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Xiao L, Wu B, Ding H, He Y, Wu X, Xie S, Tang B, Hong T. Endoscopic Endonasal Internal Carotid Artery Transposition Technique in Tumor With Parasellar Extension: A Single-Center Experience. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01175. [PMID: 38781485 DOI: 10.1227/ons.0000000000001193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Accepted: 03/14/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Lateralization or mobilization of the internal carotid artery (ICA) during a midline approach is required to expose lesions behind or lateral to the ICA. However, there have been no published data regarding the surgical outcomes of the endoscopic endonasal internal carotid transposition technique (EEITT). This study aimed to analyze the relevant surgical anatomy around the ICA and propose a grading scheme of EEITT. METHODS A retrospective review of patients who underwent EEITT at a single institution was performed. Based on structures that limited the ICA and intraoperative findings, an anatomically surgical grading scheme of EEITT was proposed. RESULTS Forty-two patients (mean age 45.6 years, 57.1% female patients) were included. Of them, 29 cases (69.0%) were Knosp grade 4 pituitary adenoma, 6 cases (14.3%) were chordoma, 6 cases (14.3%) were meningioma, and a single case (2.4%) was meningeal IgG4-related disease. The EEITT was categorized into Grades 1, 2 and 3, which was used in 24 (57.1%), 12 (28.6%), and 6 (14.3%) cases, respectively. The most common symptom was visual disturbance (45.2%). The gross total resection rate in Grade 1 (79.2%) and Grade 2 (83.3%) was much higher than that in Grade 3 (66.6%). The overall rate of visual function improvement, preoperative cranial nerve (CN) palsy improvement, and postoperative hormonal remission was 89.4%, 85.7%, and 88.9%, respectively. The rate for the following morbidities was cerebrospinal fluid leakage, 2.4%; permanent diabetes insipidus, 4.8%; new transient CN palsy, 9.5%; permanent CN palsy, 4.7%; panhypopituitarism, 7.1%; and ICA injury, 2.4%. CONCLUSION The EEITT is technically feasible and could be graded according to the extent of disconnection of limiting structures. For complex tumor with parasellar extensions, the distinction into Grades 1, 2, and 3 will be of benefit to clinicians in predicting risks, avoiding complications, and generating tailored individualized surgical strategies.
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Affiliation(s)
- Limin Xiao
- Department of Neurosurgery, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China
- Department of Neurosurgery, Stanford Hospital, Stanford, California, USA
| | - Bowen Wu
- Department of Neurosurgery, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China
| | - Han Ding
- Department of Neurosurgery, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China
| | - Yulin He
- Department of Radiology, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China
| | - Xiao Wu
- Department of Neurosurgery, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China
| | - Shenhao Xie
- Department of Neurosurgery, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China
| | - Bin Tang
- Department of Neurosurgery, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China
| | - Tao Hong
- Department of Neurosurgery, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China
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Deng S, Morisako H, Beniwal M, Sasaki T, Ikegami M, Ikeda S, Teranishi Y, Goto T. Usefulness of Opening the Diaphragma Sellae Before Transecting Interclinoidal Ligament for Endoscopic Endonasal Transoculomotor Triangle Approach: Technical Nuances and Surgical Outcomes. World Neurosurg 2024; 185:e731-e740. [PMID: 38428812 DOI: 10.1016/j.wneu.2024.02.120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 02/20/2024] [Accepted: 02/21/2024] [Indexed: 03/03/2024]
Abstract
OBJECTIVE Opening the oculomotor triangle (OT) and removing the posterior fossa lesion by endoscopic endonasal approach (EEA) is challenging for even an experienced endoscopic neurosurgeon. We summarize the treatment experience and technical nuances with EEA for resection of pituitary neuroendocrine tumors and cavernous sinus (CS) meningiomas invading through the OT. METHODS Between 2018 and 2022, 8 patients, comprising 5 with pituitary neuroendocrine tumors (3 with nonfunctioning and 2 with somatotroph tumors with increased levels of growth hormone) and 3 CS meningiomas, were treated using an endoscopic endonasal transoculomotor triangle approach. The critical surgical technique is continuously opening the diaphragma sellae from medial to lateral toward the interclinoidal ligament and transecting it to enlarge the OT. We evaluated preoperative tumor size, previous surgical history, preoperative symptoms, extent of tumor resection, histopathology, and postoperative complications for all patients. RESULTS The gross total resection (defined as complete removal) in 3 patients (38%), near-total resection (defined as >95% removal) in 4 patients (50%), and subtotal resection (defined as ≤90% removal) in 1 patient (12%) and gross total resection of tumor invading through the OT was achieved in all patients through pure EEA. Two of 3 patients with visual deficits in nonfunctioning pituitary neuroendocrine tumors improved, and the other remained stable postoperatively. One patient showed transient oculomotor nerve palsy. The growth hormone level of the 2 patients with somatotroph tumors declined to normal. For 3 patients with CS meningiomas, cranial nerve palsy improved in 2 patients, whereas the other patient developed increased facial numbness after surgery. CONCLUSIONS The endoscopic endonasal transoculomotor triangle approach is an efficient surgical option for tumors with CS invasion and OT penetration.
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Affiliation(s)
- Shengze Deng
- Department of Neurosurgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan; Department of Neurosurgery, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China
| | - Hiroki Morisako
- Department of Neurosurgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan.
| | - Manish Beniwal
- Department of Neurosurgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan; Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, India
| | - Tsuyoshi Sasaki
- Department of Neurosurgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Masaki Ikegami
- Department of Neurosurgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Shohei Ikeda
- Department of Neurosurgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Yuichi Teranishi
- Department of Otolaryngology and Head and Neck Surgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Takeo Goto
- Department of Neurosurgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
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Fang Y, Wang H, Cao D, Cai S, Qian C, Feng M, Zhang W, Cao L, Chen H, Wei L, Mu S, Pei Z, Li J, Wang R, Wang S. Multi-center application of a convolutional neural network for preoperative detection of cavernous sinus invasion in pituitary adenomas. Neuroradiology 2024; 66:353-360. [PMID: 38236424 DOI: 10.1007/s00234-024-03287-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 01/07/2024] [Indexed: 01/19/2024]
Abstract
OBJECTIVE Cavernous sinus invasion (CSI) plays a pivotal role in determining management in pituitary adenomas. The study aimed to develop a Convolutional Neural Network (CNN) model to diagnose CSI in multiple centers. METHODS A total of 729 cases were retrospectively obtained in five medical centers with (n = 543) or without CSI (n = 186) from January 2011 to December 2021. The CNN model was trained using T1-enhanced MRI from two pituitary centers of excellence (n = 647). The other three municipal centers (n = 82) as the external testing set were imported to evaluate the model performance. The area-under-the-receiver-operating-characteristic-curve values (AUC-ROC) analyses were employed to evaluate predicted performance. Gradient-weighted class activation mapping (Grad-CAM) was used to determine models' regions of interest. RESULTS The CNN model achieved high diagnostic accuracy (0.89) in identifying CSI in the external testing set, with an AUC-ROC value of 0.92 (95% CI, 0.88-0.97), better than CSI clinical predictor of diameter (AUC-ROC: 0.75), length (AUC-ROC: 0.80), and the three kinds of dichotomizations of the Knosp grading system (AUC-ROC: 0.70-0.82). In cases with Knosp grade 3A (n = 24, CSI rate, 0.35), the accuracy the model accounted for 0.78, with sensitivity and specificity values of 0.72 and 0.78, respectively. According to the Grad-CAM results, the views of the model were confirmed around the sellar region with CSI. CONCLUSIONS The deep learning model is capable of accurately identifying CSI and satisfactorily able to localize CSI in multicenters.
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Affiliation(s)
- Yi Fang
- Department of Neurosurgery, the Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuai Fu Yuan, Dongcheng District, Beijing, 100730, China
- Department of Neurosurgery, Fuzhou 900TH Hospital, Fuzong Clinical Medical College of Fujian Medical University, No. 156, Xi'erhuanbei Road, Fuzhou, Fujian, China
| | - He Wang
- Department of Neurosurgery, the Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuai Fu Yuan, Dongcheng District, Beijing, 100730, China
| | - Demao Cao
- Department of Neurosurgery, The Affiliated Hospital of Yangzhou University, Yangzhou University, Jiangsu, China
| | - Shengyu Cai
- Department of Neurosurgery, the Second Affiliated Hospital, Fujian Medical University, Quanzhou, China
| | - Chengxing Qian
- Department of Neurosurgery, the Tongling People's Hospital, Tongling, China
| | - Ming Feng
- Department of Neurosurgery, Fuzhou 900TH Hospital, Fuzong Clinical Medical College of Fujian Medical University, No. 156, Xi'erhuanbei Road, Fuzhou, Fujian, China
| | - Wentai Zhang
- Department of Neurosurgery, the Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuai Fu Yuan, Dongcheng District, Beijing, 100730, China
| | - Lei Cao
- Department of Neurosurgery, the Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hongjie Chen
- Department of Neurosurgery, Fuzhou 900TH Hospital, Fuzong Clinical Medical College of Fujian Medical University, No. 156, Xi'erhuanbei Road, Fuzhou, Fujian, China
| | - Liangfeng Wei
- Department of Neurosurgery, Fuzhou 900TH Hospital, Fuzong Clinical Medical College of Fujian Medical University, No. 156, Xi'erhuanbei Road, Fuzhou, Fujian, China
| | - Shuwen Mu
- Department of Neurosurgery, Fuzhou 900TH Hospital, Fuzong Clinical Medical College of Fujian Medical University, No. 156, Xi'erhuanbei Road, Fuzhou, Fujian, China
| | - Zhijie Pei
- Department of Neurosurgery, Fuzhou 900TH Hospital, Fuzong Clinical Medical College of Fujian Medical University, No. 156, Xi'erhuanbei Road, Fuzhou, Fujian, China
| | - Jun Li
- Department of Neurosurgery, Fuzhou 900TH Hospital, Fuzong Clinical Medical College of Fujian Medical University, No. 156, Xi'erhuanbei Road, Fuzhou, Fujian, China
| | - Renzhi Wang
- Department of Neurosurgery, the Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuai Fu Yuan, Dongcheng District, Beijing, 100730, China.
- Chinese University of Hong Kong (Shenzhen) School of Medicine, Shenzhen, Guangdong, People's Republic of China.
| | - Shousen Wang
- Department of Neurosurgery, Fuzhou 900TH Hospital, Fuzong Clinical Medical College of Fujian Medical University, No. 156, Xi'erhuanbei Road, Fuzhou, Fujian, China.
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Mosallami Aghili SM, Maroufi SF, Sabahi M, Esmaeilzadeh M, Dabecco R, Adada B, Borghei-Razavi H. Intraoperative Ultrasonography in Pituitary Surgery Revisited: An Institutional Experience and Systematic Review on Applications and Considerations. World Neurosurg 2023; 176:149-158. [PMID: 37164206 DOI: 10.1016/j.wneu.2023.04.126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 04/28/2023] [Accepted: 04/29/2023] [Indexed: 05/12/2023]
Abstract
OBJECTIVE The primary objective of this systematic review is to evaluate the effectiveness of intraoperative ultrasound (IOUS) in improving outcomes in patients undergoing pituitary surgery. METHODS A systematic review was performed by searching MEDLINE (PubMed), Web of Science, Scopus, and Embase electronic bibliographic databases from conception to 2022. RESULTS The included studies yielded a total of 660 patients, with 488 patients undergoing IOUS. Outcome were available for 341 patients treated with IOUS and 157 patients who were treated without the IOUS application, and the remission rates following surgery were 76% and 59%, respectively. Only 2 studies reported remission rates for both groups, and meta-analysis for these studies showed significant superiority of intraoperative ultrasonography (Random effect, odds ratio 4.99, P < 0.01). Regarding extent of resection, IOUS resulted in 71% gross total resection, while absence of IOUS yielded a gross total resection rate of 44%. Among studies with available follow-up on IOUS, the recurrence rate was 3%. Pituitary dysfunction (34%), cerebrospinal fluid leak (31%), and central nervous system infection (8%) were the most common complications in the IOUS group. The mean follow-up was 19.97 months in studies reporting follow-up time. CONCLUSIONS The application of the IOUS is both safe and effective and could improve the outcome of pituitary surgeries. IOUS can assist surgeons in the identification of pituitary tumors and their surrounding anatomy and can help minimize the risk of complications associated with this complex surgical procedure.
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Affiliation(s)
| | - Seyed Farzad Maroufi
- Neurosurgery Research Network (NRN), Universal Scientific Education and Research Network (USERN), Tehran, Iran; Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammadmahdi Sabahi
- Department of Neurological Surgery, Pauline Braathen Neurological Center, Cleveland Clinic Florida, Weston, Florida, USA
| | - Mahla Esmaeilzadeh
- Student Research Committee, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Rocco Dabecco
- Department of Neurological Surgery, Pauline Braathen Neurological Center, Cleveland Clinic Florida, Weston, Florida, USA
| | - Badih Adada
- Department of Neurological Surgery, Pauline Braathen Neurological Center, Cleveland Clinic Florida, Weston, Florida, USA
| | - Hamid Borghei-Razavi
- Department of Neurological Surgery, Pauline Braathen Neurological Center, Cleveland Clinic Florida, Weston, Florida, USA.
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Dumitriu-Stan RI, Burcea IF, Salmen T, Poiana C. Prognostic Models in Growth-Hormone- and Prolactin-Secreting Pituitary Neuroendocrine Tumors: A Systematic Review. Diagnostics (Basel) 2023; 13:2118. [PMID: 37371013 DOI: 10.3390/diagnostics13122118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 06/02/2023] [Accepted: 06/09/2023] [Indexed: 06/29/2023] Open
Abstract
Growth-hormone (GH)- and prolactin (PRL)-secreting PitNETs (pituitary neuroendocrine tumors) are divided into multiple histological subtypes, which determine their clinical and biological variable behavior. Proliferation markers alone have a questionable degree of prediction, so we try to identify validated prognostic models as accurately as possible. (1) Background: The data available so far show that the use of staging and clinical-pathological classification of PitNETs, along with imaging, are useful in predicting the evolution of these tumors. So far, there is no consensus for certain markers that could predict tumor evolution. The application of the WHO (World Health Organisation) classification in practice needs to be further evaluated and validated. (2) Methods: We performed the CRD42023401959 protocol in Prospero with a systematic literature search in PubMed and Web of Science databases and included original full-text articles (randomized control trials and clinical trials) from the last 10 years, published in English, and the search used the following keywords: (i) pituitary adenoma AND (prognosis OR outcome OR prediction), (ii) growth hormone pituitary adenoma AND (prognosis OR outcome OR prediction), (iii) prolactin pituitary adenoma AND (prognosis OR outcome OR prediction); (iv) mammosomatotroph adenoma AND (prognosis OR outcome OR prediction). (3) Results: Two researchers extracted the articles of interest and if any disagreements occurred in the selection process, these were settled by a third reviewer. The articles were then assessed using the ROBIS bias assessment and 75 articles were included. (4) Conclusions: the clinical-pathological classification along with factors such as GH, IGF-1, prolactin levels both preoperatively and postoperatively offer valuable information.
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Affiliation(s)
- Roxana-Ioana Dumitriu-Stan
- Department of Endocrinology, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Doctoral School of 'Carol Davila' University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Iulia-Florentina Burcea
- Department of Endocrinology, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania
- 'C. I. Parhon' National Institute of Endocrinology, 011863 Bucharest, Romania
| | - Teodor Salmen
- Doctoral School of 'Carol Davila' University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Catalina Poiana
- Department of Endocrinology, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania
- 'C. I. Parhon' National Institute of Endocrinology, 011863 Bucharest, Romania
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Pease M, Cohen MA, Tabar V. Advances in surgical approaches for refractory pituitary adenomas. Pituitary 2023; 26:293-297. [PMID: 37115293 PMCID: PMC11345687 DOI: 10.1007/s11102-023-01318-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/10/2023] [Indexed: 04/29/2023]
Abstract
Refractory pituitary adenomas are difficult to control tumors that progress through optimal surgical, medical, and radiation management. Repeat surgery is a valuable tool to reduce tumor volume for more effective radiation and/or medical therapy, and to decompress critical neurovascular structures. Advances in surgical techniques and technologies, including minimally invasive cranial approaches, intraoperative MRI suites, and cranial nerve monitoring, have improved surgical outcomes and expanded indications. Today, repeat transsphenoidal surgery has similar complications rates to upfront surgery in historical cohorts. The decision to operate on refractory adenomas should be made with multidisciplinary teams, balancing the benefit of tumor reduction with the potential for complications, including cranial nerve injury, carotid injury, and cerebrospinal fluid leak.
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Affiliation(s)
- Matthew Pease
- Department Neurological Surgery, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Marc A. Cohen
- Department of Head and Neck Cancer, Memorial Sloan Kettering Cancer Center, New York, USA
- Multidisciplinary Pituitary and Skull Base Tumor Center, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Viviane Tabar
- Department Neurological Surgery, Memorial Sloan Kettering Cancer Center, New York, USA
- Multidisciplinary Pituitary and Skull Base Tumor Center, Memorial Sloan Kettering Cancer Center, New York, USA
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DiRisio AC, Feng R, Shuman WH, Platt S, Price G, Dullea JT, Gilja S, D'Andrea MR, Delman BN, Bederson JB, Shrivastava RK. The Knosp Criteria Revisited: 3-Dimensional Volumetric Analysis as a Predictive Tool for Extent of Resection in Complex Endoscopic Pituitary Surgery. Neurosurgery 2023; 92:179-185. [PMID: 36170168 DOI: 10.1227/neu.0000000000002170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 07/29/2022] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND The Knosp criteria have been the historical standard for predicting cavernous sinus invasion, and therefore extent of surgical resection, of pituitary macroadenomas. Few studies have sought to reappraise the utility of this tool after recent advances in visualization and modeling of tumors in complex endoscopic surgery. OBJECTIVE To evaluate our proposed alternative method, using 3-dimensional (3D) volumetric imaging, and whether it can better predict extent of resection in nonfunctional pituitary adenomas. METHODS Patients who underwent endoscopic transsphenoidal resection of pituitary macroadenomas at our institution were reviewed. Information was collected on neurological, endocrine, and visual function. Volumetric segmentation was performed using 3D Slicer software. Relationship of tumor volume, clinical features, and Knosp grade on extent of resection was examined. RESULTS One hundred forty patients were identified who had transsphenoidal resection of nonfunctional pituitary adenomas. Macroadenomas had a median volume of 6 cm 3 (IQR 3.4-8.7), and 17% had a unilateral Knosp grade of at least 3B. On multiple logistic regression, only smaller log-transformed preoperative tumor volume was independently associated with increased odds of gross total resection (GTR; odds ratio: 0.27, 95% CI: 0.07-0.89, P < .05) when controlling for tumor proliferative status, age, and sex (area under the curve 0.67). The Knosp criteria did not independently predict GTR in this cohort ( P > .05, area under the curve 0.46). CONCLUSION Increasing use of volumetric 3D imaging may better anticipate extent of resection compared with the Knosp grade metric and may have a greater positive predictive value for GTR. More research is needed to validate these findings and implement them using automated methods.
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Affiliation(s)
- Aislyn C DiRisio
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Department of Neurosurgery, University of California - Los Angeles, Los Angeles, California, USA
| | - Rui Feng
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - William H Shuman
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Samantha Platt
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Department of Radiology, New York University, New York, New York, USA
| | - Gabrielle Price
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jonathan T Dullea
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Shivee Gilja
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Megan R D'Andrea
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Bradley N Delman
- Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Joshua B Bederson
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Raj K Shrivastava
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Xiao L, Ouyang T, Wu B, Xie S, Tang B, He Y, Ding H, Wu X, Hong T. Subclassification of Knosp Grade 4 Pituitary Adenoma: Bringing Insights Into the Significance of Tumor Growth Pathways. Neurosurgery 2023; 92:213-222. [PMID: 36519865 DOI: 10.1227/neu.0000000000002197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 08/15/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Understanding the growth pathway of Knosp grade 4 pituitary adenoma (KG4PA) has a direct impact on surgical planning and safety for tumor eviction. OBJECTIVE To analyze the different characteristics between KG4PAs with a focus on the tumor growth pathway and its relationship to the cavernous segment of internal carotid artery. METHODS Clinical data from 129 patients with KG4PAs who underwent endoscopic endonasal surgery were retrospectively reviewed. A subclassification scheme was proposed based on the tumor growth pathway and its relevant features. The clinical connotation of the subclassification on surgical outcomes was also analyzed. RESULTS The KG4PAs were classified into 3 types based on the tumor growth pathway and its relevant features: groups A, B, and AB. The gross total resection rate in group A (51.2%) was much lower than that in group B (87.5%) and AB (87%) with a significant difference between the 3 groups ( P = .0004). The overall rate of visual function improvement, preoperative cranial nerve (CN) palsy improvement, and postoperative hormonal remission was 85.1%, 83.3%, and 85.7%, respectively. The rate of transient CN palsy, permanent CN palsy, permanent diabetes insipidus, panhypopituitarism, CSF leakage, and internal carotid artery injury was 7.8%, 3.9%, 4.7%, 2.3%, 1.5%, and 0.7%, respectively. CONCLUSION The subclassification strengthens our understanding of KG4PAs on tumor growth corridors and topographic relations of tumor and cavernous segment of internal carotid artery. Furthermore, the distinction into groups 4A, 4B, and 4AB is of benefits for selecting approaches, predicting risk and avoiding complications, and generating more tailored individualized surgical strategies for KG4PAs with better outcomes.
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Affiliation(s)
- Limin Xiao
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Taohui Ouyang
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Bowen Wu
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Shenhao Xie
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Bin Tang
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yulin He
- Department of Radiology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Han Ding
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Xiao Wu
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Tao Hong
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
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Mamelak A. Surgery as a first-line option for prolactinomas. Expert Rev Endocrinol Metab 2022; 17:485-498. [PMID: 36200144 DOI: 10.1080/17446651.2022.2131531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 09/28/2022] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Treatment of prolactinomas with dopamine agonists has been the established first-line treatment option for many years, with surgery reserved for refractory cases or medication intolerance. This approach may not be the best option in many cases. AREAS COVERED Review of the epidemiology, biology, and treatment options available for prolactinomas, including best available data on outcomes, costs, and morbidities for each therapy. These data are then used to propose a 'surgery-first' treatment approach for a subset of prolactinomas as an alternative to primary medical management. EXPERT OPINION Based on the available data, there is a strong rationale that transsphenoidal surgery should be considered a first-line treatment option for both micro- and macro-prolactinomas that do not demonstrate high grade cavernous sinus invasion on MRI imaging, with dopamine agonists administered as a secondary therapy for tumors not in remission following surgery, and for giant tumors. This 'surgery-first' approach assumes the availability of skilled and experienced pituitary surgeons to ensure optimal outcomes. This approach should result in high cure rates and reduced DA requirements for patients not cured from initial surgery. Further, it will reduce medical costs over a patient's lifetime and the chronic morbidities associated with protracted dopamine agonist usage.
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Affiliation(s)
- Adam Mamelak
- Surgical Director, Pituitary Center & Center for Minimally Invasive Skull Base Surgery, Cedars-Sinai Medical Center, Los Angeles
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10
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Lu L, Wan X, Xu Y, Chen J, Shu K, Lei T. Development and Validation of a Prognostic Model for Post-Operative Recurrence of Pituitary Adenomas. Front Oncol 2022; 12:882049. [PMID: 35574399 PMCID: PMC9096140 DOI: 10.3389/fonc.2022.882049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 04/05/2022] [Indexed: 11/13/2022] Open
Abstract
Background We aimed to assess clinical factors associated with tumor recurrence and build a nomogram based on identified risk factors to predict postoperative recurrence in patients with pituitary adenomas (PAs) who underwent gross-total resection (GTR). Methods A total of 829 patients with PAs who achieved GTR at Tongji Hospital between January 2013 and December 2018 were included in this retrospective study. The median follow-up time was 66.7 months (range: 15.6-106.3 months). Patients were randomly divided into training (n = 553) or validation (n = 276) cohorts. A range of clinical characteristics, radiological findings, and laboratory data were collected. Uni- and multivariate Cox regression analyses were applied to determine the potential risk factors for PA recurrence. A nomogram model was built from the identified factors to predict recurrence. Concordance index (C-index), calibration curve, and receiver operating characteristic (ROC) were used to determine the predictive accuracy of the nomogram. Decision curve analysis (DCA) was performed to evaluate the clinical efficacy of the nomogram. Results Pseudocapsule-based extracapsular resection (ER), cavernous sinus invasion (CSI), and tumor size were included in the nomogram. C-indices of the nomogram were 0.776 (95% confidence interval [CI]: 0.747-0.806) and 0.714 (95% CI: 0.681-0.747) for the training and validation cohorts, respectively. The area under the curve (AUC) of the nomogram was 0.770, 0.774, and 0.818 for 4-, 6-, 8-year progression-free survival (PFS) probabilities in the training cohort, respectively, and 0.739, 0.715 and 0.740 for 4-, 6-, 8-year PFS probabilities in the validation cohort, respectively. Calibration curves were well-fitted in both training and validation cohorts. DCA revealed that the nomogram model improved the prediction of PFS in both cohorts. Conclusions Pseudocapsule-based ER, CSI, and tumor size were identified as independent predictors of PA recurrence. In the present study, we developed a novel and valid nomogram with potential utility as a tool for predicting postoperative PA recurrence. The use of the nonogram model can facilitate the tailoring of counseling to meet the individual needs of patients.
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Affiliation(s)
| | | | | | | | | | - Ting Lei
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Liu X, Dai C, Bao X, Deng K, Yao Y, Feng M, Li M, Chen G, Wang R. The Clinical and Pathological Characteristics of Refractory Pituitary Adenomas: A Single Center Experience. Front Oncol 2022; 12:846614. [PMID: 35372086 PMCID: PMC8966407 DOI: 10.3389/fonc.2022.846614] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 02/17/2022] [Indexed: 11/29/2022] Open
Abstract
Background Most of pituitary adenomas (PAs) are slow-growing benign tumors which can be cured or controlled by conventional therapies, including surgery, medical treatment or radiotherapy. A small set of PAs, usually known as aggressive PAs or refractory PAs, present with more aggressive behavior and lead to poorer prognosis than classical PAs. Methods We retrospectively analyzed the clinical and pathological characteristics of 44 patients who were diagnosed with refractory PAs by a multidisciplinary team (MDT). All the patients’ demographic characteristics, radiological findings, Knosp grade, treatment details and clinical outcomes were abstracted from the medical records. Additionally, 44 patients with nonrefractory PAs (NRPAs) matched for age and gender were selected to serve as the control group. Results Despite using all combined treatments including surgery, radiotherapy and conventional medical treatments, all the refractory PAs showed tumor progression or hormone hypersecretion which caused increased morbidity and mortality and remained challenging to management. Compared with those of the non-refractory PAs, the tumor size, invasive rate and tumor growth rate (TGR) were significantly higher in the refractory PAs. TGR >2.2% per month may be considered as a preoperative indicator of refractoriness. The Ki-67 index in the refractory PAs were all ≥3%. EGFR, but not MMP2 or MMP9, was significantly overexpressed in refractory PAs compared with the corresponding levels in nonrefractory PAs. Conclusion Refractory PAs are unresponsive to surgery, radiotherapy and conventional medical treatments with a poor prognosis. Moreover, a TGR ≥2.2% per month, Ki-67 index ≥3% and EGFR overexpression may be independent predictors of clinical refractoriness.
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Affiliation(s)
- Xiaohai Liu
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China.,Chinese Pituitary Specialists Congress, Beijing, China
| | - Congxin Dai
- Chinese Pituitary Specialists Congress, Beijing, China.,Department of Neurosurgery, Tongren Hospital Capital Medical University, Beijing, China
| | - Xinjie Bao
- Chinese Pituitary Specialists Congress, Beijing, China.,Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Kan Deng
- Chinese Pituitary Specialists Congress, Beijing, China.,Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yong Yao
- Chinese Pituitary Specialists Congress, Beijing, China.,Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ming Feng
- Chinese Pituitary Specialists Congress, Beijing, China.,Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Mingchu Li
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China.,Chinese Pituitary Specialists Congress, Beijing, China
| | - Ge Chen
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China.,Chinese Pituitary Specialists Congress, Beijing, China
| | - Renzhi Wang
- Chinese Pituitary Specialists Congress, Beijing, China.,Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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12
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Complications in Endoscopic Pituitary Surgery. Otolaryngol Clin North Am 2022; 55:431-448. [DOI: 10.1016/j.otc.2021.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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13
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Araujo-Castro M, Acitores Cancela A, Vior C, Pascual-Corrales E, Rodríguez Berrocal V. 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. Front Oncol 2022; 11:807040. [PMID: 35127519 PMCID: PMC8810816 DOI: 10.3389/fonc.2021.807040] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 12/08/2021] [Indexed: 01/26/2023] Open
Abstract
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.
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Affiliation(s)
- Marta Araujo-Castro
- Neuroendocrinology Unit, Department of Endocrinology & Nutrition, Hospital Universitario Ramón y Cajal & Instituto de Investigación Biomédica Ramón y Cajal (IRYCIS), Madrid, Spain
- Department of Medicine, Universidad de Alcalá de Henares, Madrid, Spain
- *Correspondence: Marta Araujo-Castro, ; orcid.org/0000-0002-0519-0072
| | | | - Carlos Vior
- Department of Neurosurgery, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Eider Pascual-Corrales
- Neuroendocrinology Unit, Department of Endocrinology & Nutrition, Hospital Universitario Ramón y Cajal & Instituto de Investigación Biomédica Ramón y Cajal (IRYCIS), Madrid, Spain
| | - Víctor Rodríguez Berrocal
- Department of Neurosurgery, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Department of Neurosurgery, Hospital HM Puerta del Sur, Madrid, Spain
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Guan X, Wang Y, Zhang C, Ma S, Zhou W, Jia G, Jia W. Surgical Experience of Transcranial Approaches to Large-to-Giant Pituitary Adenomas in Knosp Grade 4. Front Endocrinol (Lausanne) 2022; 13:857314. [PMID: 35634502 PMCID: PMC9133328 DOI: 10.3389/fendo.2022.857314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 04/04/2022] [Indexed: 11/15/2022] Open
Abstract
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.
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Affiliation(s)
- Xiudong Guan
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yangyang Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chengkai Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | | | - Wenjianlong Zhou
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Guijun Jia
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Wang Jia
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Neurosurgical Institute, Beijing, China
- *Correspondence: Wang Jia,
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