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Salmon MK, Eide JG, Kshirsagar RS, Blue R, Yoshor D, Sean Grady M, Lee JYK, Palmer JN, Adappa ND. Multi-institutional Analysis of Endoscopic Sellar Surgical Volumes During the COVID-19 Pandemic. Otolaryngol Head Neck Surg 2024; 170:260-264. [PMID: 37622585 DOI: 10.1002/ohn.505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 07/22/2023] [Accepted: 08/01/2023] [Indexed: 08/26/2023]
Abstract
OBJECTIVE We sought to quantify trends in operative volumes and complications of endoscopic sellar surgery before and after the COVID-19 pandemic onset. STUDY DESIGN We performed a retrospective analysis. SETTING TriNetX database analysis. METHODS All adults undergoing neuroendoscopy for resection of pituitary tumor (Current Procedural Terminology code 62165) with diagnosis of benign/malignant neoplasm of pituitary gland (D35.2/C75.1) or benign/malignant neoplasm of craniopharyngeal duct (D35.3/C75.2) were included using the TriNetX database for 2 years before (pre-COVID group) and 2 years after (post-COVID group) February 17, 2020. RESULTS A total of 1238 patients in the pre-COVID group and 1186 patients in the post-COVID group were compared. Age, gender, and race were statistically similar between the groups (P > .05). Surgical volume decreased by 6% in the post-COVID group. In 2020 Q2, operative volume decreased by 19%, and in 2021 Q4 (peak COVID-19 caseload in the United States), operative volumes decreased by 29% compared to 2 years prior. Postoperative complications including meningitis (P = .49), cerebrospinal fluid leak (P = .36), visual field deficits (P = .07), postoperative pneumonia or respiratory failure (P = .42), and 30-day readmission rates (P = .89) were similar between the 2 groups. CONCLUSION Overall, endoscopic sellar surgery may continue to fluctuate with increased COVID-19 outbreaks. Patient outcomes do not appear to be worsened by decreased operative volumes or delays in nonurgent surgeries.
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Affiliation(s)
- Mandy K Salmon
- Department of Otorhinolaryngology-Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jacob G Eide
- Department of Otorhinolaryngology-Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rijul S Kshirsagar
- Department of Otorhinolaryngology-Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rachel Blue
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Daniel Yoshor
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael Sean Grady
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - John Y K Lee
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - James N Palmer
- Department of Otorhinolaryngology-Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nithin D Adappa
- Department of Otorhinolaryngology-Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Park J, Golub D, White TG, Ruelle M, Quach ET, Yang K, Shah HA, Fastenberg JH, Eisenberg MB, Dehdashti AR. Anterior-posterior diameter is a key driver of resectability and complications for pituitary adenomas with suprasellar extension in endoscopic transsphenoidal surgery. Pituitary 2023; 26:629-641. [PMID: 37713155 DOI: 10.1007/s11102-023-01354-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/08/2023] [Indexed: 09/16/2023]
Abstract
BACKGROUND As endoscopic transsphenoidal approaches are more routinely selected for progressively larger pituitary adenomas with parasellar extension, understanding potential anatomical factors that limit resection and contribute to complications is becoming increasingly important for tailoring a surgical approach. This study aimed to reevaluate existing predictive tools for resectability in pituitary adenomas specifically with suprasellar extension, and furthermore identify any additional measurable features that may be more useful in preoperative planning. METHODS A single-center retrospective chart review of adult patients who underwent endoscopic transsphenoidal surgery for pituitary adenomas with suprasellar extension from 2015 to 2020 was performed. Preoperative MRIs were systematically assessed to assign a Knosp classification, a Zurich Pituitary Score (ZPS), and for dimensional measurements of the suprasellar aspect of the lesions. Univariate comparisons and multivariate regression models were employed to assess the influence of these factors on extent of resection and postoperative complications. RESULTS Of the 96 patients with suprasellar pituitary adenomas who underwent endoscopic transsphenoidal surgery, 74 patients (77%) had a gross total resection (GTR). Neither Knosp grade nor ZPS score, even when dichotomized, demonstrated an association with GTR (Knosp 3A-4 versus Knosp 0-2, p = 0.069; ZPS III-IV versus ZPS I-II, p = 0.079). Multivariate regression analysis identified suprasellar anterior-posterior tumor diameter (SSAP) as the only significant predictor of extent of resection in this cohort (OR 0.951, 95% CI 0.905-1.000, p = 0.048*). A higher SSAP also had the strongest association with intraoperative CSF leaks (p = 0.0012*) and an increased overall rate of postoperative complications (p = 0.002*). Further analysis of the regression model for GTR suggested an optimal cut point value for SSAP of 23.7 mm, above which predictability for failing to achieve GTR carried a sensitivity of 89% and a specificity of 41%. CONCLUSIONS This study is unique in its examination of endoscopic transsphenoidal surgical outcomes for pituitary adenomas with suprasellar extension. Our findings suggest that previously established grading systems based on lateral extension into the cavernous sinus lose their predictive value in lesions with suprasellar extension and, more specifically, with increasing suprasellar anterior-posterior diameter.
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Affiliation(s)
- Jung Park
- Department of Neurosurgery, Northwell Health, Manhasset, NY, USA
| | - Danielle Golub
- Department of Neurosurgery, Northwell Health, Manhasset, NY, USA.
| | - Timothy G White
- Department of Neurosurgery, Northwell Health, Manhasset, NY, USA
| | - Marianne Ruelle
- Zucker School of Medicine at Hofstra/Northwell Health, Hempstead, NY, USA
| | - Eric T Quach
- Department of Neurosurgery, Northwell Health, Manhasset, NY, USA
| | - Kaiyun Yang
- Department of Neurosurgery, Northwell Health, Manhasset, NY, USA
| | - Harshal A Shah
- Zucker School of Medicine at Hofstra/Northwell Health, Hempstead, NY, USA
| | - Judd H Fastenberg
- Department of Otolaryngology-Head and Neck Surgery, Northwell Health, Manhasset, NY, USA
| | - Mark B Eisenberg
- Department of Neurosurgery, Northwell Health, Manhasset, NY, USA
| | - Amir R Dehdashti
- Department of Neurosurgery, Northwell Health, Manhasset, NY, USA
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Luzzi S, Giotta Lucifero A, Rabski J, Kadri PAS, Al-Mefty O. The Party Wall: Redefining the Indications of Transcranial Approaches for Giant Pituitary Adenomas in Endoscopic Era. Cancers (Basel) 2023; 15:cancers15082235. [PMID: 37190164 DOI: 10.3390/cancers15082235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 03/14/2023] [Accepted: 03/29/2023] [Indexed: 05/17/2023] Open
Abstract
The evolution of endoscopic trans-sphenoidal surgery raises the question of the role of transcranial surgery for pituitary tumors, particularly with the effectiveness of adjunct irradiation. This narrative review aims to redefine the current indications for the transcranial approaches for giant pituitary adenomas in the endoscopic era. A critical appraisal of the personal series of the senior author (O.A.-M.) was performed to characterize the patient factors and the tumor's pathological anatomy features that endorse a cranial approach. Traditional indications for transcranial approaches include the absent pneumatization of the sphenoid sinus; kissing/ectatic internal carotid arteries; reduced dimensions of the sella; lateral invasion of the cavernous sinus lateral to the carotid artery; dumbbell-shaped tumors caused by severe diaphragm constriction; fibrous/calcified tumor consistency; wide supra-, para-, and retrosellar extension; arterial encasement; brain invasion; coexisting cerebral aneurysms; and separate coexisting pathologies of the sphenoid sinus, especially infections. Residual/recurrent tumors and postoperative pituitary apoplexy after trans-sphenoidal surgery require individualized considerations. Transcranial approaches still have a critical role in giant and complex pituitary adenomas with wide intracranial extension, brain parenchymal involvement, and the encasement of neurovascular structures.
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Affiliation(s)
- Sabino Luzzi
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy
- Neurosurgery Unit, Department of Surgical Sciences, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Alice Giotta Lucifero
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy
- Department of Brain and Behavioral Sciences, University of Pavia, 27100 Pavia, Italy
| | - Jessica Rabski
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Paulo A S Kadri
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
- Medical School, Federal University of Mato Grosso do Sul, Campo Grande 79070-900, Brazil
| | - Ossama Al-Mefty
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
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Balogun JA, Daniel A, Idowu OK. Navigating the learning curve with large and giant tumors: Initial experience with endoscopic endonasal transphenoidal resection of PitNETs. J Clin Neurosci 2023; 112:6-11. [PMID: 37023497 DOI: 10.1016/j.jocn.2023.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 03/21/2023] [Accepted: 04/01/2023] [Indexed: 04/08/2023]
Abstract
BACKGROUND The endoscopic endonasal approach (EEA) has progressively become the preferred choice of surgical intervention for PitNETs. However, the adoption in Sub-Saharan Africa has been low. We report our initial experience with the utility of the EEA in PitNETs particularly in large and giant tumors despite limited resources. METHODS The study was over a 73-month period at the University College Hospital, Ibadan, Nigeria. Pre and post-operative clinical, imaging and neuro-ophthalmological findings were documented. Perioperative and postoperative outcomes were recorded. We compared the outcomes between the early 23 and later 22 patients. Data were analyzed using descriptive statistics, student's t test, Mann-Whitney U test and Chi square test at α = 0.05. RESULTS There were 45 patients; 25(55.6%) were males. Mean age was 49.9 ± 13.4 years. Visual symptoms predominated with 12(26%) blind in at least one eye. Median tumor volume was 20.9 cm3 and mean tumor diameter was 4.09 ± 0.89 cm. 31(68.9%) had gross or near total excision. Vision improved in 31(68.9%). There were 2 procedure related mortality from CSF leak/meningitis. The mean of the tumor diameter of the earlier patients was less than that of the latter (3.84 vs 4.40 cm, p = 0.04,). The latter group also had more gross or near total resections (26.8% versus 41.5%) but this was not statistically significant. There was no difference in postoperative complications. CONCLUSIONS EEA remains a veritable option for PitNETs, including for large and huge tumors, even within resource challenged environments, with acceptable limits of complications.
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Affiliation(s)
- James Ayokunle Balogun
- Division of Neurosurgery, Department of Surgery, College of Medicine, University of Ibadan, Nigeria; Department of Neurosurgery, University College Hospital, Ibadan, Nigeria.
| | - Adekunle Daniel
- Department of Otorhinolaryngology, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Olusola Kayode Idowu
- Department of Anaesthesia, College of Medicine, University of Ibadan, Ibadan, Nigeria
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Harel E, Cossu G, Daniel RT, Messerer M. Relationship with the diaphragm to predict the surgical outcome in large and giant pituitary adenomas. Front Surg 2022; 9:962709. [PMID: 36211275 PMCID: PMC9534030 DOI: 10.3389/fsurg.2022.962709] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 07/25/2022] [Indexed: 11/23/2022] Open
Abstract
Objective Large and giant pituitary adenomas (L- and G-PAs) continue to remain a surgical challenge. The diaphragm may have a role in determining the shape of the tumor and therefore influencing the extent of resection. Our study aims to analyze our surgical series of L- and G-PAs according to their relationship with the diaphragm and invasion of cavernous sinus (CS). Material and methods We performed a retrospective analysis of our surgical series of patients operated for L- and G-PAs. We categorized the tumors into four grades according to their relationship with the diaphragm: grade 1 (supradiaphragmatic component with a wide incompetent diaphragm), grade 2 (purely infra-diaphragmatic tumor with a competent diaphragm), grade 3 (dumbbell-shape tumors), and grade 4 (multilobulated tumor with invasion of the subarachnoid space). Results A total of 37 patients were included in our analysis. According to our classification, 43.3% of patients had grade 1 tumors, 27% had grade 2, 5.4% had grade 3, and 24.3% had grade 4 tumors. CS invasion was confirmed intraoperatively in 17 out of 37 patients (46%). The gross total resection (GTR) was obtained in 19% of the cases, near-total resection in 46%, and subtotal resection in 35%. All the patients who achieved GTR had grade 1 tumors and the lowest rate of CS invasion (p < 0.01). Conclusion Radiological evaluation of the tumor relationship with the diaphragm, invasion of CS, and invasion of the subarachnoid space are crucial to plan the surgical strategy and maximize the possibilities of achieving GTR in L- and G-PAs.
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Chalif EJ, Couldwell WT, Aghi MK. Effect of facility volume on giant pituitary adenoma neurosurgical outcomes. J Neurosurg 2022; 137:658-667. [PMID: 35171824 DOI: 10.3171/2021.11.jns211936] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 11/08/2021] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Giant pituitary adenomas (PAs), defined as 4 cm or greater at their maximum diameter, are commonly treated with neurosurgical intervention as the first-line therapy. However, existing studies are from high-volume institutions whose outcomes may not be representative of many cancer centers. In the present study, the authors use a large cancer registry to evaluate demographics, national treatment trends, and outcomes by facility volume to address knowledge gaps for this uncommon tumor. METHODS The National Cancer Database was queried for adult patients with PAs who had undergone resection from 2004 to 2016. Univariate and multivariate logistic regression modeling was used to evaluate the prognostic impact of covariates on short-term outcomes including 30-day readmission (30R), 30-day mortality (30M), 90-day mortality (90M), and prolonged length of inpatient hospital stay (LOS). Propensity score matching was used for validation. RESULTS Among the 39,030 patients who met the study inclusion criteria, 3696 giant PAs were identified. These tumors had higher rates of subtotal resection (55% vs 24%, p < 0.001), adjunctive radiotherapy (15% vs 5%, p < 0.001), and hormonal therapy (8% vs 4%, p < 0.001) than nongiant PAs. The giant PAs also had worse 30M (0.6% vs 3.1%, p < 0.001), 90M (1.0% vs 5.0%, p < 0.001), 30R (4.0% vs 6.3%, p < 0.001), and LOS (22.2% vs 42.1%, p < 0.001). On multivariate analysis for giant PA, decreased tumor size, younger age, race other than African American, lower comorbidity score, and high-volume facility (HVF; defined as ≥ 2.5 giant PA cases per year) were statistically significant predictors of favorable outcomes. Specifically, 30M, 90M, 30R, and LOS were decreased by 50%, 43%, 55%, and 32%, respectively, when giant PAs were treated at HVFs (each p < 0.05). HVFs more often used the endoscopic approach (71% vs 46%, p < 0.001) and less adjuvant radiotherapy (11% vs 16%, p < 0.001). Propensity score matching validated 30M, 30R, and LOS outcome differences in a cohort of 1056 patients. CONCLUSIONS This study provides evidence of superior outcomes when giant PAs are treated at HVFs. These results likely reflect the relation between physician experience and outcomes for these uncommon tumors, which suggests the need for institutional collaboration as a potential goal in their surgical management.
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Affiliation(s)
- Eric J Chalif
- 1Department of Neurological Surgery, University of California, San Francisco, California; and
| | | | - Manish K Aghi
- 1Department of Neurological Surgery, University of California, San Francisco, California; and
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Shukla D, Konar S, Kulkarni A, Bhat DI, Sadashiva N, Devi BI, Dikshit P, Mehta S, Jain C. A new comprehensive grading for giant pituitary adenomas: SLAP grading. Br J Neurosurg 2022; 36:377-384. [PMID: 35361030 DOI: 10.1080/02688697.2022.2057432] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
AimGiant pituitary adenomas are difficult to resect due to multicompartmental extension. We developed a new grading system for giant pituitary adenomas (GPAs) considering possible extension in superior, lateral, anterior, and posterior (SLAP) directions. We also related the degree of resection to the SLAP grading.MethodsA review of case files and radiological images of patients with the GPAs defined as pituitary adenomas with a size of more than 4 cm in any dimension was done. The extent of the tumour was noted and scored as per the SLAP system. The maximum total score is 10 and represents a large tumour with maximum extensions in all directions. The subtotal resection (STR) was defined as a residual tumour volume of more than 10%. The association between individual and total score on the degree of resection was determined.ResultsA total of 103 cases of GPAs were analyzed. All patients had a suprasellar (S) extension. The lateral (L) extension was seen in 97.3% of cases. The anterior (A) extension was seen in 28 (27.2%) cases. The posterior (P) extension was seen in 45 (43.7%). Forty-eight (46.6%) had a total score of 5 or more. The STR was achieved in 64 (62.2%) cases. On regression analysis, a total score of ≥5 was associated with odds of 5.02 (1.69-14.93), p-value 0.004 for STR.ConclusionThe SLAP grading is a comprehensive grading system that can be applied easily to the GPAs and gives a complete picture of the extension of the tumour.
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Affiliation(s)
- Dhaval Shukla
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| | - Subhas Konar
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| | - Akshay Kulkarni
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| | - Dhananjaya I Bhat
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India.,Department of Neurosurgery, RV Aster Hospital, Bangalore, India
| | - Nishanth Sadashiva
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| | - Bhagavatula Indira Devi
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| | - Priyadarshi Dikshit
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India.,Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute, Lucknow, India
| | - Sarthak Mehta
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| | - Chirag Jain
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
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Tang OY, Hsueh WD, Eloy JA, Liu JK. Giant Pituitary Adenoma – Special Considerations. Otolaryngol Clin North Am 2022; 55:351-379. [DOI: 10.1016/j.otc.2021.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Ko CC, Chang CH, Chen TY, Lim SW, Wu TC, Chen JH, Kuo YT. Solid tumor size for prediction of recurrence in large and giant non-functioning pituitary adenomas. Neurosurg Rev 2021; 45:1401-1411. [PMID: 34606021 PMCID: PMC8976796 DOI: 10.1007/s10143-021-01662-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 09/16/2021] [Accepted: 09/29/2021] [Indexed: 10/31/2022]
Abstract
A subset of large non-functioning pituitary adenomas (lNFPA) and giant non-functioning pituitary adenomas (gNFPA) undergoes early progression/recurrence (P/R) after surgery. This study revealed the clinical and image predictors of P/R in lNFPA and gNFPA, with emphasis on solid tumor size. This retrospective study investigated the preoperative MR imaging features for the prediction of P/R in lNFPA (> 3 cm) and gNFPA (> 4 cm). Only the patients with a complete preoperative brain MRI and undergone postoperative MRI follow-ups for more than 1 year were included. From November 2010 to December 2020, a total of 34 patients diagnosed with lNFPA and gNFPA were included (median follow-up time 47.6 months) in this study. A total of twenty-three (23/34, 67.6%) patients had P/R, and the median time to P/R is 25.2 months. Solid tumor diameter (STD), solid tumor volume (STV), and extent of resection are associated with P/R (p < 0.05). Multivariate analysis showed large STV is a risk factor for P/R (p < 0.05) with a hazard ratio of 30.79. The cutoff points of STD and STV for prediction of P/R are 26 mm and 7.6 cm3, with AUCs of 0.78 and 0.79 respectively. Kaplan-Meier analysis of tumor P/R trends showed that patients with larger STD and STV exhibited shorter progression-free survival (p < 0.05). For lNFPA and gNFPA, preoperative STD and STV are significant predictors of P/R. The results offer objective and valuable information for treatment planning in this subgroup.
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Affiliation(s)
- Ching-Chung Ko
- Department of Medical Imaging, Chi-Mei Medical Center, Tainan, Taiwan. .,Department of Health and Nutrition, Chia Nan University of Pharmacy and Science, Tainan, Taiwan.
| | - Chin-Hong Chang
- Department of Neurosurgery, Chi Mei Medical Center, Tainan, Taiwan
| | - Tai-Yuan Chen
- Department of Medical Imaging, Chi-Mei Medical Center, Tainan, Taiwan.,Graduate Institute of Medical Sciences, Chang Jung Christian University, Tainan, Taiwan
| | - Sher-Wei Lim
- Department of Neurosurgery, Chi-Mei Medical Center, Chiali, Tainan, Taiwan.,Department of Nursing, Min-Hwei College of Health Care Management, Tainan, Taiwan
| | - Te-Chang Wu
- Department of Medical Imaging, Chi-Mei Medical Center, Tainan, Taiwan.,Graduate Institute of Medical Sciences, Chang Jung Christian University, Tainan, Taiwan
| | - Jeon-Hor Chen
- Department of Radiological Sciences, University of California, Irvine, CA, USA.,Department of Radiology, E-DA Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Yu-Ting Kuo
- Department of Medical Imaging, Chi-Mei Medical Center, Tainan, Taiwan.,Department of Medical Imaging, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
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