Change in cephalocaudal tumor cavity diameter after transsphenoidal surgery is a predictor of diabetes insipidus in pituitary adenoma

Analysis of factors influencing the occurrence of diabetes insipidus following neuroendoscopic transsphenoidal resection of pituitary adenomas and risk assessment

Objective

Studies have revealed a higher prevalence of diabetes insipidus in patients following resection of pituitary adenoma surgery. By comprehensively analysing the clinical history of patients undergoing endoscopic transnasal sphenoidal resection for pituitary adenomas, the factors influencing development of postoperative diabetes insipidus were investigated and a predictive model was developed to assess its risk.

Methods

A retrospective analysis was conducted on the medical records of 281 patients with pituitary adenomas who underwent neuroendoscopic transsphenoidal resection at our institution between October 2020 and October 2022. The Mann-Whitney U test, chi-square test, and logistic regression analysis were used to identify the independent factors that potentially contribute to the development of postoperative diabetes insipidus. Additionally, a nomogram was constructed to evaluate the predicted risk of postoperative diabetes insipidus in patients with pituitary adenomas.

Results

Diabetes insipidus occurred in 100 (35.59 %) of the 281 enrolled patients. The results of the multifactorial logistic regression analysis revealed that diabetes, hypertension, cardiopathy, preoperative serum cortisol level, cerebrospinal fluid leakage, and tumour texture independently influenced the occurrence of postoperative diabetes insipidus (P < 0.05). A nomogram was developed to evaluate the risk of postoperative diabetes insipidus in patients with pituitary adenoma.

Conclusions

Multiple independent risk factors associated with the patient and tumour were identified in predicting diabetes insipidus. Early recognition of these risk factors may contribute to the prevention or reduction of diabetes insipidus incidence following pituitary adenoma surgery.

Clinical and radiographic characteristics of patients with non-functioning pituitary adenomas categorized according to their serum prolactin concentration: novel predictors of postoperative transient diabetes insipidus following surgery

PURPOSE

Non-functioning pituitary adenomas (NFPAs) are often associated with hyperprolactinemia, which is known as the "stalk effect". However, the relationships between hyperprolactinemia and the radiographic characteristics of the tumor that affects the pituitary stalk have not been well characterized. We aimed to identify the differences in the clinical and radiographic characteristics of patients with NFPA, with and without hyperprolactinemia.

METHODS

We enrolled 107 patients with NFPA and allocated them to hyperprolactinemia and non-hyperprolactinemia groups using two different cut-off values: (1) the upper limit of the normal reference range, adjusted for sex and menopausal status, and (2) the upper quartile across the cohort, and compared their clinical and radiographic characteristics. These analyses were conducted to clarify the relationship between the "stalk effect" and the postoperative change in antidiuretic hormone secretion.

RESULTS

The specific radiographic characteristics of the patients included the presence of a cystic or hemorrhagic tumor and the presence of pituitary stalk deviation, which were more frequent in the patients with hyperprolactinemia. Interestingly, the incidence of postoperative transient diabetes insipidus was statistically significantly higher in the hyperprolactinemia group (≥40 ng/mL) and in the group with radiologic evidence of stalk deviation, which were shown to be independent risk factors on multivariate analysis.

CONCLUSION

The presence of a "stalk effect" was associated with a higher risk of postoperative transient diabetes insipidus, reflecting perioperative pituitary stalk dysfunction following NFPA surgery, especially in patients with serum prolactin concentrations ≥40 ng/mL and radiologic evidence of stalk deviation.

Impact of metabolic syndrome on postoperative outcomes of transsphenoidal pituitary surgery: analysis of U.S. nationwide inpatient sample data 2005-2018

Introduction

Transsphenoidal surgery (TSS) is the preferred surgical method for most pituitary adenomas owing to high efficacy and low mortality. This study aimed to evaluate the influence of metabolic syndrome (MetS) on postoperative outcomes of TSS for pituitary adenoma.

Methods

This population-based, retrospective observational study extracted data of adults 20-79 y receiving TSS for pituitary adenoma from the US Nationwide Inpatient Sample (NIS) between 2005-2018. Primary outcomes were pituitary-related complications, poor outcomes (i.e., in-hospital mortality or unfavorable discharge), prolonged length of stay (LOS), and patient safety indicators (PSIs). Univariate and multivariate regressions were performed to determine the associations between study variables and outcomes.

Results

19,076 patients (representing a 93,185 US in-patient population) were included, among which 2,109 (11.1%) patients had MetS. After adjustment, pre-existing MetS was not significantly associated with presence of pituitary-related complications and poor outcomes. In contrast, MetS was significantly associated with an increased risk for prolonged LOS (adjusted OR (aOR) = 1.19; 95% CI: 1.05-1.34), PSIs (aOR = 1.31; 95% CI: 1.07-1.59) and greater hospital costs (adjusted β = 8.63 thousand USD; 95% CI: 4.98-12.29). Among pituitary-related complications, MetS was independently associated with increased risk of cerebrospinal fluid (CSF) rhinorrhea (aOR = 1.22, 95% CI: 1.01, 1.47) but lowered diabetes insipidus (aOR = 0.83, 95% CI: 0.71, 0.97).

Discussion

MetS does not pose excessive risk of in-hospital mortality or unfavorable discharge. However, MetS independently predicted having PSIs, prolonged LOS, greater hospital costs, and CSF rhinorrhea. Study findings may help clinicians achieve better risk stratification before TSS.

Importance of Intraoperative Factors in Postoperative Arginine Vasopressin Deficiency After Pituitary Adenoma Surgery

OBJECTIVE

Pituitary adenoma (PA) is the most frequent tumor in the sellar region. Arginine vasopressin deficiency (AVP-D), formerly known as central diabetes insipidus, is a common complication after pituitary surgeries. In this study, we reviewed patients with PAs after endoscopic transsphenoidal surgery, evaluated the incidence of postoperative AVP-D, and determined associated risk factors.

METHODS

We retrospectively studied 520 patients who underwent endoscopic transsphenoidal surgery for PAs and evaluated perioperative risk factors and their associations with postoperative AVP-D. Patients who developed AVP-D were categorized in 3 groups: (1) early AVP-D, (2) transient AVP-D, and (3) permanent AVP-D.

RESULTS

Of the 520 patients, 24.8% experienced early AVP-D, and 1.9% (n = 10) had transient AVP-D. Permanent AVP-D was observed in only 6 patients (1.1%). Gross total resection, hormonal remission, pituitary stalk manipulation, and intraoperative cerebrospinal fluid leak were significantly associated with a higher incidence of AVP-D (P = .027, P = .002, P < .001 and P < .001, respectively). All patients who developed permanent AVP-D had somatotroph adenomas. AVP-D was not found to be related with tumor size. The length of hospital stay was prolonged by AVP-D on average by 1.5 days (P = .018).

CONCLUSION

The reported incidence of AVP-D has a considerably wide range. A consistent definition and grading for AVP-D will increase consistency and comparability among studies. Nonetheless, most patients experience AVP-D on a temporary basis, and only a few require long-term treatment. Cerebrospinal fluid leak, gross total resection, and hormonal remission were identified as risk factors for postoperative AVP-D. We believe that the intraoperative risk factors play the main role in postoperative AVP-D. The course of surgery and operative findings help us plan selective postoperative patient monitoring and care.

Skull base reconstruction using in situ bone flap in patients with pituitary adenomas treated by endoscopic endonasal approach

Objective

The objective of this study is to study the effect of in situ bone flap (ISBF) repositioning, a recently proposed rigid skull base reconstruction technique, on patients diagnosed with pituitary adenoma undergoing endoscopic endonasal approach (EEA).

Method

A retrospective analysis was conducted on 188 patients with pituitary adenomas who underwent EEA from February 2018 to September 2022. Patients were divided into the ISBF group and non-ISBF group, according to whether ISBF was used during skull base reconstruction.

Results

Of the 75 patients in the non-ISBF group, 6 had postoperative cerebrospinal fluid (CSF) leakage (8%), while only 1 of 113 patients in the ISBF group (0.8%) had postoperative CSF leakage, indicating that the incidence of postoperative CSF leakage in the ISBF group was significantly lower than that in the non-ISBF group (P = 0.033). In addition, we also found that the postoperative hospitalization days of patients in the ISBF group (5.34 ± 1.24) were significantly less than those in the non-ISBF group (6.83 ± 1.91, P = 0.015).

Conclusion

ISBF repositioning is a safe, effective, and convenient rigid skull base reconstruction method for patients with pituitary adenoma treated by EEA, which can significantly reduce the rate of postoperative CSF leakage and shorten postoperative hospital stays.

Comparative Efficacy of AZD9496 and Fulvestrant on the Growth of Pituitary Adenoma via Blocking JAK2/STAT5B Pathway

Total 158 gonadotropin-type pituitary adenoma tissue specimens were collected and the expression of ESR1 in gonadotropin-type pituitary adenoma and its association with the overall survival of patients were analyzed. Transcriptome-sequencing data containing 79 cases of gonadotropin-type pituitary adenoma was used to search for all ESR1-related genes. KEGG pathway enrichment analysis was performed to identify the altering pathway and targeting genes. The in vitro and in vivo pituitary models were used to evaluate the therapeutic efficacy of estrogen receptor (ER) inhibitors AZD9496 and fulvestrant. The mechanism of AZD9496 and fulvestrant in suppressing pituitary adenoma were also investigated. Low-level ESR1 had longer progression-free survival (PFS) in pituitary adenoma patients. ErbB signaling pathway was discovered as the main enriched pathway. Furthermore, the STAT5B gene was identified as a key ESR-1-related gene. The expression of STAT5B was significantly positively correlated with ESR1 expression in the pituitary adenoma. AZD9496, a novel ER inhibitor, exhibited a potent inhibitory effect on the growth of in vitro and in vivo pituitary adenoma cells, and its efficacy is comparable to the classic ER inhibitor, fulvestrant. Mechanically, the AZD9496 and fulvestrant significantly blocked JAK2/STAT5B pathway in GT1-1 cells and xenograft mice. Our results provide substantial evidence for the subsequent clinical use of AZD9496 in the treatment of patients with pituitary adenoma.