A decade of pituitary microsurgery. The Herbert Olivecrona lecture

Do Anatomical Variations of Sphenoid Sinus Influence Sella Exposure and Residual Disease in Pituitary Surgery? - A Study in an Indian Population

Introduction  Endoscopic transsphenoidal surgery (ETS) is the standard practice in pituitary surgeries. The sellar exposure becomes the main factor which determines the residual disease in ETS. Not many studies can be found in the literature on the influence of anatomical variations of the sphenoid on intraoperative sella exposure. Objective  The aim of the current study is to ascertain whether sphenoid sinus variations play a role in sellar exposure and residual tumor volume. Methods  This is a prospective study conducted in a south Indian tertiary care center between June 2020 to June 2022, with 21 study participants who were scheduled to have ETS. The relation of preoperative computed tomography (CT) and magnetic resonance imaging (MRI) parameters with the intraoperative area of sellar exposure and residual tumor volume was evaluated. Results  Sphenoid sinus dimensions, like presellar width (mean = 1.89 ± 0.51 cm), maximum width (mean = 2.94 ± 1.09 cm), presellar depth (mean = 1.14 ± 0.55 cm), suprasellar depth (mean = 1.08 ± 0.24 cm), infrasellar depth (mean = 2.36 ± 0.92 cm), presellar height (mean = 2.22 ± 0.47 cm), or the 9 internal carotid artery (ICA)-related measures, did not have any correlation with the mean intraoperative area of sellar exposure (0.57 ± 0.28 cm 2 ). Also, the adequacy of sellar exposure did not relate to the residual tumor. Preoperative tumor volume was found to be higher (20.2 [55.3-13.2] cm 3 ) in patients with residual tumor compared with those with no residual tumor (5.9 [6.8-5.2] cm 3 ). Tumor extension had a significant association with the residual tumor volume. Conclusion  According to the present study, anatomical variations of the sphenoid sinus do not influence the adequacy of sellar exposure. Further studies need to be undertaken concerning residual tumor volume as well as preoperative tumor volume and extension.

The open sella technique for surgical treatment of pituitary macroadenomas: Safety and efficacy in a large clinical series

PURPOSE

To analyse the efficacy and safety of the transsphenoidal microsurgical approach with open sella technique (OST) for the treatment of pituitary adenoma (PA) with suprasellar extension.

METHODS

We retrospectively reviewed 2305 consecutive patients with PA who underwent their first surgery through the transsphenoidal microsurgical approach at our department between 1990 and 2018. Focusing on tumours with suprasellar extension, in particular, grade B, C and D adenomas according to Wilson-Hardy's classification, 376 patients who received the OST surgery were identified. Outcomes and complications were evaluated and compared with those obtained in patients who underwent a standard transsphenoidal approach (TSM).

RESULTS

Two-hundred and sixty-four of 376 patients (70.2%) were found to be suffering from a non-functioning pituitary adenoma, whereas 112 of 376 patients (29.8%) from a hormone-secreting PA. The mean craniocaudal diameter of the tumor was 30.6 ± 0.3 mm (range, 21-75 mm) and 151 patients (40.1%) had a cavernous sinus invasion too. An overall surgical remission rate of 50.3% was achieved in the OST group, whereas the recurrence rate was 10.5%. Patients were followed for a mean period of 68 ± 1.4 months (range, 6-96 months). Less postoperative intrasellar haemorrhages have been recorded in the OST group than the TSM one (1.1% vs. 4.6%, p = 0.02).

CONCLUSIONS

In experienced hands, OST represents an effective and safe treatment strategy for PA with suprasellar extension.

Comparing neuroendocrine recovery between surgical and conservative management in pituitary apoplexy patients: a propensity score-matched analysis

Pituitary apoplexy is a rare and potentially life-threatening clinical syndrome. Patients may present with severeneuro-ophthalmologic or endocrine symptoms. Current evidence is unclear whether conservative or surgicalmanagement leads to the best neuroendocrine outcomes. This study aimed to compare neuroendocrine outcomesbetween surgical and conservative treatments in a single center. Cases of patients with pituitary apoplexy whoreceived transsphenoidal surgery or conservative management in Songklanagarind Hospital between January 1,2005 and December 31, 2022 were retrospectively reviewed. A propensity score matching method was used toadjust bias from treatment selection (surgery or conservative treatment). Differences in visual field, visual acuity,cranial nerve, and endocrine outcomes between the surgical and conservative treatment groups were analyzedusing logistic regression analysis. This study included 127 patients, with 98 and 29 patients in the surgical and theconservative treatment group, respectively. The optimal matching method was used for propensity score matching.Compared to the conservative group, the surgically treated patients had a significantly higher rate of visual fieldrecovery (odds ratio (OR): 12.89, P = 0.007). However, there were no statistical differences in the recovery rate ofpreoperative visual acuity, cranial nerve, and endocrine deficits between the groups. Transsphenoidal surgery wasassociated with a higher rate of visual field recovery when compared to the conservative treatment for pituitaryapoplexy patients. Careful selection of appropriate treatment based on the patient's presentation andneuroendocrine status will result in the best outcomes while avoiding unnecessary surgical intervention.

The influence of radiological tumor growth pattern on sino‑nasal health in pituitary adenomas

Pituitary adenomas are one of the most common mass lesions of the brain and are associated with a reduced quality of life. While transnasal and transsphenoidal endoscopic approaches are considered to deliver similar recovery rates for sino-nasal health (SNH), the impact of radiological tumor growth patterns on SNH has not been evaluated. In the present study, the influence of radiological tumor growth on SNH was examined before and after endoscopic transsphenoidal tumor resection. Patient data were prospectively collected between August 1, 2016 and August 31, 2022. The Knosp and Hardy classifications were used to dichotomize pituitary adenoma lesions into low- and high-graded lesions. SNH was assessed shortly before surgery and at follow-up examinations 3-6 months after operation using the Sino-Nasal Outcome Test for Neurosurgery (SNOT-NC) questionnaire. Fully completed SNOT-NC questionnaires were collected before and after surgery from a total of 101 patients. Independent t-tests showed significantly higher rates of deterioration after surgery in patients with Knosp low-graded lesions compared with those with high-graded tumors for the SNOT-NC total score P=0.048, nasal discomfort P=0.034, sleep problems P=0.024 and visual impairment P=0.042. Pre- and post-operative comparisons for the Knosp low-graded tumor cohort showed an increase of nasal discomfort (P=0.004), while the Knosp high-graded tumor cohort reported decreased visual impairment (P=0.016) after surgery. Assessing the Hardy classification, increased nasal discomfort was reported in patients with high-graded infrasellar tumors after surgery (P=0.046). Growth characteristics of pituitary adenomas based on Knosp and Hardy classifications may influence SNH. Patients with less invasive lesions were revealed to be more prone to experiencing a decrease in SNH, which went beyond the assumed deterioration of 1-3 months. These findings indicate the importance of detailed information regarding SNH as part of every pre-operative patient briefing.

Intraoperative cerebrospinal fluid leakage and residual tumors in endoscopic transsphenoidal surgery for pituitary adenoma: risk analysis and nomogram development

BACKGROUND

Endoscopic transsphenoidal surgery is the primary method used to treat pituitary adenomas (PAs) at present; however, this technique is associated with certain risks, including cerebrospinal fluid leakage (CFL) and residual tumors (RTs). In this study, we aimed to identify specific risk factors for intraoperative CFL (ioCFL) and postoperative RT in patients with pituitary adenoma and construct a corresponding nomogram for risk assessment.

METHODS

We collected a range of information from 782 patients who underwent endoscopic transsphenoidal PA resection in the Department of Neurosurgery at Beijing Tiantan Hospital between 2019 and 2021. Patients were then randomly assigned to training and validation groups (in a 8:2 ratio) with R software. Univariate and multivariable logistic regression models were then used to screen variables related to ioCFL and RT. These variables were then used to construct a predictive nomogram. Finally, the accuracy of the nomogram was validated by receiver operating characteristic curve (ROC) analysis, calibration plots, and decision curve analysis (DCA).

RESULTS

Univariate and multivariable logistic regression models identified four risk factors for ioCFL (Hardy grade, tumor size, position, and consistency) and five risk factors for RT (operation time, tumor size, consistency, Knosp grade, and primary/recurrence type). The area under the ROC curve (AUC) for the ioCFL risk model was 0.666 and 0.697 for the training and validation groups, respectively. For RT, the AUCs for the two groups were 0.788 and 0.754, respectively. The calibration plots for the ioCFL and RT models showed high calibration quality and DCA analysis yielded excellent efficiency with regards to clinical decision making.

CONCLUSION

Tumor size, growth characteristics, and invasion location were identified as the main factors affecting intraoperative CFL and RT. With our novel nomogram, surgeons can identify high-risk patients according to preoperative and intraoperative tumor performance and reduce the probability of complications.

Magnetic resonance imaging grading of pituitary macroadenoma – SIPAP classification revisited

Background

Magnetic resonance imaging (MRI) is regarded as the modality of choice in diagnosis of pituitary macroadenomas. Since surgery is the first line therapy for all pituitary adenomas, simple and reproducible MRI classification based on major directions of tumour growth is an essential tool. SIPAP MRI classification for pituitary adenoma describes tumor extension in parasellar, suprasellar, infrasellar, anterior and posterior directions. We, therefore, evaluated reproducibility of SIPAP classification in reporting of pituitary adenomas.

Methods

Forty-nine patients with biopsy-proven pituitary macroadenoma were graded according to SIPAP classification. Data was analyzed using Stata version 15. Interobserver variability was calculated using Cohen’s Kappa. Comparison between grading before and after treatment was performed by Chi-square test. P values < 0.05 were considered statistically significant.

Results

Individual tumour extensions according to SIPAP for pre- and post-operative grading showed significant difference (p-value <0.001), except for anterior extension. For suprasellar extension, 67.3 % patients had pre-operative grade-3 and 63.3 % had post-operative grade-0. For infrasellar extension, 51.0 % had pre-operative grade-2 and 71.4 % had post-operative grade-0. Anterior, posterior and parasellar extensions showed increased frequency in grade-0 in post-operative stage compared to pre-operative. Substantial inter-observer agreement was achieved for Superior, Inferior, Anterior and Posterior extent with all Kappa statistics values above 0.7 (p-value <0.001).

Conclusion

We propose incorporating simple and objective SIPAP classification in routine MR reporting for ideal pituitary tumour delineation, relationship to juxtasellar structures and tumour size, hence facilitating greater success rate in surgical and subsequent clinical management.

Imaging of Skull Base Tumors

OBJECTIVE

This article provides an overview of imaging modalities and findings associated with common skull base tumors including meningiomas and how to use imaging features to guide surveillance and treatment decision making.

LATEST DEVELOPMENTS

Ease of access to cranial imaging has led to a higher number of incidentally diagnosed skull base tumors, which merit careful consideration for management with observation or treatment. The point of origin of the tumor dictates the pattern of anatomic displacement and involvement by the tumor as it grows. Careful study of vascular encroachment on CT angiography, as well as the pattern and extent of bony invasion on CT, abets treatment planning. Quantitative analyses of imaging, such as with radiomics, may further elucidate phenotype-genotype associations in the future.

ESSENTIAL POINTS

Combinatorial application of CT and MRI analyses improves the diagnosis of skull base tumors, clarifies their point of origin, and dictates the extent of treatment needed.

Prospective evaluation of multidimensional health-related quality of life after endoscopic endonasal surgery for pituitary adenomas using the endoscopic endonasal sinus and skull base surgery questionnaire

Objective

Social functioning is an important factor in the evaluation of postoperative health-related quality of life (HRQoL) for pituitary adenoma patients. In a prospective cohort study multidimensional HRQoL of non-functioning (NFA) and functioning (FA) pituitary adenoma patients were evaluated following endoscopic endonasal surgery using the endoscopic endonasal sinus and skull base surgery questionnaire (EES-Q).

Methods

Prospectively, 101 patients were included. The EES-Q was completed preoperatively and postoperatively (2 weeks, 3 months, 1 year). Sinonasal complaints were completed daily during the first week postoperatively. Preoperative and postoperative scores were compared. A generalized estimating equation (uni- and multivariate) analysis was performed to identify significant HRQoL changes related to selected covariates.

Results

Two weeks postoperatively, physical (p < .05) and social (p < .05) HRQoL are worse and psychological (p < .05) HRQoL improved compared with preoperatively. Three months postoperatively, psychological HRQoL (p = .01) trended back to baseline and no differences in physical or social HRQoL were reported. One year postoperatively, psychological (p = .02) and social (p = .04) HRQoL improved while physical HRQoL remained stable. FA patients report a worse HRQoL preoperatively (social, p < .05) and 3 months postoperatively (social, p < .02 and psychological, p < .02). Sinonasal complaints peak in the first days postoperatively and gradually return to presurgical levels 3 months postoperatively.

Conclusions

The EES-Q provides meaningful information on multidimensional HRQoL to improve patient-centred health care. Social functioning remains the most difficult area in which to achieve improvements. Despite the relatively modest sample size, there is some indication that the FA group continues to show a downward trend (and thus improvement) even after 3 months, when most other parameters reach stability.

Level of evidence

Level II-B.

Endoscopic transcranial transdiaphragmatic approach in a single-stage surgery for giant pituitary adenomas

Background

The treatment for giant pituitary adenomas (GPAs, maximal diameter >4 cm) remains challenging, with remarkable mortality and morbidity, and there is no consensus on the optimal surgical approach. Gross total resection (GTR) for GPAs is difficult to achieve through a single transsphenoidal or transcranial approach. Any residual tumor is at risk for postoperative apoplexy. In this study, we propose a new surgical technique for resecting the GPAs in a sing-stage transcranial surgery.

Methods

A retrospective review of 4 patients with complicated GPAs, who had been treated via an endoscopic transcranial transdiaphragmatic approach in a single-stage surgery after routine transcranial resection, was performed. The following data was analyzed: clinical characteristics, preoperative imaging studies, resection rate, perioperative morbidity and mortality, as well as postoperative outcomes.

Results

All patients had nonfunctioning GPAs and preoperative visual disturbances. In three patients, GTR was achieved, and in one patient, near-total resection (90%-100% of the tumor) was achieved. Three patients attained improved postoperative visual function, while one patient's vision remained unchanged. One patient suffered a deficiency in adrenocorticotropic hormone along with thyroid-stimulating hormone, and one patient developed diabetes insipidus. Notably, none of the patients suffered cerebrospinal fluid leakage. However, one patient developed an epidural hematoma and underwent decompressive craniectomy.

Conclusions

The endoscopic transcranial transdiaphragmatic approach in a single-stage surgery can be efficiently and safely performed for maximal excision of GPAs with extensive suprasellar extension. Furthermore, relative to the conventional combined or staged approaches, this innovative surgical strategy provides neurosurgeons with a clear operative field with reduced invasiveness.

Benign and Malignant Tumors of the Pituitary Gland

Pituitary gland tumors represent approximately 10-15% of all brain tumors and the most common neoplasms of the sellar region. Among them, pituitary adenomas are the widespread accounting for more than 80%. Recently, the fourth edition of the World Health Organization (WHO) 2017 classified pituitary tumors focusing on histopathologic and molecular genetics features and introduced new entities like pituitary blastoma. Most of pituitary gland neoplasms occur sporadically, whereas 5% are related to familial syndromes. They present with several clinical manifestations including signs and symptoms related to excessive hormone secretion by the tumor, signs of hormone deficits by the normal pituitary gland and others commonly secondary to mass effects, and compression of nearby structures such as the optic chiasm; headache and visual disturbance are the most frequent mass effect symptoms. Some tumors, however, are detected as an incidental finding on magnetic resonance imaging (MRI) or computed tomography (CT) scans performed for some other reasons. A correct evaluation involves the assessment of hypothalamic-pituitary hormonal function and an ophthalmological examination once a pituitary lesion is encountered. Surgery, more specifically transsphenoidal approach, represents the primary treatment chosen for the majority of pituitary tumors (except for prolactinomas where medical treatment is indicated) allowing for pathologic analysis and complete or partial tumor removal. On the contrary, to date, craniotomy is rarely performed. Sometimes, due to the proximity of critical structures and to tumor's location and characteristics, a successful surgical procedure may often not be achievable due to the high risks related to the procedure itself. Therefore, the treatment of pituitary tumors commonly requires a multimodal approach, including surgery, radiosurgery, radiation therapy, and medical therapy. Aggressive pituitary tumors or carcinomas are associated with poor prognosis due to limited therapeutic options. Furthermore, they tend to recur quickly after initial surgical treatment or present metastasis, may be unresponsive to therapy, and are difficult to manage. In this chapter, we provide an overview of the most common pituitary gland tumors focusing on epidemiology, new pathological features, diagnosis, available treatment, and prognosis.

Predictive value of pituitary tumor morphology on outcomes and complications in endoscopic transsphenoidal surgery

Purpose

Endoscopic transsphenoidal surgery (ETSS) is an increasingly utilized approach for resection of pituitary tumors. Prior studies have evaluated preoperative tumor size, location, and extent as prognostic factors for surgical resection. There is little data on the relationship between preoperative pituitary tumor radiographic morphology and surgical outcomes.

Study Design

Retrospective longitudinal study.

Setting

Single tertiary care institution.

Subjects and Methods

Preoperative magnetic resonance imaging and computed tomography scans from patients undergoing ETSS for pituitary tumor resections from 2007 to 2017 were retrospectively evaluated. A neuroradiologist classified these pituitary tumors into six morphologic groups, each defined by volume, dimensions, extension, and shape. Surgical difficulty, rates of incomplete resection, and postoperative complications were then stratified in relation to the morphologic groups.

Results

Pituitary tumors from 131 patients were classified from preoperative imaging into six characteristic morphologies: (1) microtumor, (2) round, (3) transverse oblong, (4) superior-inferior oblong, (5) bilobed, and (6) large lobulated. Tumors that were characterized with the large lobulated, bilobed, and transverse oblong morphologies correlated with higher rates of postoperative evidence of residual tumor (70%, 36%, and 47%, respectively, all P < 0.002). Likewise, large lobulated, bilobed, and transverse oblong morphologies were also associated with intraoperative cerebrospinal fluid leaks (70%, 31%, and 35%, respectively, all P < 0.05).

Conclusions

We describe a novel descriptive system for the morphology of pituitary tumors that can be determined from preoperative imaging. Different tumor morphologic groups are associated with varying degrees of gross tumor resection, complications, and surgical difficulty. Utilizing pituitary tumor morphology may aid surgeons in planning the extent of resection, need for complex closure, and patient counseling.

Effect of facility volume on giant pituitary adenoma neurosurgical outcomes

OBJECTIVE

Giant pituitary adenomas (PAs), defined as 4 cm or greater at their maximum diameter, are commonly treated with neurosurgical intervention as the first-line therapy. However, existing studies are from high-volume institutions whose outcomes may not be representative of many cancer centers. In the present study, the authors use a large cancer registry to evaluate demographics, national treatment trends, and outcomes by facility volume to address knowledge gaps for this uncommon tumor.

METHODS

The National Cancer Database was queried for adult patients with PAs who had undergone resection from 2004 to 2016. Univariate and multivariate logistic regression modeling was used to evaluate the prognostic impact of covariates on short-term outcomes including 30-day readmission (30R), 30-day mortality (30M), 90-day mortality (90M), and prolonged length of inpatient hospital stay (LOS). Propensity score matching was used for validation.

RESULTS

Among the 39,030 patients who met the study inclusion criteria, 3696 giant PAs were identified. These tumors had higher rates of subtotal resection (55% vs 24%, p < 0.001), adjunctive radiotherapy (15% vs 5%, p < 0.001), and hormonal therapy (8% vs 4%, p < 0.001) than nongiant PAs. The giant PAs also had worse 30M (0.6% vs 3.1%, p < 0.001), 90M (1.0% vs 5.0%, p < 0.001), 30R (4.0% vs 6.3%, p < 0.001), and LOS (22.2% vs 42.1%, p < 0.001). On multivariate analysis for giant PA, decreased tumor size, younger age, race other than African American, lower comorbidity score, and high-volume facility (HVF; defined as ≥ 2.5 giant PA cases per year) were statistically significant predictors of favorable outcomes. Specifically, 30M, 90M, 30R, and LOS were decreased by 50%, 43%, 55%, and 32%, respectively, when giant PAs were treated at HVFs (each p < 0.05). HVFs more often used the endoscopic approach (71% vs 46%, p < 0.001) and less adjuvant radiotherapy (11% vs 16%, p < 0.001). Propensity score matching validated 30M, 30R, and LOS outcome differences in a cohort of 1056 patients.

CONCLUSIONS

This study provides evidence of superior outcomes when giant PAs are treated at HVFs. These results likely reflect the relation between physician experience and outcomes for these uncommon tumors, which suggests the need for institutional collaboration as a potential goal in their surgical management.

Application of “mosiac sign” on T2-WI in predicting the consistency of pituitary neuroendocrine tumors

Purpose

Tumor consistency is important for pituitary neuroendocrine tumors (PitNETs) resection to improve surgical outcomes. In this study, we evaluated the T2-WI of PitNETs and defined a specific T2-WI signaling manifestation, the “Mosaic sign,” to predict tumor consistency and resection of PitNETs.

Design

A retrospective review of MRI and tumor histology of 137 consecutive patients who underwent endoscopic endonasal resection for PitNETs was performed.

Methods

The “Mosaic sign” was defined by the ratio of the tumor itself T2-WI signals, and characterized by multiple intratumor hyperintense dots. The degree of tumor resection was an assessment by postoperative MRI examination. The presence of the “Mosaic sign” was compared with patients' basic information, tumor consistency, tumor pathological staining, and surgical result. To determine whether the presence or absence of “Mosaic sign” could predict tumor consistency and guide surgical resection of tumors.

Results

Statistical analysis showed that the consistency of the tumor and the degree of resection were correlated with the “Mosaic sign”. In the 137 cases of T2-WI, 43 had “Mosaic sign”, 39 cases had soft tumor consistency, and 4 were classified as fibrous, of which 42 were completely resected and 1 was subtotal resected. Of the 94 patients without “Mosaic sign”, the consistency of tumor of 54 cases were classified as soft, the remaining 40 cases were fibrous, 80 cases were completely resected, and 14 cases were subtotal resected. Postoperative cerebrospinal fluid leakage occurred in 1 patient. The number of corticotroph adenomas in the group of “Mosaic sign” was higher, with the statistical difference between the two groups (P = 0.0343).

Conclusions

The presence of the “Mosaic sign” in T2-WI may provide preoperative information for pituitary adenomas consistency and effectively guide surgical approaches.

A new comprehensive grading for giant pituitary adenomas: SLAP grading

AimGiant pituitary adenomas are difficult to resect due to multicompartmental extension. We developed a new grading system for giant pituitary adenomas (GPAs) considering possible extension in superior, lateral, anterior, and posterior (SLAP) directions. We also related the degree of resection to the SLAP grading.MethodsA review of case files and radiological images of patients with the GPAs defined as pituitary adenomas with a size of more than 4 cm in any dimension was done. The extent of the tumour was noted and scored as per the SLAP system. The maximum total score is 10 and represents a large tumour with maximum extensions in all directions. The subtotal resection (STR) was defined as a residual tumour volume of more than 10%. The association between individual and total score on the degree of resection was determined.ResultsA total of 103 cases of GPAs were analyzed. All patients had a suprasellar (S) extension. The lateral (L) extension was seen in 97.3% of cases. The anterior (A) extension was seen in 28 (27.2%) cases. The posterior (P) extension was seen in 45 (43.7%). Forty-eight (46.6%) had a total score of 5 or more. The STR was achieved in 64 (62.2%) cases. On regression analysis, a total score of ≥5 was associated with odds of 5.02 (1.69-14.93), p-value 0.004 for STR.ConclusionThe SLAP grading is a comprehensive grading system that can be applied easily to the GPAs and gives a complete picture of the extension of the tumour.

Radiological Knosp, Revised-Knosp, and Hardy–Wilson Classifications for the Prediction of Surgical Outcomes in the Endoscopic Endonasal Surgery of Pituitary Adenomas: Study of 228 Cases

Purpose

To evaluate which radiological classification, Knosp, revised-Knosp, or Hardy–Wilson classification, is better for the prediction of surgical outcomes in the endoscopic endonasal transsphenoidal (EET) surgery of pituitary adenomas (PAs).

Methods

This is a retrospective study of patients with PAs who underwent EET PA resection for the first time between January 2009 and December 2020. Radiological cavernous sinus invasiveness was defined as a Knosp or revised-Knosp grade >2 or a grade E in the Hardy–Wilson classification.

Results

A total of 228 patients with PAs were included. Cavernous sinus invasion was evident in 35.1% and suprasellar extension was evident in 74.6%. Overall, surgical cure was achieved in 64.3% of patients. Surgical cure was lower in invasive PAs than in non-invasive PAs (28.8% vs. 83.1%, p < 0.0001), and the risk of major complications was higher (13.8% vs. 3.4%, p = 0.003). The rate of surgical cure decreased as the grade of Knosp increased (p < 0.001), whereas the risk of complications increased (p < 0.001). Patients with Knosp 3B PAs tended to achieve surgical cure less commonly than Knosp 3A PAs (30.0% vs. 56.0%, p = 0.164). Similar results were observed based on the invasion and extension of Hardy–Wilson classification (stage A–C 83.1% vs. E 28.8% p < 0.0001, grade 0–II 81.1% vs. III–IV 59.7% p = 0.008). The Knosp classification offered the greatest diagnostic accuracy for the prediction of surgical cure (AUC 0.820), whereas the invasion Hardy–Wilson classification lacked utility for this purpose (AUC 0.654).

Conclusion

The Knosp classifications offer a good orientation for the estimation of surgical cure and the risk of complications in patients with PAs submitted to EET surgery. However, the invasion Hardy–Wilson scale lacks utility for this purpose.

Surgical Experience of Transcranial Approaches to Large-to-Giant Pituitary Adenomas in Knosp Grade 4

Pituitary adenomas in Knosp grade 4 are difficult to resect completely and are generally involved in poor prognosis, because of the close relationship between the tumor and internal carotid. In this study, the authors retrospectively reviewed the outcome of different transcranial approaches in the management of large-to-giant pituitary adenomas in Knosp grade 4. A total of 42 patients with large-to-giant pituitary adenomas in Knosp grade 4, who underwent craniotomy in the Pituitary Disease Subdivision, Department of Neurosurgery, Beijing Tiantan Hospital, between March 2012 and March 2015 were included in this study. Clinical characteristics, surgical methods, complications, and outcomes were evaluated. The median age was 45 years (range, 19-73 years old), and 42.9% of the enrolled cases were men. The mean tumor diameter was 43.6 mm, and the mean volume was 30.9 cm³. 26 patients underwent the frontolateral approach, while 16 cases accepted the frontotemporal approach. Gross total resection was achieved in 11 patients (26.2%), near total in 26 (61.9%), and subtotal in 5 (11.9%). The adenomas were larger, and the distance of the tumor extending to the lateral skull base was also further in the frontotemporal approach cases. The surgical time was shorter, and the bleeding volume was less in the frontolateral approach cases. Subsellar extension was associated with incomplete resection in pituitary macroadenomas of Knosp grade 4. The craniotomy is still an effective treatment for pituitary macroadenomas in Knosp grade 4.

Surgery for acromegaly: Indications and goals

Acromegaly is a disease that occurs secondary to high levels of GH, most often from a hormone-secreting pituitary adenoma, with multisystem adverse effects. Diagnosis includes serum GH and IGF-1 levels, and obtaining an MRI pituitary protocol to assess for a functional pituitary adenoma. Attempted gross total resection of the GH-secreting adenoma is the gold standard in treatment for patients with acromegaly for a goal of biochemical remission. Medical and radiation therapies are available when patients do not achieve biochemical cure after surgical therapy.

Fractionated Stereotactic Radiation Therapy for Pituitary Adenomas: An alternative escalating protocol of hypofractionated stereotactic radiotherapy delivering 35Gy in 5 fractions

PURPOSE

Evaluate efficacy and toxicity of hypofractionated stereotactic radiotherapy (HSRT) for patients treated for pituitary adenoma (PA) with an alternative HSRT escalating protocol delivering 35Gy in 5 fractions.

MATERIAL AND METHODS

From June 2007 to March 2017, 29 patients with pituitary adenoma were treated in Antoine Lacassagne Cancer Centre with an alternative HSRT protocol. Prescribed dose was 35Gy in 5 fractions of 7Gy. Radiographic responses were assessed by annual MRI. Hormone blood samples were evaluated each year after HSRT.

RESULTS

A total of 29 patients aged between 23 and 86 years (median 54 years) were included. Twelve patients received HSRT for recurrent cases and 12 received postoperative adjuvant HSRT, 5 patients did not have surgery. After a median follow-up period of 47 months local control rate was 96%. One patient presented an out-field tumor regrowth 73 months after HSRT. The majority of PA were endocrine-active (18 patients, 62%). After HSRT, 8 patients (44%) presented complete response on initial secretion, 4 patients (23%) presented partial response on initial secretion. Four patients (14%) presented grade 2 or more acute radiation toxicities. One grade 4 visual disorder was observed for one patient.

CONCLUSIONS

HSRT delivering 35Gy in 5 fractions represents a feasible treatment and shows promising results to reduce hormonal overproduction and to improve local control in PA.

Treatment Trends of Adult Brachial Plexus Injury: A Bibliometric Analysis

Brachial plexus injury is often debilitating because it can severely impair upper extremity function and, thus, quality of life. The surgical treatment of injuries to the brachial plexus is very demanding because it requires a profound understanding of the anatomy and expertise in microsurgery. The aim of this study was to get an overview of the landscape in adult brachial plexus injury surgery, and to understand how this has changed over the years.

Methods

The most frequently cited articles in English relevant to adult brachial plexus injury were identified through the Web of Science online database.

Results

The average number of citations per article was 32.8 (median 24, range 4-158). Authors from 26 countries contributed to our list, and the US was the biggest contributor. Almost half of all nerve transfer cases were described by Asian authors. Amongst nerve transfer, the spinal accessory nerve was the preferred donor overall, except in Asia, where intercostal nerves were preferred. Distal nerve transfers were described more often than plexo-plexal and extra-plexal-to-plexal transfers. The most common grafts were sural nerve grafts and vascularized ulnar nerve grafts, which became popular in the last decade.

Conclusions

Our study sheds light on the regional variations in treatment trends of adult brachial plexus injury, and on the evolution of the field over the last 30 years. The articles included in our analysis are an excellent foundation for those interested in the surgical management of brachial plexus injuries.

Patterns of extrasellar invasive growth of pituitary adenomas with normal sellar cavity size

BACKGROUND

Pituitary adenomas (PAs) are among the most common brain tumors which characteristically become symptomatic due to the mass effect on surrounding structures and/or hormonal imbalances. This study describes 28 cases of PAs with an extrasellar invasive growth (EIG) at the early stage of tumor growth with normal sellar cavity size.

METHODS

1200 cases of PAs either treated medically or via Endoscopic transsphenoidal surgery were reviewed during a 10-year period. Pre-operative imaging was analyzed to evaluate the tumor expansion pattern, tumor invasion sites and other relevant tumor properties. A comprehensive preoperative endocrinological along with postoperative histopathological studies were conducted to evaluate the subjects' homeostasis and further identify the lesions characteristics.

RESULTS

Of the 28 patients, patients 19, 2, 1 and 6 had a growth hormone (GH)-secreting PA, an adrenocorticotropic hormone (ACTH)-secreting PA, a nonfunctional PA (NFPA) and a mix-hormones secreting PA, respectively. There was a statistically significant difference between patients with and without EIG regarding types of PAs (P = 0.000). Post-hoc tests demonstrated that GH-secreting PAs (P = 0.0003) and mix-hormones secreting PAs (P = 0.0000) are significantly more invasive, while NFPAs (P = 0.0000) are less invasive. There was not a statistically significant difference between the invasion sites and different types of PAs (P = 0.122).

CONCLUSION

Among different histological subtypes of PAs, GH-secreting PAs revealed a remarkable tendency for EIG with normal sellar cavity size. The extra-sellar tumor extension with a normal sella did not correlate with atypical histology. Considering EIG patterns, surgeons should be vigilant to investigate and follow the tumor spreading to its enclosing boundary during surgery, the clival part of sphenoid bone should be more exposed, and both inferomedial and lateral borders of the sphenoid sinus should be carefully explored in order to remove the tumor.

Fascin promotes the invasion of pituitary adenoma through partial dependence on epithelial-mesenchymal transition

The aim of the present study was to investigate the role and potential regulatory mechanisms of fascin in the invasion and epithelial-to-mesenchymal transition of pituitary adenoma cells. A total of 30 specimens were assessed in the present study. The expression levels of fascin in the invasive pituitary adenoma group and non-invasive pituitary adenoma group were determined by immunochemistry. Fascin was downregulated via small interfering RNA in mouse pituitary AtT-20 cells. The proliferation, cell cycle and apoptosis of AtT-20 cells were assessed using Cell Counting Kit‑8 and flow cytometry. The invasion of AtT-20 cells was detected using a Transwell assay. Transmission electron microscopy was utilized to observe the ultrastructure of AtT-20 cells. Real-time quantitative PCR, Western blotting and immunofluorescence staining were utilized to detect the expression levels of fascin and EMT markers. In the present study, fascin expression and clinical characteristics were not significantly correlated in pituitary adenoma. The protein expression level of fascin in invasive pituitary adenoma was higher than that in non-invasive pituitary adenoma, as assessed by immunochemistry. Downregulation of fascin resulted in significant decreases in cell viability, proliferation and invasion, arrested the cell cycle at the G1 phase and increased apoptosis. In addition, downregulation of fascin significantly decreased the expression levels of N-cadherin, the mesenchymal cell marker vimentin and the transcription factor Twist but significantly increased the expression levels of the epithelial cell marker E-cadherin. Further experiments revealed that overexpression of E-cadherin resulted in significant decreases in cell viability, proliferation, invasion, and the expression of fascin and transcription factor Twist and also arrested the cell cycle at the G2 phase. The results of the present study suggest that suppressing the expression level of fascin could regulate the invasion, proliferation and apoptosis of pituitary tumour cells and alter the expression level of various EMT markers. The present study identified that fascin effectively promotes the invasion, proliferation and apoptosis of pituitary tumour cells partially via the EMT pathway.

Transcranial approach for pituitary adenomas - An evaluation of surgical approaches over two decades and factors influencing peri-operative morbidity

PURPOSE

Transcranial surgery(TCS) for pituitary adenoma(PA) is mostly reserved for lesions with widespread extensions. We sought to analyse the intraoperative challenges, morbidity and the factors associated with morbidity of transcranial approaches, in a large series from a tertiary neurosurgical institute.

METHODS

We retrospectively evaluated 137 patients who underwent TCS for PA in our institute. The details of their clinical features, imaging, operative and peri-operative events and complications were collected and analysed. The factors associated with morbidity were evaluated.

RESULTS

The mean age of the cohort was 40.86 ± 13.35 years. 21 (15.3%) patients developed significant post-operative hematoma, out of which 7 patients (5.1%) required re-exploration. Post-operative diabetes insipidus was noted in 45 patients (32.84%), while SIADH was noted in 10 patients (7.35%). Other complications were cranial nerve palsy in 14 patients (10.2%), visual deterioration in 7 patients (5.1%). Neither tumour characteristics nor the choice of approach was associated with occurrence of post op hematoma. SIADH was significantly associated with patients with tumours involving cavernous sinus (p = 0.019) and subfrontal extension (p = 0.031). Patients with post-operative hematoma had significantly higher incidence of post-op DI (57.1% vs 28.7%; p = 0.021), while similar correlation was not noticed with SIADH (4.7 vs 7.8%).

CONCLUSION

TCS plays a distinct, albeit a small role in surgical management of pituitary adenoma. Tumour related or approach related factors are not significantly associated with the incidence of hematoma. Post-operative hematoma significantly influences the incidence of DI. A proper and judicious selection of approach and meticulous surgical technique should result in a reduction in associated morbidity and mortality.

Results and predictors of outcome of endoscopic endonasal surgery in Cushing's disease: 20-year experience of an Italian referral Pituitary Center

PURPOSE

To assess outcomes and predictors of early and long-term remission in patients with Cushing's disease (CD) due to ACTH-secreting adenomas treated via endoscopic endonasal approach (EEA).

METHODS

This is a retrospective study. Consecutive patients operated for CD from 1998 to 2017 in an Italian referral Pituitary Center were enrolled. Clinical, radiological, and histological data at enrollment and follow-up were collected.

RESULTS

151 patients (107 F) were included; 88.7% were naïve for treatment, 11.3% had been treated surgically and 11.2% medically. At pre-operative magnetic resonance imaging (MRI), 35 had a macroadenoma and 80 a microadenoma, while tumor was undetectable in 36 patients. Mean age at surgery was 41.1 ± 16.6 years. Diagnosis was confirmed histologically in 82.4% of the cases. Patients with disease persistence underwent second surgery and/or medical and/or radiation therapy. Mean follow-up was 92.3 ± 12.0 (range 12-237.4) and median 88.2 months. Remission rate was 88.1% after the first surgery and 90.7% at last follow-up. One patient died of pituitary carcinoma. Post-surgical cortisol drop (p = 0.004), tumor detection at MRI (p = 0.03) and size < 1 cm (p = 0.045) increased the chance of disease remission; cavernous sinus invasion was a negative predictor of outcome (p = 0.002). Twenty-seven patients developed diabetes insipidus and 18 hypopituitarism. Surgery repetition increased the risk of hypopituitarism (p = 0.03), but not of other complications, which included epistaxis (N = 2), cerebrospinal fluid leakage (1), pneumonia (3), myocardial infarction (1), and pulmonary embolisms (2).

CONCLUSIONS

Selective adenomectomy via EEA performed by experienced surgeons, supported by a multidisciplinary dedicated team, allows long-term remission in the vast majority of CD patients with low complication rate.

Comparative study of complications after primary and revision transsphenoidal endoscopic surgeries

A preferred treatment for residual/recurrent pituitary adenomas has not been established. The existence of higher complication rates for revision surgeries remains under debate. This study aimed to compare complication rates of primary and revision transsphenoidal endoscopic surgeries and to identify risk factors for complications. Data from 144 primary and 39 revision surgeries were analysed. The surgical complications evaluated were intraoperative and postoperative cerebrospinal fluid (CSF) leaks; meningitis; permanent diabetes insipidus (DI) and hypopituitarism; worsening visual acuity; ophthalmoplegias; visual field defects; otorhinolaryngological, systemic and vascular complications; and death. The variables that were potentially associated with surgical complications were gender, age, comorbidities, lumbar drain use, duration of lumbar drain use, invasion of the sphenoid and cavernous sinuses, presence and degree of suprasellar expansion, preoperative identification of the pituitary, CSF leaks and intraoperative pituitary identification. Intraoperative CSF leaks, visual field losses and worsening visual acuity were more common for revision surgeries. There were no between-group differences in the occurrence of postoperative CSF leaks; systemic, vascular and otorhinolaryngological complications; meningitis; DI and hypopituitarism; ophthalmoplegias; or death. Intraoperative identification of the pituitary was associated with lower rates of permanent DI and hypopituitarism, systemic complications, intraoperative CSF leaks and worsening visual acuity. Suprasellar expansion increased the risk of intraoperative CSF leaks but not endocrinological deficits or visual impairment. Intraoperative CSF leaks were associated with postoperative CSF leaks, meningitis, anterior hypopituitarism, DI and worsening visual acuity. Intraoperative CSF leaks, worsening visual acuity and visual field losses were more common in reoperated patients.

Preoperative vascular heterogeneity and aggressiveness assessment of pituitary macroadenoma based on dynamic contrast-enhanced MRI texture analysis

PURPOSE

To assess the vascular heterogeneity and aggressiveness of pituitary macroadenomas (PM) using texture analysis based on Dynamic Contrast-Enhanced MRI (DCE-MRI).

METHOD

Fifty patients with pathologically confirmed PM, including 32 patients with aggressive PM (aggressive group) and 18 patients with non-aggressive PM (non-aggressive group), were included in this study. The preoperative DCE-MRI and clinical data were collected from all patients. The features based on Ktrans, Ve, and Kep were generated using Omni-Kinetics software. Independent-samples t-test and Mann-Whitney U test were used for comparison between two groups. Logistic regression analysis was used to determine the optimal model for distinguishing aggressive and non-aggressive PM.

RESULTS

Six features related to tumor morphology, 24 features in Ktrans, 20 features in Ve, and 3 features in Kep were significantly different between the aggressive and non-aggressive groups. Volume count, gray-level non-uniformity in Ktrans, voxel value sum in Ve and run-length non-uniformity in Kep (AUC = 0.816, 0.903, 0.785, 0.813) were considered the best feature for tumor diagnosis. After modeling, the diagnosis efficiency of mean model and total model was desirable (AUC = 0.859 and 0.957), and the diagnostic efficiency of morphological, Ktrans, Ve and Kep features model was improved (AUC = 0.845, 0.951, 0.847, 0.804).

CONCLUSIONS

Texture analysis based on DCE-MRI elucidates the vascular heterogeneity and aggressiveness of pituitary adenoma. The total model could be used as a new noninvasive method for predicting the aggressiveness of pituitary macroadenoma.

ICAR: endoscopic skull-base surgery

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.

Pituitary Adenomas and Invasiveness from Anatomo-Surgical, Radiological, and Histological Perspectives: A Systematic Literature Review

Invasiveness in pituitary adenomas has been defined and investigated from multiple perspectives, with varying results when its predictive value is considered. A systematic literature review, following PRISMA guidelines, was performed, searching PubMed and Scopus databases with terms that included molecular markers, histological, radiological, anatomical and surgical data on invasiveness of pituitary adenomas. The results showed that differing views are still present for anatomical aspects of the sellar region that are relevant to the concept of invasiveness; radiological and histological diagnoses are still limited, but might improve in the future, especially if they are related to surgical findings, which have become more accurate thanks to the introduction of the endoscope. The aim is to achieve a correct distinction between truly invasive pituitary adenomas from those that, in contrast, present with extension in the parasellar area through natural pathways. At present, diagnosis of invasiveness should be based on a comprehensive analysis of radiological, intra-operative and histological findings.

Regulating the CCNB1 gene can affect cell proliferation and apoptosis in pituitary adenomas and activate epithelial-to-mesenchymal transition

The aim of the present study was to investigate the role and potential regulatory mechanisms of cyclin B1 (CCNB1) in the proliferation, apoptosis and epithelial-to-mesenchymal transition (EMT) in pituitary adenomas. A total of 24 specimens were included in the present study. The expression levels of CCNB1 protein in two normal pituitary and 22 pituitary adenoma tissues were determined by western blotting. CCNB1 was knocked-down by lentiviral-mediated infection of short hairpin RNA (shRNA) in GH3 and MMQ cell lines. The proliferation, cell cycle and apoptosis of GH3 and MMQ cell lines were detected using a Cell Counting Kit-8 and flow cytometer. Reverse transcription-quantitative PCR was utilized to detect the expression level of CCNB1 gene and EMT markers. In the present study, resveratrol (RES) was used as an inhibitor of CCNB1. The protein expression level of CCNB1 in pituitary adenomas was higher than that in normal pituitary tissue, as assessed by western blot analysis. In addition, the expression level of CCNB1 in invasive pituitary adenomas was higher when comparing invasive pituitary adenomas and non-invasive pituitary adenomas. Knockdown of CCNB1 resulted in significant decreases in cell viability and proliferation, arrested cell cycle at the G₂/M phase and increased apoptosis. In addition, knockdown of CCNB1 significantly decreased the expression levels of the mesothelial cell marker N-cadherin (P<0.001), but significantly increased the expression levels of the epithelial cell markers E-cadherin (P<0.01) and p120-catenin (P<0.001). Further analyses identified that RES inhibited the expression level of CCNB1, and RES treatment exhibited a similar effect as CCNB1 shRNA infection. The present study suggested that suppressing the expression level of CCNB1 could regulate the proliferation and apoptosis of pituitary tumor cells and alter the expression level of various EMT markers. In addition, RES treatment could be used as an inhibitor of CCNB1. The present study also identified the molecular mechanisms underlying CCNB1 role in EMT.

Endothelial cell-specific molecule-1 as an invasiveness marker for pituitary null cell adenoma

BACKGROUND

Endothelial cell-specific molecule-1 (ESM-1) is a biomarker associated with tumor progression in pituitary adenoma. We specifically focused on one type of pituitary adenoma, namely null cell adenoma (NCA) and evaluated the relationship between invasion and ESM-1 expression in both vascular endothelial and adenoma tissues.

METHODS

Tissue samples from 94 patients with pituitary NCA were obtained through microscopic transsphenoidal resection. Tumor size and invasion were determined through preoperative magnetic resonance imaging. Immunohistochemical staining was performed to detect ESM-1 expression. ESM-1 index of ≥3 was defined as high expression.

RESULTS

Signs of invasion were observed in 46 (47.9%) of the 94 patients. Significant differences were observed in the invasion state and maximum tumor diameter between high and low expression of ESM-1 in vascular endothelial tissues (both P < 0.05). Significant positive associations were noted between ESM-1 expression in vascular endothelial tissues and tumor invasion (P = 0.002) and tumor size (P = 0.020). However, only tumor size was associated with ESM-1 expression in adenoma tissues (P = 0.016).

CONCLUSION

In NCA, a significant positive association between tumor invasion and ESM-1 expression was observed only in vascular endothelial tissues, suggesting that tumor progression occurs mainly through ESM-1-associated mechanism.

Expressions of Matrix Metalloproteinases-9 and Tissue Inhibitor of Metalloproteinase-1 in Pituitary Adenomas and Their Relationships with Prognosis

OBJECTIVE

To investigate the expression levels of matrix metalloproteinases-9 (MMP-9) and tissue inhibitor of metalloproteinase-1 (TIMP-1) in pituitary adenomas (PAs), and to analyze the relationship of the expressions of the two with the prognosis of patients.

METHODS

A total of 108 patients with PAs diagnosed in our hospital from May 2010 to May 2012 were selected and divided into the invasive PA (IPA) group (n = 58) and the non-IPA group (n = 50) according to the invasiveness of PAs. Hematoxylin and eosin (H&E) staining was used to observe the pathological state of patients. The expression levels of MMP-9 and TIMP-1 were measured by immunohistochemistry and western blotting at protein level and reverse transcription-polymerase chain reaction at gene level, respectively. The expression levels of MMP-9 and TIMP-1 in serum of patients before operation were tested using enzyme-linked immunosorbent assay, and patients with PAs after operation were followed up.

RESULT

The positive expression rate of MMP-9 in IPAs was significantly higher than that in non-IPAs, whereas that of TIMP-1 was relatively high in non-IPAs, and the differences were statistically significant (p < 0.05). At both protein and gene levels, MMP-9 was highly expressed in IPAs, whereas TIMP-1 was highly expressed in non-IPAs, and the differences were statistically significant (p < 0.05 in all comparisons). Before operation, the expression level of MMP-9 in serum of patients with IPAs was relatively high, whereas that of TIMP-1 in serum of patients with non-IPAs was relatively high, and the differences were statistically significant (p < 0.05 in all comparisons).

CONCLUSION

The postoperative survival rate of patients with highly expressed MMP-9 was relatively low, whereas that of patients with highly expressed TIMP-1 was relatively high. The abnormal expressions of MMP-9 and TIMP-1 play important roles in the invasion process of PAs. The prognoses of patients with low expression MMP-9 and high expression TIMP-1 are more positive.

Calcified ectopic TSH-secreting pituitary adenoma mimicking craniopharyngioma: a rare case report and literature review

Among pituitary adenomas, which are relatively common brain tumors, elements of ectopic, thyroid-stimulating hormone (TSH) secretion, and intratumoral calcification are unusual. Here, we present an extremely rare case of a calcified ectopic TSH-secreting pituitary adenoma arising from the pars tuberalis mimicking craniopharyngioma based on neuroimaging findings. To our knowledge, this is the first case report of calcified ectopic TSH-secreting pituitary adenoma without symptoms of excessive thyroid hormone secretion.

Giant pituitary adenoma: histological types, clinical features and therapeutic approaches

Giant pituitary adenomas comprise about 6-10% of all pituitary tumors. They are mostly clinically non-functioning adenomas and occur predominantly in males. The presenting symptoms are usually secondary to compression of neighboring structures, but also due to partial or total hypopituitarism. Functioning adenomas give rise to specific symptoms of hormonal hypersecretion. The use of dopamine agonists is considered a first-line treatment in patients with giant macroprolactinomas. Somatostatin analogs can also be used as primary treatment in cases of growth hormone and thyrotropin producing giant adenomas, although remission of the disease is not achieved in the vast majority of these patients. Neurosurgical treatment, either through transsphenoidal or transcranial surgery, continues to be the treatment of choice in the majority of patients with giant pituitary adenomas. The intrinsic complexity of these tumors requires the use of different therapies in a combined or sequential way. A multimodal approach and a therapeutic strategy involving a multidisciplinary team of expert professionals form the basis of the therapeutic success in these patients.

Endoscopic Endonasal Surgery Treatment Strategies for Invasive Pituitary Adenoma: Analysis of Four Approaches

OBJECTIVE

To explore the surgical methods and clinical effect of endoscopic endonasal approaches for the treatment of invasive pituitary adenomas (IPAs).

METHODS

A retrospective analysis was made of the clinical data of 74 patients (75 procedures) with IPAs treated by different endoscopic endonasal approaches at the Department of Neurosurgery, The First Affiliated Hospital of Shenzhen University from May 2014 to August 2017. The data include clinical manifestation, imaging features, surgical methods and complications, resection rate, cure rate, prognosis, and complications in different Knosp classifications and Hardy stages. The transcavernous approach was used in 47 patients, the lateral-cavernous approach was used in 14 patients, the tuberculum sella planum approach was used in 8 patients, and the diaphragma sellae open or dorsum sellae cut approach was used in 6 patients.

RESULTS

The gross total resection (GTR) rate was 70.7% (53 patients) and tumor residue rate was 29.3% (22 patients). GTR rate for pituitary adenoma according to Knosp classification was 89.3% in grade 3 and 28.6% in grade 4. The biology cure rate was 75.0% and 23.8%, respectively. There was significance between them (P < 0.05). In addition, the GTR rate of Hardy stage was 90.5% in stage C, 90.0% in stage D, 26.1% in stage E, and the biology cure rate was 80.1%, 75.0%, and 13.0%, respectively. There was significance among them (P < 0.05) Postoperative severe complications included 9 patients (12.0%) with cerebrospinal fluid leaks, 26 patients (34.7%)with electrolyte imbalance, 36 patients (48.0%) with transient diabetes insipidus, 22 patients (29.3%) with hypopituitarism, 2 patients (2.7%) with permanent hypopituitarism, and 2 patients (2.7%)with epistaxis. The follow-up lasted 2-41 months (average, 19.3 months). No patient experienced recurrence after GTR, 1 patient undergoing subtotal experienced recurrence and underwent reoperation, 3 patients underwent postoperative Gamma Knife treatment, and 2 patients with refractory IPA were given temozolomide and metformin chemotherapy.

CONCLUSIONS

According to the invasiveness of IPA, choosing the appropriate endoscopic surgical approach is helpful in removing tumors and reducing complications.

Phosphorylation of kinase insert domain receptor by cyclin-dependent kinase 5 at serine 229 is associated with invasive behavior and poor prognosis in prolactin pituitary adenomas

Pituitary adenomas constitute 15-20% of intracranial neoplasms. Previously we reported that cyclin-dependent kinase 5 (CDK5) is upregulated in pituitary tumors associated with activating protein p35, and plays an essential role in pituitary adenomas progression. Here we explored the mechanisms of CDK5 signaling in prolactin pituitary adenomas. Our data indicate that p35 expression and CDK5 activity are both significantly increased in human invasive prolactin pituitary adenomas as compared to noninvasive forms of pituitary adenomas. Inhibition of CDK5 activity suppressed cell migration and invasive ability in GH3 rat pituitary cells. We identified that CDK5 phosphorylates serine 229 residue (Ser-229) of kinase insert domain receptor (KDR), also known as VEGFR-2, in prolactin pituitary adenomas. Phosphorylation of Ser-229 is required for proper KDR surface localization. Phosphorylated Ser-229 in KDR (pSer-229) levels are significantly higher in noninvasive and invasive prolactin pituitary adenomas compared to normal pituitary tissues. In addition, our data indicated that higher KDR pSer-229 correlates with worse prognosis in patients with prolactin pituitary adenomas. In summary, our results illustrated that CDK5-mediated KDR phosphorylation controls prolactin pituitary adenoma progression and KDR pSer-229 serves as a potential prognostic biomarker for both noninvasive and invasive pituitary adenomas.

The changing sella: internal carotid artery shift during transsphenoidal pituitary surgery

PURPOSE

Injuries to the internal carotid artery (ICA) are potentially lethal complications in transsphenoidal surgery (TSS) for pituitary lesions. The intercarotid distance (ICD) is thus a major parameter, determining the width of the surgical corridor in TSS. The purpose of the study is to investigate changes in ICD at different levels of the ICA during and after TSS using high definition intraoperative MRI (3T-iMRI).

METHODS

Pre-, intra- and 3 months postoperative MRI images of 85 TSS patients were reviewed. ICD was measured at the horizontal (ICDC4h) and vertical (ICDC4v) intracavernous C4 segment as well as at the C6 segment (ICDC6). Association between ICD change at different levels and time points were compared and potential factors predicting ICD reduction were analyzed.

RESULTS

ICD decreased intraoperatively at all three segments of ICA by -3% (median decreases: ICDC4h: -0.5 mm, ICDC4v: -0.7 mm ICDC6: -0.4 mm). At 3 months postoperative MRI, ICD reduced by a further -4%, -2% and -4% respectively (median decreases ICDC4h: -0.7, ICDC4v: -0.4 mm, ICDC6: -0.5 mm). Postoperative narrowing in ICD occurred independent of further resection after 3T-iMRI. ICD change correlated between different levels of the ICA indicating a uniform shift perioperatively. Preoperative ICD was significantly associated with the intraoperative reduction in ICDC4v and ICDC6.

CONCLUSIONS

We have demonstrated a uniform narrowing in ICD at different levels of the ICA during and after TSS adenoma resection. Surgeons should be aware of this change since it determines the width of the surgical corridor and can thus influence the ease of surgery.

Visual Outcomes after Endoscopic Pituitary Surgery in Patients Presenting with Preoperative Visual Deficits

Introduction  Pituitary adenomas represent 15% of primary brain tumors. Visual disturbance is a common clinical manifestation of these neoplasms due, among other factors, to local mass effect on the optic system. Objective  To evaluate changes of the visual fields in patients undergoing endoscopic endonasal approach (EEA) for pituitary adenomas and to find predictive factors for successful visual field outcome. Material and Methods  This is a cross-sectional study. A review was conducted of medical records of consecutive patients with tumors of the sellar region undergoing EEA between January 2008 and December 2012 at the Skull Base Unit of Guillermo Grant Benavente Hospital, University of Concepción, Concepción, Chile, and who had undergone pre- and postoperative visual field evaluation. Results  A total of 35 patients, with a mean age of 50.2 years, fulfilled the inclusion criteria. All patients had objective visual field disturbances before the surgery. Following surgery, 25 patients (71.4%) had favorable outcomes, whereas 8 (22.8%) had no change and 2 (5.8%) had an unfavorable outcome. Complete tumor removal was associated with a better visual outcome than those obtained after a subtotal removal. Discussion  The EEA for pituitary tumors is particularly effective for visual field disturbances, with reported improvement rates ranging from 50 to 90%. Our series show similar results, with a 71.4% improvement of visual field disturbances. Conclusion  This study adds further evidence to the current belief that EEA for pituitary adenomas is a safe and effective technique to improve visual field alterations. Complete removal of the tumor during surgery seems to be a predictive factor for a good visual outcome.

EGFL7 participates in regulating biological behavior of growth hormone–secreting pituitary adenomas via Notch2/DLL3 signaling pathway

Growth hormone–secreting pituitary adenoma accounts for about 20% of the third most common intracranial neoplasm—pituitary adenomas—which makes up 15% of all intracranial tumors. The growth hormone–secreting pituitary adenoma invasion is a key risk factor associated with the operation results and highly correlated with the clinical prognosis. The epidermal growth factor–like domain multiple 7 protein, a unique 29 kDa secreted angiogenic factor, can result in pathologic angiogenesis and enhance the tumor migration and invasion. In this study, for the first time we found that epidermal growth factor–like domain multiple 7 protein expression was markedly higher in invasive growth hormone–secreting pituitary adenoma than non-invasive growth hormone–secreting pituitary adenoma. The tumor volume, histologic subtypes, invasiveness and recurrence of growth hormone–secreting pituitary adenoma were significantly associated with epidermal growth factor–like domain multiple 7 protein expression. Furthermore, we discovered that the histological classification methods of growth hormone–secreting pituitary adenoma according to electron microscopic examination and biological marker classification methods according to epidermal growth factor–like domain multiple 7 protein expression are more valuable in clinical application than the traditional classification methods based on Knosp and Hardy-Wilson grades. In summary, our results indicated epidermal growth factor–like domain multiple 7 protein participates in growth hormone–secreting pituitary adenoma proliferation and invasion regulation via Notch2/DLL3 signaling pathway. These findings raised the possibility that epidermal growth factor–like domain multiple 7 protein might serve as a useful biomarker to assess growth hormone–secreting pituitary adenoma invasion and prognosis or a potential therapeutic target for growth hormone–secreting pituitary adenoma treatment.

Long non-coding RNA C5orf66-AS1 is downregulated in pituitary null cell adenomas and is associated with their invasiveness

Pituitary null cell adenoma is a challenging clinical condition, and its pathogenesis remains to be elucidated. We performed this study to determine the roles of C5orf66-AS1, NORAD, and TINCR in the pathogenesis and invasion of pituitary null cell adenomas. Expression of the three long non-coding RNAs in pituitary null cell adenoma tissues of 11 patients and normal pituitary tissues from four donors was examined by performing quantitative reverse transcription-polymerase chain reaction. We found that C5orf66-AS1 expression was lower in pituitary null cell adenoma tissues than in normal pituitary tissues. Moreover, C5orf66-AS1 expression level was significantly lower in invasive pituitary null cell adenomas than in non-invasive ones. After transfection of C5orf66-AS1 into pituitary adenoma cells, assessment of cell viability and invasion suggested that overexpressed C5orf66-AS1 inhibited cell viability and cell invasion. In silico algorithms predicted several cis- and trans-acting target genes of C5orf66-AS1, including PITX1 and SCGB3A1. In addition, expression of some of the predicted target genes was determined using microarray data of another cohort with pituitary null cell adenomas. It showed that some of these target genes were differentially expressed between pituitary null cell adenoma tissues and normal pituitary tissues as well as between invasive and non-invasive tumors. Co-expression analysis in RNA sequencing data showed that PAQR7 was the most correlated gene of C5orf66-AS1 and that several predicted trans-acting target genes, including SCGB3A1, were highly correlated with C5orf66-AS1. NORAD and TINCR expression was not statistically significant in the complete cohort; however, a negative correlation was observed between NORAD expression and maximum tumor diameter in some subgroups. These results indicate that C5orf66-AS1 suppresses the development and invasion of pituitary null cell adenomas. However, our results do not provide enough statistical evidence to support the roles of NORAD and TINCR in the development and invasion of pituitary null cell adenomas.

The changing faces of corticotroph cell adenomas: the role of prohormone convertase 1/3

The spectrum of corticotroph cell adenomas is very wide. Though rarely, silent corticotroph cell adenomas (SCA) may transform into corticotroph cell adenomas associated with Cushing's disease (CD). The aim of the study was to investigate the role of prohormone convertase 1/3 (PC1/3) in the transformation of SCA into CD. We reviewed the records of 1259 consecutive endoscopic endonasal procedures for pituitary adenomas from 1998 to 2013. Of these, 132 were CD and 44 were SCA. During the follow-up, three patients with SCA showed a clear transformation from SCA into CD and underwent surgery once again to remove the recurrent tumour. The PC1/3 expression was analysed by both immunohistochemistry and quantitative real time-polymerase chain reaction (qRT-PCR) in primary and recurrent tumours. The immunohistochemical PC1/3 expression was negative or weak in the three patients in the initial phase of SCA, while a strong expression was observed in the majority of neoplastic cells in tissue specimens obtained from the same three patients at the time of recurrence as CD. The immunohistochemical PC1/3 expression showed a strict correlation with the PC1/3 levels obtained by qRT-PCR. In 14 cases of SCA with no change of phenotype during the follow-up, the immunohistochemical PC1/3 expression was low and strictly associated with the level of PC1/3 obtained by qRT-PCR both in primary (14/14 cases) and in recurrent tumours (4/4 cases). Our study provides insight into the crucial role of the PC1/3 protein in the transformation of phenotype from SCA to CD.

Microscopic surgery for pituitary adenomas to preserve the pituitary gland and stalk

Surgery is the primary treatment of choice for all symptomatic pituitary adenomas except prolactinomas. Common postoperative complications include endocrinopathies, vision impairment and cerebrospinal fluid leak. The present study assessed 153 continuous microscopic surgeries for pituitary adenomas performed by an author of the present study between 2010 to 2014. Patients underwent either transphenoidal or transcranial surgery depending on their individual tumor characteristics. Five typical cases are presented in the present study and intraoperative identification and preservation of the gland and stalk were discussed. Postoperative complications were analyzed and compared with the literature. In the present analysis, 90.2% patients received transphenoidal surgery, and the rest underwent transcranial operation. Gross total resection was achieved in 81.2% patients in the transphenoidal group and 46.7% patients in the transcranial group. No new hypopituitarism or worsening of the pre-existing pituitary dysfunctions was detected. The most common postoperative endocrinopathy was diabetes insipidus (transphenoidal group, 4.3%; transcranial group, 26.7%). All patients were fully recovered prior to discharge. The findings indicated the importance of pituitary gland and stalk preservation during the microscopic surgery to minimize postoperative morbidity and mortality, without compromising the extent of tumor resection. Based on preoperative imaging characteristics and intraoperative observations, surgeons should try all possible means to preserve the pituitary stalk and gland during surgery in order to minimize postoperative endocrinopathies and improve quality of life.

Increased β‑catenin and c-myc expression predict aggressive growth of non-functioning pituitary adenomas: An assessment using a tissue microarray-based approach

Non-functional pituitary adenomas (NFPAs) account for 80% of pituitary adenomas with the majority of these exhibiting recurrences post-surgery. Overexpression of β-catenin and c‑myc is common in numerous invasive tumors. The present study sought to investigate the correlation of β‑catenin and c‑myc expression levels with aggressive growth and recurrence of NFPAs, using immunohistochemical examination of tissue microarrays. Tissue microarrays comprised 212 NFPAs specimens and 10 healthy specimens as controls. NFPAs were categorized as non‑aggressive or aggressive. Immunohistochemical examination was performed to determine the expression of β‑catenin and c‑myc. Correlation of the expression levels of β‑catenin and c‑myc with clinicopathological parameters, including aggressiveness and recurrence, were assessed by univariate, multivariate and logistic regression analysis. Increased expression of β‑catenin and c‑myc was detected in the majority of aggressive NFPAs specimens (71.1 and 88.7%, respectively). There was a significant positive correlation between β‑catenin and c‑myc expression and aggressiveness [P=0.001, Odds Ratio (OR)=4.011; P<0.001, OR=30.833]. Only β‑catenin expression demonstrated a significant correlation with recurrence in NFPAs (P=0.021, OR=2.571). β‑catenin and c‑myc were demonstrated to be potential biomarkers for aggressive NFPAs and in the future, β-catenin may serve as a marker for aggressive behavior and recurrence in NFPAs.

Gd-Dtpa-Enhanced Mr Imaging of Pituitary Macroadenomas

In a study comprising 40 patients with pituitary macroadenomas, MR imaging was performed before and after administration of Gd-DTPA. Before contrast administration T1- and T2-weighted images were obtained, and after the injection, frontal and/or sagittal T1-weighted images. Tumour extension and delineation, relationship to adjacent structures, and signal intensity patterns were evaluated. Compared with pre-contrast T1-weighted images only, post-contrast images provided considerable additional information, but not infrequently this information could also be extracted from pre-contrast T2-weighted images. Post-contrast images were superior regarding the tumour relationship to the cavernous sinus and to the normal pituitary tissue. T2-weighted images were helpful in the diagnosis of degenerative changes, in particular intratumoural haemorrhage. A positive correlation was found between the T2 value (from dual echo sequences) and the degree of enhancement in areas with an appearance of solid tumour tissue, and the enhancement was significantly lower in GH-secreting tumours than in non-secreting ones. It is concluded that the use of Gd-DTPA is often justified in pituitary macroadenomas, particularly in pre-operative evaluation.

Comparison of MR Imaging and CT in Pituitary Macroadenomas

The findings on mid-field MR imaging and CT were compared retrospectively in 65 patients with pituitary macroadenomas. The evaluation comprised tumour extension and delineation, invasiveness, relationship to adjacent structures, and internal tumoral changes. MR was superior to CT except in the demonstration of bone changes and tumour calcification. The superiority of MR was most pronounced regarding cavernous sinus invasion, tumour relationship to the carotid arteries and optic chiasm, and tumour haemorrhage. Extensive bone changes were visualized with both methods; erosions were often seen only with CT. It is concluded that MR is the preferable method for evaluation of pituitary macroadenomas. CT is useful as a supplementary modality when detailed information on bone anatomy is required, particularly if a transsphenoidal surgical approach is contemplated.

Ectopic Suprasellar Thyrotropin-Secreting Pituitary Adenoma: Case Report and Literature Review

BACKGROUND

Ectopic thyroid-stimulating hormone (TSH)-secreting pituitary adenomas are rare and can often be misdiagnosed as primary hyperthyroidism. We present a case of an ectopic suprasellar TSH-secreting pituitary adenoma. A literature review of previously reported ectopic TSH-secreting and suprasellar pituitary adenomas is included to illustrate the clinical characteristics of this disease entity and the diversity of operative approaches to treating ectopic suprasellar pituitary adenomas.

CASE DESCRIPTION

A 46-year-old man presented with typical clinical signs of hyperthyroidism and a history of progressive visual field impairment and vision loss. Laboratory investigations revealed that the patient had elevated levels of free thyroxine and free triiodothyronine and a normal level of TSH. Neuro-ophthalmologic examination showed right eye/left eye = 1.0/0.6 and left temporal hemianopia. Magnetic resonance imaging revealed a mass located in the suprasellar space. The patient underwent preoperative short-term octreotide treatment followed by gross total resection of the tumor via the extended endoscopic endonasal transtuberculum sellar approach. At 6-month follow-up evaluation, the patient's endocrinologic function tests met the criteria for cure, and magnetic resonance imaging revealed a normal pituitary gland and stalk with no tumor recurrence. Histologic diagnosis confirmed the presence of a TSH-secreting pituitary adenoma.

CONCLUSIONS

To the best of our knowledge, this is the first reported case of an ectopic suprasellar TSH-secreting pituitary adenoma. Preoperative preparation and complete resection are the keys to a cure. The extended endoscopic endonasal transtuberculum sellar approach is an alternative minimally invasive method for the removal of an ectopic suprasellar pituitary adenoma.

Pituitary surgery and volumetric assessment of extent of resection: a paradigm shift in the use of intraoperative magnetic resonance imaging

OBJECTIVE

The aim of this study was to quantitatively assess the role of intraoperative high-field 3-T MRI (3T-iMRI) in improving the gross-total resection (GTR) rate and the extent of resection (EOR) in endoscopic transsphenoidal surgery (TSS) for pituitary adenomas.

METHODS

Radiological and clinical data from a prospective database were retrospectively analyzed. Volumetric measurements of adenoma volumes pre-, intraoperatively, and 3 months postoperatively were performed in a consecutive series of patients who had undergone endoscopic TSS. The quantitative contribution of 3T-iMRI was measured as a percentage of the additional rate of GTR and of the EOR achieved after 3T-iMRI.

RESULTS

The cohort consisted of 50 patients (51 operations) harboring 33 nonfunctioning and 18 functioning pituitary adenomas. Mean adenoma diameter and volume were 21.1 mm (range 5–47 mm) and 5.23 cm3 (range 0.09–22.14 cm3), respectively. According to Knosp's classification, 10 cases were Grade 0; 8, Grade 1; 17, Grade 2; 12, Grade 3; and 4, Grade 4. Gross-total resection was the surgical goal (targeted [t]GTR) in 34 of 51 operations and was initially achieved in 16 (47%) of 34 at 3T-iMRI and in 30 (88%) of 34 cases after further resection. In this subgroup, the EOR increased from 91% at 3T-iMRI to 99% at the 3-month MRI (p < 0.05). In the 17 cases in which subtotal resection (STR) had been planned (tSTR), the EOR increased from 79% to 86% (p < 0.05) and GTR could be achieved in 1 case. Intrasellar remnants were present in 20 of 51 procedures at 3T-iMRI and in only 5 (10%) of 51 procedures after further resection (median volume 0.15 cm3). Overall, the use of 3T-iMRI led to further resection in 27 (53%) of 51 procedures and permitted GTR in 15 (56%) of these 27 procedures; thus, the GTR rate in the entire cohort increased from 31% (16 of 51) to 61% (31 of 51) and the EOR increased from 87% to 95% (p < 0.05).

CONCLUSIONS

The use of high-definition 3T-iMRI allowed precise visualization and quantification of adenoma remnant volume. It helped to increase GTR and EOR rates in both tGTR and tSTR patient groups. Moreover, it helped to achieve low rates of intrasellar remnants. These data support the use of 3T-iMRI to achieve maximal, safe adenoma resection.