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Robertson FC, Nahed BV, Barkhoudarian G, Veeravagu A, Berg D, Kalkanis S, Olson JJ, Germano IM. American Association of Neurological Surgeons/Congress of the Neurological Surgeons Section on Tumors Guidelines: Assessing Their Impact on Brain Tumor Clinical Practice. Neurosurgery 2024:00006123-990000000-01294. [PMID: 39028201 DOI: 10.1227/neu.0000000000003125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Accepted: 06/18/2024] [Indexed: 07/20/2024] Open
Abstract
Clinical guidelines direct healthcare professionals toward evidence-based practices. Evaluating guideline impact can elucidate information penetration, relevance, effectiveness, and alignment with evolving medical knowledge and technological advancements. As the American Association of Neurological Surgeons/Congress of Neurological Surgeons Section on Tumors marks its 40th anniversary in 2024, this article reflects on the tumor guidelines established by the Section over the past decade and explores their impact on other publications, patents, and information dissemination. Six tumor guideline categories were reviewed: low-grade glioma, newly diagnosed glioblastoma, progressive glioblastoma, metastatic brain tumors, vestibular schwannoma, and pituitary adenomas. Citation data were collected from Google Scholar and PubMed. Further online statistics, such as social media reach, and features in policy, news, and patents were sourced from Altmetric. Online engagement was assessed through website and CNS+ mobile application visits. Data were normalized to time since publication. Metastatic Tumor guidelines (2019) had the highest PubMed citation rate at 26.1 per year and webpage visits (29 100 page views 1/1/2019-9/30/2023). Notably, this guideline had two endorsement publications by partner societies, the Society of Neuro-Oncology and American Society of Clinical Oncology, concerning antiepileptic prophylaxis and steroid use, and the greatest reach on X (19.7 mentions/y). Citation rates on Google Scholar were led by Vestibular Schwannoma (2018). Non-Functioning Pituitary Adenoma led Mendeley reads. News, patent, or policy publications were led by low-grade glioma at 1.5/year. Our study shows that the American Association of Neurological Surgeons/Congress of Neurological Surgeons Section on Tumors guidelines go beyond citations in peer-reviewed publications to include patents, online engagement, and information dissemination to the public.
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Affiliation(s)
- Faith C Robertson
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Brian V Nahed
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Garni Barkhoudarian
- Neurosurgery Division, Pacific Neuroscience Institute, Santa Monica, California, USA
| | - Anand Veeravagu
- Department of Neurosurgery, Stanford University, Stanford, California, USA
| | - David Berg
- Congress of Neurological Surgeons, Chicago, Illinois, USA
| | - Steven Kalkanis
- Department of Neurosurgery, Henry Ford Medical System, Detroit, Michigan, USA
| | - Jeffrey J Olson
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Isabelle M Germano
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Qiao N, Gao W, Deng X, Xin T, Zhang G, Wu N, Wang P, Bi Y, Cong Z, Zhou Z, Li J, Sun S, Li M, Tang W, Yan X, Wang W, Qiu W, Yao S, Ye Z, Ma Z, Zhou X, Cao X, Shen M, Shou X, Zhang Z, Wu Z, Chu L, Qiu Y, Ma H, Wu A, Ma C, Lou M, Jiang C, Wang Y, Zhao Y. Combined simultaneous transsphenoidal and transcranial regimen improves surgical outcomes in complex giant pituitary adenomas: a longitudinal retrospective cohort study. Int J Surg 2024; 110:4043-4052. [PMID: 38498406 PMCID: PMC11254263 DOI: 10.1097/js9.0000000000001330] [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: 01/14/2024] [Accepted: 03/02/2024] [Indexed: 03/20/2024]
Abstract
BACKGROUND Surgical treatment of complex giant pituitary adenomas (GPAs) presents significant challenges. The efficacy and safety of combining transsphenoidal and transcranial approaches for these tumors remain controversial. In this largest cohort of patients with complex GPAs, we compared the surgical outcomes between those undergoing a combined regimen and a non-combined regimen. We also examined the differences in risks of complications, costs, and logistics between the two groups, which might offer valuable information for the appropriate management of these patients. PATIENTS AND METHODS This was a multicenter retrospective cohort study conducted at 13 neurosurgical centers. Consecutive patients who received a combined or non-combined regimen for complex GPAs were enrolled. The primary outcome was gross total resection, while secondary outcomes included complications, surgical duration, and relapse. A propensity score-based weighting method was used to account for differences between the groups. RESULTS Out of 647 patients [298 (46.1%) women, mean age: 48.5 ± 14.0 years] with complex GPAs, 91 were in the combined group and 556 were in the noncombined group. Compared with the noncombined regimen, the combined regimen was associated with a higher probability of gross total resection [50.5% vs. 40.6%, odds ratio (OR): 2.18, 95% confidence interval (CI): 1.30-3.63, P = 0.003]. The proportion of patients with life-threatening complications was lower in the combined group than in the non-combined group (4.4% vs. 11.2%, OR: 0.25, 95% CI: 0.08-0.78, P = 0.017). No marked differences were found between the groups in terms of other surgical or endocrine-related complications. However, the combined regimen exhibited a longer average surgery duration of 1.3 h ( P < 0.001) and higher surgical costs of 22,000 CNY (~ 3,000 USD, P = 0.022) compared with the noncombined approach. CONCLUSIONS The combined regimen offered increased rates of total resection and decreased incidence of life-threatening complications, which might be recommended as the first-line choice for these patients.
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Affiliation(s)
- Nidan Qiao
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University
- National Center for Neurological Disorders
- State Key Laboratory of Medical Neurobiology and MOE Frontiers Center for Brain Science, Institutes of Brain Science, Fudan University
- Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration
- Neurosurgical Institute of Fudan University, Shanghai
| | - Wei Gao
- Department of Neurosurgery, Shengjing Hospital of China Medical University, Shenyang, Liaoning
| | - Xingli Deng
- Department of Neurosurgery, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan
| | - Tao Xin
- Department of Neurosurgery, The First Affiliated Hospital of Shandong First Medical University, Jinan, Shandong
| | - Gangli Zhang
- Department of Neurosurgery, Shanxi Provincial People's Hospital, Taiyuan, Shanxi
| | - Nan Wu
- Department of Neurosurgery, Chongqing General Hospital, Chongqing
| | - Pan Wang
- Department of Neurosurgery, Chongqing General Hospital, Chongqing
| | - Yunke Bi
- Department of Neurosurgery, Shanghai General Hospital, Shanghai
| | - Zixiang Cong
- Department of Neurosurgery, Affiliated Jinling Hospital, Medicine School of Nanjing University, Nanjing, Jiangsu
| | - Zhiyi Zhou
- Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai
| | - Junjun Li
- Department of Neurosurgery, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan
| | - Shengyu Sun
- Department of Neurosurgery, General Hospital of Ningxia Medical University, Yinchuan, Ningxia
| | - Meng Li
- Department of Neurosurgery, The First Affiliated Hospital of Shandong First Medical University, Jinan, Shandong
| | - Wenlong Tang
- Department of Neurosurgery, Heping Hospital Affiliated to Changzhi Medical College, Changzhi, Shanxi
| | - Xiaorong Yan
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian
| | - Wenxiong Wang
- Department of Neurosurgery, Shanxi Provincial People's Hospital, Taiyuan, Shanxi
| | - Wenjin Qiu
- Department of Neurosurgery, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou
| | - Shun Yao
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University
- National Center for Neurological Disorders
- State Key Laboratory of Medical Neurobiology and MOE Frontiers Center for Brain Science, Institutes of Brain Science, Fudan University
- Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration
- Neurosurgical Institute of Fudan University, Shanghai
| | - Zhao Ye
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University
- National Center for Neurological Disorders
- State Key Laboratory of Medical Neurobiology and MOE Frontiers Center for Brain Science, Institutes of Brain Science, Fudan University
- Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration
- Neurosurgical Institute of Fudan University, Shanghai
| | - Zengyi Ma
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University
- National Center for Neurological Disorders
- State Key Laboratory of Medical Neurobiology and MOE Frontiers Center for Brain Science, Institutes of Brain Science, Fudan University
- Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration
- Neurosurgical Institute of Fudan University, Shanghai
| | - Xiang Zhou
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University
- National Center for Neurological Disorders
- State Key Laboratory of Medical Neurobiology and MOE Frontiers Center for Brain Science, Institutes of Brain Science, Fudan University
- Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration
- Neurosurgical Institute of Fudan University, Shanghai
| | - Xiaoyun Cao
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University
- National Center for Neurological Disorders
- State Key Laboratory of Medical Neurobiology and MOE Frontiers Center for Brain Science, Institutes of Brain Science, Fudan University
- Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration
- Neurosurgical Institute of Fudan University, Shanghai
| | - Ming Shen
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University
- National Center for Neurological Disorders
- State Key Laboratory of Medical Neurobiology and MOE Frontiers Center for Brain Science, Institutes of Brain Science, Fudan University
- Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration
- Neurosurgical Institute of Fudan University, Shanghai
| | - Xuefei Shou
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University
- National Center for Neurological Disorders
- State Key Laboratory of Medical Neurobiology and MOE Frontiers Center for Brain Science, Institutes of Brain Science, Fudan University
- Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration
- Neurosurgical Institute of Fudan University, Shanghai
| | - Zhaoyun Zhang
- Department of Endocrinology, Huashan Hospital, Fudan University
| | - Zhenyu Wu
- School of Public Health, Fudan University
| | - Liangzhao Chu
- Department of Neurosurgery, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou
| | - Yongming Qiu
- Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai
| | - Hui Ma
- Department of Neurosurgery, General Hospital of Ningxia Medical University, Yinchuan, Ningxia
| | - Anhua Wu
- Department of Neurosurgery, Shengjing Hospital of China Medical University, Shenyang, Liaoning
| | - Chiyuan Ma
- Department of Neurosurgery, Affiliated Jinling Hospital, Medicine School of Nanjing University, Nanjing, Jiangsu
| | - Meiqing Lou
- Department of Neurosurgery, Shanghai General Hospital, Shanghai
| | - Changzhen Jiang
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian
| | - Yongfei Wang
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University
- National Center for Neurological Disorders
- State Key Laboratory of Medical Neurobiology and MOE Frontiers Center for Brain Science, Institutes of Brain Science, Fudan University
- Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration
- Neurosurgical Institute of Fudan University, Shanghai
| | - Yao Zhao
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University
- National Center for Neurological Disorders
- State Key Laboratory of Medical Neurobiology and MOE Frontiers Center for Brain Science, Institutes of Brain Science, Fudan University
- Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration
- Neurosurgical Institute of Fudan University, Shanghai
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, People’s Republic of China
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Mortini P, Albano L, Barzaghi LR, Spina A, Losa M. The open sella technique for surgical treatment of pituitary macroadenomas: Safety and efficacy in a large clinical series. Br J Neurosurg 2024; 38:674-681. [PMID: 34269154 DOI: 10.1080/02688697.2021.1950629] [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: 12/02/2020] [Revised: 03/12/2021] [Accepted: 06/28/2021] [Indexed: 01/12/2023]
Abstract
PURPOSE To analyse the efficacy and safety of the transsphenoidal microsurgical approach with open sella technique (OST) for the treatment of pituitary adenoma (PA) with suprasellar extension. METHODS We retrospectively reviewed 2305 consecutive patients with PA who underwent their first surgery through the transsphenoidal microsurgical approach at our department between 1990 and 2018. Focusing on tumours with suprasellar extension, in particular, grade B, C and D adenomas according to Wilson-Hardy's classification, 376 patients who received the OST surgery were identified. Outcomes and complications were evaluated and compared with those obtained in patients who underwent a standard transsphenoidal approach (TSM). RESULTS Two-hundred and sixty-four of 376 patients (70.2%) were found to be suffering from a non-functioning pituitary adenoma, whereas 112 of 376 patients (29.8%) from a hormone-secreting PA. The mean craniocaudal diameter of the tumor was 30.6 ± 0.3 mm (range, 21-75 mm) and 151 patients (40.1%) had a cavernous sinus invasion too. An overall surgical remission rate of 50.3% was achieved in the OST group, whereas the recurrence rate was 10.5%. Patients were followed for a mean period of 68 ± 1.4 months (range, 6-96 months). Less postoperative intrasellar haemorrhages have been recorded in the OST group than the TSM one (1.1% vs. 4.6%, p = 0.02). CONCLUSIONS In experienced hands, OST represents an effective and safe treatment strategy for PA with suprasellar extension.
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Affiliation(s)
- Pietro Mortini
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Luigi Albano
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
- Neuroimaging Research Unit, Institute of Experimental Neurology, Division of Neuroscience, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Lina Raffaella Barzaghi
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Alfio Spina
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Marco Losa
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
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Candy NG, Jukes AK, Patel S, King T, Bouras G, Vrodos N, Wormald PJ, Psaltis AJ. Neuronavigation in endoscopic skull base surgery and the accuracy of different MRI sequences. J Clin Neurosci 2024; 123:203-208. [PMID: 38608532 DOI: 10.1016/j.jocn.2024.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 03/11/2024] [Accepted: 04/04/2024] [Indexed: 04/14/2024]
Abstract
OBJECTIVE Neuronavigation is common technology used by skull base teams when performing endoscopic endonasal surgery. A common practice of MRI imagining is to obtain 3D isotopic gadolinium enhanced T1W magnetisation prepared rapid gradient echo (MPRAGE) sequences. These are prone to distortion when undertaken on 3 T magnets. The aim of this project is to compare the in vivo accuracy of MRI sequences between current and new high resolution 3D sequences. The goal is to determine if geometric distortion significantly affects neuronavigation accuracy. METHODS Patients were scanned with a 3D T1 MPRAGE sequence, 3D T1 SPACE sequence and a CT stereotactic localisation. Following general anaesthesia, patients were registered on the Stealth Station (Medtronic, USA) using a side mount emitter for Electromagnetic navigation. A variety of surgically relevant anatomical landmarks in the sagittal and coronal plane were selected with real and virtual data points measured. RESULTS A total of 10 patients agreed be enrolled in the study with datapoints collected during surgery. The distance between real and virtual datapoints trended to be lower in SPACE sequences compared to MPRAGE. Paired t test did not demonstrate a significant difference. CONCLUSION We have demonstrated that navigational accuracy is not significantly affected by the type of MRI sequence selected and that current corrective algorithms are sufficient. Navigational accuracy is affected by many factors, with registration error likely playing the most significant role. Further research involving real time imaging such as endoscopic ultrasound may hopefully address this potential error.
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Affiliation(s)
- Nicholas G Candy
- Department of Surgery - Otolaryngology, Head and Neck Surgery, The University of Adelaide, Basil Hetzel Institute for Translational Research, Woodville South, Adelaide, Australia; Department of Neurosurgery, Royal Adelaide Hospital, Adelaide, Australia; Department of Neurosurgery, Flinders Medical Centre, Adelaide, Australia.
| | - Alistair K Jukes
- Department of Neurosurgery, Royal Adelaide Hospital, Adelaide, Australia
| | - Sandy Patel
- Department of Radiology, Royal Adelaide Hospital, Adelaide, Australia; Jones Radiology, Calvary Adelaide Hospital, Australia
| | - Timothy King
- Jones Radiology, Calvary Adelaide Hospital, Australia
| | - George Bouras
- Department of Surgery - Otolaryngology, Head and Neck Surgery, The University of Adelaide, Basil Hetzel Institute for Translational Research, Woodville South, Adelaide, Australia
| | - Nick Vrodos
- Department of Neurosurgery, Flinders Medical Centre, Adelaide, Australia
| | - Peter-John Wormald
- Department of Surgery - Otolaryngology, Head and Neck Surgery, The University of Adelaide, Basil Hetzel Institute for Translational Research, Woodville South, Adelaide, Australia; Department of Otolaryngology, Queen Elizabeth Hospital, Adelaide, Australia
| | - Alkis J Psaltis
- Department of Surgery - Otolaryngology, Head and Neck Surgery, The University of Adelaide, Basil Hetzel Institute for Translational Research, Woodville South, Adelaide, Australia; Department of Otolaryngology, Queen Elizabeth Hospital, Adelaide, Australia
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Jimenez-Canizales CE, Rojas W, Alonso D, Romero I, Tabares S, Veronesi Zuluaga LA, Modica R, Colao A. Clinical presentation and recurrence of pituitary neuroendocrine tumors: results from a single referral center in Colombia. J Endocrinol Invest 2023; 46:2275-2286. [PMID: 37002436 DOI: 10.1007/s40618-023-02080-w] [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] [Received: 10/30/2022] [Accepted: 03/26/2023] [Indexed: 04/03/2023]
Abstract
INTRODUCTION Pituitary neuroendocrine tumors (PitNETs) represent 15-18.2% of all intracranial tumors. Their clinical presentation can range from chronic headache, visual defects, hypopituitarism to hormone excess syndromes. PitNETS are commonly classified as functioning neuroendocrine tumors (F-PitNETs) and non-functioning neuroendocrine tumors (NF-PitNETs). At the moment, new classification has emerged based on cell lineages. Almost 50% of all patients with PitNETs require surgical intervention, and about 25% of these have residual and persistent disease that may require additional management. SUBJECTS AND METHODS A retrospective cohort of medical records of patients with PitNETs, aiming to describe the incidence of recurrence of patients who received surgical treatment over a 12 month follow up period at San Jose Hospital (SJH) in Bogotá, Colombia, over an observation period of 10 years. Furthermore, clinical presentation, biochemical characteristics and immunohistochemistry, postoperative complications are detailed. RESULTS Eight hundred and eighty-seven patients with pituitary tumors were included in the cohort; 83% (737/887) had a diagnosis of PitNET. Of these, 18.9% (140) received surgical management. The majority 58% (98/140) had nonfunctional-PitNETs (NF-PitNETs), followed by growth-hormone-secreting pituitary adenoma (22.1%; 33/140), adrenocorticotropic- hormone-secreting pituitary adenoma (9.3%; 13/140), and prolactinomas (9.3%; 13/140). A recurrence was found in 45.71% (64/140), subclassified as biochemical in 15.71% (22/140), controlled with medications in 20% (28/140), and remission occurred in 18.57% (26/140). CONCLUSION Clinical presentation and incidence of recurrence in patients with PitNETs in a referral center in Colombia are similar to other surgical cohorts with low cure rates and high recurrence.
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Affiliation(s)
- C E Jimenez-Canizales
- Department of Endocrinology, Hospital de San José de Bogotá, University Foundation of Health Sciences, 111411, Bogotá, Colombia.
- Neuroendocrinology (MEDINE-FUCS) Research Group, Faculty of Health Sciences, University Foundation of Health Sciences, Bogotá, Colombia.
| | - W Rojas
- Department of Endocrinology, Hospital de San José de Bogotá, University Foundation of Health Sciences, 111411, Bogotá, Colombia
- Neuroendocrinology (MEDINE-FUCS) Research Group, Faculty of Health Sciences, University Foundation of Health Sciences, Bogotá, Colombia
| | - D Alonso
- Department of Endocrinology, Hospital de San José de Bogotá, University Foundation of Health Sciences, 111411, Bogotá, Colombia
- Neuroendocrinology (MEDINE-FUCS) Research Group, Faculty of Health Sciences, University Foundation of Health Sciences, Bogotá, Colombia
| | - I Romero
- Department of Endocrinology, Hospital de San José de Bogotá, University Foundation of Health Sciences, 111411, Bogotá, Colombia
- Neuroendocrinology (MEDINE-FUCS) Research Group, Faculty of Health Sciences, University Foundation of Health Sciences, Bogotá, Colombia
| | - S Tabares
- Department of Endocrinology, Hospital de San José de Bogotá, University Foundation of Health Sciences, 111411, Bogotá, Colombia
- Neuroendocrinology (MEDINE-FUCS) Research Group, Faculty of Health Sciences, University Foundation of Health Sciences, Bogotá, Colombia
| | - L A Veronesi Zuluaga
- Department of Endocrinology, Hospital de San José de Bogotá, University Foundation of Health Sciences, 111411, Bogotá, Colombia
- Neuroendocrinology (MEDINE-FUCS) Research Group, Faculty of Health Sciences, University Foundation of Health Sciences, Bogotá, Colombia
| | - R Modica
- Endocrinology, Diabetology and Andrology Unit, Department of Clinical Medicine and Surgery, Federico II University of Naples, Naples, Italy
| | - A Colao
- Endocrinology, Diabetology and Andrology Unit, Department of Clinical Medicine and Surgery, Federico II University of Naples, Naples, Italy
- UNESCO Chair, Education for Health and Sustainable Development, Federico II University, Naples, Italy
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Mosallami Aghili SM, Maroufi SF, Sabahi M, Esmaeilzadeh M, Dabecco R, Adada B, Borghei-Razavi H. Intraoperative Ultrasonography in Pituitary Surgery Revisited: An Institutional Experience and Systematic Review on Applications and Considerations. World Neurosurg 2023; 176:149-158. [PMID: 37164206 DOI: 10.1016/j.wneu.2023.04.126] [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: 03/23/2023] [Revised: 04/28/2023] [Accepted: 04/29/2023] [Indexed: 05/12/2023]
Abstract
OBJECTIVE The primary objective of this systematic review is to evaluate the effectiveness of intraoperative ultrasound (IOUS) in improving outcomes in patients undergoing pituitary surgery. METHODS A systematic review was performed by searching MEDLINE (PubMed), Web of Science, Scopus, and Embase electronic bibliographic databases from conception to 2022. RESULTS The included studies yielded a total of 660 patients, with 488 patients undergoing IOUS. Outcome were available for 341 patients treated with IOUS and 157 patients who were treated without the IOUS application, and the remission rates following surgery were 76% and 59%, respectively. Only 2 studies reported remission rates for both groups, and meta-analysis for these studies showed significant superiority of intraoperative ultrasonography (Random effect, odds ratio 4.99, P < 0.01). Regarding extent of resection, IOUS resulted in 71% gross total resection, while absence of IOUS yielded a gross total resection rate of 44%. Among studies with available follow-up on IOUS, the recurrence rate was 3%. Pituitary dysfunction (34%), cerebrospinal fluid leak (31%), and central nervous system infection (8%) were the most common complications in the IOUS group. The mean follow-up was 19.97 months in studies reporting follow-up time. CONCLUSIONS The application of the IOUS is both safe and effective and could improve the outcome of pituitary surgeries. IOUS can assist surgeons in the identification of pituitary tumors and their surrounding anatomy and can help minimize the risk of complications associated with this complex surgical procedure.
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Affiliation(s)
| | - Seyed Farzad Maroufi
- Neurosurgery Research Network (NRN), Universal Scientific Education and Research Network (USERN), Tehran, Iran; Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammadmahdi Sabahi
- Department of Neurological Surgery, Pauline Braathen Neurological Center, Cleveland Clinic Florida, Weston, Florida, USA
| | - Mahla Esmaeilzadeh
- Student Research Committee, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Rocco Dabecco
- Department of Neurological Surgery, Pauline Braathen Neurological Center, Cleveland Clinic Florida, Weston, Florida, USA
| | - Badih Adada
- Department of Neurological Surgery, Pauline Braathen Neurological Center, Cleveland Clinic Florida, Weston, Florida, USA
| | - Hamid Borghei-Razavi
- Department of Neurological Surgery, Pauline Braathen Neurological Center, Cleveland Clinic Florida, Weston, Florida, USA.
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Cheng MZ, Saraswathula A, Qureshi HA, Mukherjee D, Rowan NR. Otolaryngology Considerations of Pituitary Surgery: What an Endocrinologist Should Know. J Endocr Soc 2023; 7:bvad058. [PMID: 37313347 PMCID: PMC10259068 DOI: 10.1210/jendso/bvad058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Indexed: 06/15/2023] Open
Abstract
Endoscopic endonasal skull base surgery is the preferred surgical approach for the management of pituitary adenomas. Perioperative management of pituitary lesions requires multidisciplinary care and typically includes a dual surgeon team consisting of a neurosurgeon and an otolaryngologist. The involvement of the otolaryngologist allows for a safe surgical approach with excellent intraoperative visualization of the tumor to enable an effective resection of the tumor by the neurosurgeon. Detection and treatment of sinonasal pathology is essential prior to surgery. Patients may experience sinonasal complaints following endoscopic transsphenoidal surgery, although this is typically temporary. Sinonasal care in the postoperative period can expedite recovery to baseline. Here we discuss the perioperative factors of endoscopic pituitary surgery that endocrinologists should be aware of, ranging from preoperative patient selection and optimization to postoperative care, with a particular emphasis on anatomic and surgical factors.
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Affiliation(s)
- Michael Z Cheng
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medicine, Baltimore, MD 21287, USA
| | - Anirudh Saraswathula
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medicine, Baltimore, MD 21287, USA
| | - Hannan A Qureshi
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medicine, Baltimore, MD 21287, USA
| | - Debraj Mukherjee
- Department of Neurosurgery, Johns Hopkins Medicine, Baltimore, MD 21287, USA
| | - Nicholas R Rowan
- Correspondence: Nicholas R Rowan, MD, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medicine, 601 N Caroline St, 6th floor, Baltimore, MD 21287, USA.
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8
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Robbins AC, Winter KA, Smalley ZP, Godil S, Luzardo G, Washington CW, Prevedello DM, Stringer SP, Zachariah M. Side-Firing Intraoperative Ultrasonograhy for Resection of Giant Pituitary Adenomas. World Neurosurg 2023; 173:79-87. [PMID: 36796627 DOI: 10.1016/j.wneu.2023.02.049] [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: 12/04/2022] [Revised: 02/07/2023] [Accepted: 02/08/2023] [Indexed: 02/16/2023]
Abstract
BACKGROUND Suprasellar extension, cavernous sinus invasion, and involvement of intracranial vascular structures and cranial nerves are among the challenges faced by surgeons operating on giant pituitary macroadenomas. Intraoperative tissue shifts may render neuronavigation techniques inaccurate. Intraoperative magnetic resonance imaging can solve this problem, but it may be costly and time consuming. However, intraoperative ultrasonography (IOUS) allows for quick, real-time feedback and may be particularly useful when facing giant invasive adenomas. Here, we present the first study examining technique for IOUS-guided resection specifically focusing on giant pituitary adenomas. OBJECTIVE To describe the use of a side-firing ultrasound probe in the resection of giant pituitary macroadenomas. METHODS We describe an operative technique using a side-firing ultrasound probe (Fujifilm/Hitachi) to identify the diaphragma sellae, confirm optic chiasm decompression, identify vascular structures related to tumor invasion, and maximize extent of resection in giant pituitary macroadenomas. RESULTS Side-firing IOUS allows for identification of the diaphragma sellae to help prevent intraoperative cerebrospinal fluid leak and maximize extent of resection. Side-firing IOUS also aids in confirmation of decompression of the optic chiasm via identification of a patent chiasmatic cistern. Furthermore, direct identification of the cavernous and supraclinoid internal carotid arteries and arterial branches is achieved when resecting tumors with significant parasellar and suprasellar extension. CONCLUSIONS We describe an operative technique in which side-firing IOUS may assist in maximizing extent of resection and protecting vital structures during surgery for giant pituitary adenomas. Use of this technology may be particularly valuable in settings in which intraoperative magnetic resonance imaging is not available.
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Affiliation(s)
- Austin C Robbins
- Department of Neurosurgery, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - K Austin Winter
- Department of Neurosurgery, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Zachary P Smalley
- Department of Neurosurgery, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Saniya Godil
- Department of Neurosurgery, Wexner Medical Center, Ohio State University, Columbus, Ohio, USA
| | - Gustavo Luzardo
- Department of Neurosurgery, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Chad W Washington
- Department of Neurosurgery, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Daniel M Prevedello
- Department of Neurosurgery, Wexner Medical Center, Ohio State University, Columbus, Ohio, USA
| | - Scott P Stringer
- Department of Otolaryngology, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Marcus Zachariah
- Department of Neurosurgery, University of Mississippi Medical Center, Jackson, Mississippi, USA.
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9
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Paglia F, Caporlingua A, Armocida D, Rizzo F, Santoro A, D'angelo L. Preoperative 3D volume reconstruction of the posterior wall of the sphenoid sinus with Horos: A free, simple and reliable tool in endoscopic endonasal trans-sphenoidal surgery. NEUROCIRUGIA (ENGLISH EDITION) 2022; 33:219-226. [PMID: 36084958 DOI: 10.1016/j.neucie.2021.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 04/18/2021] [Indexed: 06/15/2023]
Abstract
BACKGROUND The purpose of the study was to create computer-aided design models of the sphenoid sinus with a free-source software in order to perform a preoperative planning during trans-sphenoidal endoscopic surgery (TES) and clarify the three-dimensional anatomical features of the sphenoid sinus and its surrounding structures. METHODS For each patient a 3D volume rendering of the sphenoid sinus was obtained from a thin slice head and maxilla-facial CT scan using a free-source DICOM viewer. The 3D models obtained preoperatively were examined preoperatively by six neurosurgeons in order to identify the boundaries of the sella. RESULTS For the main anatomical landmark, all of the observers were able to recognize the anatomical structure at a rate ranging from 80 to 98%, 28 to 60% and 25 to 58% for expert (n=3), inexpert (n=3) and the entire group of observers (n=6), respectively. The analysis of the data shows that both observation groups presented a lower recognition rate of the following parameters: right and left medial and lateral optocarotid recesses and tumor prominence, however, the sellar prominence, clival recess, planum sphenoidalis, right and left ICA prominence, right and left optic prominences represent the main anatomical landmarks to be recognized during TES immediately before the opening of the sellar floor. CONCLUSIONS The use of a preoperative 3D imaging is not in itself a novelty in the literature, however the fact that a simple tool obtained with a free-source software like Horos can represent a considerable help in surgical practice without resorting to the use of more complex software and expensive represents the real utility of this work.
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Affiliation(s)
- Francesco Paglia
- Human Neurosciences Department, Neurosurgery Division, "Sapienza" University, Italy
| | | | - Daniele Armocida
- Human Neurosciences Department, Neurosurgery Division, "Sapienza" University, Italy.
| | - Francesca Rizzo
- Human Neurosciences Department, Neurosurgery Division, "Sapienza" University, Italy
| | - Antonio Santoro
- Human Neurosciences Department, Neurosurgery Division, "Sapienza" University, Italy
| | - Luca D'angelo
- Human Neurosciences Department, Neurosurgery Division, "Sapienza" University, Italy
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10
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Cho SS, Salinas R, De Ravin E, Teng CW, Li C, Abdullah KG, Buch L, Hussain J, Ahmed F, Dorsey J, Mohan S, Brem S, Singhal S, Lee JYK. Near-Infrared Imaging with Second-Window Indocyanine Green in Newly Diagnosed High-Grade Gliomas Predicts Gadolinium Enhancement on Postoperative Magnetic Resonance Imaging. Mol Imaging Biol 2021; 22:1427-1437. [PMID: 31712948 DOI: 10.1007/s11307-019-01455-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Intraoperative molecular imaging with tumor-targeting fluorophores offers real-time detection of neoplastic tissue. The second window indocyanine green (SWIG) technique relies on passive accumulation of indocyanine green (ICG), a near-infrared fluorophore, in neoplastic tissues. In this study, we explore the ability of SWIG to detect neoplastic tissue and to predict postoperative magnetic resonance imaging (MRI) findings intraoperatively. PROCEDURES Retrospective data were collected from 36 patients with primary high-grade gliomas (HGG) enrolled as part of a larger trial between October 2014 and October 2018. Patients received systemic ICG infusions at 2.5-5 mg/kg 24 h preoperatively. Near-infrared fluorescence was recorded throughout the case and from biopsy specimens. The presence/location of residual SWIG signal after resection was compared to the presence/location of residual gadolinium enhancement on postoperative MRI. The extent of resection was not changed based on near-infrared imaging. RESULTS All 36 lesions demonstrated strong near-infrared fluorescence (signal-to-background = 6.8 ± 2.2) and 100 % of tumors reaching the cortex were visualized before durotomy. In 78 biopsy specimens, near-infrared imaging demonstrated higher sensitivity and accuracy than white light for diagnosing neoplastic tissue intraoperatively. Furthermore, near-infrared imaging predicted gadolinium enhancement on postoperative MRI with 91 % accuracy, with visualization of residual enhancement as small as 0.3 cm3. Patients with no residual near-infrared signal after resection were significantly more likely to have complete resection on postoperative MRI (p value < 0.0001). CONCLUSIONS Intraoperative imaging with SWIG demonstrates highly sensitive detection of HGG tissue in real time. Furthermore, post-resection near-infrared imaging correlates with postoperative MRI. Overall, our findings suggest that SWIG can provide surgeons with MRI-like results in real time, potentially increasing resection rates.
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Affiliation(s)
- Steve S Cho
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Ryan Salinas
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Emma De Ravin
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Clare W Teng
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Carrie Li
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Kalil G Abdullah
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Love Buch
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Jasmin Hussain
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Fahad Ahmed
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Jay Dorsey
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Suyash Mohan
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Steven Brem
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Sunil Singhal
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - John Y K Lee
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
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11
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Preoperative 3D volume reconstruction of the posterior wall of the sphenoid sinus with Horos: A free, simple and reliable tool in endoscopic endonasal trans-sphenoidal surgery. Neurocirugia (Astur) 2021. [DOI: 10.1016/j.neucir.2021.04.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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12
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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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13
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Deutschbein T, Jaursch-Hancke C, Knappe UJ, Saeger W, Flitsch J, Bojunga J, Buchfelder M, Ditzen B, Gerlach R, Gertzen E, Honegger J, Horstmann GA, Koch A, Kreitschmann-Andermahr I, Kunz M, Lagrèze WA, Nicolay NH, Paulus W, Reincke M, Schmidt MA, Weber MM, Wilhelm H, Fassnacht M. First German Guideline on Diagnostics and Therapy of Clinically Non-Functioning Pituitary Tumors. Exp Clin Endocrinol Diabetes 2021; 129:250-264. [PMID: 33690872 DOI: 10.1055/a-1373-4087] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Although non-functioning pituitary tumors are frequent, diagnostic and therapeutic concepts are not well standardized. We here present the first German multidisciplinary guideline on this topic. The single most important message is to manage the patients by a multidisciplinary team (consisting at least of an endocrinologist, a neurosurgeon, and a (neuro-) radiologist). The initial diagnostic work-up comprises a detailed characterization of both biochemical (focusing on hormonal excess or deficiency states) and morphological aspects (with magnetic resonance imaging of the sellar region). An ophthalmological examination is only needed in presence of symptoms or large tumors affecting the visual system. Asymptomatic, hormonally inactive tumors allow for a 'wait and scan' strategy. In contrast, surgical treatment by an experienced pituitary surgeon is standard of care in case of (impending) visual impairment. Therapeutic options for incompletely resected or recurrent tumors include re-operation, radiotherapy, and observation; the individual treatment plan should be developed multidisciplinary. Irrespective of the therapeutic approach applied, patients require long-term follow-up. Patient with larger pituitary tumors or former surgery/radiotherapy should be regularly counseled regarding potential symptoms of hormonal deficiency states.
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Affiliation(s)
- Timo Deutschbein
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital Würzburg, University of Würzburg, Würzburg, Germany.,Medicover Oldenburg MVZ, Oldenburg, Germany
| | | | - Ulrich J Knappe
- Department of Neurosurgery, Johannes Wesling Hospital, University Hospital of the Ruhr-University Bochum, Minden, Germany
| | - Wolfgang Saeger
- Institute for Neuropathology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Jörg Flitsch
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jörg Bojunga
- Department of Internal Medicine I, Division of Endocrinology, Goethe-University Hospital, Frankfurt, Germany
| | - Michael Buchfelder
- Department of Neurosurgery, University Hospital Erlangen, Friedrich-Alexander University of Erlangen-Nürnberg, Erlangen, Germany
| | - Beate Ditzen
- Institute of Medical Psychology, Center for Psychosocial Medicine, University Hospital Heidelberg, Ruprecht-Karls University Heidelberg, Heidelberg, Germany
| | - Rüdiger Gerlach
- Department of Neurosurgery, Helios Klinikum Erfurt, Erfurt, Germany
| | | | - Jürgen Honegger
- Department of Neurosurgery, University Hospital Tübingen, Eberhard-Karls-University Tübingen, Germany
| | | | - Arend Koch
- Department of Neuropathology, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Ilonka Kreitschmann-Andermahr
- Department of Neurosurgery and Spine Surgery, University Medicine Essen, University of Duisburg-Essen, Essen, Germany
| | - Mirjam Kunz
- Schwerpunktpraxis für Diabetologie und Endokrinologie, Ludwigshafen, Germany
| | - Wolf A Lagrèze
- Eye Center, Medical Center, Medical Faculty, University of Freiburg, Germany
| | - Nils H Nicolay
- Department of Radiation Oncology, University of Freiburg - Medical Center, Freiburg, Germany
| | - Werner Paulus
- Institute of Neuropathology, University Hospital Münster, Münster, Germany
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, München, Germany
| | - Manuel A Schmidt
- Department of Neuroradiology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Matthias M Weber
- Department of Endocrinology and Metabolism, I Medical Clinic, University Hospital, Johannes Gutenberg University of Mainz, Mainz, Germany
| | - Helmut Wilhelm
- Centre for Ophthalmology, University Hospital Tübingen, Eberhard-Karls-University Tübingen, Tübingen, Germany
| | - Martin Fassnacht
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital Würzburg, University of Würzburg, Würzburg, Germany
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14
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Chernov IV, Kutin MA, Kheyreddin AS, Konovalov AN, Shekhtman OD, Eliava SS, Kalinin PL. [Combination of pituitary adenomas and intracranial aneurysms]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2021; 85:94-103. [PMID: 33560625 DOI: 10.17116/neiro20218501194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The combination of intracranial tumors and asymptomatic brain aneurysms is an urgent problem, since it can significantly affect surgical intervention. Aneurysms are common in patients with meningioma, glioma and pituitary adenoma. According to certain authors, combination of aneurysms with pituitary adenomas is 7 times more common than with other tumors. In these cases, a comprehensive examination of the patient and decision-making on surgical strategy are required. This review is devoted to epidemiology, diagnosis and treatment of patients with a combination of pituitary adenomas and intracranial aneurysms detected intraoperatively or at the preoperative stage. The manuscript is illustrated by cases observed at the Burdenko Neurosurgery Center.
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Affiliation(s)
- I V Chernov
- Burdenko Neurosurgery Center, Moscow, Russia
| | - M A Kutin
- Burdenko Neurosurgery Center, Moscow, Russia
| | | | | | | | | | - P L Kalinin
- Burdenko Neurosurgery Center, Moscow, Russia
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15
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Micko A, Placzek F, Fonollà R, Winklehner M, Sentosa R, Krause A, Vila G, Höftberger R, Andreana M, Drexler W, Leitgeb RA, Unterhuber A, Wolfsberger S. Diagnosis of Pituitary Adenoma Biopsies by Ultrahigh Resolution Optical Coherence Tomography Using Neuronal Networks. Front Endocrinol (Lausanne) 2021; 12:730100. [PMID: 34733239 PMCID: PMC8560084 DOI: 10.3389/fendo.2021.730100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 09/29/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Despite advancements of intraoperative visualization, the difficulty to visually distinguish adenoma from adjacent pituitary gland due to textural similarities may lead to incomplete adenoma resection or impairment of pituitary function. The aim of this study was to investigate optical coherence tomography (OCT) imaging in combination with a convolutional neural network (CNN) for objectively identify pituitary adenoma tissue in an ex vivo setting. METHODS A prospective study was conducted to train and test a CNN algorithm to identify pituitary adenoma tissue in OCT images of adenoma and adjacent pituitary gland samples. From each sample, 500 slices of adjacent cross-sectional OCT images were used for CNN classification. RESULTS OCT data acquisition was feasible in 19/20 (95%) patients. The 16.000 OCT slices of 16/19 of cases were employed for creating a trained CNN algorithm (70% for training, 15% for validating the classifier). Thereafter, the classifier was tested on the paired samples of three patients (3.000 slices). The CNN correctly predicted adenoma in the 3 adenoma samples (98%, 100% and 84% respectively), and correctly predicted gland and transition zone in the 3 samples from the adjacent pituitary gland. CONCLUSION Trained convolutional neural network computing has the potential for fast and objective identification of pituitary adenoma tissue in OCT images with high sensitivity ex vivo. However, further investigation with larger number of samples is required.
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Affiliation(s)
- Alexander Micko
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Fabian Placzek
- Center for Medical Physics and Biomedical Engineering, Medical University Vienna, Vienna, Austria
| | - Roger Fonollà
- Department of Electrical Engineering, Video Coding and Architectures, Eindhoven University of Technology, Eindhoven, Netherlands
| | - Michael Winklehner
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Ryan Sentosa
- Center for Medical Physics and Biomedical Engineering, Medical University Vienna, Vienna, Austria
| | - Arno Krause
- Center for Medical Physics and Biomedical Engineering, Medical University Vienna, Vienna, Austria
| | - Greisa Vila
- Division of Endocrinology and Metabolism of the Department of Internal Medicine III, Vienna, Austria
| | - Romana Höftberger
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Marco Andreana
- Center for Medical Physics and Biomedical Engineering, Medical University Vienna, Vienna, Austria
| | - Wolfgang Drexler
- Center for Medical Physics and Biomedical Engineering, Medical University Vienna, Vienna, Austria
| | - Rainer A. Leitgeb
- Center for Medical Physics and Biomedical Engineering, Medical University Vienna, Vienna, Austria
- Christian Doppler Laboratory Innovative Optical Imaging and its Translation for “Innovative Optical Imaging and its Translation into Medicine” (OPTRAMED), Medical University of Vienna, Vienna, Austria
| | - Angelika Unterhuber
- Center for Medical Physics and Biomedical Engineering, Medical University Vienna, Vienna, Austria
| | - Stefan Wolfsberger
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
- *Correspondence: Stefan Wolfsberger,
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16
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Patil NR, Dhandapani S, Sahoo SK, Chhabra R, Singh A, Dutta P, Walia R, Verma R, Gupta R, Virk RS, Ahuja CK, Dhandapani M, Chaudhary H, Jangra K, Gupta SK. Differential independent impact of the intraoperative use of navigation and angled endoscopes on the surgical outcome of endonasal endoscopy for pituitary tumors: a prospective study. Neurosurg Rev 2020; 44:2291-2298. [PMID: 33089448 DOI: 10.1007/s10143-020-01416-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 08/26/2020] [Accepted: 10/07/2020] [Indexed: 02/07/2023]
Abstract
Despite widespread popularity of navigation and angled endoscopes in endonasal endoscopy, there are hardly few studies on their efficacy with the extent of resection or retreatment. This is probably the first study to assess the independent impact of these adjuncts among pituitary tumors. Patients with pituitary tumors undergoing endonasal endoscopy were prospectively studied for their demographics, clinico-radiological features, intraoperative use of navigation, and angled endoscopes, in relation to gross total resection (GTR), near total resection (NTR), endocrine remission, and retreatment. Pertinent statistical analyses were performed. Among a total of 139 patients, navigation and angled endoscopes could be used in 54 and 48 patients, respectively, depending upon their availability rather than chosen as per the case. There was no significant difference in baseline characteristics in relation to their use. The surgeon's perception of immediate benefit was noted among 51.9% while using navigation. The use of angled endoscopes towards the end of resection could help with additional tumor removal in 62.5% of patients. Overall, the use of navigation resulted in a significantly higher GTR (80.8% vs. 59.7%, OR 2.83, p = 0.01), a higher GTR/NTR (86.5% vs. 70.8%, OR 2.65, p = 0.04), and a lower retreatment rate (7.7% vs. 20.8%, OR 3.15, p = 0.05) than the others. In functioning tumors with cavernous sinus invasion, navigation had significantly increased remission rates (69.2% vs. 0%, p = 0.03). The use of angled endoscopes yielded a significantly higher GTR/NTR (91.7% vs. 70.6%, p = 0.04) and a lower retreatment rate (0% vs. 15.7%, p = 0.05) among only non-functioning adenomas. In multivariate analyses, the use of neuronavigation had a significant association with both GTR and retreatment rates (p values 0.005 and 0.02 respectively), independent of other confounding factors. The elective intraoperative use of navigation has a significant independent impact on the extent of resection and retreatment overall. While navigation results in better remission rates among functioning tumors with cavernous sinus invasion, angled endoscopy has a significant association with surgical outcomes in non-functioning tumors.
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Affiliation(s)
- Ninad R Patil
- Dept. of Neurosurgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Sivashanmugam Dhandapani
- Dept. of Neurosurgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.
| | - Sushant K Sahoo
- Dept. of Neurosurgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Rajesh Chhabra
- Dept. of Neurosurgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Apinderpreet Singh
- Dept. of Neurosurgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Pinaki Dutta
- Dept. of Endocrinology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Rama Walia
- Dept. of Endocrinology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Roshan Verma
- Dept. of ENT, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Rijuneeta Gupta
- Dept. of ENT, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ramandeep S Virk
- Dept. of ENT, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Chirag K Ahuja
- Dept. of Radiology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Manju Dhandapani
- NINE, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Himanshi Chaudhary
- Dept. of Pediatrics, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Kiran Jangra
- Dept. of Neuroanesthesia, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Sunil K Gupta
- Dept. of Neurosurgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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17
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van Furth WR, de Vries F, Lobatto DJ, Kleijwegt MC, Schutte PJ, Pereira AM, Biermasz NR, Verstegen MJT. Endoscopic Surgery for Pituitary Tumors. Endocrinol Metab Clin North Am 2020; 49:487-503. [PMID: 32741484 DOI: 10.1016/j.ecl.2020.05.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Endoscopic transsphenoidal surgery for pituitary adenoma is a safe and highly effective first-line treatment that is well tolerated by patients. Potential complications are plenty, and there is a large variation in complexity of surgery. This article presents the philosophy, surgical techniques, and outcomes of a high-volume pituitary adenoma center. Three surgical videos illustrate some procedures. The experience has reinforced the authors' belief that experience and surgical volume are key to high quality of care.
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Affiliation(s)
- Wouter R van Furth
- Department of Neurosurgery, Leiden University Medical Center J11-86, Center for Endocrine Tumors Leiden, PO-Box 9600, Leiden 2300 RC, the Netherlands.
| | - Friso de Vries
- Department of Endocrinology, Leiden University Medical Center, PO-Box 9600, Leiden 2300 RC, the Netherlands
| | - Daniel J Lobatto
- Department of Neurosurgery, Leiden University Medical Center J11-86, Center for Endocrine Tumors Leiden, PO-Box 9600, Leiden 2300 RC, the Netherlands
| | - Maarten C Kleijwegt
- Department of Ear Nose and Throat - Head and Neck Cancer, Leiden University Medical Center, PO-Box 9600, Leiden 2300 RC, the Netherlands
| | - Pieter J Schutte
- Department of Neurosurgery, Leiden University Medical Center J11-86, Center for Endocrine Tumors Leiden, PO-Box 9600, Leiden 2300 RC, the Netherlands
| | - Alberto M Pereira
- Department of Endocrinology, Leiden University Medical Center, PO-Box 9600, Leiden 2300 RC, the Netherlands
| | - Nienke R Biermasz
- Department of Endocrinology, Leiden University Medical Center, PO-Box 9600, Leiden 2300 RC, the Netherlands
| | - Marco J T Verstegen
- Department of Neurosurgery, Leiden University Medical Center J11-86, Center for Endocrine Tumors Leiden, PO-Box 9600, Leiden 2300 RC, the Netherlands
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AlMalki MH, Ahmad MM, Brema I, AlDahmani KM, Pervez N, Al-Dandan S, AlObaid A, Beshyah SA. Contemporary Management of Clinically Non-functioning Pituitary Adenomas: A Clinical Review. CLINICAL MEDICINE INSIGHTS-ENDOCRINOLOGY AND DIABETES 2020; 13:1179551420932921. [PMID: 32636692 PMCID: PMC7318824 DOI: 10.1177/1179551420932921] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 05/18/2020] [Indexed: 12/25/2022]
Abstract
Non-functioning pituitary adenomas (NFPAs) are benign pituitary tumours that constitute about one-third of all pituitary adenomas. They typically present with symptoms of mass effects resulting in hypopituitarism, visual symptoms, or headache. Most NFPAs are macroadenomas (>1 cm in diameter) at diagnosis that can occasionally grow quite large and invade the cavernous sinus causing acute nerve compression and some patients may develop acute haemorrhage due to pituitary apoplexy. The progression from benign to malignant pituitary tumours is not fully understood; however, genetic and epigenetic abnormalities may be involved. Non-functioning pituitary carcinoma is extremely rare accounting for only 0.1% to 0.5 % of all pituitary tumours and presents with cerebrospinal, meningeal, or distant metastasis along with the absence of features of hormonal hypersecretion. Pituitary surgery through trans-sphenoidal approach has been the treatment of choice for symptomatic NFPAs; however, total resection of large macroadenomas is not always possible. Recurrence of tumours is frequent and occurs in 51.5% during 10 years of follow-up and negatively affects the overall prognosis. Adjuvant radiotherapy can decrease and prevent tumour growth but at the cost of significant side effects. The presence of somatostatin receptor types 2 and 3 (SSTR3 and SSTR2) and D2-specific dopaminergic receptors (D2R) within NFPAs has opened a new perspective of medical treatment for such tumours. The effect of dopamine agonist from pooled results on patients with NFPAs has emerged as a very promising treatment modality as it has resulted in reduction of tumour size in 30% of patients and stabilization of the disease in about 58%. Despite the lack of long-term studies on the mortality, the available limited evidence indicates that patients with NFPA have higher standardized mortality ratios (SMR) than the general population, with women particularly having higher SMR than men. Older age at diagnosis and higher doses of glucocorticoid replacement therapy are the only known predictors for increased mortality.
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Affiliation(s)
- Mussa H AlMalki
- Obesity, Endocrine and Metabolism Centre, King Fahad Medical City, Riyadh, Saudi Arabia.,Faculty of Medicine, King Saud Bin Abdulaziz University of Health Sciences, Riyadh, Saudi Arabia
| | - Maswood M Ahmad
- Obesity, Endocrine and Metabolism Centre, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Imad Brema
- Obesity, Endocrine and Metabolism Centre, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Khaled M AlDahmani
- Department of Endocrinology, Tawam Hospital in Affiliation with Johns Hopkins Medicine, Al Ain, United Arab Emirates.,College of Medicine and Health Sciences (CMHS), UAE University, Al Ain, United Arab Emirates
| | - Nadeem Pervez
- Department of Radiation Oncology, Tawam Hospital in affiliation with Johns Hopkins Medicine, Al Ain, United Arab Emirates
| | - Sadeq Al-Dandan
- Department of Histopathology, Maternity and Children Hospital, Al-Hasa, Saudi Arabia
| | - Abdullah AlObaid
- Department of Neurosurgery, National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Salem A Beshyah
- Department of Medicine, Dubai Medical College, Dubai, United Arab Emirates.,Department of Endocrinology, Mediclinic Airport, Abu Dhabi, United Arab Emirates
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Evaluation of Diagnostic Accuracy Following the Coadministration of Delta-Aminolevulinic Acid and Second Window Indocyanine Green in Rodent and Human Glioblastomas. Mol Imaging Biol 2020; 22:1266-1279. [PMID: 32514886 DOI: 10.1007/s11307-020-01504-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
PURPOSE Fluorescence-guided-surgery offers intraoperative visualization of neoplastic tissue. Delta-aminolevulinic acid (5-ALA), which targets enzymatic abnormality in neoplastic cells, is the only approved agent for fluorescence-guided neurosurgery. More recently, we described Second Window Indocyanine Green (SWIG) which targets neoplastic tissue through enhanced vascular permeability. We hypothesized that SWIG would demonstrate similar clinical utility in identification of high-grade gliomas compared with 5-ALA. PROCEDURES Female C57/BL6 and nude/athymic mice underwent intracranial implantation of 300,000 GL261 and U87 cells, respectively. Tumor-bearing mice were euthanized after administration of 5-ALA (200 mg/kg intraperitoneal) and SWIG (5 mg/kg intravenous). Brain sections were imaged for protoporphyrin-IX and ICG fluorescence. Fluorescence and H&E images were registered using semi-automatic scripts for analysis. Human subjects with HGG were administered SWIG (2.5 mg/kg intravenous) and 5-ALA (20 mg/kg oral). Intraoperatively, tumors were imaged for ICG and protoporphyrin-IX fluorescence. RESULTS In non-necrotic tumors, 5-ALA and SWIG demonstrated 90.2 % and 89.2 % tumor accuracy (p value = 0.52) in U87 tumors and 88.1 % and 87.7 % accuracy (p value = 0.83) in GL261 tumors. The most distinct difference between 5-ALA and SWIG distribution was seen in areas of tumor-associated necrosis, which often showed weak/no protoporphyrin-IX fluorescence, but strong SWIG fluorescence. In twenty biopsy specimens from four subjects with HGG, SWIG demonstrated 100 % accuracy, while 5-ALA demonstrated 75-85 % accuracy; there was 90 % concordance between SWIG and 5-ALA fluorescence. CONCLUSION Our results provide the first direct comparison of the diagnostic utility of SWIG vs 5-ALA in both rodent and human HGG. Given the broader clinical utility of SWIG compared with 5-ALA, our data supports the use of SWIG in tumor surgery to improve the extent of safe resections. CLINICAL TRIAL NCT02710240 (US National Library of Medicine Registry; https://www.clinicaltrials.gov/ct2/show/NCT02710240?id=NCT02710240&draw=2&rank=1 ).
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Pituitary surgery's epidemiology using a national inpatient database in Japan. Acta Neurochir (Wien) 2020; 162:1317-1323. [PMID: 32125502 DOI: 10.1007/s00701-020-04270-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 02/17/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND Between 2010 and 2014, microscopic transsphenoidal surgery (mTSS) was performed more frequently than endoscopic TSS (eTSS) in the USA. However, few epidemiological studies on pituitary surgery are currently available. METHODS We performed a retrospective study on patients who had undergone pituitary surgery between July 2010 and March 2016. To this end, a nationwide inpatient database in Japan was used. Patients' characteristics, diagnoses, types of surgery, complications, and discharge status were examined. RESULTS A total of 16,253 inpatients who received pituitary surgery were identified. Patients were diagnosed with diseases for insurance claims described below: pituitary adenoma, hyperprolactinemia, other pituitary disorders (e.g., Rathke's cleft cyst), hyperpituitarism, craniopharyngioma, acromegaly, Cushing's disease, and pituitary cancer. Among them, pituitary adenomas, primarily the non-functioning ones, were the most frequent (66.9%). A total of 14,285 (88%) patients underwent TSS, while 1968 (12%) patients were treated using transcranial surgery. The number of patients undergoing TSS increased each year. The number of eTSS operations was 8140 (77%) and that of mTSS operations was 2419 (23%). Of note, eTSS increased each year. We found that high-volume hospitals more frequently selected eTSS. Compared with mTSS, eTSS was associated with a reduction of hyponatremia incidence (odds ratio, 0.69; p = 0.019). Additionally, it was not associated with other major complications. CONCLUSION The present study showed that both TSS and eTSS increased on a yearly basis. We believe that the present study will be the basis of future epidemiological investigations of pituitary surgery.
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Wang EW, Zanation AM, Gardner PA, Schwartz TH, Eloy JA, Adappa ND, Bettag M, Bleier BS, Cappabianca P, Carrau RL, Casiano RR, Cavallo LM, Ebert CS, El-Sayed IH, Evans JJ, Fernandez-Miranda JC, Folbe AJ, Froelich S, Gentili F, Harvey RJ, Hwang PH, Jane JA, Kelly DF, Kennedy D, Knosp E, Lal D, Lee JYK, Liu JK, Lund VJ, Palmer JN, Prevedello DM, Schlosser RJ, Sindwani R, Solares CA, Tabaee A, Teo C, Thirumala PD, Thorp BD, de Arnaldo Silva Vellutini E, Witterick I, Woodworth BA, Wormald PJ, Snyderman CH. ICAR: endoscopic skull-base surgery. Int Forum Allergy Rhinol 2020; 9:S145-S365. [PMID: 31329374 DOI: 10.1002/alr.22326] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 02/12/2019] [Accepted: 02/15/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Endoscopic skull-base surgery (ESBS) is employed in the management of diverse skull-base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull-base surgery have produced the International Consensus Statement on Endoscopic Skull-Base Surgery (ICAR:ESBS). METHODS Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence-based review or evidence-based review with recommendations format. Subsequently, each topic was written and then reviewed by skull-base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus. RESULTS The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull-base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated. CONCLUSION A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence-based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull-base community to embrace these opportunities and collaboratively address these shortcomings.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Adam J Folbe
- Michigan Sinus and Skull Base Institute, Royal Oak, MI
| | | | | | - Richard J Harvey
- University of Toronto, Toronto, Canada.,University of New South Wales, Sydney, Australia
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Charles Teo
- Prince of Wales Hospital, Randwick, Australia
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Cho SS, Zeh R, Pierce JT, Jeon J, Nasrallah M, Adappa ND, Palmer JN, Newman JG, White C, Kharlip J, Snyder P, Low P, Singhal S, Grady MS, Lee JYK. Folate Receptor Near-Infrared Optical Imaging Provides Sensitive and Specific Intraoperative Visualization of Nonfunctional Pituitary Adenomas. Oper Neurosurg (Hagerstown) 2020; 16:59-70. [PMID: 29635300 DOI: 10.1093/ons/opy034] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Accepted: 03/28/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Surgical resection is the primary treatment for nonfunctional (NF) pituitary adenomas, but gross-total resection is difficult to achieve in all cases. NF adenomas overexpress folate receptor alpha (FRα). OBJECTIVE To test the hypothesis that we could target FRα for highly sensitive and specific intraoperative detection of NF adenomas using near-infrared (NIR) imaging. METHODS Fourteen patients with NF pituitary adenoma were infused with the folate analog NIR dye OTL38 preoperatively. NIR fluorescence signal-to-background ratio (SBR) was recorded for each tumor during resection of the adenomas. Extent of surgery was not modified based on the presence or absence of fluorescence. Immunohistochemistry was performed to assess FRα expression in all specimens. Magnetic resonance imaging (MRI) was performed postoperatively to assess residual neoplasm. RESULTS Nine adenomas overexpressed FRα and fluoresced with a NIR SBR of 3.2 ± 0.52, whereas the 5 non-FRα-overexpressing adenomas fluoresced with an SBR of 1.5 ± 0.21. Linear regression demonstrated a significant correlation between intraoperative SBR and the FRα expression (P-value < .001). Analysis of 14 margin samples revealed that the surgeon's impression of the tissue had 83% sensitivity, 100% specificity, 100% positive predictive value, and 89% negative predictive value, while NIR fluorescence had 100% for all values. NIR fluorescence accurately predicted postoperative MRI results in 78% of FRα-overexpressing patients. CONCLUSION Preoperative injection of folate-tagged NIR dye provides strong signal and visualization of NF pituitary adenomas. It is 100% sensitive and specific for detecting margin neoplasm and can predict postoperative MRI findings. Our results suggest that NIR fluorescence may be superior to white-light visualization alone and may improve resection rates in NF pituitary adenomas.
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Affiliation(s)
- Steve S Cho
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ryan Zeh
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - John T Pierce
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jun Jeon
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - MacLean Nasrallah
- Department of Pathology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nithin D Adappa
- Department of Otorhinolaryngology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - James N Palmer
- Department of Otorhinolaryngology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jason G Newman
- Department of Otorhinolaryngology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Caitlin White
- Department of Endocrinology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Julia Kharlip
- Department of Endocrinology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Peter Snyder
- Department of Endocrinology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Philip Low
- Department of Biochemistry, Purdue University, West Lafayette, Indiana
| | - Sunil Singhal
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - M Sean Grady
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - John Y K Lee
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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Skulsampaopol J, Hansasuta A. Outcomes of the Endoscopic Transsphenoidal Surgery for Resection of Pituitary Adenomas Utilizing Extracapsular Dissection Technique with a Cotton Swab. Asian J Neurosurg 2020; 14:1089-1094. [PMID: 31903345 PMCID: PMC6896643 DOI: 10.4103/ajns.ajns_169_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Purpose The purpose of this study was to determine the effectiveness and safety of a cotton swab for extracapsular dissection in endoscopic transsphenoidal surgery (ETSS) for pituitary adenoma (PA). Materials and Methods A retrospective review of patients undergoing ETSS for PA from 2014 to 2017 was undertaken. Only patients with extracapsular dissection by cotton swab with the intent to completely remove the tumor were included. Assessment of the prospectively recorded clinical, laboratory, and radiographic presentation as well as the intra- and postoperative data was carried out. Factors influencing the extent of resection were analyzed. Results Of the 222 patients, one hundred cases met the inclusion criteria. The cohort consisted of 81 nonfunctioning and 19 functioning PAs. Fifty patients presented with visual disturbance and 34 patients had prior surgical treatment. The majority of PAs was macroadenoma (97%) with 73% modified Hardy Stage C and 38% Knosp Grade 4. Intraoperative cerebrospinal fluid (CSF) leakage was the most frequently noted complication (78%). Meningitis occurred in three cases and repeat ETSS for CSF leakage repair was necessary in three patients. No death or vascular injury was observed. At 12 months after ETSS, magnetic resonance imaging scan confirmed 43% complete tumor resection. Previous surgery and Knosp Grade 4 were the strong factors for incomplete PA removal by multivariate logistic regression analysis. For functioning PAs, thirteen patients (68.42%) achieved biochemical remission. Conclusion Cotton swab for extracapsular dissection proved its clinical effectiveness and safety. In spite of the technique, negative predictors for complete PA resection were parasellar extension and previous surgery.
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Affiliation(s)
- Janissardhar Skulsampaopol
- Division of Neurological Surgery, Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Ake Hansasuta
- Division of Neurological Surgery, Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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The Zurich Pituitary Score predicts utility of intraoperative high-field magnetic resonance imaging in transsphenoidal pituitary adenoma surgery. Acta Neurochir (Wien) 2019; 161:2107-2115. [PMID: 31392567 DOI: 10.1007/s00701-019-04018-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 07/18/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND It is currently unclear if there are subsets of patients undergoing transsphenoidal surgery (TSS) in which intraoperative high-field magnetic resonance imaging (3T-iMRI) is particularly advantageous. We aimed to investigate whether a radiological grading scale predicts the utility of 3T-iMRI in pituitary adenoma (PA) TSS. METHODS From a prospective registry, patients who underwent endoscopic TSS for PA using 3T-iMRI were identified. Adenomas were graded using the Zurich Pituitary Score (ZPS). We assessed improvement after 3T-iMRI in terms of gross total resection (GTR), residual volume (RV), and extent of resection (EOR). RESULTS Among 95 patients, rates of conversion to GTR after 3T-iMRI decreased steadily from 33% for grade I to 0% for grade IV adenomas, with a statistically significant conversion rate only for grade I (p = 0.008) and grade II (p < 0.001). All grade I adenomas were completely resected after 3T-iMRI. Median RV change was statistically significant for grades I to III, but not for grade IV (p = 0.625). EOR improvement ranged from a median change of 0.0% (IQR 0.0-4.5%) for grade I to 4.4% (IQR 0.0-9.0%) for grade IV, with a significant improvement only for grades I to III (p < 0.05). CONCLUSIONS Interestingly, this study shows that clinical utility of 3T-iMRI is highest in the more "simple" adenomas (ZPS grades I-II) than for the more "complex" ones (ZPS grade III-IV). Grade I adenomas are amenable to GTR if 3T-iMRI is implemented. In grade III adenomas, EOR and RV can be improved to clinically relevant levels. Conversely, in grade IV adenomas, 3T-iMRI may be of limited use.
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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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27
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Technological and Ideological Innovations in Endoscopic Skull Base Surgery. World Neurosurg 2019; 124:513-521. [PMID: 30708082 DOI: 10.1016/j.wneu.2019.01.120] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 01/25/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Endoscopic skull base surgery has evolved over the last several decades due to technological advances and operative techniques. Several innovations that are not yet mainstream may have significant impact on the future of endoscopic skull base surgery. METHODS Current literature pertaining to innovations in endoscopic skull base surgery was retrieved using PubMed, Embase, Web of Science, and Google Scholar. RESULTS Several recent innovations may play an influential role in the advancement of endoscopic skull base surgery, including fluorescent dyes such as indocyanine green fluorescence, fluorescein, and 5-aminolevulinic acid, 3-dimensional endoscopes, robotic surgery, and intraoperative magnetic resonance imaging. CONCLUSIONS Several technologies are under current investigation with the hope to improve future outcomes in endoscopic skull base surgery. Additional research and evolution are necessary and will require intense scrutiny before becoming standard of care.
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Cho SS, Salinas R, Lee JYK. Indocyanine-Green for Fluorescence-Guided Surgery of Brain Tumors: Evidence, Techniques, and Practical Experience. Front Surg 2019; 6:11. [PMID: 30915339 PMCID: PMC6422908 DOI: 10.3389/fsurg.2019.00011] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Accepted: 02/19/2019] [Indexed: 01/10/2023] Open
Abstract
The primary treatment for brain tumors often involves surgical resection for diagnosis, relief of mass effect, and prolonged survival. In neurosurgery, it is of utmost importance to achieve maximal safe resection while minimizing iatrogenic neurologic deficit. Thus, neurosurgeons often rely on extra tools in the operating room, such as neuronavigation, intraoperative magnetic resonance imaging, and/or intraoperative rapid pathology. However, these tools can be expensive, not readily available, time-consuming, and/or inaccurate. Recently, fluorescence-guided surgery has emerged as a cost-effective method to accurately visualize neoplastic areas in real-time to guide resection. Currently, 5-aminolevulinic-acid (5-ALA) remains the only fluorophore that has been approved specifically for fluorescence-guided tumor resection. Its use has demonstrated improved resection rates and prolonged progression-free survival. However, protoporphyrin-IX, the metabolic product of 5-ALA that accumulates in neoplastic cells, fluoresces in the visible-light range, which suffers from limited tissue penetration and significant auto-fluorescence. Near-infrared fluorescence, on the other hand, overcomes these problems with ease. Since 2012, researchers at our institution have developed a novel technique using indocyanine-green, which is a well-known near-infrared fluorophore used traditionally for angiography. This Second-Window-ICG (SWIG) technique takes advantage of the increased endothelial permeability in peritumoral tissue, which allows indocyanine-green to accumulate in these areas for intraoperative visualization of the tumor. SWIG has demonstrated utility in gliomas, meningiomas, metastases, pituitary adenomas, chordomas, and craniopharyngiomas. The main benefits of SWIG stem from its highly sensitive detection of neoplastic tissue in a wide variety of intracranial pathologies in real-time, which can help neurosurgeons both during surgical resections and in stereotactic biopsies. In this review of this novel technique, we summarize the development and mechanism of action of SWIG, provide evidence for its benefits, and discuss its limitations. Finally, for those interested in near-infrared fluorescence-guided surgery, we provide suggestions for maximizing the benefits while minimizing the limitations of SWIG based on our own experience thus far.
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Affiliation(s)
- Steve S Cho
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States.,Department of Neurosurgery at the Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Ryan Salinas
- Department of Neurosurgery at the Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - John Y K Lee
- Department of Neurosurgery at the Hospital of the University of Pennsylvania, Philadelphia, PA, United States
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Cho SS, Jeon J, Buch L, Nag S, Nasrallah M, Low PS, Grady MS, Singhal S, Lee JYK. Intraoperative near-infrared imaging with receptor-specific versus passive delivery of fluorescent agents in pituitary adenomas. J Neurosurg 2018; 131:1974-1984. [PMID: 30554181 PMCID: PMC10985533 DOI: 10.3171/2018.7.jns181642] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 07/31/2018] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Intraoperative molecular imaging with tumor-targeted fluorescent dyes can enhance resection rates. In contrast to visible-light fluorophores (e.g., 5-aminolevulinic-acid), near-infrared (NIR) fluorophores have increased photon tissue penetration and less contamination from tissue autofluorescence. The second-window ICG (SWIG) technique relies on passive accumulation of indocyanine green (ICG) in neoplastic tissues. OTL38, conversely, targets folate receptor overexpression in nonfunctioning pituitary adenomas. In this study, we compare the properties of these 2 modalities for NIR imaging of pituitary adenomas to better understand the potential for NIR imaging in neurosurgery. METHODS A total of 39 patients with pituitary adenomas were enrolled between June 2015 and January 2018 in 2, sequential, IRB-approved studies. Sixteen patients received systemic ICG infusions 24 hours prior to surgery, and another 23 patients received OTL38 infusions 2-3 hours prior to surgery. NIR fluorescence signal-to-background ratio (SBR) was recorded during and after resection. Immunohistochemistry was performed on the 23 adenomas resected from patients who received OTL38 to assess expression of folate receptor-alpha (FRα). RESULTS All 16 adenomas operated on after ICG administration demonstrated strong NIR fluorescence (mean SBR 4.1 ± 0.69 [SD]). There was no statistically significant difference between the 9 functioning and 7 nonfunctioning adenomas (p = 0.9). After administration of OTL38, the mean SBR was 1.7 ± 0.47 for functioning adenomas, 2.6 ± 0.91 for all nonfunctioning adenomas, and 3.2 ± 0.53 for the subset of FRα-overexpressing adenomas. Tissue identification with white light alone for all adenomas demonstrated 88% sensitivity and 90% specificity. SWIG demonstrated 100% sensitivity but only 29% specificity for both functioning and nonfunctioning adenomas. OTL38 was 75% sensitive and 100% specific for all nonfunctioning adenomas, but when assessment was limited to the 9 FRα-overexpressing adenomas, the sensitivity and specificity of OTL38 were both 100%. CONCLUSIONS Intraoperative imaging with NIR fluorophores demonstrates highly sensitive detection of pituitary adenomas. OTL38, a folate-receptor-targeted fluorophore, is highly specific for nonfunctioning adenomas but has no utility in functioning adenomas. SWIG, which relies on passive diffusion into neoplastic tissue, is applicable to both functioning and nonfunctioning pituitary adenomas, but it is less specific than targeted fluorophores. Thus, targeted and nontargeted NIR fluorophores play important, yet distinct, roles in intraoperative imaging. Selectively and intelligently using either agent has the potential to greatly improve resection rates and outcomes for patients with intracranial tumors.
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Affiliation(s)
- Steve S. Cho
- Department of Neurosurgery Hospital of the University of Pennsylvania
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jun Jeon
- Department of Neurosurgery Hospital of the University of Pennsylvania
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Love Buch
- Department of Neurosurgery Hospital of the University of Pennsylvania
| | - Shayoni Nag
- Department of Neurosurgery Hospital of the University of Pennsylvania
| | | | - Philip S. Low
- Department of Biochemistry, Purdue University, West Lafayette, Indiana
| | - M. Sean Grady
- Department of Neurosurgery Hospital of the University of Pennsylvania
| | - Sunil Singhal
- Department of Surgery Hospital of the University of Pennsylvania
| | - John Y. K. Lee
- Department of Neurosurgery Hospital of the University of Pennsylvania
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Kinoshita Y, Kurisu K, Arita K. Nonfunctioning pituitary adenomas in elderly patients. J Clin Neurosci 2018; 53:127-131. [PMID: 29739724 DOI: 10.1016/j.jocn.2018.04.054] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 04/22/2018] [Indexed: 10/17/2022]
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Conger A, Zhao F, Wang X, Eisenberg A, Griffiths C, Esposito F, Carrau RL, Barkhoudarian G, Kelly DF. Evolution of the graded repair of CSF leaks and skull base defects in endonasal endoscopic tumor surgery: trends in repair failure and meningitis rates in 509 patients. J Neurosurg 2018; 130:861-875. [PMID: 29749920 DOI: 10.3171/2017.11.jns172141] [Citation(s) in RCA: 85] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2017] [Accepted: 11/28/2017] [Indexed: 11/06/2022]
Abstract
Objective The authors previously described a graded approach to skull base repair following endonasal microscopic or endoscope-assisted tumor surgery. In this paper they review their experience with skull base reconstruction in the endoscopic era. Methods A retrospective review of a single-institution endonasal endoscopic patient database (April 2010–April 2017) was undertaken. Intraoperative CSF leaks were graded based on size (grade 0 [no leak], 1, 2, or 3), and repair technique was documented across grades. The series was divided into 2 epochs based on implementation of a strict perioperative antibiotic protocol and more liberal use of permanent and/or temporary buttresses; repair failure rates and postoperative meningitis rates were assessed for the 2 epochs and compared. Results In total, 551 operations were performed in 509 patients for parasellar pathology, including pituitary adenoma (66%), Rathke’s cleft cyst (7%), meningioma (6%), craniopharyngioma (4%), and other (17%). Extended approaches were used in 41% of cases. There were 9 postoperative CSF leaks (1.6%) and 6 cases of meningitis (1.1%). Postoperative leak rates for all 551 operations by grade 0, 1, 2, and 3 were 0%, 1.9%, 3.1%, and 4.8%, respectively. Fat grafts were used in 33%, 84%, 97%, and 100% of grade 0, 1, 2, and 3 leaks, respectively. Pedicled mucosal flaps (78 total) were used in 2.6% of grade 0–2 leaks (combined) and 79.5% of grade 3 leaks (60 nasoseptal and 6 middle turbinate flaps). Nasoseptal flap usage was highest for craniopharyngioma operations (80%) and lowest for pituitary adenoma operations (2%). Two (3%) nasoseptal flaps failed. Contributing factors for the 9 repair failures were BMI ≥ 30 (7/9), lack of buttress (4/9), grade 3 leak (4/9), and postoperative vomiting (4/9). Comparison of the epochs showed that grade 1–3 repair failures decreased from 6/143 (4.1%) to 3/141 (2.1%) and grade 1–3 meningitis rates decreased from 5 (3.5%) to 1 (0.7%) (p = 0.08). Prophylactic lumbar CSF drainage was used in only 4 cases (< 1%), was associated with a higher meningitis rate in grades 1–3 (25% vs 2%), and was discontinued in 2012. Comparison of the 2 epochs showed increase buttress use in the second, with use of a permanent buttress in grade 1 and 3 leaks increasing from 13% to 55% and 32% to 76%, respectively (p < 0.001), and use of autologous septal/keel bone as a permanent buttress in grade 1, 2, and 3 leaks increasing from 15% to 51% (p < 0.001). Conclusions A graded approach to skull base repair after endonasal surgery remains valid in the endoscopic era. However, the technique has evolved significantly, with further reduction of postoperative CSF leak rates. These data suggest that buttresses are beneficial for repair of most grade 1 and 2 leaks and all grade 3 leaks. Similarly, pedicled flaps appear advantageous for grade 3 leaks, while CSF diversion may be unnecessary and a risk factor for meningitis. High BMI should prompt an aggressive multilayered repair strategy. Achieving repair failure and meningitis rates lower than 1% is a reasonable goal in endoscopic skull base tumor surgery.
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Affiliation(s)
- Andrew Conger
- 1Department of Neurosurgery, Geisinger Health System, Danville, Pennsylvania
| | - Fan Zhao
- 2Department of Neurosurgery, Fudan University, Shanghai, China
| | - Xiaowen Wang
- 2Department of Neurosurgery, Fudan University, Shanghai, China
| | - Amalia Eisenberg
- 3Pacific Pituitary Disorders Center, John Wayne Cancer Institute, Providence Saint John's Health Center, Santa Monica, California
| | - Chester Griffiths
- 3Pacific Pituitary Disorders Center, John Wayne Cancer Institute, Providence Saint John's Health Center, Santa Monica, California
| | - Felice Esposito
- 4Department of Biomedical and Dental Sciences and Morpho-Functional Imaging, Division of NeuroSurgery, Università degli Studi di Messina, Messina, Italy; and
| | - Ricardo L Carrau
- 5Department of Otolaryngology-Head & Neck Surgery, The Ohio State University Medical Center, Columbus, Ohio
| | - Garni Barkhoudarian
- 3Pacific Pituitary Disorders Center, John Wayne Cancer Institute, Providence Saint John's Health Center, Santa Monica, California
| | - Daniel F Kelly
- 3Pacific Pituitary Disorders Center, John Wayne Cancer Institute, Providence Saint John's Health Center, Santa Monica, California
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Abstract
INTRODUCTION Non-functioning pituitary adenomas (NFPAs) are in general large tumors that present with symptoms secondary to local pressure on adjacent structures. Transsphenoidal surgery is the first line of treatment but residual tumor mass is often detected post-operatively. Medical therapy, in any stage of tumor management, is not well established. METHODS A literature search was performed to review the available data on medical treatment of NFPAs. RESULTS Medications investigated for the treatment of NFPAs include dopamine receptor agonists (DA) and somatostatin receptor ligands. Randomized controlled trials are lacking, but available data suggest that DA have a positive effect on tumor remnant stabilization after surgery and could be considered in this setting. Temozolomide is reserved for aggressive tumors, although future studies are required. CONCLUSIONS NFPA are often not amenable to complete surgical resection. Conservative follow-up after surgery is associated with a high prevalence of tumor remnant progression. DA therapy may prevent residual tumor enlargement in over 85% of these patients, with a substantial consequent reduction in the need for repeat surgery or radiation therapy. It is our view that DA treatment should be routinely considered for the management of NFPA patients with incompletely resected tumors.
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Affiliation(s)
- Naomi Even-Zohar
- Institute of Endocrinology, Metabolism and Hypertension, Tel Aviv-Sourasky Medical Center, Tel Aviv, Israel
| | - Yona Greenman
- Institute of Endocrinology, Metabolism and Hypertension, Tel Aviv-Sourasky Medical Center, Tel Aviv, Israel.
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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Khachatryan T, Khachatryan M, Fanarjyan R, Grigoryan M, Grigorian A. Enlargement of an incidental internal carotid artery aneurysm embedded in pituitary adenoma associated with medical shrinkage of the tumor: Case report. Surg Neurol Int 2018. [PMID: 29527388 PMCID: PMC5838828 DOI: 10.4103/sni.sni_317_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background Currently, transsphenoidal surgery (TSS) is the preferred method for surgical treatment of intrasellar pituitary adenomas. However, it carries some risk of intraoperative arterial injuries, which is mainly attributed to direct iatrogenic rupture of the internal carotid artery (ICA). There is anecdotal evidence suggesting that intracranial aneurysms are coincidentally found significantly more frequently in the setting of pituitary adenomas than when the incidence is compared to other intracranial neoplasms. The exact cause of this discrepancy remains unclear, but it certainly raises concerns about the potential existence of an ICA aneurysm, which might be encountered during TSS and in some cases may cause hemorrhagic complications. Case Description We present a case of a patient who was found to have a growth hormone (GH)-secreting pituitary adenoma and a coexisting cavernous ICA aneurysm which was embedded within the tumor. The patient underwent medical treatment of the adenoma. However, shrinkage of the tumor was associated with enlargement of the observed aneurysm, warranting endovascular intervention. Conclusions This case report is an illustration for physicians to be conscientious about the potential danger posed by the coexistence of an intratumoral aneurysm in the setting of a pituitary adenoma. Special attention should be given to recognition of an intrinsic flow void signal on the presurgical imaging of the tumor, and if observed, magnetic resonance angiography (MRA) should be performed for preoperative planning. If MRA is not performed routinely, detailed review of high-resolution magnetic resonance imaging is recommended to detect any flow artifacts suggestive of an aneurysm.
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Affiliation(s)
| | - Marina Khachatryan
- Department of Neurosurgery, Yerevan State Medical University, Yerevan, Armenia
| | - Ruben Fanarjyan
- Department of Neurosurgery, Yerevan State Medical University, Yerevan, Armenia
| | - Mikayel Grigoryan
- Glendale Adventist Comprehensive Stroke Center, Los Angeles, California, USA
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Barger J, Siow M, Kader M, Phillips K, Fatterpekar G, Kleinberg D, Zagzag D, Sen C, Golfinos JG, Lebowitz R, Placantonakis DG. The posterior nasoseptal flap: A novel technique for closure after endoscopic transsphenoidal resection of pituitary adenomas. Surg Neurol Int 2018. [PMID: 29527390 PMCID: PMC5838838 DOI: 10.4103/sni.sni_192_17] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background: While effective for the repair of large skull base defects, the Hadad-Bassagasteguy nasoseptal flap increases operative time and can result in a several-week period of postoperative crusting during re-mucosalization of the denuded nasal septum. Endoscopic transsphenoidal surgery for pituitary adenoma resection is generally not associated with large dural defects and high-flow cerebrospinal fluid (CSF) leaks requiring extensive reconstruction. Here, we present the posterior nasoseptal flap as a novel technique for closure of skull defects following endoscopic resection of pituitary adenomas. This flap is raised in all surgeries during the transnasal exposure using septal mucoperiosteum that would otherwise be discarded during the posterior septectomy performed in binostril approaches. Methods: We present a retrospective, consecutive case series of 43 patients undergoing endoscopic transsphenoidal resection of a pituitary adenoma followed by posterior nasoseptal flap placement and closure. Main outcome measures were extent of resection and postoperative CSF leak. Results: The mean extent of resection was 97.16 ± 1.03%. Radiographic measurement showed flap length to be adequate. While a defect in the diaphragma sellae and CSF leak were identified in 21 patients during surgery, postoperative CSF leak occurred in only one patient. Conclusions: The posterior nasoseptal flap provides adequate coverage of the surgical defect and is nearly always successful in preventing postoperative CSF leak following endoscopic transsphenoidal resection of pituitary adenomas. The flap is raised from mucoperiosteum lining the posterior nasal septum, which is otherwise resected during posterior septectomy. Because the anterior septal cartilage is not denuded, raising such flaps avoids the postoperative morbidity associated with the larger Hadad-Bassagasteguy nasoseptal flap.
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Affiliation(s)
- James Barger
- Department of Neurosurgery, New York University School of Medicine, New York, USA
| | - Matthew Siow
- Department of Neurosurgery, New York University School of Medicine, New York, USA
| | - Michael Kader
- Department of Neurosurgery, New York University School of Medicine, New York, USA
| | - Katherine Phillips
- Department of Neurosurgery, New York University School of Medicine, New York, USA
| | - Girish Fatterpekar
- Department of Radiology, New York University School of Medicine, New York, USA.,Department of Perlmutter Cancer Center, New York University School of Medicine, New York, USA.,Department of Brain Tumor Center, New York University School of Medicine, New York, USA
| | - David Kleinberg
- Department of Medicine, New York University School of Medicine, New York, USA
| | - David Zagzag
- Department of Neurosurgery, New York University School of Medicine, New York, USA.,Department of Pathology, New York University School of Medicine, New York, USA.,Department of Perlmutter Cancer Center, New York University School of Medicine, New York, USA.,Department of Brain Tumor Center, New York University School of Medicine, New York, USA
| | - Chandranath Sen
- Department of Neurosurgery, New York University School of Medicine, New York, USA.,Department of Perlmutter Cancer Center, New York University School of Medicine, New York, USA.,Department of Brain Tumor Center, New York University School of Medicine, New York, USA
| | - John G Golfinos
- Department of Neurosurgery, New York University School of Medicine, New York, USA.,Department of Perlmutter Cancer Center, New York University School of Medicine, New York, USA.,Department of Brain Tumor Center, New York University School of Medicine, New York, USA
| | - Richard Lebowitz
- Department of Otolaryngology-Head and Neck Surgery, New York University School of Medicine, New York, USA
| | - Dimitris G Placantonakis
- Department of Neurosurgery, New York University School of Medicine, New York, USA.,Department of Perlmutter Cancer Center, New York University School of Medicine, New York, USA.,Department of Brain Tumor Center, New York University School of Medicine, New York, USA
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Messerer M, Cossu G, George M, Daniel RT. Endoscopic Endonasal Trans-sphenoidal Approach: Minimally Invasive Surgery for Pituitary Adenomas. J Vis Exp 2018. [PMID: 29364265 DOI: 10.3791/55896] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
Endoscopic endonasal trans-sphenoidal surgery has become the gold standard for the surgical treatment of pituitary adenomas and many other pituitary lesions. Refinements in surgical techniques, technological advancements, and incorporation of neuronavigation have rendered this surgery minimally invasive. The complication rates of this surgery are very low while excellent results are consistently obtained through this approach. This paper focuses on the step-by-step surgical approach to pituitary adenomas, which is based on personal experience, and details the results obtained with this minimally invasive surgery.
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Affiliation(s)
| | - Giulia Cossu
- Department of Neurosurgery, University Hospital of Lausanne
| | - Mercy George
- Department of Otorhinolaryngology, University Hospital of Lausanne
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Aghi MK, Chen CC, Fleseriu M, Newman SA, Lucas JW, Kuo JS, Barkhoudarian G, Farrell CJ, Sheehan J, Ziu M, Dunn IF. Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on the Management of Patients With Nonfunctioning Pituitary Adenomas: Executive Summary. Neurosurgery 2017; 79:521-3. [PMID: 27635956 DOI: 10.1227/neu.0000000000001386] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Nonfunctioning pituitary adenomas (NFPAs) are the most frequent pituitary tumors. OBJECTIVE To create evidence-based guidelines for the initial management of NFPAs. METHODS A multidisciplinary task force composed of physician volunteers and evidence-based medicine-trained methodologists conducted a systematic review of the literature relevant to the management of NFPAs. To ascertain the class of evidence for the posttreatment follow-ups, the task force used the Clinical Assessment evidence-based classification. RESULTS Seven topics of importance were chosen for detailed evaluation. The topics addressed include preoperative evaluation, primary treatment, treatment options for residual tumors after surgery, and postoperative patient management. For preoperative patient evaluation, the guideline task force focused on preoperative imaging, preoperative laboratory evaluation, and preoperative ophthalmologic evaluation. For primary treatment, this guideline addresses surgical resection, medical therapy, radiation therapy, the natural history of untreated tumors, surgical methodologies, such as endoscopy, microscopy, or craniotomy, and intraoperative adjuncts like neuronavigation, cerebrospinal fluid diversion, or intraoperative imaging. For residual tumor treatment, the guideline task force evaluated radiation vs observation. Additional topics addressed in this guideline regarding postoperative patient management include the frequency of postoperative imaging, postoperative endocrine evaluation, and postoperative ophthalmologic evaluation. CONCLUSION Although there is clearly a need for more randomized trials generating higher levels of evidence to help guide physicians managing NFPAs, the existing evidence provided valuable data upon which the guidelines described in the 7 articles generated from this effort are based. The full guidelines document can be located at https://www.cns.org/guidelines/guidelines-management-patients-non-functioning-pituitary-adenomas. ABBREVIATION NFPA, nonfunctioning pituitary adenoma.
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Affiliation(s)
- Manish K Aghi
- *Department of Neurosurgery, University of California, San Francisco, San Francisco, California; ‡Center for Theoretical and Applied Neuro-Oncology, Division of Neurosurgery, University of California, San Diego, San Diego, California; §Departments of Medicine and Neurological Surgery, OHSU Northwest Pituitary Center, Oregon Health Science University, Portland, Oregon; ¶Department of Ophthalmology, University of Virginia, Charlottesville, Virginia; ‖Department of Neurosurgery, University of Southern California, Los Angeles, California; #Department of Neurological Surgery, University of Wisconsin, Madison, Wisconsin; **Brain Tumor Center & Pituitary Disorders Program, John Wayne Cancer Institute at Saint John's Health Center, Santa Monica, California; ‡‡Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania; §§Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia; ¶¶Department of Neurosurgery, Seton Brain & Spine Institute, Austin, Texas; ‖‖Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts
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37
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Inherent Tumor Characteristics That Limit Effective and Safe Resection of Giant Nonfunctioning Pituitary Adenomas. World Neurosurg 2017; 106:645-652. [DOI: 10.1016/j.wneu.2017.07.043] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 07/08/2017] [Accepted: 07/11/2017] [Indexed: 12/15/2022]
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38
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Zhang H, Wang F, Zhou T, Wang P, Chen X, Zhang J, Zhou D. Analysis of 137 Patients Who Underwent Endoscopic Transsphenoidal Pituitary Adenoma Resection Under High-Field Intraoperative Magnetic Resonance Imaging Navigation. World Neurosurg 2017; 104:802-815. [DOI: 10.1016/j.wneu.2017.04.056] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 04/07/2017] [Accepted: 04/09/2017] [Indexed: 12/17/2022]
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Marcus HJ, Vercauteren T, Ourselin S, Dorward NL. Intraoperative Ultrasound in Patients Undergoing Transsphenoidal Surgery for Pituitary Adenoma: Systematic Review [corrected]. World Neurosurg 2017; 106:680-685. [PMID: 28736351 DOI: 10.1016/j.wneu.2017.07.054] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Revised: 07/07/2017] [Accepted: 07/11/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Transsphenoidal surgery is the gold standard for pituitary adenoma resection. However, despite advances in microsurgical and endoscopic techniques, some pituitary adenomas can be challenging to cure. OBJECTIVE We sought to determine whether, in patients undergoing transsphenoidal surgery for pituitary adenoma, intraoperative ultrasound is a safe and effective technologic adjunct. METHODS The PubMed database was searched between January 1996 and January 2016 to identify relevant publications that 1) featured patients undergoing transsphenoidal surgery for pituitary adenoma, 2) used intraoperative ultrasound, and 3) reported on safety or effectiveness. Reference lists were also checked, and expert opinions were sought to identify further publications. RESULTS Ultimately, 10 studies were included, comprising 1 cohort study, 7 case series, and 2 case reports. One study reported their prototype probe malfunctioned, leading to false-positive results in 2 cases, and another study' prototype probe was too large to safely enter the sphenoid sinus in 2 cases. Otherwise, no safety issues directly related to use of intraoperative ultrasound were reported. In the only comparative study, remission occurred in 89.7% (61/68) of patients with Cushing disease in whom intraoperative ultrasound was used, compared with 83.8% (57/68) in whom it was not. All studies reported that surgeons anecdotally found intraoperative ultrasound helpful. CONCLUSIONS Although there is limited and low-quality evidence available, the use of intraoperative ultrasound appears to be a safe and effective technologic adjunct to transsphenoidal surgery for pituitary adenoma. Advances in ultrasound technology may allow for more widespread use of such devices.
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Affiliation(s)
- Hani J Marcus
- Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, London, UK; Translational Imaging Group, CMIC, Department of Medical Physics and Biomedical Engineering, University College London, London, UK.
| | - Tom Vercauteren
- Translational Imaging Group, CMIC, Department of Medical Physics and Biomedical Engineering, University College London, London, UK
| | - Sebastien Ourselin
- Translational Imaging Group, CMIC, Department of Medical Physics and Biomedical Engineering, University College London, London, UK
| | - Neil L Dorward
- Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, London, UK
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Iglesias P, Arcano K, Triviño V, García-Sancho P, Díez JJ, Cordido F, Villabona C. Non-functioning pituitary adenoma underwent surgery: A multicenter retrospective study over the last four decades (1977-2015). Eur J Intern Med 2017; 41:62-67. [PMID: 28389053 DOI: 10.1016/j.ejim.2017.03.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 03/29/2017] [Accepted: 03/30/2017] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To assess clinical features, diagnostic procedures, therapies and outcomes in patients with clinically non-functioning pituitary adenomas (NFPAs) surgically treated over the last four decades. DESIGN AND METHODS A multicenter retrospective study in NFPA patients periodically followed up in specialized neuroendocrinology units who underwent surgery in the period 1977-2015 was performed. RESULTS A total of 131 patients were studied [66 women (50.4%); mean age 52.6±14.8years (range, 15-82)]. Median diameter of the adenoma was 2.6cm (interquartile range, 2.0-3.1). The most frequently type of surgery used was endoscopic endonasal surgery (58.5%) followed by microscopic transsphenoidal surgery (37.4%). Radiation therapy was used in 19 patients (14.5%). Ki-67 labeling index performed in 54 patients was ≤2% in 70% samples. After a median follow-up time of 57months (25 to 128months), tumor diameter significantly decreased to 0.9cm (0-1.8cm), p<0.001. Multivariant analysis showed that endoscopic endonasal surgery (HR 2.74, 1.06-6.87, p=0.036) and radiotherapy (HR 0.04, 0.02-0.65, p=0.024) behaved as positive and negative predictors, respectively, of tumor absence in the follow-up. Endoscopic endonasal surgery (HR 6.71, 1.45-31.05, p=0.015) was the only positive predictor for complete cure in the follow-up. CONCLUSION NFPAs surgically treated in Spain are usually macroadenomas diagnosed around the sixth decade of life with no sex predilection. Type of surgery is associated with clinical outcome. Endoscopic endonasal surgery behaves as a positive predictor for the absence of tumor imaging and complete cure in the follow up.
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Affiliation(s)
- Pedro Iglesias
- Department of Endocrinology, Hospital Universitario Ramón y Cajal, Madrid, Spain.
| | - Karina Arcano
- Department of Endocrinology, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Vanessa Triviño
- Department of Endocrinology, Complejo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - Paula García-Sancho
- Department of Endocrinology, Hospital Universitario de Bellvitge, Barcelona, Spain
| | - Juan José Díez
- Department of Endocrinology, Hospital Universitario Ramón y Cajal, Madrid, Spain; Departament of Medicine, Universidad de Alcalá de Henares, Madrid, Spain
| | - Fernando Cordido
- Department of Endocrinology, Complejo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - Carles Villabona
- Department of Endocrinology, Hospital Universitario de Bellvitge, Barcelona, Spain
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Nishioka H. Recent Evolution of Endoscopic Endonasal Surgery for Treatment of Pituitary Adenomas. Neurol Med Chir (Tokyo) 2017; 57:151-158. [PMID: 28239067 PMCID: PMC5409268 DOI: 10.2176/nmc.ra.2016-0276] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
For the treatment of pituitary tumors, microscopic transsphenoidal surgery has been considered the "gold standard" since the late 1960s. Over the last two decades, however, a worldwide shift towards endoscopic endonasal surgery is in progress for many reasons. These include a wide panoramic view, improved illumination, an ability to look around anatomical corners using angled tip and, in addition, application to the extended approaches for parasellar tumors. Both endoscopic and microscopic approaches appear equally effective for nonfunctioning adenomas without significant suprasellar or lateral extensions, whereas the endoscopic approach may improve outcomes associated with the extent of resection and postoperative complications for larger tumors. Despite many theoretical benefits in the endoscopic surgery, remission rates of functioning adenomas do not substantially differ between the approaches in experienced hands. The endoscopic approach is a valid alternative to the microscopic approach for adenomas. The benefits will be more appreciated in the extended surgery for parasellar tumors.
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Affiliation(s)
- Hiroshi Nishioka
- Department of Hypothalamic and Pituitary Surgery, Toranomon Hospital.,Okinaka Memorial Institute for Medical Research
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