1
|
Zhang G, Wang P, Wang J, Zou D, Yao H, Liu J, Tang C, Jiang H, Tan X, Wu N. Endoscopic endonasal surgery for non-invasive pituitary neuroendocrinology tumors with incomplete pseudocapsule. Front Neurol 2023; 14:1109388. [PMID: 37051052 PMCID: PMC10083277 DOI: 10.3389/fneur.2023.1109388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 03/02/2023] [Indexed: 03/28/2023] Open
Abstract
BackgroundPituitary neuroendocrinology tumors (PitNETs) with pseudocapsule can be effectively removed by the pseudocapsule-based extracapsular resection technique. In the areas without pseudocapsule, the tumor cells can spread into the adjacent tissues at the cellular level, which brings a great challenge to achieving total tumor resection.MethodsOur surgical strategy for PitNETs with an incomplete pseudocapsule is to combine the pseudocapsule-based extracapsular resection technique with the intensive excision technique for the removal of the tumor. Specifically, the pseudocapsule-based extracapsular resection technique is applied in the areas with pseudocapsule, while in the areas without pseudocapsule, the intensive excision technique bounded by adjacent normal structures is adopted. Moreover, a pathological examination was performed to determine the situations of pseudocapsule and tumor cell remnant.ResultsAll growth hormone-secreting PitNETs achieved biochemical remission after surgery. There was no deterioration of pituitary functions postoperatively, and the preoperative hypopituitarism had improved in all patients postoperatively. In total, two cases suffered a transient diabetes insipidus, and intraoperative cerebrospinal fluid leakage was observed in two cases but no postoperative cerebrospinal fluid leakage in all cases. There was no recurrence during the follow-up. The fragmental pseudocapsule and small tumor remnants were found in the majority of suspicious tissues by histological staining.ConclusionThe effectiveness and safety of the surgical strategy were preliminarily explored for removing PitNETs without incomplete pseudocapsules. In overview, the pseudocapsule-based extracapsular resection technique is applied in areas with pseudocapsule, while the intensive excision bounded by adjacent normal structures is adopted in other areas.
Collapse
Affiliation(s)
- Gang Zhang
- Department of Neurosurgery, Chongqing General Hospital, Chongqing, China
- Chongqing Medical University, Chongqing, China
| | - Pan Wang
- Department of Neurosurgery, Chongqing General Hospital, Chongqing, China
- Chongqing Medical University, Chongqing, China
| | - Junwei Wang
- Department of Neurosurgery, Chongqing General Hospital, Chongqing, China
| | - Dewei Zou
- Department of Neurosurgery, Chongqing General Hospital, Chongqing, China
| | - Hui Yao
- Department of Pathology, Chongqing General Hospital, Chongqing, China
| | - Jie Liu
- Department of Neurosurgery, Chongqing General Hospital, Chongqing, China
- Chongqing Medical University, Chongqing, China
| | - Chao Tang
- Department of Neurosurgery, Chongqing General Hospital, Chongqing, China
- Chongqing Medical University, Chongqing, China
| | - Haotian Jiang
- Department of Neurosurgery, Chongqing General Hospital, Chongqing, China
- Chongqing Medical University, Chongqing, China
| | - Xiaorong Tan
- Department of Neurosurgery, Chongqing General Hospital, Chongqing, China
- Chongqing Medical University, Chongqing, China
| | - Nan Wu
- Department of Neurosurgery, Chongqing General Hospital, Chongqing, China
- *Correspondence: Nan Wu,
| |
Collapse
|
2
|
Extra-Pseudocapsular Transsphenoidal Surgery for Microprolactinoma in Women. J Clin Med 2022; 11:jcm11133920. [PMID: 35807204 PMCID: PMC9267792 DOI: 10.3390/jcm11133920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 06/20/2022] [Accepted: 06/30/2022] [Indexed: 11/25/2022] Open
Abstract
A recall for histological pseudocapsule (PS) and reappraisal of transsphenoidal surgery (TSS) as a viable alternative to dopamine agonists in the treatment algorithm of prolactinomas are getting vibrant. We hope to investigate the effectiveness and risks of extra-pseudocapsular transsphenoidal surgery (EPTSS) for young women with microprolactinoma, and to look into the factors that influenced remission and recurrence, and thus to figure out the possible indication shift for primary TSS. We proposed a new classification method of microprolactinoma based on the relationship between tumor and pituitary position, which can be divided into hypo-pituitary, para-pituitary and supra-pituitary groups. We retrospectively analyzed 133 patients of women (<50 yr) with microprolactinoma (≤10 mm) who underwent EPTSS in a tertiary center. PS were identified in 113 (84.96%) microadenomas intraoperatively. The long-term surgical cure rate was 88.2%, and the comprehensive remission rate was 95.8% in total. There was no severe or permanent complication, and the surgical morbidity rate was 4.5%. The recurrence rate with over 5 years of follow-up was 9.2%, and a lot lower for the tumors in the complete PS group (0) and hypo-pituitary group (2.1%). Use of the extra-pseudocapsule dissection in microprolactinoma resulted in a good chance of increasing the surgical remission without increasing the risk of CSF leakage or endocrine deficits. First-line EPTSS may offer a greater opportunity of long-term cure for young female patients with microprolactinoma of hypo-pituitary located and Knosp grade 0-II.
Collapse
|
3
|
Oldfield EH. Cushing's Disease: Lessons Learned From 1500 Cases. Neurosurgery 2017; 64:27-36. [PMID: 28899067 DOI: 10.1093/neuros/nyx378] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 07/31/2017] [Indexed: 11/12/2022] Open
Affiliation(s)
- Edward H Oldfield
- Department of Neurological Surgery, University of Virginia Health Science Center, Charlottesville, Virginia.,Depart-ment of Medicine, University of Virginia, Charlottesville, Virginia
| |
Collapse
|
4
|
Ajlan A, Achrol AS, Albakr A, Feroze AH, Westbroek EM, Hwang P, Harsh GR. Cavernous Sinus Involvement by Pituitary Adenomas: Clinical Implications and Outcomes of Endoscopic Endonasal Resection. J Neurol Surg B Skull Base 2017; 78:273-282. [PMID: 28603683 DOI: 10.1055/s-0036-1598022] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 11/30/2016] [Indexed: 10/20/2022] Open
Abstract
Background Parasellar invasion of pituitary adenomas (PAs) into the cavernous sinus (CS) is common. The management of the CS component of PA remains controversial. Objective The objective of this study was to analyze CS involvement in PA treated with endoscopic endonasal approaches, including incidence, surgical risks, surgical strategies, long-term outcomes, and our treatment algorithm. Methods We reviewed a series of 176 surgically treated PA with particular attention to CS involvement and whether the CS tumor was approached medial or lateral to the internal carotid artery. Results The median duration of follow-up was 36 months. Macroadenomas and nonfunctional adenomas represented 77 and 60% of cases, respectively. CS invasion was documented in 23% of cases. CS involvement was associated with a significantly diminished odds of gross total resection (47 vs. 86%, odds ratio [OR]: 5.2) and increased the need for subsequent intervention (4 vs. 40%, OR: 14.4). Hormonal remission was achieved in 15% of hormonally active tumors. Rates of surgical complication were similar regardless of CS involvement. Conclusion Our tailored strategy beginning with a medial approach and adding lateral exposure as needed resulted in good outcomes with low morbidity in nonfunctional adenomas. Functional adenomas involving the CS were associated with low rates of hormonal remission necessitating higher rates of additional treatment.
Collapse
Affiliation(s)
- Abdulrazag Ajlan
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, United States.,Department of Neurosurgery, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Achal S Achrol
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, United States
| | - Abdulrahman Albakr
- Department of Neurosurgery, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Abdullah H Feroze
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, United States
| | - Erick M Westbroek
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Peter Hwang
- Department of Otolaryngology, Stanford University School of Medicine, California, United States
| | - Griffith R Harsh
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, United States
| |
Collapse
|
5
|
Abstract
PURPOSE A pituitary pseudocapsule often contains tumor tissue and should be removed for radical resection. It can be used as a surgical plane for more radical resection of the tumor in many cases of pituitary adenomas. We evaluated the advantages and disadvantages of extracapsular en bloc capsulectomy. METHODS From 1992 until 2011, 1,089 treated patients were grouped according to the resection technique: en bloc capsulectomy, fragmented capsulectomy, or piecemeal resection. Their surgical and endocrinological outcomes and complications were evaluated. RESULTS Extracapsular tumor resection was performed in 263 patients; en bloc capsulectomy in 94 patients and fragmented capsulectomy in 169, whereas piecemeal resection was performed in 826. Extracapsular resection was performed more frequently in prolactin- and thyroid-stimulating hormone-secreting tumors. Total resection was more frequently achieved in extracapsular resection and its chance was 100% when tumors were removed in an en bloc fashion. For the functioning pituitary adenomas, endocrinological remission was achieved in all patients whose tumors were removed in an en bloc fashion and there was no recurrence. Postoperative cerebrospinal fluid (CSF) rhinorrhea developed in 4.2 and 2.7% in the extracapsular resection group and the piecemeal resection groups, respectively. The chance of postoperative aggravation of pituitary function was not statistically different between groups. CONCLUSIONS Extracapsular resection is critical for radical tumor resection and endocrinological remission. The removal of a pseudocapsule does not increase the risk of postoperative hypopituitarism nor postoperative CSF rhinorrhea.
Collapse
Affiliation(s)
- Eui Hyun Kim
- Neurosurgery, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, Republic of Korea
| | | | | | | |
Collapse
|
6
|
Lee JYK, Bohman LE, Bergsneider M. Contemporary neurosurgical techniques for pituitary tumor resection. J Neurooncol 2013; 117:437-44. [PMID: 24264534 DOI: 10.1007/s11060-013-1315-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Accepted: 11/10/2013] [Indexed: 12/13/2022]
Abstract
Approximately 5,000 trans-sphenoidal surgeries are performed for resection of pituitary tumors each year in the United States. The rise in popularity of the trans-spehnoidal approach, though described nearly a century ago, has been facilitated over the last decades by advances in technique and technology. In this review, we discuss the relative strengths of microscopic and endoscopic techniques for pituitary tumor resection. However, despite being the standard of care for patients with most pituitary tumors, cure rates for many subtypes of pituitary lesions, such as secretory macroadenomas or tumors with significant cavernous sinus invasion, remain unsatisfactory. We also describe two more recent advances in neurosurgical technique which may offer promise of increased rates of surgical cure: pseudocapsular resection and cavernous sinus approaches.
Collapse
Affiliation(s)
- John Y K Lee
- Department of Neurosurgery, University of Pennsylvania, Washington Square West Building, 235 S. 8th Street, Philadelphia, PA, 19106, USA,
| | | | | |
Collapse
|
7
|
Sol YL, Lee SK, Choi HS, Lee YH, Kim J, Kim SH. Evaluation of MRI Criteria for Cavernous Sinus Invasion in Pituitary Macroadenoma. J Neuroimaging 2012; 24:498-503. [DOI: 10.1111/j.1552-6569.2012.00710.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Yu Li Sol
- Department of Radiology; Pusan National University Hospital; Pusan National University School of Medicine; Busan Republic of Korea
| | - Seung-Koo Lee
- Department of Radiology; Yonsei University College of Medicine, Severance Hospital; Seoul Republic of Korea
| | - Hyun Seok Choi
- Department of Radiology; Seoul St. Mary's Hospital; The Catholic University of Korea College of Medicine; Seoul Republic of Korea
| | - Yun Hee Lee
- Department of Radiology; Yonsei University College of Medicine, Severance Hospital; Seoul Republic of Korea
| | - Jinna Kim
- Department of Radiology; Yonsei University College of Medicine, Severance Hospital; Seoul Republic of Korea
| | - Sun-Ho Kim
- Department of Radiology Neurosurgery; Yonsei University College of Medicine, Severance Hospital; Seoul Republic of Korea
| |
Collapse
|
8
|
Ciric I, Zhao JC, Du H, Findling JW, Molitch ME, Weiss RE, Refetoff S, Kerr WD, Meyer J. Transsphenoidal surgery for Cushing disease: experience with 136 patients. Neurosurgery 2012; 70:70-80; discussion 80-1. [PMID: 21772221 PMCID: PMC4051420 DOI: 10.1227/neu.0b013e31822dda2c] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND This is a retrospective study of 136 patients with Cushing disease treated with transsphenoidal microsurgery. OBJECTIVE To evaluate factors influencing immediate postoperative results and long-term outcomes. METHODS Data regarding clinical presentation, endocrine evaluation, imaging studies, surgical technique, immediate postoperative biochemical remission (IPBR), and long-term results were entered into a database and analyzed statistically. IPBR was based on biochemical evidence of adrenal cortical insufficiency and clinical evidence of such insufficiency. RESULTS IPBR for the entire series was 83.4%. In microadenomas, IPBR was 89.8% with a mean immediate postoperative plasma cortisol (IPPC) of 2.1 μg/dL (range, <0.5-5.3). Positive magnetic resonance imaging (MRI) was associated with 18 times greater odds of finding microadenoma at surgery (P < .001) and with 4.1 times greater odds of IPBR (P = .07). In patients with a negative MRI, a positive inferior petrosal sinus sampling (IPSS) test was associated with 93% of IPBR (P = .004). IPBR in macroadenomas was 30.7%. Of patients followed for 12 months or longer, 34.8% required glucocorticoid replacement for the duration of follow-up. The mean follow-up in microadenomas was 68.4 months with a 9.67% incidence of recurrences. The estimated actuarial incidence of recurrences increased with the passage of time and IPPC of greater than 2 μg/dL was associated with higher incidence of recurrences, although without statistical significance (P = .08). CONCLUSION In microadenomas, a positive MRI and positive IPSS test were associated with a higher incidence of IPBR. Recurrences increased with the passage of time, and an IPPC of greater than 2 μg/dL may be associated with higher incidence of recurrences.
Collapse
Affiliation(s)
- Ivan Ciric
- NorthShore University HealthSystem, University of Chicago, Pritzker School of Medicine, Evanston, Illinois 60201, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
9
|
Mayberg MR. Invasion of the corticotrophs. J Neurosurg 2011; 116:269-71; discussion 270-1. [PMID: 21923245 DOI: 10.3171/2011.7.jns11976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
|
10
|
The pseudocapsule surrounding a pituitary adenoma and its clinical significance. J Neurooncol 2010; 101:171-8. [PMID: 20526794 DOI: 10.1007/s11060-010-0247-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2009] [Accepted: 05/18/2010] [Indexed: 10/19/2022]
Abstract
The transsphenoidal approach is currently considered the preferred first-line treatment for pituitary adenoma. With the discovery and application of the pseudocapsule surrounding a pituitary adenoma, transsphenoidal surgery of pituitary adenoma further falls into two categories: "extracapsular" and traditional "intracapsular" resection methods, on the basis of where dissection is performed with respect to the pseudocapsule. Thus, the pseudocapsule can be used as a plane to guide the operation, helps in total resection of pituitary adenoma, and can guide subsequent treatment after surgery.
Collapse
|
11
|
Nuances and technique of the pretemporal transcavernous approach to treat low-lying basilar artery aneurysms. Neurosurg Rev 2009; 33:129-35; discussion 135. [DOI: 10.1007/s10143-009-0231-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2008] [Revised: 05/07/2009] [Accepted: 07/22/2009] [Indexed: 11/26/2022]
|
12
|
Figueiredo EG, Tavares WM, Rhoton AL, De Oliveira E. Surgical nuances of giant paraclinoid aneurysms. Neurosurg Rev 2009; 33:27-36. [PMID: 19760439 DOI: 10.1007/s10143-009-0224-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2008] [Revised: 05/20/2009] [Accepted: 07/05/2009] [Indexed: 12/14/2022]
|
13
|
Dogan S, Safavi-Abbasi S, Theodore N, Chang SW, Horn EM, Mariwalla NR, Rekate HL, Sonntag VKH. Thoracolumbar and sacral spinal injuries in children and adolescents: a review of 89 cases. J Neurosurg 2007; 106:426-33. [PMID: 17566397 DOI: 10.3171/ped.2007.106.6.426] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The authors evaluated the mechanisms and patterns of thoracic, lumbar, and sacral spinal injuries in a pediatric population as well as factors affecting the management and outcome of these injuries. METHODS The records of 89 patients (46 boys and 43 girls; mean age 13.2 years, range 3-16 years) with thoracic, lumbar, or sacral injuries were reviewed. Motor vehicle accidents were the most common cause of injury. Eighty-two patients (92.1%) were between 10 and 16 years old, and seven (7.9%) were between 3 and 9 years old. Patient injuries included fracture (91%), fracture and dislocation (6.7%), dislocation (1.1%), and ligamentous injury (1.1%). The L2-5 region was the most common injury site (29.8%) and the sacrum the least common injury site (5%). At the time of presentation 85.4% of the patients were neurologically intact, 4.5% had incomplete injuries, and 10.1% had complete injuries. Twenty-six percent of patients underwent surgery for their injuries whereas 76% received nonsurgical treatment. In patients treated surgically, an anterior approach was used in six patients (6.7%), a posterior approach in 16 (18%), and a combined approach in one (1.1%). Postoperatively, six patients (26.1%) with neurological deficits improved, one of whom recovered fully from an initially complete injury. CONCLUSIONS Thoracic and lumbar spine injuries were most common in children older than 9 years. Multilevel injuries were common and warranted imaging evaluation of the entire spinal column. Most patients were treated conservatively. The prognosis for neurological recovery is related to the initial severity of the neurological injuries. Some pediatric patients with devastating spinal cord injuries can recover substantial neurological function.
Collapse
Affiliation(s)
- Seref Dogan
- Department of Neurosurgery, Uludag University Faculty of Medicine, Bursa, Turkey
| | | | | | | | | | | | | | | |
Collapse
|