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Faropoulos K, Gioti I, Georgakopoulou VE, Spandidos DA, Papalexis P, Lempesis IG, Trakas N, Trakas I, Anagiotos A, Fotakopoulos G. When age is not an obstacle: A case series of endoscopic transsphenoidal resection of pituitary macroadenomas in older patients. Biomed Rep 2023; 19:86. [PMID: 37881600 PMCID: PMC10594072 DOI: 10.3892/br.2023.1668] [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: 07/18/2023] [Accepted: 09/21/2023] [Indexed: 10/27/2023] Open
Abstract
Due to the increase in life expectancy, the number of elderly patients suffering from a pituitary macroadenoma is expected to increase in the future. The endoscopic endonasal transsphenoidal (EET) approach tends to be the first choice for the treatment of pituitary macroadenomas in the general population. Notwithstanding, in the geriatric population, the goals of management for this condition remain unclear. The present study retrospectively evaluated and describes the cases of 6 patients >70 years of age with a pituitary macroadenoma who were treated by a skull base team, composed of one ENT surgeon and one neurosurgeon. All the patients experienced a notable improvement in their neurological deficit, while their hormonal status also improved or at least did not deteriorate after the surgery. The EET approach appears to be a safe and effective approach for the treatment of pituitary macroadenomas in the geriatric population.
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Affiliation(s)
| | - Ifigeneia Gioti
- Department of Radiotherapy, University Hospital of Patras, 26504 Patras, Greece
| | | | - Demetrios A. Spandidos
- Laboratory of Clinical Virology, School of Medicine, University of Crete, 71003 Heraklion, Greece
| | - Petros Papalexis
- Unit of Endocrinology, First Department of Internal Medicine, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
- Department of Biomedical Sciences, University of West Attica, 12243 Athens, Greece
| | - Ioannis G. Lempesis
- Department of Pathophysiology, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Nikolaos Trakas
- Department of Biochemistry, Sismanogleio Hospital, 15126 Athens, Greece
| | - Ilias Trakas
- Department of Pathophysiology, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Andreas Anagiotos
- Department of Otolaryngology, Nicosia General Hospital, 2029 Nicosia, Cyprus
| | - George Fotakopoulos
- Department of Neurosurgery, General University Hospital of Larissa, 41221 Larissa, Greece
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Garvayo M, Villa C, Jouinot A, Messerer M, Reina V, Hage M, Raffin-Sanson ML, Courtillot C, Bachelot A, Kamenicky P, Chanson P, Vatier C, Christin-Maitre S, Bertherat J, Assié G, Gaillard S, Baussart B. Pituitary surgery outcome in patients 75 years and older: a retrospective study. Acta Neurochir (Wien) 2023; 165:3409-3420. [PMID: 37736839 DOI: 10.1007/s00701-023-05809-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 09/09/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND As the population ages, the number of elderly patients with an indication for pituitary surgery is rising. Information on the outcome of patients aged over 75 is limited. This study reports a large series assessing the feasibility of surgical resection in this specific age range, focusing on surgical complications and postoperative results. METHODS A retrospective cohort study of patients with pituitary adenomas and Rathke's cleft cysts was conducted. All patients were aged 75 years or over and treated by a single expert neurosurgical team. A control population included 2379 younger adult patients operated by the same surgeons during the same period. RESULTS Between 2008 and 2022, 155 patients underwent surgery. Indication was based on vision impairment in most patients (79%). Median follow-up was 13 months (range: 3-96). The first surgery was performed with an endoscopic transsellar approach, an extended endonasal transtuberculum approach and a microscopic transcranial approach in 96%, 3%, and 1% of patients, respectively. Single surgery was sufficient to obtain volume control in 97% of patients. From Kaplan-Meier estimates, 2-year and 5-year disease control with a single surgery were 97.3% and 86.2%, respectively. Resection higher than 80% was achieved in 77% of patients. No vision worsening occurred. In acromegaly and Cushing's disease, endocrine remission was obtained in 90% of non-invasive adenomas. Surgical complications were noted in 5% of patients, with 30-day mortality, hematoma, cerebrospinal fluid leak, meningitis, and epistaxis occurring in 0.6%, 0.6%, 1.9%, 0.6%, and 1.3% respectively. New endocrine anterior deficits occurred in only 5%, while no persistent diabetes insipidus was noted. Compared with younger patients, the complication rate was not statistically different. CONCLUSIONS Surgery beyond the age of 75, mainly relying on an endoscopic endonasal transsellar approach, is effective and safe, provided that patients are managed in tertiary centers.
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Affiliation(s)
- Marta Garvayo
- Department of Neurosurgery, La Pitié-Salpêtrière University Hospital, Assistance Publique-Hôpitaux de Paris, 47-83 Boulevard de L'Hôpital, 75013, Paris, France
- Department of Neurosurgery, University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland
| | - Chiara Villa
- Université Paris Cité, CNRS, INSERM, Institut Cochin, 75014, Paris, France
- Department of Neuropathology, La Pitié-Salpêtière University Hospital, AP-HP, Sorbonne University, Paris, France
| | - Anne Jouinot
- Université Paris Cité, CNRS, INSERM, Institut Cochin, 75014, Paris, France
| | - Mahmoud Messerer
- Department of Neurosurgery, University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland
| | - Vincent Reina
- Department of Neurosurgery, La Pitié-Salpêtrière University Hospital, Assistance Publique-Hôpitaux de Paris, 47-83 Boulevard de L'Hôpital, 75013, Paris, France
| | - Mirella Hage
- Department of Endocrinology, Assistance Publique-Hôpitaux de Paris, Hôpital Ambroise Paré, Boulogne Billancourt, France
- Université de Versailles Saint-Quentin-en-Yvelines UFR Des Sciences de La Santé Simone Veil, Montigny-Le-Bretonneux, France
| | - Marie-Laure Raffin-Sanson
- Department of Endocrinology, Assistance Publique-Hôpitaux de Paris, Hôpital Ambroise Paré, Boulogne Billancourt, France
- Université de Versailles Saint-Quentin-en-Yvelines UFR Des Sciences de La Santé Simone Veil, Montigny-Le-Bretonneux, France
| | - Carine Courtillot
- Department of Endocrinology and Reproductive Medicine, Centre de Référence Des Maladies Endocriniennes Rares de La Croissance Et du Développement, CRMERC, Endo-ERN, Pitié-Salpêtrière Hospital, AP-HP, Sorbonne University, Paris, France
| | - Anne Bachelot
- Department of Endocrinology and Reproductive Medicine, Centre de Référence Des Maladies Endocriniennes Rares de La Croissance Et du Développement, CRMERC, Endo-ERN, Pitié-Salpêtrière Hospital, AP-HP, Sorbonne University, Paris, France
| | - Peter Kamenicky
- Université Paris-Saclay, Inserm, Physiologie Et Physiopathologie Endocriniennes, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d'Endocrinologie Et Des Maladies de La Reproduction, Centre de Référence des Maladies Rares de L'Hypophyse, Le Kremlin-Bicêtre, France
| | - Philippe Chanson
- Université Paris-Saclay, Inserm, Physiologie Et Physiopathologie Endocriniennes, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d'Endocrinologie Et Des Maladies de La Reproduction, Centre de Référence des Maladies Rares de L'Hypophyse, Le Kremlin-Bicêtre, France
| | - Camille Vatier
- Sorbonne University, Endocrine Unit, Reproductive Medicine, Centre de Référence Des Maladies Endocriniennes Rares de La Croissance Et du Développement (CRMERC), Endo-ERN (Id 739527), Saint-Antoine Hospital, AP-HP, Paris, France
- Inserm UMRS938, Saint-Antoine Research Center, Sorbonne University, 75012, Paris, France
| | - Sophie Christin-Maitre
- Sorbonne University, Endocrine Unit, Reproductive Medicine, Centre de Référence Des Maladies Endocriniennes Rares de La Croissance Et du Développement (CRMERC), Endo-ERN (Id 739527), Saint-Antoine Hospital, AP-HP, Paris, France
- INSERM UMR-833, Trousseau Hospital, Paris, France
| | - Jérôme Bertherat
- Université Paris Cité, CNRS, INSERM, Institut Cochin, 75014, Paris, France
- Department of Endocrinology, Center of Rare Adrenal Diseases, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Guillaume Assié
- Université Paris Cité, CNRS, INSERM, Institut Cochin, 75014, Paris, France
- Department of Endocrinology, Center of Rare Adrenal Diseases, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Stephan Gaillard
- Department of Neurosurgery, La Pitié-Salpêtrière University Hospital, Assistance Publique-Hôpitaux de Paris, 47-83 Boulevard de L'Hôpital, 75013, Paris, France
| | - Bertrand Baussart
- Department of Neurosurgery, La Pitié-Salpêtrière University Hospital, Assistance Publique-Hôpitaux de Paris, 47-83 Boulevard de L'Hôpital, 75013, Paris, France.
- Université Paris Cité, CNRS, INSERM, Institut Cochin, 75014, Paris, France.
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Teramoto S, Tahara S, Fukuda I, Hattori Y, Kondo A, Sugihara H, Morita A. Exploring endocrinological pitfalls in pituitary surgery in the elderly. Heliyon 2023; 9:e17060. [PMID: 37484278 PMCID: PMC10361224 DOI: 10.1016/j.heliyon.2023.e17060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 05/24/2023] [Accepted: 06/06/2023] [Indexed: 07/25/2023] Open
Abstract
Background Endoscopic transsphenoidal surgery (ETSS) is performed more frequently in elderly patients. We investigated endocrinological pitfalls in pituitary surgery in the elderly by a comparative study focusing only on elderly patients. Methods Ninety-nine elderly patients aged 65 years and over with non-functioning pituitary adenoma (NFPA) who underwent ETSS were retrospectively examined and classified into the early (aged 65-74 years) and late (aged 75 years and over) elderly groups. The baseline characteristics and anterior pituitary function were compared between the groups. Results Seventy patients were assigned to the early elderly group and 29 to the late elderly group. Thyroid-stimulating hormone (TSH) response in preoperative and postoperative thyrotropin-releasing hormone (TRH) tests revealed a significant difference between the groups. Preoperative and postoperative TSH responses were significantly correlated in both groups. Residual analysis of the correlation between preoperative free triiodothyronine (T3) secretion quantity and preoperative TSH response in both groups, which was significant, indicated that preoperative TSH response was significantly normal when preoperative free T3 secretion quantity was normal in the early elderly group, but preoperative free T3 secretion quantity was significantly lower regardless of preoperative TSH response in the late elderly group. Conculsions The present study suggested that preoperative and postoperative TSH secretory capacity was presumed to be normal when preoperative free T3 levels were normal in the early elderly patients with NFPA. On the other hand, TSH secretory capacity in the late elderly patients could only be assessed by the TRH test, which should be taken into account.
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Affiliation(s)
- Shinichiro Teramoto
- Department of Neurological Surgery, Nippon Medical School, Tokyo 113-8603, Japan
- Department of Neurosurgery, Juntendo University Graduate School of Medicine, Tokyo 113-8431, Japan
| | - Shigeyuki Tahara
- Department of Neurological Surgery, Nippon Medical School, Tokyo 113-8603, Japan
| | - Izumi Fukuda
- Department of Endocrinology, Diabetes and Metabolism, Nippon Medical School, Tokyo 113-8603, Japan
| | - Yujiro Hattori
- Department of Neurological Surgery, Nippon Medical School, Tokyo 113-8603, Japan
| | - Akihide Kondo
- Department of Neurosurgery, Juntendo University Graduate School of Medicine, Tokyo 113-8431, Japan
| | - Hitoshi Sugihara
- Department of Endocrinology, Diabetes and Metabolism, Nippon Medical School, Tokyo 113-8603, Japan
| | - Akio Morita
- Department of Neurological Surgery, Nippon Medical School, Tokyo 113-8603, Japan
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Abiri A, Patel TR, Nguyen E, Birkenbeuel JL, Tajudeen BA, Choby G, Wang EW, Schlosser RJ, Palmer JN, Adappa ND, Kuan EC. Postoperative protocols following endoscopic skull base surgery: An evidence-based review with recommendations. Int Forum Allergy Rhinol 2023; 13:42-71. [PMID: 35678720 DOI: 10.1002/alr.23041] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 05/30/2022] [Accepted: 05/31/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Postoperative management strategies for endoscopic skull base surgery (ESBS) vary widely because of limited evidence-based guidance. METHODS The PubMed, EMBASE, and Cochrane databases were systematically reviewed from January 1990 through February 2022 to examine 18 postoperative considerations for ESBS. Nonhuman studies, articles written in a language other than English, and case reports were excluded. Studies were assessed for levels of evidence, and each topic's aggregate grade of evidence was evaluated. RESULTS A total of 74 studies reporting on 18 postoperative practices were reviewed. Postoperative pain management, prophylactic antibiotics, and lumbar drain use had the highest grades of evidence (B). The literature currently lacks high quality evidence for a majority of the reviewed ESBS precautions. There were no relevant studies to address postoperative urinary catheter use and medical intracranial pressure reduction. CONCLUSION The evidence for postoperative ESBS precautions is heterogeneous, scarce, and generally of low quality. Although this review identified the best evidence available in the literature, it suggests the urgent need for more robust evidence. Therefore, additional high-quality studies are needed in order to devise optimal postoperative ESBS protocols.
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Affiliation(s)
- Arash Abiri
- Department of Otolaryngology, Head and Neck Surgery, University of California Irvine, Orange, California, USA
| | - Tirth R Patel
- Department of Otolaryngology, Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Emily Nguyen
- Department of Otolaryngology, Head and Neck Surgery, University of California Irvine, Orange, California, USA
| | - Jack L Birkenbeuel
- Department of Otolaryngology, Head and Neck Surgery, University of California Irvine, Orange, California, USA
| | - Bobby A Tajudeen
- Department of Otolaryngology, Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Garret Choby
- Department of Otolaryngology, Head and Neck Surgery and Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Eric W Wang
- Department of Otolaryngology, Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Rodney J Schlosser
- Department of Otolaryngology, Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - James N Palmer
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Nithin D Adappa
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Edward C Kuan
- Department of Otolaryngology, Head and Neck Surgery, University of California Irvine, Orange, California, USA
- Department of Neurological Surgery, University of California Irvine, Orange, California, USA
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5
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Shahrestani S, Brown NJ, Nasrollahi TS, Strickland BA, Bakhsheshian J, Ruzevick JJ, Bove I, Lee A, Emeh UA, Carmichael JD, Zada G. Evaluating the predictive value of comorbidity indices in pituitary surgery: a mixed-effects modeling study using the Nationwide Readmissions Database. J Neurosurg 2022; 137:1443-1451. [PMID: 35303700 DOI: 10.3171/2022.1.jns22197] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 01/31/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Although pituitary adenomas (PAs) are common intracranial tumors, literature evaluating the utility of comorbidity indices for predicting postoperative complications in patients undergoing pituitary surgery remains limited, thereby hindering the development of complex models that aim to identify high-risk patient populations. We utilized comparative modeling strategies to evaluate the predictive validity of various comorbidity indices and combinations thereof in predicting key pituitary surgery outcomes. METHODS The Nationwide Readmissions Database was used to identify patients who underwent pituitary tumor operations (n = 19,653) in 2016-2017. Patient frailty was assessed using the Johns Hopkins Adjusted Clinical Groups (ACG) System. The Charlson Comorbidity Index (CCI) and Elixhauser Comorbidity Index (ECI) were calculated for each patient. Five sets of generalized linear mixed-effects models were developed, using as the primary predictors 1) frailty, 2) CCI, 3) ECI, 4) frailty + CCI, or 5) frailty + ECI. Complications of interest investigated included inpatient mortality, nonroutine discharge (e.g., to locations other than home), length of stay (LOS) within the top quartile (Q1), cost within Q1, and 1-year readmission rates. RESULTS Postoperative mortality occurred in 73 patients (0.4%), 1-year readmission was reported in 2994 patients (15.2%), and nonroutine discharge occurred in 2176 patients (11.1%). The mean adjusted all-payer cost for the procedure was USD $25,553.85 ± $26,518.91 (Q1 $28,261.20), and the mean LOS was 4.8 ± 7.4 days (Q1 5.0 days). The model using frailty + ECI as the primary predictor consistently outperformed other models, with statistically significant p values as determined by comparing areas under the curve (AUCs) for most complications. For prediction of mortality, however, the frailty + ECI model (AUC 0.831) was not better than the ECI model alone (AUC 0.831; p = 0.95). For prediction of readmission, the frailty + ECI model (AUC 0.617) was not better than the frailty model alone (AUC 0.606; p = 0.10) or the frailty + CCI model (AUC 0.610; p = 0.29). CONCLUSIONS This investigation is to the authors' knowledge the first to implement mixed-effects modeling to study the utility of common comorbidity indices in a large, nationwide cohort of patients undergoing pituitary surgery. Knowledge gained from these models may help neurosurgeons identify high-risk patients who require additional clinical attention or resource utilization prior to surgical planning.
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Affiliation(s)
- Shane Shahrestani
- 1Department of Neurosurgery, University of Southern California, Los Angeles
- 2Department of Medical Engineering, California Institute of Technology, Pasadena
| | - Nolan J Brown
- 3Department of Neurosurgery, University of California, Irvine Medical Center, Irvine
| | - Tasha S Nasrollahi
- 4Department of Otolaryngology, Cedars-Sinai Medical Center, Los Angeles; and
| | - Ben A Strickland
- 1Department of Neurosurgery, University of Southern California, Los Angeles
| | | | - Jacob J Ruzevick
- 1Department of Neurosurgery, University of Southern California, Los Angeles
| | - Ilaria Bove
- 1Department of Neurosurgery, University of Southern California, Los Angeles
| | - Ariel Lee
- 3Department of Neurosurgery, University of California, Irvine Medical Center, Irvine
| | - Ugochi A Emeh
- 5Department of Molecular and Cell Biology, University of California, Berkeley, California
| | - John D Carmichael
- 1Department of Neurosurgery, University of Southern California, Los Angeles
| | - Gabriel Zada
- 1Department of Neurosurgery, University of Southern California, Los Angeles
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Sukys JM, Jiang R, Manes RP. Assessing Risk of Severe Complications after Endoscopic Transnasal Transsphenoidal Surgery: A Comparison of Frailty, American Society of Anesthesiologists, and Comorbidity Scores. J Neurol Surg B Skull Base 2022; 83:536-547. [PMID: 36097501 PMCID: PMC9462967 DOI: 10.1055/s-0041-1740577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Accepted: 11/11/2021] [Indexed: 10/19/2022] Open
Abstract
Objective This study aimed to improve age-independent risk stratification for patients undergoing endoscopic transnasal transsphenoidal (TNTS) approach to pituitary mass resection by investigating the associations between frailty, American Society of Anesthesiologists (ASA), and comorbidity scores with severe complications following TNTS. Design This study is a retrospective review. Setting This review was conducted utilizing the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Participants A total of 680 cases of TNTS identified from 2010 to 2013 were included in this study. Main Outcome Measures The modified frailty index (mFI) was calculated to quantify frailty. ASA and Charlson's comorbidity index (CCI) scores were obtained as physiologic status and comorbidity-based prognostic markers. Severe complications were separated into intensive care unit (ICU)-level complications, defined by Clavien-Dindo grade IV (CDIV) criteria, and mortality. Results Overall, 24 CDIV complications (3.5%) and 6 deaths (0.9%) were recorded. Scores for mFI ( p = 0.01, R 2 = 0.97) and ASA ( p = 0.04., R 2 = 0.87) were significantly correlated with CDIV complications. ASA scores were significantly correlated with mortality ( p = 0.03, R 2 = 0.87), as well as independently associated with CDIV complication by multivariable regression models (odds ratio [OR] = 2.96, 95% confidence interval [CI]: 1.35-6.83, p < 0.01), while mFI was not. CCI was not significantly associated with CDIV complications or mortality. A multivariable regression model incorporating ASA had a lower Akaike's Information Criteria (AIC; 188.55) than a model incorporating mFI (195.99). Conclusion Frailty and physiologic status, as measured by mFI and ASA scores respectively, both correlate with ICU-level complications after TNTS. ASA scores demonstrate greater clinical utility than mFI scores; however, as they are more easily generated, uniquely correlated with mortality and independently associated with ICU-level complication risk on multivariable regression analysis.
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Affiliation(s)
- Jordan M. Sukys
- Division of Otolaryngology, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, United States
- Address for correspondence Jordan M. Sukys, MD 47 College Place, Suite 216, New Haven, Connecticut 06510United States
| | - Roy Jiang
- Department of Surgery, Division of Otolaryngology, Yale University School of Medicine, New Haven, Connecticut, United States
| | - Richard P. Manes
- Division of Otolaryngology, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, United States
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7
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Chalif EJ, Morshed RA, Young JS, Haddad AF, Jain S, Aghi MK. Pituitary adenoma in the elderly: surgical outcomes and treatment trends in the United States. J Neurosurg 2022; 137:1687-1698. [PMID: 35535847 DOI: 10.3171/2022.3.jns212940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 03/21/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Decision-making in how to manage pituitary adenomas (PAs) in the elderly (age ≥ 65 years) can be challenging given the benign nature of these tumors and concerns about surgical morbidity in these patients. In this study involving a large multicenter national registry, the authors examined treatment trends and surgical outcomes in elderly compared to nonelderly patients. METHODS The National Cancer Data Base (NCDB) was queried for adults aged ≥ 18 years with PA diagnosed by MRI (in observed cases) or pathology (in surgical cases) from 2004 to 2016. Univariate and multivariate logistic regressions were used to evaluate the prognostic impact of age and other covariates on 30- and 90-day postsurgical mortality (30M/90M), prolonged (≥ 5 days) length of inpatient hospital stay (LOS), and extent of resection. RESULTS A total of 96,399 cases met the study inclusion criteria, 27% of which were microadenomas and 73% of which were macroadenomas. Among these cases were 25,464 elderly patients with PA. Fifty-three percent of these elderly patients were treated with surgery, 1.9% underwent upfront radiotherapy, and 44.9% were observed without treatment. Factors associated with surgical treatment compared to observation included younger age, higher income, private insurance, higher Charlson-Deyo comorbidity (CD) score, larger tumor size, and receiving treatment at an academic hospital (each p ≤ 0.01). Elderly patients undergoing surgery had increased rates of 30M (1.4% vs 0.6%), 90M (2.8% vs 0.9%), prolonged LOS (26.1% vs 23.0%), and subtotal resection (27.2% vs 24.5%; each p ≤ 0.01) compared to those in nonelderly PA patients. On multivariate analysis, age, tumor size, and CD score were independently associated with worse postsurgical mortality. High-volume facilities (HVFs) had significantly better outcomes than low-volume facilities: 30M (0.9% vs 1.8%, p < 0.001), 90M (2.0% vs 3.5%, p < 0.001), and prolonged LOS (21.8% vs 30.3%, p < 0.001). A systematic literature review composed of 22 studies demonstrated an elderly PA patient mortality rate of 0.7%, which is dramatically lower than real-world NCDB outcomes and speaks to substantial selection bias in the previously published literature. CONCLUSIONS The study findings confirm that elderly patients with PA are at higher risk for postoperative mortality than younger patients. Surgical risk in this age group may have been previously underreported in the literature. Resection at HVFs better reflects these historical rates, which has important implications in elderly patients for whom surgery is being considered.
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8
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Quah BL, Edwards-Bailey A, Gnanalingham K, Pathmanaban O, Vasilopoulos H, Roncaroli F, Kearney T, Balogun J, Karabatsou K. Endoscopic transsphenoidal surgery for biochemically and clinically non-functioning adenohypophyseal tumours in the elderly: experience from a single UK centre. Endocrine 2022; 75:872-882. [PMID: 34741239 DOI: 10.1007/s12020-021-02910-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 10/13/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE To assess and compare outcome of surgical management of non-functioning pituitary adenohypophyseal tumours in patients under 65-years, and 65-years and older at tertiary neurosurgical referral centre. METHODS Data was retrospectively analysed from pituitary database. Forty-four patients aged 65 or older (Group 1) and 93 patients under 65 (Group 2) underwent endoscopic trans-sphenoidal surgery (ETSS) between January 2017 and July 2019. The surgical, endocrinological, ophthalmological and radiological outcomes were compared. RESULTS 6.8% of Group 1 patients had peri-operative surgical complications compared to 12.9% in Group 2 (p = 0.29). Improved visual fields and acuity were seen in 65.2% and 82.8% of Group 1 and Group 2 respectively (p = 0.124), although there were pre-existing ocular problems in 15.9% of Group 1. New hormone deficiencies were observed in 31.8% of Group 1 patients, and 24.7% of Group 2 (p = 0.555). Tumour regrowth/recurrence was seen in 2.3% of Group 1 (p = 0.553). The rate of repeat surgery was 6.8% in the Group 1 and 12.9% in Group 2 (p = 0.28). There was no significant relationship between extent of resection, complications or hormonal deficiency. The mean duration of follow-up was 10.5 ± 13.0 months for Group 1 patients and 13.0 ± 16.0 months for Group 2 patients (p = 0.526). CONCLUSIONS ETSS for non-functioning pituitary adenohypophyseal tumours is safe and well tolerated in the patients aged 65 and older. Advanced age by itself should not be a contra-indication for ETSS. It is however highly recommended that the care of such patients to be offered at a high volume, dedicated pituitary surgical units.
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Affiliation(s)
- Boon Leong Quah
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Andrew Edwards-Bailey
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Kanna Gnanalingham
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Omar Pathmanaban
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- Geoffrey Jefferson Brain Research Centre, Division of Neuroscience & Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, UK
| | - Hariclea Vasilopoulos
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Federico Roncaroli
- Geoffrey Jefferson Brain Research Centre, Division of Neuroscience & Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, UK
- Neuropathology Unit, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Tara Kearney
- Department of Endocrinology, Salford Royal Hospital NHS Foundation Trust, Manchester, UK
| | - James Balogun
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- Division of Neurosurgery, Department of Surgery, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Konstantina Karabatsou
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.
- Geoffrey Jefferson Brain Research Centre, Division of Neuroscience & Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, UK.
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Alexander TD, Chitguppi C, Collopy S, Murphy K, Lavergne P, Patel P, Khoury T, Rabinowitz M, Nyquist GG, Rosen MR, Farrell CJ, Karsy M, Evans JJ. Surgical Outcomes of Endoscopic Transsphenoidal Pituitary Adenoma Resection in Elderly Versus Younger Patients. Skull Base Surg 2022; 83:405-410. [PMID: 35903649 PMCID: PMC9324315 DOI: 10.1055/a-1680-1572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 10/24/2021] [Indexed: 02/02/2023]
Abstract
Introduction Pituitary adenomas (PAs) are one of the most common types of intracranial neoplasm with increased incidence in elderly patients. The outcomes of endoscopic transsphenoidal surgery (ETS) specifically on elderly patients remain unclear. Methods We performed a retrospective cohort study to compare elderly patients (age ≥65 years) with nonelderly patients (age <65 years) who underwent ETS for PA from January 2005 to December 2020. Surgical outcomes, including extent of resection, complication profile, length of stay, and endocrinopathy rates, were compared between elderly and nonelderly patients. Results A total of 690 patients were included, with 197 (29%) being elderly patients. Elderly patients showed higher rates of hypertension ( p < 0.05), myocardial infarction ( p < 0.01), and atrial fibrillation ( p = 0.01) but not other comorbidities. Elderly patients also had more frequent optic nerve involvement (72 vs. 61% of cases, p = 0.01). Tumor characteristics and other patient variables were otherwise similar between younger and elderly patients. Postoperative cerebrospinal fluid (CSF) leaks (2 vs. 2%, p = 0.8), 30-day readmission, reoperation, postoperative complications, and postoperative endocrinopathies were similar between younger and older patients. Subdividing patients into age <65, 65 to 79, and >80 years also did not demonstrate a worsening of surgical outcomes with age. Conclusion For well-selected elderly patients in experienced endoscopic skull base centers, good surgical outcomes similarly to younger patients may be achieved.
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Affiliation(s)
- Tyler D. Alexander
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States
| | - Chandala Chitguppi
- Department of Otolaryngology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States
| | - Sarah Collopy
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States
| | - Kira Murphy
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States
| | - Pascal Lavergne
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States
| | - Prachi Patel
- Department of Otolaryngology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States
| | - Tawfiq Khoury
- Department of Otolaryngology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States
| | - Mindy Rabinowitz
- Department of Otolaryngology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States
| | - Gurston G. Nyquist
- Department of Otolaryngology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States
| | - Marc R. Rosen
- Department of Otolaryngology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States
| | - Christopher J. Farrell
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States
| | - Michael Karsy
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States
| | - James J. Evans
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States,Address for correspondence James J. Evans, MD Center for Minimally Invasive Cranial Base Surgery and Endoscopic Neurosurgery, Thomas Jefferson University HospitalPhiladelphia, PAUnited States
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10
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Kinoshita Y, Taguchi A, Tominaga A, Arita K, Yamasaki F. Pseudocapsular resection in elderly patients with non-functioning pituitary adenoma. Clin Neurol Neurosurg 2021; 210:106997. [PMID: 34741976 DOI: 10.1016/j.clineuro.2021.106997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 09/22/2021] [Accepted: 10/17/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The safety of transsphenoidal surgery (TSS) for pituitary adenoma in elderly populations is becoming a new topic in our aging society. However, previous studies did not focus on the surgical procedures in elderly patients. We attempted to clarify the safety of TSS and the influence of pseudocapsular resection in elderly patients with non-functioning pituitary adenoma (NFPA). METHODS A total of 284 patients undergoing initial TSS for NFPA were categorized into two groups as follows: 1) Elderly group (n = 69; age ≥ 70 years); and 2) Younger group (n = 215; age < 70 years). Furthermore, all patients were newly divided into the two following categories: 1) Resected group (n = 121, with total pseudocapsule resection); and 2) Non-Resected group (n = 163, without total pseudocapsule resection). The main outcome measure was the incidence of perioperative complications and the rate of severe growth hormone deficiency (sGHD) after TSS. RESULTS There were no significant differences in the rates of perioperative complication between the Elderly and Younger groups. Furthermore, pseudocapsular resection did not increase the surgical risks in either group. On the other hand, sGHD only showed a significant improvement in the Younger group. The only factor predicting the new development of sGHD following TSS was an older age, not pseudocapsule resection. CONCLUSIONS Aging does not increase the perioperative complications of TSS for NFPA; however, aging has a negative influence on the postoperative function of GH secretion. In contrast, pseudocapsular resection does not have any negative influence on the perioperative complications or postoperative function of GH secretion, even in elderly patients, based on the authors' experience and surgical technique.
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Affiliation(s)
- Yasuyuki Kinoshita
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan.
| | - Akira Taguchi
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan
| | - Atsushi Tominaga
- Department of Neurosurgery and Neuro-Endovascular Therapy, 1-5-54 Ujinakanda, Minami-ku, Hiroshima 734-8530, Japan
| | - Kazunori Arita
- Department of Neurosurgery, Izumi Regional Medical Center, 4513 Akasegawa, Akune 899-1611, Japan
| | - Fumiyuki Yamasaki
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan
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11
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Slot EM, Sabaoglu R, Voormolen EH, Hoving EW, van Doormaal TP. Cerebrospinal Fluid Leak after Transsphenoidal Surgery: A Systematic Review and Meta-analysis. J Neurol Surg B Skull Base 2021; 83:e501-e513. [DOI: 10.1055/s-0041-1733918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 07/01/2021] [Indexed: 10/20/2022] Open
Abstract
Abstract
Background Cerebrospinal fluid (CSF) leak is widely recognized as a challenging and commonly occurring postoperative complication of transsphenoidal surgery (TSS).The primary objective of this study is to benchmark the current prevalence of CSF leak after TSS in the adult population.
Methods The authors followed the PRISMA guidelines. The PubMed, Embase, and Cochrane Library databases were searched for articles reporting CSF leak after TSS in the adult population. Meta-analysis was performed using the Untransformed Proportion metric in OpenMetaAnalyst. For two between-group comparisons a generalized linear mixed model was applied.
Results We identified 2,408 articles through the database search, of which 70, published since 2015, were included in this systematic review. These studies yielded 24,979 patients who underwent a total of 25,034 transsphenoidal surgeries. The overall prevalence of postoperative CSF leak was 3.4% (95% confidence interval or CI 2.8–4.0%). The prevalence of CSF leak found in patients undergoing pituitary adenoma resection was 3.2% (95% CI 2.5–4.2%), whereas patients who underwent TSS for another indication had a CSF leak prevalence rate of 7.1% (95% CI 3.0–15.7%) (odds ratio [OR] 2.3, 95% CI 0.9–5.7). Patients with cavernous sinus invasion (OR 3.0, 95% CI 1.1–8.7) and intraoperative CSF leak (OR 5.9, 95% CI 3.8–9.0) have increased risk of postoperative CSF leak. Previous TSS and microscopic surgery are not significantly associated with postoperative CSF leak.
Conclusion The overall recent prevalence of CSF leak after TSS in adults is 3.4%. Intraoperative CSF leak and cavernous sinus invasion appear to be significant risk factors for postoperative CSF leak.
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Affiliation(s)
- Emma M.H. Slot
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Translational Neuroscience, University Medical Center, Utrecht Brain Center, Utrecht University, Utrecht, The Netherlands
| | - Rengin Sabaoglu
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Eduard H.J. Voormolen
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Eelco W. Hoving
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Neuro-oncology, Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Tristan P.C. van Doormaal
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Translational Neuroscience, University Medical Center, Utrecht Brain Center, Utrecht University, Utrecht, The Netherlands
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
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12
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Hardesty DA, Montaser A, Kreatsoulas D, Shah VS, VanKoevering KK, Otto BA, Carrau RL, Prevedello DM. Complications after 1002 endoscopic endonasal approach procedures at a single center: lessons learned, 2010-2018. J Neurosurg 2021; 136:393-404. [PMID: 34359021 DOI: 10.3171/2020.11.jns202494] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 11/19/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The endoscopic endonasal approach (EEA) has evolved into a mainstay of skull base surgery over the last two decades, but publications examining the intraoperative and perioperative complications of this technique remain scarce. A prior landmark series of 800 patients reported complications during the first era of EEA (1998-2007), parallel to the development of many now-routine techniques and technologies. The authors examined a single-institution series of more than 1000 consecutive EEA neurosurgical procedures performed since 2010, to elucidate the safety and risk factors associated with surgical and postoperative complications in this modern era. METHODS After obtaining institutional review board approval, the authors retrospectively reviewed intraoperative and postoperative complications and their outcomes in patients who underwent EEA between July 2010 and June 2018 at a single institution. RESULTS The authors identified 1002 EEA operations that met the inclusion criteria. Pituitary adenoma was the most common pathology (n = 392 [39%]), followed by meningioma (n = 109 [11%]). No patients died intraoperatively. Two (0.2%) patients had an intraoperative carotid artery injury: 1 had no neurological sequelae, and 1 had permanent hemiplegia. Sixty-one (6.1%) cases of postoperative cerebrospinal fluid leak occurred, of which 45 occurred during the original surgical hospitalization. Transient postoperative sodium dysregulation was noted after 87 (8.7%) operations. Six (0.6%) patients were treated for meningitis, and 1 (0.1%) patient died of a fungal skull base infection. Three (0.3%) patients died of medical complications, thereby yielding a perioperative 90-day mortality rate of 0.4% (4 deaths). High-grade (Clavien-Dindo grade III-V) complications were identified after 103 (10%) EEA procedures, and multivariate analysis was performed to determine the associations between factors and these more serious complications. Extradural EEA was significantly associated with decreased rates of these high-grade complications (OR [95% CI] 0.323 [0.153-0.698], p = 0.0039), whereas meningioma pathology (OR [95% CI] 2.39 [1.30-4.40], p = 0.0053), expanded-approach intradural surgery (OR [95% CI] 2.54 [1.46-4.42], p = 0.0009), and chordoma pathology (OR [95% CI] 9.31 [3.87-22.4], p < 0.0001) were independently associated with significantly increased rates of high-grade complications. CONCLUSIONS The authors have reported a large 1002-operation cohort of EEA procedures and associated complications. Modern EEA surgery for skull base pathologies has an acceptable safety profile with low morbidity and mortality rates. Nevertheless, significant intraoperative and postoperative complications were correlated with complex intradural procedures and meningioma and chordoma pathologies.
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Affiliation(s)
- Douglas A Hardesty
- Departments of1Neurosurgery and.,2Otolaryngology-Head and Neck Surgery, Wexner Medical Center
| | - Alaa Montaser
- Departments of1Neurosurgery and.,3Department of Neurosurgery, Ain Shams University, Cairo, Egypt
| | | | | | | | - Bradley A Otto
- 2Otolaryngology-Head and Neck Surgery, Wexner Medical Center
| | | | - Daniel M Prevedello
- Departments of1Neurosurgery and.,2Otolaryngology-Head and Neck Surgery, Wexner Medical Center
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13
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Villar-Taibo R, Díaz-Ortega C, Sifontes-Dubon M, Fernández-Pombo A, Serramito-García R, Martínez-Capoccioni G, Bernabeu I. Pituitary surgery in elderly patients: a safe and effective procedure. Endocrine 2021; 72:814-822. [PMID: 33665774 DOI: 10.1007/s12020-021-02665-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 02/17/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE The incidence of pituitary adenoma (PA) increases with age. Transsphenoidal surgery (TSS) in elderly patients is often considered to have greater risk compared to the younger population. The aim of this study is to compare surgical results, evolution and postoperative complications between elderly and young patients undergoing TSS. METHODS Retrospective review of patients undergoing TSS between 2011 and 2018 in our institution. Patients were divided into two cohorts: elderly (≥65 years) and non-elderly (<65 years). Characteristics and outcomes of both groups were compared at diagnosis, before surgery and for an average of 5.9 years of postoperative follow-up. RESULTS One hundred and twenty-five patients were included, 53 patients were ≥65 years (42%). The elderly patients were more likely to have non-functioning PA (NFPA) (90.5% vs. 45.8%, p: <0.01), a higher proportion of macroadenomas (92.4% vs. 77.8%, p = 0.029) and greater extrasellar extension (88.7% vs. 68.1%, p = 0.007). The elderly group also had more compressive symptoms (54.7% vs. 34.7%, p = 0.035) and hypopituitarism (66% vs. 47.2%, p = 0.029). Overall, surgical and endocrinological outcomes between the two groups were similar. Inpatient mortality in the elderly group was 1.8%. Regarding long-term outcomes, elderly patients had more postoperative hypopituitarism (67.9% vs. 45.8%, p = 0.03) with no differences in permanent diabetes insipidus, less residual tumours (24.5% vs. 40.3%, p = 0.019) and a higher rate of remission after surgery (71.7% vs. 52.8%, p = 0.034). When only NFPA cases were compared, the only significant difference was a higher frequency of macroadenomas in the elderly group. CONCLUSIONS Our results support the safety and efficacy of TSS in elderly patients with PA. Age should not be considered an exclusion criterion for TSS given that successful results can be achieved if an experienced pituitary team is available.
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Affiliation(s)
- R Villar-Taibo
- Endocrinology Department, University Hospital of Santiago de Compostela, Santiago de Compostela (A Coruña), Spain.
- Neoplasia and Differentiation of Endocrine Cells Group, Instituto de Investigación Sanitaria-IDIS (Health Research Institute), Santiago de Compostela (A Coruña), Spain.
| | - C Díaz-Ortega
- Endocrinology Department, University Hospital of A Coruña, A Coruña (A Coruña), Spain
| | - M Sifontes-Dubon
- Endocrinology Department, Mateu Orfila General Hospital, Menorca (Balearic Islands), Spain
| | - A Fernández-Pombo
- Endocrinology Department, University Hospital of Santiago de Compostela, Santiago de Compostela (A Coruña), Spain
| | - R Serramito-García
- Neoplasia and Differentiation of Endocrine Cells Group, Instituto de Investigación Sanitaria-IDIS (Health Research Institute), Santiago de Compostela (A Coruña), Spain
- Neurosurgery Department, University Hospital of Santiago de Compostela, Santiago de Compostela (A Coruña), Spain
| | - G Martínez-Capoccioni
- Otolaryngology Department, University Hospital of Santiago de Compostela, Santiago de Compostela (A Coruña), Spain
| | - I Bernabeu
- Endocrinology Department, University Hospital of Santiago de Compostela, Santiago de Compostela (A Coruña), Spain
- Neoplasia and Differentiation of Endocrine Cells Group, Instituto de Investigación Sanitaria-IDIS (Health Research Institute), Santiago de Compostela (A Coruña), Spain
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14
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Biamonte E, Betella N, Milani D, Lasio GB, Ariano S, Radice S, Lavezzi E, Mazziotti G, Lania A. Impact of age on postsurgical outcomes of nonfunctioning pituitary adenomas. Endocrine 2021; 72:915-922. [PMID: 33242176 DOI: 10.1007/s12020-020-02554-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 11/11/2020] [Indexed: 12/17/2022]
Abstract
PURPOSE The management of pituitary adenomas in the elderly has become a relevant clinical issue, in relationship with improved life expectancy and spreading use of imaging techniques. In this single-center and retrospective study, we investigated the impact of age on peri- and postsurgical outcomes in patients undergoing transnasal sphenoidal (TNS) surgery for pituitary adenomas. METHODS One-hundred-sixty-nine patients (62% males) undergoing endoscopic transphenoidal (TNS) surgery for nonfunctioning pituitary adenomas (NFPAs) were enrolled. Patients were subdivided into three groups according to age tertiles: ≤56 (group 1), 57-69 (group 2), and ≥70 (group 3) years. Postsurgical and endocrinological outcomes were evaluated and compared among the three age groups. RESULTS 37/169 patients (21.9%) developed at least one perisurgical complication, without significant association with the patients' age (P = 0.838), Charlson co-morbidity score (P = 0.326), and American Society of Anesthesiologist score (P = 0.616). In the multivariate regression analysis, the adenoma size resulted the only determinant of perisurgical complication (odds ratio [OR] 1.07, 95% confidence interval [C.I.] 1.00-1.13; P = 0.044). The development and the recovery of at least one pituitary hormone deficiency were observed in 12.2% and 14.2% of patients, respectively. The risk of developing new pituitary hormone deficiencies was correlated with cavernous sinus invasion as evaluated by magnetic resonance imaging (hazard ratio [HR] 4.19, 95% C.I. 1.39-12.66; P = 0.010), whereas the probability to normalize at least one pituitary hormone deficiency was significantly correlated with younger age of patients (HR 0.27, 95% CI 0.12-0.61; P = 0.002). CONCLUSIONS The results of this study reinforce the concept that endoscopic TNS surgery is a safe therapeutic option in the elderly patients with NFPA, even in presence of comorbidities and high anesthetic risk.
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Affiliation(s)
- E Biamonte
- Endocrinology, Diabetology and Andrology Unit, Humanitas Clinical and Research Center IRCCS, Rozzano, MI, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, MI, Italy
| | - N Betella
- Endocrinology, Diabetology and Andrology Unit, Humanitas Clinical and Research Center IRCCS, Rozzano, MI, Italy
| | - D Milani
- Neurosurgery Unit, Humanitas Clinical and Research Center IRCCS, Rozzano, MI, Italy
| | - G B Lasio
- Neurosurgery Unit, Humanitas Clinical and Research Center IRCCS, Rozzano, MI, Italy
| | - S Ariano
- Endocrinology, Diabetology and Andrology Unit, Humanitas Clinical and Research Center IRCCS, Rozzano, MI, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, MI, Italy
| | - S Radice
- Neurosurgery Unit, Humanitas Clinical and Research Center IRCCS, Rozzano, MI, Italy
| | - E Lavezzi
- Endocrinology, Diabetology and Andrology Unit, Humanitas Clinical and Research Center IRCCS, Rozzano, MI, Italy
| | - G Mazziotti
- Endocrinology, Diabetology and Andrology Unit, Humanitas Clinical and Research Center IRCCS, Rozzano, MI, Italy.
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, MI, Italy.
| | - A Lania
- Endocrinology, Diabetology and Andrology Unit, Humanitas Clinical and Research Center IRCCS, Rozzano, MI, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, MI, Italy
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Thakur JD, Corlin A, Mallari RJ, Huang W, Eisenberg A, Sivakumar W, Krauss H, Griffiths C, Rettinger S, Cohan P, Barkhoudarian G, Araque KA, Kelly D. Pituitary adenomas in older adults (≥ 65 years): 90-day outcomes and readmissions: a 10-year endoscopic endonasal surgical experience. Pituitary 2021; 24:14-26. [PMID: 32936381 DOI: 10.1007/s11102-020-01081-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/04/2020] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Longer lifespan and newer imaging protocols have led to more older adults being diagnosed with pituitary adenomas. Herein, we describe outcomes of patients ≥ 65 years undergoing endoscopic adenoma removal. To address selection criteria, we also assess a conservatively managed cohort. METHODS A retrospective analysis of 90-day outcomes of patients undergoing endoscopic pituitary adenomectomy from 2010 to 2019 by a neurosurgical/ENT team was performed. Tumor subtype, cavernous sinus invasion, extent of resection/early remission, endocrinology outcomes, complications, re-operations and readmissions were analyzed. A comparator cohort ≥ 65 years undergoing clinical surveillance without surgery was also analyzed. RESULTS Of 468 patients operated on for pituitary adenoma, 123 (26%) were ≥ 65 years (range 65-93 years); 106 (86.2%) had endocrine-inactive adenomas; 18 (14.6%) had prior surgery. Of 106 patients with endocrine-inactive adenomas, GTR was achieved in 70/106 (66%). Of 17 patients with endocrine-active adenomas, early biochemical remission was: Cushing's 6/8; acromegaly 1/4; prolactinomas 1/5. Gland function recovery occurred in 28/58 (48.3%) patients with various degrees of preoperative hypopituitarism. New anterior hypopituitarism occurred in 3/110 (2.4%) patients; permanent DI in none. Major complications in 123 patients were: CSF leak 2 (1.6%), meningitis 1 (0.8%), vision decline 1 (0.8%). There were no vascular injuries, operative hematomas, anosmia, deaths, MIs, or thromboembolic events. Median length of stay was 2 days. Readmissions occurred in 14/123 (11.3%) patients, 57% for delayed hyponatremia. Intra-cohort analysis by age (65-69, 70-74, 75-79, ≥ 80 years) revealed no outcome differences. Cavernous sinus invasion (OR 7.7, CI 1.37-44.8; p = 0.02) and redo-surgery (OR 8.5, CI 1.7-42.8; p = 0.009) were negative predictors for GTR/NTR. Of 105 patients evaluated for presumed pituitary adenoma beginning in 2015, 72 (69%) underwent surgery, 8 (7%) had prolactinomas treated with cabergoline and 25 (24%) continue clinical surveillance without surgery, including two on new hormone replacement. CONCLUSION This study suggests that elderly patients carefully selected for endoscopic adenoma removal can have excellent short-term outcomes including high resection rates, low complication rates and short length of stay. Our experience supports a multidisciplinary approach and the concept of pituitary centers of excellence. Based on our observations, approximately 25% of elderly patients with pituitary adenomas referred for possible surgery can be monitored closely without surgery.
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Affiliation(s)
- Jai Deep Thakur
- Pacific Neuroscience Institute, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
- John Wayne Cancer Institute, Providence Saint John's Health Center, Santa Monica, CA, USA
- Department of Neurosurgery, University of South Alabama, Mobile, AL, USA
| | - Alex Corlin
- Pacific Neuroscience Institute, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
| | - Regin Jay Mallari
- Pacific Neuroscience Institute, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
| | - Weichao Huang
- Pacific Neuroscience Institute, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
| | - Amalia Eisenberg
- Pacific Neuroscience Institute, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
| | - Walavan Sivakumar
- Pacific Neuroscience Institute, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
- John Wayne Cancer Institute, Providence Saint John's Health Center, Santa Monica, CA, USA
| | - Howard Krauss
- Pacific Neuroscience Institute, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
- John Wayne Cancer Institute, Providence Saint John's Health Center, Santa Monica, CA, USA
| | - Chester Griffiths
- Pacific Neuroscience Institute, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
- John Wayne Cancer Institute, Providence Saint John's Health Center, Santa Monica, CA, USA
| | - Sarah Rettinger
- Pacific Neuroscience Institute, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
| | - Pejman Cohan
- Pacific Neuroscience Institute, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
| | - Garni Barkhoudarian
- Pacific Neuroscience Institute, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
- John Wayne Cancer Institute, Providence Saint John's Health Center, Santa Monica, CA, USA
| | - Katherine A Araque
- Pacific Neuroscience Institute, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
- John Wayne Cancer Institute, Providence Saint John's Health Center, Santa Monica, CA, USA
| | - Daniel Kelly
- Pacific Neuroscience Institute, 2125 Arizona Ave., Santa Monica, CA, 90404, USA.
- John Wayne Cancer Institute, Providence Saint John's Health Center, Santa Monica, CA, USA.
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16
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Cai X, Yang J, Zhu J, Tang C, Cong Z, Liu Y, Ma C. Reconstruction strategies for intraoperative CSF leak in endoscopic endonasal skull base surgery: systematic review and meta-analysis. Br J Neurosurg 2021; 36:436-446. [PMID: 33475004 DOI: 10.1080/02688697.2020.1849548] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Endoscopic endonasal surgery (EES) is one of the preferred options for skull base pathologies. Cerebrospinal fluid (CSF) leak is a significant complication of EES and neurosurgeons have proposed various reconstructive strategies to decrease this morbidity. We describe and compare the efficacy of these strategies. METHODS We searched PubMed, Cochrane Library, and Web of Science for publications between 1990 and November 2019. We defined a reconstruction hierarchy of seven levels from inside to outside: fat graft, intracranial intradural layer (inlay), intracranial extradural layer (onlay), buttress, mucosal flap, nasal packing and lumbar drainage. A single-arm analysis was performed for the primary outcome of CSF leak rate. RESULTS Of 3641 records identified, 48 studies met the inclusion criteria. Pituitary tumors had lower postoperative CSF leak rate than other diseases (1.8% vs. 6.5%, RD = -4.7% [-7.1%, -2.1%]). In high CSF flow group, the post-operative leak rate was reduced by application of mucosal flap (4.3% vs. without mucosal flap at 12.8%, RD = -8.5% [-15.1%, -1.9%]). The use of inlay showed potential of decreasing the post-operative leak rate (5.0% vs. 7.2%, RD = -2.2% [-7.7%, 3.3%]). In low CSF flow group, tampon was better than balloon for nasal packing (1.0% vs. 10.5%, RD = -9.5% [-16.5%, -2.4%]). CONCLUSIONS Mucosal flap and inlay for high-flow intraoperative CSF leak and tampon (compared with balloon) for low-flow intraoperative CSF leak, improved the postoperative CSF leak rate. Further studies are required to establish more robust evidence.
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Affiliation(s)
- Xiangming Cai
- School of Medicine, Southeast University, Nanjing, China
| | - Jin Yang
- Department of Neurosurgery, Jinling Hospital, Nanjing, China
| | - Junhao Zhu
- School of Medicine, Nanjing Medical University, Nanjing, China
| | - Chao Tang
- Department of Neurosurgery, Jinling Hospital, Nanjing, China
| | - Zixiang Cong
- Department of Neurosurgery, Jinling Hospital, Nanjing, China
| | - Yuxiu Liu
- Department of Critical Care Medicine, Jinling Hospital, Nanjing Medical University, Nanjing, China.,Department of Biostatistics, School of Public Health, Southern Medical University, Guangzhou, China
| | - Chiyuan Ma
- Department of Neurosurgery, Jinling Hospital, Nanjing, China.,School of Medicine, Nanjing University, Nanjing, China
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17
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Butenschoen VM, Schwendinger N, von Werder A, Bette S, Wienke M, Meyer B, Gempt J. Visual acuity and its postoperative outcome after transsphenoidal adenoma resection. Neurosurg Rev 2020; 44:2245-2251. [PMID: 33040306 PMCID: PMC8338826 DOI: 10.1007/s10143-020-01408-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 09/28/2020] [Accepted: 09/30/2020] [Indexed: 12/04/2022]
Abstract
Transsphenoidal surgery (TSS) represents the gold standard of pituitary adenoma resection, providing a safe and minimal invasive treatment for patients suffering from symptoms of mass effect. The aim of this study is to analyze the postoperative improvement of visual function after adenoma resection and to identify prognostic factors for the postoperative clinical recovery. We performed a retrospective analysis of all consecutive patients treated via a transsphenoidal approach for pituitary adenomas from April 2006 to December 2019 in a high-volume neurosurgical department. Our primary outcome was postoperative visual acuity and visual field impairment; the clinical findings were followed up to 3 months after surgery and correlated with clinical and radiographic findings. In total, 440 surgeries were performed in our department for tumors of the sella region in a time period of 13 years via transsphenoidal approach, and 191 patients included in the analysis. Mean age was 55 years, and 98% were macroadenomas. Mean preoperative visual acuity in patients with preoperative impairment (n = 133) improved significantly from 0.64/0.65 to 0.72/0.75 and 0.76/0.8 (right eye R/left eye L) postoperatively and at 3 months follow-up (p < 0.001). Visual acuity significantly depended on Knosp classification but not Hardy grading. The strongest predictor for visual function recovery was age. Transsphenoidal pituitary tumor resection remains a safe and effective treatment in patients with preoperative visual impairment. It significantly improves visual acuity and field defects after surgery, and recovery continues at the 3 months follow-up examination.
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Affiliation(s)
- Vicki M Butenschoen
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University Munich, Ismaningerstr. 22, 81675, Munich, Germany.
| | - Nina Schwendinger
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University Munich, Ismaningerstr. 22, 81675, Munich, Germany
| | - Alexander von Werder
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Stefanie Bette
- Abteilung für Diagnostische und Interventionelle Radiologie, Klinikum Augsburg, Augsburg, Germany
| | - Maximilian Wienke
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University Munich, Ismaningerstr. 22, 81675, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University Munich, Ismaningerstr. 22, 81675, Munich, Germany
| | - Jens Gempt
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University Munich, Ismaningerstr. 22, 81675, Munich, Germany
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18
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Pereira MP, Oh T, Joshi RS, Haddad AF, Pereira KM, Osorio RC, Donohue KC, Peeran Z, Sudhir S, Jain S, Beniwal A, Gurrola J, El-Sayed IH, Blevins LS, Theodosopoulos PV, Kunwar S, Aghi MK. Clinical characteristics and outcomes in elderly patients undergoing transsphenoidal surgery for nonfunctioning pituitary adenoma. Neurosurg Focus 2020; 49:E19. [DOI: 10.3171/2020.7.focus20524] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 07/20/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVELife expectancy has increased over the past century, causing a shift in the demographic distribution toward older age groups. Elderly patients comprise up to 14% of all patients with pituitary tumors, with most lesions being nonfunctioning pituitary adenomas (NFPAs). Here, the authors evaluated demographics, outcomes, and postoperative complications between nonelderly adult and elderly NFPA patients.METHODSA retrospective review of 908 patients undergoing transsphenoidal surgery (TSS) for NFPA at a single institution from 2007 to 2019 was conducted. Clinical and surgical outcomes and postoperative complications were compared between nonelderly adult (age ≥ 18 and ≤ 65 years) and elderly patients (age > 65 years).RESULTSThere were 614 and 294 patients in the nonelderly and elderly groups, respectively. Both groups were similar in sex (57.3% vs 60.5% males; p = 0.4), tumor size (2.56 vs 2.46 cm; p = 0.2), and cavernous sinus invasion (35.8% vs 33.7%; p = 0.6). Regarding postoperative outcomes, length of stay (1 vs 2 days; p = 0.5), extent of resection (59.8% vs 64.8% gross-total resection; p = 0.2), CSF leak requiring surgical revision (4.3% vs 1.4%; p = 0.06), 30-day readmission (8.1% vs 7.3%; p = 0.7), infection (3.1% vs 2.0%; p = 0.5), and new hypopituitarism (13.9% vs 12.0%; p = 0.3) were similar between both groups. Elderly patients were less likely to receive adjuvant radiation (8.7% vs 16.3%; p = 0.009), undergo future reoperation (3.8% vs 9.5%; p = 0.003), and experience postoperative diabetes insipidus (DI) (3.7% vs 9.4%; p = 0.002), and more likely to have postoperative hyponatremia (26.7% vs 16.4%; p < 0.001) and new cranial nerve deficit (1.9% vs 0.0%; p = 0.01). Subanalysis of elderly patients showed that patients with higher Charlson Comorbidity Index scores had comparable outcomes other than higher DI rates (8.1% vs 0.0%; p = 0.006). Elderly patients’ postoperative sodium peaked and troughed on postoperative day 3 (POD3) (mean 138.7 mEq/L) and POD9 (mean 130.8 mEq/L), respectively, compared with nonelderly patients (peak POD2: mean 139.9 mEq/L; trough POD8: mean 131.3 mEq/L).CONCLUSIONSThe authors’ analysis revealed that TSS for NFPA in elderly patients is safe with low complication rates. In this cohort, more elderly patients experienced postoperative hyponatremia, while more nonelderly patients experienced postoperative DI. These findings, combined with the observation of higher DI in patients with more comorbidities and elderly patients experiencing later peaks and troughs in serum sodium, suggest age-related differences in sodium regulation after NFPA resection. The authors hope that their results will help guide discussions with elderly patients regarding risks and outcomes of TSS.
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Affiliation(s)
| | - Taemin Oh
- Departments of 2Neurological Surgery and
| | | | | | - Kaitlyn M. Pereira
- 3University of South Florida Morsani College of Medicine, Tampa, Florida
| | | | | | | | | | - Saket Jain
- Departments of 2Neurological Surgery and
| | | | - José Gurrola
- 4Otolaryngology–Head and Neck Surgery, University of California, San Francisco, California; and
| | - Ivan H. El-Sayed
- 4Otolaryngology–Head and Neck Surgery, University of California, San Francisco, California; and
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19
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Memel Z, Chesney K, Pangal DJ, Bonney PA, Carmichael JD, Zada G. Outcomes Following Transsphenoidal Pituitary Surgery in the Elderly: A Retrospective Single-Center Review. Oper Neurosurg (Hagerstown) 2020; 16:302-309. [PMID: 29800459 DOI: 10.1093/ons/opy109] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 04/11/2018] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Transsphenoidal surgery (TSS) for pituitary adenomas (PAs) is performed on elderly patients with increasing frequency. More research is necessary to assess the risk factors that are associated with TSS in an aging population. OBJECTIVE To perform a retrospective study on postoperative safety outcomes following TSS in the elderly population stratified by decade of life. METHODS A retrospective chart review of the USC Pituitary Database was conducted to identify patients ≥70 yr, who underwent TSS for PAs between 1995 and 2017. Surgical outcomes were analyzed in elderly (≥70 yr) vs nonelderly (<70 yr) patients. Elderly patients were additionally stratified according to age 70 to 79 vs ≥80 yr. RESULTS The cohorts included 115 elderly patients (70-79 yr: 94 patients; ≥80 yr: 21 patients) and 770 nonelderly patients. Elderly patients presented with more vision loss (62% vs 38%, P < .0001), dizziness (17% vs 6%, P = .0001) and altered mental status (7.3% vs 3%, P = .0451). Overall rates of surgical, medical, and endocrine complications were similar; however, elderly patients had significantly higher rates of postoperative hyponatremia (9.3% vs 4.7%, P = .0401) and lower rates of transient diabetes insipidus (0.9% vs 7.9%, P = .0038). Patients ≥ 80 yr had significantly more surgical complications (26.3%) compared to the 70 to 79 group (7.87%; P = .021) and <70 group (12.5%; P = .04). CONCLUSION Patients >70 yr are appropriate surgical candidates for TSS given the similar safety outcomes as younger patients. Given the higher propensity for surgical complications; however, a higher level of operative selectivity should be maintained in octogenarian patients.
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Affiliation(s)
- Zoe Memel
- Department of Neurological Surgery, Keck School of Medicine of USC, Los Angeles, California
| | - Kelsi Chesney
- Department of Neurological Surgery, Keck School of Medicine of USC, Los Angeles, California
| | - Dhiraj J Pangal
- Department of Neurological Surgery, Keck School of Medicine of USC, Los Angeles, California
| | - Phillip A Bonney
- Department of Neurological Surgery, Keck School of Medicine of USC, Los Angeles, California
| | - John D Carmichael
- Division of Endocrinology, Department of Medicine, Keck School of Medicine of USC, Los Angeles, California
- USC Pituitary Center, USC Keck School of Medicine, Los Angeles, California
| | - Gabriel Zada
- Department of Neurological Surgery, Keck School of Medicine of USC, Los Angeles, California
- USC Pituitary Center, USC Keck School of Medicine, Los Angeles, California
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20
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Transsphenoidal resection for pituitary adenoma in elderly versus younger patients: a systematic review and meta-analysis. Acta Neurochir (Wien) 2020; 162:1297-1308. [PMID: 32221730 DOI: 10.1007/s00701-020-04300-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 03/19/2020] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Pituitary adenomas (PA) are common intracranial tumors. In the context of the aging of the population, the question is whether postsurgical outcomes are comparable to the younger ones. The primary objective of the present study was to review published resection and recurrence rates after transsphenoidal resection. The secondary aim was to evaluate visual improvement and complication rates. METHODS The authors searched PubMed and Medline databases, of published English series, with no time frame limit, evaluating outcomes of transsphenoidal resection in populations aged more or less than 65, 70, and 80 years. We performed a systematic review and meta-analysis. RESULTS Median overall resection rates for younger population was 70.7% (range 54-76.8) and for elderly one was 65.7% (range 16.6-78.2) (two-sample t test, p = 0.35). The only statistically significant difference for gross total resection rates (GTR) favored patients aged less than 80 (p = 0.01). There was no statistically significant difference among recurrence rates. There was a statistically significant difference for visual improvement favoring patients aged more than 80 (p = 0.03). For the age groups of less versus more than 70, there was a statistically significant difference for overall complication rate favoring younger groups (p < 0.05). CONCLUSION Present data shows GTR rates favoring younger patients. Recurrence rates remain similar over the mean follow-up period. Moreover, visual improvement favors patients aged more than 80. Overall complication rates favor patients younger than 70, which might be also related to additional comorbidities, frequently present in seniors. Transsphenoidal surgery is safe and effective even for older patients.
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21
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Wang EW, Zanation AM, Gardner PA, Schwartz TH, Eloy JA, Adappa ND, Bettag M, Bleier BS, Cappabianca P, Carrau RL, Casiano RR, Cavallo LM, Ebert CS, El-Sayed IH, Evans JJ, Fernandez-Miranda JC, Folbe AJ, Froelich S, Gentili F, Harvey RJ, Hwang PH, Jane JA, Kelly DF, Kennedy D, Knosp E, Lal D, Lee JYK, Liu JK, Lund VJ, Palmer JN, Prevedello DM, Schlosser RJ, Sindwani R, Solares CA, Tabaee A, Teo C, Thirumala PD, Thorp BD, de Arnaldo Silva Vellutini E, Witterick I, Woodworth BA, Wormald PJ, Snyderman CH. ICAR: endoscopic skull-base surgery. Int Forum Allergy Rhinol 2020; 9:S145-S365. [PMID: 31329374 DOI: 10.1002/alr.22326] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 02/12/2019] [Accepted: 02/15/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Endoscopic skull-base surgery (ESBS) is employed in the management of diverse skull-base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull-base surgery have produced the International Consensus Statement on Endoscopic Skull-Base Surgery (ICAR:ESBS). METHODS Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence-based review or evidence-based review with recommendations format. Subsequently, each topic was written and then reviewed by skull-base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus. RESULTS The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull-base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated. CONCLUSION A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence-based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull-base community to embrace these opportunities and collaboratively address these shortcomings.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Adam J Folbe
- Michigan Sinus and Skull Base Institute, Royal Oak, MI
| | | | | | - Richard J Harvey
- University of Toronto, Toronto, Canada.,University of New South Wales, Sydney, Australia
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Charles Teo
- Prince of Wales Hospital, Randwick, Australia
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22
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The sellar barrier and intraoperative CSF leak in elderly patients. J Clin Neurosci 2020; 73:48-50. [PMID: 32070673 DOI: 10.1016/j.jocn.2020.01.078] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 12/19/2019] [Accepted: 01/26/2020] [Indexed: 12/30/2022]
Abstract
Cerebral spinal fluid (CSF) leak is a significant complication in pituitary surgery, increasing both patient morbidity and mortality. In a recent publication, Campero et al. observed worse postoperative prognosis and increased risk of intraoperative CSF leak in patients with reduced sellar barrier thickness. The objective of this study was to analyze the association between sellar barrier thickness and intraoperative CSF leak in older individuals. A retrospective review was conducted of 44 transsphenoidal surgery resections for pituitary adenomas, 24 microscopic and 20 purely endoscopic procedures. Presence of intraoperative CSF fistula was significantly greater in patients with weak sellar barrier (thickness under 1 mm), compared to strong sellar barrier (52.94% vs 3.70% p < 0.0001, respectively). Application of this novel concept may help improve surgical technique selection as well as predict risk of intraoperative CSF leak and need for eventual use of flaps for reconstruction.
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23
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Asemota AO, Gallia GL. Impact of frailty on short-term outcomes in patients undergoing transsphenoidal pituitary surgery. J Neurosurg 2020; 132:360-370. [PMID: 30797214 DOI: 10.3171/2018.8.jns181875] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 08/16/2018] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Frailty, a state of decreased physiological reserve, has been shown to significantly impact outcomes of surgery. The authors sought to examine the impact of frailty on the short-term outcomes of patients undergoing transsphenoidal pituitary surgery. METHODS Weighted data from the 2000-2014 National (Nationwide) Inpatient Sample were studied. Patients diagnosed with pituitary tumors or disorders who had undergone transsphenoidal pituitary surgery were identified. Frailty was determined using the Johns Hopkins Adjusted Clinical Groups (ACG) frailty-defining diagnoses indicator. Standard descriptive techniques and matched propensity score analyses were used to explore the odds ratios of postoperative complications, discharge dispositions, and costs. RESULTS A total of 115,317 cases were included in the analysis. Frailty was present in 1.48% of cases. The mean age of frail versus non-frail patients was 57.14 ± 16.96 years (mean ± standard deviation) versus 51.91 ± 15.88 years, respectively (p < 0.001). A greater proportion of frail compared to non-frail patients had an age ≥ 65 years (37.08% vs 24.08%, respectively, p < 0.001). Frail patients were more likely to be black or Hispanic (p < 0.001), possess Medicare or Medicaid insurance (p < 0.001), belong to lower-median-income groups (p < 0.001), and have greater comorbidity (p < 0.001). Results of propensity score-matched multivariate analysis revealed that frail patients were more likely to develop fluid and electrolyte disorders (OR 1.61, 95% CI 1.07-2.43, p = 0.02), intracranial vascular complications (OR 2.73, 95% CI 1.01-7.49, p = 0.04), mental status changes (OR 3.60, 95% CI 1.65-7.82, p < 0.001), and medical complications including pulmonary insufficiency (OR 2.01, 95% CI 1.13-4.05, p = 0.02) and acute kidney failure (OR 4.70, 95% CI 1.88-11.74, p = 0.01). The mortality rate was higher among frail patients (1.46% vs 0.37%, p < 0.001). Frail patients also demonstrated a greater likelihood for nonroutine discharges (p < 0.001), higher mean total charges ($109,614.33 [95% CI $92,756.09-$126,472.50] vs $56,370.35 [95% CI $55,595.72-$57,144.98], p < 0.001), and longer hospitalizations (9.27 days [95% CI 7.79-10.75] vs 4.46 days [95% CI 4.39-4.53], p < 0.001). CONCLUSIONS Frailty in patients undergoing transsphenoidal pituitary surgery is associated with worse postoperative outcomes and higher costs, indicating that state's potential role in routine preoperative risk stratification.
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24
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Spina A, Losa M, Mortini P. Pituitary adenomas in elderly patients: clinical and surgical outcome analysis in a large series. Endocrine 2019; 65:637-645. [PMID: 31209675 DOI: 10.1007/s12020-019-01959-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Accepted: 05/12/2019] [Indexed: 12/30/2022]
Abstract
PURPOSE The increased life expectancy in the general population is causing rapid growth of the number of elderly patients. Pituitary adenomas (PAs) are one of those tumors whose incidence increases with age. Pituitary surgery in elderly has usually been considered riskier than in the younger population. The aim of this study was to evaluate the surgical outcome of a large series of patients who underwent transsphenoidal surgery for PAs. METHODS We retrospectively reviewed a series of patients who underwent transsphenoidal surgery for PAs in our institution. Inclusion criteria were: 65 years of age or more, and no previous pituitary surgery. Surgical outcomes of patients aged <70 years (group 1) was compared to those aged 70 years or more (group 2) at the time of surgery. RESULTS A total of 336 patients met the inclusion criteria. Clinically, 230 (68.5%) patients had a non-functioning PAs. Among the remaining 106 patients with a hormone-secreting PA, 57 (53.8%) had acromegaly, 39 (36.8%) Cushing's disease, 5 patients (4.7%) had a prolactinoma, and 5 a thyrotropin-secreting PA (4.7%). Mortality rate was 1.5%. Groups 1 and 2 showed no significantly different surgery-related complication, visual recovery, radical surgery, and remission rates. CONCLUSIONS Surgical management of PAs in the elderly has been considered riskier than in the younger population. Our results demonstrated that transsphenoidal surgery is a safe and effective treatment for PAs. No statistically significant differences in terms of outcome were found in two group ages, showing that, when clinically indicated, transsphenoidal surgery can be performed even in very old subjects.
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Affiliation(s)
- Alfio Spina
- Pituitary Unit of the Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy.
| | - Marco Losa
- Pituitary Unit of the Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Pietro Mortini
- Pituitary Unit of the Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
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25
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Gerges MM, Arnaout MM, El Asri AC, Cummock MD, Roshdy A, Anand VK, Dinkin MJ, Oliveira C, Schwartz TH. Increased frequency of cataract surgery in patients over age 50 with pituitary macroadenomas and chiasmal compression. Pituitary 2019; 22:405-410. [PMID: 31144107 DOI: 10.1007/s11102-019-00970-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Patients with visual loss from macroadenomas compressing their optic apparatus may also have concomitant age-related visual pathology such as cataracts. How these two pathologies interact with each other is not well documented. OBJECTIVE The interaction between these two pathologies in elderly patients is the subject of this study. METHODS We identified a series of non-functioning macroadenoma patients over age 50 years with tumors compressing the chiasm who underwent transsphenoidal surgery at our institution between 2004 and 2018. Pre- and post-operative visual complaints, tumor size and extent of resection were analyzed. Prevalence of the diagnosis of cataract and prevalence of cataract surgery in each decade were compared with national averages. RESULTS We identified 200 patients who met selection criteria. 18% of these patients had a diagnosis of cataract and 12.5% had cataract surgery. Compared with the Eye Diseases Prevalence Research Group (EDPRG) study, the prevalence of cataract surgery was 2.5 times the national average of 5.1%. 32% of these patients had no improvement in their vision after cataract surgery but 76% improved after transsphenoidal surgery. CONCLUSIONS We reported a high prevalence of cataract surgery in patients over age 50 in patients with pituitary macroadenomas compressing the optic pathway compared with national averages in patients without adenomas. While visual loss from adenoma likely precipitated more cataract surgeries in this group of patients, some who may not have required it, those patients with cataracts who did not have their cataracts extracted were less likely to recover vision after transsphenoidal surgery. Addressing both pathologies is beneficial.
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Affiliation(s)
- Mina M Gerges
- Department of Neurosurgery, Faculty of Medicine, Ain Shams University, Cairo, Egypt
- Department of Neurological Surgery, Weill Cornell Medicine, NewYork-Presbyterian Hospital, New York, USA
| | - Mohamed M Arnaout
- Department of Neurological Surgery, Weill Cornell Medicine, NewYork-Presbyterian Hospital, New York, USA
- Department of Neurosurgery, Faculty of Medicine, Zagazig University, Sharqia, Egypt
| | - Abad Cherif El Asri
- Department of Neurological Surgery, Weill Cornell Medicine, NewYork-Presbyterian Hospital, New York, USA
- Department of Neurological Surgery, Military hospital Mohamed V, Rabat, Morocco
| | - Matthew D Cummock
- Department of Neurological Surgery, Weill Cornell Medicine, NewYork-Presbyterian Hospital, New York, USA
- Department of Neurological Surgery, St. Barnabas Medical Center, Livingston, New Jersey, USA
| | - Ahmed Roshdy
- Department of Neurosurgery, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Vijay K Anand
- Department of Otolaryngology, Weill Cornell Medicine, NewYork-Presbyterian Hospital, New York, USA
| | - Marc J Dinkin
- Department of Ophthalmology, Weill Cornell Medicine, NewYork-Presbyteian Hospital, New York, NY, USA
| | - Cristiano Oliveira
- Department of Ophthalmology, Weill Cornell Medicine, NewYork-Presbyteian Hospital, New York, NY, USA
| | - Theodore H Schwartz
- Department of Neurological Surgery, Weill Cornell Medicine, NewYork-Presbyterian Hospital, New York, USA.
- Department of Otolaryngology, Weill Cornell Medicine, NewYork-Presbyterian Hospital, New York, USA.
- Department of Neuroscience, Weill Cornell Medicine, NewYork-Presbyterian Hospital, New York, USA.
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26
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Gupta A, Xu Z, Kano H, Sisterson N, Su YH, Krsek M, Nabeel AM, El-Shehaby A, Karim KA, Martínez-Moreno N, Mathieu D, McShane BJ, Martínez-Álvarez R, Reda WA, Liscak R, Lee CC, Lunsford LD, Sheehan JP. Upfront Gamma Knife radiosurgery for Cushing's disease and acromegaly: a multicenter, international study. J Neurosurg 2019; 131:532-538. [PMID: 30117768 DOI: 10.3171/2018.3.jns18110] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 03/21/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Gamma Knife radiosurgery (GKS) is typically used after failed resection in patients with Cushing's disease (CD) and acromegaly. Little is known about the upfront role of GKS for patients with CD and acromegaly. In this study, the authors examine the outcome of upfront GKS for patients with these functioning adenomas. METHODS An international group of 7 Gamma Knife centers sent pooled data from 46 patients (21 with CD and 25 with acromegaly) undergoing upfront GKS to the coordinating center of the study for analysis. Diagnosis was established on the basis of clinical, endocrine, and radiological studies. All patients were treated on a common radiosurgical platform and longitudinally followed for tumor control, endocrine remission, and hypopituitarism. Patients received a tumor median margin dose of 25 Gy (range 12-40.0 Gy) at a median isodose of 50%. RESULTS The median endocrine follow-up was 69.5 months (range 9-246 months). Endocrine remission was achieved in 51% of the entire cohort, with 28% remission in acromegaly and 81% remission for those with CD at the 5-year interval. Patients with CD achieved remission earlier as compared to those with acromegaly (p = 0.0005). In patients post-GKS, the pituitary adenoma remained stable (39%) or reduced (61%) in size. Hypopituitarism occurred in 9 patients (19.6%), and 1 (2.2%) developed third cranial nerve (CN III) palsy. Eight patients needed further intervention, including repeat GKS in 6 and transsphenoidal surgery in 2. CONCLUSIONS Upfront GKS resulted in good tumor control as well as a low rate of adverse radiation effects in the whole group. Patients with CD achieved a faster and far better remission rate after upfront GKS in comparison to patients with acromegaly. GKS can be considered as an upfront treatment in carefully selected patients with CD who are unwilling or unable to undergo resection, but it has a more limited role in acromegaly.
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Affiliation(s)
- Amitabh Gupta
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Zhiyuan Xu
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Hideyuki Kano
- 2Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Nathaniel Sisterson
- 2Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Yan-Hua Su
- 3Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan, Republic of China
| | - Michal Krsek
- 4Second Department of Medicine, Third Faculty of Medicine of the Charles University, Faculty Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Ahmed M Nabeel
- 5Gamma Knife Center Cairo-Nasser Institute, Neurosurgery Department, Benha University, Benha, Egypt
| | - Amr El-Shehaby
- 6Gamma Knife Center Cairo-Nasser Institute, Neurosurgery Department, Ain Shams University, Cairo, Egypt
| | - Khaled A Karim
- 7Gamma Knife Center Cairo-Nasser Institute, Clinical Oncology Department, Ain Shams University, Cairo, Egypt
| | - Nuria Martínez-Moreno
- 8Department of Functional Neurosurgery and Radiosurgery, Ruber International Hospital, Madrid, Spain
| | - David Mathieu
- 9Division of Neurosurgery, Université de Sherbrooke, Centre de Recherche du CHUS, Sherbrooke, Québec, Canada; and
| | - Brendan J McShane
- 10Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Roberto Martínez-Álvarez
- 8Department of Functional Neurosurgery and Radiosurgery, Ruber International Hospital, Madrid, Spain
| | - Wael A Reda
- 6Gamma Knife Center Cairo-Nasser Institute, Neurosurgery Department, Ain Shams University, Cairo, Egypt
| | - Roman Liscak
- 10Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Cheng-Chia Lee
- 3Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan, Republic of China
| | - L Dade Lunsford
- 2Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jason P Sheehan
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
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Kinoshita Y, Kurisu K, Arita K. Nonfunctioning pituitary adenomas in elderly patients. J Clin Neurosci 2018; 53:127-131. [PMID: 29739724 DOI: 10.1016/j.jocn.2018.04.054] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 04/22/2018] [Indexed: 10/17/2022]
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