1
|
Little AS, Karsy M, Evans JJ, Kim W, Pacione DR, Kim AH, Gardner PA, Hendricks BK, Sarris CE, Torok IE, Low TM, Crocker TA, Valappil B, Kanga M, Abdallah H, Collopy S, Fernandez-Miranda JC, Vigo V, Ljubimov VA, Zada G, Garrett NE, Delery W, Yuen KCJ, Rennert RC, Couldwell WT, Silverstein JM, Kshettry VR, Chicoine MR. Multicenter Registry of Adenomas of the Pituitary and Related Disorders: Initial Description of Cushing Disease Cohort, Surgical Outcomes, and Surgeon Characteristics. Neurosurgery 2024; 95:372-379. [PMID: 39008545 DOI: 10.1227/neu.0000000000002888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 01/04/2024] [Indexed: 07/17/2024] Open
Abstract
BACKGROUND AND OBJECTIVES To address the lack of a multicenter pituitary surgery research consortium in the United States, we established the Registry of Adenomas of the Pituitary and Related Disorders (RAPID). The goals of RAPID are to examine surgical outcomes, improve patient care, disseminate best practices, and facilitate multicenter surgery research at scale. Our initial focus is Cushing disease (CD). This study aims to describe the current RAPID patient cohort, explore surgical outcomes, and lay the foundation for future studies addressing the limitations of previous studies. METHODS Prospectively and retrospectively obtained data from participating sites were aggregated using a cloud-based registry and analyzed retrospectively. Standard preoperative variables and outcome measures included length of stay, unplanned readmission, and remission. RESULTS By July 2023, 528 patients with CD had been treated by 26 neurosurgeons with varying levels of experience at 9 academic pituitary centers. No surgeon treated more than 81 of 528 (15.3%) patients. The mean ± SD patient age was 43.8 ± 13.9 years, and most patients were female (82.2%, 433/527). The mean tumor diameter was 0.8 ± 2.7 cm. Most patients (76.6%, 354/462) had no prior treatment. The most common pathology was corticotroph tumor (76.8%, 381/496). The mean length of stay was 3.8 ± 2.5 days. The most common discharge destination was home (97.2%, 513/528). Two patients (0.4%, 2/528) died perioperatively. A total of 57 patients (11.0%, 57/519) required an unplanned hospital readmission within 90 days of surgery. The median actuarial disease-free survival after index surgery was 8.5 years. CONCLUSION This study examined an evolving multicenter collaboration on patient outcomes after surgery for CD. Our results provide novel insights on surgical outcomes not possible in prior single-center studies or with national administrative data sets. This collaboration will power future studies to better advance the standard of care for patients with CD.
Collapse
Affiliation(s)
- Andrew S Little
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix , Arizona , USA
| | - Michael Karsy
- Department of Neurosurgery, Drexel University College of Medicine, Drexel University, Philadelphia , Pennsylvania , USA
| | - James J Evans
- Department of Neurosurgery, Jefferson University, Philadelphia , Pennsylvania , USA
| | - Won Kim
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles , California , USA
| | - Donato R Pacione
- Department of Neurosurgery, New York University, New York , New York , USA
| | - Albert H Kim
- Department of Neurosurgery, Washington University School of Medicine, St Louis , Missouri , USA
| | - Paul A Gardner
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh , Pennsylvania , USA
| | - Benjamin K Hendricks
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix , Arizona , USA
| | - Christina E Sarris
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix , Arizona , USA
| | - Ildiko E Torok
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix , Arizona , USA
| | - Trevor M Low
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix , Arizona , USA
| | - Tomiko A Crocker
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix , Arizona , USA
| | - Benita Valappil
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh , Pennsylvania , USA
| | - Mridu Kanga
- Department of Neurosurgery, Washington University School of Medicine, St Louis , Missouri , USA
| | - Hussein Abdallah
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh , Pennsylvania , USA
| | - Sarah Collopy
- Department of Neurosurgery, Jefferson University, Philadelphia , Pennsylvania , USA
| | | | - Vera Vigo
- Department of Neurosurgery, Stanford University, Palo Alto , California , USA
| | - Vladimir A Ljubimov
- Department of Neurosurgery, Stanford University, Palo Alto , California , USA
| | - Gabriel Zada
- Department of Neurosurgery, University of Southern California, Los Angeles , California , USA
| | - Norman E Garrett
- Department of Neurosurgery, University of Southern California, Los Angeles , California , USA
| | - William Delery
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles , California , USA
| | - Kevin C J Yuen
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix , Arizona , USA
| | - Robert C Rennert
- Department of Neurosurgery, University of Utah, Salt Lake City , Utah , USA
| | | | - Julie M Silverstein
- Division of Endocrinology, Metabolism and Lipid Research, Washington University School of Medicine, St Louis , Missouri , USA
| | - Varun R Kshettry
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland , Ohio , USA
| | - Michael R Chicoine
- Department of Neurosurgery, University of Missouri, Columbia , Missouri , USA
| |
Collapse
|
2
|
Findlay MC, Tenhoeve S, Alt J, Rennert RC, Couldwell WT, Evans J, Collopy S, Kim W, Delery W, Pacione D, Kim A, Silverstein JM, Chicoine MR, Gardner P, Rotman L, Yuen KCJ, Barkhoudarian G, Fernandez-Miranda J, Benjamin C, Kshettry VR, Zada G, Van Gompel J, Catalino MHS, Little AS, Karsy M. Predictors of Durable Remission After Successful Surgery for Cushing Disease: Results From the Multicenter RAPID Registry. Neurosurgery 2024:00006123-990000000-01223. [PMID: 38905223 DOI: 10.1227/neu.0000000000003042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 04/14/2024] [Indexed: 06/23/2024] Open
Abstract
BACKGROUND AND OBJECTIVE Cushing disease (CD) affects mortality and quality of life along with limited long-term remission, underscoring the need to better identify recurrence risk. The identification of surgical or imaging predictors for CD remission after transsphenoidal surgery has yielded some inconsistent results and has been limited by single-center, single-surgeon, or meta-analyses studies. We sought to evaluate the multicenter Registry of Adenomas of the Pituitary and Related Disorders (RAPID) database of academic US pituitary centers to assess whether robust nonhormonal recurrence predictors could be elucidated. METHODS Patients with treated CD from 2011 to 2023 were included. The perioperative and long-term characteristics of CD patients with and without recurrence were assessed using univariable and multivariable analyses. RESULTS Of 383 patients with CD from 26 surgeons achieving postoperative remission, 288 (75.2%) maintained remission at last follow-up while 95 (24.8%) showed recurrence (median time to recurrence 9.99 ± 1.34 years). Patients with recurrence required longer postoperative hospital stays (5 ± 3 vs 4 ± 2 days, P = .002), had larger average tumor volumes (1.76 ± 2.53 cm3 vs 0.49 ± 1.17 cm3, P = .0001), and more often previously failed prior treatment (31.1% vs 14.9%, P = .001) mostly being prior surgery. Multivariable hazard prediction models for tumor recurrence found younger age (odds ratio [OR] = 0.95, P = .002) and Knosp grade of 0 (OR = 0.09, reference Knosp grade 4, P = .03) to be protective against recurrence. Comparison of Knosp grade 0 to 2 vs 3 to 4 showed that lower grades had reduced risk of recurrence (OR = 0.27, P = .04). Other factors such as length of stay, surgeon experience, prior tumor treatment, and Knosp grades 1, 2, or 3 failed to reach levels of statistical significance in multivariable analysis. CONCLUSION This multicenter study centers suggests that the strongest predictors of recurrence include tumor size/invasion and age. This insight can help with patient counseling and prognostication. Long-term follow-up is necessary for patients, and early treatment of small tumors may improve outcomes.
Collapse
Affiliation(s)
- Matthew C Findlay
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
- School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Sam Tenhoeve
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
- School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Jeremiah Alt
- Department of Otolaryngology-Head and Neck Surgery, University of Utah, Salt Lake City, Utah, USA
| | - Robert C Rennert
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - William T Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - James Evans
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Sarah Collopy
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Won Kim
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, California, USA
| | - William Delery
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, California, USA
| | - Donato Pacione
- Department of Neurosurgery, New York University, Lagone Medical Center, New York, New York, USA
| | - Albert Kim
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Julie M Silverstein
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri, USA
- Division of Endocrinology, Metabolism, & Lipid Research, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Michael R Chicoine
- Department of Neurosurgery, University of Missouri, Columbia, Missouri, USA
| | - Paul Gardner
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburg, Pennsylvania, USA
| | - Lauren Rotman
- Department of Neurosurgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Kevin C J Yuen
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Garni Barkhoudarian
- Department of Neurosurgery, Providence Medical Center, Los Angeles, California, USA
| | | | - Carolina Benjamin
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Varun R Kshettry
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Gabriel Zada
- Department of Neurosurgery, University of Southern California, Los Angeles, California, USA
| | - Jamie Van Gompel
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael H S Catalino
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Andrew S Little
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Michael Karsy
- Global Neurosciences Institute, Philadelphia, Pennsylvania, USA
- Department of Neurosurgery, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| |
Collapse
|
3
|
Pontes JPM, Udoma-Udofa OC, de Oliveira JS, Larcipretti ALL, Dagostin CS, Gomes FC, Nager GB, de Andrade Bannach M. Efficacy and safety of cavernous sinus medial wall resection in pituitary adenoma surgery: a systematic review and a single-arm meta-analysis. Pituitary 2023:10.1007/s11102-023-01332-5. [PMID: 37382779 DOI: 10.1007/s11102-023-01332-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/04/2023] [Indexed: 06/30/2023]
Abstract
INTRODUCTION Pituitary adenomas, benign tumors, can lower quality of life. Pituitary adenomas that invade the medial wall and cavernous sinus (CS) indicate tumor recurrence and partial surgical excision. Despite the cavernous sinus's complexity and risks, new research has improved the surgical procedure and made excision safer. This comprehensive review and single-arm meta-analysis evaluates endocrinological remission and resection rates in pituitary adenomas to determine the benefits and risks of MWCS resection. METHODS Databases were systematically searched for studies documenting the resection of the medial wall of the cavernous sinus. The primary outcome was endocrinological remission in patients who underwent resection of the MWCS. RESULTS Eight studies were included in the final analysis. The pooled proportion of endocrinological remission (ER) was 63.3%. The excision of MWCS pooled a gross total resection (GTR) proportion of 72.9%. Finally, ICA injury attained a pooled ratio of 0.5%, indicating minimal morbidity in the procedure. CONCLUSION The cavernous sinus was ruled out, proving the MWCS excision is safe. Limiting population selection to Knosp 3A or lower enhanced GTR frequencies and lowered recurrence, according to subgroup analyses. This meta-analysis shows that MWCS resection can be a beneficial treatment option for pituitary tumors, when there is no macroscopic medial wall invasion and careful patient selection is done, especially for GH- and ACTH-producing tumors that can cause life-threatening metabolic changes.
Collapse
Affiliation(s)
- Julia Pereira Muniz Pontes
- Department of Surgical Specialties, Neurosurgery Teaching and Assistance Unit, Pedro Ernesto University Hospital, Rio de Janeiro State University, Rio de Janeiro, Brazil.
| | | | | | | | | | | | - Gabriela Borges Nager
- Faculty of Medicine, Federal University of the State of Rio de Janeiro, Rio de Janeiro, Brazil
| | | |
Collapse
|
4
|
Castle-Kirszbaum M, Amukotuwa S, Fuller P, Goldschlager T, Gonzalvo A, Kam J, Kow CY, Shi MD, Stuckey S. MRI for Cushing Disease: A Systematic Review. AJNR Am J Neuroradiol 2023; 44:311-316. [PMID: 36759141 PMCID: PMC10187804 DOI: 10.3174/ajnr.a7789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 10/11/2022] [Indexed: 02/11/2023]
Abstract
BACKGROUND MR imaging is key in the diagnostic work-up of Cushing disease. The sensitivity of MR imaging in Cushing disease is not known nor is the prognostic significance of "MR imaging-negative" disease. PURPOSE Our aim was to determine the overall sensitivity and prognostic significance of MR imaging localization of Cushing disease. DATA SOURCES We performed a systematic review of the MEDLINE and PubMed databases for cohort studies reporting the sensitivity of MR imaging for the detection of adenomas in Cushing disease. STUDY SELECTION This study included 57 studies, comprising 5651 patients. DATA ANALYSIS Risk of bias was assessed using the methodological index for non-randomized studies criteria. Meta-analysis of proportions and pooled subgroup analysis were performed. DATA SYNTHESIS Overall sensitivity was 73.4% (95% CI, 68.8%-77.7%), and the sensitivity for microadenomas was 70.6% (66.2%-74.6%). There was a trend toward greater sensitivity in more recent studies and with the use of higher-field-strength scanners. Thinner-section acquisitions and gadolinium-enhanced imaging, particularly dynamic sequences, also increased the sensitivity. The use of FLAIR and newer 3D spoiled gradient-echo and FSE sequences, such as spoiled gradient-echo sequences and sampling perfection with application-optimized contrasts by using different flip angle evolutions, may further increase the sensitivity but appear complementary to standard 2D spin-echo sequences. MR imaging detection conferred a 2.63-fold (95% CI, 2.06-3.35-fold) increase in remission for microadenomas compared with MR imaging-negative Cushing disease. LIMITATIONS Pooled analysis is limited by heterogeneity among studies. We could not account for variation in image interpretation and tumor characteristics. CONCLUSIONS Detection on MR imaging improves the chances of curative resection of adenomas in Cushing disease. The evolution of MR imaging technology has improved the sensitivity for adenoma detection. Given the prognostic importance of MR imaging localization, further effort should be made to improve MR imaging protocols for Cushing disease.
Collapse
Affiliation(s)
- M Castle-Kirszbaum
- From the Departments of Neurosurgery (M.C.-K., T.G., J.K., C.Y.K.)
- Surgery (M.C.-K., T.G.), Monash Health, Melbourne, Australia
| | | | - P Fuller
- Endocrinology (P.F.)
- Hudson Institute (P.F.), Melbourne, Australia
| | - T Goldschlager
- From the Departments of Neurosurgery (M.C.-K., T.G., J.K., C.Y.K.)
- Surgery (M.C.-K., T.G.), Monash Health, Melbourne, Australia
| | - A Gonzalvo
- Department of Neurosurgery (A.G., J.K.), Austin Hospital, Melbourne, Australia
| | - J Kam
- From the Departments of Neurosurgery (M.C.-K., T.G., J.K., C.Y.K.)
- Department of Neurosurgery (A.G., J.K.), Austin Hospital, Melbourne, Australia
| | - C Y Kow
- From the Departments of Neurosurgery (M.C.-K., T.G., J.K., C.Y.K.)
| | - M D Shi
- Barwon Health (M.D.S.), Geelong, Australia
| | - S Stuckey
- Department of Radiology (S.S.), Peter MacCallum Cancer Centre, Melbourne, Australia
| |
Collapse
|
5
|
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.
Collapse
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
| |
Collapse
|
6
|
Wang B, Zheng S, Ren J, Zhong Z, Jiang H, Sun Q, Su T, Wang W, Sun Y, Bian L. Reoperation for Recurrent and Persistent Cushing's Disease without Visible MRI Findings. J Clin Med 2022; 11:jcm11226848. [PMID: 36431325 PMCID: PMC9699622 DOI: 10.3390/jcm11226848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 11/11/2022] [Accepted: 11/17/2022] [Indexed: 11/22/2022] Open
Abstract
PURPOSE Transsphenoidal surgery is the first-line treatment for Cushing's disease (CD), even with negative preoperative magnetic resonance imaging (MRI) results. Some patients with persistent or recurring hypercortisolism have negative MRI findings after the initial surgery. We aimed to analyze the efficacy of repeat surgery in two groups of patients and determine if there is an association between positive MRI findings and early remission. PATIENTS AND METHODS Clinical, imaging, and biochemical information of 42 patients who underwent repeat surgery by a single neurosurgeon between 2002 and 2021 was retrospectively analyzed. We compared the endocrinological, histopathological, and surgical outcomes before and after repeat surgery among 14 CD patients with negative MRI findings and 28 patients with positive MRI findings. RESULTS Immediate remission was achieved in 29 patients (69.0%) who underwent repeat surgery. Among all patients, 28 (66.7%) had MRI findings consistent with solid lesions. There was no significant difference in remission rates between the recurrence and persistence groups (77.8% vs. 57.1%, odds ratio = 2.625, 95% confidence interval = 0.651 to 10.586). Patients in remission after repeat surgery were not associated with positive MRI findings (odds ratio = 3.667, 95% confidence interval = 0.920 to 14.622). CONCLUSIONS In terms of recurrence, repeat surgery in patients with either positive or negative MRI findings showed reasonable remission rates. For persistent disease with positive MRI findings, repeat surgery is still an option; however, more solid evidence is needed to determine if negative MRI findings are predictors for failed reoperations for persistent hypercortisolism.
Collapse
Affiliation(s)
- Baofeng Wang
- Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Shuying Zheng
- Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Jie Ren
- Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Zhihong Zhong
- Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Hong Jiang
- Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Qingfang Sun
- Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Tingwei Su
- Department of Endocrinology and Metabolic Disease, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Weiqing Wang
- Department of Endocrinology and Metabolic Disease, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Yuhao Sun
- Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
- Correspondence: (Y.S.); or (L.B.)
| | - Liuguan Bian
- Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
- Correspondence: (Y.S.); or (L.B.)
| |
Collapse
|
7
|
de Macêdo Filho LJM, Diógenes AVG, Barreto EG, Pahwa B, Samson SL, Chaichana K, Quinones-Hinojosa A, Almeida JP. Endoscopic Endonasal Resection of the Medial Wall of the Cavernous Sinus and Its Impact on Outcomes of Pituitary Surgery: A Systematic Review and Meta-Analysis. Brain Sci 2022; 12:brainsci12101354. [PMID: 36291288 PMCID: PMC9599381 DOI: 10.3390/brainsci12101354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 09/21/2022] [Accepted: 09/28/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction. Pituitary adenomas have the potential to infiltrate the dura mater, skull, and the venous sinuses. Tumor extension into the cavernous sinus is often observed in pituitary adenomas and techniques and results of surgery in this region are vastly discussed in the literature. Infiltration of parasellar dura and its impact for pituitary surgery outcomes is significantly less studied but recent studies have suggested a role of endoscopic resection of the medial wall of the cavernous sinus, in selected cases. In this study, we discuss the techniques and outcomes of recently proposed techniques for selective resection of the medial wall of the cavernous sinus in endoscopic pituitary surgery. Methods. We performed a systematic review of the literature using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and protocol and a total of 4 studies with 106 patients that underwent an endoscopic approach for resection of pituitary tumors with resection of medial wall from cavernous sinus were included. Clinical and radiological data were extracted (sex, mean age, Knosp, prior surgery, tumor size and type, complication rate, and remission) and a meta-analysis using the RevMan 5.4 software was performed. Results. A total of 5 studies with 208 patients were included in this analysis. The mean age of the study population was 48.87 years (range 25−82) with a female/male ratio of 1:1.36. Majority of the patients had Knosp Grade 1 (n = 77, 37.02%) and Grade 2 (n = 53, 25.48%). The complication rate was 4.81% (n = 33/106) and the most common complication observed was a new transient CN dysfunction and diplopia. Early disease remission was observed in 94.69% of the patients (n = 196/207). The prevalence rate of CS medial wall invasion varied from 10.4 % up to 36.7%. This invasion rate increased in frequency with higher Knosp Grade. The forest plot of persistent disease vs. remission in this surgery approach showed a p < 0.00001 and heterogeneity (I^2 = 0%). Discussion. Techniques to achieve resection of the medial wall of the cavernous sinus via the endoscopic endonasal approach include the “anterior to posterior” technique (opening of the anterior wall of the cavernous sinus) and the “medial to lateral” technique (opening of the inferior intercavernous sinus and). Although potentially related with improved endocrinological outcomes, these are advanced surgical techniques and require extensive anatomical knowledge and extensive surgical experience. Furthermore, to avoid procedure complications, extensive study of the patient’s configuration of cavernous ICA, Doppler-guided intraoperative imaging, surgical navigation system, and blunt tip knives to dissect the ICA’s plane are recommended. Conclusion. Endoscopic resection of the medial wall of the cavernous sinus has been associated with reports of high rates of postoperative hormonal control in functioning pituitary adenomas. However, it represents a more complex approach and requires advanced experience in endoscopic skull base surgery. Additional studies addressing case selection and studies evaluating long term results of this technique are still necessary.
Collapse
Affiliation(s)
- Leonardo J. M. de Macêdo Filho
- Health Science Center, University of Fortaleza, Av. Washington Soares 1321, Fortaleza 60811-905, Ceará, Brazil
- Department of Neurosurgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224, USA
| | - Ana Vitória G. Diógenes
- Health Science Center, University of Fortaleza, Av. Washington Soares 1321, Fortaleza 60811-905, Ceará, Brazil
| | - Esther G. Barreto
- Health Science Center, University of Fortaleza, Av. Washington Soares 1321, Fortaleza 60811-905, Ceará, Brazil
| | - Bhavya Pahwa
- Department of Medicine, University College of Medical Sciences, 2, Tahirpur Rd, GTB Enclave, Dilshad Garden, New Delhi, Delhi 110095, India
| | - Susan L. Samson
- Department of Neurosurgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224, USA
- Department of Medicine, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Kaisorn Chaichana
- Department of Neurosurgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224, USA
| | | | - Joao Paulo Almeida
- Department of Neurosurgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224, USA
- Correspondence:
| |
Collapse
|
8
|
Ahmadi S, Dayyani M, Etemadrezaie H, Bateni F, Mohabbati H, Pooyan A, Zabihyan S. Diaphragma sellae orifice ratio, is it an applicable anatomical index to determine the direction of the growth of pituitary macroadenomas? INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2022.101547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
|
9
|
Ishida A, Shiramizu H, Yoshimoto H, Kato M, Inoshita N, Miki N, Ono M, Yamada S. Resection of the Cavernous Sinus Medial Wall Improves Remission Rate in Functioning Pituitary Tumors: Retrospective Analysis of 248 Consecutive Cases. Neurosurgery 2022; 91:775-781. [PMID: 36001781 DOI: 10.1227/neu.0000000000002109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 06/12/2022] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The purpose of transsphenoidal surgery (TSS) for a functioning pituitary tumor (FPT) is to achieve endocrinological remission. The biggest challenge is aggressive tumor resection invading the cavernous sinus (CS). OBJECTIVE To evaluate the effects of the medial wall of CS (MWCS) resection during FPT surgery. METHODS Consecutive FPTs were reviewed for CS invasion (CSI) between April 2018 and December 2021. We operated on more than 250 FPTs, including 134 somatotroph tumors, 70 corticotroph tumors, 35 lactotroph tumors, and 9 thyrotroph tumors. RESULTS The patients were classified into 3 groups based on the relationship between the tumor and the CS: group A (no clear wall invasion), in which MWCS was not removed because of no tumorous direct contact with MWCS (N = 92) and group B (possible wall invasion), where MWCS was removed because we were not confident of MWCS invasion (N = 102). Among these 102 patients, histological tumor invasion was confirmed in 45 of 79 patients (57%) for whom histology findings were available. Tumors invading the CS clearly during surgery were classified into the "clear CS invasion" (group C: N = 55) group. The overall complete remission rate in group B was 94%, which was as high as that in group A (87%). Moreover, we clarified that microscopic invasion of MWCS could not always be predicted from Knosp grading. CONCLUSION MWCS invasion occurred in 57% of cases confirmed histologically where it was unclear during surgery, and its resection can improve the overall complete remission rate in FPT cases.
Collapse
Affiliation(s)
- Atsushi Ishida
- Department of Neurosurgery, Moriyama Memorial Hospital, Tokyo, Japan
| | - Hideki Shiramizu
- Department of Neurosurgery, Moriyama Memorial Hospital, Tokyo, Japan
| | - Haruko Yoshimoto
- Department of Neurosurgery, Moriyama Memorial Hospital, Tokyo, Japan
| | - Masataka Kato
- Department of Neurosurgery, Moriyama Memorial Hospital, Tokyo, Japan
| | - Naoko Inoshita
- Department of Pathology, Moriyama Memorial Hospital, Tokyo, Japan
| | - Nobuhiro Miki
- Hypothalamic & Pituitary Center, Moriyama Neurological Center Hospital, Tokyo, Japan
| | - Masami Ono
- Hypothalamic & Pituitary Center, Moriyama Neurological Center Hospital, Tokyo, Japan
| | - Shozo Yamada
- Hypothalamic & Pituitary Center, Moriyama Neurological Center Hospital, Tokyo, Japan
| |
Collapse
|
10
|
Prospective intraoperative and histologic evaluation of cavernous sinus medial wall invasion by pituitary adenomas and its implications for acromegaly remission outcomes. Sci Rep 2022; 12:9919. [PMID: 35705579 PMCID: PMC9200976 DOI: 10.1038/s41598-022-12980-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 05/13/2022] [Indexed: 11/09/2022] Open
Abstract
Recurrence and biochemical remission rates vary widely among different histological subtypes of pituitary adenoma. In this prospective study, we evaluated 107 consecutive primary pituitary adenomas operated on by a single neurosurgeon including 28 corticotroph, 27 gonadotroph, 24 somatotroph, 17 lactotroph, 5 null-cell and 6 plurihormonal. In each case, we performed direct endoscopic intraoperative inspection of the medial wall of the cavernous sinus, which was surgically removed when invasion was visualized. This was performed irrespective of tumor functional status. Medial wall resection was performed in 47% of pituitary adenomas, and 39/50 walls confirmed pathologic evidence of invasion, rendering a positive predictive value of intraoperative evaluation of medial wall invasion of 78%. We show for the first-time dramatic disparities in the frequency of medial wall invasion among pathological subtypes. Somatotroph tumors invaded the medial wall much more often than other adenoma subtypes, 81% intraoperatively and 69% histologically, followed by plurihormonal tumors (40%) and gonadotroph cell tumors (33%), both with intraoperative positive predictive value of 100%. The least likely to invade were corticotroph adenomas, at a rate of 32% intraoperatively and 21% histologically, and null-cell adenomas at 0%. Removal of the cavernous sinus medial wall was not associated with permanent cranial nerve morbidity nor carotid artery injury, although 4 patients (all Knosp 3-4) experienced transient diplopia. Medial wall resection in acromegaly resulted in the highest potential for biochemical remission ever reported, with an average postoperative day 1 GH levels of 0.96 ug/L and surgical remission rates of 92% based on normalization of IGF-1 levels after surgery (mean = 15.56 months; range 3-30 months). Our findings suggest that tumor invasion of the medial wall of the cavernous sinus may explain the relatively low biochemical remission rates currently seen for acromegaly and illustrate the relevance of advanced intradural surgical approaches for successful and durable outcomes in endonasal pituitary surgery for functional adenomas.
Collapse
|
11
|
Cooper O, Bonert V, Mamelak AN, Bannykh S, Melmed S. Dural Invasion as a Marker of Aggressive Pituitary Adenomas. Neurosurgery 2022; 90:775-783. [PMID: 35262532 PMCID: PMC9514742 DOI: 10.1227/neu.0000000000001912] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 12/16/2021] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Predictive markers of aggressive pituitary tumors have not been consistently demonstrated. Dural invasion and invasion-associated proteins, including matrix metalloproteinase-9 (MMP9) and cofilin, have been proposed to predict aggressive behavior and recurrence, but findings to date have been inconsistent. OBJECTIVE To assess whether microscopic dural invasion predicts aggressive pituitary adenoma behavior and whether MMP9 and cofilin expression correlates with pathological and clinical invasion markers. METHODS We retrospectively studied 328 consecutive pituitary mass resections by a single neurosurgeon at a single center; 254 were adenomas, and 98 had dural biopsies sent for routine pathological evaluation. Assessments included clinical features, postoperative course, and immunochemical expression of MMP9, cofilin, and phospho-cofilin. Recurrence was evaluated in those with at least 12 months of postoperative follow-up. RESULTS Dural invasion was evident in 48% of biopsy specimens and was associated with male sex, larger tumors, suprasellar extension and sphenoid sinus invasion, cranial nerve palsies, and hypogonadism. Recurrence rates and the expression of MMP9, cofilin, and phospho-cofilin did not differ between those with and without dural invasion. However, differential expression of phospho-cofilin was associated with growth hormone deficiency and compressive pituitary mass effects. CONCLUSION Dural invasion is associated with larger tumors, suprasellar and sphenoid sinus invasion, and pituitary failure but is not predictive of a more aggressive postoperative course. Routine dural biopsy is therefore of limited benefit in predicting postoperative recurrences. Cofilin expression may be an adjunctive biomarker of invasion in recurrent tumors, but MMP9 expression does not predict tumor behavior.
Collapse
Affiliation(s)
- Odelia Cooper
- Pituitary Center, Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA;
| | - Vivien Bonert
- Pituitary Center, Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA;
| | - Adam N. Mamelak
- Pituitary Center, Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA;
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California, USA;
| | - Serguei Bannykh
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Shlomo Melmed
- Pituitary Center, Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA;
| |
Collapse
|
12
|
Dai C, Feng M, Lu L, Sun B, Fan Y, Bao X, Yao Y, Deng K, Wang R, Kang J. Transsphenoidal Surgery of Corticotroph Adenomas With Cavernous Sinus Invasion: Results in a Series of 86 Consecutive Patients. Front Oncol 2022; 12:810234. [PMID: 35211404 PMCID: PMC8861297 DOI: 10.3389/fonc.2022.810234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 01/03/2022] [Indexed: 11/13/2022] Open
Abstract
Objective Transsphenoidal surgery (TSS) is the first-line treatment for corticotroph adenomas. Although most corticotroph adenomas are noninvasive microadenomas, a small subset of them invading cavernous sinus (CS) is notoriously difficult to manage. The aim of this study was to evaluate the surgical outcome of corticotroph adenomas with CSI from a single center. Patients and Methods The clinical features and outcomes of CD patients who underwent TSS between January 2000 and September 2019 at Peking Union Medical College Hospital were collected from medical records. The clinical, endocrinological, radiological, histopathological, and surgical outcomes, and a minimum 12-month follow-up of patients with corticotroph adenomas invading CS were retrospectively reviewed. Results Eighty-six patients with corticotroph adenomas invading CS were included in the study. The average age at TSS was 37.7 years (range, 12 to 67 years), with a female-to-male ratio of 3.1:1 (65/21). The median duration of symptoms was 52.6 months (range, 1.0 to 264 months). The average of maximum diameter of tumor was 17.6 mm (range, 4.5–70 mm). All included 86 patients underwent TSS using a microscopic or an endoscopic approach. Gross total resection was achieved in 63 patients (73.3%), subtotal resection was attained in 18 (20.9%), and partial resection was achieved in 5 (5.8%). After surgery, the overall postoperative immediate remission rate was 48.8% (42/86); 51.2% (44/86) of patients maintained persistent hypercortisolism. In 42 patients with initial remission, 16.7% (7/42) experienced a recurrence. In these patients with persistent disease and recurrent CD, data about further treatment were available for 30 patients. Radiotherapy was used for 15 patients, and 4 (26.7%) of them achieved biochemical remission. Repeat TSS was performed in 5 patients, and none achieved remission. Medication was administered in 4 patients, and one of them obtained disease control. Adrenalectomy was performed in 6 patients, and 5 (83.3%) achieved biochemical remission. At the last follow-up, 10 of 30 patients (33.3%) were in remission, and 20 patients still had persistent disease. The remission rate in corticotroph adenomas with cavernous sinus invasion (CSI) that underwent gross total resection and first TSS was significantly higher than that in patients undergoing subtotal resection, partial resection, and a second TSS (all p < 0.05). However, there was no significant difference in the remission rate between patients with different tumor sizes, Knosp grades, and surgical approaches (p > 0.05). Conclusion The management of corticotroph adenomas with CSI remain a therapeutic challenge due to incomplete resection of invasive and/or a large adenoma. With the application of multiple techniques, approximately half of the patients could achieve gross total resection and biochemical remission via TSS by experienced neurosurgeons. The extent of tumor resection and the number of operations were associated with surgical remission rate in corticotroph adenomas with CSI. If the remission was not achieved by surgery, other treatments including radiotherapy, medical therapy, and even bilateral adrenalectomy are required.
Collapse
Affiliation(s)
- Congxin Dai
- Department of Neurosurgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Ming Feng
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lin Lu
- Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bowen Sun
- Department of Neurosurgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Yanghua Fan
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xinjie Bao
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yong Yao
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Kan Deng
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Renzhi Wang
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jun Kang
- Department of Neurosurgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
13
|
Update in Cushing disease: What the neurosurgeon has to KNOW, on behalf of the EANS skull base section. BRAIN AND SPINE 2022; 2:100917. [PMID: 36248125 PMCID: PMC9560580 DOI: 10.1016/j.bas.2022.100917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 06/27/2022] [Accepted: 07/19/2022] [Indexed: 12/02/2022]
Abstract
Introduction Cushing's disease is a state of chronic and excessive cortisol levels caused by a pituitary adenoma Research question CD is a complex entity and often entails difficulties in its diagnosis and management. For that reason, there are still controversial points to that respect. The aim of this consensus paper of the skull base section of the EANS is to review the main aspects of the disease a neurosurgeon has to know and also to offer updated recommendations on the controversial aspects of its management. Material and methods PUBMED database was used to search the most pertinent articles published on the last 5 years related with the management of CD. A summary of literature evidence was proposed for discussion within the EANS skull base section and other international experts. Results This article represents the consensual opinion of the task force regarding optimal management and surgical strategy in CD Discussion and conclusion After discussion in the group several recommendations and suggestions were elaborated. Patients should be treated by an experienced multidisciplinary team. Accurate clinical, biochemical and radiological diagnosis is mandatory. The goal of treatment is the complete adenoma resection to achieve permanent remission. If this is not possible, the treatment aims to achieving eucortisolism. Radiation therapy is recommended to patients with CD when surgical options have been exhausted. All patients in remission should be tested all life-long. Modalities of management of Cushing disease and recommendations based on the literature and expert's opinion.
Collapse
|
14
|
Omar AT, Munoz DG, Goguen J, Lee JM, Rotondo F, Kovacs K, Cusimano MD. Resection of the medial wall of the cavernous sinus in functioning pituitary adenomas: Technical note and outcomes in a matched-cohort study. Clin Neurol Neurosurg 2020; 200:106306. [PMID: 34756392 DOI: 10.1016/j.clineuro.2020.106306] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 09/08/2020] [Accepted: 10/11/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Parasellar dural invasion can be associated with treatment failure after excision of functioning pituitary adenomas. Because the medial wall of the cavernous sinus is a common site of microscopic disease, we hypothesize that its resection may lead to improvement in biochemical remission and recurrence rates. We aim to describe our technique in the resection of the medial wall of the cavernous sinus using binasal endoscopic transsphenoidal surgery (BETS); and compare tumor control and biochemical remission rates against a matched cohort. METHODS Patients with functioning pituitary adenomas who underwent resection of the medial cavernous wall in addition to tumor excision via BETS were compared to a cohort matched for tumor type, size, and Knosp grade. Biochemical remission rates, tumor control at follow-up, and complication rates were assessed. RESULTS Sixteen patients underwent resection of the medial wall of the cavernous sinus. Of 14 cases with wall specimens deemed adequate for histopathologic analysis, 43 % had microscopic evidence of tumor. Two of three patients with Knosp grade 0 scores had microscopic tumor invasion of the medial wall. The mean blood loss in the cohort was 175 mL (comparable to control, p = 0.895), with no operative complications noted. Gross total excision was achieved in 81 % of cases in the treatment cohort. At a median follow-up of 11 months, no statistical difference was noted in the biochemical remission and oncologic control rates between groups. CONCLUSION Resection of the medial wall of the cavernous sinus is safe and technically feasible using BETS when performed by experienced surgeons. The Knosp classification may not be reliable for microscopic tumor invasion. The effect of this technique on clinical outcomes remains to be determined by larger cohorts with matched controls and long-term follow-up.
Collapse
Affiliation(s)
- Abdelsimar T Omar
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Division of Neurosurgery, St Michael's Hospital, Toronto, Ontario, Canada; Neuroscience Research Program, Keenan Research Centre of the Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
| | - David G Munoz
- Department of Laboratory Medicine, Division of Pathology, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Jeannette Goguen
- Department of Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
| | - John M Lee
- Department of Otolaryngology, Head and Neck Surgery, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Fabio Rotondo
- Department of Laboratory Medicine, Division of Pathology, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Kalman Kovacs
- Department of Laboratory Medicine, Division of Pathology, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Michael D Cusimano
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Division of Neurosurgery, St Michael's Hospital, Toronto, Ontario, Canada; Neuroscience Research Program, Keenan Research Centre of the Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
| |
Collapse
|
15
|
Cabuk B, Anik I, Kokturk S, Ceylan S, Ceylan S. Anatomic and histologic features of diaphragma sellae that effects the suprasellar extension. J Clin Neurosci 2019; 71:234-244. [PMID: 31843433 DOI: 10.1016/j.jocn.2019.11.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 10/16/2019] [Accepted: 11/18/2019] [Indexed: 10/25/2022]
Abstract
This study aimed to determine the anatomical and histological features of diaphragma sellae that affect the suprasellar extension of intrasellar tumours. Twenty-four fresh adult cadavers were dissected for the study. Diaphragma sellae and pituitary capsules with sellar structures were resected. The diaphragma sellae was anatomically reviewed in detail. Immunohistochemical staining was performed for collagen types I, II, III, and IV. We examined the suprasellar growth of 13 sellar tumours extending superiorly through the diaphragma sellae by performing a series of 2704 endoscopic transnasal operations to analyse the anatomic and histologic results of the study. The diameter of the foramen of diaphragma sellae varied between specimens. Of 24 specimens, the diaphragma sellae in five (21%) had a tight-type foramen and those in 19 (79%) were more spacious. An increased expression of collagen types I and IV was observed in the pituitary capsule and the diaphragma sellae. In this clinical series, we observed that all types of sellar tumours could expand through the foramen. We observed radiologically and intraoperatively that the diaphragma sellae was displaced laterally and formed a dome in two cases with an adenoma extending to the suprasellar area. Two types of suprasellar extension through the diaphragma sellae are possible: 1) The collagen structure of diaphragma sellae can be destroyed by invasive tumours; 2) The morphology of the foramen of the diaphragma sellae facilitates suprasellar tumoural extension. All sellar tumours, including non-invasive cystic tumours, may invade the suprasellar area by expanding through the foramen of the diaphragma sellae.
Collapse
Affiliation(s)
- Burak Cabuk
- Kocaeli University, School of Medicine, Department of Neurosurgery and Kocaeli University, Pituitary Research Center, Kocaeli, Turkey
| | - Ihsan Anik
- Kocaeli University, School of Medicine, Department of Neurosurgery and Kocaeli University, Pituitary Research Center, Kocaeli, Turkey
| | - Sibel Kokturk
- Ordu University, School of Medicine, Department of Histology, Ordu, Turkey
| | - Sureyya Ceylan
- Kocaeli University, School of Medicine, Department of Histology, Kocaeli, Turkey
| | - Savas Ceylan
- Kocaeli University, School of Medicine, Department of Neurosurgery and Kocaeli University, Pituitary Research Center, Kocaeli, Turkey.
| |
Collapse
|
16
|
Serioli S, Doglietto F, Fiorindi A, Biroli A, Mattavelli D, Buffoli B, Ferrari M, Cornali C, Rodella L, Maroldi R, Gasparotti R, Nicolai P, Fontanella MM, Poliani PL. Pituitary Adenomas and Invasiveness from Anatomo-Surgical, Radiological, and Histological Perspectives: A Systematic Literature Review. Cancers (Basel) 2019; 11:E1936. [PMID: 31817110 PMCID: PMC6966643 DOI: 10.3390/cancers11121936] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 11/27/2019] [Accepted: 11/28/2019] [Indexed: 12/20/2022] Open
Abstract
Invasiveness in pituitary adenomas has been defined and investigated from multiple perspectives, with varying results when its predictive value is considered. A systematic literature review, following PRISMA guidelines, was performed, searching PubMed and Scopus databases with terms that included molecular markers, histological, radiological, anatomical and surgical data on invasiveness of pituitary adenomas. The results showed that differing views are still present for anatomical aspects of the sellar region that are relevant to the concept of invasiveness; radiological and histological diagnoses are still limited, but might improve in the future, especially if they are related to surgical findings, which have become more accurate thanks to the introduction of the endoscope. The aim is to achieve a correct distinction between truly invasive pituitary adenomas from those that, in contrast, present with extension in the parasellar area through natural pathways. At present, diagnosis of invasiveness should be based on a comprehensive analysis of radiological, intra-operative and histological findings.
Collapse
Affiliation(s)
- Simona Serioli
- Neurosurgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25123 Brescia, Italy; (S.S.); (A.F.); (A.B.); (C.C.); (M.M.F.)
| | - Francesco Doglietto
- Neurosurgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25123 Brescia, Italy; (S.S.); (A.F.); (A.B.); (C.C.); (M.M.F.)
- Neurosurgery, Spedali Civili Hospital, 25123 Brescia, Italy
| | - Alessandro Fiorindi
- Neurosurgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25123 Brescia, Italy; (S.S.); (A.F.); (A.B.); (C.C.); (M.M.F.)
| | - Antonio Biroli
- Neurosurgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25123 Brescia, Italy; (S.S.); (A.F.); (A.B.); (C.C.); (M.M.F.)
| | - Davide Mattavelli
- Otorhinolaryngology–Head and Neck Surgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25123 Brescia, Italy; (D.M.); (M.F.); (P.N.)
| | - Barbara Buffoli
- Section of Anatomy and Physiopathology, Department of Clinical and Experimental Sciences, University of Brescia, 25123 Brescia, Italy; (B.B.); (L.R.)
| | - Marco Ferrari
- Otorhinolaryngology–Head and Neck Surgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25123 Brescia, Italy; (D.M.); (M.F.); (P.N.)
| | - Claudio Cornali
- Neurosurgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25123 Brescia, Italy; (S.S.); (A.F.); (A.B.); (C.C.); (M.M.F.)
- Neurosurgery, Spedali Civili Hospital, 25123 Brescia, Italy
| | - Luigi Rodella
- Section of Anatomy and Physiopathology, Department of Clinical and Experimental Sciences, University of Brescia, 25123 Brescia, Italy; (B.B.); (L.R.)
| | - Roberto Maroldi
- Radiology, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25123 Brescia, Italy;
| | - Roberto Gasparotti
- Neuroradiology, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25123 Brescia, Italy;
| | - Piero Nicolai
- Otorhinolaryngology–Head and Neck Surgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25123 Brescia, Italy; (D.M.); (M.F.); (P.N.)
| | - Marco Maria Fontanella
- Neurosurgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25123 Brescia, Italy; (S.S.); (A.F.); (A.B.); (C.C.); (M.M.F.)
- Neurosurgery, Spedali Civili Hospital, 25123 Brescia, Italy
| | - Pietro Luigi Poliani
- Section of Pathology, Department of Molecular and Translational Medicine, University of Brescia, 25123 Brescia, Italy
| |
Collapse
|
17
|
Surgical and radiosurgical treatment strategies for Cushing’s disease. J Neurooncol 2019; 145:403-413. [DOI: 10.1007/s11060-019-03325-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 10/26/2019] [Indexed: 12/11/2022]
|
18
|
Mayberg M, Reintjes S, Patel A, Moloney K, Mercado J, Carlson A, Scanlan J, Broyles F. Dynamics of postoperative serum cortisol after transsphenoidal surgery for Cushing's disease: implications for immediate reoperation and remission. J Neurosurg 2019; 129:1268-1277. [PMID: 29271716 DOI: 10.3171/2017.6.jns17635] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 06/05/2017] [Indexed: 01/01/2023]
Abstract
OBJECTIVESuccessful transsphenoidal surgery for adrenocorticotropin hormone (ACTH)-producing pituitary tumors is associated with subnormal postoperative serum cortisol levels, which may guide decisions regarding immediate reoperation. However, little is known about the detailed temporal course of changes in serum cortisol in the immediate postoperative period, and the relationship of postoperative cortisol dynamics to remission and late recurrence.METHODSA single-center retrospective cohort analysis was performed for all patients undergoing pituitary surgery from 2007 through 2015. Standardized diagnostic and treatment algorithms were applied to all patients with potential Cushing's disease (CD), including microsurgical transsphenoidal adenomectomy (TSA) by a single surgeon. All patients had serum cortisol levels drawn at 6-hour intervals for 72 hours after surgery, and were offered reoperation within 3 days for normal or supranormal postoperative cortisol levels. Primary outcomes were 6-month remission and late recurrence; secondary outcomes were persistent postoperative hypocortisolism and surgical morbidity. Discriminatory levels of postoperative serum cortisol for predicting remission were calculated at various intervals after surgery using receiver operating characteristic (ROC) curves.RESULTSAmong 89 patients diagnosed with CD, 81 underwent initial TSA for a potentially curable lesion; 23 patients (25.8%) underwent an immediate second TSA. For the entire cohort, 6-month remission was achieved in 77.8% and late recurrences occurred in 9.5%, at a mean of 43.5 months. Compared with patients with a single surgery, those with an immediate second TSA had similar rates of remission (78.3% vs 77.6%) and late recurrence (5.6% vs 11.1%). The rate of hypocortisolism for patients with 2 surgeries (12/23, 52.2%) was significantly greater than that for patients with single surgeries (13/58, 22.4%; p < 0.001). There was no difference in the incidence of CSF leaks between the first and second operations. Remission was achieved in 58 (92.1%) of 64 patients who completed the 2-surgery protocol. The temporal course of postoperative serum cortisol levels among patients varied considerably, with subnormal nadir levels < 2 μg/dl occurring between 12 hours and 66 hours. Patients achieving remission had significantly lower mean serum cortisol levels at every time point after surgery (p < 0.01). By ROC curve analysis, nadir cortisol levels < 2.1 μg/dl were predictive of 6-month remission for the entire cohort over 3 days (positive predictive value [PPV] = 94%); discriminating cortisol levels for predicting remission on postoperative day (POD) 2 were < 5.4 μg/dl (PPV = 97%), although patients with remission after postoperative cortisol levels of 2-5 μg/dl had a significantly higher rate of late recurrence.CONCLUSIONSThere is substantial variation in the temporal course of serum cortisol levels over the first 72 hours after TSA for CD, with nadir levels predictive for remission occurring as late as POD 3. Although a cortisol level of 2.1 μg/dl at any point was an accurate predictor of 6-month remission, levels less than 5.4 μg/dl on POD 2 were reasonably accurate. These data may enable decisions regarding the efficacy of an immediate second surgical procedure performed during the same hospitalization; immediate reoperation is associated with excellent remission rates and low recurrence rates in patients otherwise unlikely to achieve remission, but carries a higher risk of permanent hypocortisolism.
Collapse
Affiliation(s)
- Marc Mayberg
- 4Department of Neurological Surgery, University of Washington, Seattle, Washington; and
| | - Stephen Reintjes
- 3Department of Neurological Surgery, University of South Florida, Tampa, Florida
| | - Anika Patel
- 1Swedish Pituitary Center, Swedish Neuroscience Institute
| | - Kelley Moloney
- 1Swedish Pituitary Center, Swedish Neuroscience Institute
| | | | - Alex Carlson
- 2Swedish Center for Research and Innovation; and
| | | | | |
Collapse
|
19
|
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.
Collapse
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
| | | |
Collapse
|
20
|
Mastorakos P, Taylor DG, Chen CJ, Buell T, Donahue JH, Jane JA. Prediction of cavernous sinus invasion in patients with Cushing's disease by magnetic resonance imaging. J Neurosurg 2018; 130:1593-1598. [PMID: 29979125 DOI: 10.3171/2018.2.jns172704] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 02/08/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Cavernous sinus invasion (CSI) in Cushing's disease (CD) negatively affects the probability of complete resection, biochemical cure, and need for adjuvant therapy. However, the prediction of CSI based on MRI findings has been inconsistent and variable. Among macroadenomas, the Knosp classification is the most widely utilized radiographic predictor of CSI, but its accuracy in predicting CSI and the probability of gross-total resection is limited in the setting of microadenomas or Knosp grade 0-2 macroadenomas. The authors noticed that the presence of a triangular shape of adenomas adjacent to the cavernous sinus on coronal MR images is frequently associated with CSI. The authors aimed to determine the correlation of this radiographic finding ("sail sign" [SS]) with CSI. METHODS The authors performed a retrospective review of all patients with a pituitary lesion < 20 mm and a biochemical diagnosis of CD treated with endoscopic or microscopic transsphenoidal resection from November 2007 to May 2017. Overall 185 patients with CD were identified: 27 were excluded for negative preoperative imaging, 32 for lacking tumors adjacent to the sinus, 7 for Knosp grade 3 or higher, and 4 for inadequate intraoperative assessment of the CSI. Following application of inclusion and exclusion criteria, 115 cases were available for statistical analysis. Intraoperative CSI was prospectively evaluated at the time of surgery by one of two neurosurgical attending surgeons, and MRI data were evaluated retrospectively by a neurosurgical resident and attending neuroradiologist blinded to the intraoperative results. RESULTS A positive SS was identified in 23 patients (20%). Among patients with positive SS, 91% demonstrated CSI compared to 10% without an SS (p < 0.001). Using the SS as a predictor of CSI provided a sensitivity of 0.7 and a specificity of 0.98, with a positive predictive value (PPV) of 0.91 and a negative predictive value of 0.9. Among patients with positive SS, 30% did not achieve immediate postoperative remission, compared to 3.3% of patients without an SS (p < 0.001). CONCLUSIONS The presence of a positive SS among Cushing's adenomas adjacent to the CS provides strong PPV, specificity, and positive likelihood ratio for the prediction of CSI. This can be a useful tool for preoperative planning and for predicting the likelihood of long-term biochemical remission and the need for adjuvant radiosurgery.
Collapse
Affiliation(s)
- Panagiotis Mastorakos
- 1Department of Neurological Surgery, University of Virginia Health Science Center, University of Virginia, Charlottesville, Virginia
- 2Department of Neurological Surgery, NIH/NINDS, Bethesda, Maryland; and
| | - Davis G Taylor
- 1Department of Neurological Surgery, University of Virginia Health Science Center, University of Virginia, Charlottesville, Virginia
| | - Ching-Jen Chen
- 1Department of Neurological Surgery, University of Virginia Health Science Center, University of Virginia, Charlottesville, Virginia
| | - Thomas Buell
- 1Department of Neurological Surgery, University of Virginia Health Science Center, University of Virginia, Charlottesville, Virginia
| | - Joseph H Donahue
- 3Department of Radiology and Medical Imaging, University of Virginia Health Science Center, University of Virginia, Charlottesville, Virginia
| | - John A Jane
- 1Department of Neurological Surgery, University of Virginia Health Science Center, University of Virginia, Charlottesville, Virginia
| |
Collapse
|
21
|
Ioachimescu AG. Prognostic Factors of Long-Term Remission After Surgical Treatment of Cushing's Disease. Endocrinol Metab Clin North Am 2018; 47:335-347. [PMID: 29754635 DOI: 10.1016/j.ecl.2018.02.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Transsphenoidal surgery is the main treatment of patients with adrenocorticotropic hormone (ACTH)-secreting pituitary adenomas. Although biochemical remission occurs in most patients undergoing operations at specialized centers, the recurrence risk is significant. Visualization of microadenomas on preoperative imaging and confirmation of ACTH-positive adenomas have been associated with higher remission rates. Low cortisol levels in the first 2 weeks postoperatively have been associated with durable remission; however, recurrence cannot be excluded by any cortisol threshold. The decision to perform a pituitary reoperation is based on this parameter; the protocols are institution specific. Patients with Cushing's disease warrant lifelong endocrinologic surveillance.
Collapse
Affiliation(s)
- Adriana G Ioachimescu
- Department of Medicine (Endocrinology) and Neurosurgery, Emory University School of Medicine, 1365 B Clifton Road Northeast, B6209, Atlanta, GA 30322, USA.
| |
Collapse
|
22
|
Bier G, Hempel JM, Grimm F, Ernemann U, Bender B, Honegger J. Quantification of specific growth patterns and frequency of the empty sella phenomenon in growth hormone-secreting pituitary adenomas. Eur J Radiol 2018; 104:79-86. [PMID: 29857870 DOI: 10.1016/j.ejrad.2018.05.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 03/22/2018] [Accepted: 05/07/2018] [Indexed: 12/30/2022]
Abstract
PURPOSE To assess and quantify the prevalence and co-occurence of a sellar floor lowering and empty sella phenomenon in patients with GH (growth hormone)-secreting pituitary adenoma. METHODS A total number of 159 acromegalic patients were included in this study, as well as two control groups (150 patients with non-GH-secreting adenomas and 50 patients without pituitary adenomas). Magnetic resonance images of all patients were evaluated for presence of an empty sella, downward and lateral tumor extension, and maximum superoinferior diameter of the mass. Additionally, these values were correlated with growth hormone and IGF-1 levels. RESULTS The empty sella phenomenon was detected significantly more often in patients with a GH-secreting adenoma with a prevalence of 22% vs. 5.3% in non-GH-secreting adenomas (p < 0.001) or 8% in the healthy control group (p = .036). Moreover, GH-secreting adenomas presented with a significant rate of downward tumor extension (74.8% vs. 35.5%; p < 0.001), whose extent correlated inversely but weakly with the GH hormone level (r = - 0.17; p = .036). It was also found that a decreased superoinferior diameter and higher ratio of intrasellar to suprasellar extension are predictive quantitative values for the presence of a GH-secreting adenoma (area under curve, 0.712). CONCLUSIONS GH-secreting pituitary adenomas are frequently associated with an empty sella phenomenon. Moreover, GH-secreting adenomas are frequently accompanied by an enhanced, quantitatively measurable impression of the sellar floor. Hypothetically, this is caused by tumor-induced local bone remodeling processes.
Collapse
Affiliation(s)
- Georg Bier
- Department of Radiology, Diagnostic and Interventional Neuroradiology, Eberhard Karls University Tuebingen, Hoppe-Seyler-Str. 3, D-72076 Tuebingen, Germany.
| | - Johann-Martin Hempel
- Department of Radiology, Diagnostic and Interventional Neuroradiology, Eberhard Karls University Tuebingen, Hoppe-Seyler-Str. 3, D-72076 Tuebingen, Germany
| | - Florian Grimm
- Department of Neurosurgery, Eberhard Karls University Tuebingen, Hoppe-Seyler-Str. 3, D-72076 Tuebingen, Germany
| | - Ulrike Ernemann
- Department of Radiology, Diagnostic and Interventional Neuroradiology, Eberhard Karls University Tuebingen, Hoppe-Seyler-Str. 3, D-72076 Tuebingen, Germany
| | - Benjamin Bender
- Department of Radiology, Diagnostic and Interventional Neuroradiology, Eberhard Karls University Tuebingen, Hoppe-Seyler-Str. 3, D-72076 Tuebingen, Germany
| | - Juergen Honegger
- Department of Neurosurgery, Eberhard Karls University Tuebingen, Hoppe-Seyler-Str. 3, D-72076 Tuebingen, Germany
| |
Collapse
|
23
|
Ram Z, Lonser RR. In Memoriam: Edward H. Oldfield, MD, 1947 to 2017. Neurosurgery 2017. [DOI: 10.1093/neuros/nyx562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
|
24
|
Mehta GU, Ding D, Patibandla MR, Kano H, Sisterson N, Su YH, Krsek M, Nabeel AM, El-Shehaby A, Kareem KA, Martinez-Moreno N, Mathieu D, McShane B, Blas K, Kondziolka D, Grills I, Lee JY, Martinez-Alvarez R, Reda WA, Liscak R, Lee CC, Lunsford LD, Vance ML, Sheehan JP. Stereotactic Radiosurgery for Cushing Disease: Results of an International, Multicenter Study. J Clin Endocrinol Metab 2017; 102:4284-4291. [PMID: 28938462 DOI: 10.1210/jc.2017-01385] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2017] [Accepted: 08/24/2017] [Indexed: 11/19/2022]
Abstract
CONTEXT Cushing disease (CD) due to adrenocorticotropic hormone-secreting pituitary tumors can be a management challenge. OBJECTIVE To better understand the outcomes of stereotactic radiosurgery (SRS) for CD and define its role in management. DESIGN International, multicenter, retrospective cohort analysis. SETTING Ten medical centers participating in the International Gamma Knife Research Foundation. PATIENTS Patients with CD with >6 months endocrine follow-up. INTERVENTION SRS using Gamma Knife radiosurgery. MAIN OUTCOME MEASURES The primary outcome was control of hypercortisolism (defined as normalization of free urinary cortisol). Radiologic response and adverse radiation effects (AREs) were recorded. RESULTS In total, 278 patients met inclusion criteria, with a mean follow-up of 5.6 years (0.5 to 20.5 years). Twenty-two patients received SRS as a primary treatment of CD. Mean margin dose was 23.7 Gy. Cumulative initial control of hypercortisolism was 80% at 10 years. Mean time to cortisol normalization was 14.5 months. Recurrences occurred in 18% with initial cortisol normalization. Overall, the rate of durable control of hypercortisolism was 64% at 10 years and 68% among patients who received SRS as a primary treatment. AREs included hypopituitarism (25%) and cranial neuropathy (3%). Visual deficits were related to treatment of tumor within the suprasellar cistern (P = 0.01), whereas both visual (P < 0.0001) and nonvisual cranial neuropathy (P = 0.02) were related to prior pituitary irradiation. CONCLUSIONS SRS for CD is well tolerated and frequently results in control of hypercortisolism. However, recurrences can occur. SRS should be considered for patients with persistent hypercortisolism after pituitary surgery and as a primary treatment in those unfit for surgery. Long-term endocrine follow-up is essential after SRS.
Collapse
Affiliation(s)
- Gautam U Mehta
- Department of Neurologic Surgery, University of Virginia Health System, Charlottesville, Virginia 22908
| | - Dale Ding
- Department of Neurologic Surgery, University of Virginia Health System, Charlottesville, Virginia 22908
| | - Mohana Rao Patibandla
- Department of Neurologic Surgery, University of Virginia Health System, Charlottesville, Virginia 22908
| | - Hideyuki Kano
- Department of Neurologic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213
| | - Nathaniel Sisterson
- Department of Neurologic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213
| | - Yan-Hua Su
- Department of Neurosurgery, Neurologic Institute, Taipei Veterans General Hospital, Taipei 11217, Taiwan, Republic of China
| | - Michal Krsek
- Second Department of Medicine, Third Faculty of Medicine of the Charles University, Faculty Hospital Kralovske Vinohrady, 11636 Prague, Czech Republic
| | - Ahmed M Nabeel
- Neurosurgery Department, Gamma Knife Center Cairo-Nasser Institute, Benha University, Benha, Egypt 11566
| | - Amr El-Shehaby
- Neurosurgery Department, Gamma Knife Center Cairo-Nasser Institute, Ain Shams University, Cairo, Egypt 11566
| | - Khaled A Kareem
- Clinical Oncology Department, Gamma Knife Center Cairo-Nasser Institute, Ain Shams University, Cairo, Egypt 11566
| | - Nuria Martinez-Moreno
- Department of Functional Neurosurgery and Radiosurgery, Ruber International Hospital, 28034 Madrid, Spain
| | - David Mathieu
- Division of Neurosurgery, Université de Sherbrooke, Centre de recherche du CHUS, Sherbrooke, Québec J1H 5N4, Canada
| | - Brendan McShane
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania 19104
| | - Kevin Blas
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan 48073
| | - Douglas Kondziolka
- Department of Neurosurgery, New York University Lagone, Medical Center, New York, New York 10016
| | - Inga Grills
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan 48073
| | - John Y Lee
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania 19104
| | - Roberto Martinez-Alvarez
- Department of Functional Neurosurgery and Radiosurgery, Ruber International Hospital, 28034 Madrid, Spain
| | - Wael A Reda
- Neurosurgery Department, Gamma Knife Center Cairo-Nasser Institute, Ain Shams University, Cairo, Egypt 11566
| | - Roman Liscak
- Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, 11636 Prague, Czech Republic
| | - Cheng-Chia Lee
- Department of Neurosurgery, Neurologic Institute, Taipei Veterans General Hospital, Taipei 11217, Taiwan, Republic of China
| | - L Dade Lunsford
- Department of Neurologic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213
| | - Mary Lee Vance
- Department of Neurologic Surgery, University of Virginia Health System, Charlottesville, Virginia 22908
- Department of Medicine, University of Virginia Health System, Charlottesville, Virginia 22908
| | - Jason P Sheehan
- Department of Neurologic Surgery, University of Virginia Health System, Charlottesville, Virginia 22908
| |
Collapse
|
25
|
Song JY, Mun SJ, Sung SK, Hwang JY, Baik SK, Kim JY, Cheon CK, Kim SY, Kim YM. A rare case of multiple pituitary adenomas in an adolescent Cushing disease presenting as a vertebral compression fracture. Ann Pediatr Endocrinol Metab 2017; 22:197-202. [PMID: 29025207 PMCID: PMC5642078 DOI: 10.6065/apem.2017.22.3.197] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 03/16/2017] [Accepted: 03/27/2017] [Indexed: 12/03/2022] Open
Abstract
Cushing disease in children and adolescents, especially with multiple pituitary adenomas (MPAs), is very rare. We report 17-year-old boy with MPAs. He presented with a vertebral compression fracture, weight gain, short stature, headache, and hypertension. On magnetic resonance imaging (MRI), only a left pituitary microadenoma was found. After surgery, transient clinical improvement was observed but headache and hypertension were observed again after 3 months later. Follow-up MRI showed a newly developed right pituitary microadenoma 6 months after the surgery. The need for careful clinical and radiographic follow-up should be emphasized in the search for potential MPAs in patients with persistent Cushing disease.
Collapse
Affiliation(s)
- Ji-Yeon Song
- Department of Pediatrics, Pusan National University Children’s Hospital, Yangsan, Korea
| | - Sue-Jean Mun
- Departments of Otorhinolaryngology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Soon-Ki Sung
- Departments of Neurosergery, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Jae-Yeon Hwang
- Departments of Radiology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Seung-Kug Baik
- Departments of Radiology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Jee Yeon Kim
- Departments of Pathology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Chong-Kun Cheon
- Department of Pediatrics, Pusan National University Children’s Hospital, Yangsan, Korea
| | - Su-Young Kim
- Department of Pediatrics, Pusan National University Children’s Hospital, Yangsan, Korea
| | - Yoo-Mi Kim
- Department of Pediatrics, Pusan National University Children’s Hospital, Yangsan, Korea,Address for correspondence: Yoo-Mi Kim, MD, PhD https://orcid.org/0000-0002-8440-5069 Department of Pediatrics, Pusan National University Children’s Hospital, 20 Geumo-ro, Mulgeumeup, Yangsan 50612, Korea Tel: +82-55-360-3173 Fax: +82-55-360-2181 E-mail:
| |
Collapse
|
26
|
Oldfield EH. Cushing's Disease: Lessons Learned From 1500 Cases. Neurosurgery 2017; 64:27-36. [PMID: 28899067 DOI: 10.1093/neuros/nyx378] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 07/31/2017] [Indexed: 11/12/2022] Open
Affiliation(s)
- Edward H Oldfield
- Department of Neurological Surgery, University of Virginia Health Science Center, Charlottesville, Virginia.,Depart-ment of Medicine, University of Virginia, Charlottesville, Virginia
| |
Collapse
|
27
|
Asa SL, Ezzat S. Gonadotrope Tumors. PROGRESS IN MOLECULAR BIOLOGY AND TRANSLATIONAL SCIENCE 2016; 143:187-210. [PMID: 27697203 DOI: 10.1016/bs.pmbts.2016.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Gonadotrope tumors arise from the gonadotropes of the adenohypophysis. These cells rarely give rise to hyperplasia, usually only in the setting of long-standing premature gonadal failure. In contrast, gonadotrope tumors represent one of the most frequent types of pituitary tumors. Despite their relatively common occurrence, the pathogenesis of gonadotrope tumors remains unknown. Effective nonsurgical therapies remain out of reach. We review the pituitary gonadotrope from the morphologic and functional perspectives to better understand its involvement as the cell of origin of a frequent type of pituitary tumor.
Collapse
Affiliation(s)
- S L Asa
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada; Department of Pathology, Laboratory Medicine Program, University Health Network, Toronto, ON, Canada.
| | - S Ezzat
- Department of Medicine, University of Toronto, Endocrine Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| |
Collapse
|
28
|
Lonser RR, Nieman L, Oldfield EH. Cushing's disease: pathobiology, diagnosis, and management. J Neurosurg 2016; 126:404-417. [PMID: 27104844 DOI: 10.3171/2016.1.jns152119] [Citation(s) in RCA: 98] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Cushing's disease (CD) is the result of excess secretion of adrenocorticotropic hormone (ACTH) by a benign monoclonal pituitary adenoma. The excessive secretion of ACTH stimulates secretion of cortisol by the adrenal glands, resulting in supraphysiological levels of circulating cortisol. The pathophysiological levels of cortisol are associated with hypertension, diabetes, obesity, and early death. Successful resection of the CD-associated ACTH-secreting pituitary adenoma is the treatment of choice and results in immediate biochemical remission with preservation of pituitary function. Accurate and early identification of CD is critical for effective surgical management and optimal prognosis. The authors review the current pathophysiological principles, diagnostic methods, and management of CD.
Collapse
Affiliation(s)
- Russell R Lonser
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Lynnette Nieman
- Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland; and
| | - Edward H Oldfield
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| |
Collapse
|
29
|
Lin AL, Sum MW, DeAngelis LM. Is there a role for early chemotherapy in the management of pituitary adenomas? Neuro Oncol 2016; 18:1350-6. [PMID: 27106409 DOI: 10.1093/neuonc/now059] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 03/16/2016] [Indexed: 12/25/2022] Open
Abstract
Pituitary adenomas are benign intracranial neoplasms that are frequently well-controlled with standard treatments that include surgical resection, radiotherapy, and agents that modulate hormonal excess. Unfortunately, a subset of patients remains uncontrolled or develops complications from these interventions. For these patients, chemotherapy is an additional treatment option that could improve outcomes. Temozolomide is an oral chemotherapy with a favorable side-effect profile that has shown activity against pituitary adenomas. Its non-overlapping toxicity and ability to induce rapid tumor regression renders it a potentially important adjunctive treatment. In patients with tumors that cannot be optimally addressed with standard treatments, there may be a role for early initiation of temozolomide.
Collapse
Affiliation(s)
- Andrew L Lin
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York (A.L.L., L.M.D.A.)
| | - Melissa W Sum
- Division of Endocrinology, Columbia University Medical Center, New York, New York (M.W.S.)
| | - Lisa M DeAngelis
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York (A.L.L., L.M.D.A.)
| |
Collapse
|
30
|
Chittiboina P, Talagala SL, Merkle H, Sarlls JE, Montgomery BK, Piazza MG, Scott G, Ray-Chaudhury A, Lonser RR, Oldfield EH, Koretsky AP, Butman JA. Endosphenoidal coil for intraoperative magnetic resonance imaging of the pituitary gland during transsphenoidal surgery. J Neurosurg 2016; 125:1451-1459. [PMID: 26991390 DOI: 10.3171/2015.11.jns151465] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Pituitary MR imaging fails to detect over 50% of microadenomas in Cushing's disease and nearly 80% of cases of dural microinvasion. Surface coils can generate exceptionally high-resolution images of the immediately adjacent tissues. To improve imaging of the pituitary gland, a receive-only surface coil that can be placed within the sphenoid sinus (the endosphenoidal coil [ESC]) during transsphenoidal surgery (TSS) was developed and assessed. METHODS Five cadaver heads were used for preclinical testing of the ESC. The ESC (a double-turn, 12-mm-diameter surface coil made from 1-mm-diameter copper wire) was developed to obtain images in a 1.5-T MR scanner. The ESC was placed (via a standard sublabial TSS approach) on the anterior sella face. Clinical MR scans were obtained using the 8-channel head coil and ESC as the receiver coils. Using the ESC, ultra-high-resolution, 3D, balanced fast field echo (BFFE) and T1-weighted imaging were performed at resolutions of 0.25 × 0.25 × 0.50 mm3 and 0.15 × 0.15 × 0.30 mm3, respectively. RESULTS Region-of-interest analysis indicated a 10-fold increase in the signal-to-noise ratio (SNR) of the pituitary when using the ESC compared with the 8-channel head coil. ESC-related improvements (p < 0.01) in the SNR were inversely proportional to the distance from the ESC tip to the anterior pituitary gland surface. High-resolution BFFE MR imaging obtained using ESC revealed a number of anatomical features critical to pituitary surgery that were not visible on 8-channel MR imaging, including the pituitary capsule, the intercavernous sinus, and microcalcifications in the pars intermedia. These ESC imaging findings were confirmed by the pathological correlation with whole-mount pituitary sections. CONCLUSIONS ESC can significantly improve SNR in the sellar region intraoperatively using current 1.5-T MR imaging platforms. Improvement in SNR can provide images of the sella and surrounding structures with unprecedented resolution. Clinical use of this ESC may allow for MR imaging detection of previously occult pituitary adenomas and identify microscopic invasion of the dura or cavernous sinus.
Collapse
Affiliation(s)
- Prashant Chittiboina
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke
| | | | - Hellmut Merkle
- Laboratory of Functional and Molecular Imaging, National Institute of Neurological Disorders and Stroke; and
| | | | - Blake K Montgomery
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke
| | - Martin G Piazza
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke
| | - Gretchen Scott
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke
| | - Abhik Ray-Chaudhury
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke
| | - Russell R Lonser
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke.,Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio; and
| | - Edward H Oldfield
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke.,Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Alan P Koretsky
- Laboratory of Functional and Molecular Imaging, National Institute of Neurological Disorders and Stroke; and
| | - John A Butman
- Radiology and Imaging Sciences, the National Institutes of Health, Bethesda, Maryland
| |
Collapse
|
31
|
Asa SL, Ezzat S. Aggressive Pituitary Tumors or Localized Pituitary Carcinomas: Defining Pituitary Tumors. Expert Rev Endocrinol Metab 2016; 11:149-162. [PMID: 30058871 DOI: 10.1586/17446651.2016.1153422] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Pituitary tumors are common and exhibit a wide spectrum of hormonal, proliferative and invasive behaviors. Traditional classifications consider them malignant only when they exhibit metastasis. Patients who suffer morbidity and mortality from aggressive tumors classified as "adenomas" are denied support provided to patients with "cancers" and in many jurisdictions, these tumors are considered curiosities that do not warrant reporting in health registries. We propose use of the term "tumor" rather than "adenoma" to align with other neuroendocrine tumors. The features that can serve as diagnostic, prognostic and predictive markers are reviewed. Clinico-pathological and radiographic classifications provide important information and to date, no single biomarker has been able to offer valuable insight to guide the management of patients with pituitary tumors.
Collapse
Affiliation(s)
- Sylvia L Asa
- a Department of Pathology , University Health Network, University of Toronto , Toronto , Canada
- b Department of Laboratory Medicine and Pathobiology , University of Toronto , Toronto , Canada
| | - Shereen Ezzat
- c Department of Medicine , University Health Network, University of Toronto , Toronto , Canada
| |
Collapse
|
32
|
Abstract
BACKGROUND Transsphenoidal selective adenomectomy is the first-line treatment for Cushing's disease. At experienced centers, early remission rates after transsphenoidal surgery range from 65 to 98%, however disease relapse frequently occurs with rates ranging from 2 to 35% at long-term follow up. METHODS This article discusses recently reported studies on the surgical outcomes from transsphenoidal surgery for Cushing's disease. CONCLUSIONS One of the keys to a successful long-term surgical outcome is meticulous dissection using the adenoma's pseudocapsule as a surgical plane for complete resection. MRI-negative and invasive ACTH-secreting adenomas pose particular challenges for pituitary surgeons.
Collapse
Affiliation(s)
- Robert F Dallapiazza
- Department of Neurosurgery, University of Virginia, PO Box 800212, Charlottesville, VA, 22908-0711, USA,
| | | | | |
Collapse
|
33
|
Micko ASG, Wöhrer A, Wolfsberger S, Knosp E. Invasion of the cavernous sinus space in pituitary adenomas: endoscopic verification and its correlation with an MRI-based classification. J Neurosurg 2015; 122:803-11. [PMID: 25658782 DOI: 10.3171/2014.12.jns141083] [Citation(s) in RCA: 301] [Impact Index Per Article: 33.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECT An important prognostic factor for the surgical outcome and recurrence of a pituitary adenoma is its invasiveness into parasellar tissue, particularly into the space of the cavernous sinus (CS). The aims of this study were to reevaluate the existing parasellar classifications using an endoscopic technique and to evaluate the clinical and radiological outcomes associated with each grade. METHODS The authors investigated 137 pituitary macroadenomas classified radiologically at least on one side as Grade 1 or higher (parasellar extension) and correlated the surgical findings using an endoscopic technique, with special reference to the invasiveness of the tumor into the CS. In each case, postoperative MRI was performed to evaluate the gross-total resection (GTR) rate and the rate of endocrinological remission (ER) in functioning adenomas. RESULTS The authors found a 16% rate of CS invasion during surgery for these macroadenomas. Adenomas radiologically classified as Grade 1 were found to be invasive in 1.5%, and the GTR/ER rate was 83%/88%. For Grade 2 adenomas, the rate of invasion was 9.9%, and the GTR/ER rate was 71%/60%. For Grade 3 adenomas, the rate of invasion was 37.9%, and the GTR/ER rate was 75%/33%. When the superior compartment of the CS (Grade 3A) was involved, the authors found a rate of invasion that was lower (p < 0.001) than that when the inferior compartment was involved (Grade 3B). The rate of invasion in Grade 3A adenomas was 26.5% with a GTR/ER rate of 85%/67%, whereas for Grade 3B adenomas, the rate of surgically observed invasion was 70.6% with a GTR/ER rate of 64%/0%. All of the Grade 4 adenomas were invasive, and the GTR/ER rate was 0%. A comparison of microscopic and endoscopic techniques revealed no difference in adenomas with Grade 1 or 4 parasellar extension. In Grade 2 adenomas, however, the CS was found by the endoscopic technique to be invaded in 9.9% and by microscopic evaluation to be invaded in 88% (p < 0.001); in Grade 3 adenomas, the difference was 37.9% versus 86%, respectively (p = 0.002). Grade 4 adenomas had a statistically significant lower rate of GTR than those of all the other grades. In case of ER only, Grade 1 adenomas had a statistically significant higher rate of remission than did Grade 3B and Grade 4 adenomas. CONCLUSIONS The proposed classification proved that with increasing grades, the likelihood of surgically observed invasion rises and the chance of GTR and ER decreases. The direct endoscopic view confirmed the low rate of invasion of Grade 1 adenomas but showed significantly lower rates of invasion in Grade 2 and 3 adenomas than those previously found using the microscopic technique. In cases in which the intracavernous internal carotid artery was encased (Grade 4), all the adenomas were invasive and the GTR/ER rate was 0%/0%. The authors suggest the addition of Grades 3A and 3B to distinguish the strikingly different outcomes of adenomas invading the superior CS compartments and those invading the inferior CS compartments.
Collapse
|
34
|
Affiliation(s)
- Edward H Oldfield
- Department of Neurosurgery, University of Virginia Health Sciences Center, University of Virginia, Charlottesville, Virginia
| |
Collapse
|
35
|
Dallapiazza R, Bond AE, Grober Y, Louis RG, Payne SC, Oldfield EH, Jane JA. Retrospective analysis of a concurrent series of microscopic versus endoscopic transsphenoidal surgeries for Knosp Grades 0-2 nonfunctioning pituitary macroadenomas at a single institution. J Neurosurg 2014; 121:511-7. [PMID: 24995783 DOI: 10.3171/2014.6.jns131321] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The object of this study was to compare surgical outcomes and complications in a contemporaneous series of patients undergoing either microscopic or endoscopic transsphenoidal surgery for nonfunctioning pituitary macroadenomas without imaging evidence of cavernous sinus invasion. METHODS This is a retrospective analysis of a prospectively collected database from a single institution. Data were collected from patients whose surgery had occurred in the period from June 2010 to January 2013. Patients who underwent microscopic or endoscopic surgery for Knosp Grade 0, 1, or 2 nonfunctioning pituitary macroadenomas were included in the study. Patients who had clinically secreting or Knosp Grade 3 or 4 tumors and patients who were undergoing revision surgery were excluded from analysis. Eligible patient records were analyzed for outcomes and complications. Statistical analyses were performed on tumor volume, intraoperative factors, postoperative complications, and degree of resection on 1-year postoperative MRI. The results were used to compare the outcomes after microscopic and endoscopic approaches. RESULTS Forty-three patients underwent microscopic transsphenoidal surgery, and 56 underwent endoscopic transsphenoidal surgery. There were no statistical differences in the intraoperative extent of resection or endocrinological complications. There were significantly more intraoperative CSF leaks in the endoscopic group (58% vs 16%); however, there was no difference in the incidence of postoperative CSF rhinorrhea (12% microscopic vs 7% endoscopic). Length of hospitalization was significantly shorter in patients undergoing an endoscopic approach (3.0 days vs 2.4 days). Two-month follow-up imaging was available in 95% of patients, and 75% of patients had 1-year follow-up imaging. At 2 months postprocedure, there was no evidence of residual tumor in 79% (31 of 39) and 85% (47 of 55) of patients in the microscopic and endoscopic groups, respectively. At 1 year postprocedure, 83% (25 of 30) of patients in the microscopic group had no evidence of residual tumor and 82% (36 of 44) of those in the endoscopic group had no evidence of residual tumor. CONCLUSIONS The microscopic and endoscopic techniques provide similar outcomes in the surgical treatment of Knosp Grades 0-2 nonfunctioning pituitary macroadenomas.
Collapse
|
36
|
Schroeder JL, Spiotta AM, Fleseriu M, Prayson RA, Hamrahian AH, Weil RJ. Absence of immunostaining for growth hormone in a subset of patients with acromegaly. Pituitary 2014; 17:103-8. [PMID: 23475513 DOI: 10.1007/s11102-013-0474-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The presence of growth hormone (GH) immunostaining in patients who lack the biochemical and clinical features of acromegaly has been described. In contrast, there is little information on the absence of GH immunostaining in patients with acromegaly. We describe five patients with acromegaly with no intratumoral immunostaining for GH. We reviewed all patients undergoing surgery for acromegaly. Out of 136 patients treated surgically in a 10 year period, five (3.7%) were found to have no GH immunostaining on repetitive testing at pathological examination. Their pathology slides were re-examined by an experienced neuropathologist, along with twenty nonfunctional pituitary tumors and ten GH-positive adenomas as negative and positive controls, respectively. All patients had clinical features consistent with acromegaly and elevated baseline insulin-like growth factor-1 (IGF-1) and GH. All patients had no immunostaining for GH on multiple inspections. Of twenty patients with nonfunctional tumors, two had ≤25% staining for GH in a scattered and non-coherent pattern and the rest were negative. In all ten positive control patients >25% of the tumor cells stained diffusely for GH. All five patients achieved biochemical remission at 1.4-8 years post-op using a combination of primary surgery alone (n = 1), repeat surgery (n = 1), radiotherapy (n = 3) and/or medical therapy (n = 2). GH immunostaining of an adenoma may not be sufficient to confirm the diagnosis of acromegaly. All patients in our small series achieved remission by multimodality therapies. Further studies are needed to evaluate the significance of our observation and whether this subset of patients follows a distinct long term clinical course.
Collapse
Affiliation(s)
- Jason L Schroeder
- Department of Neurological Surgery, Cleveland Clinic, Cleveland, OH, 44195, USA,
| | | | | | | | | | | |
Collapse
|
37
|
Connor SEJ, Wilson F, Hogarth K. Magnetic resonance imaging criteria to predict complete excision of parasellar pituitary macroadenoma on postoperative imaging. J Neurol Surg B Skull Base 2013; 75:41-6. [PMID: 24498588 DOI: 10.1055/s-0033-1353362] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2013] [Accepted: 06/18/2013] [Indexed: 10/26/2022] Open
Abstract
Purpose To evaluate preoperative magnetic resonance imaging (MRI) criteria for their ability to predict the complete removal of parasellar pituitary macroadenoma on the 3-month postoperative MRI. Methods Dedicated pre- and postoperative pituitary MRI studies were reviewed in 49 patients who had undergone transsphenoidal surgery for macroadenomas with potential unilateral parasellar involvement. Twelve preoperative MRI findings and postoperative MRI outcomes were statistically compared. Results Depiction of the inferolateral (positive predictive value [PPV]: 0.6; negative predictive value [NPV], 0.92) and lateral (PPV: 0.65; NPV: 0.85) compartments of the cavernous sinus and the percentage of intracavernous carotid artery encasement (PPV: 0.63; NPV, 1.0 for <50% encasement) were the only criteria significantly predictive of parasellar tumor complete resection. The odds ratios indicated that depiction of the lateral venous or inferolateral venous compartments increased the likelihood of a complete resection by 6 times, whereas for every 25% reduction in intracavernous carotid artery encasement, the chance of a complete resection increased 3.4 times. Conclusion The preoperative MR imaging features that are useful in predicting the complete removal of the parasellar component of a pituitary adenoma as assessed by postoperative MRI are (1) depiction of the lateral and inferolateral compartment of the cavernous sinus and (2) decreasing encasement of the intracavernous carotid artery.
Collapse
Affiliation(s)
- S E J Connor
- Department of Neuroradiology, King's College Hospital, London, United Kingdom
| | - F Wilson
- Department of Paediatric Radiology, Starship Children's Health, Auckland, New Zealand
| | - K Hogarth
- Department of Neuroradiology, John Radcliffe Hospital, Oxford University Hospitals NHS Trust, Headley Way, Headington, Oxford, United Kingdom
| |
Collapse
|
38
|
Cao L, Chen H, Hong J, Ma M, Zhong Q, Wang S. Magnetic resonance imaging appearance of the medial wall of the cavernous sinus for the assessment of cavernous sinus invasion by pituitary adenomas. J Neuroradiol 2013; 40:245-51. [PMID: 23886874 DOI: 10.1016/j.neurad.2013.06.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2013] [Revised: 05/31/2013] [Accepted: 06/18/2013] [Indexed: 12/01/2022]
Abstract
PURPOSE The diagnostic criteria for cavernous sinus invasion (CSI) by pituitary adenomas are still unsatisfactory and controversial. For this reason, the study examined the appearance of the medial wall of the cavernous sinus (MWCS) on proton-density-weighted (PDW) magnetic resonance imaging (MRI) to determine its value for preoperative assessment of CSI. METHODS A 3.0-Tesla MRI scanner was used to obtain preoperative PDW images and conventional MRI sequences of 48 consecutive pituitary adenomas, and the MWCS was examined in PDW images to determine the presence of CSI in comparison to surgical findings and three traditional MRI criteria: Knosp grading system (KGS); percentage of encasement of the internal carotid artery (PEICA); and replacement of cavernous sinus compartments (RCSC) by tumors. The value of the MWCS as seen on MRI was compared with that of the Ki-67 labelling index (Ki-67 LI). RESULTS CSI images showed that continuity of the MWCS was interrupted and that tumor tissue had infiltrated the cavernous sinus (CS) compartments through the defects. In 96 CSs from 48 patients, the sensitivity of MRI visualization of the MWCS for detection of CSI was 93.3% with a specificity of 93.8%, which was significantly higher than with KGS, PEICA and RCSC (P=0.007, P=0.008 and P=0.056, respectively). Histopathological results showed no significant differences between MRI visualization of the MWCS and the Ki-67 LI. CONCLUSION PDW imaging permits adequate visualization of the MWCS and is superior to traditional diagnostic criteria for the detection of CSI, providing accurate preoperative images for intraoperative navigation.
Collapse
Affiliation(s)
- Lei Cao
- Department of Neurosurgery, Fuzhou General Hospital, 156, Xihuanbei Road, Fuzhou Fujian 350025, China; Capital Medical University, Beijing Neurosurgical Institute, 6, Tiantanxili, Beijing 100050, China
| | | | | | | | | | | |
Collapse
|
39
|
McCutcheon IE. Pituitary adenomas: Surgery and radiotherapy in the age of molecular diagnostics and pathology. Curr Probl Cancer 2013; 37:6-37. [PMID: 23391140 DOI: 10.1016/j.currproblcancer.2012.10.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Ian E McCutcheon
- Department of Neurosurgery, The University of Texas M D Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, Texas 77030, USA
| |
Collapse
|
40
|
Hamilton A, Sibson NR. Role of the systemic immune system in brain metastasis. Mol Cell Neurosci 2013; 53:42-51. [PMID: 23073146 DOI: 10.1016/j.mcn.2012.10.004] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2012] [Revised: 09/24/2012] [Accepted: 10/04/2012] [Indexed: 10/27/2022] Open
Abstract
Metastatic disease in the central nervous system (CNS) is a cause of increasing mortality amongst cancer patients. As with other types of cancer, cells of the systemic immune system play a range of important roles in the development of metastatic lesions in the CNS, both repressing and promoting tumour growth. Recent advances in immunotherapy have changed the emphasis in cancer treatment away from conventional chemotherapy and radiotherapy for certain tumour types. Despite this, our understanding of systemic immune system involvement in CNS metastases remains poor. The blood-brain barrier prevents the majority of diagnostic and therapeutic agents from crossing into the brain parenchyma until the late stages of metastatic disease. Thus, the development of immunotherapy for CNS pathologies is particularly desirable. This review draws together our current understanding in the relationships between CNS metastases and circulating systemic immune cells. We discuss the roles that circulating systemic immune cells may play in the homing of metastatic cells to the perivascular space, and the pro-metastatic and antagonistic roles that infiltrating systemic immune cells may play at sites of metastasis. This article is part of a Special Issue entitled 'Neuroinflammation in neurodegeneration and neurodysfunction'.
Collapse
Affiliation(s)
- Alastair Hamilton
- CR-UK/MRC Gray Institute for Radiation Oncology and Biology, Department of Oncology, University of Oxford, Oxford, UK
| | | |
Collapse
|
41
|
Lonser RR, Wind JJ, Nieman LK, Weil RJ, DeVroom HL, Oldfield EH. Outcome of surgical treatment of 200 children with Cushing's disease. J Clin Endocrinol Metab 2013; 98:892-901. [PMID: 23372173 PMCID: PMC3590477 DOI: 10.1210/jc.2012-3604] [Citation(s) in RCA: 94] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Factors influencing the outcome of surgical treatment of pediatric Cushing's disease (CD) have not been fully established. OBJECTIVE The aim of this study was to examine features influencing the outcome of surgery for pediatric CD. DESIGN In this prospective observational study, the clinical, imaging, endocrinological, and operative outcomes were analyzed in consecutive patients treated at the National Institutes of Health (NIH) from 1982 through 2010. SETTING The study was conducted in a tertiary referral center. RESULTS Two hundred CD patients (106 females, 94 males) were included. Mean age at symptom development was 10.6 ± 3.6 years (range, 4.0 to 19.0 y). Mean age at NIH operation was 13.7 ± 3.7 years. Twenty-seven patients (13%) had prior surgery at another institution. Magnetic resonance imaging identified adenomas in 97 patients (50%). When positive, magnetic resonance imaging accurately defined a discrete adenoma in 96 of the 97 patients (99%), which was more accurate than the use of ACTH ratios during inferior petrosal sinus sampling to determine adenoma lateralization (accurate in 72% of patients without prior surgery). A total of 195 of the 200 patients (98%) achieved remission after surgery (189 [97%] were hypocortisolemic; 6 [3%] were eucortisolemic postoperatively). Factors associated with initial remission (P < .05) included identification of an adenoma at surgery, immunohistochemical ACTH-producing adenoma, and noninvasive ACTH adenoma. Younger age, smaller adenoma, and absence of cavernous sinus wall or other dural invasion were associated with long-term remission (P < .05). A minimum morning serum cortisol of less than 1 μg/dl after surgery had a positive predictive value for lasting remission of 96%. CONCLUSIONS With rare disorders, such as pediatric CD, enhanced outcomes are obtained by evaluation and treatment at centers with substantial experience. Resection of pituitary adenomas in pediatric CD in that setting can be safe, effective, and durable. Early postoperative endocrine testing predicts lasting remission. Because lasting remission is associated with younger age at surgery, smaller adenomas, and lack of dural invasion, early diagnosis should improve surgical outcome.
Collapse
Affiliation(s)
- Russell R Lonser
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland 20892, USA
| | | | | | | | | | | |
Collapse
|
42
|
Hueng DY, Ma HI, Chen CM. Letter to the Editor: Cushing's disease and dural invasion. J Neurosurg 2012; 117:189-90; author reply 190-1. [DOI: 10.3171/2012.2.jns111890] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
|