data including demographic, clinical, laboratory, radiological, and operative details were collected from electronic medical records. Logistic regression was utilized to identify potential predictors associated with sustained remission. RESULTS Among the cases, 40 (61.5%) had previously undergone microscopic surgery, while 25 (38.5%) had prior endoscopic procedures. Remission was achieved in 47 (83.9%) patients after the first repeat ETS, with an additional 9 (16.1%) achieving remission after the second repeat procedure. During an average follow-up period of 97.25 months, the recurrence rate post repeat surgery was 6.38%. Sustained remission was achieved in 48 patients (85.7%), with 44 after the first repeat ETS and 4 following the second repeat ETS. Complications included transient diabetes insipidus (DI) in 5 (7.6%) patients, permanent (DI) in 2 (3%) patients, and one case (1.5%) of panhypopituitarism. Three patients (4.6%) experienced rhinorrhea necessitating reoperation. A serum cortisol level > 5 µg/dL on postoperative day 1 was associated with a reduced likelihood of sustained remission. CONCLUSION Repeat ETS is a safe and effective treatment option for residual or recurrent CD with satisfactory remission rates and low rates of complications.
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Affiliation(s)
- Sahin Hanalioglu
- Department of Neurosurgery, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Muhammet Enes Gurses
- Department of Neurosurgery, Faculty of Medicine, Hacettepe University, Ankara, Turkey
- Department of Neurosurgery, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Neslihan Nisa Gecici
- Department of Neurosurgery, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Baylar Baylarov
- Department of Neurosurgery, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Ilkay Isikay
- Department of Neurosurgery, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Alper Gürlek
- Department of Endocrinology and Metabolism, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Mustafa Berker
- Department of Neurosurgery, Hacettepe University School of Medicine, Sihhiye, Ankara, 06230, Turkey.
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Chavez-Herrera VR, Desai R, Gel G, Nilchian P, Schwartz TH. Endonasal endoscopic surgery for pituitary adenomas. Clin Neurol Neurosurg 2024; 237:108172. [PMID: 38359520 DOI: 10.1016/j.clineuro.2024.108172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 01/22/2024] [Accepted: 02/09/2024] [Indexed: 02/17/2024]
Abstract
Pituitary adenomas are slow-growing, benign intracranial tumors that can be characterized as functional (hormone-producing) or non-functional (non-hormone producing). Symptoms therefore arise from either endocrinologic abnormalities or mass effect on surrounding structures resulting in symptoms such as visual impairment and headache. In the last two decades, technical innovations have shifted surgical resection of such adenomas to endoscopic endonasal approaches. In this review, we describe the evolving approach to pituitary adenomas in the modern endoscopic era, including preoperative multidisciplinary review, relevant surgical anatomy, and a description of the technical nuances of standard and expanded approaches to the anterior skull base.
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Affiliation(s)
- Victor Ramzes Chavez-Herrera
- Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY, USA
| | - Rupen Desai
- Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY, USA
| | - Gülce Gel
- Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY, USA
| | - Parsa Nilchian
- Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY, USA
| | - Theodore H Schwartz
- Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY, USA.
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3
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Campana C, Coopmans EC, Chiloiro S. Editorial: Treatment outcomes, comorbidities and impact of discordant biochemical values in acromegaly. Front Endocrinol (Lausanne) 2024; 15:1351350. [PMID: 38348419 PMCID: PMC10859404 DOI: 10.3389/fendo.2024.1351350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 01/15/2024] [Indexed: 02/15/2024] Open
Affiliation(s)
- Claudia Campana
- Endocrinology Unit, Department of Internal Medicine and Medical Specialties, School of Medical and Pharmaceutical Sciences, University of Genova, Genova, Italy
- Division of Endocrinology, Department of Internal Medicine, Erasmus Medical Center, Rotterdam, Netherlands
| | - Eva Christine Coopmans
- Division of Endocrinology, Department of Medicine, Leiden University Medical Center, Leiden, Netherlands
| | - Sabrina Chiloiro
- Pituitary Unit, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Rome, Italy
- Endocrinology and Diabetes Unit, Università Cattolica del Sacro Cuore, Rome, Italy
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4
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Ali A, Cai X, Zhu J, Geng Y, Du C, Yuan F, Yang J, Tang C, Cong Z, Ma C. A Preoperative Nomogram for Prediction of Postoperative Hypocortisolism in Patients with Pituitary Adenomas: A Single-Center Retrospective Cohort Study. World Neurosurg 2023; 179:e135-e149. [PMID: 37586551 DOI: 10.1016/j.wneu.2023.08.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 08/06/2023] [Accepted: 08/07/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND Patients with pituitary adenomas (PAs) are at an increased risk preoperatively and postoperatively for hypopituitarism. Postoperative hypocortisolism is associated with increased mortality and morbidity as well as poor quality of life. However, research about the risk factors for postoperative hypocortisolism is limited, and a predictive nomogram for postoperative hypocortisolism has not yet been developed. We aimed to investigate the predictive factors for postoperative hypocortisolism and construct a dynamic online nomogram. METHODS Our database included 438 consecutive PA patients who were hospitalized and treated with transsphenoidal surgery by experienced neurosurgeons from the different medical teams in the Neurosurgery Department, Jinling Hospital, between January 2018 and October 2020. The final study group included 238 eligible patients. Data on possible predictors, including age, sex, treatment history of PAs, preoperative signs and symptoms, primary recurrence subtype, and clinical subtypes, were collected. Univariable and multivariable logistic regression analyses were applied to identify independent predictors, which were included in constructing the nomogram model. The calibration curve and receiver operating characteristic curve were computed to evaluate the predictive performance of the nomogram model. RESULTS The incidence of postoperative hypocortisolism was 12.08%. Three preoperative predictors were identified to construct the nomogram: surgical type (microscopic or endoscopic, with endoscopic surgery proven to be the protective factor) (odds ratio, 0.24; 95% confidence interval [CI], 0.093-0.610; P = 0.003), prothrombin time (odds ratio, 2.40; 95% CI, 1.332-4.326; P = 0.004), and basophil cell count (odds ratio, 5.25; 95% CI, 1.270-21.816; P = 0.022,). The area under the curve of receiver operating characteristic curve for the constructed nomogram was 0.749 (95% CI, 0.640-0.763); a well-fixed calibration curve was generated for the nomogram model. An interactive web-based dynamic nomogram application was also constructed. CONCLUSIONS In this study, surgical type, prothrombin time, and basophil cell count were the most relevant predictive factors for postoperative hypocortisolism. A predictive nomogram that can preoperatively assess the risk of hypocortisolism after surgical treatment of PAs was developed. This nomogram could be helpful in identifying high-risk patients who require close monitoring of serum cortisol levels and initiating clinical procedures for patients requiring cortisol administration therapy as a lifesaving strategy.
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Affiliation(s)
- Alleyar Ali
- Department of Neurosurgery, The Affiliated Jinling Hospital of Nanjing Medical University, Nanjing, China
| | - Xiangming Cai
- School of Medicine, Southeast University, Nanjing, China
| | - Junhao Zhu
- Department of Neurosurgery, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Yuanming Geng
- Department of Neurosurgery, The Affiliated Jinling Hospital of Nanjing Medical University, Nanjing, China
| | - Chaonan Du
- Department of Neurosurgery, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Feng Yuan
- Department of Neurosurgery, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Jin Yang
- Department of Neurosurgery, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Chao Tang
- Department of Neurosurgery, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Zixiang Cong
- Department of Neurosurgery, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Chiyuan Ma
- Department of Neurosurgery, The Affiliated Jinling Hospital of Nanjing Medical University, Nanjing, China; School of Medicine, Southeast University, Nanjing, China; Department of Neurosurgery, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, China; Department of Neurosurgery, Jinling Hospital, The First School of Clinical Medicine, Southern Medical University, Guangzhou, China.
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5
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Wang L, Xu D. Regulation of long noncoding RNAs in the pathogenesis and clinical implications of pituitary adenomas. Immun Inflamm Dis 2023; 11:e1047. [PMID: 37904679 PMCID: PMC10571498 DOI: 10.1002/iid3.1047] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 09/20/2023] [Accepted: 09/29/2023] [Indexed: 11/01/2023] Open
Abstract
BACKGROUND Pituitary adenoma (PA) is a type of tumor that develops in the sella turcica and is one of the most frequent intracranial tumors. It belongs to a type of adenoma derived from a single clone of cells in the pituitary gland. PA ranks third among all intracranial tumors, following only gliomas and meningioma. The average prevalence rate is approximately 15% at autopsy and 22.5% at radiological examinations. OBJECTIVE AND SIGNIFICANCE Most PAs are benign and non-invasive adenomas that can be removed surgically or controlled with medication. However, approximately 35% of them show invasion into nearby anatomical structures and cannot be completely resected. 0.1%~0.2% of PA cases eventually develop into pituitary carcinomas. Additionally, PA may cause severe morbidity due to mass effects and the disorder of pituitary hormone secretion. Therefore, there is an urgent need to clarify the pathological mechanism of PA, improve the accuracy of diagnosis, and develop targeted therapies. RESEARCH STATUS Although current knowledge about the pathogenesis of PA remains limited, epigenetic modulation of PA has been increasingly implicated. Long non-coding RNAs (lncRNAs) are known to regulate gene expression post-transcriptionally and exert substantial roles in the initiation, progression, or suppression of various tumors. Accumulating evidence has shown close relationships between lncRNA dysregulation and PA development. CONCLUSIONS This review highlights recent progress in the study of lncRNAs in PA pathogenesis and their potential as diagnostic/prognostic biomarkers or therapeutic targets for PA patients.
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Affiliation(s)
- Ling Wang
- Department of EndocrinologyLiangzhou HospitalWuweiGansuChina
| | - Dingkai Xu
- Department of NeurosurgeryLiangzhou HospitalWuweiGansuChina
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Findlay MC, Drexler R, Khan M, Cole KL, Karbe A, Rotermund R, Ricklefs FL, Flitsch J, Smith TR, Kilgallon JL, Honegger J, Nasi-Kordhishti I, Gardner PA, Gersey ZC, Abdallah HM, Jane JA, Marino AC, Knappe UJ, Uksul N, Rzaev JA, Galushko EV, Gormolysova EV, Bervitskiy AV, Schroeder HWS, Eördögh M, Losa M, Mortini P, Gerlach R, Antunes ACM, Couldwell WT, Budohoski KP, Rennert RC, Azab M, Karsy M. A Multicenter, Propensity Score-Matched Assessment of Endoscopic Versus Microscopic Approaches in the Management of Pituitary Adenomas. Neurosurgery 2023; 93:794-801. [PMID: 37057921 DOI: 10.1227/neu.0000000000002497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 02/21/2023] [Indexed: 04/15/2023] Open
Abstract
BACKGROUND AND OBJECTIVES There is considerable controversy as to which of the 2 operating modalities (microsurgical or endoscopic transnasal surgery) currently used to resect pituitary adenomas (PAs) is the safest and most effective intervention. We compared rates of clinical outcomes of patients with PAs who underwent resection by either microsurgical or endoscopic transnasal surgery. METHODS To independently assess the outcomes of each modality type, we sought to isolate endoscopic and microscopic PA surgeries with a 1:1 tight-caliper (0.01) propensity score-matched analysis using a multicenter, neurosurgery-specific database. Surgeries were performed between 2017 and 2020, with data collected retrospectively from 12 international institutions on 4 continents. Matching was based on age, previous neurological deficit, American Society of Anesthesiologists (ASA) score, tumor functionality, tumor size, and Knosp score. Univariate and multivariate analyses were performed. RESULTS Among a pool of 2826 patients, propensity score matching resulted in 600 patients from 9 surgery centers being analyzed. Multivariate analysis showed that microscopic surgery had a 1.91 odds ratio (OR) ( P = .03) of gross total resection (GTR) and shorter operative duration ( P < .01). However, microscopic surgery also had a 7.82 OR ( P < .01) for intensive care unit stay, 2.08 OR ( P < .01) for intraoperative cerebrospinal fluid (CSF) leak, 2.47 OR ( P = .02) for postoperative syndrome of inappropriate antidiuretic hormone secretion (SIADH), and was an independent predictor for longer postoperative stay (β = 2.01, P < .01). Overall, no differences in postoperative complications or 3- to 6-month outcomes were seen by surgical approach. CONCLUSION Our international, multicenter matched analysis suggests microscopic approaches for pituitary tumor resection may offer better GTR rates, albeit with increased intensive care unit stay, CSF leak, SIADH, and hospital utilization. Better prospective studies can further validate these findings as matching patients for outcome analysis remains challenging. These results may provide insight into surgical benchmarks at different centers, offer room for further registry studies, and identify best practices.
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Affiliation(s)
- Matthew C Findlay
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City , Utah , USA
- School of Medicine, University of Utah, Salt Lake City , Utah , USA
| | - Richard Drexler
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg , Germany
| | - Majid Khan
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City , Utah , USA
- Reno School of Medicine, University of Nevada, Reno , Nevada , USA
| | - Kyril L Cole
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City , Utah , USA
- School of Medicine, University of Utah, Salt Lake City , Utah , USA
| | - Arian Karbe
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg , Germany
| | - Roman Rotermund
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg , Germany
| | - Franz L Ricklefs
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg , Germany
| | - Jörg Flitsch
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg , Germany
| | - Timothy R Smith
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston , Massachusetts , USA
| | - John L Kilgallon
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston , Massachusetts , USA
| | - Jürgen Honegger
- Department of Neurosurgery, University Hospital Tübingen, Eberhard-Karls-University Tübingen, Tübingen , Germany
| | - Isabella Nasi-Kordhishti
- Department of Neurosurgery, University Hospital Tübingen, Eberhard-Karls-University Tübingen, Tübingen , Germany
| | - Paul A Gardner
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh , Pennsylvania , USA
| | - Zachary C Gersey
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh , Pennsylvania , USA
| | - Hussein M Abdallah
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh , Pennsylvania , USA
| | - John A Jane
- Department of Neurosurgery, University of Virginia Health System, Charlottesville , Virginia , USA
| | - Alexandria C Marino
- Department of Neurosurgery, University of Virginia Health System, Charlottesville , Virginia , USA
| | - Ulrich J Knappe
- Department of Neurosurgery, Johannes Wesling Hospital Minden, Minden , Germany
| | - Nesrin Uksul
- Department of Neurosurgery, Johannes Wesling Hospital Minden, Minden , Germany
| | - Jamil A Rzaev
- Federal Center of Neurosurgery, Novosibirsk , Russia
- Novosibirsk State Medical University, Novosibirsk , Russia
| | | | | | - Anatoliy V Bervitskiy
- Federal Center of Neurosurgery, Novosibirsk , Russia
- Novosibirsk State Medical University, Novosibirsk , Russia
| | - Henry W S Schroeder
- Department of Neurosurgery, University Medicine Greifswald, Greifswald , Germany
| | - Márton Eördögh
- Department of Neurosurgery, University Medicine Greifswald, Greifswald , Germany
| | - Marco Losa
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan , Italy
| | - Pietro Mortini
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan , Italy
| | - Rüdiger Gerlach
- Department of Neurosurgery, Helios Kliniken, Erfurt , Germany
| | - Apio C M Antunes
- Department of Neurosurgery, Hospital de Clínicas de Porto Alegre, Porto Alegre , Rio Grande do Sul , Brazil
| | - William T Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City , Utah , USA
| | - Karol P Budohoski
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City , Utah , USA
| | - Robert C Rennert
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City , Utah , USA
- Department of Neurosurgery, University of Southern California, Los Angeles , California , USA
| | - Mohammed Azab
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City , Utah , USA
- Boise State University, Boise , Idaho , USA
| | - Michael Karsy
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City , Utah , USA
- Global Neurosciences Institute, Philadelphia , Pennsylvania , USA
- Department of Neurosurgery, Drexel University College of Medicine, Philadelphia , Pennsylvania , USA
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Tosi U, Guadix SW, Souweidane MM. Neuroendoscopy: The State of the Art. World Neurosurg 2023; 178:305-310. [PMID: 37803686 DOI: 10.1016/j.wneu.2023.07.125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 07/27/2023] [Indexed: 10/08/2023]
Abstract
Over the past century, neuroendoscopy developed into a mainstay of neurosurgical practice, allowing for minimally invasive approaches to the ventricles, skull base, and spine. Its development, however, is far from over. Current challenges are inherent in the very feature that renders neuroendoscopy appealing-the small channels of the modern endoscope allow surgery to be performed with minimal tissue retraction, but they also make hemostasis and resection of large masses difficult. New optics allow for significantly improved image quality; yet open craniotomy often allows for 3-dimensional visualization and bimanual dissection and is part of everyday neurosurgical training. Finally, the utilization of neuroendoscopy remains limited, presenting ongoing challenges for neurosurgical teaching and achievement of technical mastery.
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Affiliation(s)
- Umberto Tosi
- Department of Neurological Surgery, NewYork-Presbyterian Weill Cornell Medicine, New York, New York, USA
| | - Sergio W Guadix
- Department of Neurological Surgery, NewYork-Presbyterian Weill Cornell Medicine, New York, New York, USA
| | - Mark M Souweidane
- Department of Neurological Surgery, NewYork-Presbyterian Weill Cornell Medicine, New York, New York, USA.
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8
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Vassilyeva N, Mena N, Kirov K, Diatlova E. Comparative effectiveness of endoscopic and microscopic adenoma removal in acromegaly. Front Endocrinol (Lausanne) 2023; 14:1128345. [PMID: 37766690 PMCID: PMC10519786 DOI: 10.3389/fendo.2023.1128345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 08/16/2023] [Indexed: 09/29/2023] Open
Abstract
Introduction Somatotropinomas are the main cause of acromegaly. Surgery is the primary and most efficient method of treatment. The study aimed to compare the radicality of small-sized and medium (<30 mm) somatotropinoma removal and the incidence of postoperative complications in patients with acromegaly when using microscopic and endoscopic techniques. Methods In this randomized controlled trial, a total of 83 patients with acromegaly underwent transspheroidal endoscopy or microscopic surgery. Somatotropinoma was the cause of acromegaly in all cases. Patients were randomly divided into two comparison groups depending on the applied surgical technique. Group 1 (n = 40) consisted of patients who underwent adenomectomy with transnasal transsphenoidal access by a microscope. Group 2 (n = 43) included patients who underwent the same surgical procedure with an endoscope. The following indicators were assessed: radicality of tumor removal, treatment effectiveness, postoperative complications, and remission rate. Results The study has shown that removal of somatotropinoma in patients with acromegaly using endoscopic technique increases the radicality of tumor removal in comparison with microscopic technique. Total removal of somatotropinoma was successful in 88.4% of cases when using the endoscopic technique. Secondly, the segmentation of patients according to their tumor characteristics poses challenges, primarily owing to the rarity of acromegaly as a disease. The difference between groups was not statistically significant (p=1.02). There were no statistically significant differences in basal GH level and IGF-1 level between groups (p=0.546 and p=0.784, respectively). Discussion Endonasal transsphenoidal endoscopic adenomectomy is proven efficacy, a less traumatic degree, and higher somatotropinoma removal radicality. Both surgical methods lead to disease remission.
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Affiliation(s)
- Natalya Vassilyeva
- Department Emergency Medicine, Anesthesiology and Resuscitation, Karaganda Medical University, Karaganda, Kazakhstan
| | - Natmir Mena
- Department of General Surgery, Medical University Pleven, Pleven, Bulgaria
| | - Kiril Kirov
- Research Institute, Medical University Pleven, Pleven, Bulgaria
| | - Ekaterina Diatlova
- Department of Nursing Management and Social Work, Sechenov First Moscow State Medical University, Moscow, Russia
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9
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Kwon TH, Shin HK, Yoon WK, Kim JH, Byun J. Antibiotics Prophylaxis for Endoscopic Endonasal Approach for Skull Base Tumor Surgery: A Meta-Analysis. World Neurosurg 2023; 174:e82-e91. [PMID: 36894007 DOI: 10.1016/j.wneu.2023.02.143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Revised: 02/27/2023] [Accepted: 02/28/2023] [Indexed: 03/09/2023]
Abstract
BACKGROUND The regimen of prophylactic antibiotic for endoscopic endonasal skull base surgery (EE-SBS) varies considerably depending on surgeons and their institutes. The purpose of the present meta-analysis is to assess the effect of antibiotic regimens on EE-SBS surgery for anterior skull base tumor. METHODS The PubMed, Embase, Web of Science, and Cochrane clinical trial databases were systematically searched through October 15, 2022. RESULTS The 20 included studies were all retrospective. The studies included a total of 10,735 patients who underwent EE-SBS for skull base tumor. The proportion of patients with postoperative intracranial infection across all 20 studies was 0.9% (95% confidence interval [CI] 0.5%-1.3%). The proportion of postoperative intracranial infection in the multiple antibiotics group did not show statistically significant difference to that of the single antibiotic agent group (proportion: 0.6%, 95% CI 0%-1.4% vs. proportion: 1%, 95% CI 0.6%-1.5%, respectively, P = 0.39). The ultra-short duration maintenance group showed lower incidence of postoperative intracranial infection, although it did not reach statistical significance (ultra-short group: 0.7%, 95% CI 0.5%-0.9%; short duration: 1.8%, 95% CI 0.5%-3%; and long duration: 1%, 95% CI 0.2%-1.9%, P = 0.22) The combination of the multiple antibiotics group did not show meaningful low incidence of postoperative intracranial infection (antibiotics combination group: 0.6%, 95% CI 0%-1.4%; cefazolin single group: 0.8%, 95% CI 0%-1.6%; and single antibiotics other than cefazolin: 1.2%, 95% CI 0.7%-1.7%, P = 0.22). CONCLUSIONS Multiple antibiotics did not show superiority compared with single antibiotic agent. Also, long maintenance duration of antibiotics did not reduce the incidence of postoperative intracranial infection.
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Affiliation(s)
- Taek Hyun Kwon
- Department of Neurosurgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Hong Kyung Shin
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Won Ki Yoon
- Department of Neurosurgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Jong Hyun Kim
- Department of Neurosurgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Joonho Byun
- Department of Neurosurgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea.
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10
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Zhang Q, Yao B, Long X, Chen Z, He M, Wu Y, Qiao N, Ma Z, Ye Z, Zhang Y, Yao S, Wang Y, Cheng H, Chen H, Ye H, Wang Y, Li Y, Chen J, Zhang Z, Guo F, Zhao Y. Single-cell sequencing identifies differentiation-related markers for molecular classification and recurrence prediction of PitNET. Cell Rep Med 2023; 4:100934. [PMID: 36754052 PMCID: PMC9975294 DOI: 10.1016/j.xcrm.2023.100934] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 11/29/2022] [Accepted: 01/13/2023] [Indexed: 02/10/2023]
Abstract
Pituitary neuroendocrine tumor (PitNET) is one of the most common intracranial tumors with variable recurrence rate. Currently, the recurrence prediction is unsatisfying and can be improved by understanding the cellular origins and differentiation status. Here, to comprehensively reveal the origin of PitNET, we perform comparative analysis of single-cell RNA sequencing data from 3 anterior pituitary glands and 21 PitNETs. We identify distinct genes representing major subtypes of well and poorly differentiated PitNETs in each lineage. To further verify the predictive value of differentiation biomarkers, we include an independent cohort of 800 patients with an average follow-up of 7.2 years. In both PIT1 and TPIT lineages, poorly differentiated groups show significantly higher recurrence rates while well-differentiated groups show higher recurrence rates in SF1 lineage. Our findings reveal the possible origin and differentiation status of PitNET based on which new differentiation classification is proposed and verified to predict tumor recurrence.
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Affiliation(s)
- Qilin Zhang
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China; National Center for Neurological Disorders, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
| | - Boyuan Yao
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China; National Center for Neurological Disorders, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
| | - Xin Long
- State Key Laboratory of Stem Cell and Reproductive Biology, Institute of Zoology, Chinese Academy of Sciences, Beijing 100101, China; Institute for Stem Cell and Regeneration, Chinese Academy of Sciences, Beijing 100101, China; Beijing Institute for Stem Cell and Regenerative Medicine, Beijing 100101, China; University of Chinese Academy of Sciences, Beijing 100049, China
| | - Zhengyuan Chen
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China; National Center for Neurological Disorders, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
| | - Min He
- National Center for Neurological Disorders, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China; Department of Endocrinology and Metabolism, Huashan Hospital, Fudan University, Shanghai, China
| | - Yue Wu
- National Center for Neurological Disorders, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China; Department of Radiology, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
| | - Nidan Qiao
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China; National Center for Neurological Disorders, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
| | - Zengyi Ma
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China; National Center for Neurological Disorders, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
| | - Zhao Ye
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China; National Center for Neurological Disorders, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
| | - Yichao Zhang
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China; National Center for Neurological Disorders, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
| | - Shun Yao
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China; National Center for Neurological Disorders, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
| | - Ye Wang
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China; National Center for Neurological Disorders, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
| | - Haixia Cheng
- National Center for Neurological Disorders, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China; Department of Pathology, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
| | - Hong Chen
- National Center for Neurological Disorders, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China; Department of Pathology, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
| | - Hongying Ye
- National Center for Neurological Disorders, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China; Department of Endocrinology and Metabolism, Huashan Hospital, Fudan University, Shanghai, China
| | - Yongfei Wang
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China; National Center for Neurological Disorders, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
| | - Yimin Li
- National Center for Neurological Disorders, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China; Department of Endocrinology and Metabolism, Huashan Hospital, Fudan University, Shanghai, China
| | - Jianhua Chen
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, China
| | - Zhaoyun Zhang
- National Center for Neurological Disorders, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China; Department of Endocrinology and Metabolism, Huashan Hospital, Fudan University, Shanghai, China.
| | - Fan Guo
- State Key Laboratory of Stem Cell and Reproductive Biology, Institute of Zoology, Chinese Academy of Sciences, Beijing 100101, China; Institute for Stem Cell and Regeneration, Chinese Academy of Sciences, Beijing 100101, China; Beijing Institute for Stem Cell and Regenerative Medicine, Beijing 100101, China; University of Chinese Academy of Sciences, Beijing 100049, China.
| | - Yao Zhao
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China; National Center for Neurological Disorders, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China; State Key Laboratory of Medical Neurobiology and MOE Frontiers Center for Brain Science, Institutes of Brain Science, Fudan University, Shanghai 200032, China; Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai 200040, China; Neurosurgical Institute of Fudan University, Shanghai 200040, China; National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China; Shanghai Clinical Medical Center of Neurosurgery, Huashan Hospital, Fudan University, Shanghai 200040, China.
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CSF rhinorrhoea after endonasal intervention to the skull base (CRANIAL): A multicentre prospective observational study. Front Oncol 2023; 12:1049627. [PMID: 36688936 PMCID: PMC9846732 DOI: 10.3389/fonc.2022.1049627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 10/24/2022] [Indexed: 01/09/2023] Open
Abstract
Objective Despite progress in endonasal skull-base neurosurgery, cerebrospinal fluid (CSF) rhinorrhoea remains common and significant. The CRANIAL study sought to determine 1) the scope of skull-base repair methods used, and 2) corresponding rates of postoperative CSF rhinorrhoea in the endonasal transsphenoidal approach (TSA) and the expanded endonasal approach (EEA) for skull-base tumors. Methods A prospective observational cohort study of 30 centres performing endonasal skull-base neurosurgery in the UK and Ireland (representing 91% of adult units). Patients were identified for 6 months and followed up for 6 months. Data collection and analysis was guided by our published protocol and pilot studies. Descriptive statistics, univariate and multivariable logistic regression models were used for analysis. Results A total of 866 patients were included - 726 TSA (84%) and 140 EEA (16%). There was significant heterogeneity in repair protocols across centres. In TSA cases, nasal packing (519/726, 72%), tissue glues (474/726, 65%) and hemostatic agents (439/726, 61%) were the most common skull base repair techniques. Comparatively, pedicled flaps (90/140, 64%), CSF diversion (38/140, 27%), buttresses (17/140, 12%) and gasket sealing (11/140, 9%) were more commonly used in EEA cases. CSF rhinorrhoea (biochemically confirmed or requiring re-operation) occurred in 3.9% of TSA (28/726) and 7.1% of EEA (10/140) cases. A significant number of patients with CSF rhinorrhoea (15/38, 39%) occurred when no intraoperative CSF leak was reported. On multivariate analysis, there may be marginal benefits with using tissue glues in TSA (OR: 0.2, CI: 0.1-0.7, p<0.01), but no other technique reached significance. There was evidence that certain characteristics make CSF rhinorrhoea more likely - such as previous endonasal surgery and the presence of intraoperative CSF leak. Conclusions There is a wide range of skull base repair techniques used across centres. Overall, CSF rhinorrhoea rates across the UK and Ireland are lower than generally reported in the literature. A large proportion of postoperative leaks occurred in the context of occult intraoperative CSF leaks, and decisions for universal sellar repairs should consider the risks and cost-effectiveness of repair strategies. Future work could include longer-term, higher-volume studies, such as a registry; and high-quality interventional studies.
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Optimizing Perioperative Care in Transsphenoidal Pituitary Surgery: Considerations for Enhanced Recovery After Surgery. J Craniofac Surg 2023; 34:83-91. [PMID: 35968948 DOI: 10.1097/scs.0000000000008893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 06/04/2022] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE To identify key recommendations for maximizing the efficiency and efficacy of perioperative care in transsphenoidal pituitary surgery. METHODS The authors performed a comprehensive literature search of Enhanced Recovery After Surgery protocols implemented for patients undergoing transsphenoidal adenomectomy (TSA); individual recommendations were abstracted, and the evidence base thoroughly reviewed. RESULTS The authors identified 19 individual recommendations pertinent to the care of patients undergoing TSA, which were subdivided into preoperative (n=6), intraoperative (n=6), and postoperative (n=7) interventions. Key factors recommended for minimizing length of stay, preventing readmission, and improving patient outcomes included comprehensive patient education, multidisciplinary evaluation, avoidance of routine lumbar drain placement and nasal packing, and rigorous postoperative monitoring of pituitary function and salt-water imbalances. The overall level of evidence for 7/19 (37%) implemented recommendations was found to be low, suggesting a need for continued research in this patient population. CONCLUSION Several key interventions should be considered in the development of Enhanced Recovery After Surgery protocols for TSA, which may aid in further decreasing length of stay and promoting positive patient outcomes.
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Machine learning driven prediction of cerebrospinal fluid rhinorrhoea following endonasal skull base surgery: A multicentre prospective observational study. Front Oncol 2023; 13:1046519. [PMID: 37035179 PMCID: PMC10076706 DOI: 10.3389/fonc.2023.1046519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 01/27/2023] [Indexed: 04/11/2023] Open
Abstract
Background Cerebrospinal fluid rhinorrhoea (CSFR) is a common complication following endonasal skull base surgery, a technique that is fundamental to the treatment of pituitary adenomas and many other skull base tumours. The CRANIAL study explored CSFR incidence and related risk factors, particularly skull base repair techniques, via a multicentre prospective observational study. We sought to use machine learning to leverage this complex multicentre dataset for CSFR prediction and risk factor analysis. Methods A dataset of 865 cases - 725 transsphenoidal approach (TSA) and 140 expanded endonasal approach (EEA) - with cerebrospinal fluid rhinorrhoea as the primary outcome, was used. Relevant variables were extracted from the data, and prediction variables were divided into two categories, preoperative risk factors; and repair techniques, with 6 and 11 variables respectively. Three types of machine learning models were developed in order to predict CSFR: logistic regression (LR); decision tree (DT); and neural network (NN). Models were validated using 5-fold cross-validation, compared via their area under the curve (AUC) evaluation metric, and key prediction variables were identified using their Shapley additive explanations (SHAP) score. Results CSFR rates were 3.9% (28/725) for the transsphenoidal approach and 7.1% (10/140) for the expanded endonasal approach. NNs outperformed LR and DT for CSFR prediction, with a mean AUC of 0.80 (0.70-0.90) for TSA and 0.78 (0.60-0.96) for EEA, when all risk factor and intraoperative repair data were integrated into the model. The presence of intraoperative CSF leak was the most prominent risk factor for CSFR. Elevated BMI and revision surgery were also associated with CSFR for the transsphenoidal approach. CSF diversion and gasket sealing appear to be strong predictors of the absence of CSFR for both approaches. Conclusion Neural networks are effective at predicting CSFR and uncovering key CSFR predictors in patients following endonasal skull base surgery, outperforming traditional statistical methods. These models will be improved further with larger and more granular datasets, improved NN architecture, and external validation. In the future, such predictive models could be used to assist surgical decision-making and support more individualised patient counselling.
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Ibrahim B, Mandel M, Ali A, Najera E, Obrzut M, Adada B, Borghei-Razavi H. Pituitary Adenomas: Classification, Clinical Evaluation and Management. Skull Base Surg 2022. [DOI: 10.5772/intechopen.103778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Pituitary adenomas are one of the most common brain tumors. They represent approximately 18% of all intracranial, and around 95% of sellar neoplasms. In recent years, our understanding of the pathophysiology and the behavior of these lesions has led to better control and higher curative rates. The treatment decision is largely dependent on type of the adenoma, clinical presentation, and the size of the lesion. In addition, incidental pituitary lesions add uncertainty in the decision-making process, especially for pituitary adenomas that can be medically managed. When surgery is indicated, the endoscopic endonasal transsphenoidal approach is the technique of choice, but open standard craniotomy approaches can also be the option in selected cases. The following chapter will review the classification, clinical presentation, pathophysiology, diagnostic work-up, selection of surgical approach, and treatment complications in pituitary adenomas.
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Abramov I, Labib MA, Houlihan LM, Loymak T, Srinivasan VM, Preul MC, Lawton MT. Quantitative Anatomic Comparison of the Extreme Lateral Transodontoid vs Extreme Medial Endoscopic Endonasal Approaches to the Jugular Foramen and Craniovertebral Junction. Oper Neurosurg (Hagerstown) 2022; 23:396-405. [PMID: 36103356 DOI: 10.1227/ons.0000000000000350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 05/10/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Large, destructive intracranial and extracranial lesions at the jugular foramen (JF) and anterior craniovertebral junction (CVJ) are among the most challenging lesions to resect. OBJECTIVE To compare the extreme lateral transodontoid approach (ELTOA) with the extreme medial endoscopic endonasal approach (EMEEA) to determine the most effective surgical approach to the JF and CVJ. METHODS Seven formalin-fixed cadaveric heads were dissected. Using neuronavigation, we quantitatively measured and compared the exposure of the intracranial and extracranial neurovascular structures, the drilled area of the clivus and the C1 vertebra, and the area of exposure of the brainstem. RESULTS The mean total drilled area of the clivus was greater with the EMEEA than with the ELTOA (1043.5 vs 909.4 mm2, P = .02). The EMEEA provided a longer exposure of the extracranial cranial nerves (CNs) IX, X, and XI compared with the ELTOA (cranial nerve [CN] IX: 18.8 vs 12.0 mm, P = .01; CN X: 19.2 vs 10.4 mm, P = .003; and CN XI, 18.1 vs 11.9 mm, P = .04). The EMEEA, compared with the ELTOA, provided a significantly greater area of exposure of the contralateral ventromedial medulla (289.5 vs 80.9 mm2, P < .001) and pons (237.5 vs 86.2 mm2, P = .005) but less area of exposure of the ipsilateral dorsolateral medulla (51.5 vs 205.8 mm2, P = .008). CONCLUSION The EMEEA and ELTOA provide optimal exposures to different aspects of the CVJ and JF. A combination of these approaches can compensate for their disadvantages and achieve significant exposure.
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Affiliation(s)
- Irakliy Abramov
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
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Effects of Staged Nursing Care on Neuroendoscopic Transsphenoidal Pituitary Adenoma Resection and Postoperative Complications. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2022; 2022:2171529. [PMID: 35966740 PMCID: PMC9374548 DOI: 10.1155/2022/2171529] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 07/01/2022] [Accepted: 07/02/2022] [Indexed: 12/30/2022]
Abstract
Objective The purpose of this study was to determine whether staged nursing had an impact on the outcome of neuroendoscopic transsphenoidal pituitary tumor resection and postoperative complications. Methods As research participants, we chose 88 individuals with pituitary adenomas who were treated at our institution between February 2020 and November 2021; all patients received endoscopic transsphenoidal pituitary adenoma excision. The patients were randomly divided into two groups: the routine group (n = 44) and the stage group (n = 44). Patients in the routine group received care according to the routine nursing mode, and patients in the stage group received care according to the stage nursing mode. The staged nursing interventions included preoperative, intraoperative, and postoperative nursing. Postoperative recovery-related indicators such as the self-rating anxiety scale (SAS) and a self-rating depression scale (SDS), contentment, comfort, and postoperative complications were compared between the two groups. Results The postoperative recovery-related indexes of patients in the stage group were significantly lower than those in the routine group (P < 0.05); the SAS and SDS scores in the stage group after treatment were significantly lower than those in the routine group (P < 0.05); patients in the stage group were significantly more satisfied with their treatment after treatment than those in the routine group (P < 0.05); patients in the stage group were significantly more comfortable after treatment than those in the routine group (P < 0.05); a significantly lower incidence of postoperative complications was observed in the stage group compared to the routine group (P < 0.05). Conclusion Patients with neuroendoscopic transsphenoidal pituitary tumor excision benefit greatly from staged nursing. The nursing approach may successfully assure the procedure's smooth completion, boost patients' postoperative recovery, and reduce patients' worry, despair, and other unpleasant feelings. The nursing approach may successfully increase clinical satisfaction and comfort of patients by minimizing the likelihood of postoperative problems, and it is well-suited for practical use.
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Lenga P, Jakobs M, Jesser J, Trong PD, Unterberg AW, Beynon C. The use of quantitative pupillometry in patients with pituitary tumors: a technical note. Acta Neurochir (Wien) 2022; 164:1599-1604. [PMID: 35445853 PMCID: PMC9160135 DOI: 10.1007/s00701-022-05214-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 04/11/2022] [Indexed: 11/27/2022]
Abstract
Background Pituitary tumors may cause compression of the optic chiasm, resulting in decreased visual acuity. Therefore, decompression of the optic chiasm is a major goal of surgical treatment in such patients. Quantitative pupillometry has been used in various clinical settings for assessing the optic system but has not been applied in patients with pituitary tumors. This study aimed to evaluate the potential of this technique to improve treatment modalities in patients undergoing surgical resection of pituitary tumors. Method Pupillometry using the automated NPi 200® Pupillometer was performed in seven patients who underwent surgical resection of large pituitary tumors at the University of Heidelberg in 2018. The neurological pupil index (NPi) was assessed preoperatively and postoperatively, and correlations with visual acuity and magnetic resonance imaging (MRI) findings regarding optic chiasm compression were determined. Results All patients experienced visual disturbance due to a large pituitary tumor. The NPi was < 4.0 in all patients in at least one pupil. Intraoperative MRI demonstrated successful decompression of the optic chiasm in all cases. Postoperatively, the NPi values increased, and this increase was correlated with improved visual acuity. Conclusions We found that quantitative pupillometry can detect optic chiasm compression in patients with pituitary tumors. Furthermore, postoperative improvement of NPi values may indicate sufficient decompression of the optic chiasm. Further studies are warranted to substantiate the granularity of this technique to gain valuable information for patients with pituitary tumors who are indicated for surgery.
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Affiliation(s)
- Pavlina Lenga
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.
| | - Martin Jakobs
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Jessica Jesser
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Philip Dao Trong
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Andreas W Unterberg
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Christopher Beynon
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
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The Benefit of Intraoperative Magnetic Resonance Imaging in Endoscopic and Microscopic Transsphenoidal Resection of Recurrent Pituitary Adenomas. Curr Oncol 2022; 29:392-401. [PMID: 35049709 PMCID: PMC8774543 DOI: 10.3390/curroncol29010035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 01/09/2022] [Accepted: 01/13/2022] [Indexed: 11/18/2022] Open
Abstract
The surgical treatment of recurrent adenomas can be challenging. Intraoperative magnetic resonance imaging (iMRI) can improve the orientation and increase the safe extent of resection. We conducted a quantitative and qualitative retrospective analysis of recurrent adenomas treated by endoscopic or microscopic iMRI-assisted transsphenoidal surgery. A total number of 59 resections were selected. Detailed volumetric measurements, tumor characteristics, and MRI features of intraoperative remnants were evaluated. Intraoperative MRI increased the gross total resection (GTR) rate from 33.9% to 49.2%. Common locations of tumor remnants after iMRI were the clivus, the wall of the cavernous sinus or the perforation of the diaphragm. Increasing tumor volume and the microscopic technique were significantly associated with further resection after iMRI in the univariate analysis (p = 0.004, OR 1.6; p = 0.009, OR 4.4). Only the increasing tumor volume was an independent predictor for further resection (p = 0.007, OR 1.5). A significantly higher proportion of GTRs was achieved with the endoscopic technique (p = 0.001). Patients with a large recurrent pituitary adenoma who underwent microscopic transsphenoidal resection were the most likely to benefit from iMRI regarding the extent of resection. Occult invasions of the cavernous sinus and/or the clivus were the most common findings leading to further resection of tumor remnants after iMRI.
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Phua QS, Lu L, Harding M, Poonnoose SI, Jukes A, To MS. Systematic Analysis of Publication Bias in Neurosurgery Meta-Analyses. Neurosurgery 2022; 90:262-269. [DOI: 10.1227/neu.0000000000001788] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 09/19/2021] [Indexed: 12/11/2022] Open
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Chen Y, Xu X, Cao J, Jie Y, Wang L, Cai F, Chen S, Yan W, Hong Y, Zhang J, Wu Q. Transsphenoidal Surgery of Giant Pituitary Adenoma: Results and Experience of 239 Cases in A Single Center. Front Endocrinol (Lausanne) 2022; 13:879702. [PMID: 35600598 PMCID: PMC9120954 DOI: 10.3389/fendo.2022.879702] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 04/08/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Transsphenoidal surgery (TSS) is first-line treatment for giant pituitary adenomas (PAs). Although PA is a benign neuroendocrine tumor that originates from adenohypophysial cells, the surgical outcomes and prognosis of giant PAs differ significantly due to multiple factors such as tumor morphology, invasion site, pathological characteristics and so on. The aim of this study was to evaluate surgical outcomes of giant PAs in a single-center cohort. METHODS The clinical features and outcomes of 239 patients with giant PA who underwent sphenoidal surgery at the Second Affiliated Hospital of Zhejiang University School of Medicine from January 2015 to October 2021 were collected from medical records. The basic clinical information (age, gender, function etc.), surgical procedure, imaging features (maximum diameter, invasion characteristics, tumor shape etc.) and histopathological characteristics (pathological results, Ki-67, P53 etc.) were retrospectively reviewed. SPSS 25.0 and Stata 12.0 software were used for statistical analysis. RESULTS A total of 239 patients with giant PAs underwent TSS, of which 168 surgeries (70.29%) were endoscopic endonasal transsphenoidal (EETS) and 71 (29.71%) were microscopic transsphenoidal (MTS). The mean preoperative maximum diameter in the cohort was 45.64 mm. Gross-total resection was achieved in 46 patients (19.25%), near-total in 56 (23.43%), subtotal in 68 (28.45%), and partial in 69 (28.87%) patients. The maximum tumor diameter and Knosp grade were the significant factors that limited the extent of the resection of giant PAs. A total of 193 patients (80.75%) experienced surgical complications, and the most common complications were postoperative diabetes insipidus (DI) (91, 38.08%), intracranial infection (36, 15.06%) and cerebrospinal fluid (CSF) leaks (37, 15.48%). In addition, there was a significant difference in the incidence of CSF leaks between the neuroendoscopy group and the microscopic group (P < 0.05). CONCLUSION The management of giant PAs remains a therapeutic challenge due to their large size and postoperative complications. The maximum diameter and Knosp grade of giant PAs significantly limited the extent of resection, which warrants a reasonable surgical plan.
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Affiliation(s)
- Yike Chen
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xiaohui Xu
- Department of Neurosurgery, The Fourth Affiliated Hospital, School of Medicine, Zhejiang University, Yiwu, China
| | - Jing Cao
- Department of Statistical Office, The Affiliated Changsha Central Hospital, Hengyang Medical School, University of South, Changsha, China
| | - Yuanqing Jie
- Department of Neurosurgery, The Affiliated Quzhou People’s Hospital of Wenzhou Medical University, Quzhou, China
| | - Linkai Wang
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Feng Cai
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Sheng Chen
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Wei Yan
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yuan Hong
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jianmin Zhang
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- *Correspondence: Qun Wu, ; Jianmin Zhang,
| | - Qun Wu
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- *Correspondence: Qun Wu, ; Jianmin Zhang,
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Gong X, Zhuo Y, Yuan H, Yang K, Li C, Feng S, Zhang M, Li Z, Zhou H, Liu Z. Outcome of Endoscopic Transsphenoidal Surgery for Recurrent or Residual Pituitary Adenomas and Comparison to Non-Recurrent or Residual Cohort by Propensity Score Analysis. Front Endocrinol (Lausanne) 2022; 13:837025. [PMID: 35547003 PMCID: PMC9081813 DOI: 10.3389/fendo.2022.837025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 03/21/2022] [Indexed: 11/15/2022] Open
Abstract
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.
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Affiliation(s)
- Xuan Gong
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
| | - Yang Zhuo
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
| | - Huichun Yuan
- Department of Neurosurgery, The First People’s Hospital of Changde, Changde, China
| | - Kui Yang
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
| | - Chuntao Li
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
| | - Songshan Feng
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
| | - Mingyu Zhang
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
| | - Zhenyan Li
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
| | - Hongshu Zhou
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
- *Correspondence: Zhixiong Liu, ; Hongshu Zhou,
| | - Zhixiong Liu
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
- *Correspondence: Zhixiong Liu, ; Hongshu Zhou,
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22
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Cossu G, Jouanneau E, Cavallo LM, Froelich S, Starnoni D, Giammattei L, Harel E, Mazzatenta D, Bruneau M, Meling TR, Berhouma M, Chacko AG, Cornelius JF, Paraskevopoulos D, Schroeder HW, Zazpe I, Manet R, Gardner PA, Dufour H, Cappabianca P, Daniel RT, Messerer M. Surgical management of giant pituitary neuroendocrine tumors: Meta-analysis and consensus statement on behalf of the EANS skull base section. BRAIN AND SPINE 2022; 2:100878. [PMID: 36248137 PMCID: PMC9560664 DOI: 10.1016/j.bas.2022.100878] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 02/07/2022] [Accepted: 03/09/2022] [Indexed: 12/12/2022]
Abstract
Introduction The optimal surgical treatment for giant pituitary neuroendocrine tumors(GPitNETs) is debated. Research question The aim of this paper is to optimize the surgical management of these patients and to provide a consensus statement on behalf of the EANS Skull Base Section. Material and methods We constituted a task force belonging to the EANS skull base committee to define some principles for the management of GPitNETs. A systematic review was performed according to PRISMA guidelines to perform a meta-analysis on surgical series of GPitNETs. Weighted summary rates were obtained for the pooled extent of resection and according to the surgical technique. These data were discussed to obtain recommendations after evaluation of the selected articles and discussion among the experts. Results 20articles were included in our meta-analysis, for a total of 1263 patients. The endoscopic endonasal technique was used in 40.3% of cases, the microscopic endonasal approach in 34% of cases, transcranial approaches in 18.7% and combined approaches in 7% of cases. No difference in terms of gross total resection (GTR) rate was observed among the different techniques. Pooled GTR rate was 36.6%, while a near total resection (NTR) was possible in 45.2% of cases. Cavernous sinus invasion was associated with a lower GTR rate (OR: 0.061). After surgery, 35% of patients had endocrinological improvement and 75.6% had visual improvement. Recurrent tumors were reported in 10% of cases Discussion and conclusion After formal discussion in the working group, we recommend the treatment of G-PitNETs tumors with a more complex and multilobular structure in tertiary care centers. The endoscopic endonasal approach is the first option of treatment and extended approaches should be planned according to extension, morphology and consistency of the lesion. Transcranial approaches play a role in selected cases, with a multicompartmental morphology, subarachnoid invasion and extension lateral to the internal carotid artery and in the management of residual tumor apoplexy.
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Affiliation(s)
- Giulia Cossu
- Department of Neurosurgery, Lausanne University Hospital and University of Lausanne, Switzerland
| | - Emmanuel Jouanneau
- Department of Neurosurgery, Hopital Neurologique Pierre Wertheimer, Lyon, France
| | - Luigi M. Cavallo
- Department of Neurosurgery, University Hospital of Naples Federico II, Italy
| | | | - Daniele Starnoni
- Department of Neurosurgery, Lausanne University Hospital and University of Lausanne, Switzerland
| | - Lorenzo Giammattei
- Department of Neurosurgery, Lausanne University Hospital and University of Lausanne, Switzerland
| | - Ethan Harel
- Department of Neurosurgery, Lausanne University Hospital and University of Lausanne, Switzerland
| | - Diego Mazzatenta
- IRCCS Institute of Neurological Sciences of Bologna, Bellaria Hospital, Bologna, Italy
| | - Micheal Bruneau
- Department of Neurosurgery, UZ Brussel - Vrije Universiteit Brussel, Brussels, Belgium
| | | | - Moncef Berhouma
- Department of Neurosurgery, Hopital Neurologique Pierre Wertheimer, Lyon, France
| | - Ari G. Chacko
- Department of Neurological Science, Christian Medical College, Vellore, Tamilnadu, India
| | - Jan F. Cornelius
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Dimitrios Paraskevopoulos
- Department of Neurosurgery, Barts Health NHS Trust, St. Bartholomew's and the Royal London Hospital, London, UK
- Blizard Institute, Barts and the London School of Medicine, Queen Mary University of London, UK
| | | | - Idoya Zazpe
- Servicio de Neurocirugía, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Romain Manet
- Department of Neurosurgery, Hopital Neurologique Pierre Wertheimer, Lyon, France
| | - Paul A. Gardner
- Department of Neurosurgery, University Hospital of Pittsburgh, PA, USA
| | - Henry Dufour
- Department of Neurosurgery, Hopital de la Timone, Marseille, France
| | - Paolo Cappabianca
- Department of Neurosurgery, University Hospital of Naples Federico II, Italy
| | - Roy T. Daniel
- Department of Neurosurgery, Lausanne University Hospital and University of Lausanne, Switzerland
| | - Mahmoud Messerer
- Department of Neurosurgery, Lausanne University Hospital and University of Lausanne, Switzerland
- Corresponding author. Department of Neurosurgery Lausanne University Hospital and University of Lausanne, Rue du Bugnon 44 1011, Lausanne, Switzerland.
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23
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Domino JS, Gattozzi DA, Jack M, Carroll M, Harn N, Beahm DD, Chamoun R. Outcomes of intraoperative ultrasound for endoscopic endonasal transsphenoidal pituitary surgery in adenomas with parasellar extension. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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24
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Májovský M, Grotenhuis A, Foroglou N, Zenga F, Froehlich S, Ringel F, Sampron N, Thomas N, Komarc M, Netuka D. What is the current clinical practice in pituitary adenoma surgery in Europe? European Pituitary Adenoma Surgery Survey (EU-PASS) results-technical part. Neurosurg Rev 2021; 45:831-841. [PMID: 34337683 DOI: 10.1007/s10143-021-01614-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 07/15/2021] [Accepted: 07/20/2021] [Indexed: 10/20/2022]
Abstract
Pituitary adenoma surgery has evolved rapidly in recent decades, changing clinical practice markedly and raising new challenges. There is no current consensus or guidelines for perioperative care that includes possible complication management. This study aims to determine current practice across European neurosurgical centres. We created a list of eligible departments performing pituitary adenoma surgery based on cooperation with EANS, national neurosurgical societies, and personal communication with local neurosurgeons. We contacted the chairpersons from each department and asked them (or another responsible neurosurgeon) to fill out the survey. The survey consisted of 58 questions. For further analysis, departments were divided into subgroups: "academic"/ "non-academic centre", "high-volume"/"low-volume", "mainly endoscopic"/ "mainly microscopic"/ "mixed practise", and by geographical regions. Data from 254 departments from 34 countries were obtained. The average time to complete the survey was 18 min. Notably, the endoscopic approach is the predominant surgical approach in Europe, used in 56.8% of the centres. In routine cases without intraoperative cerebrospinal fluid leak, high-volume centres are less pedantic with sellar closure when compared with low-volume centres (p < 0.001). On the other hand, when a postoperative cerebrospinal fluid leak occurs, high-volume centres are more active and indicate early reoperation (p = 0.013). Less than 15% of the participating centres perform early postoperative MRI scans. Marked variation was noted among different groups of respondents and some contentious issues are discussed. Such information can encourage useful debate about the reasons for the variations seen and perhaps help develop standardised protocols to improve patient outcomes. A future research focus is to compare European results with other regions.
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Affiliation(s)
- Martin Májovský
- Department of Neurosurgery and Neurooncology, First Faculty of Medicine, Charles University and Military University Hospital, Prague, Czech Republic.
| | - Andre Grotenhuis
- Neurosurgery Department, Radboud University Medical Center, Nijmegen, Netherlands
| | - Nicolas Foroglou
- 1St Department of Neurosurgery, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Francesco Zenga
- Neurosurgery Unit, Department of Neuroscience "Rita Levi Montalcini", University of Turin, Turin, Italy
| | | | - Florian Ringel
- Department of Neurosurgery, Johannes Gutenberg-Universität Mainz, Mainz, Germany
| | - Nicolas Sampron
- Neurosurgery Department, University Hospital Donostia, San Sebastian, Spain
| | - Nick Thomas
- Department of Neurosurgery, King's College, London, UK
| | - Martin Komarc
- Institute of Biophysics and Informatics, First Faculty of Medicine, Charles University, Prague, Czech Republic.,Department of Methodology, Faculty of Physical Education and Sport, Charles University, Prague, Czech Republic
| | - David Netuka
- Department of Neurosurgery and Neurooncology, First Faculty of Medicine, Charles University and Military University Hospital, Prague, Czech Republic
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25
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Vivancos Sánchez C, Palpán Flores A, Rodríguez Domínguez V, Zamarrón Pérez A, Álvarez-Escolá C, Pérez López C. Role of pituitary stalk and gland radiological status on endocrine function and outcome after endoscopic transsphenoidal surgery for non-functioning pituitary adenomas. Endocrine 2021; 73:416-423. [PMID: 33880732 DOI: 10.1007/s12020-021-02726-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 04/05/2021] [Indexed: 12/28/2022]
Abstract
PURPOSE To investigate endocrine function changes after non-functioning pituitary adenomas (NFPA) transsphenoidal surgery and to search for predictors of hypopituitarism resolution and development. METHODS We included 117 patients with NFPA who underwent endoscopic transsphenoidal surgery from 2005 to 2019 by two neurosurgeons. Twenty-one patients were excluded because of previous pituitary surgery or radiotherapy. We assessed symptoms at diagnosis, tumour volume, tumour removal, hormonal status at diagnosis, hormonal outcomes at 2- and 12-month follow-up, and complications. Pituitary stalk and gland MRI status (visible or not) were included, and it theirs association to hormonal function was studied for the first time, to our knowledge. RESULTS Pituitary gland visualization was more frequent in those patients who showed a smaller number of axes affected at 12 months (p = 0.011). Pituitary stalk status showed no association to hormonal function. The hormonal normalization rate at 12 months was 13%. The endocrine improvement rate at 12 months was 16.7%. Worsening of hormonal function occurred in 19.8% of patients. Younger age was associated to hormonal improvement (p = 0.004). Higher preoperative tumour volume (p = 0.015) and absence of gross total resection (GTR) (p = 0.049) were associated with worsening in at least one hormonal axis after surgery. CONCLUSIONS Pituitary gland visibility was higher in those patients who showed better hormonal outcomes. Assessment of initial hormonal function and outcome after surgery regarding pituitary stalk status showed no significant association. Higher preoperative tumour volumes and absence of GTR were associated to postoperative endocrine function worsening, while younger age was associated to its improvement.
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Affiliation(s)
- C Vivancos Sánchez
- Neurosurgery Department, Hospital Universitario La Paz, Paseo de la Castellana, 261, Madrid, 28046, Spain.
| | - A Palpán Flores
- Neurosurgery Department, Hospital Universitario La Paz, Paseo de la Castellana, 261, Madrid, 28046, Spain
| | - V Rodríguez Domínguez
- Neurosurgery Department, Hospital Universitario La Paz, Paseo de la Castellana, 261, Madrid, 28046, Spain
| | - A Zamarrón Pérez
- Neurosurgery Department, Hospital Universitario La Paz, Paseo de la Castellana, 261, Madrid, 28046, Spain
| | - C Álvarez-Escolá
- Endocrinology Department, Hospital Universitario La Paz, Paseo de la Castellana, 261, Madrid, 28046, Spain
| | - C Pérez López
- Neurosurgery Department, Hospital Universitario La Paz, Paseo de la Castellana, 261, Madrid, 28046, Spain
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26
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Juthani RG, Reiner AS, Patel AR, Cowan A, Roguski M, Panageas KS, Geer EB, Karimi S, Cohen MA, Tabar V. Radiographic and clinical outcomes using intraoperative magnetic resonance imaging for transsphenoidal resection of pituitary adenomas. J Neurosurg 2021; 134:1824-1835. [PMID: 32619972 PMCID: PMC11107335 DOI: 10.3171/2020.4.jns20178] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 04/10/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The utility and safety of intraoperative MRI (iMRI) for resection of pituitary adenomas is not clearly established in the context of advances in endoscopic approaches. The goal in this study was to evaluate the safety and efficacy of iMRI for pituitary adenoma resection, with endoscopic transsphenoidal (ETS) versus microscopic transsphenoidal (MTS) approaches. METHODS Radiographic and clinical outcomes of all pituitary adenomas resected using iMRI between 2008 and 2017 at a single institution were retrospectively evaluated. RESULTS Of 212 tumors treated, 131 (62%) underwent further resection based on iMRI findings, resulting in a significant increase in gross-total resection on postoperative MRI compared with iMRI (p = 0.0001) in both ETS and MTS groups. iMRI increased rates of gross-total resection for cavernous sinus invasion Knosp grades 1 and 2, but not in Knosp ≥ 3 across treatment groups (p < 0.0001). The extent of resection on postoperative MRI was significantly correlated with increased progression-free survival (p < 0.0001). Initial hormone remission off medical therapy was achieved in 64%, with a significantly higher rate of remission in tumors resected via the ETS approach (81%) compared with the MTS approach (55%) (p = 0.02). The rate of persistent new hormone deficit was low at 8%, including a 2.8% rate of permanent diabetes insipidus, and 45% of patients had improvement in preoperative hormone deficit following surgery. Serious postoperative complications including CSF leaks requiring reoperation were rare at 1%, with no postoperative infections. CONCLUSIONS These results suggest that iMRI is a safe and effective method of increasing the extent of resection for pituitary adenomas while preserving hormone function. When paired with the endoscope, iMRI may offer the ability to tailor more aggressive removal of tumors while optimizing pituitary function, resulting in high rates of secretory hormone remission. Secretory tumors and adenomas with Knosp grade < 3 cavernous sinus invasion may benefit most from the use of iMRI.
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Affiliation(s)
- Rupa G. Juthani
- Department of Neurosurgery, Weill Cornell Medical College, New York
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Anne S. Reiner
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ankur R. Patel
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Aimee Cowan
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Marie Roguski
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Neurosurgery, Tufts University, Boston, Massachusetts
| | - Katherine S. Panageas
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Eliza B. Geer
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
- Multidisciplinary Pituitary and Skull Base Tumor Center, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sasan Karimi
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Marc A. Cohen
- Department of Head and Neck Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
- Multidisciplinary Pituitary and Skull Base Tumor Center, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Viviane Tabar
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York
- Multidisciplinary Pituitary and Skull Base Tumor Center, Memorial Sloan Kettering Cancer Center, New York, New York
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27
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Utility of intraoperative ultrasonography for resection of pituitary adenomas: a comparative retrospective study. Acta Neurochir (Wien) 2021; 163:1725-1734. [PMID: 33403430 DOI: 10.1007/s00701-020-04674-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 12/04/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND The evolution of pituitary surgery has made it a safe and effective form of treatment; however, risks of inadequate tumor resection, cerebrospinal fluid (CSF) leak, pituitary dysfunction, and vascular injury still exist. The use of intraoperative ultrasonography (IOUS) in pituitary surgery has been well described. Recent advancements in ultrasound technology have allowed for expanded utility as described here. METHODS A retrospective review was performed between January 2016 and December 2019. One hundred thirty-eight patients (mean age 53.7 years, 47% females) were identified undergoing transsphenoidal surgery for pituitary tumors. Thirty-four patients had IOUS performed using a side-firing ultrasound probe, while 104 did not. Data was analyzed for preoperative (demographics, clinical, and radiographic features), perioperative (blood loss, operative time), and postoperative (complications, length of stay, hormone remission, and extent of resection) outcomes. RESULTS There were no significant differences in patient age, gender, tumor volume, Knosp grade, and hormone-secreting status between the two groups. Patients treated using IOUS had significantly higher rates of gross total resection (79% vs. 44%, p = 0.0008), shorter operative times (74 vs. 146 min, p < 0.0001), lower blood loss (119 vs. 284 cc, p < 0.0001), and hospital stays (2.9 vs. 4.2 days, p = 0.001). Overall complication rates were lower in the IOUS group compared to standard pituitary surgery but did not reach significance. CONCLUSIONS Recent improvements in ultrasound technology have allowed for miniaturization of probes capable of delivering high-resolution images. The use of IOUS in transsphenoidal pituitary surgery may significantly increase rates of gross total resection, while decreasing blood loss, hospital LOS, and operative time.
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28
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Van Gerven L, Qian Z, Starovoyt A, Jorissen M, Meulemans J, van Loon J, De Vleeschouwer S, Lambert J, Bex M, Vander Poorten V. Endoscopic, Endonasal Transsphenoidal Surgery for Tumors of the Sellar and Suprasellar Region: A Monocentric Historical Cohort Study of 369 Patients. Front Oncol 2021; 11:643550. [PMID: 34026618 PMCID: PMC8138557 DOI: 10.3389/fonc.2021.643550] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 04/06/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The endoscopic endonasal transsphenoidal approach (EETA) is an established technique for the resection of a large variety of benign sellar and suprasellar lesions, mostly pituitary adenomas. It has clear advantages over the microscopic approach, like a superior close-up view of the relevant anatomy and the tumor-gland interface, an enlarged working angle, as well as an increased panoramic vision inside the surgical area. We have been performing the EETA for over a decade, and this study will focus on perioperative and postoperative outcomes and complications and their association with the learning curve. MATERIAL AND METHODS All patients in our tertiary referral center (n = 369) undergoing an EETA for a lesion of the sellar and suprasellar region between January 1st 2008 and December 31st 2018 were included, and data were retrospectively retrieved from the electronic patient records. RESULTS Median follow-up after surgery was 55 months. Pituitary adenomas (n = 322) were the most frequent pathology. Headache (43.4%) and loss of vision (29.3%) were the most common presenting symptoms. Median procedure duration was significantly longer during the initial 5 years (106 versus 79 minutes; p <0.0001), but incidence of peri- and postoperative CSF leaks in the early years was not significantly higher. Knosp grade >2 was associated with perioperative CSF leak (p =0.002), and perioperative CSF leak was associated with postoperative CSF leak (p <0.001). Almost all cases of meningitis were preceded by a postoperative CSF leak. In 22.4% of patients, tumor recurrence required additional therapy. Perioperative (iatrogenic) mortality was 0.8%. The overall hospital stay decreased over time from an average of 7 to 5 days, and the case load increased yearly (p =0.015). CONCLUSION The EETA is an excellent technique with complication rates comparable to or even lower than those in large microsurgical series in the literature. EETA has a significant learning curve affecting the procedure duration. Throughout the first 10 years following the transition from the microscopic approach to the EETA in our cohort, the caseload increased and hospital stay was reduced, while no increase in peri- and postoperative complications was observed.
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Affiliation(s)
- Laura Van Gerven
- Otorhinolaryngology, Head and Neck Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Neurosciences, Experimental Otorhinolaryngology, KU Leuven, Leuven, Belgium
- Department of Microbiology, Immunology and transplantation, Allergy and Clinical Immunology Research Unit, KU Leuven, Leuven, Belgium
| | - Zhen Qian
- Otorhinolaryngology, Head and Neck Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Anastasiya Starovoyt
- Department of Neurosciences, Experimental Otorhinolaryngology, KU Leuven, Leuven, Belgium
| | - Mark Jorissen
- Otorhinolaryngology, Head and Neck Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Jeroen Meulemans
- Otorhinolaryngology, Head and Neck Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Oncology, Section Head and Neck Oncology, KU Leuven, Leuven, Belgium
| | - Johannes van Loon
- Neurosciences, Research Group Experimental Neurosurgery and Neuroanatomy and Leuven Brain Institute, Leuven, Belgium
| | - Steven De Vleeschouwer
- Neurosciences, Research Group Experimental Neurosurgery and Neuroanatomy and Leuven Brain Institute, Leuven, Belgium
| | - Julie Lambert
- Radiology, University Hospitals Leuven, Leuven, Belgium
| | - Marie Bex
- Endocrinology, University Hospitals Leuven, Leuven, Belgium
| | - Vincent Vander Poorten
- Otorhinolaryngology, Head and Neck Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Oncology, Section Head and Neck Oncology, KU Leuven, Leuven, Belgium
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29
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Goshtasbi K, Lehrich BM, Abouzari M, Abiri A, Birkenbeuel J, Lan MY, Wang WH, Cadena G, Hsu FPK, Kuan EC. Endoscopic versus nonendoscopic surgery for resection of pituitary adenomas: a national database study. J Neurosurg 2021; 134:816-824. [PMID: 32168478 PMCID: PMC8080843 DOI: 10.3171/2020.1.jns193062] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 01/02/2020] [Indexed: 12/30/2022]
Abstract
OBJECTIVE For symptomatic nonsecreting pituitary adenomas (PAs), resection remains a critical option for treatment. In this study, the authors used a large-population national database to compare endoscopic surgery (ES) to nonendoscopic surgery (NES) for the surgical management of PA. METHODS The National Cancer Database was queried for all patients diagnosed with histologically confirmed PA who underwent resection between 2010 and 2016 in which the surgical approach was specified. Due to database limitations, microsurgery and craniotomy were both categorized as NES. RESULTS Of 30,488 identified patients, 16,373 (53.7%) underwent ES and 14,115 (46.3%) underwent NES. There was a significant increase in the use of ES over time (OR 1.16, p < 0.01). Furthermore, there was a significant temporal increase in ES approach for tumors ≥ 2 cm (OR 1.17, p < 0.01). Compared to NES, patients who underwent ES were younger (p = 0.01), were treated at academic centers (p < 0.01), lived a greater distance from their treatment site (p < 0.01), had smaller tumors (p < 0.01), had greater medical comorbidity burden (p = 0.04), had private insurance (p < 0.01), and had a higher household income (p < 0.01). After propensity score matching to control for age, tumor size, Charlson/Deyo score, and type of treatment center, patients who underwent ES had a shorter length of hospital stay (LOS) (3.9 ± 4.9 days vs 4.3 ± 5.4 days, p < 0.01), although rates of gross-total resection (GTR; p = 0.34), adjuvant radiotherapy (p = 0.41), and 90-day mortality (p = 0.45) were similar. On multivariate logistic regression, African American race (OR 0.85, p < 0.01) and tumor size ≥ 2 cm (OR 0.89, p = 0.01) were negative predictors of receiving ES, whereas diagnosis in more recent years (OR 1.16, p < 0.01), greater Charlson/Deyo score (OR 1.10, p = 0.01), receiving treatment at an academic institution (OR 1.67, p < 0.01) or at a treatment site ≥ 20 miles away (OR 1.17, p < 0.01), having private insurance (OR 1.09, p = 0.01), and having a higher household income (OR 1.11, p = 0.01) were predictive of receiving ES. Compared to the ES cohort, patients who started with ES and converted to NES (n = 293) had a higher ratio of nonwhite race (p < 0.01), uninsured insurance status (p < 0.01), longer LOS (p < 0.01), and higher rates of GTR (p = 0.04). CONCLUSIONS There is an increasing trend toward ES for PA resection including its use for larger tumors. Although ES may result in shorter LOS compared to NES, rates of GTR, need for adjuvant therapy, and short-term mortality may be similar. Factors such as tumor size, insurance status, facility type, income, race, and existing comorbidities may predict receiving ES.
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Affiliation(s)
- Khodayar Goshtasbi
- 1Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, California
| | - Brandon M Lehrich
- 1Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, California
| | - Mehdi Abouzari
- 1Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, California
| | - Arash Abiri
- 1Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, California
| | - Jack Birkenbeuel
- 1Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, California
| | - Ming-Ying Lan
- 2Department of Otorhinolaryngology-Head and Neck Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wei-Hsin Wang
- 3Department of Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan; and
| | - Gilbert Cadena
- 4Department of Neurological Surgery, University of California, Irvine, California
| | - Frank P K Hsu
- 4Department of Neurological Surgery, University of California, Irvine, California
| | - Edward C Kuan
- 1Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, California
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Shimony N, Popovits N, Shofty B, Abergel A, Ram Z, Grossman R. Endoscopic transsphenoidal surgery reduces the need for re-operation compared to the microscopic approach in pituitary macroadenomas. Eur J Surg Oncol 2021; 47:1352-1356. [PMID: 33637372 DOI: 10.1016/j.ejso.2021.02.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 01/16/2021] [Accepted: 02/03/2021] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Pituitary surgery has shifted in recent years from microscopic surgery(MS) to endoscopic endonasal surgery (EES). However, the comparative long-term outcome of these surgical approaches, including the need for subsequent re-operation has never been reported. We present our experience in a high-volume referral center experienced in both endoscopic and microscopic approaches to compare the need for re-operation after initial resection of non-functioning pituitary macroadenomas using these surgical approaches. METHODS 684 patients (398 with NF adenomas) underwent trans-sphenoidal pituitary surgery in our institution between 2006 and 2017. Complete follow-up (mean 72 months, minimum two years) was available in 87 newly diagnosed patients with non-functioning pituitary macroadenomas (NFPMA; 48-microscopic and 39-endoscopic). The EES approach has been used almost exclusively since 2012. The need for repeat operation for tumor resection during the follow-up period was assessed as the primary end-point of the study. Extracted data included various demographic and clinical parameters, radiographic findings as well as the extent of resection (EOR). RESULTS The EOR was similar for both groups, with a trend towards better EOR in the EES group. The rate of surgical complications was also similar for both groups. There was a strong trend towards lower need for re-operation in the EES group compared to the MS group (12.8% vs. 29.2%, p = 0.056). In a multivariate analysis, only EOR and Knosp grade were independently associated with the need for re-operation surgery. CONCLUSION Our data indicate that EES in NFPMA tends to be associated with a lower need for re-operation compared to the MS approach, with a similar rate of EOR and complications.
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Affiliation(s)
- Nir Shimony
- Institute of Neuroscience, Geisinger Commonwealth School of Medicine, Danville, PA, USA; Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nataly Popovits
- Department of Neurosurgery, Tel-Aviv Medical Center, Tel-Aviv, Israel, Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ben Shofty
- Department of Neurosurgery, Tel-Aviv Medical Center, Tel-Aviv, Israel, Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Avraham Abergel
- Department of Otolaryngology-Head and Neck Surgery, Tel-Aviv Medical Center, Tel-Aviv, Israel, Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Zvi Ram
- Department of Neurosurgery, Tel-Aviv Medical Center, Tel-Aviv, Israel, Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Rachel Grossman
- Department of Neurosurgery, Tel-Aviv Medical Center, Tel-Aviv, Israel, Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
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Gerges MM, Rumalla K, Godil SS, Younus I, Elshamy W, Dobri GA, Kacker A, Tabaee A, Anand VK, Schwartz TH. Long-term outcomes after endoscopic endonasal surgery for nonfunctioning pituitary macroadenomas. J Neurosurg 2021; 134:535-546. [PMID: 32005016 DOI: 10.3171/2019.11.jns192457] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 11/20/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Nonfunctioning pituitary adenomas are benign, slow-growing tumors. After gross-total resection (GTR) or subtotal resection (STR), tumors can recur or progress and may ultimately require additional intervention. A greater understanding of long-term recurrence and progression rates following complete or partial resection and the need for further intervention will help clinicians provide meaningful counsel for their patients and assist data-driven decision-making. METHODS The authors retrospectively analyzed their institutional database for patients undergoing endoscopic endonasal surgery (EES) for nonfunctioning pituitary macroadenomas (2003-2014). Only patients with follow-up of at least 5 years after surgery were included. Tumor volumes were measured on pre- and postoperative MRI. Tumor recurrence was defined as the presence of a 0.1-cm3 tumor volume after GTR, and tumor progression was defined as a 25.0% increase in residual tumor after STR. RESULTS A total of 190 patients were included, with a mean age of 63.8 ± 13.2 years; 79 (41.6%) were female. The mean follow-up was 75.0 ± 18.0 months. GTR was achieved in 127 (66.8%) patients. In multivariate analysis, age (p = 0.04), preoperative tumor volume (p = 0.03), Knosp score (p < 0.001), and Ki-67 (p = 0.03) were significant predictors of STR. In patients with GTR, the probability of recurrence at 5 and 10 years was 3.9% and 4.7%, and the probability of requiring treatment for recurrence was 0.79% and 1.6%, respectively. In 63 patients who underwent STR, 6 (9.5%) received early postoperative radiation and did not experience progression, while the remaining 57 (90.5%) were observed. Of these, the probability of disease progression at 5 and 10 years was 21% and 24.5%, respectively, and the probability of requiring additional treatment for progression was 17.5% and 21%. Predictors of recurrence or progression in the entire group were Knosp score (p < 0.001) and elevated Ki-67 (p = 0.03). Significant predictors of progression after STR in those who did not receive early radiotherapy were cavernous sinus location (p < 0.05) and tumor size > 1.0 cm3 (p = 0.005). CONCLUSIONS Following GTR for nonfunctioning pituitary adenomas, the 10-year chance of recurrence is low and the need for treatment even lower. After STR, although upfront radiation therapy may prevent progression, even without radiotherapy, the need for intervention at 10 years is only approximately 20% and a period of observation may be warranted to prevent unnecessary prophylactic radiation therapy. Tumor volume > 1 cm3, Knosp score ≥ 3, and Ki-67 ≥ 3% may be useful metrics to prompt closer follow-up or justify early prophylactic radiation therapy.
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Affiliation(s)
- Mina M Gerges
- Departments of1Neurosurgery
- 2Department of Neurosurgery, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Kavelin Rumalla
- 6Department of Biomedical and Health Informatics, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Saniya S Godil
- Departments of1Neurosurgery
- 3Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee; and
| | - Iyan Younus
- 5Weill Cornell Medical College, New York, New York
| | - Walid Elshamy
- 2Department of Neurosurgery, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Georgiana A Dobri
- Departments of1Neurosurgery
- 7Endocrinology, Weill Cornell Medicine, NewYork-Presbyterian Hospital, New York
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CSF Rhinorrhoea After Endonasal Intervention to the Skull Base (CRANIAL) - Part 1: Multicenter Pilot Study. World Neurosurg 2021; 149:e1077-e1089. [PMID: 33444844 PMCID: PMC8105646 DOI: 10.1016/j.wneu.2020.12.171] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 12/24/2020] [Accepted: 12/26/2020] [Indexed: 01/29/2023]
Abstract
Background CRANIAL (CSF Rhinorrhoea After Endonasal Intervention to the Skull Base) is a prospective multicenter observational study seeking to determine 1) the scope of skull base repair methods used and 2) corresponding rates of postoperative cerebrospinal fluid (CSF) rhinorrhea in the endonasal transsphenoidal approach (TSA) and the expanded endonasal approach (EEA) for skull base tumors. We sought to pilot the project, assessing the feasibility and acceptability by gathering preliminary data. Methods A prospective observational cohort study was piloted at 12 tertiary neurosurgical units in the United Kingdom. Feedback regarding project positives and challenges were qualitatively analyzed. Results A total of 187 cases were included: 159 TSA (85%) and 28 EEA (15%). The most common diseases included pituitary adenomas (n = 142/187), craniopharyngiomas (n = 13/187). and skull base meningiomas (n = 4/187). The most common skull base repair techniques used were tissue glues (n = 132/187, most commonly Tisseel), grafts (n = 94/187, most commonly fat autograft or Spongostan) and vascularized flaps (n = 51/187, most commonly nasoseptal). These repairs were most frequently supported by nasal packs (n = 125/187) and lumbar drains (n = 20/187). Biochemically confirmed CSF rhinorrhea occurred in 6/159 patients undergoing TSA (3.8%) and 2/28 patients undergoing EEA (7.1%). Four patients undergoing TSA (2.5%) and 2 patients undergoing EEA (7.1%) required operative management for CSF rhinorrhea (CSF diversion or direct repair). Qualitative feedback was largely positive (themes included user-friendly and efficient data collection and strong support from senior team members), demonstrating acceptability. Conclusions Our pilot experience highlights the acceptability and feasibility of CRANIAL. There is a precedent for multicenter dissemination of this project, to establish a benchmark of contemporary practice in skull base neurosurgery, particularly with respect to patients undergoing EEA.
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Araujo-Castro M, Pascual-Corrales E, Martínez San Millan J, Rebolleda G, Pian H, Ruz-Caracuel I, De Los Santos Granados G, Ley Urzaiz L, Escobar-Morreale HF, Rodríguez Berrocal V. Multidisciplinary protocol of preoperative and surgical management of patients with pituitary tumors candidates to pituitary surgery. ANNALES D'ENDOCRINOLOGIE 2020; 82:20-29. [PMID: 33278380 DOI: 10.1016/j.ando.2020.11.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 10/05/2020] [Accepted: 11/22/2020] [Indexed: 12/11/2022]
Abstract
The optimal planning of preoperative diagnosis, management and treatment of pituitary tumors (PT) candidates to pituitary surgery (PS) requires a multidisciplinary approach involving a team of endocrinologists, neurosurgeons, ENT, neuro-ophthalmologists and neuroradiologists with experience in pituitary diseases. Such teams improve surgical results, minimize complications and facilitate their correct treatment if occurring, and optimize the hormonal, ophthalmological and radiological preoperative and follow-up evaluation. We have developed a clinical practice protocol for patients with PT who are candidates to PS based on the most recent national and international guidelines and the relevant literature regarding PT published in the last years. The protocol has been elaborated by a multidisciplinary team of a Spanish Pituitary Tumor Center of Excellence (PTCE) that includes at least one neurosurgeon, ENT, neuroradiologist, neuro-ophthalmologist, endocrine pathologist and endocrinologist specialized in pituitary diseases. We elaborated this guideline with the aim of sharing our experience with other centers involved in the perioperative and surgical management of PT thereby facilitating the management of patients undergoing PS.
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Affiliation(s)
- Marta Araujo-Castro
- Neuroendocrinology unit, department of endocrinology and nutrition, hospital universitario Ramón y Cajal, M-607, km. 9, 100, 28034 Madrid, Spain; Instituto de investigación Sanitaria Ramón y Cajal (IRYCIS), Madrid, Spain.
| | - Eider Pascual-Corrales
- Neuroendocrinology unit, department of endocrinology and nutrition, hospital universitario Ramón y Cajal, M-607, km. 9, 100, 28034 Madrid, Spain
| | - Juan Martínez San Millan
- Neuroradiology unit, department of diagnostic imaging, hospital universitario Ramón y Cajal, Madrid, Spain
| | - Gema Rebolleda
- Neuro-ophthalmology unit, department of ophthalmology, hospital universitario Ramón y Cajal, Madrid, Spain; Universidad de Alcalá, Madrid, Spain
| | - Héctor Pian
- Endocrinology unit, department of pathology, hospital universitario Ramón y Cajal, Madrid, Spain
| | - Ignacio Ruz-Caracuel
- Endocrinology unit, department of pathology, hospital universitario Ramón y Cajal, Madrid, Spain
| | - Gonzalo De Los Santos Granados
- Rinology unit, department of otorhinolaryngology (ENT), hospital universitario Ramón y Cajal, Madrid, Spain; Universidad de Alcalá, Madrid, Spain; Instituto de investigación Sanitaria Ramón y Cajal (IRYCIS), Madrid, Spain
| | - Luis Ley Urzaiz
- Pituitary surgery unit, department of neurosurgery, hospital universitario Ramón y Cajal, Madrid, Spain
| | - Héctor Francisco Escobar-Morreale
- Neuroendocrinology unit, department of endocrinology and nutrition, hospital universitario Ramón y Cajal, M-607, km. 9, 100, 28034 Madrid, Spain; Universidad de Alcalá, Madrid, Spain; Instituto de investigación Sanitaria Ramón y Cajal (IRYCIS), Madrid, Spain; Centro de investigación biomédica en red diabetes y enfermedades metabólicas asociadas (CIBERDEM), Madrid, Spain
| | - Victor Rodríguez Berrocal
- Pituitary surgery unit, department of neurosurgery, hospital universitario Ramón y Cajal, Madrid, Spain
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Hung NM, He DV, Kien VD. Reappraisal of microscopic microsurgical transsphenoidal surgery for GH-secreting pituitary macroadenoma in patients with acromegaly: Historical data from Vietnam (2010–2013). INTERDISCIPLINARY NEUROSURGERY 2020. [DOI: 10.1016/j.inat.2020.100811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Younus I, Gerges MM, Godil SS, Uribe-Cardenas R, Dobri GA, Ramakrishna R, Schwartz TH. Incidence and risk factors associated with reoperation for sellar hematoma following endoscopic transsphenoidal pituitary surgery. J Neurosurg 2020; 133:702-708. [PMID: 31443077 DOI: 10.3171/2019.6.jns191169] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 06/06/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Postoperative sellar hematoma is an uncommon complication of endonasal endoscopic transsphenoidal surgery (EETS) for pituitary adenoma that often requires emergency surgical evacuation. Sellar hematomas can cause mass effect and compress parasellar structures, leading to clinically significant symptoms such as visual impairment and severe headache. The objective of this study was to determine the incidence and risk factors associated with reoperation for postoperative hematoma after EETS for pituitary adenoma. METHODS The authors reviewed a prospectively acquired database of EETS for pituitary adenoma over 13 years at Weill Cornell Medicine, NewYork-Presbyterian Hospital and identified cases that required reoperation for confirmed hematoma. They also reviewed clinical and radiographic data of a consecutive series of patients undergoing EETS for pituitary adenoma who did not have postoperative hematoma, which served as the control group. Demographic data and risk factors were compared between the groups using univariate and multivariate analyses via binary logistic regression. RESULTS Among a cohort of 583 patients undergoing EETS for pituitary adenoma, 9 patients (1.5%) required operation for sellar hematoma evacuation. All 9 patients with reoperation for sellar hematoma presented with worsening in their vision, and severe headache was present in 67%. New postoperative endocrine dysfunction developed in 78%. Clot evacuation improved vision in 88%. The mean time to hematoma evacuation was 4.5 days. The median length of stay for patients with sellar hematoma was 8 days (range 4-210 days) compared with a median length of stay of 3 days (range 1-32 days) for the control patients (p < 0.005). Significant risk factors in univariate analysis were tumor diameter ≥ 30 mm (p < 0.005), suprasellar extension (p < 0.005), tumor volume (p < 0.005), cavernous sinus invasion (p < 0.05), gonadotroph histology (p < 0.05), antiplatelet use (p < 0.05), and elevated BMI (p < 0.05). On multivariate analysis, tumor diameter ≥ 30 mm (OR 4.555, CI 1.30-28.90; p < 0.05) and suprasellar extension (OR 1.048, CI 1.01-1.10; p < 0.05) were found to be the only independent predictors of sellar hematoma. The incidence of hematoma in tumors ≥ 30 mm was 5% (7/139). CONCLUSIONS Postoperative sellar hematoma requiring reoperation is a rare phenomenon after transsphenoidal surgery, often presenting with visual loss and headache. Clot evacuation results in improvement in vision, but long-term endocrinopathy often ensues. Tumor diameter ≥ 30 mm and suprasellar extent are the most reliable risk factors. Close postoperative scrutiny should be given to patients at high risk.
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Affiliation(s)
| | | | | | | | - Georgiana A Dobri
- Departments of2Neurosurgery
- 4Neuroscience, and
- 5Endocrinology, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York
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Araujo-Castro M, Pascual-Corrales E, Martínez San Millan JS, Rebolleda G, Pian H, Ruz-Caracuel I, De Los Santos Granados G, Ley Urzaiz L, Escobar-Morreale HF, Rodríguez Berrocal V. Postoperative management of patients with pituitary tumors submitted to pituitary surgery. Experience of a Spanish Pituitary Tumor Center of Excellence. Endocrine 2020; 69:5-17. [PMID: 32170587 DOI: 10.1007/s12020-020-02247-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 02/26/2020] [Indexed: 12/13/2022]
Abstract
There is a lack of evidence on timing, frequency, and duration of postoperative endocrine, radiologic, and ophthalmologic assessments that should be performed after pituitary surgery (PS). However, it is known that careful optimization of treatment and follow-up strategies as well as a multidisciplinary approach may have a significant impact on long-term outcomes, improving surgical results, minimize complications and facilitate their correct treatment if occurring, and optimize the hormonal, ophthalmological, and radiological reassessment throughout the follow-up. Considering that there are no specific guidelines on the postoperative management of patients with pituitary tumors (PT), we present our protocol for the postoperative management of patients with PT. It has been elaborated by the multidisciplinary team of a Spanish Pituitary Tumor Center of Excellence (PTCE) that includes at least one neurosurgeon, ENT, neuroradiologist, neuro-ophthalmologist, endocrine pathologist and endocrinologist specialized in pituitary diseases. We elaborated this guideline with the aim of sharing our experience with other centers involved in the management of PT thereby facilitating the postoperative management of patients submitted to PS.
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Affiliation(s)
- M Araujo-Castro
- Neuroendocrinology Unit, Department of Endocrinology & Nutrition, Hospital Universitario Ramón y Cajal, Madrid, Spain.
- Hospital Universitario Ramón y Cajal, M-607, km. 9, 100, 28034, Madrid, Spain.
| | - E Pascual-Corrales
- Neuroendocrinology Unit, Department of Endocrinology & Nutrition, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - J S Martínez San Millan
- Neuroradiology Unit, Department of Diagnostic Imaging, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - G Rebolleda
- Neuro-Ophthalmology Unit, Department of Ophthalmology, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Universidad de Alcalá, Madrid, Spain
| | - H Pian
- Endocrinology Unit, Department of Pathology, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - I Ruz-Caracuel
- Endocrinology Unit, Department of Pathology, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - G De Los Santos Granados
- Universidad de Alcalá, Madrid, Spain
- Rinology Unit, Department of Otorhinolaryngology (ENT), Hospital Universitario Ramón y Cajal, Madrid, Spain
- Instituto de Investigación Sanitaria Ramón y Cajal (IRYCIS), Madrid, Spain
| | - L Ley Urzaiz
- Pituitary Surgery Unit, Department of Neurosurgery, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - H F Escobar-Morreale
- Neuroendocrinology Unit, Department of Endocrinology & Nutrition, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Universidad de Alcalá, Madrid, Spain
- Instituto de Investigación Sanitaria Ramón y Cajal (IRYCIS), Madrid, Spain
- Centro de Investigación Biomédica en Red Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Madrid, Spain
| | - V Rodríguez Berrocal
- Pituitary Surgery Unit, Department of Neurosurgery, Hospital Universitario Ramón y Cajal, Madrid, Spain
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Romano-Feinholz S, Alcocer-Barradas V, Benítez-Gasca A, Martínez-de la Maza E, Valencia-Ramos C, Gómez-Amador JL. Hybrid fluorescein-guided surgery for pituitary adenoma resection: a pilot study. J Neurosurg 2020; 132:1490-1498. [PMID: 30952130 DOI: 10.3171/2019.1.jns181512] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 01/03/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The authors conducted a pilot study on hybrid fluorescein-guided surgery for pituitary adenoma resection and herein describe the feasibility and safety of this technique. METHODS In this pilot study, the authors included all consecutive patients presenting with pituitary adenomas, functioning and nonfunctioning. They performed a hybrid fluorescein-guided surgical technique for tumor resection. An endonasal endoscopic approach was used; after exposure of the rostrum of the sphenoid sinus, they administered a bolus of 8 mg/kg of fluorescein sodium (FNa) intravenously, and during resection, they alternated between endoscopic and microscopic techniques to guide the resection under a YELLOW 560 filter. RESULTS The study included 15 patients, 7 men (47%) and 8 women (53%). Of the pituitary adenomas, 7 (46%) were nonfunctioning, 6 (40%) were GH secreting, 1 (7%) was prolactin secreting, and 1 (7%) was ACTH secreting. There were no FNa-related complications (anaphylactic reactions); yellowish staining of urine, skin, and mucosa was seen in all patients and resolved in a maximum time of 24 hours. After color spectrophotometric analysis, the authors identified a statistical difference in fluorescence among tumor, gland, and scar tissue (p = 0.01). CONCLUSIONS This is the first study of its kind to describe the feasibility and safety of using FNa to guide the resection of pituitary adenomas. The authors found this technique to be safe and feasible. It may be used to obtain better surgical results, especially for hormone-producing and recurring tumors, as well as for reducing the learning curve in pituitary adenoma surgery.
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Dai W, Zhuang Z, Ling H, Yang Y, Hang C. Systematic review and network meta-analysis assess the comparative efficacy and safety of transsphenoidal surgery for pituitary tumor. Neurosurg Rev 2020; 44:515-527. [PMID: 32036504 DOI: 10.1007/s10143-020-01240-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 01/03/2020] [Accepted: 01/08/2020] [Indexed: 12/27/2022]
Abstract
To quantitatively synthesize the comparative efficacy and safety of the most common surgical approaches including endonasal transsphenoidal endoscopic surgery (ETES), sublabial transsphenoidal microsurgery (STMS) and endonasal transsphenoidal microsurgery (ETMS) for all kinds of pituitary tumors. This systematic review and network meta-analysis was performed on randomized controlled trials (RCTs) and comparison studies from databases of Pubmed, EMBASE, and the Cochrane library. We selected the rate of gross complete resection as our primary outcome of efficacy. And the incidence of all complications, cerebrospinal fluid (CSF) leak, diabetes insipidus, nasal septal perforation, death, and bleeding were designed as our primary outcomes of safety. Twenty-seven studies with 2618 patients were included in this network meta-analysis. On efficacy, there was no statistical difference among the three methods including ETES, STMS, and ETMS. As for safety, results indicated that the incidence of total complications of STMS (OR = 4.74; 95% CI 1.03, 40.14) is significantly superior to ETES. And the incidence of diabetes insipidus of ETMS (OR = 2.21; 95% CI 1.31, 3.81) was significantly superior to that of ETES. Besides, there was no statistical difference in the other complications including CSF leak, nasal septal perforation, death, and bleeding. We clarified the overpraise of the efficacy of endoscopy especially the endonasal transsphenoidal approach, and verified that all the approaches owned similar efficacy. Moreover, we recommended the endoscopy to be the first choice for pituitary tumors, because it demonstrated the best safety.
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Affiliation(s)
- Wei Dai
- Department of Neurosurgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, No. 321 Zhongshan Road, Nanjing, 210000, China
| | - Zong Zhuang
- Department of Neurosurgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, No. 321 Zhongshan Road, Nanjing, 210000, China
| | - Haiping Ling
- Department of Neurosurgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, No. 321 Zhongshan Road, Nanjing, 210000, China
| | - Yongbo Yang
- Department of Neurosurgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, No. 321 Zhongshan Road, Nanjing, 210000, China
| | - Chunhua Hang
- Department of Neurosurgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, No. 321 Zhongshan Road, Nanjing, 210000, China.
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Hayhurst C, Taylor PN, Lansdown AJ, Palaniappan N, Rees DA, Davies JS. Current perspectives on recurrent pituitary adenoma: The role and timing of surgery vs adjuvant treatment. Clin Endocrinol (Oxf) 2020; 92:89-97. [PMID: 31715012 DOI: 10.1111/cen.14127] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 11/02/2019] [Accepted: 11/10/2019] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Caroline Hayhurst
- Department of Neurosurgery, University Hospital of Wales, Cardiff, UK
| | - Peter N Taylor
- Thyroid Research Group, Systems Immunity Research Institute, Cardiff University School of Medicine, Cardiff, UK
- Centre for Diabetes and Endocrinology, University Hospital of Wales, Cardiff, UK
| | - Andrew J Lansdown
- Centre for Diabetes and Endocrinology, University Hospital of Wales, Cardiff, UK
| | | | - Dafydd Aled Rees
- Neuroscience and Mental Health Research Institute, Cardiff University, Cardiff, UK
| | - John Stephen Davies
- Centre for Diabetes and Endocrinology, University Hospital of Wales, Cardiff, UK
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Cozzi R, Ambrosio MR, Attanasio R, Bozzao A, De Marinis L, De Menis E, Guastamacchia E, Lania A, Lasio G, Logoluso F, Maffei P, Poggi M, Toscano V, Zini M, Chanson P, Katznelson L. Italian Association of Clinical Endocrinologists (AME) and Italian AACE Chapter Position Statement for Clinical Practice: Acromegaly - Part 2: Therapeutic Issues. Endocr Metab Immune Disord Drug Targets 2020; 20:1144-1155. [PMID: 31995025 PMCID: PMC7579256 DOI: 10.2174/1871530320666200129113328] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 12/02/2019] [Accepted: 12/02/2019] [Indexed: 12/03/2022]
Abstract
Any newly diagnosed patient should be referred to a multidisciplinary team experienced in the treatment of pituitary adenomas. The therapeutic management of acromegaly always requires a personalized strategy. Normal age-matched IGF-I values are the treatment goal. Transsphenoidal surgery by an expert neurosurgeon is the primary treatment modality for most patients, especially if there are neurological complications. In patients with poor clinical conditions or who refuse surgery, primary medical treatment should be offered, firstly with somatostatin analogs (SSAs). In patients who do not reach hormonal targets with first-generation depot SSAs, a second pharmacological option with pasireotide LAR or pegvisomant (alone or combined with SSA) should be offered. Irradiation could be proposed to patients with surgical remnants who would like to be free from long-term medical therapies or those with persistent disease activity or tumor growth despite surgery or medical therapy. Since the therapeutic tools available enable therapeutic targets to be achieved in most cases, the challenge is to focus more on the quality of life.
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Affiliation(s)
- Renato Cozzi
- Address correspondence to this author at the Endocrinologia, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore 3, 20162 Milano, Italy; Tel: +39.347.5225490; E-mail:
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Iglesias P, Magallón R, Mitjavila M, Rodríguez Berrocal V, Pian H, Díez JJ. Multimodal therapy in aggressive pituitary tumors. ACTA ACUST UNITED AC 2019; 67:469-485. [PMID: 31740190 DOI: 10.1016/j.endinu.2019.08.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 07/19/2019] [Accepted: 08/01/2019] [Indexed: 01/09/2023]
Abstract
The concept of aggressive pituitary tumor (APT) has been precisely defined in recent years. These tumors are characterized by morphological (radiological or histopathological) data of invasion, proliferative activity superior to that of typical adenomas and a clinical behavior characterized by resistance to standard therapies and frequent recurrences. The absence of cerebrospinal or distant metastases differentiates them from the pituitary carcinoma. APTs account for about 10% of all pituitary neoplasm. Proper diagnostic implies participation not only of radiological and hormonal investigation but also a thorough pathological assessment including proliferation markers and immunohistochemistry for hormones and transcription factors. Surgical resection, aiming gross total resection or tumor debulking, is the mainstay initial therapy in most patients. Most patients with APTs need more than one surgical intervention, pituitary radiation, sometimes on more than one occasion, and multiple sequential or combined medical treatments, to finally be doomed to unusual treatments, such as alkylating agents (temozolomide alone or in combination), molecular targeted therapies, or peptide receptor radionuclide therapy. Multimodal therapy, implemented by experts, preferably in specialized centers with high volume caseload, is the only way to improve the prognosis of patients with these uncommon tumors. The research needs in this area are multiple and include a greater knowledge of the molecular biology of these tumors, establishment of protocols for monitoring and sequencing of treatments, development of multicenter studies and international registries.
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Affiliation(s)
- Pedro Iglesias
- Department of Endocrinology, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain.
| | - Rosa Magallón
- Department of Radiation Oncology, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain
| | - Mercedes Mitjavila
- Department of Nuclear Medicine, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain
| | | | - Héctor Pian
- Department of Pathology, Hospital Universitario, Ramón y Cajal, Madrid, Spain
| | - Juan J Díez
- Department of Endocrinology, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain
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Rutkowski M, Zada G. Management of Pituitary Adenomas Invading the Cavernous Sinus. Neurosurg Clin N Am 2019; 30:445-455. [DOI: 10.1016/j.nec.2019.05.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Jeon C, Park KA, Hong SD, Choi JW, Seol HJ, Nam DH, Lee JI, Shin HJ, Kong DS. Clinical Efficacy of Optical Coherence Tomography to Predict the Visual Outcome After Endoscopic Endonasal Surgery for Suprasellar Tumors. World Neurosurg 2019; 132:e722-e731. [PMID: 31421301 DOI: 10.1016/j.wneu.2019.08.031] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 08/05/2019] [Accepted: 08/06/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Prediction of visual outcome after endoscopic endonasal tumor resection still remains a challenge. We investigated the prognostic value of the preoperative peripapillary retinal nerve fiber layer (pRNFL) using optical coherence tomography for visual outcome after endoscopic endonasal surgery (EES) for suprasellar tumors. METHODS We retrospectively analyzed 122 patients who underwent EES for sellar and suprasellar tumors between January 2016 and January 2018. We retrospectively analyzed the pre- and postoperative relationship between pRNFL thickness and visual outcome based on visual acuity (visual acuity score) and visual field (mean deviation [MD]). RESULTS Preoperatively, 216 eyes (mean global pRNFL thickness, 94.3 ± 12.4 μm; 88.5%) were included in the normal pRNFL group (≥70 μm) and 28 eyes (mean global pRNFL thickness, 54.3 ± 11.0 μm; 11.5%) were included in the thin pRNFL group (<70 μm). There was a very strong correlation between pre- and postoperative pRNFL thickness (r = 0.930). The thin pRNFL group showed a stronger correlation between pre- and postoperative MDs than the normal pRNFL group (r = 0.619 and r = 0.420, respectively; P < 0.01). Multivariate analyses identified pRNFL thickness as the only significant predictor of postoperative visual acuity (odds ratio [OR], 25.02; 95% confidence interval [CI], 7.68-81.50; P < 0.01) and visual field (OR, 39.46; 95% CI, 10.39-149.83; P < 0.01). CONCLUSIONS Preoperative pRNFL thickness plays a prognostic value in postoperative visual outcome after EES for sellar and suprasellar tumors. Patients with pRNFL thickness ≥70 μm before surgery are more likely to improve visual outcome than those with thickness <70 μm.
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Affiliation(s)
- Chiman Jeon
- Department of Neurosurgery, Endoscopic Skull Base Surgery Clinic, Brain Tumor Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyung-Ah Park
- Department of Ophthalmology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sang Duk Hong
- Department of Neurosurgery, Endoscopic Skull Base Surgery Clinic, Brain Tumor Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea; Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung Won Choi
- Department of Neurosurgery, Endoscopic Skull Base Surgery Clinic, Brain Tumor Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ho Jun Seol
- Department of Neurosurgery, Endoscopic Skull Base Surgery Clinic, Brain Tumor Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Do-Hyun Nam
- Department of Neurosurgery, Endoscopic Skull Base Surgery Clinic, Brain Tumor Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung-Il Lee
- Department of Neurosurgery, Endoscopic Skull Base Surgery Clinic, Brain Tumor Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyung Jin Shin
- Department of Neurosurgery, Endoscopic Skull Base Surgery Clinic, Brain Tumor Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Doo-Sik Kong
- Department of Neurosurgery, Endoscopic Skull Base Surgery Clinic, Brain Tumor Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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Farrell CJ, Garzon-Muvdi T, Fastenberg JH, Nyquist GG, Rabinowitz MR, Rosen MR, Evans JJ. Management of Nonfunctioning Recurrent Pituitary Adenomas. Neurosurg Clin N Am 2019; 30:473-482. [PMID: 31471054 DOI: 10.1016/j.nec.2019.05.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Christopher J Farrell
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
| | - Tomas Garzon-Muvdi
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Judd H Fastenberg
- Department of Otolaryngology, Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Gurston G Nyquist
- Department of Otolaryngology, Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Mindy R Rabinowitz
- Department of Otolaryngology, Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Marc R Rosen
- Department of Otolaryngology, Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - James J Evans
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
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Gerges MM, Arnaout MM, El Asri AC, Cummock MD, Roshdy A, Anand VK, Dinkin MJ, Oliveira C, Schwartz TH. Increased frequency of cataract surgery in patients over age 50 with pituitary macroadenomas and chiasmal compression. Pituitary 2019; 22:405-410. [PMID: 31144107 DOI: 10.1007/s11102-019-00970-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Patients with visual loss from macroadenomas compressing their optic apparatus may also have concomitant age-related visual pathology such as cataracts. How these two pathologies interact with each other is not well documented. OBJECTIVE The interaction between these two pathologies in elderly patients is the subject of this study. METHODS We identified a series of non-functioning macroadenoma patients over age 50 years with tumors compressing the chiasm who underwent transsphenoidal surgery at our institution between 2004 and 2018. Pre- and post-operative visual complaints, tumor size and extent of resection were analyzed. Prevalence of the diagnosis of cataract and prevalence of cataract surgery in each decade were compared with national averages. RESULTS We identified 200 patients who met selection criteria. 18% of these patients had a diagnosis of cataract and 12.5% had cataract surgery. Compared with the Eye Diseases Prevalence Research Group (EDPRG) study, the prevalence of cataract surgery was 2.5 times the national average of 5.1%. 32% of these patients had no improvement in their vision after cataract surgery but 76% improved after transsphenoidal surgery. CONCLUSIONS We reported a high prevalence of cataract surgery in patients over age 50 in patients with pituitary macroadenomas compressing the optic pathway compared with national averages in patients without adenomas. While visual loss from adenoma likely precipitated more cataract surgeries in this group of patients, some who may not have required it, those patients with cataracts who did not have their cataracts extracted were less likely to recover vision after transsphenoidal surgery. Addressing both pathologies is beneficial.
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Affiliation(s)
- Mina M Gerges
- Department of Neurosurgery, Faculty of Medicine, Ain Shams University, Cairo, Egypt
- Department of Neurological Surgery, Weill Cornell Medicine, NewYork-Presbyterian Hospital, New York, USA
| | - Mohamed M Arnaout
- Department of Neurological Surgery, Weill Cornell Medicine, NewYork-Presbyterian Hospital, New York, USA
- Department of Neurosurgery, Faculty of Medicine, Zagazig University, Sharqia, Egypt
| | - Abad Cherif El Asri
- Department of Neurological Surgery, Weill Cornell Medicine, NewYork-Presbyterian Hospital, New York, USA
- Department of Neurological Surgery, Military hospital Mohamed V, Rabat, Morocco
| | - Matthew D Cummock
- Department of Neurological Surgery, Weill Cornell Medicine, NewYork-Presbyterian Hospital, New York, USA
- Department of Neurological Surgery, St. Barnabas Medical Center, Livingston, New Jersey, USA
| | - Ahmed Roshdy
- Department of Neurosurgery, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Vijay K Anand
- Department of Otolaryngology, Weill Cornell Medicine, NewYork-Presbyterian Hospital, New York, USA
| | - Marc J Dinkin
- Department of Ophthalmology, Weill Cornell Medicine, NewYork-Presbyteian Hospital, New York, NY, USA
| | - Cristiano Oliveira
- Department of Ophthalmology, Weill Cornell Medicine, NewYork-Presbyteian Hospital, New York, NY, USA
| | - Theodore H Schwartz
- Department of Neurological Surgery, Weill Cornell Medicine, NewYork-Presbyterian Hospital, New York, USA.
- Department of Otolaryngology, Weill Cornell Medicine, NewYork-Presbyterian Hospital, New York, USA.
- Department of Neuroscience, Weill Cornell Medicine, NewYork-Presbyterian Hospital, New York, USA.
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Baig MZ, Laghari AA, Darbar A, Abdullah UEH, Abbasi S. Endoscopic Transsphenoidal Surgery for Cushing's Disease: A Review. Cureus 2019; 11:e5254. [PMID: 31572639 PMCID: PMC6760885 DOI: 10.7759/cureus.5254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Accepted: 07/26/2019] [Indexed: 11/12/2022] Open
Abstract
Ever since the 1960s, transsphenoidal surgery has been the modality of choice for treating Cushing's disease. Subsequent visualization of the pituitary fossa and sphenoid sinus may be done either with the operating microscope or with the relatively new endoscope. The endoscope due to its panoramic view allows greater visualization as compared to the operating microscope. It confers greater access to the cavernous sinus, sella, suprasellar, and parasellar regions and accommodates higher magnifications. It is bi-dimensional, however as opposed to the operating microscope that provides a three-dimensional view and allows greater depth perception. This article provides a comprehensive review of the advantages and disadvantages of the endoscope and compares it to the operating microscope. We hope this article will prove useful to both clinicians and academicians alike in their approach and management of Cushing's disease.
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Affiliation(s)
- Mirza Zain Baig
- Surgical Oncology, Rudy L. Ruggles Biomedical Research Institute, Danbury, USA
| | | | - Aneela Darbar
- Neurosurgery, Aga Khan University Hospital, Karachi, PAK
| | | | - Sumiya Abbasi
- Epidemiology, Liaquat College of Medicine & Dentistry, Karachi, PAK
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Meyer J, Perry A, Graffeo CS, Carlstrom LP, Marcellino CR, Burrows A, Bancos I, Driscoll C, Meyer FB. Carotid Artery Injury during Transsphenoidal Pituitary Surgery: Lessons from a 15-Year Modern Microsurgery Cohort. J Neurol Surg B Skull Base 2019; 81:594-602. [PMID: 33134028 DOI: 10.1055/s-0039-1692484] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 05/08/2019] [Indexed: 10/26/2022] Open
Abstract
Background Internal carotid artery (ICA) injury is a rare but potentially catastrophic complication of transsphenoidal resection (TSR) of pituitary tumors, potentially resulting in a host of deficits due to the risk of hemorrhage, ischemia, or even death. The endoscopic endonasal approach (EEA) has gained considerable popularity in the modern era, with few busy neurosurgeons remaining committed to practicing transnasal pituitary microsurgery. Our objective was therefore to characterize the overall incidence of ICA injury in a large, longitudinal, single-surgeon microscopic TSR series conducted during the modern EEA era. Methods Retrospective case series. Results Overall TSR volume by the senior author (F.B.M.) was 817 pituitary tumors during the study period, 2002 to 2017. Within that cohort, two instances of ICA injury were identified (0.2%), including one each with Cushing's disease and acromegaly, both of whom ultimately recovered without residual neurologic deficit. No pediatric injuries were identified. Conclusion Vascular injury is an exceedingly rare complication of transsphenoidal pituitary surgery. Adjuncts to prevent this complication include careful review of the coronal magnetic resonance imaging, identification of the midline, as needed use of the Doppler, and initial caudal opening of the sellar dura. Although potentially disastrous, good neurologic outcomes may be obtained, with immediate judicious packing followed by immediate digital subtraction angiography to assess vessel patency and secondary complications such as pseudoaneurysm.
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Affiliation(s)
- Jenna Meyer
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Avital Perry
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | | | - Lucas P Carlstrom
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | | | - Anthony Burrows
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Irina Bancos
- Department of Endocrinology, Mayo Clinic, Rochester, Minnesota, United States
| | - Colin Driscoll
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Fredric B Meyer
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
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Perry A, Graffeo CS, Meyer J, Carlstrom LP, Oushy S, Driscoll CLW, Meyer FB. Beyond the Learning Curve: Comparison of Microscopic and Endoscopic Incidences of Internal Carotid Injury in a Series of Highly Experienced Operators. World Neurosurg 2019; 131:e128-e135. [PMID: 31319187 DOI: 10.1016/j.wneu.2019.07.074] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Revised: 07/06/2019] [Accepted: 07/08/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND As the endoscopic endonasal approach (EEA) has gained popularity as an alternative to microsurgery (MS) for transsphenoidal resection (TSR), numerous studies have attempted to assess the differential risk of internal carotid artery (ICA) injury between the techniques, yet results have been equivocal and contradictory. The aim of this study was to evaluate ICA injury in MS versus EEA among highly experienced neurosurgeons. METHODS We performed a systematic literature review of publications from 2002-2017 reporting ICA injury outcomes in ≥250 cases using MS or EEA. RESULTS Seventeen series reporting 11,149 patients were included: 3 MS series, 13 EEA series, and 1 series with adequate samples for each. ICA injury incidences were 0.0%-1.6% in cohorts of 275-3000. MS series documented 5 ICA injuries in 2672 operations, for an overall incidence of 0.2% (range, 0.0%-0.4%), and EEA series reported 30 ICA injuries in 8477 operations, for a 0.4% injury rate (range, 0.0%-1.6%); the difference was nonsignificant (P = 0.25). Increased operative experience was associated with decreased incidence of ICA injury, a finding preserved in the overall study cohort and within discretely examined MS and EEA subgroups (overall r2 = 0.08, MS r2 = 0.23, EEA r2 = 0.07). CONCLUSIONS ICA injury is the most serious complication of TSR of pituitary neoplasms. Operator inexperience may be a more important risk factor than choice of surgical technique, given the comparably low rates of injury obtained by highly experienced surgeons independent of technique. This emphasizes the need for consolidated care in pituitary centers of excellence, improvement of high-fidelity simulators, and skull base mentorship between senior and junior staff.
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Affiliation(s)
- Avital Perry
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Jenna Meyer
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Lucas P Carlstrom
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Soliman Oushy
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Colin L W Driscoll
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Fredric B Meyer
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA.
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Agam MS, Wedemeyer MA, Wrobel B, Weiss MH, Carmichael JD, Zada G. Complications associated with microscopic and endoscopic transsphenoidal pituitary surgery: experience of 1153 consecutive cases treated at a single tertiary care pituitary center. J Neurosurg 2019; 130:1576-1583. [PMID: 29999459 DOI: 10.3171/2017.12.jns172318] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 12/11/2017] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Pituitary adenomas (PAs) are benign neoplasms that are frequently encountered during workup for endocrinopathy, headache, or visual loss. Transsphenoidal surgery remains the first-line approach for PA resection. The authors retrospectively assessed complication rates associated with transsphenoidal PA resection from an institutional database. METHODS A retrospective analysis of 1153 consecutive transsphenoidal pituitary adenoma resections performed at the Keck Hospital of USC between November 1992 and March 2017 was conducted. Microscopic transsphenoidal resection was performed in 85.3% of cases, and endoscopic transsphenoidal resection was performed in 14.7%. Analysis of perioperative complications and patient and tumor risk factors was conducted. RESULTS The overall median hospital stay was 3 days. There was 1 perioperative death (0.1%). Surgical complications included postoperative cerebrospinal fluid leak (2.6%), epistaxis (1.1%), postoperative hematoma (1.1%), meningitis (1.0%), cranial nerve paresis (0.8%), hydrocephalus (0.8%), vision loss (0.6%), stroke (0.3%), abdominal hematoma or infection (0.2%), carotid artery injury (0.1%), and vegetative state (0.2%). Perioperative medical complications included bacteremia/sepsis (0.5%), pneumonia (0.3%), myocardial infarction (0.3%), and deep venous thrombosis/pulmonary embolism (0.1%). Endocrine complications were the most frequent, including transient diabetes insipidus (4.3%), symptomatic hyponatremia (4.2%), new hypopituitarism (any axis) (3.6%), permanent diabetes insipidus (0.3%), and adrenal insufficiency (0.2%). There were no significant differences between microscopic and endoscopic approaches with regard to surgical complications (6.4% vs 8.8%, p = 0.247) or endocrine complications (11.4 vs 11.8%, p = 0.888). Risk factors for surgical complications included prior transsphenoidal surgery (11.4% vs 6.8%, p = 0.025), preoperative vision loss (10.3% vs 6.8%, p = 0.002), and presence of PA invasion on MRI (8.5% vs 4.4%, p = 0.007). CONCLUSIONS In this single tertiary center study assessing complications associated with transsphenoidal PA resection, the rate of death or major disability was 0.26%. Risk factors for complications included prior surgical treatment and PA invasion. No differences in complication rates between endoscopic and microscopic surgery were observed. When performed at experienced pituitary centers, transsphenoidal surgery for PAs may be performed with a high degree of safety.
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Affiliation(s)
| | | | | | | | - John D Carmichael
- 2Division of Endocrinology, Department of Medicine, University of Southern California, Keck School of Medicine, Los Angeles, California
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50
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Broersen LHA, van Haalen FM, Biermasz NR, Lobatto DJ, Verstegen MJT, van Furth WR, Dekkers OM, Pereira AM. Microscopic versus endoscopic transsphenoidal surgery in the Leiden cohort treated for Cushing's disease: surgical outcome, mortality, and complications. Orphanet J Rare Dis 2019; 14:64. [PMID: 30866993 PMCID: PMC6416951 DOI: 10.1186/s13023-019-1038-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 02/28/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND First-choice treatment for Cushing's disease is transsphenoidal adenomectomy. Since its introduction in the 1970s, many centers have now switched from microscopic to endoscopic surgery. We compared both techniques for the treatment of Cushing's disease at the Leiden University Medical Center, a European reference center for pituitary diseases. METHODS Cohort study with inclusion and follow-up of consecutive Cushing's disease patients primarily treated by transsphenoidal surgery at the Leiden University Medical Center between 1978 and 2016. We compared remission rates (primary endpoint), mortality, and complications between microscopic (performed up to 2005) and endoscopic (performed from 2003 onwards) surgery. Subgroup analyses were performed by tumor size, surgical experience, and preoperative imaging techniques. Additionally, surgeons' intraoperative findings regarding presence and removal of the adenoma were related to surgical outcome. RESULTS Of 137 included patients, 87 were treated microscopically and 50 endoscopically. Three months after microscopic surgery, 74 patients (86%) were in remission. Five-year recurrence-free survival was 89% (95% confidence interval [CI]: 82-96%), and ten-year recurrence free survival was 84% (95% CI: 75-93%). After endoscopic surgery, 39 patients (83%) were in remission. Both five-year and ten-year recurrence-free survival were 71% (95% CI: 55-87%). Hazard ratio for recurrence was 0.47 (95% CI: 0.19-1.14), and for mortality 2.79 (95% CI: 0.35-22.51), for microscopic versus endoscopic surgery. No learning curve was found for endoscopy, nor an influence of preoperative imaging technique for microscopy. In addition, we did not find a clear relation between the surgeons' intraoperative findings and surgical outcomes. CONCLUSIONS This study did not identify a clear advantage of microscopic or endoscopic transsphenoidal surgery for the treatment of Cushing's disease based on clinical outcome. The transition to endoscopic surgery at our center was not accompanied by transient worsening of outcomes, which may be reassuring for those considering transitioning.
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Affiliation(s)
- Leonie H. A. Broersen
- Department of Medicine, Division of Endocrinology, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
- Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Femke M. van Haalen
- Department of Medicine, Division of Endocrinology, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
- Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Nienke R. Biermasz
- Department of Medicine, Division of Endocrinology, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
- Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Daniel J. Lobatto
- Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
- Department of Neurosurgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Marco J. T. Verstegen
- Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
- Department of Neurosurgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Wouter R. van Furth
- Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
- Department of Neurosurgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Olaf M. Dekkers
- Department of Medicine, Division of Endocrinology, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
- Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Alberto M. Pereira
- Department of Medicine, Division of Endocrinology, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
- Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
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