Surgery and perioperative management of patients with Cushing's disease

Transsphenoidal surgery (TSS) is the initial treatment modality of first choice in Cushing's disease (CD). With microscopic TSS and endoscopic TSS, two operative techniques with equally favourable remission rates and operative morbidity are available. On average, remission is achieved with primary TSS in 80% of patients with microadenomas and 60% of patients with macroadenomas. The current literature indicates that remission rates in repeat TSS for microadenomas can also exceed 70%. Experience with TSS in CD plays an important role in the success rate and centralization in Pituitary Centres of Excellence has been proposed. Microadenoma stage, imaging-visible adenoma, confirmation of ACTH-positive adenoma on histopathology and noninvasiveness are positive predictors for postoperative remission. In postoperative management, a steroid-sparing protocol with early postoperative assessment of remission status is recommended. Convincing evidence suggests that prolonged postoperative prophylactic antithrombotic measures can significantly reduce the risk of postoperative thromboembolic events in CD. Prevention or successful treatment of cortisol withdrawal syndrome remains an unsolved issue that should be a focus of future research. The further development and broad availability of functional imaging hold promise for improved preoperative detection of microadenomas. Intraoperative identification of microadenomas by specific fluorescent targeting could be a promising future avenue for the treatment of patients with negative imaging.

Outcomes of Initial Management Strategies in Patients With Autoimmune Lymphocytic Hypophysitis: A Systematic Review and Meta-analysis

CONTEXT

Lymphocytic hypophysitis (LyHy) is characterized by inflammation of the pituitary and or neuroinfundibulum and is uncommon. Treatment options include observation, high-dose glucocorticoids (HD-GCs) or surgery. Optimal first-line management strategy, however, remains unknown.

OBJECTIVE

This work aimed to assess response to first-line treatment options (observation, HD-GCs, or surgery) of clinically relevant outcomes (symptomatic, hormonal, and radiographic improvement) among patients with LyHy.

METHODS

A systematic review was conducted in 6 databases through 2020. Meta-analysis was conducted when feasible using a random-effects model.

RESULTS

We included 33 studies reporting on 591 patients (423 women, 72%) with LyHy. Improvement/resolution of anterior pituitary dysfunction was highest when HD-GCs was first-line treatment. Surgery was associated with the greatest proportion of patients who had regression on imaging. Subgroup analysis comparing HD-GCs to observation showed the odds of anterior pituitary hormone recovery (OR 3.41; 95% CI, 1.68-6.94) or radiographic regression (OR 3.13; 95% CI, 1.54-6.36) were higher with HD-GCs, but so was the need for additional forms of treatment (OR 4.37; 95% CI, 1.70-11.22). No statistically significant difference was seen in recovery of diabetes insipidus (OR 0.9; 95% CI, 0.26-3.10). Certainty in these estimates was very low.

CONCLUSION

Observation and use of HD-GCs both are successful first-line management strategies in LyHy. Although use of HD-GCs was associated with increased recovery of anterior pituitary hormone deficit, it also was associated with greater likelihood of additional treatment after withdrawal. Optimal dosing and duration of HD-GCs remains unknown.

Corticotroph tumor progression after bilateral adrenalectomy (Nelson's syndrome): systematic review and expert consensus recommendations

BACKGROUND

Corticotroph tumor progression (CTP) leading to Nelson's syndrome (NS) is a severe and difficult-to-treat complication subsequent to bilateral adrenalectomy (BADX) for Cushing's disease. Its characteristics are not well described, and consensus recommendations for diagnosis and treatment are missing.

METHODS

A systematic literature search was performed focusing on clinical studies and case series (≥5 patients). Definition, cumulative incidence, treatment and long-term outcomes of CTP/NS after BADX were analyzed using descriptive statistics. The results were presented and discussed at an interdisciplinary consensus workshop attended by international pituitary experts in Munich on October 28, 2018.

RESULTS

Data covered definition and cumulative incidence (34 studies, 1275 patients), surgical outcome (12 studies, 187 patients), outcome of radiation therapy (21 studies, 273 patients), and medical therapy (15 studies, 72 patients).

CONCLUSIONS

We endorse the definition of CTP-BADX/NS as radiological progression or new detection of a pituitary tumor on thin-section MRI. We recommend surveillance by MRI after 3 months and every 12 months for the first 3 years after BADX. Subsequently, we suggest clinical evaluation every 12 months and MRI at increasing intervals every 2-4 years (depending on ACTH and clinical parameters). We recommend pituitary surgery as first-line therapy in patients with CTP-BADX/NS. Surgery should be performed before extrasellar expansion of the tumor to obtain complete and long-term remission. Conventional radiotherapy or stereotactic radiosurgery should be utilized as second-line treatment for remnant tumor tissue showing extrasellar extension.

[Field trial for eradication of methicillin- resistant Staphylococcus aureus (MRSA) in a pig breeding farm by bacteriophages]

INTRODUCTION

In recent years, Livestock Associated Methicillin-Resistant Staphylococcus aureus (LA-MRSA) are found frequently in pigs. The colonization of the care staff with LA-MRSA is strongly associated with the intensity and duration of animal contact and LA-MRSA herd prevalence. In human medicine, staphylococcal infections have been controlled successfully by topical or systemic administration of Staphylococcus - associated bacteriophages. Therefore, the present study investigated the effect of a bacteriophage cocktail on skin and mucosal colonization of pigs with MRSA in a pig farm with high MRSA prevalence. In a first experiment, the sows were washed with a bacteriophage cocktail and nose, mouth and vagina were rinsed before the sows were admitted to the farrowing house. Then, 10 ml of the bacteriophage cocktail was administered daily to the sows over the feed until weaning. The suckling piglets were sprayed and sampled twice a week during the suckling period and treated with the bacteriophage cocktail over the feed during the weaning period. In further experiments, the weaning room was nebulized three times a day with a bacteriophage cocktail and different concentrations of bacteriophages were added to the drinking water via Dosatron®. None of the experiments, however, showed an eradication of MRSA neither in nose nor in feces.

Papillary tumor of the pineal region: a single-center experience

Papillary tumor of the pineal region (PTPR) is a rare entity. Its clinical presentation is diverse, and establishing an accurate and timely diagnosis may be challenging. Treatment recommendations are based on the evidence level of case series. Recently, several key advances have been made for immunohistochemical characterization, molecular diagnostics, and neurosurgical treatment of PTPR. Here, we describe our single-center experience.

Clinical Situation, Therapy, and Follow-Up of Adult Craniopharyngioma

CONTEXT

Craniopharyngioma is a rare neoplastic entity of the central nervous system. Childhood-onset craniopharyngioma is the subject of frequent research whereas the information on adult-onset craniopharyngioma is scarce.

OBJECTIVE

The objective of this study was to examine the level of daily impairment in adult patients suffering from craniopharyngioma.

DESIGN

Noninterventional patient registry indexed as PV4842 with the local ethics committee.

SETTING

The study is set in a hospitalized and ambulatory setting.

PATIENTS

148 patients with adult-onset craniopharyngioma were recruited from 8 centers, 22 prospectively and 126 retrospectively. Mean follow-up was 31 months.

INTERVENTIONS

No interventions performed.

MAIN OUTCOME MEASURES

Complications, symptoms, body mass index (BMI), and quality of life (QoL; EORTC QLQ C30 and BN20) were recorded preoperatively and at follow-up. The hypotheses tested were generated after data collection.

RESULTS

Complications were more frequent after transcranial than transsphenoidal approaches (31 % vs. 11%; P < 0.01). Preoperative obesity was present in 0% papillary and in 38% of all adamantinomatous craniopharyngiomas (P = 0.05), and diabetes insipidus was more frequent for papillary craniopharyngioma (36.8% vs. 16,7%; P < 0.05). Hormone deficits at follow-up were reduced in 16.9%, equal in 31.4%, and increased in 63.6% (P < 0.001). BMI increased from 28.7 ± 7.4 kg/m2 before surgery to 30.2 ± 7.4 kg/m2 at follow-up (P < 0.001). In QoL, a decrease of future uncertainty (62.5 vs. 36.8; P = 0.02) and visual disorders (38.9 vs. 12.0; P = 0.01) were observed in the prospective collective after surgery.

CONCLUSIONS

Adult craniopharyngioma is associated with a complex sociological and psychological burden and hypothalamic dysfunction, warranting further investigation and emphasizing the need for a wider treatment approach.

Interoptic, Trans-lamina Terminalis, Opticocarotid Triangle, and Caroticosylvian Windows From Mini-Supraorbital, Frontomedial, and Pterional Perspectives: A Comparative Cadaver Study With Artificial Lesions

Introduction: The mini-supraorbital (MSO) and pterional (PT) approaches have been compared in a number of studies focusing on the treatment of aneurysms, craniopharyngiomas, and meningiomas. The goal of this study was to analyze the surgical exposure to different artificial lesions through interoptic (IO), trans-lamina terminalis (TLT), opticocarotid triangle (OCT), and caroticosylvian (CS) windows from the MSO, frontomedial (FM), and PT perspectives. Methods: The MSO, PT, and FM approaches were performed sequentially in two fixed cadaver heads. Three colored spheres were placed around the optic chiasm: (1) between the optic nerves; (2) between the optic nerve and the internal carotid artery; and (3) between the internal carotid artery and the oculomotor nerve. The surgical exposures to these structures by using the IO, TLT, OCT, and CS windows were compared. Results: (1) IO window: from the MSO and PT approaches, the total surgical exposure mainly allows visualization of contralateral lesions. The FM approach was superior for exploration of both sides of the area between the optic nerves. (2) TLT pathway: the MSO and PT approaches mainly expose the contralateral third ventricle wall. (3) OCT window: the PT approach allows exposure of a larger part of the sphere between the optic nerve and the internal carotid artery than the MSO approach. (4) CS window: the PT approach allows a better exposure of lateral structures such as the oculomotor nerve and of the medial prepontine area in comparison to the MSO approach. Conclusion: Simulation of the surgical situation with artificial lesions is a good model for comparing surgical perspectives and for analyzing feasibility of lesion exposure and resection.

Optimization of analgesia for piglet castration under isoflurane anaesthesia with parenteral butorphanol, meloxicam or intratesticular lidocaine

INTRODUCTION

This blinded prospective study investigated analgesic effects of intramuscular (IM) butorphanol, meloxicam or intratesticular (IT) lidocaine for castration of 7-14 days old piglets under isoflurane anaesthesia. 66 piglets were randomly injected with: meloxicam IM (0.4 mg/kg; group M), butorphanol IM (0.2 mg/kg; group B), or both (group BM) 20 minutes prior to castration, or lidocaine IT (4 mg/kg (group ML4) or 8 mg/kg (group ML8)) together with meloxicam IM (0.4 mg/kg) under anaesthesia with 1.8% end-tidal isoflurane. Heart rate, respiratory rate, mean arterial blood pressure and end-tidal carbon dioxide were recorded. Anaesthesia quality was scored and postoperative behaviour assessed. As butorphanol caused unacceptable side effects, its use was stopped. Group M showed worse anaesthesia quality than ML4 and ML8 (higher incidence of movements: 11/17, 3/18 and 4/17, respectively). There were no significant differences between groups regarding parameters measured during castration. Postoperative behaviour did not differ between groups. For castration of 7-14 days old piglets under isoflurane anaesthesia, IT lidocaine provides an additional side effect free analgesia.

Quantification of specific growth patterns and frequency of the empty sella phenomenon in growth hormone-secreting pituitary adenomas

PURPOSE

To assess and quantify the prevalence and co-occurence of a sellar floor lowering and empty sella phenomenon in patients with GH (growth hormone)-secreting pituitary adenoma.

METHODS

A total number of 159 acromegalic patients were included in this study, as well as two control groups (150 patients with non-GH-secreting adenomas and 50 patients without pituitary adenomas). Magnetic resonance images of all patients were evaluated for presence of an empty sella, downward and lateral tumor extension, and maximum superoinferior diameter of the mass. Additionally, these values were correlated with growth hormone and IGF-1 levels.

RESULTS

The empty sella phenomenon was detected significantly more often in patients with a GH-secreting adenoma with a prevalence of 22% vs. 5.3% in non-GH-secreting adenomas (p < 0.001) or 8% in the healthy control group (p = .036). Moreover, GH-secreting adenomas presented with a significant rate of downward tumor extension (74.8% vs. 35.5%; p < 0.001), whose extent correlated inversely but weakly with the GH hormone level (r = - 0.17; p = .036). It was also found that a decreased superoinferior diameter and higher ratio of intrasellar to suprasellar extension are predictive quantitative values for the presence of a GH-secreting adenoma (area under curve, 0.712).

CONCLUSIONS

GH-secreting pituitary adenomas are frequently associated with an empty sella phenomenon. Moreover, GH-secreting adenomas are frequently accompanied by an enhanced, quantitatively measurable impression of the sellar floor. Hypothetically, this is caused by tumor-induced local bone remodeling processes.

Clinical Impact of the Current WHO Classification of Pituitary Adenomas

WHO classifications should be used for comparing the results from different groups of pathologist and clinicians by standardized histopathological methods. Our present report describes the important parameters of pituitary adenoma pathology as demand of the WHO classification for correlation to endocrine data and prognosis. The combination of HE stain based structures with immunostainings for pituitary hormones allows subclassification of adenomas as the best method not only for correlations to clinical hyperfunctions but also for statements to the sensitivity of drug therapies (somatostatin analogs, dopamine agonists). GH-, PRL- and ACTH-secreting pituitary adenomas are further classified based on the size and number of their secretory granules by electron microscopy, or as is mostly the case nowadays by cytokeratin staining pattern, into densely and sparsely granulated. Granulation pattern may be considered for the prediction of treatment response in patients with GH-secreting adenomas, since the sparsely granulated subtype was shown to be less responsive to somatostatin analog treatment. For prognosis, it is important to identify aggressive adenomas by measurements of the Ki-67 index, of the number of mitoses, and of nuclear expression of p53. Among the criteria for atypical adenomas, high Ki-67 labeling index and invasive character are the most important adverse prognostic factors. Promising molecular markers have been identified that might supplement the currently used proliferation parameters. For defining atypical adenomas in a future histopathological classification system, we propose to provide the proliferative potential and the invasive character separately.

Emerging Histopathological and Genetic Parameters of Pituitary Adenomas: Clinical Impact and Recommendation for Future WHO Classification

The review assesses immunohistochemical findings of somatostatin receptors and of metalloproteinases in different pituitary adenoma types and the significance of molecular genetic data. Current evidence does not support routine immunohistochemical assessment of somatostatin or dopamine receptor subtype expression on hormone-secreting or nonfunctioning pituitary adenomas. Further prospective studies are needed to define its role for clinical decision making. Until then we suggest to restrict membrane receptor profiling to individual cases or for study purposes. The problems of adenoma expansion and invasion are discussed. Despite partially contradictory publications, proteases clearly play a major role in permission of infiltrative growth of pituitary adenomas. Therefore, detection of at least MMP-2, MMP-9, TIMP-2, and uPA seems to be justified. Molecular characterization is important for familial adenomas, adenomas in MEN, Carney complex, and McCune-Albright syndrome and can gain insight into pathogenesis of sporadic adenomas.

Assessing pesticide risks to threatened and endangered species using population models: Findings and recommendations from a CropLife America Science Forum

This brief communication reports on the main findings and recommendations from the 2014 Science Forum organized by CropLife America. The aim of the Forum was to gain a better understanding of the current status of population models and how they could be used in ecological risk assessments for threatened and endangered species potentially exposed to pesticides in the United States. The Forum panelists' recommendations are intended to assist the relevant government agencies with implementation of population modeling in future endangered species risk assessments for pesticides. The Forum included keynote presentations that provided an overview of current practices, highlighted the findings of a recent National Academy of Sciences report and its implications, reviewed the main categories of existing population models and the types of risk expressions that can be produced as model outputs, and provided examples of how population models are currently being used in different legislative contexts. The panel concluded that models developed for listed species assessments should provide quantitative risk estimates, incorporate realistic variability in environmental and demographic factors, integrate complex patterns of exposure and effects, and use baseline conditions that include present factors that have caused the species to be listed (e.g., habitat loss, invasive species) or have resulted in positive management action. Furthermore, the panel advocates for the formation of a multipartite advisory committee to provide best available knowledge and guidance related to model implementation and use, to address such needs as more systematic collection, digitization, and dissemination of data for listed species; consideration of the newest developments in good modeling practice; comprehensive review of existing population models and their applicability for listed species assessments; and development of case studies using a few well-tested models for particular species to demonstrate proof of concept. To advance our common goals, the panel recommends the following as important areas for further research and development: quantitative analysis of the causes of species listings to guide model development; systematic assessment of the relative role of toxicity versus other factors in driving pesticide risk; additional study of how interactions between density dependence and pesticides influence risk; and development of pragmatic approaches to assessing indirect effects of pesticides on listed species.

Validation of the Tuebingen CD-25 Inventory as a Measure of Postoperative Health-Related Quality of Life in Patients Treated for Cushing's Disease

BACKGROUND

To evaluate the construct and criterion validity of the Tuebingen Cushing's disease quality of life inventory (Tuebingen CD-25) for application in patients treated for Cushing's disease (CD).

METHODS

A total of 176 patients with adrenocorticotropin hormone-dependent CD (144 of them female, overall mean age 46.1 ± 13.7 years) treated at 3 large tertiary referral centers in Germany were studied. Construct validity was assessed by hypothesis testing (self-perceived symptom reduction assessment) and contrasted groups (patients with vs. without hypercorticolism). For this purpose, already existing data from 55 CD patients was used, representing the hypercortisolemic group. Criterion validity (concurrent validity) was assessed in relation to the Cushing's quality of life questionnaire (CushingQoL), the Short Form 36 health survey (SF-36), and the body mass index (BMI).

RESULTS

Patients with self-perceived remarkable symptom reduction had significant lower Tuebingen CD-25 scores (i.e. better health-related quality of life) than patients with self-perceived insufficient symptom reduction (p < 0.05). Similarly, the mean scores of the Tuebingen CD-25 scales were lower in patients without hypercortisolism (total score 27.0 ± 17.2) compared to those with hypercortisolism (total score 45.3 ± 22.1; each p < 0.05), providing evidence for construct validity. Criterion validity was confirmed by the correlations between the Tuebingen CD-25 total score and the CushingQoL (Spearman's coefficient -0.733), as well as all scales of the SF-36 (Spearman's coefficient between -0.447 and -0.700).

CONCLUSION

The analyses presented in this large-sample study provide robust evidence for the construct and criterion validity of the Tuebingen CD-25.

Long-term remission and recurrence rates after first and second transsphenoidal surgery for Cushing's disease: care reality in the Munich Metropolitan Region

OBJECTIVE

Transsphenoidal surgery (TSS) presents the treatment of choice for Cushing's disease (CD). Remission and recurrence rates vary dependent on tumor size, extension, adenoma visibility on magnetic resonance imaging, and neurosurgical expertise. Other than published from single-surgeon neurosurgical series so far, we have aimed to describe long-term remission and recurrence rates of CD in a series incorporating different neurosurgeons, trying to reflect care reality in the Munich Metropolitan Region, which is accommodated by three tertiary university and multiple, smaller neurosurgical centers.

DESIGN

We conducted a retrospective analysis of 120 patients who underwent first and 36 patients who underwent second TSS as treatment for CD between 1990 and 2012.

METHODS

Patients were divided into three groups according to remission status. Potential risk factors for recurrence, pituitary function, and strategy in persistent disease were assessed.

RESULTS

THREE OUTCOME GROUPS WERE IDENTIFIED ACCORDING TO REMISSION STATUS AFTER FIRST TSS (MEAN FOLLOW-UP 79 MONTHS): remission, 71% (85/120), disease persistence, 29% (35/120), and disease recurrence, 34% (29/85) (mean time to recurrence 54 months). After second TSS (n=36, mean follow-up 62 months), we documented remission in 42% (15/36), disease persistence in 58% (21/36), and disease recurrence in 40% (6/15) (mean time to recurrence 42 months). Postoperative hypocortisolism after first, though not after second, TSS was associated with a lower risk of suffering disease recurrence (risk=0.72; 95% CI 0.60-0.88; exact significance (two-sided) P=0.035).

CONCLUSIONS

Our study shows higher recurrence rates of CD after first TSS than previously reported. Second TSS leads an additional 8% of the patients to long-term CD remission.

Similar psychopathological profiles in female and male Cushing's disease patients after treatment but differences in the pathogenesis of symptoms

BACKGROUND

Female Cushing's disease (CD) patients with active disease present more frequently with depression compared to their male co-sufferers. This study investigated whether the gender difference prevails after remission and whether gender-specific factors contributing to mental health exist.

METHODS

72 biochemically cured CD patients (11 male, mean age 45.9 ± 13.7 years) who underwent transsphenoidal tumour removal filled out the Symptom Checklist-90-Revised inventory on average 42.1 ± 32.9 months after surgery. Multiple regression analyses included the following independent factors: (i) age, (ii) presence of comorbidities, (iii) presence of hypocortisolism, (iv) presence of hypopituitarism, (v) disease duration until diagnosis, (vi) time elapsed since surgery, and (vii) postoperative radiotherapy to predict postoperative psychopathology.

RESULTS

Regarding the Global Severity Index, 23.0% of the female and 27.3% of the male CD patients presented with abnormal scores. In all nine dimensions, psychopathological abnormalities were present in both female and male patients with the same frequency and intensity (each p > 0.05). Prolonged time to diagnosis was a strong predictive factor for worse psychopathological status only in male patients. Among female patients, only the presence of comorbidities and to some extent pituitary deficiencies were related to psychopathological status.

CONCLUSIONS

During the remission phase of CD, female and male patients present with similar psychopathological profiles. In males, long-term biochemical effects of previous hypercortisolism seem to be salient for psychopathology. In contrast, in females, the presence of comorbidities/stressors they have to cope with is the predictive factor for psychopathology. The results underline gender differences in CD and the need to separate them on various issues.

Prognostic relevance of global histone 3 lysine 9 acetylation in ependymal tumors

OBJECT

Ependymal tumors are highly variable in clinical and molecular behavior and affect both children and adults. Regarding the paucity of appropriate experimental models, the underlying molecular mechanisms of their behavioral variability are poorly understood. Considering the increasing evidence of epigenetic changes in various tumors, in addition to the preclinical success of epigenetic-based therapeutics in tumors of the CNS, epigenetic study of ependymal tumors is warranted.

METHODS

Using immunohistochemistry, the authors investigated the patterns of global acetylation of lysine position 9 of histone 3 (H3K9Ac), an epigenetic marker of active gene transcription, in 85 ependymal tumors with various WHO grades and clinicopathological characteristics.

RESULTS

Most of the nuclei in all ependymal tumors were H3K9Ac negative (mean ± SD 65.9% ± 26.5 vs 34.1% ± 26.5% positive, p < 0.0001). Subependymomas had more H3K9Ac-positive nuclei (67.2% ± 10.2%) than myxopapillary ependymomas, ependymomas, and anaplastic ependymomas (p < 0.05). Additionally, intracranial parenchymal tumors had significantly fewer H3K9Ac-positive nuclei (13.1% ± 21.9%) than tumors of other CNS localizations (p < 0.001), and supratentorial ventricular tumors had the highest number of H3K9Ac-positive nuclei (66.4% ± 11.8%) among CNS ependymal tumors (p < 0.0001). The H3K9Ac pattern in ependymal tumors also revealed prognostic significance such that tumors with less than 20% acetylated nuclei had a higher probability of recurrence than tumors with 20% or more acetylated nuclei (p = 0.0327), and recurrent tumors had significantly fewer H3K9Ac-positive nuclei than primary ones (16% ± 22.5% vs. 38% ± 25.8%; p < 0.0001). However, the effect of tumor location on survival of patients was nonsignificant in a multivariate survival analysis, and H3K9 acetylation levels of tumors contributed independently to the survival of patients. In addition, ependymal tumors with more than or equal to 20% H3K9 acetylated cells had lower MIB-1 expression than those with less than 20% H3K9 acetylated cells (p < 0.01).

CONCLUSIONS

Global H3K9Ac contributes independently to the prognosis of patients with ependymal tumors such that tumors with lower H3K9Ac values have a higher probability of recurrence and are more proliferative. Additionally, subependymomas have a higher H3K9Ac profile than other ependymal tumor subclasses, underlining their benign clinical behavior.

Osteonectin Expression in Surrounding Stroma of Craniopharyngiomas

Craniopharyngioma is an epithelial tumor of the sellar region with a high survival rate but a high rate of recurrence, especially in children. Hypothalamic involvement, tumor recurrence, and multiple treatments result in clinical deterioration and impaired quality of life. Using immunohistochemistry, we investigated the expression pattern of osteonectin, a marker of tumor invasion and aggressive behavior, in 43 cases of craniopharyngioma. We observed a positive correlation of osteonectin expression in connective-type stromal tissue surrounding the epithelial tumor cells of craniopharyngioma with the extent of central nervous system infiltration and recurrence rate ( P < .001). Given the previous success of chemotherapeutic agents that target the tumor microenvironment, our findings on osteonectin expression in stroma of craniopharyngiomas might, hopefully, be a guide to find newer prognostic markers capable of estimating the risk of progression or recurrence. They may also aid in the development of therapeutics that target tumor microenvironment to improve patient outcome.

[Modern surgery of meningiomas affecting anterior visual pathways]

Meningiomas are the most common form of primary intracranial tumors. If the anterior visual pathways are affected clinical visual compromise, visual field defects, oculomotor nerve disturbances or propotosis are predominant. Meningiomas of the anterior visual pathway remain therapeutically challenging due to the direct anatomical relationship to the circulus arteriosus cerebri, the cavernous sinus and cranial nerves. The therapy of choice is microsurgical resection. In many cases a curative approach can be achieved with modern surgical techniques and simultaneously maintaining patient quality of life. Problematic are cases in which resection would be associated with the risk of clinical impairment and in these cases radiotherapy is an important therapeutic option. In cases involving complex invasiveness an interdisciplinary treatment to control local clinical symptoms is favored.

[Meningiomas. Clinical case examples]

Using four case reports as examples the best treatment is discussed by considering the specific history and magnetic resonance imaging (MRI) findings. In many cases different therapeutic alternatives are possible for treatment of meningiomas.

Tuebingen CD-25 is a sensitive tool to investigate health-related quality of life in Cushing's disease patients in the course of the disease

BACKGROUND

The primary object was to investigate whether the Tuebingen CD-25 captures changes in health-related quality of life (HRQoL) sensitively in Cushing's disease (CD) and to identify factors that favour postoperative HRQoL.

METHODS

17 CD patients were scheduled for transsphenoidal tumour removal and filled out the inventory before and after surgery. The mean time elapsed after surgery was 14.4 ± 11.3 months. All patients were in remission at the second timepoint of investigation.

RESULTS

HRQoL as assessed with the Tuebingen CD-25 improved significantly after successful surgical tumour removal. A large effect size (Cohen's d = 0.84) in the total score indicates good sensitivity to change. 13 patients (76.5%) showed impaired HRQoL preoperatively compared with a general population sample. Postoperatively, 35.3% of the patients still suffered from an impaired HRQoL. Stepwise linear regression analysis revealed that less comorbidities (≤2) and greater morning cortisol decrease were promotive factors for better postoperative HRQoL (p < 0.05). The postoperative improvement in HRQoL could be best predicted by the presence of preoperative HRQoL impairment and age of the patients, i.e. patients who were younger were more likely to improve. Moreover, patients without postoperative pituitary deficiencies improved significantly more in the cognition scale. A tendency towards more improvement in overall HRQoL was observed in non-hypocortisolaemic patients.

CONCLUSIONS

The Tuebingen CD-25 has proved to be a capable and sensitive instrument to investigate HRQoL in the course of disease. The number of postoperative comorbidities had the greatest impact on postoperative well-being.

Pituicytoma in a patient with Cushing's disease: case report and review of the literature

Pituicytoma is an exceptionally rare low-grade glioma (WHO grade I) of the neurohypophysis and infundibulum. We are reporting the case of a 48-year-old man who presented with severe Cushing's syndrome. Endocrinological evaluation unequivocally confirmed pituitary-dependent Cushing's syndrome (=Cushing's disease). Cranial MR-imaging displayed a conspicuous area in the dorsal and basal pituitary gland and a minimal bulging of the pituitary gland paramedian of the pituitary stalk on the right side. Transsphenoidal inspection revealed a small tumor in the basal and dorsal pituitary gland. Surprisingly, the definite postoperative histopathological diagnosis of the removed tumor was pituicytoma and not pituitary adenoma. Hence, the microadenoma responsible for Cushing's disease was not yet removed and persistent hypercortisolism necessitated transsphenoidal re-operation. During re-operation, hemihypophysectomy was performed on the right side. The non-tumorous specimen of the adeno-hypophysis showed signs of Crooke's hyalinization consistent with Cushing's disease. Undetectable postoperative ACTH- and cortisol levels provided clear evidence that the underlying ACTH-source was successfully removed during re-operation. Coincidence of pituicytoma and pituitary-dependent Cushing's disease has not previously been reported.

Predictors for visual dysfunction in nonfunctioning pituitary adenomas - implications for neurosurgical management

BACKGROUND

Despite ample experience with surgical treatment of nonfunctioning pituitary adenomas, objective data defining the risk for visual compromise depending on the suprasellar extension in pituitary adenomas are sparse.

DESIGN AND PATIENTS

We measured the suprasellar extension of 98 newly diagnosed suprasellar nonfunctioning pituitary adenomas on sagittal and coronal magnetic resonance images using reference lines for the skull base level. In addition, the position of the optic chiasm in relation to the suprasellar adenoma was assessed. The findings were correlated with the degree of visual dysfunction and with the type of visual field defects (VFD).

RESULTS

Seventy per cent of the patients suffered from VFD. The most frequent perimetric findings were bilateral (81·2%) or unilateral (10·1%) temporal hemifield defects. For the coronal view, a suprasellar extension of 12 mm was a practicable cut-off value for emergence of visual disturbances (87·0% sensitivity, 72·4% specificity). For the sagittal view, 8-mm suprasellar extension was a suitable cut-off for appearance of chiasma syndrome (87·0% sensitivity, 75·9% specificity). In five of seven cases without a chiasma syndrome despite a suprasellar extension >12 (coronal) and 8 mm (sagittal), the optic chiasm was found in an anterior position. No correlation was found between the position of the chiasm (i.e. anterior, superior or posterior) and the type of VFD (P = 0·647). A highly significant correlation was found between the decline of visual acuity and the suprasellar adenoma extension (P < 0·0001).

CONCLUSION

Cut-off values possess a high sensitivity and specificity for imminent visual disturbances and are helpful for clinical decision-making. A delayed emergence of visual dysfunction may be observed with an anterior position of the optic chiasm.

The development of the Tuebingen Cushing's disease quality of life inventory (Tuebingen CD-25). Part II: normative data from 1784 healthy people

OBJECTIVE

In part I of the study, a health-related quality of life (HRQoL) inventory for Cushing's disease (CD), the Tuebingen Cushing-25 quality of life inventory (Tuebingen CD-25) was developed. In this second part, we aimed to assess normative data from healthy controls (HC) with which the individual patients' scores can be compared.

DESIGN

Cross-sectional study.

PARTICIPANTS

Sixty-three patients with CD (52 women, 11 men) and 1784 HC (1210 women, 574 men) filled out the Tuebingen CD-25.

MEASUREMENTS

HC received the inventory as a nondisease-specific quality of life questionnaire omitting the introductory sentence 'Because of my Cushing's disease' which was included in the CD group to be able to compare HRQoL in persons with and without CD. Slight and severe impairments were categorized according to the following principles: percent ranges >84.0% were classified as slight and percent ranges >95.0% as severe impairment.

RESULTS

In 28.6% of our patients with CD, we found slight and in 41.3% severe impairment in the Total Score of the Tuebingen CD-25 compared with HC. Less than one-third of our patient sample presented with unimpaired HRQoL. In the patient population, impairment was found in all scales of the Tuebingen CD-25 to a similar extent (P = 0.444), pointing to the fact that all HRQoL domains are similarly impaired. We observed that female patients perceived a worse HRQoL than men in the domains depressive symptoms and social environment (P < 0.05).

CONCLUSION

The Tuebingen CD-25 is a feasible instrument to assess HRQoL in CD in a clinical and investigative setting and provides normative data for all age groups and genders.

The development of the Tuebingen Cushing's disease quality of life inventory (Tuebingen CD-25). Part I: construction and psychometric properties

OBJECTIVE

To develop a disease-specific questionnaire for Cushing's disease (CD), the Tuebingen Cushing's disease quality of life inventory (Tuebingen CD-25).

METHODS

Sources for item generation consisted of technical literature, interviews with patients and the rating of neurosurgeons, endocrinologists and a neuropsychologist. A preliminary inventory with 64 items was handed out to 63 CD patients. Twenty-eight patients filled out the questionnaire preoperative, the remaining 35 patients evaluated their health-related quality of life (HRQoL) retrospectively. Item reduction and scale generation followed the principles of classical test theory. Validation was performed with the WHOQoL-BREF.

RESULTS

The final version of the Tuebingen CD-25 contained 25 items, showed high reliability (Cronbach's alpha = 0.93) and validity (r = -0.65) and includes the subdomains Depression, Sexual Activity, Environment, Eating Behaviour, Bodily Restrictions and Cognition. The retrospective rating of the Tuebingen CD-25 showed similar results compared to the pretreatment group. We found a non-linear correlation between the Tuebingen CD-25 scores and patients' age, younger (21-30 years) and middle-aged (51-60 years) patients having inferior HRQoL than patients between 31 and 50 years and older than 61 years. Preoperative 24 h urinary free cortisol (UFC) levels correlated significantly with the subscale Cognition and only marginally failed significance level for the subscale Eating Behaviour, while preoperative cortisol and ACTH levels did not correlate with any scale.

CONCLUSION

The Tuebingen CD-25 is a valid and reliable instrument to evaluate HRQoL in CD. Based on impairment of HRQoL for the different subdimensions, specific support can be offered to the patients.

Contemporary microsurgical concept for the treatment of Cushing's disease: endocrine outcome in 83 consecutive patients

BACKGROUND

Evidence suggests that occult adenoma remnants are responsible for persistent Cushing's disease (CD) following transsphenoidal surgery (TSS). To optimize the outcome, we have adapted our microsurgical concept. The influence of our surgical strategy on remission rate and pituitary function is presented.

DESIGN AND PATIENTS

83 patients undergoing TSS for newly diagnosed CD. An enlarged resection was performed in 36 patients. A modified exploration technique with radial incisions was performed in 19 patients in whom an adenoma was not readily detectable.

RESULTS

The overall remission rate of primary surgery was 84·3% (70/83). A remission rate of 87·5% (63/72) was achieved in microadenomas. Six patients with microadenomas were re-operated for persistence, and hypercortisolism was corrected in five of them. With re-operation included, the overall remission rate for microadenomas was 94·4%. No procedure-related complications occurred in primary surgery. Of the patients in remission, 72·5% had early postoperative random cortisol levels below 2 μg/dl, 17·4% had cortisol levels between 2 and 5 μg/dl, and 10·1% had cortisol levels >5 μg/dl. 15·2% of the patients with microadenomas developed postoperative partial hypopituitarism and 3% diabetes insipidus. No increased rate of hypopituitarism was found with enlarged adenomectomy compared to selective adenomectomy. Only a slightly higher rate of partial hypopituitarism (23·1%) was found if extensive exploration was required.

CONCLUSION

With our microsurgical concept, a high initial cure rate is achievable with minimal surgical morbidity. Enlarged adenomectomy has no adverse effect on the rate of postoperative hypopituitarism. Early repeat surgery is a successful option if CD persists.

Treatment Options in Cushing's Disease

Endogenous Cushing’s syndrome is a grave disease that requires a multidisciplinary and individualized treatment approach for each patient. Approximately 80% of all patients harbour a corticotroph pituitary adenoma (Cushing’s disease) with excessive secretion of adrenocorticotropin-hormone (ACTH) and, consecutively, cortisol. The goals of treatment include normalization of hormone excess, long-term disease control and the reversal of comorbidities caused by the underlying pathology. The treatment of choice is neurosurgical tumour removal of the pituitary adenoma. Second-line treatments include medical therapy, bilateral adrenalectomy and radiation therapy. Drug treatment modalities target at the hypothalamic/pituitary level, the adrenal gland and at the glucocorticoid receptor level and are commonly used in patients in whom surgery has failed. Bilateral adrenalectomy is the second-line treatment for persistent hypercortisolism that offers immediate control of hypercortisolism. However, this treatment option requires a careful individualized evaluation, since it has the disadvantage of permanent hypoadrenalism which requires lifelong glucocorticoid and mineralocorticoid replacement therapy and bears the risk of developing Nelson’s syndrome. Although there are some very promising medical therapy options it clearly remains a second-line treatment option. However, there are numerous circumstances where medical management of CD is indicated. Medical therapy is frequently used in cases with severe hypercortisolism before surgery in order to control the metabolic effects and help reduce the anestesiological risk. Additionally, it can help to bridge the time gap until radiotherapy takes effect. The aim of this review is to analyze and present current treatment options in Cushing’s disease.

Executive functions recover earlier than episodic memory after microsurgical transsphenoidal resection of pituitary tumors in adult patients--a longitudinal study

Pituitary tumors may lead to cognitive dysfunction, and the most prevalent deficits are impaired memory and attention. To investigate whether memory and executive functions improve after surgical treatment we performed a prospective longitudinal study comprising 106 patients with pituitary tumors. Psychometric evaluation was performed with the d2-Letter Cancellation test, the Trail Making test, the Digit Span test and the Intelligence Structure test-Verbal Memory test at three timepoints: preoperatively, and at 3 months and 12 months after surgery. The preoperative and postoperative maximum suprasellar tumor extension and hormone status was assessed in all participants. The main finding was that concentration, working memory, and attentional speed improved significantly within the first 3 months after surgery (p<0.05), while improvement of episodic memory was not observed until 12 months after surgery (p<0.001). In the patients harbouring non-functioning adenomas, prolactinomas or other sellar lesions, the most important factor promoting improvement of neurocognitive function was the removal of the suprasellar tumor extension.

Predictive factors for neurocognitive function and Quality of Life after surgical treatment for Cushing's disease and acromegaly

BACKGROUND

Cushing's disease (CD) and acromegaly (AC) are associated with impairment in quality of life (QoL) and neurocognition that can persist after successful treatment.

AIM

To investigate the influence of current disease status (remission vs no remission) on neurocognitive function and QoL in treated CD and AC patients and to determine predictive factors (e.g. demographic, clinical, neurosurgical, endocrinological) for post-operative neurocognition and QoL.

SUBJECTS AND METHODS

Twenty-four CD and 37 AC patients underwent neuropsychological testing 1 to 10 yr following surgical therapy. Additionally, QoL was assessed. An overnight 2-mg dexamethasone suppression test in CD and IGF-I and GH levels in AC patients were assessed to determine current disease status. The results were compared with 28 sex-, education- and age-matched healthy controls (HC).

RESULTS

Impaired QoL was more pronounced than neurocognitive decrease in both pathologies compared to HC. This finding was independent of the current status of disease. In AC, persistent comorbidities were associated with impaired QoL (p<0.05). Older age at operation in AC patients was a significant predictor for adverse effects on psychomotor speed and attentional functions (p<0.05). In CD persistent hypocortisolism, not hypercortisolism, had adverse effects on neurocognition (p<0.01).

CONCLUSIONS

The current status of disease plays a subordinate role in postoperative outcome concerning QoL and neurocognition in either pathology. A possible explanation might be the considerably improved endocrinopathy after treatment compared to untreated patients, even if no cure is achieved. The lasting impairments might be explained by irreversible changes that have occurred during the active phase of the disease.

Histone acetylation patterns of typical and atypical pituitary adenomas indicate epigenetic shift of these tumours

Pituitary adenomas are benign endocrine tumours of the anterior pituitary that are subclassified as typical (conventional) or atypical adenomas, with uncertain prognosis based on histopathological features. Clarifying epigenetic alterations of pituitary tumours, as well as the mechanisms underlying them, will hopefully open new windows to treatment and the classification of these tumours and maybe even prediction of patient survival. In the present study, using immunohistochemistry, we investigated the acetylation pattern of histone 3 lysine 9 (H3K9), an epigenetic marker of active chromatin state and gene transcription, in typical and atypical pituitary adenomas and the normal pituitary. We observed a significant increase in H3K9 acetylation from the normal pituitary to typical and atypical pituitary adenomas, which was associated with significant hyperacetylation of H3K9 in atypical adenomas (P < 0.0001). MIB-1 (Ki-67) overexpression was also highly associated with increased acetylation of H3K9, correlating prositively with tumour severity (P < 0.0001). p53 overexpression had a contributing effect on altered global H3K9 acetylation of atypical pituitary adenomas (P < 0.05). These data suggests that H3K9 acetylation status might serve as a relevant additional biomarker of tumour severity in pituitary adenomas, and also as a proper target for epigenetic-based therapies.

Craniometric changes in patients with acromegaly from a surgical perspective

OBJECT

The objective of this study was to evaluate and analyze morphometric and volumetric changes of the skull due to acromegaly in areas relevant for neurosurgical practice, focusing on the surgical implications.

METHODS

On preoperatively acquired CT scans, cephalometric and volumetric measurements were performed on 45 patients with acromegaly (Group A) and 45 control patients (Group B). The authors determined thickness of the cranial vault, inner and outer diameters of the skull, and the diameter of sphenoidal and maxillary sinus, as well as frontal and maxillary sinus volumetry. The morphometric and volumetric CT data of the patients with acromegaly were compared with the data of a control group and correlated with clinical parameters.

RESULTS

Cranial vault thickness differed significantly (p < 0.0001) between the 2 groups. A correlation of the vault thickness with preoperative human growth hormone, insulin-like growth factor-I levels, and duration of clinical history in acromegaly could not be established. The outer anterior-posterior skull diameter of Group A (18.47 ± 0.94 cm) differed significantly (p = 0.0146) from Group B (17.98 ± 0.93 cm) and correlated significantly with preoperative human growth hormone (r = 0.3277; p = 0.0299) and insulin-like growth factor-–I serum levels (r = 0.3756; p = 0.0120). Measurements of the anterior-posterior diameter of the sphenoidal sinus differed significantly (p = 0.0074) between patients with acromegaly and controls. Volumetric analysis of the frontal sinus resulted in a statistically significant difference (p = 0.0382) between patients with acromegaly (14.89 ± 10.85 cm3) and controls (10.06 ± 6.93 cm3).

CONCLUSIONS

Significant craniometric changes and volumetric remodelling of the paranasal sinus occur in acromegaly. The bone alterations are of surgical importance for using the transsphenoidal approach. Detailed preoperative diagnostic examination and planning as well as selection of appropriate instruments are mandatory for safe and successful pituitary adenoma removal in patients with acromegaly.

Parotid carcinoma metastasis to parietal meningioma: case report and molecular biologic considerations

INTRODUCTION

A combination of factors as the meningioma's rich vascularity, its low metabolic rate, immunologic factors and the molecular pattern explains the affinity of some cancer metastasis to seed inside meningiomas. In this context, the importance of surface adhesion molecules is of rising interest.

CASE REPORT

We report the exceptional case of a parotid carcinoma metastasis within a meningioma. A 68-year old male was referred to our hospital with headache and progressive right hemiparesis. Four years before he was diagnosed with parotid gland cancer for which he had undergone parotidectomy, radiation, neck dissection and chemotherapy. MRI showed a left sided high-parietal, dural-based, extraaxial, contrast enhancing tumor which was consequently removed microsurgically. Histological examination revealed a dedifferentiated parotid carcinoma metastasis inside a microcystic meningioma WHO grade I. Mechanisms that have been suggested to be responsible for metastasis into meningioma include meningiomas' rich vascularity, slow growth, their high collagen and lipid content, immunologic factors but also the expression of certain surface adhesion molecules, in particular E-cadherin. In the presented case E-cadherin immunostaining was strongly positive in the metastatic tissue that invaded the meningioma in a droppled-like fashion. We discuss the potential role of E-cadherin, re-expression of a modified E-cadherin complex and the potential importance of mesenchymal surface proteins in the pathophysiology of carcinoma metastasis into meningioma.

CONCLUSION

Surface proteins of carcinoma cells might play a key role regarding their affinity to seed inside meningiomas. This might be a leading mechanism to the multifactorial process of carcinoma-to-meningioma metastasis.

Are there gender-specific differences concerning quality of life in treated acromegalic patients?

OBJECTIVE

Acromegaly is associated with deleterious comorbidities that can remain irreversible even after successful cure has been achieved and lead to a persistently impaired Quality of Life (QoL). The aim of the study was to assess frequency and degree of persistent comorbidities and complaints after treatment of acromegaly and to investigate their impact on QoL. Another scope of interest was to determine gender-specific factors that influence perceived QoL in men and women.

METHODS

We developed an Acromegaly Comorbidities & Complaints Questionnaire (ACCQ) consisting of 8 items (e. g. acral enlargement, joint complaints, hypertension, diabetes) known to affect QoL in order to assess frequency and degree of comorbidities. Additionally, the Acromegaly Quality of Life Questionnaire (AcroQoL) and the Short-form 36 (SF-36) questionnaire were handed out to 55 treated acromegalic patients.

RESULTS

Both genders suffer from a lasting impairment in quality of life to a considerable degree. Complaints impairing manual skills (e. g. acral enlargement, arthralgias) were the most frequent findings (73% of all participants) in both genders. Multivariate analyses revealed that in men numbness of fingers and persistent joint-complaints were decisively responsible for impaired QoL. In women, it was the persistence of hypertension.

CONCLUSIONS

Persistent joint complaints have adverse effects on QoL after treatment of acromegaly in men, possibly because they lead to impairment of manual motor skills and a handicap in their working life. Women seem to perceive late effects of hypertension as a manifest health threat.

Aftercare in patients with Cushing's disease and acromegaly: is there room for improvement?

PURPOSE

Evaluation of aftercare, medical therapy and remission rate for Cushing's disease (CD) and acromegaly (AC).

METHODS

Fifty-eight CD and 83 AC patients operated on over 10 years were carefully evaluated. The patients received a disease-related questionnaire and were invited for a follow-up at the outpatient clinic of the Department of Neurosurgery. Thirty-three CD and 52 AC patients returned the questionnaire; 25 CD and 37 AC patients participated personally. CD patients underwent a dexamethasone suppression test, and IGF-1 levels were assessed in AC patients. Data on postoperative therapy were assessed.

RESULTS

84.8% of those with CD and 75.0% of those with AC had been followed by endocrinologists; 9.1% of CD and 1.9% of AC patients had been under no aftercare; 96% of CD patients were in remission. A recurrence occurred in four patients, two were newly detected by our study. IGF-1 was postoperatively normalized in 25 of 37 AC patients (67.6%). Twenty patients remained in remission, five relapsed. One patient received medical therapy upon recurrence and presented normal IGF-1; four patients with relapse had not been treated yet. Ten of 12 patients with elevated early postoperative IGF-1 received medical therapy that was commenced within 6 months in nine cases. The mean duration of medical therapy was 36 months (range 2-92). IGF-1 was still elevated at the last follow-up in eight of these ten patients, all of them receiving monotherapy. In four patients, the dose had been increased once.

CONCLUSIONS

The postoperative transfer back to the endocrinologist after operative treatment is achieved well in both groups. In uncured AC, medical therapy is initiated early, but options of therapy offer room for improvement. Therapy of recurrence is delayed in both pathologies.

Postoperative intracranial seeding of craniopharyngiomas--report of three cases and review of the literature

PURPOSE

Seeding of craniopharyngioma has been rarely reported. We present three cases that ectopically recurred with seeding along the surgical route and CSF spaces.

METHODS

The first patient was a 13-year-old boy who had initially undergone radical excision of a suprasellar and retrosellar craniopharyngioma by a right pterional approach. Postoperative MRI showed no evidence of residual tumor. Two years later, MRI revealed a local recurrence and in addition a separated cystic tumor on the right side adjacent to the middle cerebral artery consistent with seeding along the surgical route. Both tumors were removed by re-operation. On histopathological examination, both, the local recurrent tumor and the distant deposit turned out to be adamantinomatous craniopharyngiomas. The second patient was a 27-year-old woman who was operated on for the first time via a right pterional and 1 year later for a recurrent craniopharyngioma via a transsphenoidal approach. Two years later, MRI revealed a right fronto-lateral intracranial metastasis at the site of the former craniotomy, which was removed by re-craniotomy. This deposit in the operative pathway was found to be an adamantinomatous craniopharyngioma, as was the initial tumor. The third patient was a 42-year-old man who was operated on 10 years ago for the first time via a right fronto-temporal approach. The recent control MRT revealed a right parietal intracranial tumor with peripheral contrast enhancement, which was located distant to the former craniotomy. The tumor was removed and histopathological examination revealed an adamantinomatous craniopharyngioma in accordance with the initial tumor. Postoperatively, the three patients were neurologically intact.

CONCLUSION

Although craniopharyngiomas exhibit a benign histopathological pattern, cerebrospinal fluid seeding along the surgical route or along the CSF pathways has been observed. Ectopic recurrence of craniopharyngioma suggests that meticulous protection of the whole surgical field and careful handling of the tumor during the operation are required. It should be emphasized that long-term follow-up is mandatory, even in patients undergoing a total removal.