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Yuzkan S, Erkan B, Dogukan FM, Ozkiziltan U, Balsak S, Arslan FZ, Tutuncuoglu B, Arikan CC, Karatay H, Akpinar E, Ertan Y, Hatipoglu E, Eraslan C, Kitis O, Calli C, Kocak B. Distinguishing Pituitary Metastasis and Pituitary Neuroendocrine Tumors through Conventional MR Imaging and Clinical Features. AJNR Am J Neuroradiol 2024:ajnr.A8302. [PMID: 38871368 DOI: 10.3174/ajnr.a8302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 03/14/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND AND PURPOSE Given their overlapping features, pituitary metastases frequently imitate pituitary neuroendocrine tumors in neuroimaging studies. This study aimed to distinguish pituitary metastases from pituitary neuroendocrine tumors on the basis of conventional MR imaging and clinical features as a practical approach. MATERIALS AND METHODS In this 2-center retrospective study, backward from January 2024, preoperative pituitary MR imaging examinations of 22 pituitary metastases and 74 pituitary neuroendocrine tumors were analyzed. Exclusion criteria were as follows: absence of a definitive histopathologic diagnosis, history of pituitary surgery or radiation therapy before MR imaging, and pituitary neuroendocrine tumors treated with medical therapy. Two radiologists systematically evaluated 13 conventional MR imaging features that have been reported more commonly as indicative of pituitary metastases and pituitary neuroendocrine tumors in the literature. Age, sex, history of cancer, and maximum tumor size constituted the clinical/epidemiologic features. The primary cancer origin for this study was also noted. Univariable and multivariable logistic regression was used for the selection of variables, determining independent predictors, and modeling. Interobserver agreement was evaluated for all imaging parameters using the Cohen κ statistic or intraclass correlation coefficient. RESULTS A total of 22 patients with pituitary metastases (8 women; mean age, 49.5 [SD, 13] years) and 74 patients with pituitary neuroendocrine tumors (36 women; mean age, 50.1 [SD, 11] years) were enrolled. There was no statistically significant distributional difference in age, sex, or maximum tumor size between the 2 groups. Lung cancer (9/22; 41%) was the most commonly reported primary tumor, followed by breast (3/22; 13.6%) and unknown cancer (3/22; 13.6%). Logistic regression revealed 3 independent predictors: rapid growth on control MR imaging, masslike or nodular expansion of the pituitary stalk, and a history of cancer. The model based on these 3 features achieved an area under the curve, accuracy, sensitivity, specificity, and Brier score of 0.987 (95% CI, 0.964-1), 97.9% (95% CI, 92.7%-99.8%), 95.5% (95% CI, 77.2%-99.9%), 98.6% (95% CI, 92.7%-100%), and 0.025, respectively. CONCLUSIONS Two conventional features based on pituitary MR imaging with the clinical variable of history of cancer had satisfying predictive performance, making them potential discriminators between pituitary metastases and pituitary neuroendocrine tumors. In cases in which differentiation between pituitary metastases and pituitary neuroendocrine tumors poses a challenge, the results of this study may help with the diagnosis.
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Affiliation(s)
- Sabahattin Yuzkan
- From the Department of Radiology (S.Y.), Koc University Hospital, Istanbul, Turkey
| | - Buruc Erkan
- Department of Neurosurgery (B.E., E.A.), Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
- Pituitary Diseases Practice and Research Center (B.E.), University of Health Sciences, Istanbul, Turkey
| | - Fatih Mert Dogukan
- Department of Pathology (F.M.D., H.K.), Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| | - Uluc Ozkiziltan
- Department of Radiology (U.O., C.E., O.K., C.C.), Ege University School of Medicine, Izmir, Turkey
| | - Serdar Balsak
- Department of Radiology (S.B.), Bezmialem Vakif University Hospital, Istanbul, Turkey
| | - Fatma Zeynep Arslan
- Department of Radiology (F.Z.A., B.T., C.C.A., B.K.), Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| | - Berk Tutuncuoglu
- Department of Radiology (F.Z.A., B.T., C.C.A., B.K.), Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| | - Ceyda Ceren Arikan
- Department of Radiology (F.Z.A., B.T., C.C.A., B.K.), Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| | - Huseyin Karatay
- Department of Pathology (F.M.D., H.K.), Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| | - Ebubekir Akpinar
- Department of Neurosurgery (B.E., E.A.), Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| | - Yesim Ertan
- Department of Pathology (Y.E.), Ege University School of Medicine, Izmir, Turkey
| | - Esra Hatipoglu
- Division of Endocrinology (E.H.), Department of Internal Medicine, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| | - Cenk Eraslan
- Department of Radiology (U.O., C.E., O.K., C.C.), Ege University School of Medicine, Izmir, Turkey
| | - Omer Kitis
- Department of Radiology (U.O., C.E., O.K., C.C.), Ege University School of Medicine, Izmir, Turkey
| | - Cem Calli
- Department of Radiology (U.O., C.E., O.K., C.C.), Ege University School of Medicine, Izmir, Turkey
| | - Burak Kocak
- Department of Radiology (F.Z.A., B.T., C.C.A., B.K.), Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
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Liu Z, Hou B, You H, Lu L, Duan L, Li M, Fan X, Deng K, Yao Y, Zhu H, Feng F. Three-Dimensional Fast Spin Echo Pituitary MRI in Treatment-Naïve Cushing's Disease: Reduced Impact of Reader Experience and Increased Diagnostic Accuracy. J Magn Reson Imaging 2024; 59:2115-2123. [PMID: 37656167 DOI: 10.1002/jmri.28975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 08/05/2023] [Accepted: 08/07/2023] [Indexed: 09/02/2023] Open
Abstract
BACKGROUND In patients with Cushing's disease, the preoperative identification of pituitary adenomas is crucial to treatment. However, increasing diagnostic accuracy remains an unresolved issue. PURPOSE To evaluate the diagnostic accuracy and the impact of readers' experience regarding high-resolution contrast-enhanced magnetic resonance imaging (hrMRI) for identifying pituitary adenomas in comparison with conventional contrast-enhanced MRI (cMRI) and dynamic contrast-enhanced MRI (dMRI). STUDY TYPE Retrospective. POPULATION Sixty-five patients (median age, 39 years; interquartile range [IQR], 28-53 years; 60% females) with treatment-naïve Cushing's disease. FIELD STRENGTH/SEQUENCE 3-T, seven fast spin echo sequences. ASSESSMENT The diagnostic accuracies of identifying pituitary adenomas on cMRI, dMRI, combined cMRI and dMRI (cdMRI), and hrMRI were independently evaluated by six readers with three experience levels (high: >20 years, modest: 10-20 years, low: <10 years; two readers for each experience level). Readers were asked to localize the lesion, and measure its diameter on the sequence where identified. The reference standard was postoperative histopathology. The impact of readers' experience and interobserver agreement were assessed. Image quality was assessed using a 5-point Likert scale, including overall image quality, sharpness, and structural conspicuity. STATISTICAL TESTS McNemar's test, Cochran's test, Wilcoxon signed-rank test, Mann-Whitney U test, and κ statistics for interobserver agreement. A P-value <0.05 was considered statistically significant. RESULTS For identifying pituitary adenomas (median diameter, 5 mm; IQR, 4-5 mm), hrMRI had significantly higher sensitivity (87.7%-93.8%) than cMRI, dMRI, and cdMRI (52.3%-75.4%) for readers with different experience levels. The interobserver agreement was moderate (κ = 0.461-0.523). The sensitivity for hrMRI was comparable between readers with different experience levels (P = 0.371). All image quality scores on hrMRI were significantly higher than cMRI and dMRI (5.0 vs. 4.0). DATA CONCLUSION For identifying pituitary adenomas in patients with treatment-naïve Cushing's disease, hrMRI may show high diagnostic accuracy and seems not to be affected by readers' experience. LEVEL OF EVIDENCE 3 TECHNICAL EFFICACY: Stage 2.
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Affiliation(s)
- Zeyu Liu
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bo Hou
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hui You
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lin Lu
- Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lian Duan
- Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Mingli Li
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaoyuan Fan
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Kan Deng
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yong Yao
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- State Key Laboratory of Complex Severe and Rare Disease, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Huijuan Zhu
- Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- State Key Laboratory of Complex Severe and Rare Disease, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Feng Feng
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- State Key Laboratory of Complex Severe and Rare Disease, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Sitoci-Ficici KH, Sippl C, Prajsnar A, Saffour S, Linsler S. Sellar metastasis: A rare intraoperative finding - surgical treatment, strategies and outcome. Clin Neurol Neurosurg 2024; 241:108280. [PMID: 38636360 DOI: 10.1016/j.clineuro.2024.108280] [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: 03/02/2024] [Revised: 04/05/2024] [Accepted: 04/06/2024] [Indexed: 04/20/2024]
Abstract
OBJECTIVE The sellar region, though uncommon for metastatic spread, may become more prevalent due to longer survival of patients with metastatic malignancies. Compression of adjacent vital anatomy can cause disabling symptoms and endocrine disturbances, leading to significant morbidity METHODS: This study analyzed sellar pathologies treated via endonasal approach from January 2011 to December 2021 to assess the incidence of sellar metastases. Patient demographics, presenting symptoms, radiological and histological findings, management, and outcomes were evaluated RESULTS: Among 334 patients treated during the study period, eight (2.3 %) had metastases confirmed histopathologically, with one having a known malignant tumor history. Preoperative imaging suspected malignancy or metastasis in two cases. Diagnosis was unexpectedly confirmed in 57 % of cases. Subtotal resection was achieved in three cases, near-total resection in one. Mean follow-up was 2.4 years, with 71 % mortality CONCLUSIONS: The sellar region can manifest metastatic disease, with sellar symptoms potentially indicating neoplastic disease onset. Rapid hormonal dysfunction or ophthalmoplegia suggests metastasis, even without a known primary. Further meta analysis of reported cases is necessary to determine the incidence and optimal treatment of these rare metastases.
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Affiliation(s)
| | - Christoph Sippl
- Klinik für Neurochirurgie, Universitätsklinikum des Saarlandes, Homburg, Germany; Klinik für Neurochirurgie, Klinikum Bayreuth, Medizincampus Oberfranken FAU, Erlangen, Germany
| | - Anna Prajsnar
- Klinik für Neurochirurgie, Universitätsklinikum des Saarlandes, Homburg, Germany
| | - Safwan Saffour
- Klinik für Neurochirurgie, Universitätsklinikum des Saarlandes, Homburg, Germany; Klinik für Neurochirurgie, Klinikum Bayreuth, Medizincampus Oberfranken FAU, Erlangen, Germany
| | - Stefan Linsler
- Klinik für Neurochirurgie, Universitätsklinikum des Saarlandes, Homburg, Germany; Klinik für Neurochirurgie, Klinikum Bayreuth, Medizincampus Oberfranken FAU, Erlangen, Germany.
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Gologorsky R, Harake E, von Oiste G, Nasir-Moin M, Couldwell W, Oermann E, Hollon T. Generating novel pituitary datasets from open-source imaging data and deep volumetric segmentation. Pituitary 2022; 25:842-853. [PMID: 35943676 DOI: 10.1007/s11102-022-01255-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/08/2022] [Indexed: 10/15/2022]
Abstract
PURPOSE The estimated incidence of pituitary adenomas in the general population is 10-30%, yet radiographic diagnosis remains a challenge. Diagnosis is complicated by the heterogeneity of radiographic features in both normal (e.g. complex anatomy, pregnancy) and pathologic states (e.g. primary endocrinopathy, hypophysitis). Clinical symptoms and laboratory testing are often equivocal, which can result in misdiagnosis or unnecessary specialist referrals. Computer vision models can aid in pituitary adenoma diagnosis; however, a major challenge to model development is the lack of dedicated pituitary imaging datasets. We hypothesized that deep volumetric segmentation models trained to extract the sellar and parasellar region from existing whole-brain MRI scans could be used to generate a novel dataset of pituitary imaging. METHODS Six open-source whole-brain MRI datasets, created for research purposes, were included for model development. Deep learning-based volumetric segmentation models were trained using 318 manually annotated MRI scans from a single open-source MRI dataset. Out-of-distribution volumetric segmentation performance was then tested on 418 MRIs from five held-out research datasets. RESULTS On our annotated images, agreement between manual and model volumetric segmentations was high. Dice scores (a measure of overlap) ranged 0.76-0.82 for both in-distribution and out-of-distribution model testing. In total, 6,755 MRIs from six data sources were included in the final generated pituitary dataset. CONCLUSIONS We present the first and largest dataset of pituitary imaging constructed using existing MRI data and deep volumetric segmentation models trained to identify sellar and parasellar anatomy. The model generalizes well across patient populations and MRI scanner types. We hope our pituitary dataset will be an integral part of future machine learning research on pituitary pathologies.
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Affiliation(s)
- Rachel Gologorsky
- Department of Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, 10029, New York, NY, USA
| | - Edward Harake
- Department of Medicine, University of Michigan Medical School, 1500 E Medical Center Dr, 48109, Ann Arbor, MI, USA
| | - Grace von Oiste
- Department of Neurosurgery, NYU Langone Health System, 530 First Ave, 10016, New York, NY, USA
| | - Mustafa Nasir-Moin
- Department of Neurosurgery, NYU Langone Health System, 530 First Ave, 10016, New York, NY, USA
| | - William Couldwell
- Department of Neurosurgery, University of Utah, 201 Presidents' Cir, 84132, Salt Lake City, UT, USA
| | - Eric Oermann
- Department of Neurosurgery, NYU Langone Health System, 530 First Ave, 10016, New York, NY, USA
- Department of Radiology, NYU Langone Health System, 530 First Ave, 10016, New York, NY, USA
- Center for Data Science, New York University, 60 5th Ave, 10011, New York, NY, USA
| | - Todd Hollon
- Machine Learning in Neurosurgery Laboratory, Department of Neurosurgery, University of Michigan, 1500 E Medical Center Dr, 48109, Ann Arbor, MI, USA.
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5
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Jiang C, Bhattacharya A, Linzey JR, Joshi RS, Cha SJ, Srinivasan S, Alber D, Kondepudi A, Urias E, Pandian B, Al-Holou WN, Sullivan SE, Thompson BG, Heth JA, Freudiger CW, Khalsa SSS, Pacione DR, Golfinos JG, Camelo-Piragua S, Orringer DA, Lee H, Hollon TC. Rapid Automated Analysis of Skull Base Tumor Specimens Using Intraoperative Optical Imaging and Artificial Intelligence. Neurosurgery 2022; 90:758-767. [PMID: 35343469 PMCID: PMC9514725 DOI: 10.1227/neu.0000000000001929] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 12/16/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Accurate specimen analysis of skull base tumors is essential for providing personalized surgical treatment strategies. Intraoperative specimen interpretation can be challenging because of the wide range of skull base pathologies and lack of intraoperative pathology resources. OBJECTIVE To develop an independent and parallel intraoperative workflow that can provide rapid and accurate skull base tumor specimen analysis using label-free optical imaging and artificial intelligence. METHODS We used a fiber laser-based, label-free, nonconsumptive, high-resolution microscopy method (<60 seconds per 1 × 1 mm2), called stimulated Raman histology (SRH), to image a consecutive, multicenter cohort of patients with skull base tumor. SRH images were then used to train a convolutional neural network model using 3 representation learning strategies: cross-entropy, self-supervised contrastive learning, and supervised contrastive learning. Our trained convolutional neural network models were tested on a held-out, multicenter SRH data set. RESULTS SRH was able to image the diagnostic features of both benign and malignant skull base tumors. Of the 3 representation learning strategies, supervised contrastive learning most effectively learned the distinctive and diagnostic SRH image features for each of the skull base tumor types. In our multicenter testing set, cross-entropy achieved an overall diagnostic accuracy of 91.5%, self-supervised contrastive learning 83.9%, and supervised contrastive learning 96.6%. Our trained model was able to segment tumor-normal margins and detect regions of microscopic tumor infiltration in meningioma SRH images. CONCLUSION SRH with trained artificial intelligence models can provide rapid and accurate intraoperative analysis of skull base tumor specimens to inform surgical decision-making.
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Affiliation(s)
- Cheng Jiang
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Joseph R. Linzey
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Rushikesh S. Joshi
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Sung Jik Cha
- School of Medicine, Western Michigan University, Kalamazoo, Michigan, USA
| | | | - Daniel Alber
- Division of Applied Mathematics, Brown University, Providence, Rhode Island, USA
| | - Akhil Kondepudi
- College of Literature, Science and the Arts, University of Michigan, Ann Arbor, Michigan, USA
| | - Esteban Urias
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Balaji Pandian
- School of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Wajd N. Al-Holou
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Stephen E. Sullivan
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - B. Gregory Thompson
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Jason A. Heth
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | | | | | - Donato R. Pacione
- Department of Neurosurgery, NYU Langone Health, New York, New York, USA
| | - John G. Golfinos
- Department of Neurosurgery, NYU Langone Health, New York, New York, USA
| | | | - Daniel A. Orringer
- Department of Neurosurgery, NYU Langone Health, New York, New York, USA
- Department of Pathology, NYU Langone Health, New York, New York, USA
| | - Honglak Lee
- Department of Computer Science and Engineering, University of Michigan, Ann Arbor, Michigan, USA
| | - Todd C. Hollon
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
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Muro-Fuentes EA, Stunkel L. Diagnostic Error in Neuro-ophthalmology: Avenues to Improve. Curr Neurol Neurosci Rep 2022; 22:243-256. [PMID: 35320466 PMCID: PMC8940596 DOI: 10.1007/s11910-022-01189-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2022] [Indexed: 11/06/2022]
Abstract
Purpose of Review To highlight potential avenues to reduce preventable diagnostic error of neuro-ophthalmic conditions and avoid patient harm. Recent Findings Recent prospective studies and studies of patient harm have advanced our understanding. Additionally, recent studies of fundus photography, telemedicine, and artificial intelligence highlight potential avenues for diagnostic improvement. Summary Diagnostic error of neuro-ophthalmic conditions can often be traced to failure to gather an adequate history, perform a complete physical exam, obtain adequate/appropriate neuroimaging, and generate a complete, appropriate differential diagnosis. Improving triage and identification of neuro-ophthalmic conditions by other providers and increasing access to subspecialty neuro-ophthalmology evaluation are essential avenues to reduce diagnostic error. Further research should evaluate the relationship between misdiagnosis and patient harm, and help identify the most impactful potential targets for improvement.
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Affiliation(s)
| | - Leanne Stunkel
- John F. Hardesty, MD Department of Ophthalmology and Visual Sciences and Department of Neurology, Washington University in St. Louis, 660 S. Euclid Ave, Campus Box 8096, St. Louis, MO, 63110, USA
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Dai C, Yu R, Wang H, Castaño JP. Editorial: The progress of rare lesions of the sellar region. Front Endocrinol (Lausanne) 2022; 13:978284. [PMID: 36093097 PMCID: PMC9449839 DOI: 10.3389/fendo.2022.978284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Accepted: 08/05/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
- Congxin Dai
- Department of Neurosurgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
- *Correspondence: Congxin Dai,
| | - Run Yu
- David Geffen School of Medicine, University of California, Los Angeles, CA, United States
| | - Haijun Wang
- Department of Neurosurgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Justo P. Castaño
- Maimonides Biomedical Research Institute of Córdoba (IMIBIC), Reina Sofia University Hospital, CIBERobn, University of Córdoba, Córdoba, Spain
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