Long-term outcomes after endoscopic endonasal surgery for nonfunctioning pituitary macroadenomas

Reappraising prediction of surgical complexity of non-functioning pituitary adenomas after transsphenoidal surgery: the modified TRANSSPHER grade

PURPOSE

Prognostication of surgical complexity is crucial for optimizing decision-making and patient counseling in pituitary surgery. This study aimed to develop a clinical score to predict gross-total resection (GTR) in non-functioning pituitary adenomas (NFPAs) using externally validated machine-learning (ML) models.

METHODS

Clinical and radiological data were collected from two tertiary medical centers. Patients had pre- and postoperative structural T1-weighted MRI with gadolinium and T2-weighted preoperative scans. Three ML classifiers were trained on the National Hospital for Neurology and Neurosurgery dataset and tested on the Foundation IRCCS Ca' Granda Polyclinic of Milan dataset. Feature importance analyses and hierarchical-tree inspection identified predictors of surgical complexity, which were used to create the grading score. The prognostic performance of the proposed score was compared to that of the state-of-the art TRANSSPHER grade in the external dataset. Surgical morbidity was also analyzed.

RESULTS

All ML models accurately predicted GTR, with the random forest classifier achieving the best performance (weighted-F1 score of 0.87; CIs: 0.71, 0.97). Key predictors-Knosp grade, tumor maximum diameter, consistency, and supra-sellar nodular extension-were included in the modified (m)-TRANSSPHER grade. The ROC analysis showed superior performance of the m-TRANSSPHER grade over the TRANSSPHER grade for predicting GTR in NFPAs (AUC 0.85 vs. 0.79).

CONCLUSIONS

This international multi-center study used validated ML algorithms to refine predictors of surgical complexity in NFPAs, yielding the m-TRANSSPHER grade, which demonstrated enhanced prognostic accuracy for surgical complexity prediction compared to existing scales.

Gonadotropic axis following endoscopic surgery for pituitary neuroendocrine tumor in patients of reproductive age

PURPOSE

Pituitary neuroendocrine tumor (PitNET), excluding prolactinoma, often requires endoscopic endonasal surgery (EES). Identifying predictive factors for complications, and particularly rare ones such as hypogonadotropic hypogonadism (HH) that may affect fertility, is challenging. This study investigated de-novo postoperative HH and its potential impact on fertility.

METHODS

We conducted a retrospective study of 211 patients undergoing EES. HH was evaluated using age- and gender-specific criteria. The characteristics of patients of reproductive age were analyzed to identify risk factors for de-novo postoperative HH.

RESULTS

Twelve of the 60 patients of reproductive age with no preoperative HH (20%) developed de-novo HH within 4-6months' follow-up, with 7 (12%) presenting long-term HH (median: 893 days). De-novo HH was significantly associated with corticotroph adenoma (P=0.01). Median tumor size was greater in HH than non-HH patients (P<0.01).

CONCLUSION

De-novo HH is a frequent complication of pituitary surgery, affecting 1 in 5 patients in our cohort, and is persistent in most cases. While risk factors such as large tumor size and corticotroph subtype were identified, the condition is still difficult to predict. These findings underscore the importance of integrating this risk into preoperative counseling and follow-up.

Association between transcription factors expression and growth patterns of nonfunctioning pituitary adenomas

Transcription factors (TFs), including steroidogenic factor-1 (SF-1), T-box transcription factor (TPIT) and pituitary transcription factor-1 (PIT-1), play a pivotal role in the cytodifferentiation of adenohypophysis. However, the impact of TFs on the growth patterns of nonfunctioning pituitary adenomas (NFPAs) remains unclear. This study aims to investigate the correlation between the expression of TFs and NFPAs growth patterns. Preoperative MRI in 171 patients who underwent surgery for nonfunctioning pituitary macroadenomas were analyzed to determine tumor growth patterns. Immunohistochemical staining for transcription factors PIT-1, TPIT, and SF-1 was done on all samples. Extrasellar growth was divided into three principal directions: infrasellar, suprasellar and lateral cavernous sinus invasion (CSI). Suprasellar extension was defined as tumor extension superior to the tuberculum sellae-dorsum sellae line, inferior extension as invasion through the sellar floor into the sphenoid sinus or clivus and CSI as Knosp grading score of 3 ~ 4. Statistical analysis to compare the groups was conducted using the Fisher's exact test and t-test. TPIT-expressing tumors were more likely to exhibit combined infrasellar extension (55.17 vs 17.70%, p < 0.0001), as well as isolated infrasellar extension (18.97 vs 0%, p < 0.0001) compared to SF-1-expressing tumors. Conversely, SF-1-expressing tumors were more likely to exhibit combined suprasellar extension (92.92 vs 77.59%, p = 0.0061), as well as isolated suprasellar extension (75.22 vs 41.38%, p < 0.0001). TPIT-expressing tumors had a significantly higher CSI invasion (55.17 vs 35.40%, p = 0.0148). The mean maximal tumor diameter in TPIT and SF-1 macroadenomas was similar (28 vs 26 mm, p = 0.1213). The expression of TFs affects the extrasellar growth pattern of NFPAs. TPIT tumors exhibit a higher propensity for bone invasion and CSI, while SF-1 tumors tend to extend into the suprasellar region. Isolated infrasellar extension is specific to TPIT tumors and can serve as a radiologic sign to distinguish between TPIT tumors and SF-1 tumors.

Endoscopic Reconstruction of the Sellar Floor by Extended Inferior Turbinate Flap in Recurrent Pituitary Tumors

Objective  This aim of this study was to address the outcome of endoscopic reconstruction of the sellar floor by extended inferior turbinate flap. Patients and Methods  This is a retrospective study of 34 patients with a recurrent pituitary tumor. They were treated between March 2018 and December 2021 by endoscopic extended endonasal approach with the reconstruction of the sellar floor by an extended posterior pedicle inferior turbinate flap. The clinical and radiological follow-up was performed immediately postoperation and regularly every 3 months up to 1 year, and the available data from the last follow-up visit were included in the analysis. Results  The patients' age ranged between 40 and 65 years, with a slight female predominance (55.9%). Headache was the main presentation (47.1%), and functional tumors were found in 50.0% patients. Visual disturbances were field defects among 61.8% and papilledema among 52.9% patients. Preoperative endoscopy revealed postseptectomy as the significant finding (73.5%), followed by postseptectomy and adhesion (14.7%) and finally postseptectomy and hypertrophied inferior turbinate (11.8%). Total tumor resection was achieved in 76.5%, visual improvement was recorded in 52.9%, and no complications were reported in 82.4% patients. Cerebrospinal fluid (CSF) leak was not reported in any of the studied patients. Finally, total resection was significantly associated with younger age, non-functioning tumor and improvement of headache. Conclusion  The extended inferior turbinate flap is an effective and safe approach for sellar floor reconstruction in endoscopic endonasal surgery for recurrent pituitary tumors. The extension overcomes the relatively small inferior flap and its limited arc of rotation.

3 Tesla intra-operative MRI as an adjunct to endoscopic pituitary surgery: an early assessment of clinical utility

BACKGROUND

Extent of resection is a major determinant of outcomes following pituitary surgery. Intra-operative magnetic resonance imaging (iMRI), provides an immediate assessment of the extent of resection, allowing further tumour resection during the same procedure. However, such systems are expensive and significantly increase operative time, prompting some authors to question the additional benefit conferred by iMRI when combined with endoscopy. Our aim was to assess the impact of combining 3 T iMRI with endoscopy in patients with pituitary tumours.

METHODS

We retrospectively reviewed a prospectively maintained database to identify patients who underwent iMRI guided endoscopic resection of pituitary tumours between May 2017 and November 2018 (iMRI cohort). This cohort was compared with a pre-iMRI cohort of patients who underwent endoscopic resection of pituitary adenomas. Operative time, extent of resection, control of endocrine disease and post-operative complications were recorded and analysed.

RESULTS

Thirty-seven patients were included in each cohort. iMRI facilitated additional tumour resection in 6/37 (16%) of cases. In 4/37 cases (11%), iMRI prompted a return to theatre but no further tumour could be identified. The overall GTR rate, following iMRI was 24/37 (65%) as compared to 21/37 (57%) in the pre-iMRI cohort. Cure of endocrine disease associated with hormonally active tumours was achieved in 9/11 (82%) of cases in the iMRI cohort. The mean operative time in the iMRI cohort was 327 minutes (five hours 27 minutes).

CONCLUSIONS

3 T iMRI provides immediate identification of residual tumour following endoscopic pituitary surgery. This allows for resection of surgically accessible residual disease during the same procedure and is likely to reduce the requirement for later re-intervention. However, the use of iMRI in this setting is associated with significant resource allocation issues which must be considered prior to the widespread adoption of this technique.

Pathological characteristics of reoperated regrowing clinically nonfunctioning pituitary tumor cases in comparison with initial surgical cases

Objective

Postoperative nonfunctioning pituitary tumor (NFPT) regrowth is a significant concern, but its predictive factors are not well established. This study aimed to elucidate the pathological characteristics of NFPTs indicated for reoperation for tumor regrowth.

Methods

Pathological, radiological, and clinical data were collected from patients who underwent repeat operation for NFPT at Moriyama Memorial Hospital (MMH) between April 2018 and September 2023. For comparison, we also gathered data from patients who underwent initial surgery for NFPT during the same period at MMH.

Results

Overall, 61 and 244 NFPT patients who respectively underwent reoperation and initial operation were evaluated. The mean period between the previous operation and reoperation was 113 months. Immunonegativity for any adenohypophyseal hormone was significantly more frequent in the reoperation group than in the initial operation group. In addition, the rate of hormone-negative but transcription factor-positive (H-/TF+) tumors among silent gonadotroph tumors was significantly higher in the reoperation group than in the initial operation group. Furthermore, seven silent corticotroph tumors (SCTs) in the reoperation group were ACTH-negative but TPIT-positive. Because most of the previous surgeries were performed in other hospitals a long time ago, we could procure the previous pathological results with immunohistochemistry (IHC) only from 21 patients. IHC for TF had not been performed in all the previous specimens. IHC for adenohypophyseal hormone was almost the same as the current results, and many H-/TF+ tumors were previously diagnosed as NCT. In addition, the reoperated patients were classified into 3 groups on the basis of the condition of the previous operation: gross total resection (GTR), 12 patients; subtotal resection (STR), 17 patients; and partial resection (PR), 32 patients. The mean Ki-67 LI in the GTR, STR, and PR subgroups were 1.82, 1.37, and 0.84, respectively, with the value being significantly higher in the GTR subgroup than in the PR subgroup (P < 0.05).

Conclusions

The ratio of H-/TF+ tumors is significantly higher in symptomatically regrown tumors than in the initial cases, which used to be diagnosed as NCT. PR cases tend to grow symptomatically in a shorter period, even with lower Ki-67 LI than GTR cases.

Prognostic indicators in pituitary adenoma surgery: a comprehensive analysis of surgical outcomes and complications

Objective

The primary aim of this study was to identify predictive factors associated with onset of de-novo clinically significant pituitary insufficiencies following endoscopic endonasal surgery (EES) for pituitary adenomas. The secondary objective explored the predictive factors of surgical success.

Methods

A retrospective analysis was conducted on 211 patients who underwent EES. Logistic regression models were employed for the primary and secondary objectives. Patients were stratified into specific groups based on surgical indications and prolactin levels for nuanced analysis.

Results

Significant predictors for de-novo pituitary insufficiencies included male sex (OR 3.3, CI95% 1.3-8.1, p=0.01), immediate postoperative insufficiencies (OR 5.6, CI95% 2.8-11.1, p<0.001), and HYPRONOS criteria (OR 5.7, CI95% 1.6-20.9, p=0.008). For surgical success, preoperative insufficiencies (OR 0.7, CI95% 0.5-0.9, p=0.008), repeat surgeries (OR 0.1, CI95% 0-0.4, p=0.001), and gonadotroph or somatotroph adenomas were significant. Age and adenoma size were not predictive in multivariate analysis. Furthermore, we observed a "dip and recover" effect of prolactin after surgery and lower prolactin levels at follow-up (< 3 ng/ml) are correlated with more anterior pituitary insufficiencies than normoprolactinemic patients (p = 0.004).

Conclusion

This study identifies key predictors for outcomes in pituitary surgery. Our research is the first to employ individualized success criteria for EES, challenging existing perceptions about the role of age and adenoma size. These findings open avenues for nuanced, individualized preoperative risk assessment and postoperative management.

The incidence and risk factors of unplanned reoperation in endoscopic endonasal surgeries: a single center study

The incidence of unplanned reoperation after surgery during the same hospitalization is considered one of most important evaluation indicators for health care quality. The purpose of this study was to determine the incidence and risk factors related to unplanned reoperation after an endoscopic endonasal approach (EEA). All patients who underwent elective endoscopic endonasal surgery from January 2016 to December 2021 in the Department of Neurosurgery, Tangdu Hospital, Air Force Military Medical University, were included. We identified the patients who underwent an unplanned reoperation and those who did not and divided them into two groups. The demographic data and risk factors were compared between the groups by univariate and multivariate logistic regression analyses. Of the 1783 patients undergoing EEA for various lesions of the skull base, the incidence of unplanned reoperation was 2.3%. The most common unplanned reoperations were repair of cerebrospinal fluid (CSF) leakage (39%), sellar hematoma evacuation (34.1%), hemostasis of epistaxis (14.6%) and external ventricular drainage for obstructive hydrocephalus (9.8%). The maximum diameter of tumor ≥ 3 cm (OR 2.654, CI 1.236-5.698; p = 0.012), meningioma (OR 4.198, CI 1.169-15.072; p = 0.028), craniopharyngioma (OR 5.020, CI 2.020-12.476; p = 0.001) and other sellar lesions (OR 4.336, CI 1.390-13.527; p = 0.012) and an operation time ≥ 240 min (OR 2.299, CI 1.170-4.518; p = 0.016) were the independent risk factors for unplanned reoperations in multivariate regression analysis. Of the 41 patients undergoing unplanned reoperation, 16 patients died, twenty-one patients had panhypopituitarism, 13 patients had transient and 6 had permanent diabetes insipidus, and 11 patients presented with intracranial infection and 6 of these patients were cured. By reviewing our department's data, we stated the incidence and risk factors for unplanned reoperation. It is important for the hospital administration and neurosurgeons to place more emphasis on these indicators. Furthermore, we suggest some effective quality improvement initiatives to reduce the incidence of unplanned reoperation.

Post-operative surveillance for somatotroph, lactotroph and non-functional pituitary adenomas after curative resection: a systematic review

CONTEXT

Pituitary tumors are the third most common brain tumor and yet there is no standardization of the surveillance schedule and assessment modalities after transsphenoidal surgery.

EVIDENCE ACQUISITION

OVID, EMBASE and the Cochrane Library databases were systematically screened from database inception to March 5, 2020. Inclusion and exclusion criteria were designed to capture studies examining detection of pituitary adenoma recurrence in patients 18 years of age and older following surgical resection with curative intent.

EVIDENCE SYNTHESIS

A total of 7936 abstracts were screened, with 812 articles reviewed in full text and 77 meeting inclusion criteria for data extraction. A pooled analysis demonstrated recurrence rates at 1 year, 5 years and 10 years for non-functioning pituitary adenomas (NFPA; N = 3533 participants) were 1%, 17%, and 33%, for prolactin-secreting adenomas (PSPA; N = 1295) were 6%, 21%, and 28%, and for growth-hormone pituitary adenomas (GHPA; N = 1257) were 3%, 8% and 13%, respectively. Rates of recurrence prior to 1 year were 0% for NFPA, 1-2% for PSPA and 0% for GHPA. The mean time to disease recurrence for NFPA, PSPA and GHPA were 4.25, 2.52 and 4.18 years, respectively.

CONCLUSIONS

This comprehensive review of the literature quantified the recurrence rates for commonly observed pituitary adenomas after transsphenoidal surgical resection with curative intent. Our findings suggest that surveillance within 1 year may be of low yield. Further clinical trials and cohort studies investigating cost-effectiveness of surveillance schedules and impact on quality of life of patients under surveillance will provide further insight to optimize follow-up.

Sellar and parasellar lesions in the transition age: a retrospective Italian multi-centre study

BACKGROUND

Sellar/parasellar lesions have been studied in the adult and paediatric age range, but during the transition age their epidemiology, clinical manifestations, management and treatment outcomes have been poorly investigated.

MATERIALS AND METHODS

An Italian multicentre cohort study, in which hospital records of patients with diagnosis of sellar/parasellar lesions during the transition age and young adulthood (15-25 years), were reviewed in terms of prevalence, clinical and hormonal features at diagnosis, and outcomes where available. Both pituitary neuroendocrine tumours (pituitary tumours, Group A) and non-endocrine lesions (Group B) were included.

RESULTS

Among Group A (n = 170, 46.5% macroadenomas), the most frequent were prolactin and GH-secreting tumours, with a female predominance. Among Group B (n = 28), germinomas and Rathke cells cysts were the most common. In Group A, the most frequent hormonal deficiency was gonadal dysfunction. Galactorrhoea and amenorrhoea were relatively common in female patients with prolactinomas. Pre-surgical diabetes insipidus was only seen in Group B, in which also hormone deficiencies were more frequent and numerous. Larger lesions were more likely to be seen in Group B. Patients in Group B were more frequently male, younger, and leaner than those of Group A, whereas at last follow-up they showed more obesity and dyslipidaemia. In our cohort, the percentage of patients with at least one pituitary deficiency increased slightly after surgery.

CONCLUSIONS

The management of sellar/parasellar lesions is challenging in the transition age, requiring an integrated and multidisciplinary approach. Hormone and metabolic disorders can occur many years after treatment, therefore long-term follow-up is mandatory.

Preoperative Risk Stratification of Increased MIB-1 Labeling Index in Pituitary Adenoma: A Newly Proposed Prognostic Scoring System

The MIB-1 index is an important risk factor for progression-free survival (PFS) in pituitary adenoma (PA). Preoperatively, the MIB-1 index is not available in the decision-making process. A preoperative method regarding MIB-1 index estimation in PA has not been evaluated so far. Between 2011 and 2021, 109 patients with tumor morphology data, MIB-1 index data, and inflammatory and pituitary hormone laboratory values underwent surgery for PA. An MIB-1 index cutoff point (≥4/<4%) determines the probability of PFS in completely resected PA. An elevated MIB-1 index (≥4%) was present in 32 cases (29.4%) and was significantly associated with increased IGF-1, age ≤ 60, increased ACTH, and increased fibrinogen levels in the multivariable analysis. A scoring system (“FATE”) using preoperative IGF-1, age, ACTH, and plasma fibrinogen level enables the estimation of the MIB-1 index (sensitivity 72%, specificity 68%). The FATE score is also significantly associated with the time to PA progression after the complete resection of the PA. We propose the FATE score to preoperatively estimate the risk of an elevated MIB-1 index (≥4%), which might enable tailoring to medical decision-making, and follow-up interval scheduling, as well as inform future studies analyzing proliferative activities.

Prediction of Higher Ki-67 Index in Pituitary Adenomas by Pre- and Intra-Operative Clinical Characteristics

Objective: The Ki-67 index is an indicator of the active proliferation and aggressive behavior of pituitary adenomas (PAs). Appropriate pre- and intra-operatives of the Ki-67 index can help surgeons develop better and more personalized treatment strategies for patients with PAs. This study aimed to investigate the influence factors for predicting the Ki-67 index in PAs. Methods: Data of 178 patients with PAs confirmed by pathology were retrospectively analyzed. According to the Ki-67 index, the patients were divided into the Ki-67 < 3% and Ki-67 ≥ 3% cohorts. Patient data, including age, sex, postoperative immunohistochemical pituitary hormone positive index, Knosp grade, tumor breaking through the sellar floor, rich blood supply to the tumor, tumor located inside the sella, erosion of the dorsum sellae bone, and pituitary-specific transcription factor, were collected. A univariate logistic analysis was used to evaluate the influence factors for a high Ki-67 index. Multiple regression and receiver operating characteristic (ROC) curve were used to analyze the factors with p < 0.05. The mutant status of Ki-67 index was predicted by nomogram. Results: Multivariate regression analysis showed that rich blood supply to the tumor and erosion of the dorsum sellae bone were independent risk factors for the Ki-67 proliferation index. The ROC curves demonstrated that age, rich blood supply to the tumor, and erosion of the dorsum sellae bone can predict the occurrence of a high Ki-67 index. Together, the three risk factors provide a stronger ability to predict the Ki-67 index. The nomogram was developed and validated. Conclusion: Age, rich blood supply to the tumor, and erosion of the dorsum sellae bone are influencing factors for predicting the Ki-67 index. Suitable nomogram prediction models were developed and validated, and there is potential for personalized treatment for PA patients.

Endoscopic vs. microscopic transsphenoidal surgery outcomes in 514 nonfunctioning pituitary adenoma cases

Transsphenoidal surgery remains the preference choice for patients with nonfunctioning pituitary tumors at present, but the superiority of surgical modalities is still debated. Moreover, the efficacy of microscopic and endoscopic transsphenoidal surgery has not been fully studied. Therefore, the present study was designed to compare the postoperative outcomes of the two widely used approaches worldwide. This retrospective study included 514 patients with the first transsphenoidal pituitary adenoma resection in Shandong Provincial Hospital from January 2015 to July 2020 and compared the outcomes of microscope transsphenoidal surgery (MTSS) and endoscopy transsphenoidal surgery (ETSS). A total of 514 patients were included in this study, of whom 210 received the ETSS and 304 received the MTSS. The patients in two groups were similar in terms of postoperative hyponatremia (p = 0.229), diabetes insipidus (p = 0.264), the recovery of hormonal axis (p < 0.05), and extent of resection (EOR) (p = 0.067). ETSS was more likely to cause cerebrospinal fluid leakage than MTSS (p = 0.017, 3.6% vs. 8.6%). CSF leakage might be related to tumor size (95% CI = 1.305-2.766, p = 0.001), and the surgeon's transsphenoidal surgery volume < 300 was also a risk factor (95% CI = 1.396-9.067, p = 0.008). The effect of different surgeries on postoperative vision improvement was statistically difference in univariate analysis (p = 0.048) but not after adjustment for confounders (p = 0.112). Furthermore, there were statistical difference in EOR between MTSS and ETSS when adenomas were performed suprasellar extension (p = 0.037) or optic chiasm compression (p = 0.045). Both techniques are valid for the treatment of nonfunctional adenomas. But CSF leakage is more likely after ETSS. In addition, ETSS is more conducive to resection of nonfunctional adenomas with suprasellar extension or optic chiasm compression.

Apparent Diffusion Coefficient Histogram Analysis for the Preoperative Evaluation of Ki-67 Expression in Pituitary Macroadenoma

PURPOSE

To explore the value of an apparent diffusion coefficient (ADC) histogram in predicting the Ki-67 proliferation index in pituitary macroadenomas.

MATERIAL AND METHODS

This retrospective study analyzed the pathological and imaging data of 102 patients with pathologically confirmed pituitary macroadenoma. Immunohistochemistry staining was used to assess Ki-67 expression in tumor tissue samples, and a high Ki-67 labeling index was defined as 3%. The ADC images of the maximum slice of tumors were selected and the region of interest (ROI) of each slice was delineated using the MaZda software (version 4.7, Technical University of Lodz, Institute of Electronics, Łódź, Poland) and analyzed by ADC histogram. Histogram characteristic parameters were compared between the high Ki-67 group (n = 42) and the low Ki-67 group (n = 60). The important parameters were further analyzed by receiver operating characteristic (ROC).

RESULTS

The mean value, and the 1st, 10th, 50th, 90th, and 99th percentiles were found to be negatively correlated with Ki-67 expression (all P < 0.05), with correlation coefficients of -0.292, -0.352, -0.344, -0.289, -0.253 and -0.267, respectively. The mean ADC and the 1st, 10th, 50th, 90th, and 99th quantiles extracted from the histogram were significantly lower in the high Ki-67 group than in the low Ki-67 group (all P < 0.05). The area under the ROC curve was 0.699-0.720; however, there were no significant between-group differences in variance, skewness and kurtosis (all P > 0.05).

CONCLUSION

An ADC histogram can be a reliable tool to predict the Ki-67 proliferation status in patients with pituitary macroadenomas.

Complication avoidance protocols in endoscopic pituitary adenoma surgery: a retrospective cohort study in 514 patients

PURPOSE

To evaluate the impact of using consistent complication-avoidance protocols in patients undergoing endoscopic pituitary adenoma surgery including techniques for avoiding anosmia, epistaxis, carotid artery injury, hypopituitarism, cerebrospinal fluid leaks and meningitis.

METHODS

All patients undergoing endoscopic adenoma resection from 2010 to 2020 were included. Primary outcomes included 90-day complication rates, gland function outcomes, reoperations, readmissions and length of stay. Secondary outcomes were extent of resection, short-term endocrine remission, vision recovery.

RESULTS

Of 514 patients, (mean age 51 ± 16 years; 78% macroadenomas, 19% prior surgery) major complications occurred in 18(3.5%) patients, most commonly CSF leak (9, 1.7%) and meningitis (4, 0.8%). In 14 of 18 patients, complications were deemed preventable. Four (0.8%) had complications with permanent sequelae (3 before 2016): one unexplained mortality, one stroke, one oculomotor nerve palsy, one oculoparesis. There were no internal carotid artery injuries, permanent visual worsening or permanent anosmia. New hypopituitarism occurred in 23/485(4.7%). Partial or complete hypopituitarism resolution occurred in 102/193(52.8%) patients. Median LOS was 2 days; 98.3% of patients were discharged home. Comparing 18 patients with major complications versus 496 without, median LOS was 7 versus 2 days, respectively p < 0.001. Readmissions occurred in 6%(31/535), mostly for hyponatremia (18/31). Gross total resection was achieved in 214/312(69%) endocrine-inactive adenomas; biochemical remission was achieved in 148/209(71%) endocrine-active adenomas. Visual field or acuity defects improved in 126/138(91.3%) patients.

CONCLUSION

This study suggests that conformance to established protocols for endoscopic pituitary surgery may minimize complications, re-admissions and LOS while enhancing the likelihood of preserving gland function, although there remains opportunity for further improvements.

Outcomes of transsphenoidal surgery in dopamine agonist-resistant prolactinomas: a retrospective study

PURPOSE

Dopamine agonists (DA) comprise first-line treatment for prolactinomas. However, some patients show no response to DA and are considered resistant. In this study, we retrospectively analyzed the outcomes of DA-resistant prolactinoma patients after transsphenoidal surgery (TSS).

METHODS

A total of 94 consecutive patients with DA-resistant prolactinomas who underwent TSS were retrospectively enrolled in the present study. Early postoperative remission rate, prolactin (PRL) levels, and recurrence rate were analyzed.

RESULTS

Of 94 DA-resistant patients, 47 (50%) achieved early remission 1 week post-surgery, including 41.18% of macroprolactinoma patients and 73.08% of microprolactinoma patients. PRL levels on the first postoperative day were significantly lower than preoperative PRL levels (p < 0.001). Total resection rate in macro- and microprolactinomas were, respectively, 75 and 96.15%. A recurrence of hyperprolactinemia and tumor was, respectively, found in 31.91 and 19.15% of patients with a follow-up of 39.53 ± 2.172 months (range 3-86). A higher hyperprolactinemia recurrence was observed in patients with invasive prolactinomas (p = 0.021) or preoperative PRL levels ≥ 200 ng/ml (p = 0.029). Univariate logistic regression indicated that larger maximum tumor diameter (p = 0.045), invasive prolactinomas (p = 0.002), and absence of early postoperative remission (p = 0.004) were significant predictors of tumor recurrence. However, using multivariate stepwise logistic regression, only invasiveness and early postoperative remission remained significant.

CONCLUSION

Tumor invasiveness and preoperative PRL levels were significant predictors of hyperprolactinemia recurrence after TSS. For tumor recurrence, invasiveness and early postoperative remission were independent predictors.

The intestinal flora of patients with GHPA affects the growth and the expression of PD-L1 of tumor

Context

Pituitary adenoma (PA) is a common intracranial tumor. The evidence indicates that the tumor immune microenvironment (TIME) is associated with PA and that the intestinal flora influences other tumors' growth through interacting with the TIME. However, how the intestinal microbial flora contributes to the development of PA through the immune response is unknown.

Objective and methods

Here we used high-throughput Illumina MiSeq sequencing targeting the V3−V4 region of the 16S ribosomal RNA gene to investigate the intestinal flora of patients with growth hormone-secreting pituitary adenoma (GHPA), nonfunctional pituitary adenoma (NFPA), and healthy controls. We determined their effects on tumor growth and the TIME. Fecal microbiota transplantation (FMT) was performed after adoptive transfer via peripheral blood mononuclear cells to tumor-bearing nude mice, which allowed the study of the immune response.

Result

We discovered differences in the structures and quantities of intestinal flora between patients with GHPA, patients with NFPA, and healthy controls. After FMT, the intestinal flora of GHPA patients promoted the growth of tumors in mouse models. The number of programmed cell death ligand 1 (PD-L1)-positive cells increased in tumor tissues as well as the extent of infiltration of CD8⁺ cells. Increased numbers of CD3⁺CD8⁺ cells and increased levels of sPD-L1 were detected in peripheral blood.

Conclusion

These findings indicated that the intestinal flora of patients with GHPA promoted tumor growth and that the immune system may mediate this change.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00262-021-03080-6.

Role of pituitary stalk and gland radiological status on endocrine function and outcome after endoscopic transsphenoidal surgery for non-functioning pituitary adenomas

PURPOSE

To investigate endocrine function changes after non-functioning pituitary adenomas (NFPA) transsphenoidal surgery and to search for predictors of hypopituitarism resolution and development.

METHODS

We included 117 patients with NFPA who underwent endoscopic transsphenoidal surgery from 2005 to 2019 by two neurosurgeons. Twenty-one patients were excluded because of previous pituitary surgery or radiotherapy. We assessed symptoms at diagnosis, tumour volume, tumour removal, hormonal status at diagnosis, hormonal outcomes at 2- and 12-month follow-up, and complications. Pituitary stalk and gland MRI status (visible or not) were included, and it theirs association to hormonal function was studied for the first time, to our knowledge.

RESULTS

Pituitary gland visualization was more frequent in those patients who showed a smaller number of axes affected at 12 months (p = 0.011). Pituitary stalk status showed no association to hormonal function. The hormonal normalization rate at 12 months was 13%. The endocrine improvement rate at 12 months was 16.7%. Worsening of hormonal function occurred in 19.8% of patients. Younger age was associated to hormonal improvement (p = 0.004). Higher preoperative tumour volume (p = 0.015) and absence of gross total resection (GTR) (p = 0.049) were associated with worsening in at least one hormonal axis after surgery.

CONCLUSIONS

Pituitary gland visibility was higher in those patients who showed better hormonal outcomes. Assessment of initial hormonal function and outcome after surgery regarding pituitary stalk status showed no significant association. Higher preoperative tumour volumes and absence of GTR were associated to postoperative endocrine function worsening, while younger age was associated to its improvement.

Non-functioning pituitary macroadenomas: factors affecting postoperative recurrence, and pre- and post-surgical endocrine and visual function

BACKGROUND

Non-functioning pituitary macroadenomas (NFPAs) with visual field defects are ideally managed by transsphenoidal tumour resection to improve vision, and long-term postsurgical follow up is necessary to monitor for tumour recurrence. Regular updates from global data are necessary for developing optimal management strategies of these tumours.

METHODS

Pre- and postoperative visual and endocrine profile, imaging characteristics and details of surgical interventions among patients with NFPAs managed between 2008 and 2019 in a UK regional centre were assessed. The radiological and surgical outcomes including postoperative complications, recurrence risk and the factors influencing outcomes also were assessed.

RESULTS

105 cases with mean (SD) age 60.1 (14.3) years and follow-up duration 60 (37) months were studied. 67 (64%) patients were male. Five-year recurrence-free survival rate was 71.5% (95% confidence interval [CI] 62.7% to 81.6%) with 33 (31%) tumour recurrences of whom 20 (60%) received radiotherapy and 9 (27%) underwent further surgery. Younger age, tumour volume, and bilateral cavernous sinus extension were the predictors of recurrence on univariate analysis, while younger age was the only factor on multivariate analysis (Hazard ratio 0.95; 95% CI: 0.92, 0.97). 72/78 patients (92%) with preoperative visual field defects improved after surgery, of whom 27 (35%) had full recovery. 20 (24%) patients had recovery of an abnormal hormone axis. 15 patients (16%) developed perioperative complications such as cerebrospinal fluid leak (12 cases), meningitis (2 cases), and bleeding (2 cases).

CONCLUSIONS

Five-year recurrence-free survival after transsphenoidal resection for NFPAs was 71.5% with older age at surgery conferring lower risk of recurrence. Visual recovery/ improvement occurred in 92% of cases with preoperative visual defects following surgery.

Pituitary function after transsphenoidal surgery including measurement of basal morning cortisol as predictor of adrenal insufficiency

INTRODUCTION

Patients with pituitary adenomas undergoing transsphenoidal surgery require pre- and post-surgery examination of pituitary hormones. There is currently no consensus on how to evaluate the adrenal axis post-surgery. The aims of this study were to investigate factors that may predict postoperative adrenal insufficiency (AI) and to investigate the overall effect of transsphenoidal surgery on pituitary function.

METHODS

One hundred and forty-three consecutive patients who had undergone transsphenoidal surgery for pituitary adenomas were included. Data on tumour size, pituitary function pre-surgery, plasma basal cortisol measured within 48 h post-surgery and pituitary function 6 months post-surgery were collected. Patients with AI prior to surgery, perioperative glucocorticoid treatment, Cushing's disease and no re-evaluation after 1 month were excluded (n = 93) in the basal cortisol analysis.

RESULTS

Low plasma basal cortisol post-surgery, tumour size and previous pituitary surgery were predictors of AI (all P < 0.05). A basal cortisol cut-off concentration of 300 nmol/L predicted AI 6 months post-surgery with sensitivity and negative predictive value of 100%, specificity of 81% and positive predictive value of 25%. New gonadal, thyroid and adrenal axis insufficiencies accounted for 2, 10 and 10%, respectively. The corresponding recovery rates were 17, 7 and 24%, respectively.

CONCLUSION

Transsphenoidal surgery had an overall beneficial effect on pituitary endocrine function. Low basal plasma cortisol measured within 48 h after surgery, tumour size and previous surgery were identified as risk factors for AI. Measurement of basal cortisol post-surgery may help to identify patients at risk of developing AI.

Fibroblast Growth Factor Receptor-4 Expression in Pituitary Adenomas is Associated with Aggressive Tumor Features

PURPOSE

To investigate the relationship of Fibroblast Growth Factor Receptor-4 (FGFR-4) expression with radiologic, pathologic, and clinical parameters in pituitary adenomas.

METHODS

Among 307 patients who underwent pituitary surgery for a pituitary adenoma between 2000 and 2015, we included 161 patients (53 gonadotroph, 26 corticotroph, 25 null cell, 22 lactotroph, 13 somatotroph, 8 adenomas with unusual combination, 7 Pit-1 positive adenomas, and 7 lactosomatotroph) based on availability of pathology specimens. Patients' radiologic, pathologic, and clinical parameters were determined. FGFR-4 immunostaining was evaluated using a semi-quantitative histologic score (H-score).

RESULTS

The mean follow-up period was 61 (IQR=32-84) months. The median H-scores for FGFR-4 were higher in patients without remission, those with residual lesion, and T2-hyperintense adenoma (p<0.05). Ki-67 level was higher in patients without remission compared to those in remission (p<0.05). The mean Ki-67 levels did not differ between patients with and without residual lesion or T2-hyperintense tumor (p>0.05). There was no significant difference (p>0.05) when the H-score and Ki-67 levels were assessed in terms of sex, sellar-dural invasion, Knosp and a grading system for superior, inferior, parasellar, anterior and posterior tumor extension Classification, tumor function or presence of poor subtype. Adenomas with Ki-67 expression ≥3% had higher FGFR4 expression levels than those with <3% expression (p=0.002). There was a weak positive correlation between H-score and Ki-67 (p=0.011; r=0.201).

CONCLUSIONS

Higher levels of FGFR-4 in pituitary adenomas could be use a marker for more aggressive tumor behavior.

A Nomogram for Preoperatively Predicting the Ki-67 Index of a Pituitary Tumor: A Retrospective Cohort Study

Background

The Ki-67 index is an indicator of proliferation and aggressive behavior in pituitary adenomas (PAs). This study aims to develop and validate a predictive nomogram for forecasting Ki-67 index levels preoperatively in PAs.

Methods

A total of 439 patients with PAs underwent PA resection at the Department of Neurosurgery in Jinling Hospital between January 2018 and October 2020; they were enrolled in this retrospective study and were classified randomly into a training cohort (n = 300) and a validation cohort (n = 139). A range of clinical, radiological, and laboratory characteristics were collected. The Ki-67 index was classified into the low Ki-67 index (<3%) and the high Ki-67 index (≥3%). Least absolute shrinkage and selection operator algorithm and uni- and multivariate logistic regression analyses were applied to identify independent risk factors associated with Ki-67. A nomogram was constructed to visualize these risk factors. The receiver operation characteristic curve and calibration curve were computed to evaluate the predictive performance of the nomogram model.

Results

Age, primary-recurrence subtype, maximum dimension, and prolactin were included in the nomogram model. The areas under the curve (AUCs) of the nomogram model were 0.694 in the training cohort and 0.658 in the validation cohort. A well-fitted calibration curve was also generated for the nomogram model. A subgroup analysis revealed stable predictive performance for the nomogram model. A correlation analysis revealed that age (R = −0.23; p < 0.01), maximum dimension (R = 0.17; p < 0.01), and prolactin (R = 0.16; p < 0.01) were all significantly correlated with the Ki-67 index level.

Conclusions

Age, primary-recurrence subtype, maximum dimension, and prolactin are independent predictors for the Ki-67 index level. The current study provides a novel and feasible nomogram, which can further assist neurosurgeons to develop better, more individualized treatment strategies for patients with PAs by predicting the Ki-67 index level preoperatively.

Volumetric Study of Nonfunctioning Pituitary Adenomas: Predictors of Gross Total Resection

OBJECTIVE

Despite the efforts made to determine the achieved resection grade after pituitary adenoma surgery, there is a high level of disagreement among all the available classifications and measurement methods used. Our objective is to identify the factors that preoperatively could predict a gross total resection (GTR) of a clinically nonfunctioning pituitary adenoma through an endoscopic endonasal approach.

METHODS

Across 100 surgeries, we analyzed epidemiologic and clinical data, radiologic relevant data, extent of resection (EOR), and postoperative outcomes. The EOR was measured objectively through an accurate volumetric analysis.

RESULTS

The median presurgical volume was 8.58 cm³ (range, 0.5-58 cm³), the median maximum diameter was 27.3 mm (range, 7-67 mm), and the Knosp grade was 0 in 1 patient, 1 in 23%, 2 in 31%, 3 in 23% and 4 in 22% of patients. In the multivariate logistic regression analysis, we found 3 factors that significantly predicted the chances of a successful GTR: previous sellar surgery, Knosp grade, and tumor signal in the T2-weighted magnetic resonance imaging scan. Another 10 radiologic variables were analyzed and had no effect on the EOR.

CONCLUSIONS

Knosp grade (P < 0.001; odds ratio [OR], 25.65; 95% confidence interval, 7.19-91.52) is the most predictive factor for performing a GTR of nonfunctioning pituitary adenoma. Previous pituitary surgery (P = 0.023; OR, 5.81) and an isointense T2-weighted signal (P = 0.034; OR, 3.75) also negatively influenced the chances of GTR. We highlight the influence of T2-weighted signal in the chances of GTR.