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Lefevre E, Chasseloup F, Hage M, Chanson P, Buchfelder M, Kamenický P. Clinical and therapeutic implications of cavernous sinus invasion in pituitary adenomas. Endocrine 2024; 85:1058-1065. [PMID: 38761347 DOI: 10.1007/s12020-024-03877-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 05/12/2024] [Indexed: 05/20/2024]
Abstract
Invasion of the cavernous sinus by pituitary adenomas impedes complete surgical resection, compromises biochemical remission, and increases the risk of further tumor recurrence. Accurate preoperative MRI-based diagnosis or intraoperative direct inspection of cavernous sinus invasion are essential for optimal surgical planning and for tailoring postoperative therapeutic strategies, depending on whether a total resection has been achieved, or tumoral tissue has been left in surgically inaccessible locations. The molecular mechanisms underlying the invasive behavior of pituitary adenomas remain poorly understood, hindering the development of targeted therapies. Some studies have identified genes overexpressed in pituitary adenomas invading the cavernous sinus, offering insights into the acquisition of invasive behavior. Their main limitation however lies in comparing purely intrasellar specimens obtained from invasive and non-invasive adenomas. Further, precise anatomical knowledge of the medial wall of the cavernous sinus is crucial for grasping the mechanisms of invasion. Recently, alongside the standard intrasellar surgery, extended endoscopic intracavernous surgical procedures with systematic selective resection of the medial wall of the cavernous sinus have shown promising results for invasive secreting pituitary adenomas. The first- and second-generation somatostatin agonist ligands and cabergoline are used with variable efficacy to control secretory activity and/or growth of intracavernous remnants. Tumor regrowth usually requires surgical reintervention, sometimes combined with radiotherapy or radiosurgery which is applied despite their benign nature. Unraveling the molecular pathways driving invasive behavior of pituitary adenomas and their tropism to the cavernous sinuses is the key for developing efficient innovative treatment modalities that could reduce the need for repeated surgery or radiotherapy.
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Affiliation(s)
- Etienne Lefevre
- INSERM U1185, Physiologie et Physiopathologie Endocriniennes, Université Paris-Saclay, 94276, Le Kremlin-Bicêtre, France.
- Service de Neurochirurgie, AP-HP, Hôpital Pitié-Salpêtrière, 75013, Paris, France.
| | - Fanny Chasseloup
- INSERM U1185, Physiologie et Physiopathologie Endocriniennes, Université Paris-Saclay, 94276, Le Kremlin-Bicêtre, France
- Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des maladies Rares de l'Hypophyse, AP-HP, Hôpital Bicêtre, 94276, Le Kremlin-Bicêtre, France
| | - Mirella Hage
- INSERM U1185, Physiologie et Physiopathologie Endocriniennes, Université Paris-Saclay, 94276, Le Kremlin-Bicêtre, France
| | - Philippe Chanson
- INSERM U1185, Physiologie et Physiopathologie Endocriniennes, Université Paris-Saclay, 94276, Le Kremlin-Bicêtre, France
- Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des maladies Rares de l'Hypophyse, AP-HP, Hôpital Bicêtre, 94276, Le Kremlin-Bicêtre, France
| | - Michael Buchfelder
- Department of Neurosurgery, University Hospital Erlangen, 91054, Erlangen, Germany
| | - Peter Kamenický
- INSERM U1185, Physiologie et Physiopathologie Endocriniennes, Université Paris-Saclay, 94276, Le Kremlin-Bicêtre, France
- Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des maladies Rares de l'Hypophyse, AP-HP, Hôpital Bicêtre, 94276, Le Kremlin-Bicêtre, France
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Ryba A, Gonzalez Lopez D, Rotermund R, Flitsch J. Preoperative treatment with dopamine agonist therapy influences surgical outcome in prolactinoma: a retrospective single-center on 159 patients. Acta Neurochir (Wien) 2024; 166:316. [PMID: 39085706 PMCID: PMC11291524 DOI: 10.1007/s00701-024-06198-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 07/16/2024] [Indexed: 08/02/2024]
Abstract
INTRODUCTION Prolactinoma account to the most common pituitary adenomas and current therapy regime constitutes of dopamine agonist therapy (DA) and surgery in selected cases [17]. Due to tumor fibrosis induced by previous DA therapy, surgical removal can be challenging though. Therefore, this study investigates how preoperative DA usage influences perioperative treatment and surgical outcome in prolactinoma and aims to ascertain whether a specific subgroup of prolactinoma patients could derive greater benefit from exclusive surgical intervention. METHODS We retrospectively analyzed n = 159 surgically treated and histologically confirmed prolactinomas in the sella region from 2013-2022 in our institution. Clinical, radiological and surgical features were analyzed. Univariate and multivariate analyses were performed. RESULTS Out of total of 159 prolactinoma patients, 83.6% received previous treatment with DA followed by surgery, while only 16.4% received exclusive surgery. Both groups presented similar initial tumor volumes (1.9cm3 vs. 1.5cm3, p = 0.59) and equal preoperative prolactin levels (PRL) (199.7 µg/l vs. 191.0 µg/l, p = 0.44). Surgical procedures took significantly longer when patients received prior DA treatment (79 min. vs. 70 min., p = 0.0479). Six months after surgery, pretreated patients revealed significantly higher PRL compared to non-treated (107 g/l vs. 8.64 µg/, p = 0.0009). Additionally, untreated microprolactinoma presented a remission of 100%, whereas pretreated exhibited a remission rate of 88.75%. CONCLUSION The current study demonstrates that prior DA treatment is associated with significantly longer surgeries, higher recurrence rates and lower rates of normalization of PRL levels after surgery, particularly in microprolactinomas and support the latest recommendations of the Pituitary Society's Consensus Statement 2023, which favors the option of surgery alone as first-line therapy for microprolactinomas.
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Affiliation(s)
- Alice Ryba
- Department of Neurosurgery, Medical Center Hamburg-Eppendorf, Martinistraße 52, 20253, Hamburg, Germany.
| | - Diego Gonzalez Lopez
- Department of Neurosurgery, Medical Center Hamburg-Eppendorf, Martinistraße 52, 20253, Hamburg, Germany
| | - Roman Rotermund
- Department of Neurosurgery, Diako Krankenhaus, Flensburg, Germany
| | - Jörg Flitsch
- Department of Neurosurgery, Medical Center Hamburg-Eppendorf, Martinistraße 52, 20253, Hamburg, Germany
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Shah H, Slavin A, Botvinov J, O'Malley GR, Sarwar S, Patel NV. Endoscopic Endonasal Transsphenoidal Surgery for the Resection of Pituitary Adenomas: A Prime Candidate for a Shortened Length of Stay Enhanced Recovery after Surgery Protocol? A Systematic Review. World Neurosurg 2024; 186:145-154. [PMID: 38552787 DOI: 10.1016/j.wneu.2024.03.135] [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: 03/17/2024] [Revised: 03/22/2024] [Accepted: 03/23/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) is a perioperative model of care aimed at optimizing postoperative rehabilitation and reducing hospital length of stay (LOS). Decreasing LOS avoids hospital-acquired complications, reduces cost of care, and improves patient satisfaction. Given the lack of ERAS protocols for endoscopic endonasal transsphenoidal surgery (EETS) resection of pituitary adenomas, a systematic review of EETS was performed to compile patient outcomes and analyze factors that may lead to increased LOS, reoperation, and readmission rates with the intention to contribute to the development of a successful ERAS protocol for EETS. METHODS The authors performed a Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines-based systematic review of the literature. Information was extracted regarding patient LOS, surgery complications, and readmission/reoperation rates. Pearson's correlations to LOS and reoperation/readmission rates were performed with variables normalized to the number of participants. Statistical significance was set at P value <0.05. RESULTS Fourteen studies were included, consisting of 2083 patients. The most common complications were cerebrospinal fluid leaks (37%) and postoperative diabetes insipidus (DI) (9%). Transient DI was significantly correlated with shorter LOS. Functional pituitary adenomas were significantly correlated with lower readmission rates while nonfunctional pituitary adenomas were correlated with higher readmission rates. No other factor was found to be significantly correlated with a change in LOS or reoperation rate. CONCLUSIONS EETS may be an ideal candidate for the development of ERAS cranial protocols. While our data largely supports the safe implementation of shortened LOS protocols in EETS, our findings highlight the importance of transient DI and nonfunctional pituitary adenomas management when formulating ERAS protocols.
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Affiliation(s)
- Harshal Shah
- Department of Neurosurgery, Hackensack Meridian School of Medicine, Nutley, New Jersey, USA.
| | - Avi Slavin
- Department of Neurosurgery, Hackensack Meridian School of Medicine, Nutley, New Jersey, USA
| | - Julia Botvinov
- Department of Neurosurgery, Hackensack Meridian School of Medicine, Nutley, New Jersey, USA
| | - Geoffrey R O'Malley
- Department of Neurosurgery, Hackensack Meridian School of Medicine, Nutley, New Jersey, USA
| | - Syed Sarwar
- Department of Neurosurgery, HMH-Jersey Shore University Medical Center, Neptune, New Jersey, USA
| | - Nitesh V Patel
- Department of Neurosurgery, Hackensack Meridian School of Medicine, Nutley, New Jersey, USA; Department of Neurosurgery, HMH-Jersey Shore University Medical Center, Neptune, New Jersey, USA
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Eguiluz-Melendez A, Sangrador-Deitos MV, Calderón-Yrigoyen PJ, Rodríguez-Hernández AL, Guinto-Nishimura YG, Alcazar-Felix JR, Caballero-Delgado S, Portocarrero-Ortiz AL, Valencia-Ramos C, Gómez-Amador LJ. Clinical and Surgical Outcomes of Endoscopic Endonasal Approach for Giant Pituitary Adenomas: Analysis of Predictive Factors. World Neurosurg 2024; 184:e659-e673. [PMID: 38342172 DOI: 10.1016/j.wneu.2024.02.009] [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: 12/27/2023] [Revised: 02/01/2024] [Accepted: 02/02/2024] [Indexed: 02/13/2024]
Abstract
BACKGROUND Giant pituitary adenomas (GPAs) are defined as tumors with ≥40 mm in any maximum diameter, and these tend to invade multiple intracranial compartments. Hence, treatment remains a surgical challenge. OBJECTIVE To describe the clinical and surgical outcomes of the endoscopic endonasal approach (EEA) for GPA in a pituitary referral center in Latin America and to analyze associated predictive factors. METHODS 37 patients with histologically-confirmed GPA treated solely through the EEA between a 2-year period were included. Preoperative and postoperative clinical and neuroimaging findings; surgical morbidity and mortality; and binary logistic regression analysis to assess predictive factors were analyzed. RESULTS Preoperative visual impairment prevalence was 97.3%. Mean tumor volume was 32 cc and gross total resection rate was 40.5%. Favorable visual acuity and visual fields outcome rate was 75% and 82.9%, respectively. In the multivariate analysis, bilateral cavernous sinus invasion (P = 0.018) and postoperative cerebrospinal fluid (CSF) leak (P = 0.036) were associated with an unfavorable visual acuity outcome, while radiation therapy (P = 0.035) was for visual fields. Similarly, intraoperative CSF leak was a predictive factor for postoperative CSF leak (10.8%) (P = 0.042) and vascular injury (13.5%) (P = 0.048). CONCLUSIONS In this first Mexican clinical series, we demonstrated that the EEA is a safe and effective technique for GPA, although early diagnosis and prompt intervention may promote further visual function preservation without significant endocrine morbidity.
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Affiliation(s)
- Aldo Eguiluz-Melendez
- Department of Neurological Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico; Department of Neurological Surgery, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico
| | | | - P Juan Calderón-Yrigoyen
- Department of Neurological Surgery, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico
| | - A Luis Rodríguez-Hernández
- Department of Neurological Surgery, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico
| | - Y Gerardo Guinto-Nishimura
- Department of Neurological Surgery, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico
| | | | - Silvia Caballero-Delgado
- Department of Neurological Surgery, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico
| | - A Lesly Portocarrero-Ortiz
- Department of Neuroendocrinology, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico
| | - Cristopher Valencia-Ramos
- Department of Neurological Surgery, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico
| | - L Juan Gómez-Amador
- Department of Neurological Surgery, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico
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Yagnik KJ, Erickson D, Bancos I, Choby G, Laack N, Van Gompel JJ. Stereotactic Radiosurgery Outcomes in Medically and Surgically Failed or Nonsurgical Candidates with Medically Failed Prolactinomas: A Systematic Review and Meta-Analysis. J Neurol Surg B Skull Base 2023; 84:538-547. [PMID: 37854534 PMCID: PMC10581828 DOI: 10.1055/a-1934-9028] [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: 04/20/2022] [Accepted: 08/29/2022] [Indexed: 10/14/2022] Open
Abstract
Objective Prolactinomas are treated with dopamine agonists (DAs) as first-line therapy and transsphenoidal surgery as an alternative approach for medically failed tumors. We sought to summarize the efficacy of stereotactic radiosurgery (SRS) in the medically and surgically failed prolactinomas as well as in nonsurgical candidates with medically failed prolactinomas by systematic review and meta-analysis. Method A literature search was conducted according to the Preferred Reporting Items for Systematic Review and Meta-Analyses guideline. Results A total of 11 articles (total N = 709) met inclusion criteria. Thirty-three percent of patients were able to achieve endocrine remission at a mean follow-up of 54.2 ± 42.2 months with no association between stopping DA and endocrine remission. Sixty-two percent of patients were able to achieve endocrine control with DA therapy and 34% of patients were able to decrease the dose of DA dose when compared with pre-SRS DA dose at the end of the follow-up period. However, 54% of patients required DA at the end of the follow-up to control hyperprolactinemia. Ninety percent of patients were able to achieve radiologic control at the end of the follow-up in comparison to pre-SRS imagings. Furthermore, 26% of patients newly developed hypopituitarism (one or more pituitary hormones) post-SRS throughout the follow-up period. Conclusion This systematic review and meta-analysis demonstrates SRS as an effective adjunct therapy in medically failed nonsurgical candidates or surgically and medically recalcitrant prolactinomas with a 33% chance of achieving endocrine remission, 62% of patients achieved hormonal control with DA and GKRS (gamma knife radio-surgery), with a 34% chance of decreasing DA dose and 90% chance of achieving radiologic control.
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Affiliation(s)
- Karan J. Yagnik
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Dana Erickson
- Department of Endocrinology, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, United States
| | - Irina Bancos
- Department of Endocrinology, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, United States
| | - Garret Choby
- Department of Otorhinolaryngology, Mayo Clinic, Rochester, Minnesota, United States
| | - Nadia Laack
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, United States
| | - Jamie J. Van Gompel
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, United States
- Department of Otorhinolaryngology, Mayo Clinic, Rochester, Minnesota, United States
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McKevitt C, Gabriel E, Marenco-Hillembrand L, Otamendi-Lopez A, Jeevaratnam S, Almeida JP, Samson S, Chaichana KL. Supervised machine learning to validate a novel scoring system for the prediction of disease remission of functional pituitary adenomas following transsphenoidal surgery. Sci Rep 2023; 13:15409. [PMID: 37717023 PMCID: PMC10505180 DOI: 10.1038/s41598-023-42157-3] [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: 06/05/2023] [Accepted: 09/06/2023] [Indexed: 09/18/2023] Open
Abstract
Functional pituitary adenomas (FPAs) are associated with hormonal hypersecretion resulting in systemic endocrinopathies and increased mortality. The heterogenous composition of the FPA population has made modeling predictive factors of postoperative disease remission a challenge. Here, we aim to define a novel scoring system predictive of disease remission following transsphenoidal surgery (TSS) for FPAs and validate our process using supervised machine learning (SML). 392 patients with FPAs treated at one of the three Mayo Clinic campuses were retrospectively reviewed. Variables found significant on multivariate analysis were incorporated into our novel Pit-SCHEME score. The Pit-SCHEME score with a cut-off value ≥ 6 achieved a sensitivity of 86% and positive likelihood ratio of 2.88. In SML models, without the Pit-SCHEME score, the k-nearest neighbor (KNN) model achieved the highest accuracy at 75.6%. An increase in model sensitivity was achieved with inclusion of the Pit-SCHEME score with the linear discriminant analysis (LDA) model achieving an accuracy of 86.9%, which suggests the Pit-SCHEME score is the variable of most importance for prediction of postoperative disease remission. Ultimately, these results support the potential clinical utility of the Pit-SCHEME score and its prospective future for aiding in the perioperative decision making in patients with FPAs.
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Affiliation(s)
- Chase McKevitt
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA.
| | - Ellie Gabriel
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Lina Marenco-Hillembrand
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Andrea Otamendi-Lopez
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Suren Jeevaratnam
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Joao Paulo Almeida
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Susan Samson
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Kaisorn L Chaichana
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
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Zhang AS, Jonker BP, Morris CL, Campbell RG, Alvarado R, Winder M, Sacks R, Seresirikachorn K, Harvey RJ. Endoscopic Endonasal Biopsy for Diagnosis of Undifferentiated Lesions of the Cavernous Sinus. World Neurosurg 2023; 175:e391-e396. [PMID: 37004883 DOI: 10.1016/j.wneu.2023.03.103] [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: 01/25/2023] [Revised: 03/23/2023] [Accepted: 03/24/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND Radiologically undifferentiated lesions of the cavernous sinus can pose a diagnostic challenge. Although radiotherapy is the mainstay for treatment of cavernous sinus lesions, histologic diagnosis allows access to a wide variety of alternative treatment modalities. The region is considered a high-risk area for open transcranial surgical access, and the endoscopic endonasal approach presents an alternative technique for biopsy. METHODS A retrospective case series was performed of all patients undergoing endoscopic endonasal biopsy of isolated cavernous sinus lesions at 2 tertiary institutions. The primary outcomes were the percentage of patients in whom a histologic diagnosis was achieved and the proportion of patients in whom therapy differed from radiotherapy alone. Secondary outcomes included preoperative and postoperative 22-item Sino-Nasal Outcome Test symptom scores, as well as perioperative adverse outcomes. RESULTS Eleven patients underwent endoscopic endonasal biopsy, with a diagnosis achieved in 10 patients. The most common diagnosis was perineural spread of squamous cell carcinoma, followed by perineuroma and single cases of metastatic melanoma, metastatic adenoid cystic carcinoma, mycobacterium lepri infection, neurofibroma, and lymphoma. Six patients had treatments other than radiotherapy, including immunotherapy, antibiotics, corticosteroids, chemotherapy, and observation alone. There was no significant difference in prebiopsy and postbiopsy 22-item Sino-Nasal Outcome Test scores. There was 1 case of epistaxis requiring return to theater for cautery of the sphenopalatine artery and there were no mortalities. CONCLUSIONS In a limited case series, endoscopic endonasal biopsy was safe and effective in obtaining diagnosis for cavernous sinus lesions and had a significant impact on therapeutic decision making.
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Affiliation(s)
- Alexander S Zhang
- Rhinology and Skull Base Research Group, Applied Medical Research Centre, University of New South Wales, Sydney, Australia; Department of Otolaryngology, Head and Neck Surgery, St Vincent's Hospital, Sydney, Australia.
| | - Benjamin P Jonker
- Department of Neurosurgery, St Vincent's Hospital, Sydney, Australia; Department of Neurosurgery, Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, Australia; Brain and Mind Centre, University of Sydney, Camperdown, Sydney, New South Wales, Australia
| | - Cara L Morris
- Rhinology and Skull Base Research Group, Applied Medical Research Centre, University of New South Wales, Sydney, Australia; Department of Otolaryngology, Head and Neck Surgery, St Vincent's Hospital, Sydney, Australia
| | - Raewyn G Campbell
- Rhinology and Skull Base Research Group, Applied Medical Research Centre, University of New South Wales, Sydney, Australia; Department of Otolaryngology, Head and Neck Surgery, Royal Prince Alfred Hospital, Sydney, Australia; Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| | - Raquel Alvarado
- Rhinology and Skull Base Research Group, Applied Medical Research Centre, University of New South Wales, Sydney, Australia; School of Clinical Medicine, St Vincent's Healthcare Clinical Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
| | - Mark Winder
- Department of Neurosurgery, St Vincent's Hospital, Sydney, Australia
| | - Raymond Sacks
- Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia; Department of Otolaryngology, Head and Neck Surgery, Concord Repatriation General Hospital, Sydney, Australia; Faculty of Medicine, University of Sydney, Sydney, Australia
| | - Kachorn Seresirikachorn
- Rhinology and Skull Base Research Group, Applied Medical Research Centre, University of New South Wales, Sydney, Australia; Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia; Department of Otolaryngology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Endoscopic Nasal and Sinus Surgery Excellence Center, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Richard J Harvey
- Rhinology and Skull Base Research Group, Applied Medical Research Centre, University of New South Wales, Sydney, Australia; Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia; School of Clinical Medicine, St Vincent's Healthcare Clinical Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
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Ottenhausen M, Conrad J, Wolters LM, Ringel F. Surgery as first-line treatment for prolactinoma? Discussion of the literature and results of a consecutive series of surgically treated patients. Neurosurg Rev 2023; 46:128. [PMID: 37249700 PMCID: PMC10229663 DOI: 10.1007/s10143-023-02033-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 04/21/2023] [Accepted: 05/14/2023] [Indexed: 05/31/2023]
Abstract
Initial treatment for prolactinoma is usually conservative with dopamine agonists. However, the duration of treatment is often lifelong and can be associated with significant side effects. Surgical outcomes are usually favorable and treatment complications low, raising the question whether surgical therapy should be included earlier in the treatment of prolactinoma. The aim of this study was to analyze the outcome of surgical resection of prolactinomas at our institution, to compare it with other published surgical and conservative series and to discuss the role of surgery in modern prolactinoma therapy. The authors reviewed a database of single-center consecutively operated prolactinoma cases and analyzed the extent of resection (EOR), endocrinological and neurological outcomes, and complications. Thirty patients were analyzed. Mean patient age was 37.2 ± 15.5 years (range 16-76) and consisted of 17 (56.7%) females and 13 (43.3%) males. Twenty-one patients (70%) failed medical therapy, the main reasons being intolerable side effects in 11 cases (52.4%) and insufficient response in 10 cases (47.6%). Nine patients (30%) received no medical treatment prior to surgery, of which five (55.6%) were operated because of pituitary apoplexy, two (22.2%) because of acute visual deterioration and two (22.2%) refused medical treatment and opted for surgery as first-line treatment. Of the 30 operated tumors, 56.7% (n = 17) were microadenomas, 30% (n = 9) were macroadenomas (≥ 10 mm), and 13.3% (n = 4) were giant adenomas (≥ 40 mm). GTR was achieved in 75% (n = 21) of cases. The overall remission rate was 63.3%. MRI showed a residual tumor in seven patients (25%), typically with invasive growth. Postoperative CSF leaks did not occur. Mean follow-up was 34.9 ± 60.3 months (range 0-246 months). Endocrine remission was defined as a morning fasting basal PRL level of 22.3 < ng/mL and measured at the last available follow-up. Postoperative Prolactine levels were missing in three patients. Our analysis describes a highly selected sample with a disproportionate number of larger, invasive tumors and emergency cases. Nevertheless, the results are satisfactory and comparable with other published series. The consistently good results of transphenoidal surgery, especially for microprolactinomas, have led to a greater acceptance of surgery in the treatment of prolactinomas in recent years. The timing of surgery in each individual case must be determined by a multidisciplinary team to ensure the best possible outcome.
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Affiliation(s)
- Malte Ottenhausen
- Department of Neurosurgery, University Medical Center Mainz, Langenbeckstr. 1, 55131, Mainz, Germany.
| | - Jens Conrad
- Department of Neurosurgery, University Medical Center Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Lea-Marie Wolters
- Department of Neurosurgery, University Medical Center Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Florian Ringel
- Department of Neurosurgery, University Medical Center Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
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DiRisio AC, Feng R, Shuman WH, Platt S, Price G, Dullea JT, Gilja S, D'Andrea MR, Delman BN, Bederson JB, Shrivastava RK. The Knosp Criteria Revisited: 3-Dimensional Volumetric Analysis as a Predictive Tool for Extent of Resection in Complex Endoscopic Pituitary Surgery. Neurosurgery 2023; 92:179-185. [PMID: 36170168 DOI: 10.1227/neu.0000000000002170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 07/29/2022] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND The Knosp criteria have been the historical standard for predicting cavernous sinus invasion, and therefore extent of surgical resection, of pituitary macroadenomas. Few studies have sought to reappraise the utility of this tool after recent advances in visualization and modeling of tumors in complex endoscopic surgery. OBJECTIVE To evaluate our proposed alternative method, using 3-dimensional (3D) volumetric imaging, and whether it can better predict extent of resection in nonfunctional pituitary adenomas. METHODS Patients who underwent endoscopic transsphenoidal resection of pituitary macroadenomas at our institution were reviewed. Information was collected on neurological, endocrine, and visual function. Volumetric segmentation was performed using 3D Slicer software. Relationship of tumor volume, clinical features, and Knosp grade on extent of resection was examined. RESULTS One hundred forty patients were identified who had transsphenoidal resection of nonfunctional pituitary adenomas. Macroadenomas had a median volume of 6 cm 3 (IQR 3.4-8.7), and 17% had a unilateral Knosp grade of at least 3B. On multiple logistic regression, only smaller log-transformed preoperative tumor volume was independently associated with increased odds of gross total resection (GTR; odds ratio: 0.27, 95% CI: 0.07-0.89, P < .05) when controlling for tumor proliferative status, age, and sex (area under the curve 0.67). The Knosp criteria did not independently predict GTR in this cohort ( P > .05, area under the curve 0.46). CONCLUSION Increasing use of volumetric 3D imaging may better anticipate extent of resection compared with the Knosp grade metric and may have a greater positive predictive value for GTR. More research is needed to validate these findings and implement them using automated methods.
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Affiliation(s)
- Aislyn C DiRisio
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Department of Neurosurgery, University of California - Los Angeles, Los Angeles, California, USA
| | - Rui Feng
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - William H Shuman
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Samantha Platt
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Department of Radiology, New York University, New York, New York, USA
| | - Gabrielle Price
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jonathan T Dullea
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Shivee Gilja
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Megan R D'Andrea
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Bradley N Delman
- Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Joshua B Bederson
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Raj K Shrivastava
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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10
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Cai X, Zhu J, Yang J, Tang C, Cong Z, Ma C. Are dopamine agonists still the first-choice treatment for prolactinoma in the era of endoscopy? A systematic review and meta-analysis. Chin Neurosurg J 2022; 8:9. [PMID: 35395837 PMCID: PMC8994364 DOI: 10.1186/s41016-022-00277-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 03/21/2022] [Indexed: 11/16/2022] Open
Abstract
Background For prolactinoma patients, dopamine agonists (DAs) are indicated as the first-line treatment and surgery is an adjunctive choice. However, with the development of surgical technique and equipment, the effect of surgery has improved. The aim of this study was to assess the efficacy and safety of surgery versus DAs in patients with different types of prolactinomas. Methods A systematic search of literature using Web of Science, PubMed, Cochrane Library, and Clinical Trial databases was conducted until July 12, 2019. Prolactinoma patients treated with DAs (bromocriptine or cabergoline) or surgery (microscopic or endoscopic surgery) were included. Outcomes included the biochemical cure rate, recurrence rate, prolactin level, improvement rates of symptoms, and incidence rates of complications. A random-effects model was used to pool the extracted data. Qualitative comparisons were conducted instead of quantitative comparison. Results DAs were better than surgery in terms of the biochemical cure rate (0.78 versus 0.66), but surgery had a much lower recurrence rate (0.19 versus 0.57). Full advantages were not demonstrated in improvement rates of symptoms and incidence rates of complications with both treatment options. In microprolactinoma patients, the biochemical cure rate of endoscopic surgery was equal to the average cure rate of DAs (0.86 versus 0.86) and it surpassed the biochemical cure rate of bromocriptine (0.86 versus 0.76). In macroprolactinoma patients, endoscopic surgery was slightly higher than bromocriptine (0.66 versus 0.64) in terms of the biochemical cure rate. Conclusion For patients with clear indications or contraindications for surgery, choosing surgery or DAs accordingly is unequivocal. However, for patients with clinical equipoise, such as surgery, especially endoscopic surgery, in microprolactinoma and macroprolactinoma patients, we suggest that neurosurgeons and endocrinologists conduct high-quality clinical trials to address the clinical equipoise quantitatively. Supplementary Information The online version contains supplementary material available at 10.1186/s41016-022-00277-1.
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Affiliation(s)
- Xiangming Cai
- School of Medicine, Southeast University, Nanjing, China
| | - Junhao Zhu
- School of Medicine, Nanjing Medical University, Nanjing, China
| | - Jin Yang
- School of Medicine, Nanjing Medical University, Nanjing, China
| | - Chao Tang
- Department of Neurosurgery, Jinling Hospital, Nanjing, China
| | - Zixiang Cong
- Department of Neurosurgery, Jinling Hospital, Nanjing, China
| | - Chiyuan Ma
- School of Medicine, Southeast University, Nanjing, China. .,School of Medicine, Nanjing Medical University, Nanjing, China. .,Department of Neurosurgery, Jinling Hospital, Nanjing, China. .,School of Medicine, Nanjing University, Nanjing, China.
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11
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Rutland JW, Dullea JT, Oermann EK, Feng R, Villavisanis DF, Gilja S, Shuman W, Lander T, Govindaraj S, Iloreta AMC, Chelnis J, Post K, Bederson JB, Shrivastava RK. Post-operative vision loss: analysis of 587 patients undergoing endoscopic surgery for pituitary macroadenoma. Br J Neurosurg 2022; 36:494-500. [PMID: 35264032 DOI: 10.1080/02688697.2022.2047888] [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: 11/02/2022]
Abstract
PURPOSE Vision loss following surgery for pituitary adenoma is poorly described in the literature and cannot be reliably predicted with current prognostic models. Detailed characterization of this population is warranted to further understand the factors that predispose a minority of patients to post-operative vision loss. MATERIALS AND METHODS The medical records of 587 patients who underwent endoscopic transsphenoidal surgery at the Mount Sinai Medical Centre between January 2013 and August 2018 were reviewed. Patients who experienced post-operative vision deterioration, defined by reduced visual acuity, worsened VFDs, or new onset of blurry vision, were identified and analysed. RESULTS Eleven out of 587 patients who received endoscopic surgery for pituitary adenoma exhibited post-operative vision deterioration. All eleven patients presented with preoperative visual impairment (average duration of 13.1 months) and pre-operative optic chiasm compression. Seven patients experienced visual deterioration within 24 h of surgery. The remaining four patients experienced delayed vision loss within one month of surgery. Six patients had complete blindness in at least one eye, one patient had complete bilateral blindness. Four patients had reduced visual acuity compared with preoperative testing, and four patients reported new-onset blurriness that was not present before surgery. High rates of graft placement (10/11 patients) and opening of the diaphragma sellae (9/11 patients) were found in this series. Four patients had hematomas and four patients had another significant post-operative complication. CONCLUSIONS While most patients with pituitary adenoma experience favourable ophthalmological outcomes following endoscopic transsphenoidal surgery, a subset of patients exhibit post-operative vision deterioration. The present study reports surgical and disease features of this population to further our understanding of factors that may underlie vision loss following pituitary adenoma surgery. Graft placement and opening of the diaphragma sellae may be important risk factors in vision loss following ETS and should be an area of future investigation.
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Affiliation(s)
- John W Rutland
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jonathan T Dullea
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Eric K Oermann
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rui Feng
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Dillan F Villavisanis
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Shivee Gilja
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - William Shuman
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Travis Lander
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Satish Govindaraj
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Alfred M C Iloreta
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - James Chelnis
- Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kalmon Post
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Joshua B Bederson
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Raj K Shrivastava
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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12
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Thommen R, Kazim SF, Cole KL, Olson GT, Shama L, Lovato CM, Gonzales KM, Dicpinigaitis AJ, Couldwell WT, Mckee RN, Cole CD, Schmidt MH, Bowers CA. Worse Pituitary Adenoma Surgical Outcomes Predicted by Increasing Frailty, Not Age. World Neurosurg 2022; 161:e347-e354. [DOI: 10.1016/j.wneu.2022.02.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 01/31/2022] [Accepted: 02/01/2022] [Indexed: 11/30/2022]
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13
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Gong X, Zhuo Y, Yuan H, Yang K, Li C, Feng S, Zhang M, Li Z, Zhou H, Liu Z. Outcome of Endoscopic Transsphenoidal Surgery for Recurrent or Residual Pituitary Adenomas and Comparison to Non-Recurrent or Residual Cohort by Propensity Score Analysis. Front Endocrinol (Lausanne) 2022; 13:837025. [PMID: 35547003 PMCID: PMC9081813 DOI: 10.3389/fendo.2022.837025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 03/21/2022] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To evaluate the long-term outcomes and safety of endoscopic transsphenoidal surgery (ETS) in recurrent and residual pituitary adenomas (rrPAs), as well as the predictors of gross total resection (GTR) and intraoperative CSF leakage. Furthermore, to compare outcomes and complications with non-rrPAs cohort. METHODS Clinical and radiological characteristics of patients with rrPAs who underwent ETS were collected between 2017 and 2020. Data of patients with non-rrPAs were collected from 2019 to 2020. Logistic regression analyses were performed to investigate the factors influencing gross total resection (GTR) and intraoperative CSF leakage. Between-group comparisons of outcomes and complications were performed through propensity score analysis. RESULTS We enrolled 73 patients with rrPAs. GTR was achieved in 41 (56.1%) cases; further, GTR or near-total resection was achieved in 93.2% of patients. The mean tumor volumes for GTR and non-GTR cases were 6.2 ±7.2 cm3 and 11.1 ±9.1 cm3, respectively. Multivariate regression analysis of the GTR rate in patients with rrPAs revealed that Knosp grade was an independent factor (odds ratio [OR] = 0.324; p=0.005). Moreover, previous transcranial surgery and non-functional pituitary adenomas were risk factors for intraoperative CSF leakage in patients with rrPAs (OR=6.450, p=0.019 and OR=7.472, p=0.012, respectively). After propensity score matching, There was no significant difference in the GTR rate between patients with rrPAs and patients with non-rrPAs. Contrastingly, patients with rrPAs had a higher rate of intraoperative CSF leakage and longer postoperative hospital stay than patients with non-rrPAs. During the follow-up, vision improved in 9 (22.0%) and 24 (62.5%) patients with rrPAs and non-rrPAs, respectively. Although there was a trend that reoperation of rrPAs involved a lower hypopituitarism recovery rate and biochemical remission rate, as well as a higher hypopituitarism rate, there was no statistically significant between-group difference. CONCLUSIONS Knosp grade was an independent factor for GTR in endoscopic transsphenoidal surgery in patients with rrPAs. Previous transcranial surgery and non-functional PAs were risk factors for intraoperative CSF leakage. Although associated with longer hospital stay, rrPAs did not associate with lower GTR rate or more frequent postoperative complications than non-rrPAs cohort.
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Affiliation(s)
- Xuan Gong
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
| | - Yang Zhuo
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
| | - Huichun Yuan
- Department of Neurosurgery, The First People’s Hospital of Changde, Changde, China
| | - Kui Yang
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
| | - Chuntao Li
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
| | - Songshan Feng
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
| | - Mingyu Zhang
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
| | - Zhenyan Li
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
| | - Hongshu Zhou
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
- *Correspondence: Zhixiong Liu, ; Hongshu Zhou,
| | - Zhixiong Liu
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
- *Correspondence: Zhixiong Liu, ; Hongshu Zhou,
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14
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Intraoperative imaging with mobile CT in endoscopic pituitary surgery: An early experience. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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15
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Park JY, Choi W, Hong AR, Yoon JH, Kim HK, Jang WY, Jung S, Kang HC. Surgery is a safe, effective first-line treatment modality for noninvasive prolactinomas. Pituitary 2021; 24:955-963. [PMID: 34189717 DOI: 10.1007/s11102-021-01168-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/19/2021] [Indexed: 12/24/2022]
Abstract
PURPOSE Dopamine agonists (DAs) have long been the recommended first-line treatment for prolactinoma. Given the remarkable developments in surgical techniques, however, surgery is on the rise. We compared the treatment outcomes of patients with noninvasive prolactinomas receiving two different initial treatments (DAs and transsphenoidal surgery). METHODS We reviewed 745 patients with hyperprolactinemia or pituitary tumors treated from 2004 to 2020 at Chonnam National University Hwasun Hospital and identified 310 with prolactinomas. After selecting patients who had pituitary tumors with Knosp grade 0 to 1 with follow-up period over 1 year, 70 patients (29 who underwent surgery and 41 who received DAs as the initial treatment) were finally included for a comparative study. RESULTS The surgery group exhibited better outcomes in terms of DA-free remission and the structural response, although the tumor size was significantly larger than in the DA group. The groups exhibited comparable results in terms of symptom control and the biochemical response. Univariate and multivariate analyses indicated that surgery as the initial treatment modality provided significantly better clinical outcomes in terms of DA-free remission. In the surgery group, a postoperative prolactin level < 10 ng/mL was the only significant predictor of DA-free remission. CONCLUSIONS Transsphenoidal surgery showed comparable clinical outcomes in patients with prolactinomas, and low complication rates. The decision regarding the first-line treatment modality for non-invasive prolactinomas should be made on an individual basis.
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Affiliation(s)
- Ji Yong Park
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chonnam National University Medical School, 264 Seoyang-ro, Hwasun-eup, Hwasun-gun, Jeollanam-do, 58128, Korea
| | - Wonsuk Choi
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chonnam National University Medical School, 264 Seoyang-ro, Hwasun-eup, Hwasun-gun, Jeollanam-do, 58128, Korea
| | - A Ram Hong
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chonnam National University Medical School, 264 Seoyang-ro, Hwasun-eup, Hwasun-gun, Jeollanam-do, 58128, Korea
| | - Jee Hee Yoon
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chonnam National University Medical School, 264 Seoyang-ro, Hwasun-eup, Hwasun-gun, Jeollanam-do, 58128, Korea
| | - Hee Kyung Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chonnam National University Medical School, 264 Seoyang-ro, Hwasun-eup, Hwasun-gun, Jeollanam-do, 58128, Korea.
| | - Woo-Youl Jang
- Department of Neurosurgery, Chonnam National University Medical School, Gwangju, Korea
| | - Shin Jung
- Department of Neurosurgery, Chonnam National University Medical School, Gwangju, Korea
| | - Ho-Cheol Kang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chonnam National University Medical School, 264 Seoyang-ro, Hwasun-eup, Hwasun-gun, Jeollanam-do, 58128, Korea
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16
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The PRolaCT studies - a study protocol for a combined randomised clinical trial and observational cohort study design in prolactinoma. Trials 2021; 22:653. [PMID: 34563236 PMCID: PMC8465768 DOI: 10.1186/s13063-021-05604-y] [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] [Received: 11/11/2020] [Accepted: 09/05/2021] [Indexed: 11/30/2022] Open
Abstract
Background First-line treatment for prolactinomas is a medical treatment with dopamine agonists (DAs), which effectively control hyperprolactinaemia in most patients, although post-withdrawal remission rates are approximately 34%. Therefore, many patients require prolonged DA treatment, while side effects negatively impact health-related quality of life (HRQoL). Endoscopic transsphenoidal resection is reserved for patients with severe side effects, or with DA-resistant prolactinoma. Surgery has a good safety profile and high probability of remission and may thus deserve a more prominent place in prolactinoma treatment. The hypothesis for this study is that early or upfront surgical resection is superior to DA treatment both in terms of HRQoL and remission rate in patients with a non-invasive prolactinoma of limited size. Methods We present a combined randomised clinical trial and observational cohort study design, which comprises three unblinded randomised controlled trials (RCTs; PRolaCT-1, PRolaCT-2, PRolaCT-3), and an observational study arm (PRolaCT-O) that compare neurosurgical counselling, and potential subsequent endoscopic transsphenoidal adenoma resection, with current standard care. Patients with a non-invasive prolactinoma (< 25 mm) will be eligible for one of three RCTs based on the duration of pre-treatment with DAs: PRolaCT-1: newly diagnosed, treatment-naïve patients; PRolaCT-2: patients with limited duration of DA treatment (4–6 months); and PRolaCT-3: patients with persisting prolactinoma after DA treatment for > 2 years. PRolaCT-O will include patients who decline randomisation, due to e.g. a clear treatment preference. Primary outcomes are disease remission after 36 months and HRQoL after 12 months. Discussion Early or upfront surgical resection for patients with a limited-sized prolactinoma may be a reasonable alternative to the current standard practice of DA treatment, which we will investigate in three RCTs and an observational cohort study. Within the three RCTs, patients will be randomised between neurosurgical counselling and standard care. The observational study arm will recruit patients who refuse randomisation and have a pronounced treatment preference. PRolaCT will collect randomised and observational data, which may facilitate a more individually tailored practice of evidence-based medicine. Trial registration US National Library of Medicine registry (ClinicalTrials.gov) NCT04107480. Registered on 27 September 2019, registered retrospectively (by 2 months). Supplementary Information The online version contains supplementary material available at 10.1186/s13063-021-05604-y.
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17
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Sharifi G, Sabahi M, Amin A, Dilmaghani NA, Nejad AM, Davoudi Z, Mohajeri-Tehrani M, Rezaei O, Borghei-Razavi H. Patterns of extrasellar invasive growth of pituitary adenomas with normal sellar cavity size. Clin Neurol Neurosurg 2021; 209:106942. [PMID: 34547643 DOI: 10.1016/j.clineuro.2021.106942] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 08/20/2021] [Accepted: 09/06/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Pituitary adenomas (PAs) are among the most common brain tumors which characteristically become symptomatic due to the mass effect on surrounding structures and/or hormonal imbalances. This study describes 28 cases of PAs with an extrasellar invasive growth (EIG) at the early stage of tumor growth with normal sellar cavity size. METHODS 1200 cases of PAs either treated medically or via Endoscopic transsphenoidal surgery were reviewed during a 10-year period. Pre-operative imaging was analyzed to evaluate the tumor expansion pattern, tumor invasion sites and other relevant tumor properties. A comprehensive preoperative endocrinological along with postoperative histopathological studies were conducted to evaluate the subjects' homeostasis and further identify the lesions characteristics. RESULTS Of the 28 patients, patients 19, 2, 1 and 6 had a growth hormone (GH)-secreting PA, an adrenocorticotropic hormone (ACTH)-secreting PA, a nonfunctional PA (NFPA) and a mix-hormones secreting PA, respectively. There was a statistically significant difference between patients with and without EIG regarding types of PAs (P = 0.000). Post-hoc tests demonstrated that GH-secreting PAs (P = 0.0003) and mix-hormones secreting PAs (P = 0.0000) are significantly more invasive, while NFPAs (P = 0.0000) are less invasive. There was not a statistically significant difference between the invasion sites and different types of PAs (P = 0.122). CONCLUSION Among different histological subtypes of PAs, GH-secreting PAs revealed a remarkable tendency for EIG with normal sellar cavity size. The extra-sellar tumor extension with a normal sella did not correlate with atypical histology. Considering EIG patterns, surgeons should be vigilant to investigate and follow the tumor spreading to its enclosing boundary during surgery, the clival part of sphenoid bone should be more exposed, and both inferomedial and lateral borders of the sphenoid sinus should be carefully explored in order to remove the tumor.
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Affiliation(s)
- Guive Sharifi
- Department of Neurosurgery, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Skull Base Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammadmahdi Sabahi
- Skull Base Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Neurosurgery Research Group (NRG), Student Research Committee, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Amirarsalan Amin
- Department of Neurosurgery, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Skull Base Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Nader Akbari Dilmaghani
- Skull Base Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Department of Otolaryngology, Head and Neck Surgery, Loghman Hakim Educational Hospital, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ali Mousavi Nejad
- Department of Neurosurgery, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Skull Base Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Zahra Davoudi
- Department of Endocrinology, Loghman Hakim Hospital, Shahid Beheshti Medical University, Tehran, Iran
| | - Mohammadreza Mohajeri-Tehrani
- Endocrinology and Metabolism Research Center, Tehran University of Medical Sciences, Shariati Hospital, Tehran, Iran
| | - Omidvar Rezaei
- Department of Neurosurgery, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Skull Base Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hamid Borghei-Razavi
- Department of Neurosurgery, Pauline Braathen Neurological Institute, 2950 Cleveland Clinic Blvd, Weston, FL 33331, USA.
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Gómez-Amador JL, Martínez-Anda JJ, Guerrero-Suarez PD, Rosales-Amaya AM, Delgado-Arce JC, Guerrero-López DA. Endoscopic endonasal lateral transellar approach for growth hormone-secreting adenomas with cavernous sinus invasion: Technical note and surgical results. NEUROCIRUGÍA (ENGLISH EDITION) 2021; 32:170-177. [PMID: 34218877 DOI: 10.1016/j.neucie.2020.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 05/27/2020] [Indexed: 10/21/2022]
Abstract
BACKGROUND Cavernous sinus (CS) invasion is found in 15-20% of pituitary adenomas; it represents a poor prognosis factor and a surgical challenge even in experienced pituitary centers. We present our experience and technical note description for surgical management of pituitary adenomas with CS invasion in acromegaly by the transsellar lateral approach with an endoscopic endonasal transsphenoidal route. METHOD prospective case series of patients who underwent endoscopic endonasal surgery for Growing Hormone (GH) producing adenomas with CS invasion treated at the Neurosurgery departments of National Institute of Neurology and Neurosurgery in Mexico City, and of Toluca Medical Center of Social Security Institute of the State of Mexico and Provinces between January 2014 and March 2019. RESULTS Thirty-two of 94 patients with diagnosis of pituitary adenoma treated at our institutions (34%) had acromegaly; thirteen of patients with acromegaly diagnosis met the inclusion criteria for CS invasion. Postoperative images reported gross total resection in 10 patients (76.9%). Mean follow-up time was 28.3 months. Remission criteria were achieved in nine patients (69.2%), with one of these patients (11.1%) having recurrence during follow up. All patients with no biochemical remission had improvement in GH and IGF profiles. Three patients without remission underwent radiosurgery (14Gy), and one patient had remission after the procedure. CONCLUSIONS We consider this to be a safe and efficient approach for tumors invading CS, when surgical team have good experience in endoscopy of the skull base and reconstruction techniques, appropriate instruments are available, and tumor has soft consistency.
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Affiliation(s)
- Juan Luis Gómez-Amador
- Department of Neurosurgery, National Institute of Neurology and Neurosurgery Manuel Velasco Suarez, Insurgentes Sur Av. 3877, Barrio La Fama, Postal Code 14269 Mexico City, Mexico
| | - Jaime Jesús Martínez-Anda
- Neurosurgery Department, Toluca Medical Center of Social Security Institute of the State of Mexico and Provinces Baja Velocidad, Av. 57.5km Mexico - Toluca Highway, Postal Code 52140 Metepec, State of Mexico, Mexico.
| | - Pablo David Guerrero-Suarez
- Neurosurgery Department, Toluca Medical Center of Social Security Institute of the State of Mexico and Provinces Baja Velocidad, Av. 57.5km Mexico - Toluca Highway, Postal Code 52140 Metepec, State of Mexico, Mexico
| | - Arturo Miguel Rosales-Amaya
- Neurosurgery Department, Toluca Medical Center of Social Security Institute of the State of Mexico and Provinces Baja Velocidad, Av. 57.5km Mexico - Toluca Highway, Postal Code 52140 Metepec, State of Mexico, Mexico
| | - Julio Cesar Delgado-Arce
- Neurosurgery Department, Toluca Medical Center of Social Security Institute of the State of Mexico and Provinces Baja Velocidad, Av. 57.5km Mexico - Toluca Highway, Postal Code 52140 Metepec, State of Mexico, Mexico
| | - David Antonio Guerrero-López
- Neurosurgery Department, Toluca Medical Center of Social Security Institute of the State of Mexico and Provinces Baja Velocidad, Av. 57.5km Mexico - Toluca Highway, Postal Code 52140 Metepec, State of Mexico, Mexico
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Rutland JW, Goldrich D, Loewenstern J, Banihashemi A, Shuman W, Sharma S, Balchandani P, Bederson JB, Iloreta AM, Shrivastava RK. The Role of Advanced Endoscopic Resection of Diverse Skull Base Malignancies: Technological Analysis during an 8-Year Single Institutional Experience. J Neurol Surg B Skull Base 2021; 82:417-424. [PMID: 35573925 PMCID: PMC9100431 DOI: 10.1055/s-0040-1714115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 06/02/2020] [Indexed: 10/23/2022] Open
Abstract
Background Resection of skull base malignancies poses complex pathological and treatment-related morbidities. Recent technological advancements of endoscopic endonasal surgery (EES) offer the ability to reexamine traditional treatment paradigms with endoscopic procedures. The utility of EES was quantitatively examined in a longitudinal series with attention to morbidities and postoperative outcomes. Methods A single-center retrospective review was performed of all malignant sinonasal tumors from 2010 to 2018. Patients with purely EES were selected for analysis. Disease features, resection extent, complications, adjuvant treatment, recurrence, and survivability were assessed. Despite the mixed pathological cohort, analysis was performed to identify technical aspects of resection. Results A total of 68 patients (47.6% males and 52.4% females, average age: 60.3 years) were included. A diversity of histotypes included clival chordoma (22.1%), olfactory neuroblastoma (14.7%), squamous cell carcinoma (11.8%), and adenoid cystic carcinoma (11.8%). Gross total resection (GTR) was achieved in 83.8% of cases. Infection (4.4%) and cerebrospinal fluid leak (1.5%) were the most common postoperative complications. Total 46 patients (67.6%) underwent adjuvant treatment. The average time between surgery and initiation of adjunctive surgery was 55.7 days. Conclusion In our 8-year experience, we found that entirely endoscopic resection of mixed pathology of malignant skull base tumors is oncologically feasible and can be accomplished with high GTR rates. There may be a role for EES to reduce operative morbidity and attenuate time in between surgery and adjuvant treatment, which can be augmented through recent mixed reality platforms. Future studies are required to systematically compare the outcomes with those of open surgical approaches.
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Affiliation(s)
- John W. Rutland
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York City, New York, United States
| | - David Goldrich
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York City, New York, United States
| | - Joshua Loewenstern
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York City, New York, United States
| | - Amir Banihashemi
- Department of Pathology, Icahn School of Medicine at Mount Sinai, New York City, New York, United States
| | - William Shuman
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York City, New York, United States
| | - Sonam Sharma
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York City, New York, United States
| | - Priti Balchandani
- Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, New York City, New York, United States
| | - Joshua B. Bederson
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York City, New York, United States
| | - Alfred M. Iloreta
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York City, New York, United States
| | - Raj K. Shrivastava
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York City, New York, United States
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Determinants of Surgical Remission in Prolactinomas: A Systematic Review and Meta-Analysis. World Neurosurg 2021; 154:e349-e369. [PMID: 34325023 DOI: 10.1016/j.wneu.2021.07.035] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 07/07/2021] [Accepted: 07/08/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Prolactin-secreting tumors respond well to medical management, with a few patients requiring surgery. We conducted a systematic review and meta-analysis to study the determinants of surgical remission in these tumors. METHODS We searched PubMed to identify eligible studies reporting postoperative remission in patients treated with transsphenoidal surgery for prolactinoma. Primary outcomes included postoperative remission, follow-up remission, and recurrence. Postoperative and follow-up remission were defined as normoprolactinemia at <1 year and >1 year after operation, respectively. Recurrence was defined as hyperprolactinemia after initial normalization of prolactin levels. Odds ratios (ORs) were calculated, stratified by radiologic size, tumor extension, and tumor invasion, and analyzed using a random-effects model meta-analysis. RESULTS Thirty-five studies were included. Macroadenomas were associated with lower rates of postoperative remission (OR, 0.20; 95% confidence interval [CI], 0.16-0.24) and lower rates of remission at follow-up (OR, 0.11; 95% CI, 0.053-0.22). Postoperative remission was less likely in tumors with extrasellar or suprasellar extension (OR, 0.16; 95% CI, 0.06-0.43) and tumors with cavernous sinus invasion (OR, 0.03; 95% CI, 0.01-0.13). Female gender and absence of preoperative dopamine agonist treatment were also associated with higher remission rates. Across the included studies, there was considerable heterogeneity in each primary outcome (postoperative remission, I2 = 94%; follow-up remission, I2 = 86%; recurrence, I2 = 68%). CONCLUSIONS Transsphenoidal surgery for prolactinomas may be particularly effective in small, noninvasive, treatment-naive tumors and may provide a viable first-line alternative to dopamine agonist therapy in such patients.
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21
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Ouyang T, Zhang N, Xie S, Tang B, Li J, Xiao L, Zhang F, Wu B, Zhou D, Li M, Hong T. Outcomes and Complications of Aggressive Resection Strategy for Pituitary Adenomas in Knosp Grade 4 With Transsphenoidal Endoscopy. Front Oncol 2021; 11:693063. [PMID: 34235083 PMCID: PMC8255811 DOI: 10.3389/fonc.2021.693063] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 05/20/2021] [Indexed: 11/30/2022] Open
Abstract
Surgery for pituitary adenomas (PAs) with cavernous sinus (CS) invasion in Knosp grade 4 is a great challenge and whether to adopt a conservative or aggressive surgical strategy is controversial. The aim of this study is to provide the outcomes and complications of an aggressive resection strategy for Knosp grade 4 PAs with transsphenoidal endoscopic surgery. Outcomes and complications were retrospectively analyzed in 102 patients with Knosp grade 4 PAs. Among them, primary PAs were seen in 60 patients and recurrent PAs were seen in 42 cases. Gross total resection (GTR) of the entire tumor was achieved in 72 cases (70.6%), subtotal tumor resection (STR) in 18 cases (17.6%), and partial tumor resection (PTR) in 12 cases (11.8%). Additionally, GTR of the tumor within the CS was achieved in 82 patients (80.4%), STR in 17 patients (16.7%), and PTR in 3 patients (2.9%). Statistical analyses showed that both recurrent tumors and firm consistency tumors were adverse factors for complete resection (P<0.05). Patients with GTR of the entire tumor were more likely to have favorable endocrine and visual outcomes than those with incomplete resection (P<0.05). Overall, the most common surgical complication was new cranial nerve palsy (n=7, 6.8%). The incidence of internal carotid artery (ICA) injury and postoperative cerebrospinal fluid (CSF) leakage was 2.0% (n=2) and 5.9% (n=6), respectively. Six patients (5.9%) experienced tumor recurrence postoperatively. For experienced neuroendoscopists, an aggressive tumor resection strategy via transsphenoidal endoscopic surgery may be an effective and safe option for Knosp grade 4 PAs.
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Affiliation(s)
- Taohui Ouyang
- Department of Neurosurgery, the First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Na Zhang
- Department of Neurology, the First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Shenhao Xie
- Department of Neurosurgery, the First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Bin Tang
- Department of Neurosurgery, the First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Junjun Li
- Department of Neurosurgery, Wuhan Union Hospital, Wuhan, China
| | - Limin Xiao
- Department of Neurosurgery, the First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Fabao Zhang
- Department of Radiology, the First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Bowen Wu
- Department of Neurosurgery, the First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Dongwei Zhou
- Department of Neurosurgery, the First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Meihua Li
- Department of Neurosurgery, the First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Tao Hong
- Department of Neurosurgery, the First Affiliated Hospital of Nanchang University, Nanchang, China
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22
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Techniques and challenges of the expanded endoscopic endonasal sellar and parasellar approaches to invasive pituitary tumors. Acta Neurochir (Wien) 2021; 163:1717-1723. [PMID: 33825972 DOI: 10.1007/s00701-021-04805-3] [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: 10/05/2020] [Accepted: 03/10/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Superb knowledge of surgical anatomy and nuances to remove the natural barriers preventing full access to the paramedian skull base determines the ease of using the expanded sellar/parasellar approaches as the main gateway for all the parasagittal modules during endoscopic endonasal access (EEA) to pituitary tumors with cavernous sinus (CS) invasion. METHODS Throughout stepwise-cadaveric dissections and pertinent intraoperative analysis, we describe surgical pearls and pitfalls of the parasellar-EEA with special references to the utility of various lines/classifications on neuroimaging correlated with strategies to enhance surgical safety and tumor resection. CONCLUSION EEA to invasive parasellar pathologies needs to address strict bleeding control and displacement of neurovascular structures inside the CS, posing a chance for neurologic morbidities/ICA injury. Meticulous utilization of operative landmarks and strategies can help avoid and mitigate surgical complications.
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Voznyak O, Lytvynenko A, Maydannyk O, Ilyuk R, Zinkevych Y, Hryniv N. Outcomes of Transsphenoidal Surgery in Growth Hormone-Secreting Pituitary Adenomas. INDIAN JOURNAL OF NEUROSURGERY 2021. [DOI: 10.1055/s-0041-1726134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
AbstractGrowth hormone (GH)-secreting pituitary adenomas (PA) make up 15 to 20% of total amount of hormonally active adenomas. In addition to acromegaly and gigantism, these tumors cause deep metabolic disturbances. Its systemic impact leads to increased mortality ratio of 1.32 compared with general population. Surgical removal remains the priority treatment option in controlling acromegaly and provides endocrinologic remission in up to 72% patients. A total of 92 patients were included in the study. All surgeries were performed via microscopic transsphenoidal approach (TSA) by the senior author in our institution between December 2009 and October 2019. Only patients who were followed-up with 75 g oral glucose tolerance tests (OGTTs), GH, and insulin-like growth factor I (IFG-I) measurements preoperatively, 1 week, and every 6 months postoperatively were analyzed. Based on standard preoperative 1.5-T MR imaging with contrast enhancement, the adenomas were identified and distributed according to the size and KNOSP classification. The efficacy depends on KNOSP grade, which is directly correlated with invasiveness to cavernous sinus (CS). Grades 3 and 4 are unfavorable factors influencing prognosis. Excluding grade 0 adenomas, as the surgery was not difficult with the excellent outcomes, we reached 75% (36 out of 48) remission in grade 1 to 2 groups. In contrast, only 17% (2 out of 12) had successful outcomes after surgery alone. In conclusion, the study demonstrates the efficiency of TS surgery in patients with confirmed GH-secreting PA.
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Affiliation(s)
- Oleksandr Voznyak
- Centre of Neurosurgery, Clinical Hospital “Feofaniya,” Kyiv, Ukraine
| | - Andrii Lytvynenko
- Centre of Neurosurgery, Clinical Hospital “Feofaniya,” Kyiv, Ukraine
| | - Oleg Maydannyk
- Centre of Neurosurgery, Clinical Hospital “Feofaniya,” Kyiv, Ukraine
| | - Roman Ilyuk
- Centre of Neurosurgery, Clinical Hospital “Feofaniya,” Kyiv, Ukraine
| | | | - Nazarii Hryniv
- Department of Neurosurgery, Shupyk National Medical Academy of Postgraduate Education, Kyiv, Ukraine
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24
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Pérez-López C, Álvarez-Escolá C, Isla Guerrero A. Therapeutic approach to non-functioning pituitary adenomas. Med Clin (Barc) 2021; 156:284-289. [PMID: 33454125 DOI: 10.1016/j.medcli.2020.08.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 08/03/2020] [Accepted: 08/04/2020] [Indexed: 10/22/2022]
Abstract
The treatment of non-functioning pituitary adenomas raises two questions: when should they be treated and what role does each available treatment play. We review the usefulness of the different treatments and propose a therapeutic scheme based on the existing literature. Active treatment of pituitary adenomas should be performed when they produce symptoms, have contact with the optic tract, or have grown on imaging tests. The treatment is surgical, using radiotherapy for cases with significant non-removable postsurgical tumour remnants and for those in which histopathology studies show aggressive features. Medical treatment is reserved for situations in which surgical and radiotherapy treatments have been exhausted. The most advisable surgical treatment is endoscopic, although experienced neurosurgeons achieve results with microsurgery that are only slightly inferior.
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Affiliation(s)
- Carlos Pérez-López
- Servicio de Neurocirugía. Hospital Universitario La Paz, Madrid, España.
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25
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Lu J, Cai L, Wu Z, Lin W, Xu J, Zhu Z, Wang C, Li Q, Su Z. Surgery and Medical Treatment in Microprolactinoma: A Systematic Review and Meta-Analysis. Int J Endocrinol 2021; 2021:9930059. [PMID: 34504526 PMCID: PMC8423556 DOI: 10.1155/2021/9930059] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 08/19/2021] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE Dopamine agonists (DAs) are recommended as the first-line treatment for prolactinomas; however, tumour recurrence after drug withdrawal remains a clinical problem. Recent studies have reported high remission rates via surgery in microprolactinomas. The aim of this systematic review and meta-analysis was to compare the clinical result of DA treatment with surgery as initial therapy in patients with treatment-naive microprolactinoma. METHODS A comprehensive literature search for studies and reports regarding microprolactinoma patients treated with DAs and/or surgery published between January 1970 and November 2020 was conducted using four electronic databases (PubMed, Embase, Google Scholar, and the Cochrane Library). Clinical treatment outcome was evaluated by the biochemical remission of serum prolactin level to normal after treatment. The I 2 statistic was used to quantify heterogeneity. Pooled data were analysed according to a random effect model. RESULTS Eighteen studies with 661 patients were included for analysis. The DA treatment group achieved a higher remission rate at ≥12 months follow-up (96% vs. 86%; P=0.019). Surgery showed a higher remission rate than the DA treatment group after the treatment withdrawal (78% vs. 44%; P=0.003). Patients with preoperative prolactin level of ≤200 ng/mL had a higher remission rate than patients with preoperative prolactin level of >200 ng/mL (92% vs. 40%; P=0.029). CONCLUSION Surgery showed a high remission rate in treatment-naive microprolactinoma patients after treatment withdrawal and may be an alternative first-line treatment strategy in addition to DAs, particularly in patients with a preoperative prolactin level of ≤200 ng/mL.
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Affiliation(s)
- Jianglong Lu
- Department of Neurosurgery, First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Lin Cai
- Department of Neurosurgery, First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Zerui Wu
- Department of Neurosurgery, First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Weiwei Lin
- Department of Neurosurgery, First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Jiadong Xu
- Department of Neurosurgery, First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Zhangzhang Zhu
- Department of Neurosurgery, First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Chengde Wang
- Department of Neurosurgery, First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Qun Li
- Department of Neurosurgery, First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Zhipeng Su
- Department of Neurosurgery, First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
- Department of Neurosurgery, Wencheng Country People's Hospital, Wenzhou 325000, China
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Placzek F, Micko A, Sentosa R, Fonollà R, Winklehner M, Hosmann A, Andreana M, Höftberger R, Drexler W, Leitgeb RA, Wolfsberger S, Unterhuber A. Towards ultrahigh resolution OCT based endoscopical pituitary gland and adenoma screening: a performance parameter evaluation. BIOMEDICAL OPTICS EXPRESS 2020; 11:7003-7018. [PMID: 33408976 PMCID: PMC7747926 DOI: 10.1364/boe.409987] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 10/22/2020] [Accepted: 10/27/2020] [Indexed: 05/06/2023]
Abstract
Ultrahigh resolution optical coherence tomography (UHR-OCT) for differentiating pituitary gland versus adenoma tissue has been investigated for the first time, indicating more than 80% accuracy. For biomarker identification, OCT images of paraffin embedded tissue are correlated to histopathological slices. The identified biomarkers are verified on fresh biopsies. Additionally, an approach, based on resolution modified UHR-OCT ex vivo data, investigating optical performance parameters for the realization in an in vivo endoscope is presented and evaluated. The identified morphological features-cell groups with reticulin framework-detectable with UHR-OCT showcase a promising differentiation ability, encouraging endoscopic OCT probe development for in vivo application.
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Affiliation(s)
- Fabian Placzek
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Waehringer Guertel 18-20, 4L, 1090 Vienna, Austria
- These authors contributed equally to this work
| | - Alexander Micko
- Department of Neurosurgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
- These authors contributed equally to this work
| | - Ryan Sentosa
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Waehringer Guertel 18-20, 4L, 1090 Vienna, Austria
| | - Roger Fonollà
- Department of Electrical Engineering, Video Coding and Architectures, Eindhoven University of Technology, 5612 AZ Eindhoven, Noord-Brabant, The Netherlands
| | - Michael Winklehner
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Arthur Hosmann
- Department of Neurosurgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Marco Andreana
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Waehringer Guertel 18-20, 4L, 1090 Vienna, Austria
| | - Romana Höftberger
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Wolfgang Drexler
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Waehringer Guertel 18-20, 4L, 1090 Vienna, Austria
| | - Rainer A. Leitgeb
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Waehringer Guertel 18-20, 4L, 1090 Vienna, Austria
- Christian Doppler Laboratory OPTRAMED, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Stefan Wolfsberger
- Department of Neurosurgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Angelika Unterhuber
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Waehringer Guertel 18-20, 4L, 1090 Vienna, Austria
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Younus I, Gerges MM, Dobri GA, Ramakrishna R, Schwartz TH. Readmission after endoscopic transsphenoidal pituitary surgery: analysis of 584 consecutive cases. J Neurosurg 2020; 133:1242-1247. [PMID: 31561225 DOI: 10.3171/2019.7.jns191558] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 07/01/2019] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Hospital readmission is a key component in value-based healthcare models but there are limited data about the 30-day readmission rate after endonasal endoscopic transsphenoidal surgery (EETS) for pituitary adenoma. The objective of this study was to determine the incidence and identify factors associated with 30-day readmission after EETS for pituitary adenoma. METHODS The authors analyzed a prospectively acquired database of patients who underwent EETS for pituitary adenoma from 2005 to 2018 at NewYork-Presbyterian Hospital, Weill Cornell Medicine. Clinical, socioeconomic, and radiographic data were reviewed for cases of unplanned readmission within 30 days of surgery and, as a control group, for all other patients in the series who were not readmitted. Statistical significance was determined with an alpha < 0.05 using Pearson's chi-square and Fisher's exact tests for categorical variables and the independent-samples t-test for continuous variables. RESULTS Of 584 patients undergoing EETS for pituitary adenoma, 27 (4.6%) had unplanned readmission within 30 days. Most readmissions occurred within the first week after surgery, with a mean time to readmission of 6.6 ± 3.9 days. The majority of readmissions (59%) were for hyponatremia. These patients had a mean sodium level of 120.6 ± 4.6 mEq/L at presentation. Other causes of readmission were epistaxis (11%), spinal headache (11%), sellar hematoma (7.4%), CSF leak (3.7%), nonspecific headache (3.7%), and pulmonary embolism (3.7%). The postoperative length of stay was significantly shorter for patients who were readmitted than for the controls (2.7 ± 1.0 days vs 3.9 ± 3.2 days; p < 0.05). Patients readmitted for hyponatremia had an initial length of stay of 2.6 ± 0.9 days, the shortest of any cause for readmission. The mean BMI was significantly lower for readmitted patients than for the controls (26.4 ± 3.9 kg/m2 vs 29.3 ± 6.1 kg/m2; p < 0.05). CONCLUSIONS Readmission after EETS for pituitary adenoma is a relatively rare phenomenon, with delayed hyponatremia being the primary cause. The study results demonstrate that shorter postoperative length of stay and lower BMI were associated with 30-day readmission.
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Affiliation(s)
| | - Mina M Gerges
- Departments of2Neurosurgery
- 6Department of Neurosurgery, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Georgiana A Dobri
- Departments of2Neurosurgery
- 4Neuroscience, and
- 5Endocrinology, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York; and
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Castaño-Leon AM, Paredes I, Munarriz PM, Jiménez-Roldán L, Hilario A, Calatayud M, Hernandez-Lain A, Garcia E, Garcia A, Lagares A, Alén JF. Endoscopic Transnasal Trans-Sphenoidal Approach for Pituitary Adenomas: A Comparison to the Microscopic Approach Cohort by Propensity Score Analysis. Neurosurgery 2020; 86:348-356. [PMID: 31173138 DOI: 10.1093/neuros/nyz201] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 01/21/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Despite some evidence for the adoption of endoscopic transnasal trans-sphenoidal surgery (ETSS) for pituitary adenomas, the advantages of this technique over the traditional approach have not been robustly confirmed. OBJECTIVE To compare ETSS with the microscopic sublabial trans-septal trans-sphenoidal surgery (MTSS) for pituitary adenomas. METHODS We retrospectively reviewed 2 cohorts of ETSS and MTSS performed at our institution from 1995 to 2017. Patient characteristics, surgical data, and outcomes were recorded prospectively. We performed a univariate and multivariable analysis to determine the best surgical approach. To improve the quality of the results, we matched the distribution of patient characteristics between groups by propensity score (PS) method. RESULTS A total of 187 procedures (90 MTSS, 97 ETSS) were reviewed. We found better results in the ETSS group in terms of gross total resection (P = .002) and hormone-excess secretion control (P = .014). There was also a lower incidence of cerebrospinal fluid leakage (P = .039), transitory diabetes insipidus (P = .028), and postoperative hypopituitarism (P = .045), as well as a shorter hospital length of stay (P < .001). After PS matching, we confirmed by multivariable logistic regression analysis an increased odds ratio of gross total resection for the ETSS (3.910; 95% CI 1.720-8.889; P = .001). CONCLUSION By PS method, our results suggest that the ETSS provides advantages over the traditional MTSS approach for tumor resection. Better control of secreting tumors and a lower rate of most complications also support the selection of the ETSS approach for the treatment of pituitary adenomas.
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Affiliation(s)
- Ana M Castaño-Leon
- Department of Neurosurgery, Instituto de Investigación i+12, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain
| | - Igor Paredes
- Department of Neurosurgery, Instituto de Investigación i+12, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain
| | - Pablo M Munarriz
- Department of Neurosurgery, Instituto de Investigación i+12, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain
| | - Luis Jiménez-Roldán
- Department of Neurosurgery, Instituto de Investigación i+12, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain
| | - Amaya Hilario
- Department of Neurosurgery, Instituto de Investigación i+12, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain
| | - Maria Calatayud
- Department of Neurosurgery, Instituto de Investigación i+12, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain
| | - Aurelio Hernandez-Lain
- Department of Neurosurgery, Instituto de Investigación i+12, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain
| | - Ester Garcia
- Department of Neurosurgery, Instituto de Investigación i+12, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain
| | - Alfredo Garcia
- Department of Neurosurgery, Instituto de Investigación i+12, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain
| | - Alfonso Lagares
- Department of Neurosurgery, Instituto de Investigación i+12, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain
| | - Jose F Alén
- Department of Neurosurgery, Instituto de Investigación i+12, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain
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Hung YC, Lee CC, Yang HC, Mohammed N, Kearns KN, Nabeel AM, Abdel Karim K, Emad Eldin RM, El-Shehaby AMN, Reda WA, Tawadros SR, Liscak R, Jezkova J, Lunsford LD, Kano H, Sisterson ND, Martínez Álvarez R, Martínez Moreno NE, Kondziolka D, Golfinos JG, Grills I, Thompson A, Borghei-Razavi H, Maiti TK, Barnett GH, McInerney J, Zacharia BE, Xu Z, Sheehan JP. The benefit and risk of stereotactic radiosurgery for prolactinomas: an international multicenter cohort study. J Neurosurg 2020; 133:717-726. [PMID: 31374549 DOI: 10.3171/2019.4.jns183443] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Accepted: 04/03/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The most common functioning pituitary adenoma is prolactinoma. Patients with medically refractory or residual/recurrent tumors that are not amenable to resection can be treated with stereotactic radiosurgery (SRS). The aim of this multicenter study was to evaluate the role of SRS for treating prolactinomas. METHODS This retrospective study included prolactinomas treated with SRS between 1997 and 2016 at ten institutions. Patients' clinical and treatment parameters were investigated. Patients were considered to be in endocrine remission when they had a normal level of prolactin (PRL) without requiring dopamine agonist medications. Endocrine control was defined as endocrine remission or a controlled PRL level ≤ 30 ng/ml with dopamine agonist therapy. Other outcomes were evaluated including new-onset hormone deficiency, tumor recurrence, and new neurological complications. RESULTS The study cohort comprised 289 patients. The endocrine remission rates were 28%, 41%, and 54% at 3, 5, and 8 years after SRS, respectively. Following SRS, 25% of patients (72/289) had new hormone deficiency. Sixty-three percent of the patients (127/201) with available data attained endocrine control. Three percent of patients (9/269) had a new visual complication after SRS. Five percent of the patients (13/285) were recorded as having tumor progression. A pretreatment PRL level ≤ 270 ng/ml was a predictor of endocrine remission (p = 0.005, adjusted HR 0.487). An increasing margin dose resulted in better endocrine control after SRS (p = 0.033, adjusted OR 1.087). CONCLUSIONS In patients with medically refractory prolactinomas or a residual/recurrent prolactinoma, SRS affords remarkable therapeutic effects in endocrine remission, endocrine control, and tumor control. New-onset hypopituitarism is the most common adverse event.
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Affiliation(s)
- Yi-Chieh Hung
- 1Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
- 2Departments of Neurosurgery and Surgery, Chi-Mei Medical Center, Tainan
- 3Department of Recreation and Healthcare Management, Chia Nan University of Pharmacy and Science, Tainan
| | - Cheng-Chia Lee
- 4Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei
- 5School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Huai-Che Yang
- 4Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei
| | - Nasser Mohammed
- 1Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Kathryn N Kearns
- 1Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Ahmed M Nabeel
- 6Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo
- 7Department of Neurosurgery, Benha University, Qalubya, Egypt
| | - Khaled Abdel Karim
- 6Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo
- 17Clinical Oncology, Ain Shams University, Cairo; and
| | - Reem M Emad Eldin
- 6Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo
- 18Department of Radiation Oncology, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Amr M N El-Shehaby
- 6Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo
- Departments of16Neurosurgery and
| | - Wael A Reda
- 6Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo
- Departments of16Neurosurgery and
| | - Sameh R Tawadros
- 6Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo
- Departments of16Neurosurgery and
| | - Roman Liscak
- 8Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague
| | - Jana Jezkova
- 9Department of Endocrinology and Metabolism, 3rd Department of Medicine, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - L Dade Lunsford
- 10Department of Neurological Surgery, University of Pittsburgh, Pennsylvania
| | - Hideyuki Kano
- 10Department of Neurological Surgery, University of Pittsburgh, Pennsylvania
| | | | | | | | - Douglas Kondziolka
- 12Department of Neurosurgery, NYU Langone Health System, New York, New York
| | - John G Golfinos
- 12Department of Neurosurgery, NYU Langone Health System, New York, New York
| | - Inga Grills
- 13Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Andrew Thompson
- 13Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | | | | | - Gene H Barnett
- 14Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio
| | - James McInerney
- 15Department of Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Brad E Zacharia
- 15Department of Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Zhiyuan Xu
- 1Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Jason P Sheehan
- 1Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
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Gómez-Amador JL, Martínez-Anda JJ, Guerrero-Suarez PD, Rosales-Amaya AM, Delgado-Arce JC, Guerrero-López DA. Endoscopic endonasal lateral transellar approach for growth hormone-secreting adenomas with cavernous sinus invasion: Technical note and surgical results. Neurocirugia (Astur) 2020; 32:S1130-1473(20)30081-6. [PMID: 32690399 DOI: 10.1016/j.neucir.2020.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 05/07/2020] [Accepted: 05/27/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Cavernous sinus (CS) invasion is found in 15-20% of pituitary adenomas; it represents a poor prognosis factor and a surgical challenge even in experienced pituitary centers. We present our experience and technical note description for surgical management of pituitary adenomas with CS invasion in acromegaly by the transsellar lateral approach with an endoscopic endonasal transsphenoidal route. METHOD prospective case series of patients who underwent endoscopic endonasal surgery for Growing Hormone (GH) producing adenomas with CS invasion treated at the Neurosurgery departments of National Institute of Neurology and Neurosurgery in Mexico City, and of Toluca Medical Center of Social Security Institute of the State of Mexico and Provinces between January 2014 and March 2019. RESULTS Thirty-two of 94 patients with diagnosis of pituitary adenoma treated at our institutions (34%) had acromegaly; thirteen of patients with acromegaly diagnosis met the inclusion criteria for CS invasion. Postoperative images reported gross total resection in 10 patients (76.9%). Mean follow-up time was 28.3 months. Remission criteria were achieved in nine patients (69.2%), with one of these patients (11.1%) having recurrence during follow up. All patients with no biochemical remission had improvement in GH and IGF profiles. Three patients without remission underwent radiosurgery (14Gy), and one patient had remission after the procedure. CONCLUSIONS We consider this to be a safe and efficient approach for tumors invading CS, when surgical team have good experience in endoscopy of the skull base and reconstruction techniques, appropriate instruments are available, and tumor has soft consistency.
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Affiliation(s)
- Juan Luis Gómez-Amador
- Department of Neurosurgery, National Institute of Neurology and Neurosurgery Manuel Velasco Suarez, Insurgentes Sur Av. 3877, Barrio La Fama, Postal Code 14269 Mexico City, Mexico
| | - Jaime Jesús Martínez-Anda
- Neurosurgery Department, Toluca Medical Center of Social Security Institute of the State of Mexico and Provinces Baja Velocidad, Av. 57.5km Mexico - Toluca Highway, Postal Code 52140 Metepec, State of Mexico, Mexico.
| | - Pablo David Guerrero-Suarez
- Neurosurgery Department, Toluca Medical Center of Social Security Institute of the State of Mexico and Provinces Baja Velocidad, Av. 57.5km Mexico - Toluca Highway, Postal Code 52140 Metepec, State of Mexico, Mexico
| | - Arturo Miguel Rosales-Amaya
- Neurosurgery Department, Toluca Medical Center of Social Security Institute of the State of Mexico and Provinces Baja Velocidad, Av. 57.5km Mexico - Toluca Highway, Postal Code 52140 Metepec, State of Mexico, Mexico
| | - Julio Cesar Delgado-Arce
- Neurosurgery Department, Toluca Medical Center of Social Security Institute of the State of Mexico and Provinces Baja Velocidad, Av. 57.5km Mexico - Toluca Highway, Postal Code 52140 Metepec, State of Mexico, Mexico
| | - David Antonio Guerrero-López
- Neurosurgery Department, Toluca Medical Center of Social Security Institute of the State of Mexico and Provinces Baja Velocidad, Av. 57.5km Mexico - Toluca Highway, Postal Code 52140 Metepec, State of Mexico, Mexico
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Micko A, Oberndorfer J, Weninger WJ, Vila G, Höftberger R, Wolfsberger S, Knosp E. Challenging Knosp high-grade pituitary adenomas. J Neurosurg 2020; 132:1739-1746. [PMID: 31151112 DOI: 10.3171/2019.3.jns19367] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 03/04/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Parasellar growth is one of the most important prognostic variables of pituitary adenoma surgery, with adenomas regarded as not completely resectable if they invade the cavernous sinus (CS) but potentially curable if they displace CS structures. This study was conducted to correlate surgical treatment options and outcomes to the different biological behaviors (invasion vs displacement) of adenomas with parasellar extension into the superior or inferior CS compartments or completely encasing the carotid artery (Knosp high grades 3A, 3B, and 4). METHODS This was a retrospective cohort analysis of 106 consecutive patients with Knosp high-grade pituitary adenomas with parasellar extension who underwent surgery via a primary endoscopic transsphenoidal approach between 2003 and 2017. Biological tumor characteristics (surgical status of invasiveness and tumor texture, 2017 WHO classification, proliferation rate), extent of resection, and complication rate were correlated with parasellar extension grades 3A, 3B, and 4 on preoperative MRI studies. RESULTS Invasiveness was significantly less common in grade 3A (44%) than in grade 3B (72%, p = 0.037) and grade 4 (100%, p < 0.001) adenomas. Fibrous tumor texture was significantly more common in grade 4 (52%) compared to grade 3A (20%, p = 0.002), but not compared to grade 3B (28%) adenomas. Functioning macroadenomas had a significantly higher rate of invasiveness than nonfunctioning adenomas (91% vs 55%, p = 0.002). Mean proliferation rate assessed by MIB-1 was > 3% in all groups but without significant difference between the groups (grade 3A, 3.2%; 3B, 3.9%; 4, 3.7%). Rates of endocrine remission/gross-total resection were significantly higher in grade 3A (64%) than in grade 3B (33%, p = 0.021) and grade 4 (0%, p < 0.001) adenomas. In terms of complication rates, no significant difference was observed between grades. CONCLUSIONS According to the authors' data, the biological behavior of pituitary adenomas varies significantly between parasellar extension patterns. Adenomas with extension into the superior CS compartment have a lower rate of invasive growth than adenomas extending into the inferior CS compartment or encasing the carotid artery. Consequently, a significantly higher rate of remission can be achieved in grade 3A than in grade 3B and grade 4 adenomas. Therefore, the distinction into grades 3A, 3B, and 4 is of importance for prediction of adenoma invasion and surgical treatment considerations.
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Affiliation(s)
| | | | | | - Greisa Vila
- 3Department of Internal Medicine III, Clinical Division of Endocrinology and Metabolism, and
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Micko A, Hosmann A, Marik W, Bartsch S, Weber M, Knosp E, Wolfsberger S. Optimizing MR imaging for intraoperative image guidance in sellar pathologies. Pituitary 2020; 23:266-272. [PMID: 32170516 PMCID: PMC7181417 DOI: 10.1007/s11102-020-01035-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE With the advancement of extended endonasal approaches, the ability to surgically reach parasellar tumor extensions increase. The aim of the study was to propose an optimized imaging protocol for surgical guidance in the cavernous sinus (CS) for proper visualization structures at risk. METHODS Prospective case control analysis of 20 consecutive pituitary adenoma patients scheduled for endoscopic transnasal surgery. Assessment of the capability of three different MRI sequences (MPRAGE, VIBE, CISS) by 4 investigators to correctly visualize sellar and parasellar structures. Invasiveness and position of the normal pituitary gland were compared with the intraoperative findings. RESULTS The consensus between the 4 examiners to achieve the same results for all modalities was 40% for MPRAGE, 70% for VIBE and 60% for CISS sequences (p = 0.155). A consensus of Knosp Grade per patient was 80% for MPRAGE, 100% for VIBE and 90% for CISS (overall kappa 0.60). A higher Knosp Grade was found in MPRAGE sequences compared to the other sequences. Intraoperative status of invasiveness was correctly identified in 12/20 (60%) with MPRAGE, 19/20 (95%) with VIBE and 11/20 (55%) with CISS sequences. The position of the normal pituitary gland was most frequent evaluable in 15/20 (75%) and correctly identified in 12/15 (80%) cases. CONCLUSION Our data showed that VIBE sequences obtain the highest degree of consensus with intraoperative findings of invasiveness and position of the normal pituitary gland. VIBE sequences, due to their high spatial resolution and at the same time fast image acquisition could provide improved imaging for neuronavigation.
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Affiliation(s)
- Alexander Micko
- Department of Neurosurgery, Medical University of Vienna, Waehringer Guertel 18-20, 1097, Vienna, Austria
| | - Arthur Hosmann
- Department of Neurosurgery, Medical University of Vienna, Waehringer Guertel 18-20, 1097, Vienna, Austria
| | - Wolfgang Marik
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Sophie Bartsch
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Michael Weber
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Engelbert Knosp
- Department of Neurosurgery, Medical University of Vienna, Waehringer Guertel 18-20, 1097, Vienna, Austria
| | - Stefan Wolfsberger
- Department of Neurosurgery, Medical University of Vienna, Waehringer Guertel 18-20, 1097, Vienna, Austria.
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Soliman MAR, Eaton S, Quint E, Alkhamees AF, Shahab S, O'Connor A, Haberfellner E, Im J, Elashaal AA, Ling F, Elbreki M, Dang T, Morassutti DJ, Shamisa A. Challenges, Learning Curve, and Safety of Endoscopic Endonasal Surgery of Sellar-Suprasellar Lesions in a Community Hospital. World Neurosurg 2020; 138:e940-e954. [PMID: 32298827 PMCID: PMC7195030 DOI: 10.1016/j.wneu.2020.04.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 04/04/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND AND OBJECTIVE Endoscopic endonasal surgery (EES) for the management of sellar, suprasellar, and anterior skull base lesions is gaining popularity. Our aim was to analyze and present the clinical outcomes of EES for the management of these lesions in a community hospital setting. METHODS We retrospectively reviewed the charts of 56 patients with sellar, suprasellar, and anterior skull base lesions who underwent EES between 2010 and 2018. RESULTS There was male predominance (53.6%) with a mean age of 54.9 ± 13.7 years. Lesions were 45 pituitary adenomas, 5 meningiomas, 3 metastatic, 1 craniopharyngioma, 1 Rathke cyst, and 1 mucocele. Gross total excision was achieved in 57.1%, subtotal excision occurred in 37.5%, and decompression and biopsy were achieved in 5.4% patients. Postoperative vision normalized or improved in 27 patients (86.1%) and was stable in 4 patients (13.9%). Recovery of a preexisting hormonal deficit occurred in 13 (23.2%) patients, and a new hormonal deficit occurred in 9 patients (16.1%). The mean hospital stay was 6.1 ± 4.9 days. Postoperative complications included cerebrospinal fluid leak in 8 patients (14.3%). Four patients (7.1%) had meningitis. Diabetes insipidus was present in 19 patients (33.9%), and postoperative intracranial hematoma requiring evacuation was necessary in 2 patients (3.6%). The mean follow-up duration was 47.5 ± 25.8 months. Lesion progression or recurrence requiring redo surgery occurred in 5 patients (8.9%). Regarding the learning curve, the postoperative cerebrospinal fluid leak, meningitis, new hormonal deficits, and diabetes insipidus decreased in the second half of the patients. CONCLUSIONS EES provides an effective and safe surgical option with low morbidity and mortality for the treatment of sellar, suprasellar, and anterior skull base lesions in a community hospital setting.
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Affiliation(s)
- Mohamed A R Soliman
- Neurosurgery Department, Cairo University, Cairo, Egypt; Schulich School of Medicine and Density, Western University, London.
| | - Sydney Eaton
- Schulich School of Medicine and Density, Western University, London
| | - Elise Quint
- Schulich School of Medicine and Density, Western University, London
| | - Abdullah F Alkhamees
- Schulich School of Medicine and Density, Western University, London; Neurosurgery Department, Qassim University, Qassim, Kingdom of Saudi Arabia
| | - Saba Shahab
- Schulich School of Medicine and Density, Western University, London
| | - Avalon O'Connor
- Schulich School of Medicine and Density, Western University, London
| | | | - Jacob Im
- Schulich School of Medicine and Density, Western University, London
| | | | - Francis Ling
- Ear, Nose and Throat Department, Windsor Regional Hospital, Western University, ON, Canada
| | - Mustafa Elbreki
- Ear, Nose and Throat Department, Windsor Regional Hospital, Western University, ON, Canada
| | - Tommy Dang
- Neurosurgery Department, Windsor Regional Hospital, Western University, ON, Canada
| | - Dante J Morassutti
- Neurosurgery Department, Windsor Regional Hospital, Western University, ON, Canada
| | - Abdalla Shamisa
- Neurosurgery Department, Windsor Regional Hospital, Western University, ON, Canada
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Micko A, Vila G, Höftberger R, Knosp E, Wolfsberger S. Endoscopic Transsphenoidal Surgery of Microprolactinomas: A Reappraisal of Cure Rate Based on Radiological Criteria. Neurosurgery 2020; 85:508-515. [PMID: 30169711 DOI: 10.1093/neuros/nyy385] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 08/15/2018] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Current standard treatment of microprolactinomas is dopamine agonist therapy. As this drug treatment is lifelong in up to 80% of cases, many patients consult pituitary surgeons regarding a surgical alternative. OBJECTIVE To identify prognostic criteria for surgical remission, we reviewed outcomes of our series of microprolactinomas treated with endoscopic transsphenoidal surgery, with a special emphasis on magnetic resonance adenoma delineation and position. METHODS Our study cohort comprises a single center series of 60 patients operated for histopathologically verified magnetic resonance imaging unequivocally identifiable endosellar microprolactinoma between 2003 and 2017. In 31 patients the adenoma was enclosed by pituitary gland (group ENC), in 29 patients the adenoma was located lateral to the gland adherent to the medial cavernous sinus wall (group LAT). RESULTS After a mean follow-up of 37 mo (range 4-143 mo), remission rate was significantly higher in adenomas enclosed by pituitary gland (group ENC) than adenomas located lateral to the gland (group LAT), with 87% vs 45%, P = .01. Intraoperatively, 4 patients showed signs of invasiveness. Preoperative prolactin levels did not differ between the groups (mean 155 and 187 ng/ml in group ENC and LAT, respectively).A binary logistic regression model revealed that only the radiological criteria applied showed a significant correlation (P = .003) with endocrine remission. CONCLUSION According to our results, remission rate is significantly higher in microprolactinomas enclosed by the pituitary gland. However, the decision for surgery should take into account surgeons experience and possibility of complications.
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Affiliation(s)
- Alexander Micko
- Department of Neurosurgery, Medical University Vienna, Vienna, Austria
| | - Greisa Vila
- Department of Internal Medicine III, Division of Endocrinology and Metabolism, Medical University Vienna, Vienna, Austria
| | | | - Engelbert Knosp
- Department of Neurosurgery, Medical University Vienna, Vienna, Austria
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Aiyer RG, Upreti G. Endoscopic Endo-nasal Trans-Sphenoidal Approach for Pituitary Adenomas: A Prospective Study. Indian J Otolaryngol Head Neck Surg 2020; 72:36-43. [PMID: 32158653 PMCID: PMC7040117 DOI: 10.1007/s12070-019-01725-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 08/09/2019] [Indexed: 11/30/2022] Open
Abstract
The surgical approach for hypophysectomy has undergone sweeping revolution in the past three decades. With the advent of endoscopes, better instrumentation, better illumination and viewing cameras, endoscopic endo-nasal trans-sphenoidal approach to sella has now largely become the norm. The aim of this study is to present our experience, analysing the surgical outcomes of this approach in patients with pituitary adenoma, pertaining to entirety of tumor removal, alleviation of symptoms and rate of complications. This prospective study was conducted at our tertiary health care centre from June 2012 to June 2015. A total of 14 patients, meeting the inclusion criteria, underwent endoscopic trans-sphenoidal hypophysectomy for pituitary adenoma. Age of presentation ranged from 19 to 73 years (mean 43.6 years). 9 patients were female and 5 were male. The most common presenting symptom was headache, followed by visual disturbances. Amongst those with hormonal imbalance, most common were prolactinomas and growth hormone secreting adenomas. Preoperative MRI brain showed macroadenomas in all 14 patients. 7 (50%) patients had suprasellar extension, while 5 (36%) patients had intracavernous extension too. CT paranasal sinuses provided the roadmap for surgery by identifying anatomical variations. Alleviation of headache occurred in all cases. Normalization of altered hormonal profile was seen in all cases. 83.3% of our patients with visual field defects on perimetry showed improvement post-surgery. Recidivism was directly related to the size and extent of adenoma. Transient diabetes insipidus was seen in 4 (28%) cases. Persistent diabetes insipidus occurred in 1 (7%) patient. CSF leak was seen in 2 (14%) patients, 1 (7%) patient developed postoperative meningitis. Most common nasal complication was excessive crusting. There was no incidence of any vascular complications, focal neurological deficit or hypopituitarism in our study. The pure endoscopic approach is a safe, efficacious, and minimally invasive technique for the removal of pituitary adenomas. The results have been encouraging in our prospective study. However, the importance of learning curve in endoscopic skull base surgery and use of a multi-disciplinary collaboration cannot be overemphasized.
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Affiliation(s)
- R. G. Aiyer
- Department of ENT and Head Neck Surgery, Baroda Medical College and SSG Hospital, Vadodara, Gujarat India
| | - Garima Upreti
- Department of ENT and Head Neck Surgery, Government Medical College Silvassa, Shri Vinoba Bhave Civil Hospital, Silvassa, Dadra and Nagar Haveli India
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Chen S, Xu S, Lin F, Zhang X, Liu F, Dong M, Li X, Ma X. Endoscopic surgical treatment of Cushing's disease: A single-center experience of cauterization of peritumoral tissues. Exp Ther Med 2019; 18:4420-4426. [PMID: 31777545 PMCID: PMC6862633 DOI: 10.3892/etm.2019.8075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 09/24/2018] [Indexed: 11/23/2022] Open
Abstract
Endoscopic transsphenoidal surgery is a form of treatment for Cushing's disease that is initially preferred compared with other types of treatment. Peritumoral tissue is inactivated by cauterization if a clear border of the lesion cannot be identified. In order to compare the surgical outcomes and post-operative complications between patients who underwent inactivation (cauterization of peritumoral tissues is referred to as inactivation) and those who did not, the medical records of patients treated between January 2010 and June 2016 were retrospectively reviewed. Furthermore, the results of conventional examinations performed in order to diagnose and locate the tumors, including neuroimaging, high-dose dexamethasone suppression tests and/or bilateral inferior petrosal sinus sampling, were collected. A total of 79 consecutive patients with Cushing's disease were included in the present analysis. Inactivation of peritumoral tissue had been applied in 35 (44.3%) of the cases. A gross total resection was achieved in 73 (92.4%) of the cases, while partial resection had been performed in the remaining six (7.6%). Early post-operative endocrinological remission was attained in 71 (89.8%) of the patients. A total of seven cases suffered from hypopituitarism, while cerebrospinal fluid rhinorrhea and brain stem infarction were recorded in four cases and one case, respectively. During the follow-up, the duration of which ranged between 11 and 62 months, recurrence was documented in five patients, as determined by endocrinal examinations. All of the cases that were initially treated unsuccessfully and those with recurrence achieved endocrinological remission following radiotherapy. Enhanced pituitary magnetic resonance imaging revealed no further enlargement of tumors during follow-up. The extent of endocrinological remission, recurrence and post-operative complications did not significantly differ between patients who underwent inactivation and those who did not. In conclusion, inactivation of peritumoral tissue by cauterization achieved satisfactory results in patients with intricate lesions, however it is comparable to conventional procedures.
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Affiliation(s)
- Songyu Chen
- Department of Neurosurgery, Shanghai Tenth People's Hospital, Tongji University, Shanghai 200072, P.R. China.,Department of Neurosurgery, Qilu Hospital of Shandong University, Jinan, Shandong 250012, P.R. China.,Brain Science Research Institute, Shandong University, Jinan, Shandong 250012, P.R. China
| | - Shujun Xu
- Department of Neurosurgery, Qilu Hospital of Shandong University, Jinan, Shandong 250012, P.R. China.,Brain Science Research Institute, Shandong University, Jinan, Shandong 250012, P.R. China
| | - Fuxin Lin
- Department of Neurosurgery, Qilu Hospital of Shandong University, Jinan, Shandong 250012, P.R. China.,Brain Science Research Institute, Shandong University, Jinan, Shandong 250012, P.R. China.,Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fujian Medical University, Fuzhou, Fujian 350004, P.R. China
| | - Xin Zhang
- Department of Neurosurgery, Qilu Hospital of Shandong University, Jinan, Shandong 250012, P.R. China.,Brain Science Research Institute, Shandong University, Jinan, Shandong 250012, P.R. China
| | - Fuqiang Liu
- Department of Endocrinology, Qilu Hospital of Shandong University, Jinan, Shandong 250012, P.R. China
| | - Ming Dong
- Department of Endocrinology, Qilu Hospital of Shandong University, Jinan, Shandong 250012, P.R. China
| | - Xingang Li
- Department of Neurosurgery, Qilu Hospital of Shandong University, Jinan, Shandong 250012, P.R. China.,Brain Science Research Institute, Shandong University, Jinan, Shandong 250012, P.R. China
| | - Xiangyu Ma
- Department of Neurosurgery, Qilu Hospital of Shandong University, Jinan, Shandong 250012, P.R. China.,Brain Science Research Institute, Shandong University, Jinan, Shandong 250012, P.R. China
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37
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Rutkowski M, Zada G. Management of Pituitary Adenomas Invading the Cavernous Sinus. Neurosurg Clin N Am 2019; 30:445-455. [DOI: 10.1016/j.nec.2019.05.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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38
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Romero ADCB, Lal Gangadharan J, Bander ED, Gobin YP, Anand VK, Schwartz TH. Managing Arterial Injury in Endoscopic Skull Base Surgery: Case Series and Review of the Literature. Oper Neurosurg (Hagerstown) 2019; 13:138-149. [PMID: 28931251 DOI: 10.1227/neu.0000000000001180] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 10/18/2015] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The most feared complications following endoscopic endonasal skull base surgery are arterial vascular injuries. Previously published literature is restricted to internal carotid artery injuries. The ideal method for controlling arterial bleeding during this kind of procedure is debated, and a variety of techniques have been advocated. OBJECTIVE To evaluate the management and outcome following intraoperative arterial injury during endoscopic endonasal skull base surgery. METHODS We performed a retrospective review of a prospectively acquired database of consecutive endonasal endoscopic surgeries at the New York-Presbyterian Hospital/Weill Cornell Medical Center from December 2003 to June 2015 and identified all cases of arterial injury. RESULTS Of 800 cases, there were 4 arterial injuries (0.5%), of which only one involved the internal carotid artery (ICA), for a risk of 0.125%. The other 3 involved the ophthalmic artery, anterior communicating artery, and A1 segment of the anterior cerebral artery. In all cases, definitive treatment involved occlusion of the artery either through endovascular means (3 cases) or direct surgical ligation (1 case). Neurological examinations were unchanged after arterial repair with only 1 small asymptomatic stroke. Literature review identified 7336 patients, of which there were 25 arterial injuries, of which 19 were of the ICA. Hence, the total rate of arterial injury was 0.34% and the rate of ICA injury was 0.26%. Arterial sacrifice was the only reliable method for managing arterial injury. CONCLUSION Arterial injury is an uncommon event after endoscopic endonasal surgery. Attempts at arterial repair are rarely successful, and vessel sacrifice is the most reliable technique at this point.
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Affiliation(s)
- Alicia Del Carmen Becerra Romero
- Department of Neurological Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, New York.,Department of Neurosurgery and Skull Base Surgery, Hospital Ernesto Dornelles, Porto Alegre, Brazil
| | - Jagath Lal Gangadharan
- Department of Neurological Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, New York
| | - Evan D Bander
- Department of Neurological Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, New York
| | - Yves Pierre Gobin
- Department of Neurological Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, New York.,Department of Neuroscience, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, New York.,Department of Radiology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, New York
| | - Vijay K Anand
- Department of Otolaryngology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, New York
| | - Theodore H Schwartz
- Department of Neurological Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, New York.,Department of Neuroscience, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, New York.,Department of Otolaryngology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, New York
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Cohen-Cohen S, Gardner PA, Alves-Belo JT, Truong HQ, Snyderman CH, Wang EW, Fernandez-Miranda JC. The medial wall of the cavernous sinus. Part 2: Selective medial wall resection in 50 pituitary adenoma patients. J Neurosurg 2019; 131:131-140. [PMID: 30192191 DOI: 10.3171/2018.5.jns18595] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 05/02/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Pituitary adenomas often invade the medial wall of the cavernous sinus (CS), but this structure is generally not surgically removed because of the risk of vascular and cranial nerve injury. The purpose of this study was to report the surgical outcomes in a large series of cases of invasive pituitary adenoma in which the medial wall of the CS was selectively removed following an anatomically based, stepwise surgical technique. METHODS The authors' institutional database was reviewed to identify cases of pituitary adenoma with isolated invasion of the medial wall, based on an intraoperative evaluation, in which patients underwent an endoscopic endonasal approach with selective resection of the medial wall of the CS. Cases with CS invasion beyond the medial wall were excluded. Patient complications, resection, and remission rates were assessed. RESULTS Fifty patients were eligible for this study, 15 (30%) with nonfunctional adenomas and 35 (70%) with functional adenomas, including 16 growth hormone-, 10 prolactin-, and 9 adrenocorticotropic hormone (ACTH)-secreting tumors. The average tumor size was 2.3 cm for nonfunctional and 1.3 cm for functional adenomas. Radiographically, 11 cases (22%) were Knosp grade 1, 23 (46%) Knosp grade 2, and 16 (32%) Knosp grade 3. Complete tumor resection, based on intraoperative impression and postoperative MRI, was achieved in all cases. The mean follow-up was 30 months (range 4-64 months) for patients with functional adenomas and 16 months (range 4-30 months) for those with nonfunctional adenomas. At last follow-up, complete biochemical remission (using current criteria) without adjuvant treatment was seen in 34 cases (97%) of functional adenoma. No imaging recurrences were seen in patients who had nonfunctional adenomas. A total of 57 medial walls were removed in 50 patients. Medial wall invasion was histologically confirmed in 93% of nonfunctional adenomas and 83% of functional adenomas. There were no deaths or internal carotid artery injuries, and the average blood loss was 378 ml. Four patients (8%) developed a new, transient cranial nerve palsy, and 2 of these patients required reoperation for blood clot evacuation and fat graft removal. There were no permanent cranial nerve palsies. CONCLUSIONS The medial wall of the CS can be removed safely and effectively, with minimal morbidity and excellent resection and remission rates. Further follow-up is needed to determine the long-term results of this anatomically based technique, which should only be performed by very experienced endonasal skull base teams.
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Affiliation(s)
- Salomon Cohen-Cohen
- Departments of1Neurological Surgery and
- 3Department of Neurological Surgery, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | | | | | | | - Carl H Snyderman
- 2Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and
| | - Eric W Wang
- 2Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and
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Amano K, Aihara Y, Tsuzuki S, Okada Y, Kawamata T. Application of indocyanine green fluorescence endoscopic system in transsphenoidal surgery for pituitary tumors. Acta Neurochir (Wien) 2019; 161:695-706. [PMID: 30762125 DOI: 10.1007/s00701-018-03778-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 12/18/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND For the precise removal of pituitary tumors, preserving the surrounding normal structures, we need real-time intraoperative information on tumor location, margins, and surrounding structures. The aim of this study was to evaluate the benefits of a new intraoperative real-time imaging modality using indocyanine green (ICG) fluorescence through an endoscopic system during transsphenoidal surgery (TSS) for pituitary tumors. METHODS Between August 2013 and October 2014, 20 patients with pituitary and parasellar region tumors underwent TSS using the ICG fluorescence endoscopic system. We used a peripheral vein bolus dose of 6.25 mg/injection of ICG, started with a time counter, and examined how each tissue type increased and decreased in fluorescence through time. RESULTS A total of 33 investigations were performed for 20 patients: 9 had growth hormone secreting adenomas, 6 non-functioning pituitary adenomas, 3 Rathke's cleft cysts, 1 meningioma, and 1 pituicytoma. After the injection of ICG, the intensity of fluorescence of tumor and normal tissues under near-infrared light showed clear differences. We could differentiate tumor margins from adjacent normal tissues and define clearly the surrounding normal structures using the different fluorescent intensities time changes and tissue-specific fluorescence patterns. CONCLUSIONS The ICG endoscopic system is simple, user-friendly, quick, cost-effective, and reliable. The method offered real-time information during TSS to delimit pituitary and parasellar region tumor tissue from surrounding normal structures. This method can contribute to the improvement of total removal rates of tumors, reduction of complications after TSS, saving surgical time, and preserving endocrinological functions.
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Affiliation(s)
- Kosaku Amano
- Department of Neurosurgery, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan.
| | - Yasuo Aihara
- Department of Neurosurgery, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Shunsuke Tsuzuki
- Department of Neurosurgery, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Yoshikazu Okada
- Department of Neurosurgery, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Takakazu Kawamata
- Department of Neurosurgery, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
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Shenouda K, Yuhan BT, Mir A, Gonik N, Eloy JA, Liu JK, Folbe AJ, Svider PF. Endoscopic Resection of Pediatric Skull Base Tumors: An Evidence-Based Review. J Neurol Surg B Skull Base 2018; 80:527-539. [PMID: 31534896 DOI: 10.1055/s-0038-1676305] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Accepted: 10/13/2018] [Indexed: 10/27/2022] Open
Abstract
Objectives To perform a systematic review examining experiences with endoscopic resection of skull base lesions in the pediatric population, with a focus on outcomes, recurrence, and surgical morbidities. Methods PubMed/MEDLINE, Cochrane Library, Embase, and Web of Science databases were evaluated. Studies were assessed for level of evidence. Bias risk was evaluated using the Cochrane Bias tool, Grades of Recommendation, Assessment, Development and Evaluation (GRADE), and Methodological Index for Non-Randomized Studies (MINORS) criteria. Patient characteristics, pathology, site of primary disease, presenting symptoms, stage, procedure specific details, and complications were evaluated. Results were reported using the Preferred Reporting Systems for Systematic Reviews and Meta-Analysis guidelines. Results Ninety-three studies met criteria for inclusion, encompassing 574 patients with skull base tumors. The GRADE and MINORS criteria determined the overall evidence to be moderate quality. The most common benign and malignant pathologies included juvenile nasopharyngeal angiofibromas ( n = 239) and chondrosarcomas ( n = 11) at 41.6 and 1.9%, respectively. Of all juvenile nasopharyngeal angiofibroma tumors, most presented at stage IIIa and IIIb (25.8 and 27.3%, respectively). Nasal obstruction (16.5%) and headache (16.0%) were common symptoms at initial presentation. Surgical approaches included endoscopic endonasal ( n = 193, 41.2%) and endoscopic extended transsphenoidal ( n = 155, 33.1%). Early (< 6 weeks) and late (>6 weeks) complications included cerebrospinal fluid leak ( n = 36, 17.3%) and endocrinopathy ( n = 43, 20.7%). Mean follow-up time was 37 months (0.5-180 months), with 86.5% showing no evidence of disease and 2.1% having died from disease at last follow-up. Conclusion Endoscopic skull base surgery has been shown to be a safe and effective method of treating a variety of pediatric skull base tumors. If appropriately employed, the minimally invasive approach can provide optimal results in the pediatric population.
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Affiliation(s)
- Kerolos Shenouda
- Department of Otolaryngology - Head and Neck Surgery, Wayne State University School of Medicine, Detroit, Michigan, United States
| | - Brian T Yuhan
- Department of Otolaryngology - Head and Neck Surgery, Wayne State University School of Medicine, Detroit, Michigan, United States.,Department of Otolaryngology, William Beaumont Hospital, Royal Oak, Michigan, United States
| | - Ahsan Mir
- Department of Otolaryngology - Head and Neck Surgery, Wayne State University School of Medicine, Detroit, Michigan, United States
| | - Nathan Gonik
- Department of Otolaryngology - Head and Neck Surgery, Wayne State University School of Medicine, Detroit, Michigan, United States.,Children's Hospital of Michigan, Detroit, Michigan, United States
| | - Jean Anderson Eloy
- Department of Otolaryngology - Head and Neck Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey, United States.,Department of Ophthalmology and Visual Science, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey, United States.,Department of Neurological Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey, United States.,Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey, United States
| | - James K Liu
- Department of Otolaryngology - Head and Neck Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey, United States.,Department of Neurological Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey, United States.,Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey, United States
| | - Adam J Folbe
- Department of Otolaryngology, William Beaumont Hospital, Royal Oak, Michigan, United States.,Barbara Ann Karmanos Cancer Institute, Detroit, Michigan, United States
| | - Peter F Svider
- Department of Otolaryngology - Head and Neck Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey, United States
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Abstract
PURPOSE Surgical experience is considered paramount for excellent outcome of transsphenoidal surgery (TSS). However, objective data demonstrating the surgical success in relation to the experience of pituitary surgery units or individual experience of pituitary surgeons is sparse. METHODS Based on literature data, we have investigated the influence of experience with TSS for pituitary adenomas on endocrinological remission rates and on operative complications. The surgical experience was assessed by calculating the number of transsphenoidal operations per year. RESULTS For TSS of microprolactinomas, mean remission rates were 77% in centers with < 2 operations per year for microprolactinomas, 82% with 2-4 operations, 84% with 4-6 operations, and 91% with > 6 operations. A yearly experience with more than 10 initial operations for Cushing's disease (CD) warrants a remission rate exceeding 70%. Remission rates in CD exceeding 86% have only been reported for single surgeon series. Extraordinarily high complication rates were found in some series with < 25 yearly total operations for pituitary adenomas. Major vascular complications were less than 2% and revision rates for rhinorrhea usually < 2.5% in centers performing > 25 transsphenoidal operations per year. CONCLUSIONS We conclude that a center with experience of > 25 transsphenoidal operations for pituitary adenomas per year provides a high likelihood of safe TSS. Surgery for CD requires a particularly high level of practice to guarantee excellent remission rates. The endocrinologist has the unique opportunity to audit the surgical success by hormone measurement and to refer patients to neurosurgeons with proven excellence.
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Affiliation(s)
- Jürgen Honegger
- Department of Neurosurgery, University of Tuebingen, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany.
| | - Florian Grimm
- Department of Neurosurgery, University of Tuebingen, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
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Park HH, Kim EH, Ku CR, Lee EJ, Kim SH. Outcomes of Aggressive Surgical Resection in Growth Hormone–Secreting Pituitary Adenomas with Cavernous Sinus Invasion. World Neurosurg 2018; 117:e280-e289. [DOI: 10.1016/j.wneu.2018.06.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Revised: 06/01/2018] [Accepted: 06/02/2018] [Indexed: 12/19/2022]
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Darwish H, El-Hadi U, Haddad G, Najjar M. Management of Pituitary Adenomas: Mononostril Endoscopic Transsphenoidal Surgery. Basic Clin Neurosci 2018; 9:121-128. [PMID: 29967671 PMCID: PMC6026095 DOI: 10.29252/nirp.bcn.9.2.121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Introduction: The endoscopic transsphenoidal approach for pituitary adenomas and other sellar lesions is quickly becoming the procedure of choice in their surgical management. The most common approach is binostril three-hand technique which requires a large exposure and subjects both nasal cavities to potential trauma. To reduce nasal morbidity, we employ a mononostril two-hand technique with the help of the endoscope holder. In this research, we review our series to determine efficacy of this approach in the management of pituitary adenomas. Methods: We performed a retrospective analysis of our initial series of 64 consecutive patients with pituitary adenomas operated by the same surgical team from 2008 till 2014 using a mononostril endoscopic approach. After categorizing the lesions into microadenomas, noninvasive macroadenomas, and invasive macroadenomas, we reviewed the radiological and biochemical outcomes of the surgeries after 3 months, 12 months, and 18 months. We also assessed recurrences and complications. Extent of resection was divided into gross total resection, near total resection (>90% resection), and partial resection for the remaining. Results: Our results show resection rates comparable to most series in the literature, with a gross total resection of 87% in non-invasive macroadenomas, and surgical disease control in 75% of invasive nonfunctioning adenomas. The remission rate in Cushing’s disease was 81%, where it achieved up to 58% surgical remission in growth hormone secreting pituitary adenomas (including the invasive adenomas). The complication rate was very low. Conclusion: We conclude that the mononostril endoscopic approach is well suited for most pituitary tumor operations and carries comparable remission and resection rates to most endoscopic series with minimal complications and nasal morbidity.
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Affiliation(s)
- Houssein Darwish
- Department of Neurosurgery, School of Medicine, University of Virginia System, Charlottesville, USA.,Department of Neurosurgery, Bahman Hospital, Tehran, Iran
| | - Usamah El-Hadi
- Department of Otolaryngology- Head & Neck Surgery, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Georges Haddad
- Department of Surgery, Division of Neurosurgery, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Marwan Najjar
- Department of Surgery, Division of Neurosurgery, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
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Almutairi RD, Muskens IS, Cote DJ, Dijkman MD, Kavouridis VK, Crocker E, Ghazawi K, Broekman MLD, Smith TR, Mekary RA, Zaidi HA. Gross total resection of pituitary adenomas after endoscopic vs. microscopic transsphenoidal surgery: a meta-analysis. Acta Neurochir (Wien) 2018; 160:1005-1021. [PMID: 29307020 DOI: 10.1007/s00701-017-3438-z] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 12/14/2017] [Indexed: 01/08/2023]
Abstract
BACKGROUND Microscopic transsphenoidal surgery (mTSS) is a well-established method to address adenomas of the pituitary gland. Endoscopic transsphenoidal surgery (eTSS) has become a viable alternative, however. Advocates suggest that the greater illumination, panoramic visualization, and angled endoscopic views afforded by eTSS may allow for higher rates of gross total tumor resection (GTR). The aim of this meta-analysis was to determine the rate of GTR using mTSS and eTSS. METHODS A meta-analysis of the literature was conducted using PubMed, EMBASE, and Cochrane databases through July 2017 in accordance with PRISMA guidelines. RESULTS Seventy case series that reported GTR rate in 8257 pituitary adenoma patients were identified. For all pituitary adenomas, eTSS (GTR=74.0%; I2 = 92.1%) was associated with higher GTR as compared to mTSS (GTR=66.4%; I2 = 84.0%) in a fixed-effect model (P-interaction < 0.01). For functioning pituitary adenomas (FPAs) (n = 1170 patients), there was no significant difference in GTR rate between eTSS (GTR=75.8%; I2 = 63.9%) and mTSS (GTR=75.5%; I2 = 79.0%); (P-interaction = 0.92). For nonfunctioning pituitary adenomas (NFPAs) (n = 2655 patients), eTSS (GTR=71.0%; I2 = 86.4%) was associated with higher GTR as compared to mTSS (GTR=60.7%; I2 = 87.5%) in a fixed-effect model (P-interaction < 0.01). None of the associations were significant in a random-effect model (all P-interaction > 0.05). No significant publication bias was identified for any of the outcomes. CONCLUSION Among patients who were not randomly allocated to either approach, eTSS resulted in a higher rate of GTR as compared to mTSS for all patients and for NFPA patients alone, but only in a fixed-effect model. For FPA, however, eTSS did not seem to offer a significantly higher rate of GTR. These conclusions should be interpreted with caution because of the nature of the included non-comparative studies.
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Affiliation(s)
- Reem D Almutairi
- Department of Pharmaceutical Business and Administrative Sciences, MCPHS University, Boston, MA, USA
- School of Pharmacy, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Ivo S Muskens
- Brain Center Rudolf Magnus, Utrecht University Medical Center, Utrecht, The Netherlands
- Cushing Neurosurgical Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - David J Cote
- Cushing Neurosurgical Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA.
| | - Mark D Dijkman
- Brain Center Rudolf Magnus, Utrecht University Medical Center, Utrecht, The Netherlands
| | - Vasileios K Kavouridis
- Cushing Neurosurgical Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Erin Crocker
- Cushing Neurosurgical Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Kholoud Ghazawi
- Department of Pharmaceutical Business and Administrative Sciences, MCPHS University, Boston, MA, USA
| | - Marike L D Broekman
- Brain Center Rudolf Magnus, Utrecht University Medical Center, Utrecht, The Netherlands
- Cushing Neurosurgical Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Timothy R Smith
- Cushing Neurosurgical Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Rania A Mekary
- Department of Pharmaceutical Business and Administrative Sciences, MCPHS University, Boston, MA, USA
- Cushing Neurosurgical Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Hasan A Zaidi
- Cushing Neurosurgical Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
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Rehman L, Rehman UL, Jabeen R, Rizvi R. Endoscopic Trans-Sphenoidal surgery; Efficacy and response in Pituitary Adenoma. Pak J Med Sci 2018; 34:412-417. [PMID: 29805418 PMCID: PMC5954389 DOI: 10.12669/pjms.342.14002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Objectives: The purpose of the study was to access the efficacy and response of the endoscopic transsphenoidal surgery in pituitary adenomas. Methods: It was descriptive case study, conducted at Neurosurgery Department in collaboration with the Endocrine Unit (Medical Unit-II) Of Jinnah Post Graduate Medical Center Karachi from January 2015 to July 2017. Patients with sellar, supra sellar and para sellar tumors were enrolled in the study. Patients with prolactinoma and recurrent pituitary tumors were excluded. Data was analyzed using SPPS 17. Results: Sixty three patients were included in the study with mean age of 42±8.34 years. There were 40(63.5%) male patients and 23(36.5%) female patients with pituitary adenoma. Headache and visual impairment were the main presentation 55(87.3%) and 56 (88.8%) respectively. Out of all these patients the pituitary adenomas, 51(81%) patients had non secretory and 12 (19%) patients had secretory tumor. Out of these pituitary adenomas 53(84.1%) were macroadenomas and 10(15.9%) were microadenoma. Post operatively marked improvement in the headache was in all 100% patients and vision improved in 54 (96.4%). The most common post operative complication was cerebrospinal fluid (CSF) leak in 10 (15.9%) with 44 (69.8%) having no post complications at all. Mortality was reported to be just 1.6% i-e one patient. Conclusion: The endoscopic transsphenoidal approach for pituitary adenoma is the safest procedure with marked improvement in complications and reduction in patient’s hospital stay.
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Affiliation(s)
- Lal Rehman
- Dr. Lal Rehman, FCPS (NS), MS (NS). Department of Neurosurgery, Jinnah Post Graduate Medical Centre/ Jinnah Sindh Medical University, Karachi, Pakistan
| | - Urooj Lal Rehman
- Dr. Urooj Lal Rehman, MCPS (Med), FCPS (Med), FCPS (Endocrinol). Department of Medicine, Endocrinology and Rheumatology, Jinnah Post Graduate Medical Centre/ Jinnah Sindh Medical University, Karachi, Pakistan
| | - Rukhshanda Jabeen
- Dr. Rukhshanda Jabeen, FCPS (Med). Department of Medicine, Endocrinology and Rheumatology, Jinnah Post Graduate Medical Centre/ Jinnah Sindh Medical University, Karachi, Pakistan
| | - Raza Rizvi
- Dr. Saleem Shah, FCPS PG Trainee (NS). Department of Neurosurgery, Jinnah Post Graduate Medical Centre/ Jinnah Sindh Medical University, Karachi, Pakistan
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Rutkowski MJ, Aghi MK. Medical versus surgical treatment of prolactinomas: an analysis of treatment outcomes. Expert Rev Endocrinol Metab 2018; 13:25-33. [PMID: 30063440 DOI: 10.1080/17446651.2018.1411798] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Prolactinomas are unique tumors that may go into both hormonal and radiographic remission with dopamine agonist therapy or transsphenoidal surgery. Regardless of modality, the goals of therapy remain the same: (1) biochemical remission, including reduction of prolactin and normalization of sex hormones; (2) radiographic tumor control, with a range including prevention of tumor growth, tumor regression, or complete tumor resolution; (3) resolution of preoperative symptoms, including those that are hormonal or neurologic; and (4) prevention of new hypopituitarism or new neurologic symptoms. AREAS COVERED In the following review, we performed a search of the literature using keywords 'prolactinoma,' 'dopamine agonist,' 'surgery,' 'cost-effectiveness,' 'recurrence,' and 'complication' to compare the relative merits of medical versus surgical therapy for prolactinoma, including special circumstances such as cystic tumors, pregnant patients, and the cost-effectiveness of different strategies. EXPERT COMMENTARY Medical therapy can offer a cure, but surgery provides an important adjunct to patients with resistance or intolerance to dopamine agonists, and offers excellent outcomes including when combined with continued postoperative medical therapy. Further head to head comparisons will benefit patients and practitioners weighing the relative risks and benefits of medical and surgical intervention, including the issue of their relative cost-effectiveness.
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Affiliation(s)
- Martin J Rutkowski
- a California Center for Pituitary Disorders, Department of Neurological Surgery , University of California , San Francisco , CA , USA
| | - Manish K Aghi
- a California Center for Pituitary Disorders, Department of Neurological Surgery , University of California , San Francisco , CA , USA
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Ogando-Rivas E, Alalade AF, Boatey J, Schwartz TH. Double pituitary adenomas are most commonly associated with GH- and ACTH-secreting tumors: systematic review of the literature. Pituitary 2017; 20:702-708. [PMID: 28766078 DOI: 10.1007/s11102-017-0826-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Double adenomas in the pituitary gland are a rare occurrence. The ability to cure a hormone-producing adenoma with surgery is dependent on the ability to identify and completely remove the correct adenoma. The relative frequency of each subtype of hormone-secreting adenomas confirmed with magnetic resonance image (MRI), surgery and immunohistochemistry is not defined. METHODS Following PRISMA guidelines, we performed a systematic review of PubMed Central, Google Scholar, Scopus Database, Cochrane database and Science Research, using the key-words: "double pituitary adenomas", "multiple pituitary adenomas" and only papers where multiple or truly separate double pituitary adenomas were identified pre-surgically by MRI and/or confirmed by pathology/immunohistochemistry staining were included. RESULTS We reviewed papers from 1975 to 2016 and found 17 cases with two pituitary adenomas and 1 with three pituitary adenomas. The ages ranged from 22 to 67 years old, and there were twelve females and five males. Immunohistochemical staining showed that the most common double pituitary adenomas were growth hormone (GH)- followed by adrenocorticotropic (ACTH)-secreting. CONCLUSION Double pituitary adenomas are rare but most commonly found with GH- or ACTH-producing tumors. It is critical to remove all identified possible adenomas to achieve biochemical cure and clinicians should have heightened sensitivity in patients with acromegaly or Cushing's Disease.
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Affiliation(s)
- Elizabeth Ogando-Rivas
- Department of Neurosurgery, New York Presbyterian Hospital, Weill Cornell Medical College, Box 99, 525 East 68th St., New York, NY, 10065, USA
| | - Andrew F Alalade
- Department of Neurosurgery, New York Presbyterian Hospital, Weill Cornell Medical College, Box 99, 525 East 68th St., New York, NY, 10065, USA
| | - Jerome Boatey
- Department of Neurosurgery, New York Presbyterian Hospital, Weill Cornell Medical College, Box 99, 525 East 68th St., New York, NY, 10065, USA
| | - Theodore H Schwartz
- Department of Neurosurgery, New York Presbyterian Hospital, Weill Cornell Medical College, Box 99, 525 East 68th St., New York, NY, 10065, USA.
- Department of Otolaryngology, New York Presbyterian Hospital, Weill Cornell Medical College, Box 99, 525 East 68th St., New York, NY, 10065, USA.
- Department of Neuroscience, New York Presbyterian Hospital, Weill Cornell Medical College, Box 99, 525 East 68th St., New York, NY, 10065, USA.
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Sarkar S, Philip VJ, Cherukuri SK, Chacko AG, Chacko G. Implications of the World Health Organization definition of atypia on surgically treated functional and non-functional pituitary adenomas. Acta Neurochir (Wien) 2017; 159:2179-2186. [PMID: 28573325 DOI: 10.1007/s00701-017-3223-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 05/11/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND The World Health Organization (WHO) defines atypical pituitary adenomas as tumours with a MIB-1 labelling index ≥3%, p53 positivity and increased mitotic activity. Although a few reports have described the clinical and radiological correlates of atypia in pituitary adenomas, its impact on postoperative outcomes is not clearly defined. METHOD We reviewed preoperative and postoperative records of patients undergoing surgery for pituitary adenomas. Postoperative outcomes for functional adenomas (FPAs) were assessed according to contemporary definitions of remission and recurrence. For non-functional pituitary adenomas (NFPAs), extent of resection and disease progression were defined on the basis of postoperative magnetic resonance imaging. RESULTS Of 394 patients included for analysis, 29 cases (7.4%) fulfilled criteria for atypia. Patients with atypical tumours were significantly younger than those with typical adenomas. Remission was possible in 47.4% of FPAs, and was unrelated to the presence of atypia. In NFPAs, local invasiveness was negatively associated with extent of resection (OR, 0.255; 95% CI, 0.086-0.753; p < 0.001). In 93 NFPAs followed postoperatively with serial imaging over a mean duration of 37.5 months, disease progression/recurrence was significantly associated with the presence of atypia (OR, 5.058; 95% CI, 1.273-20.098; p = 0.021) on multivariate analysis. CONCLUSIONS Patients with atypical non-functional pituitary adenomas are at risk for postoperative recurrence and disease progression, suggesting a need for adjuvant therapy. However, only a small fraction of pituitary tumours demonstrate atypia, as defined by the WHO, limiting its clinical utility.
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Negm HM, Al-Mahfoudh R, Pai M, Singh H, Cohen S, Dhandapani S, Anand VK, Schwartz TH. Reoperative endoscopic endonasal surgery for residual or recurrent pituitary adenomas. J Neurosurg 2017; 127:397-408. [DOI: 10.3171/2016.8.jns152709] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVERegrowth of the lesion after surgical removal of pituitary adenomas is uncommon unless subtotal resection was originally achieved in the first surgery. Treatment for recurrent tumor can involve surgery or radiotherapy. Locations of residual tumor may vary based on the original approach. The authors evaluated the specific sites of residual or recurrent tumor after different transsphenoidal approaches and describe the surgical outcome of endoscopic endonasal transsphenoidal reoperation.METHODSThe authors analyzed a prospectively collected database of a consecutive series of patients who had undergone endoscopic endonasal surgeries for residual or recurrent pituitary adenomas after an original transsphenoidal microscopic or endoscopic surgery. The site of the recurrent tumor and outcome after reoperation were noted and correlated with the primary surgical approach. The chi-square or Fisher exact test was used to compare categorical variables, and the Mann-Whitney U-test was used to compare continuous variables between surgical groups.RESULTSForty-one patients underwent surgery for residual/recurrent pituitary adenoma from 2004 to 2015 at Weill Cornell Medical College. The previous treatment was a transsphenoidal microscopic (n = 22) and endoscopic endonasal (n = 19) surgery. In 83.3% patients (n = 30/36) there was postoperative residual tumor after the initial surgery. A residual tumor following endonasal endoscopic surgery was less common in the sphenoid sinus (10.5%; 2/19) than it was after microscopic transsphenoidal surgery (72.7%; n =16/22; p = 0.004). Gross-total resection (GTR) was achieved in 58.5%, and either GTR or near-total resection was achieved in 92.7%. Across all cases, the average extent of resection was 93.7%. The rate of GTR was lower in patients with Knosp-Steiner Grade 3–4 invasion (p < 0.0005). Postoperative CSF leak was seen in only one case (2.4%), which stopped with lumbar drainage. Visual fields improved in 52.9% (n = 9/17) of patients and were stable in 47% (n = 8/17). Endocrine remission was achieved in 77.8% (n = 14/18) of cases, 12 by surgery alone and 2 by adjuvant medical (n = 1) and radiation (n = 1) therapy. New diabetes insipidus occurred in 4.9% (n = 2/41) of patients—in one of whom an additional single anterior hormonal axis was compromised—and 9.7% (n = 4/41) of patients had a new anterior pituitary hormonal insufficiency.CONCLUSIONSEndonasal endoscopic reoperation is extremely effective at removing recurrent or residual pituitary adenomas that remain after a prior surgery, and it may be preferable to radiation therapy particularly in symptomatic patients. Achievement of GTR is less common when lateral cavernous sinus invasion is present. The locations of residual/recurrent tumor were more likely sphenoidal and parasellar following a prior microscopic transsphenoidal surgery and sellar following a prior endonasal endoscopic surgery.
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Affiliation(s)
- Hazem M. Negm
- Departments of 1Neurological Surgery,
- 4Department of Neurosurgery, Menoufia University, Menoufia, Egypt
| | - Rafid Al-Mahfoudh
- Departments of 1Neurological Surgery,
- 5South East Neurosurgery and Spinal Surgery, Brighton and Sussex University Hospitals NHS Trust, East Sussex, United Kingdom
| | - Manish Pai
- Departments of 1Neurological Surgery,
- 6Tata Main Hospital, Jamshedpur, India
| | - Harminder Singh
- Departments of 1Neurological Surgery,
- 9Stanford University School of Medicine, Stanford, California
| | - Salomon Cohen
- Departments of 1Neurological Surgery,
- 7Department of Neurosurgery, National Institute of Neurology and Neurosurgery, “Manuel Velasco Suarez,” Mexico City, Mexico
| | - Sivashanmugam Dhandapani
- Departments of 1Neurological Surgery,
- 8Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India; and
| | | | - Theodore H. Schwartz
- Departments of 1Neurological Surgery,
- 2Otolaryngology, and
- 3Neuroscience, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York
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