Gross total resection of pituitary adenomas after endoscopic vs. microscopic transsphenoidal surgery: a meta-analysis

Impact of intraoperative magnetic resonance imaging on gross total resection, extent of resection, and residual tumor volume in pituitary surgery: systematic review and meta-analysis

BACKGROUND

Residual tumor tissue after pituitary adenoma surgery, is linked with additional morbidity and mortality. Intraoperative magnetic resonance imaging (ioMRI) could improve resection. We aim to assess the improvement in gross total resection (GTR), extent of resection (EOR), and residual tumor volume (RV) achieved using ioMRI.

METHODS

A systematic review was carried out on PubMed/MEDLINE to identify any studies reporting intra- and postoperative (1) GTR, (2) EOR, or (3) RV in patients who underwent resection of pituitary adenomas with ioMRI. Random effects meta-analysis of the rate of improvement after ioMRI for these three surgical outcomes was intended.

RESULTS

Among 34 included studies (2130 patients), the proportion of patients with conversion to GTR (∆GTR) after ioMRI was 0.19 (95% CI 0.15-0.23). Mean ∆EOR was + 9.07% after ioMRI. Mean ∆RV was 0.784 cm3. For endoscopically treated patients, ∆GTR was 0.17 (95% CI 0.09-0.25), while microscopic ∆GTR was 0.19 (95% CI 0.15-0.23). Low-field ioMRI studies demonstrated a ∆GTR of 0.19 (95% CI 0.11-0.28), while high-field and ultra-high-field ioMRI demonstrated a ∆GTR of 0.19 (95% CI 0.15-0.24) and 0.20 (95% CI 0.13-0.28), respectively.

CONCLUSIONS

Our meta-analysis demonstrates that around one fifth of patients undergoing pituitary adenoma resection convert from non-GTR to GTR after the use of ioMRI. EOR and RV can also be improved to a certain extent using ioMRI. Endoscopic versus microscopic technique or field strength does not appear to alter the impact of ioMRI. Statistical heterogeneity was high, indicating that the improvement in surgical results due to ioMRI varies considerably by center.

Pituitary Tumor Surgery: Comparison of Endoscopic and Microscopic Techniques at a Single Center

OBJECTIVE

To understand the transition from microscopic surgery (MS) to endoscopic surgery (ES) on the pituitary across the United States, we assessed a single institution practicing both procedures to discern advantages and disadvantages for each.

PATIENTS AND METHODS

Retrospective institutional chart review of 534 patients in a large practice over a 6-year period (January 1, 2014, to December 31, 2019) comparing a single MS neurosurgeon with a single ES neurosurgeon operating on the same days.

RESULTS

In this series, 14% (n=75) of patients had a prior operation, there were no carotid artery injuries, the overall risk for a postoperative infection was 0.4% (n=2), and risk for a postoperative cerebrospinal fluid leak requiring treatment was 2.0% (n=11). Mean ± SD hospital stay was 1.3±0.04 days; readmission for any reason within 30 days occurred in 3.4% (n=18) of patients. The mean volumetric resection for MS was 86.9%±1.7% and for ES was 91.7%±1.3% (P=.03). There was a higher rate of notable events (P=.015) with MS, but MS had 16% lower cost and operative times were 48 minutes shorter than for ES (83±7 vs 131±6 minutes). The ES required substantially fewer postoperative secondary treatments such as radiation therapy (P=.003).

CONCLUSION

Pituitary surgery is a very safe and effective procedure regardless of technique. The MS has shorter operative times and overall lower cost. The ES results in increased volumetric resection and fewer secondary treatments. Both techniques can be valuable to a large practice, and understanding these niches is important when selecting optimal approaches to pituitary surgery for a given patient.

Optimizing pre-, intra-, and postoperative management of patients with sellar pathology undergoing transsphenoidal surgery

OBJECTIVE

Perioperative management of patients with sellar lesions is complex, requiring input from a multidisciplinary team of specialists for ongoing management of both endocrinological and neurosurgical issues. Here, the authors reviewed the experience of a single multidisciplinary center over 10 years to identify key postoperative practices that ensure positive outcomes for patients with sellar lesions who undergo transsphenoidal surgery.

METHODS

The authors performed a retrospective review of all transsphenoidal operations carried out by the senior author at a single center from April 2008 through November 2018. They included only adult patients and recorded perioperative management. They also reviewed the evolution of clinical practices for perioperative care at their institution to identify strategies for ensuring positive patient outcomes, and they reviewed the literature on select related topics.

RESULTS

In total, 1023 operations in 928 patients were reviewed. Of these, 712 operations were for pituitary adenomas (69.6%), and 122 were for Rathke cleft cysts (11.9%). The remainder included operations for craniopharyngiomas (3.6%), arachnoid cysts (1.7%), pituitary tumor apoplexy (1.0%), and other sellar pathologies (12.2%). Among the reviewed operations, the median hospital stay was 3 days (IQR 2-3). Patient management details during the pre-, intra-, and postoperative periods were identified, including both shared characteristics of all patients undergoing transsphenoidal surgery and unique characteristics that are specific to certain lesion types or patient populations.

CONCLUSIONS

Patients with sellar lesions who undergo transsphenoidal surgery require complex, multidisciplinary perioperative care to monitor for common adverse events and to improve outcomes, but there is a dearth of high-quality evidence guiding most perioperative practices. Here, the authors reviewed practices at their institution across more than 1000 transsphenoidal operations that may help ensure successful patient outcomes.

Research advances on the immune research and prospect of immunotherapy in pituitary adenomas

Background

Pituitary adenomas are one type of intracranial tumor, which can be divided into microadenoma (≤ 1 cm), macroadenoma (> 1 cm), and giant adenoma (≥ 4 cm) according to their diametral sizes. They are benign, typically slow-progressing, whereas the biological behavior of some of them is invasive, which presents a major clinical challenge. Treatment of some pituitary adenomas is still difficult due to drug resistance or multiple relapses, usually after surgery, medication, and radiation. At present, no clear prediction and treatment biomarkers have been found in pituitary adenomas and some of them do not cause clinical symptoms, so patients are often found to be ill through physical examination, and some are even found through autopsy. With the development of research on pituitary adenomas, the immune response has become a hot spot and may serve as a novel disease marker and therapeutic target.

The distribution and function of immune cells and their secreted molecules in pituitary adenomas are extremely complex. Researchers found that infiltration of immune cells may have a positive effect on the treatment and prognosis of pituitary adenomas. In this review, we summarized the advance of tumor immunity in pituitary adenomas, revealing the immunity molecules as potential biomarkers as well as therapeutic agents for pituitary adenomas.

Conclusion

The immune studies related to pituitary adenomas may help us find relevant immune markers. At the same time, the exploration of immunotherapy also provides new options for the treatment of pituitary adenomas.

Endoscopic, Endonasal Transsphenoidal Surgery for Tumors of the Sellar and Suprasellar Region: A Monocentric Historical Cohort Study of 369 Patients

BACKGROUND

The endoscopic endonasal transsphenoidal approach (EETA) is an established technique for the resection of a large variety of benign sellar and suprasellar lesions, mostly pituitary adenomas. It has clear advantages over the microscopic approach, like a superior close-up view of the relevant anatomy and the tumor-gland interface, an enlarged working angle, as well as an increased panoramic vision inside the surgical area. We have been performing the EETA for over a decade, and this study will focus on perioperative and postoperative outcomes and complications and their association with the learning curve.

MATERIAL AND METHODS

All patients in our tertiary referral center (n = 369) undergoing an EETA for a lesion of the sellar and suprasellar region between January 1st 2008 and December 31st 2018 were included, and data were retrospectively retrieved from the electronic patient records.

RESULTS

Median follow-up after surgery was 55 months. Pituitary adenomas (n = 322) were the most frequent pathology. Headache (43.4%) and loss of vision (29.3%) were the most common presenting symptoms. Median procedure duration was significantly longer during the initial 5 years (106 versus 79 minutes; p <0.0001), but incidence of peri- and postoperative CSF leaks in the early years was not significantly higher. Knosp grade >2 was associated with perioperative CSF leak (p =0.002), and perioperative CSF leak was associated with postoperative CSF leak (p <0.001). Almost all cases of meningitis were preceded by a postoperative CSF leak. In 22.4% of patients, tumor recurrence required additional therapy. Perioperative (iatrogenic) mortality was 0.8%. The overall hospital stay decreased over time from an average of 7 to 5 days, and the case load increased yearly (p =0.015).

CONCLUSION

The EETA is an excellent technique with complication rates comparable to or even lower than those in large microsurgical series in the literature. EETA has a significant learning curve affecting the procedure duration. Throughout the first 10 years following the transition from the microscopic approach to the EETA in our cohort, the caseload increased and hospital stay was reduced, while no increase in peri- and postoperative complications was observed.

Endoscopic Assistance in the Deep and Narrow Spaces of the Brain-Microscopic Tumor Surgery Supported by the New Micro-Inspection Tool QEVO® (Technical Note)

Introduction: To evaluate the feasibility and efficacy of the innovative micro-inspection tool QEVO® (Carl Zeiss Meditec, Oberkochen, Germany) as an endoscopic adjunct to microscopes for better visualization of the surgical field in complex deep-seated intracranial tumors in infants and adults.

Materials and Methods: We retrospectively assessed the surgical videos of 25 consecutive patients with 26 complex intracranial lesions (time frame 2018–2020). Lesions were classified according to their anatomical area: 1 = sellar region (n = 6), 2 = intra-ventricular (except IV.ventricle, n = 9), 3 = IV.ventricle and rhomboid fossa (n = 4), and 4 = cerebellopontine angle (CPA) and foramen magnum (n = 7). Indications to use the QEVO® tool were divided into five “QEVO® categories”: A = target localization, B = tailoring of the approach, C = looking beyond the lesion, D = resection control, and E = inspection of remote areas.

Results: Overall, the most frequent indications for using the QEVO® tool were categories D (n = 19), C (n = 17), and E (n = 16). QEVO® categories B (n = 8) and A (n = 5) were mainly applied to intra-ventricular procedures (anatomical area 2).

Discussion: The new micro-inspection tool QEVO® is a powerful endoscopic device to support the comprehensive visualization of complex intracranial lesions and thus instantly increases intraoperative morphological understanding. However, its use is restricted to the specific properties of the respective anatomical area.

Endoscopic versus nonendoscopic surgery for resection of pituitary adenomas: a national database study

OBJECTIVE

For symptomatic nonsecreting pituitary adenomas (PAs), resection remains a critical option for treatment. In this study, the authors used a large-population national database to compare endoscopic surgery (ES) to nonendoscopic surgery (NES) for the surgical management of PA.

METHODS

The National Cancer Database was queried for all patients diagnosed with histologically confirmed PA who underwent resection between 2010 and 2016 in which the surgical approach was specified. Due to database limitations, microsurgery and craniotomy were both categorized as NES.

RESULTS

Of 30,488 identified patients, 16,373 (53.7%) underwent ES and 14,115 (46.3%) underwent NES. There was a significant increase in the use of ES over time (OR 1.16, p < 0.01). Furthermore, there was a significant temporal increase in ES approach for tumors ≥ 2 cm (OR 1.17, p < 0.01). Compared to NES, patients who underwent ES were younger (p = 0.01), were treated at academic centers (p < 0.01), lived a greater distance from their treatment site (p < 0.01), had smaller tumors (p < 0.01), had greater medical comorbidity burden (p = 0.04), had private insurance (p < 0.01), and had a higher household income (p < 0.01). After propensity score matching to control for age, tumor size, Charlson/Deyo score, and type of treatment center, patients who underwent ES had a shorter length of hospital stay (LOS) (3.9 ± 4.9 days vs 4.3 ± 5.4 days, p < 0.01), although rates of gross-total resection (GTR; p = 0.34), adjuvant radiotherapy (p = 0.41), and 90-day mortality (p = 0.45) were similar. On multivariate logistic regression, African American race (OR 0.85, p < 0.01) and tumor size ≥ 2 cm (OR 0.89, p = 0.01) were negative predictors of receiving ES, whereas diagnosis in more recent years (OR 1.16, p < 0.01), greater Charlson/Deyo score (OR 1.10, p = 0.01), receiving treatment at an academic institution (OR 1.67, p < 0.01) or at a treatment site ≥ 20 miles away (OR 1.17, p < 0.01), having private insurance (OR 1.09, p = 0.01), and having a higher household income (OR 1.11, p = 0.01) were predictive of receiving ES. Compared to the ES cohort, patients who started with ES and converted to NES (n = 293) had a higher ratio of nonwhite race (p < 0.01), uninsured insurance status (p < 0.01), longer LOS (p < 0.01), and higher rates of GTR (p = 0.04).

CONCLUSIONS

There is an increasing trend toward ES for PA resection including its use for larger tumors. Although ES may result in shorter LOS compared to NES, rates of GTR, need for adjuvant therapy, and short-term mortality may be similar. Factors such as tumor size, insurance status, facility type, income, race, and existing comorbidities may predict receiving ES.

Analysis of 7-tesla diffusion-weighted imaging in the prediction of pituitary macroadenoma consistency

OBJECTIVE

Endoscopic surgery is an effective treatment strategy for pituitary adenomas; however, intrinsic tumor properties such as tumor consistency can challenge or preclude gross-total resection. Preoperative characterization of tumor consistency may help to guide the surgical approach and to predict the extent of resection that is possible. Advanced radiological modalities such as 7T diffusion-weighted imaging (DWI) may be useful in probing biological tissue properties of pituitary adenomas. The objective of the present study was to examine 7T DWI as a novel method of measuring the consistency of pituitary adenomas.

METHODS

Thirteen patients with pituitary macroadenomas underwent 7T MRI, including a DWI image acquisition. Tumor apparent diffusion coefficient (ADC) was normalized to the adjacent temporal gray matter ADC. All patients underwent resection, and a single neurosurgeon blinded to ADC values rated tumor firmness from 1 (least firm) to 5 (most firm) using objective criteria. The tumor specimens were evaluated histopathologically for cellularity, collagen content, and vascularity by a neuropathologist who was also blinded to ADC values. The tumor ADC was correlated with intraoperative consistency rating, histopathology, and extent of resection. Receiver operating characteristic (ROC) curve analyses were performed to identify thresholds to predict tumor consistency.

RESULTS

Corrected ADC values were significantly correlated with both tumor firmness (r = -0.60, p = 0.029) and the extent of trichrome staining (r = -0.72, p = 0.009) such that greater ADC values were associated with both decreased tumor firmness and decreased collagen staining. Correlations between ADC values and tumor vascularity were not significant (r = -0.09, p = 0.78). Corrected ADC values in totally resected tumors (1.54) were greater than those in subtotally resected tumors (0.85) (p = 0.02), and ADC values were greater with moderate tumor cellularity (1.51) than with high tumor cellularity (0.8) (p = 0.035). There was a trend-level association for partial resections to exhibit greater tumor firmness rating (3 vs 1.7; p = 0.051). Finally, the degree of trichrome staining positively correlated with tumor firmness (r = 0.60, p = 0.04). The optimal threshold for predicting intraoperative consistency rating was an ADC ratio of 0.87 (sensitivity 80%, specificity 100%, area under the curve [AUC] 0.90; p = 0.043). The optimal cutoff for distinguishing the extent of resection was 1.19 (sensitivity 85.7%, specificity 83.3% AUC 0.833; p = 0.046).

CONCLUSIONS

The authors' results suggest that a high-resolution ADC of pituitary adenomas is a sensitive measure of tumor consistency. 7T DWI may hold clinical value in the preoperative workup and surgical management of patients with pituitary macroadenomas.

The impact of endoscopic transsphenoidal pituitary adenoma surgery on endocrine function: a single-centre study

INTRODUCTION

The outcome for pituitary endocrine function following endoscopic transsphenoidal surgery remains unclear. This study aims to evaluate endocrine outcomes following endoscopic surgery in order to provide a benchmark to assist in the counselling of patients perioperatively.

METHODS

A prospectively held pituitary database was retrospectively analysed for all adult pituitary adenoma patients undergoing endoscopic surgery from May 2011 to May 2017. All operations were performed by a single neurosurgeon at a regional centre for pituitary surgery. Functioning and non-functioning adenomas were included. Hormonal status was assessed at most recent follow-up.

RESULTS

One hundred forty-five patients (69 M, 76 F) were included in the study with a median age of 52 years. Median follow-up was 52 months. Eighty-eight patients (61%) were not taking any hormone replacement medications, whilst 57 patients (39%) required hormone replacement therapy (HRT) preoperatively. Preoperatively, 29 patients (20%) had hypothalamo-pituitary-adrenal (HPA) axis dysfunction, 39 patients (27%) had thyroid axis dysfunction, 11 males (16%) and 7 females (9%) had gonadal axis dysfunction, and one patient had preoperative diabetes insipidus. Postoperatively, 26 patients (18%) had a new deficiency in pituitary function, whilst 6 patients (11%) were able to cease HRT. Nineteen patients (13%) had new HPA axis deterioration, 12 (8%) had new thyroid axis dysfunction, 8 males (11%) and 4 females (5%) had gonadal axis deterioration, and 6 patients (4%) had new diabetes insipidus (DI).

CONCLUSIONS

The ability to restore pituitary function following endoscopic surgery remains limited, whilst new deficits still occur. It is essential that patients are counselled accordingly as hormonal replacement therapy can have a significant impact on quality of life. Larger longer-term collaborative studies of endocrine outcome in endoscopic pituitary surgery are needed.

Nomogram predictive model of post-operative recurrence in non-functioning pituitary adenoma

Background

To analyze and predict the possibility of post-operative recurrence in non-functioning pituitary adenoma (NFPA) patients, we investigated the clinical factors leading to tumor recurrence and built a nomogram predictive model based on these risk factors.

Methods

A single-center retrospective study was performed. A total of 145 NFPA patients who underwent surgical treatment at Shenzhen People's Hospital from September 2013 to January 2019 were selected. Among them, 52 patients were diagnosed with recurrence of NFPA according to follow-up investigations. Binary logistic regression analysis was used to determine the significant risk factors. A nomogram model was then built to predict recurrence using these factors.

Results

The univariate analysis and the binary logistic regression analysis showed that age, tumor size, cavernous invasion, sphenoid sinus invasion, and surgical extension were significant factors affecting tumor recurrence. We then built a nomogram model to predict post-operative recurrence in NFPA patients using these factors. The correlation analysis indicated that sphenoid sinus invasion [hazard ratio (HR) =13.14, 95% confidence interval (CI): 7.03-24.58, P<0.0001], cavernous sinus invasion (HR =7.53, 95% CI: 4.27-13.28, P<0.0001), and tumor size (HR =11.06, 95% CI: 6.11-20.03, P<0.0001) could promote the recurrence of NFPA. In contrast, advanced age (HR =0.50, 95% CI: 0.28-0.86, P<0.0001) and gross total resection (HR =0.12, 95% CI: 0.07-0.22, P<0.0001) could effectively inhibit recurrence.

Conclusions

In this study, we developed a nomogram predictive model based on the significant recurrence-associated factors for NFPA. This nomogram may aid neurosurgeons in the post-operative prediction of recurrence, and may facilitate tailored counseling of individual patients.

Therapeutic approach to non-functioning pituitary adenomas

The treatment of non-functioning pituitary adenomas raises two questions: when should they be treated and what role does each available treatment play. We review the usefulness of the different treatments and propose a therapeutic scheme based on the existing literature. Active treatment of pituitary adenomas should be performed when they produce symptoms, have contact with the optic tract, or have grown on imaging tests. The treatment is surgical, using radiotherapy for cases with significant non-removable postsurgical tumour remnants and for those in which histopathology studies show aggressive features. Medical treatment is reserved for situations in which surgical and radiotherapy treatments have been exhausted. The most advisable surgical treatment is endoscopic, although experienced neurosurgeons achieve results with microsurgery that are only slightly inferior.

Endoscopic vs. microscopic transsphenoidal pituitary surgery: a single centre study

Endoscopic pituitary surgery has shown promising results. This study reports the experiences of experienced microscopic pituitary surgeons changing to the endoscopic technique, and the beneficial effects on the postoperative outcomes. 45 transsphenoidal endoscopic-assisted surgeries performed in 2016–2017 were compared with 195 microscope-assisted surgeries performed in 2007–2017 for pituitary adenoma. Tumour size, hormonal status and vision were assessed preoperatively and 3–5 months postoperatively. Cases were identified through electronic patient records. GTR was achieved in 39% of the endoscopic operations vs. 22% of microscopic operations, p = 0.018. Mean duration of surgery was 86 min (77–95) with the endoscopic technique vs. 106 min (101–111) with the microscopic technique, p < 0.001. New hypothalamus–pituitary–adrenal axis deficiencies were observed after 3% of endoscopic vs. 34% microscopic operations, p = 0.001, and overall fewer postoperative pituitary deficiencies were observed in the endoscope-assisted group. Complications within 30 days of surgery occurred in 17% of endoscopic operations vs. 27% of microscopic operations (p > 0.05). Normalization of visual impairment occurred in 37% of the cases with preoperative visual impairment in the endoscopic group vs. 35% of those in the microscopic group (p > 0.05). The endoscopic technique performed better as a surgical procedure for pituitary adenomas. We found no statistically significant differences in complication rate or visual improvement between the two techniques.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Multidisciplinary protocol of preoperative and surgical management of patients with pituitary tumors candidates to pituitary surgery

The optimal planning of preoperative diagnosis, management and treatment of pituitary tumors (PT) candidates to pituitary surgery (PS) requires a multidisciplinary approach involving a team of endocrinologists, neurosurgeons, ENT, neuro-ophthalmologists and neuroradiologists with experience in pituitary diseases. Such teams improve surgical results, minimize complications and facilitate their correct treatment if occurring, and optimize the hormonal, ophthalmological and radiological preoperative and follow-up evaluation. We have developed a clinical practice protocol for patients with PT who are candidates to PS based on the most recent national and international guidelines and the relevant literature regarding PT published in the last years. The protocol has been elaborated by a multidisciplinary team of a Spanish Pituitary Tumor Center of Excellence (PTCE) that includes at least one neurosurgeon, ENT, neuroradiologist, neuro-ophthalmologist, endocrine pathologist and endocrinologist specialized in pituitary diseases. We elaborated this guideline with the aim of sharing our experience with other centers involved in the perioperative and surgical management of PT thereby facilitating the management of patients undergoing PS.

The IDEAL framework in neurosurgery: a bibliometric analysis

BACKGROUND

The Idea, Development, Exploration, Assessment and Long-term study (IDEAL) framework was created to provide a structured way for assessing and evaluating novel surgical techniques and devices.

OBJECTIVES

The aim of this paper was to investigate the utilization of the IDEAL framework within neurosurgery, and to identify factors influencing implementation.

METHODS

A bibliometric analysis of the 7 key IDEAL papers on Scopus, PubMed, Embase, Web of Science, and Google Scholar databases (2009-2019) was performed. A second journal-specific search then identified additional papers citing the IDEAL framework. Publications identified were screened by two independent reviewers to select neurosurgery-specific articles.

RESULTS

The citation search identified 1336 articles. The journal search identified another 16 articles. Following deduplication and review, 51 relevant articles remained; 14 primary papers (27%) and 37 secondary papers (73%). Of the primary papers, 5 (36%) papers applied the IDEAL framework to their research correctly; two were aligned to the pre-IDEAL stage, one to the Idea and Development stages, and two to the Exploration stage. Of the secondary papers, 21 (57%) explicitly discussed the IDEAL framework. Eighteen (86%) of these were supportive of implementing the framework, while one was not, and two were neutral.

CONCLUSION

The adoption of the IDEAL framework in neurosurgery has been slow, particularly for early-stage neurosurgical techniques and inventions. However, the largely positive reviews in secondary literature suggest potential for increased use that may be achieved with education and publicity.

Endonasal endoscopic resection of suprasellar craniopharyngioma: A retrospective single-center case series

INTRODUCTION

Endoscopic endonasal approach (EEA) has recently been proposed as an option for resection of primary and recurrent suprasellar craniopharyngioma. However, surgical outcome has not yet been fully evaluated, especially in regards to recurrent cases.

METHODS

We analysed our institution (Sir Charles Gairdner University Hospital, Perth, Australia) case-series retrospectively. There were 16 patients operated through an endonasal endoscopic approach from February 2014 to February 2019 for suprasellar craniopharyngiomas. There were 14 primary, and two recurrent lesions. Extent of resection, complications, visual and endocrinological outcomes are presented.

RESULTS

Mean age of the patients was 42.9 ± 19.3 years old, with 56% female. The most common clinical symptoms were headaches (9 patients, 56%) and bi-temporal hemianopsia (9 patients, 56%), followed by unilateral optic neuropathy (5 cases, 31%), memory loss (1 case, 6%), hydrocephalus (1 case, 6%), delayed growth and puberty (1 case, 6%), and secondary amenorrhoea (1 case, 6%). Only two cases (12%) initially presented with normal visual function. Gross total resection (GTR) was achieved in 10/16 patients (62.5%), with subtotal resection (STR) in the remainder. Visual symptoms improved in 13/16 patients (81%) and remained unchanged in 3/16 patients (19%). Most common complications included new endocrinological deficit in nine patients (56%), mostly diabetes insipidus, and cerebrospinal fluid leak requiring a new intervention in three patients (19%). There was one mortality case (complicated meningitis, stroke and vasospasm). Mean follow-up time was 22.05 ± 14 months and three patients (19%) had a recurrence of the disease during this period and were referred for radiation therapy.

CONCLUSION

Endonasal endoscopic approach is a safe and effective surgical option for both primary and recurrent suprasellar craniopharyngiomas.

Differential independent impact of the intraoperative use of navigation and angled endoscopes on the surgical outcome of endonasal endoscopy for pituitary tumors: a prospective study

Despite widespread popularity of navigation and angled endoscopes in endonasal endoscopy, there are hardly few studies on their efficacy with the extent of resection or retreatment. This is probably the first study to assess the independent impact of these adjuncts among pituitary tumors. Patients with pituitary tumors undergoing endonasal endoscopy were prospectively studied for their demographics, clinico-radiological features, intraoperative use of navigation, and angled endoscopes, in relation to gross total resection (GTR), near total resection (NTR), endocrine remission, and retreatment. Pertinent statistical analyses were performed. Among a total of 139 patients, navigation and angled endoscopes could be used in 54 and 48 patients, respectively, depending upon their availability rather than chosen as per the case. There was no significant difference in baseline characteristics in relation to their use. The surgeon's perception of immediate benefit was noted among 51.9% while using navigation. The use of angled endoscopes towards the end of resection could help with additional tumor removal in 62.5% of patients. Overall, the use of navigation resulted in a significantly higher GTR (80.8% vs. 59.7%, OR 2.83, p = 0.01), a higher GTR/NTR (86.5% vs. 70.8%, OR 2.65, p = 0.04), and a lower retreatment rate (7.7% vs. 20.8%, OR 3.15, p = 0.05) than the others. In functioning tumors with cavernous sinus invasion, navigation had significantly increased remission rates (69.2% vs. 0%, p = 0.03). The use of angled endoscopes yielded a significantly higher GTR/NTR (91.7% vs. 70.6%, p = 0.04) and a lower retreatment rate (0% vs. 15.7%, p = 0.05) among only non-functioning adenomas. In multivariate analyses, the use of neuronavigation had a significant association with both GTR and retreatment rates (p values 0.005 and 0.02 respectively), independent of other confounding factors. The elective intraoperative use of navigation has a significant independent impact on the extent of resection and retreatment overall. While navigation results in better remission rates among functioning tumors with cavernous sinus invasion, angled endoscopy has a significant association with surgical outcomes in non-functioning tumors.

The Immune Profile of Pituitary Adenomas and a Novel Immune Classification for Predicting Immunotherapy Responsiveness

CONTEXT

The tumor immune microenvironment is associated with clinical outcomes and immunotherapy responsiveness.

OBJECTIVE

To investigate the intratumoral immune profile of pituitary adenomas (PAs) and its clinical relevance and to explore a novel immune classification for predicting immunotherapy responsiveness.

DESIGN, PATIENTS, AND METHODS

The transcriptomic data from 259 PAs and 20 normal pituitaries were included for analysis. The ImmuCellAI algorithm was used to estimate the abundance of 24 types of tumor-infiltrating immune cells (TIICs) and the expression of immune checkpoint molecules (ICMs).

RESULTS

The distributions of TIICs differed between PAs and normal pituitaries and varied among PA subtypes. T cells dominated the immune microenvironment across all subtypes of PAs. The tumor size and patient age were correlated with the TIIC abundance, and the ubiquitin-specific protease 8 (USP8) mutation in corticotroph adenomas influenced the intratumoral TIIC distributions. Three immune clusters were identified across PAs based on the TIIC distributions. Each cluster of PAs showed unique features of ICM expression that were correlated with distinct pathways related to tumor development and progression. CTLA4/CD86 expression was upregulated in cluster 1, whereas programmed cell death protein 1/programmed cell death 1 ligand 2 (PD1/PD-L2) expression was upregulated in cluster 2. Clusters 1 and 2 exhibited a "hot" immune microenvironment and were predicted to exhibit higher immunotherapy responsiveness than cluster 3, which exhibited an overall "cold" immune microenvironment.

CONCLUSIONS

We summarized the immune profile of PAs and identified 3 novel immune clusters. These findings establish a foundation for further immune studies on PAs and provide new insights into immunotherapy strategies for PAs.

Postoperative management of patients with pituitary tumors submitted to pituitary surgery. Experience of a Spanish Pituitary Tumor Center of Excellence

There is a lack of evidence on timing, frequency, and duration of postoperative endocrine, radiologic, and ophthalmologic assessments that should be performed after pituitary surgery (PS). However, it is known that careful optimization of treatment and follow-up strategies as well as a multidisciplinary approach may have a significant impact on long-term outcomes, improving surgical results, minimize complications and facilitate their correct treatment if occurring, and optimize the hormonal, ophthalmological, and radiological reassessment throughout the follow-up. Considering that there are no specific guidelines on the postoperative management of patients with pituitary tumors (PT), we present our protocol for the postoperative management of patients with PT. It has been elaborated by the multidisciplinary team of a Spanish Pituitary Tumor Center of Excellence (PTCE) that includes at least one neurosurgeon, ENT, neuroradiologist, neuro-ophthalmologist, endocrine pathologist and endocrinologist specialized in pituitary diseases. We elaborated this guideline with the aim of sharing our experience with other centers involved in the management of PT thereby facilitating the postoperative management of patients submitted to PS.

Challenges, Learning Curve, and Safety of Endoscopic Endonasal Surgery of Sellar-Suprasellar Lesions in a Community Hospital

BACKGROUND AND OBJECTIVE

Endoscopic endonasal surgery (EES) for the management of sellar, suprasellar, and anterior skull base lesions is gaining popularity. Our aim was to analyze and present the clinical outcomes of EES for the management of these lesions in a community hospital setting.

METHODS

We retrospectively reviewed the charts of 56 patients with sellar, suprasellar, and anterior skull base lesions who underwent EES between 2010 and 2018.

RESULTS

There was male predominance (53.6%) with a mean age of 54.9 ± 13.7 years. Lesions were 45 pituitary adenomas, 5 meningiomas, 3 metastatic, 1 craniopharyngioma, 1 Rathke cyst, and 1 mucocele. Gross total excision was achieved in 57.1%, subtotal excision occurred in 37.5%, and decompression and biopsy were achieved in 5.4% patients. Postoperative vision normalized or improved in 27 patients (86.1%) and was stable in 4 patients (13.9%). Recovery of a preexisting hormonal deficit occurred in 13 (23.2%) patients, and a new hormonal deficit occurred in 9 patients (16.1%). The mean hospital stay was 6.1 ± 4.9 days. Postoperative complications included cerebrospinal fluid leak in 8 patients (14.3%). Four patients (7.1%) had meningitis. Diabetes insipidus was present in 19 patients (33.9%), and postoperative intracranial hematoma requiring evacuation was necessary in 2 patients (3.6%). The mean follow-up duration was 47.5 ± 25.8 months. Lesion progression or recurrence requiring redo surgery occurred in 5 patients (8.9%). Regarding the learning curve, the postoperative cerebrospinal fluid leak, meningitis, new hormonal deficits, and diabetes insipidus decreased in the second half of the patients.

CONCLUSIONS

EES provides an effective and safe surgical option with low morbidity and mortality for the treatment of sellar, suprasellar, and anterior skull base lesions in a community hospital setting.

Pituitary surgery's epidemiology using a national inpatient database in Japan

BACKGROUND

Between 2010 and 2014, microscopic transsphenoidal surgery (mTSS) was performed more frequently than endoscopic TSS (eTSS) in the USA. However, few epidemiological studies on pituitary surgery are currently available.

METHODS

We performed a retrospective study on patients who had undergone pituitary surgery between July 2010 and March 2016. To this end, a nationwide inpatient database in Japan was used. Patients' characteristics, diagnoses, types of surgery, complications, and discharge status were examined.

RESULTS

A total of 16,253 inpatients who received pituitary surgery were identified. Patients were diagnosed with diseases for insurance claims described below: pituitary adenoma, hyperprolactinemia, other pituitary disorders (e.g., Rathke's cleft cyst), hyperpituitarism, craniopharyngioma, acromegaly, Cushing's disease, and pituitary cancer. Among them, pituitary adenomas, primarily the non-functioning ones, were the most frequent (66.9%). A total of 14,285 (88%) patients underwent TSS, while 1968 (12%) patients were treated using transcranial surgery. The number of patients undergoing TSS increased each year. The number of eTSS operations was 8140 (77%) and that of mTSS operations was 2419 (23%). Of note, eTSS increased each year. We found that high-volume hospitals more frequently selected eTSS. Compared with mTSS, eTSS was associated with a reduction of hyponatremia incidence (odds ratio, 0.69; p = 0.019). Additionally, it was not associated with other major complications.

CONCLUSION

The present study showed that both TSS and eTSS increased on a yearly basis. We believe that the present study will be the basis of future epidemiological investigations of pituitary surgery.

Ten years’ experience with intraoperative MRI-assisted transsphenoidal pituitary surgery

OBJECTIVE

Many innovations have been introduced into pituitary surgery in the quest to maximize the extent of tumor resection. Because of the deep and narrow surgical corridor as well as the heterogeneity of confronted pathologies, anatomical orientation and identification of the target tissue can become difficult. Intraoperative MRI (iMRI) may have the potential to increase extent of resection (EOR) in transsphenoidal pituitary surgery. Furthermore, it may simplify anatomical orientation and risk assessment in difficult cases. Here, the authors evaluated the additional value of iMRI for the resection of pituitary adenomas performed in the past 10 years in their department.

METHODS

They performed a retrospective single-center analysis of patients treated for pituitary adenoma in their department after the introduction of iMRI between 2008 and 2018. Of 495 transsphenoidal approaches, 300 consecutive MRI-assisted surgeries for pituitary adenomas encompassing 294 patients were selected for further analysis. Microscopic, endoscopic, or endoscope-assisted microscopic transsphenoidal approaches were distinguished. EOR as well as additional resection following iMRI was evaluated via detailed volumetric analysis. Patients were stratified according to the Knosp adenoma classification. Furthermore, demographic data, clinical symptoms, endocrine outcome, and complications were evaluated. Univariable and multivariable Cox regression analyses of progression-free survival (PFS) were performed.

RESULTS

Pituitary adenomas classified as Knosp grades 0–2 were found in 60.3% of cases (n = 181). The most common tumors were nonfunctioning adenomas (75%). Continued resection following iMRI significantly increased EOR (7.5%, p < 0.001) and the proportion of gross-total resections (GTRs) in transsphenoidal pituitary surgery (54% vs 68.3%, p < 0.001). Additional resection after iMRI was performed in 37% of cases. Only in the subgroup of patients with Knosp grades 0–2 adenomas treated with the microsurgical technique was additional resection significantly more common than in the endoscopic group (p = 0.039). Residual tumor volume, Knosp grade, and age were confirmed as independent predictors of PFS (p < 0.001, p = 0.021, and p = 0.029, respectively) in a multivariable Cox regression analysis. Improvement of visual field deficits was documented in 78.6% of patients whose optic apparatus had been affected preoperatively. Revision surgery was done in 7.3% of cases; in 5.6% of cases, it was performed for cerebrospinal fluid fistula.

CONCLUSIONS

In this series, iMRI led to the detection of a resectable tumor remnant in a high proportion of patients, resulting in a greater EOR and higher proportion of GTRs after continued resection in microsurgical and endoscopic transsphenoidal resection of pituitary adenomas. The volume of residual tumor was the most important predictor of PFS. Given the study data, the authors postulated that every bit of removed tumor serves the patient and increases their chances of a favorable outcome.

Systematic review and network meta-analysis assess the comparative efficacy and safety of transsphenoidal surgery for pituitary tumor

To quantitatively synthesize the comparative efficacy and safety of the most common surgical approaches including endonasal transsphenoidal endoscopic surgery (ETES), sublabial transsphenoidal microsurgery (STMS) and endonasal transsphenoidal microsurgery (ETMS) for all kinds of pituitary tumors. This systematic review and network meta-analysis was performed on randomized controlled trials (RCTs) and comparison studies from databases of Pubmed, EMBASE, and the Cochrane library. We selected the rate of gross complete resection as our primary outcome of efficacy. And the incidence of all complications, cerebrospinal fluid (CSF) leak, diabetes insipidus, nasal septal perforation, death, and bleeding were designed as our primary outcomes of safety. Twenty-seven studies with 2618 patients were included in this network meta-analysis. On efficacy, there was no statistical difference among the three methods including ETES, STMS, and ETMS. As for safety, results indicated that the incidence of total complications of STMS (OR = 4.74; 95% CI 1.03, 40.14) is significantly superior to ETES. And the incidence of diabetes insipidus of ETMS (OR = 2.21; 95% CI 1.31, 3.81) was significantly superior to that of ETES. Besides, there was no statistical difference in the other complications including CSF leak, nasal septal perforation, death, and bleeding. We clarified the overpraise of the efficacy of endoscopy especially the endonasal transsphenoidal approach, and verified that all the approaches owned similar efficacy. Moreover, we recommended the endoscopy to be the first choice for pituitary tumors, because it demonstrated the best safety.

Comparison of Short-Term Outcomes Between Endoscopic and Microscopic Trans-Sphenoidal Surgery for the Treatment of Pituitary Adenoma

OBJECTIVE

Until today, it is unclear if endoscopic or microscopic transsphenoidal surgery is the most adequate treatment technique for pituitary adenoma, while microscopic transsphenoidal surgery is termed as a fully-established mechanism that has reasonable performances and is well recognized for addressing adenomas of the pituitary gland. The present research work aims at assessing the short-term results of these surgical methodologies in those patients, who have pituitary adenoma.

METHODS

The authors comprehensively searched PubMed, together with EMBASE, and Cochrane Library databases for the purpose of identifying associated investigations. The strength of the relationship was figured out through the calculation of the risk ratio (RR) with corresponding 95% credible interval (95% CI) were put to use for the evaluation of the association.

RESULTS

An aggregate of 17 retrospective studies that involved 1177 participants were included in the present research work. Our results shed light on the fact that endoscopic transsphenoidal surgery was linked to the lower occurrence of diabetes insipidus (RR = 1.42, 95%CI = 1.03-1.98, P = 0.03), fewer septal perforation (RR = 3.16, 95%CI = 1.27-7.85, P = 0.01), and fewer postoperative complications (RR = 1.29, 95% CI = 1.08-1.56, P = 0.006). Moreover, further analyzing indicated no substantial differences existing between the 2 surgical methods in gross tumor removal, meningitis, epistaxis, and cerebrospinal fluid leak.

CONCLUSION

Endoscopic transsphenoidal surgery reduces diabetes insipidus, septal perforation, and postoperative complications in treating those patients, who have pituitary adenoma. Endoscopic transsphenoidal surgery is worth suggesting as a productive as well as secure process for the treatment of pituitary adenoma.

Endoscopic subperichondrial transseptal transsphenoidal approach is safe and efficient for non-extended pituitary surgery

PURPOSE

To report the results of a series of patients undergoing the endoscopic subperichondrial transseptal (STRAS) approach for pituitary surgery and to evaluate the efficiency and the safety of this approach.

METHODS

This is a single-centre retrospective study including all patients undergoing pituitary lesion resection through the STRAS approach from January 2002 to December 2017 by a multidisciplinary surgical team (ENT and neurosurgeon). Demographic data, tumour type, complication rate and pre- and post-operative visual, endocrine and tumour status were retrospectively analysed.

RESULTS

119 patients were included in the study, 80 (67%) presenting macroadenoma, 24 (20%) microadenoma (20%) and 6 (5%) giant adenoma. 61 (51%) patients had secreting adenoma and 51 (42%) patient had non-functioning adenoma. The STRAS approach allowed a good visualization of intrasphenoidal and intrasellar anatomical landmarks in all cases and no patient needed turbinate resection. No patient died or had neurological deficit. Endocrine remission or control was achieved in 90.5% of hormone-secreting microadenomas and in 84.2% of hormone-secreting macroadenomas. Gross-total resection was achieved for 39 patients (48.8%) of the 80 macroadenomas. Nasal complication rate was very low, with no septal perforation and two epistaxis (1.7%) medically treated.

CONCLUSION

The STRAS approach is an elegant approach to the sphenoid sinus that enables a good exposure of the intrasphenoidal anatomical landmarks with a maximal preservation of the nasal mucosa. This approach allows an intrasellar work with great comfort and safety for the surgeon using a two-hand or a four-hand technique.

Intra-operative MRI vs endoscopy in achieving gross total resection of pituitary adenomas: a systematic review

BACKGROUND

Intraoperative magnetic resonance imaging (iMRI) is a technology that may improve rates of gross total resection (GTR) for pituitary adenomas. The endoscope is another less expensive technology, which also may maximize resection rates. A direct comparison of these approaches and their additive benefit has never been performed.

METHODS

A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) standard. PubMed and Embase databases were searched for studies that examined GTR for pituitary adenoma resection with either endoscopic transsphenoidal surgery (eTSS), microscopic transsphenoidal surgery with iMRI (mTSS + iMRI), or endoscopic transsphenoidal surgery with iMRI (eTSS + iMRI).

RESULTS

Eighty-five studies that reported GTR rates in 7124 pituitary adenoma patients were identified. For all pituitary adenomas, eTSS had a pooled proportion of GTR of 68.9% (95% CI 64.7-73.0%) which was similar to that of mTSS + iMRI (GTR 68.3%; 95% CI = 59.4-76.5%) and eTSS + iMRI (GTR 70.7%; 95% CI = 56.9-89.6%). For the subgroup of pituitary macroadenomas, pooled proportions for GTR were similar between eTSS and mTSS + iMRI (eTSS: GTR 59.4%; 95% CI = 49.6-68.7% vs mTSS + iMRI: GTR 68.8%; 95% CI = 57.3-79.3%), and higher for eTSS + iMRI (81.1%; 95% CI = 75.5-86.2%). The post-operative CSF leak proportion for eTSS (4.7%; 95% CI = 3.6-5.9%) was similar to that for eTSS + iMRI (3.7%; 95% CI = 1.6-6.5%) and mTSS + iMRI (4.6%; 95% CI = 2.0-8.3%). No direct statistical comparisons could be performed.

CONCLUSION

Final GTR proportions are similar whether the surgeon uses a microscope supplemented with iMRI or endoscope with or without iMRI. The benefit of the two technologies may be complementary for macroadenomas. These findings are important to consider when comparing the efficacy of different technical strategies in the management of pituitary adenomas.

Non-functioning pituitary adenomas: indications for pituitary surgery and post-surgical management

PURPOSE

Non-functioning pituitary adenomas (NFPAs) are associated with impaired well-being, increased comorbidities, and reduced long-term survival. Data on optimal management of NFPAs around surgical treatment are scarce, and postoperative treatment and follow-up strategies have not been evaluated in prospective trials. Here, we review the preoperative, perioperative, and early postoperative management of patients with NFPAs.

METHODS

We searched Medline and the Cochrane Library for articles published in English with the following items "Pituitary neoplasms AND Surgery" and "Surgery AND Hypopituitarism". Studies containing detailed analyses of the management of NFPAs in adult patients, including pituitary surgery, endocrine care, imaging, ophthalmologic assessment and long-term outcome were reviewed.

RESULTS

Treatment options for NFPAs include active surveillance, surgical resection, and radiotherapy. Pituitary surgery is currently recommended as first-line treatment in patients with visual impairment due to adenomas compressing the optic nerves or chiasma. Radiotherapy is reserved for large tumor remnants or tumor recurrence following one or more surgical attempts. There is no consensus of optimal pre-, peri-, and postoperative management such as timing, frequency, and duration of endocrine, radiologic, and ophthalmologic assessments as well as management of smaller tumor remnants or tumor recurrence.

CONCLUSIONS

In clinical practice, there is a great variation in the treatment and follow-up of patients with NFPAs. We have, based on available data, suggested an optimal management strategy for patients with NFPAs in relation to pituitary surgery. Prospective trials oriented at drawing up strategies for the management of NFPAs are needed.

Economics of Acromegaly Treatment in Brazil: A Budget Impact Analysis of Pituitary Surgery Compared with Long-Term Octreotide LAR

BACKGROUND

Acromegaly is a rare, chronic and debilitating disease whose treatment places a high burden on health systems. In the reality of the Brazilian public health network, many patients are kept on drug treatment because of barriers to access to surgery.

OBJECTIVE

The aim of this study was to estimate the costs and budget impact of routine transsphenoidal endoscopic surgery in relation to those of long-term drug treatment with octreotide long-acting release (LAR) from a cohort of patients followed at the referral medical centre for acromegaly treatment in the Federal District, Brazil.

METHODS

Based on micro-costing data collected using mixed methods from a local perspective of the public health system, we performed a budget impact analysis (BIA) on a 3-year time horizon. Uncertainty was handled with deterministic (tornado and scenario) and probabilistic (Monte Carlo simulations) sensitivity analyses.

RESULTS

Compared with the continued use of octreotide LAR at a dose of 30 mg every 28 days, the incremental budget impact of conducting two surgeries per month, considering a cure rate of 55%, could bring savings of approximately US$879,362.18 (95% CI 860,176.29-898,548.08) over 3 years. Depending on the key variable values, the savings amplitude ranged from US$431,836.39 to US$1,519,132.04.

CONCLUSIONS

Improving access to surgery could result in significant cost reductions in acromegaly treatment. The present study stands out for being the first to estimate the costs of transsphenoidal surgery in the context of the public health system in Brazil.

Indocyanine-Green for Fluorescence-Guided Surgery of Brain Tumors: Evidence, Techniques, and Practical Experience

The primary treatment for brain tumors often involves surgical resection for diagnosis, relief of mass effect, and prolonged survival. In neurosurgery, it is of utmost importance to achieve maximal safe resection while minimizing iatrogenic neurologic deficit. Thus, neurosurgeons often rely on extra tools in the operating room, such as neuronavigation, intraoperative magnetic resonance imaging, and/or intraoperative rapid pathology. However, these tools can be expensive, not readily available, time-consuming, and/or inaccurate. Recently, fluorescence-guided surgery has emerged as a cost-effective method to accurately visualize neoplastic areas in real-time to guide resection. Currently, 5-aminolevulinic-acid (5-ALA) remains the only fluorophore that has been approved specifically for fluorescence-guided tumor resection. Its use has demonstrated improved resection rates and prolonged progression-free survival. However, protoporphyrin-IX, the metabolic product of 5-ALA that accumulates in neoplastic cells, fluoresces in the visible-light range, which suffers from limited tissue penetration and significant auto-fluorescence. Near-infrared fluorescence, on the other hand, overcomes these problems with ease. Since 2012, researchers at our institution have developed a novel technique using indocyanine-green, which is a well-known near-infrared fluorophore used traditionally for angiography. This Second-Window-ICG (SWIG) technique takes advantage of the increased endothelial permeability in peritumoral tissue, which allows indocyanine-green to accumulate in these areas for intraoperative visualization of the tumor. SWIG has demonstrated utility in gliomas, meningiomas, metastases, pituitary adenomas, chordomas, and craniopharyngiomas. The main benefits of SWIG stem from its highly sensitive detection of neoplastic tissue in a wide variety of intracranial pathologies in real-time, which can help neurosurgeons both during surgical resections and in stereotactic biopsies. In this review of this novel technique, we summarize the development and mechanism of action of SWIG, provide evidence for its benefits, and discuss its limitations. Finally, for those interested in near-infrared fluorescence-guided surgery, we provide suggestions for maximizing the benefits while minimizing the limitations of SWIG based on our own experience thus far.

Recovery of Adrenal Function after Pituitary Surgery in Patients with Cushing Disease: Persistent Remission or Recurrence?

BACKGROUND

Cushing disease (CD) represents the principal cause of endogenous hypercortisolism. The first-line therapy of CD is surgical removal of the ACTH-secreting pituitary adenoma, which is generally followed by adrenal insufficiency (AI).

OBJECTIVE

To analyze the recovery of AI in patients with CD after pituitary surgery in relation with recurrence and persistent remission of CD.

PATIENTS AND METHODS

We performed a retrospective analysis of patients with CD who met the following inclusion criteria: adult age, presence of AI 2 months after the surgical intervention, and a minimum follow-up of 3 years after the surgical intervention.

RESULTS

Sixty-one patients were followed for a median of 6 years. Ten (16.4%) patients recurred during follow-up. The patients who restored adrenal function did so after a median time of 19 months, with a significantly shorter time in the recurrence group (12.5 vs. 25 months, p = 0.008). All 10 patients who recurred recovered their adrenal function within 22 months. The recovery rate of AI in the persistent remission group was 37.3% (19/51) at 3 years and 55.8% (24/43) at 5 years. In all patients the duration of AI was negatively associated with disease recurrence.

CONCLUSION

The duration of postsurgical AI in patients with recurrent CD is significantly shorter than that in patients with persistently remitted CD, and this parameter may be a useful predictor of recurrence. Patients showing a normal pituitary-adrenal axis within 2 years after surgery should be strictly monitored as they are at higher risk of disease relapse.

Nasal Morbidity and Quality of Life After Endoscopic Transsphenoidal Surgery: A Single-Center Prospective Study

OBJECTIVE

The aim of this study was to assess nasal morbidity of endoscopic transsphenoidal approaches (ETAs) for treatment of sellar and parasellar diseases through evaluation of quality of life (QoL) and nasal function. The impact of different ETAs, according to extent and reconstruction technique, was also studied.

METHODS

Patients undergoing ETA for treatment of sellar or parasellar lesions were prospectively recruited and examined preoperatively and at 6 months after surgery according to the following workup: nasal endoscopy, rhinomanometry, acoustic rhinometry, University of Pennsylvania Smell Identification Test, Anterior Skull Base Nasal Inventory-12, Sino-nasal Outcome Test-22, and Short-Form Health Survey-36 (SF-36).

RESULTS

Of 34 patients initially recruited, 29 completed follow-up examinations. Seven patients (24.14%) developed turbinoseptal synechiae; anterior septal perforations were observed in 3 patients (10.35%). More extended surgical dissection was associated with the presence of postoperative septal perforation and synechiae. No significant difference was noted between preoperative and postoperative results on the University of Pennsylvania Smell Identification Test, acoustic rhinometry, Sino-nasal Outcome Test-22, or Anterior Skull Base Nasal Inventory-12. There was a significant increase in nasal airflow after surgery and improvement of the Short-Form Health Survey-36 score in 4 of 8 domains.

CONCLUSIONS

The modular ETA technique is associated with minimal morbidity and preserves nasal patency, airflow, and olfactory function. Quality of life is not affected and although small septal perforations and synechiae can be observed, nasal physiology is not compromised. Nonetheless, careful manipulation of sinonasal structures is recommended to minimize postoperative sequelae.

The experience with transsphenoidal surgery and its importance to outcomes

PURPOSE

Surgical experience is considered paramount for excellent outcome of transsphenoidal surgery (TSS). However, objective data demonstrating the surgical success in relation to the experience of pituitary surgery units or individual experience of pituitary surgeons is sparse.

METHODS

Based on literature data, we have investigated the influence of experience with TSS for pituitary adenomas on endocrinological remission rates and on operative complications. The surgical experience was assessed by calculating the number of transsphenoidal operations per year.

RESULTS

For TSS of microprolactinomas, mean remission rates were 77% in centers with < 2 operations per year for microprolactinomas, 82% with 2-4 operations, 84% with 4-6 operations, and 91% with > 6 operations. A yearly experience with more than 10 initial operations for Cushing's disease (CD) warrants a remission rate exceeding 70%. Remission rates in CD exceeding 86% have only been reported for single surgeon series. Extraordinarily high complication rates were found in some series with < 25 yearly total operations for pituitary adenomas. Major vascular complications were less than 2% and revision rates for rhinorrhea usually < 2.5% in centers performing > 25 transsphenoidal operations per year.

CONCLUSIONS

We conclude that a center with experience of > 25 transsphenoidal operations for pituitary adenomas per year provides a high likelihood of safe TSS. Surgery for CD requires a particularly high level of practice to guarantee excellent remission rates. The endocrinologist has the unique opportunity to audit the surgical success by hormone measurement and to refer patients to neurosurgeons with proven excellence.