1
|
Ueberschaer M, Katzendobler S, Biczok A, Schmutzer M, Greve T, Tonn JC, Thorsteinsdottir J, Rachinger W. A simple surgical technique for sellar closure after transsphenoidal resection of pituitary adenomas in the context of risk factors for cerebrospinal fluid leaks and meningitis. Neurosurg Focus 2022; 53:E7. [PMID: 36455277 DOI: 10.3171/2022.9.focus22225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 09/22/2022] [Indexed: 12/05/2022]
Abstract
OBJECTIVE The transsphenoidal approach is the standard for most pituitary tumors. Despite low morbidity, postoperative CSF fistulas and meningitis are specific complications. Various surgical closure techniques for intraoperative CSF (iCSF) leak and sellar reconstruction have been described. For many years the authors have applied synthetic materials for iCSF leak repair and sellar closure in a standardized fashion in their department. Here they analyze the surgical outcome as well as risk factors for iCSF leak and meningitis. METHODS All patients with transsphenoidal resection of a pituitary adenoma performed by the same surgeon between January 2013 and December 2019 were screened retrospectively. A small amount of iCSF flow without a diaphragmatic defect was classified as a minor leak, and obvious CSF flow with or without a diaphragmatic defect was classified as a major leak. In case of iCSF leak, a fibrin- and thrombin-coated sponge was used to cover the diaphragmatic defect and another one was used for the sellar opening. A gelatin sponge was placed in the sphenoid sinus as an abutment. The primary and secondary outcomes were the number of postoperative CSF (pCSF) leaks and meningitis, respectively. Clinical, histological, and perioperative data from medical records were collected to identify risk factors for CSF leak and meningitis. RESULTS Of 417 transsphenoidal surgeries, 359 procedures in 348 patients with a median age of 54 years were included. There were 96 iCSF leaks (26.7%; 37.5% major, 62.5% minor). In 3 of 359 cases (0.8%) a pCSF fistula occurred, requiring revision surgery in 2 patients and a lumbar drain in 1 patient. Meningitis occurred in 3 of 359 cases (0.8%). All 3 patients recovered without sequelae after antibiotic therapy. According to univariate analysis, risk factors for iCSF leak were macroadenoma (p = 0.006) and recurrent adenoma (p = 0.032). An iCSF leak was found less often in functioning adenomas (p = 0.025). In multivariate analysis recurrent tumors remained as a risk factor (p = 0.021) for iCSF leak. Patients with iCSF leak were at increased risk for a pCSF leak (p = 0.005). A pCSF leak in turn represented the key risk factor for meningitis (p = 0.033). CONCLUSIONS Patients with macroadenomas and recurrent adenomas are especially at risk for iCSF leak. An iCSF leak in turn increases the risk for a pCSF leak, which carries the risk for meningitis. The authors' surgical technique leads to a very low rate of pCSF leaks and meningitis without using autologous graft materials. Hence, this technique is safe and improves patient comfort by avoiding the disadvantages of autologous graft harvesting.
Collapse
Affiliation(s)
| | | | - Annamaria Biczok
- 1Department of Neurosurgery, Ludwig-Maximilians-University, Munich; and
| | - Michael Schmutzer
- 1Department of Neurosurgery, Ludwig-Maximilians-University, Munich; and
| | - Tobias Greve
- 1Department of Neurosurgery, Ludwig-Maximilians-University, Munich; and
| | - Joerg-Christian Tonn
- 1Department of Neurosurgery, Ludwig-Maximilians-University, Munich; and.,2German Cancer Consortium (DKTK partner site Munich), Germany
| | | | - Walter Rachinger
- 1Department of Neurosurgery, Ludwig-Maximilians-University, Munich; and
| |
Collapse
|
2
|
Kim K, Cho J, Moon JH, Kim EH, Yoon HI. Radiation Therapy for Recurrent or Residual Pituitary Macroadenoma Invading Extrasellar Structures. Yonsei Med J 2022; 63:1059-1068. [PMID: 36444541 PMCID: PMC9760886 DOI: 10.3349/ymj.2022.0323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 10/12/2022] [Accepted: 10/26/2022] [Indexed: 11/22/2022] Open
Abstract
PURPOSE This study aimed to evaluate the efficacy of radiation therapy (RT) for recurrent or residual pituitary macroadenoma (PMA) invading extrasellar regions. MATERIALS AND METHODS Patients from 2000 to 2020 who received RT with conventional fractionation for recurrent or residual PMA were included. The patients were divided according to the type of tumor [functioning (fx) or non-fx] and the aim of RT (salvage RT alone, immediate postoperative RT, delayed postoperative RT). Local and biochemical failure-free rates (FFR) were calculated using the Kaplan-Meier method. RESULTS With a median follow up of 82 months (IQR; 42-132 months), 36 patients treated with conventional RT (total 45-54 Gy in 1.8 or 2 Gy per fraction) for recurrent or residual PMA were analyzed. The 10-year local FFRs after RT for non-fx and fx tumor were 100% and 74.4%, respectively (p=0.047). In the immediate postoperative RT group, the 10-year local FFR was 100%, which was higher than the 90% FFR for salvage RT alone or 80% FFR for the delayed postoperative RT group (overall p=0.043, immediate vs. salvage; p=0.312, immediate vs. delayed; p=0.072). The local FFR was compared according to size of tumor with a cut-off value of 4 cm, and there was no significant difference (10-year local FFR 100% vs. 84.7% for >4 cm vs. <4 cm, p=0.320). The extents of extrasellar region invasion were not predictive of local failure after RT. We found no grade ≥3 acute toxicities or newly developed visual impairments as a late toxicity of RT. CONCLUSION Conventional RT is safe and effective for the local control of recurrent or residual PMA. Our data suggest that immediate postoperative RT can be beneficial in recurrent or residual PMA, although further studies to evaluate risk factors of treatment failure in terms of treatment and disease characteristics are required.
Collapse
Affiliation(s)
- Kangpyo Kim
- Department of Radiation Oncology, Heavy Ion Therapy Research Institute, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Jaeho Cho
- Department of Radiation Oncology, Heavy Ion Therapy Research Institute, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Ju Hyung Moon
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea
- Pituitary Tumor Center, Severance Hospital, Seoul, Korea
| | - Eui-Hyun Kim
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea
- Pituitary Tumor Center, Severance Hospital, Seoul, Korea.
| | - Hong In Yoon
- Department of Radiation Oncology, Heavy Ion Therapy Research Institute, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea.
| |
Collapse
|
3
|
Cai X, Zhu J, Yang J, Tang C, Cong Z, Ma C. Are dopamine agonists still the first-choice treatment for prolactinoma in the era of endoscopy? A systematic review and meta-analysis. Chin Neurosurg J 2022; 8:9. [PMID: 35395837 PMCID: PMC8994364 DOI: 10.1186/s41016-022-00277-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 03/21/2022] [Indexed: 11/16/2022] Open
Abstract
Background For prolactinoma patients, dopamine agonists (DAs) are indicated as the first-line treatment and surgery is an adjunctive choice. However, with the development of surgical technique and equipment, the effect of surgery has improved. The aim of this study was to assess the efficacy and safety of surgery versus DAs in patients with different types of prolactinomas. Methods A systematic search of literature using Web of Science, PubMed, Cochrane Library, and Clinical Trial databases was conducted until July 12, 2019. Prolactinoma patients treated with DAs (bromocriptine or cabergoline) or surgery (microscopic or endoscopic surgery) were included. Outcomes included the biochemical cure rate, recurrence rate, prolactin level, improvement rates of symptoms, and incidence rates of complications. A random-effects model was used to pool the extracted data. Qualitative comparisons were conducted instead of quantitative comparison. Results DAs were better than surgery in terms of the biochemical cure rate (0.78 versus 0.66), but surgery had a much lower recurrence rate (0.19 versus 0.57). Full advantages were not demonstrated in improvement rates of symptoms and incidence rates of complications with both treatment options. In microprolactinoma patients, the biochemical cure rate of endoscopic surgery was equal to the average cure rate of DAs (0.86 versus 0.86) and it surpassed the biochemical cure rate of bromocriptine (0.86 versus 0.76). In macroprolactinoma patients, endoscopic surgery was slightly higher than bromocriptine (0.66 versus 0.64) in terms of the biochemical cure rate. Conclusion For patients with clear indications or contraindications for surgery, choosing surgery or DAs accordingly is unequivocal. However, for patients with clinical equipoise, such as surgery, especially endoscopic surgery, in microprolactinoma and macroprolactinoma patients, we suggest that neurosurgeons and endocrinologists conduct high-quality clinical trials to address the clinical equipoise quantitatively. Supplementary Information The online version contains supplementary material available at 10.1186/s41016-022-00277-1.
Collapse
Affiliation(s)
- Xiangming Cai
- School of Medicine, Southeast University, Nanjing, China
| | - Junhao Zhu
- School of Medicine, Nanjing Medical University, Nanjing, China
| | - Jin Yang
- School of Medicine, Nanjing Medical University, Nanjing, China
| | - Chao Tang
- Department of Neurosurgery, Jinling Hospital, Nanjing, China
| | - Zixiang Cong
- Department of Neurosurgery, Jinling Hospital, Nanjing, China
| | - Chiyuan Ma
- School of Medicine, Southeast University, Nanjing, China. .,School of Medicine, Nanjing Medical University, Nanjing, China. .,Department of Neurosurgery, Jinling Hospital, Nanjing, China. .,School of Medicine, Nanjing University, Nanjing, China.
| |
Collapse
|
4
|
Dekkers AJ, de Vries F, Zamanipoor Najafabadi AH, van der Hoeven EM, Verstegen MJT, Pereira AM, van Furth WR, Biermasz NR. Costs and Its Determinants in Pituitary Tumour Surgery. Front Endocrinol (Lausanne) 2022; 13:905019. [PMID: 35872986 PMCID: PMC9302462 DOI: 10.3389/fendo.2022.905019] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Accepted: 05/04/2022] [Indexed: 11/22/2022] Open
Abstract
PURPOSE Value-based healthcare (VBHC) provides a framework to improve care by improving patient outcomes and reducing healthcare costs. To support value-based decision making in clinical practice we evaluated healthcare costs and cost drivers in perioperative care for pituitary tumour patients. METHODS We retrospectively assessed financial and clinical data for surgical treatment up to the first year after surgery of pituitary tumour patients treated between 2015 and 2018 in a Dutch tertiary referral centre. Multivariable regression analyses were performed to identify determinants of higher costs. RESULTS 271 patients who underwent surgery were included. Mean total costs (SD) were €16339 (13573) per patient, with the following cost determinants: surgery time (€62 per minute; 95% CI: 50, 74), length of stay (€1331 per day; 95% CI 1139, 1523), admission to higher care unit (€12154 in total; 95% CI 6413, 17895), emergency surgery (€10363 higher than elective surgery; 95% CI: 1422, 19305) and postoperative cerebrospinal fluid leak (€14232; 95% CI 9667, 18797). Intradural (€7128; 95% CI 10421, 23836) and combined transsphenoidal/transcranial surgery (B: 38494; 95% CI 29191, 47797) were associated with higher costs than standard. Further, higher costs were found in these baseline conditions: Rathke's cleft cyst (€9201 higher than non-functioning adenoma; 95% CI 1173, 17230), giant adenoma (€19106 higher than microadenoma; 95% CI 12336, 25877), third ventricle invasion (€14613; 95% CI 7613, 21613) and dependent functional status (€12231; 95% CI 3985, 20477). In patients with uncomplicated course, costs were €8879 (3210) and with complications €17551 (14250). CONCLUSIONS Length of hospital stay, and complications are the main drivers of costs in perioperative pituitary tumour healthcare as were some baseline features, e.g. larger tumors, cysts and dependent functional status. Costs analysis may correspond with healthcare resource utilization and guide further individualized care path development and capacity planning.
Collapse
Affiliation(s)
- Alies J. Dekkers
- Department of Medicine, Division of Endocrinology, Pituitary Center and Center for Endocrine Tumors, Leiden University Medical Center, Leiden, Netherlands
- Department of Medicine, Center for Endocrine Tumours Leiden, Leiden University Medical Center, Leiden, Netherlands
- *Correspondence: Alies J. Dekkers,
| | - Friso de Vries
- Department of Medicine, Division of Endocrinology, Pituitary Center and Center for Endocrine Tumors, Leiden University Medical Center, Leiden, Netherlands
- Department of Medicine, Center for Endocrine Tumours Leiden, Leiden University Medical Center, Leiden, Netherlands
| | - Amir H. Zamanipoor Najafabadi
- Department of Neurosurgery, Leiden University Medical Center, University Neurosurgical Center Holland, Leiden, Netherlands
| | | | - Marco J. T. Verstegen
- Department of Medicine, Center for Endocrine Tumours Leiden, Leiden University Medical Center, Leiden, Netherlands
- Department of Neurosurgery, Leiden University Medical Center, University Neurosurgical Center Holland, Leiden, Netherlands
| | - Alberto M. Pereira
- Department of Medicine, Division of Endocrinology, Pituitary Center and Center for Endocrine Tumors, Leiden University Medical Center, Leiden, Netherlands
- Department of Medicine, Center for Endocrine Tumours Leiden, Leiden University Medical Center, Leiden, Netherlands
- Department of Endocrinology and Metabolism, Amsterdam University Medical Center, Meibergdreef 9, Amsterdam, Netherlands
| | - Wouter R. van Furth
- Department of Medicine, Center for Endocrine Tumours Leiden, Leiden University Medical Center, Leiden, Netherlands
- Department of Neurosurgery, Leiden University Medical Center, University Neurosurgical Center Holland, Leiden, Netherlands
| | - Nienke R. Biermasz
- Department of Medicine, Division of Endocrinology, Pituitary Center and Center for Endocrine Tumors, Leiden University Medical Center, Leiden, Netherlands
- Department of Medicine, Center for Endocrine Tumours Leiden, Leiden University Medical Center, Leiden, Netherlands
| |
Collapse
|
5
|
Ashraf M, Kamboh UA, Raza MA, Haq NU, Choudhary N, Sultan KA, Hussain SS, Ashraf N. Usefulness of Intraoperative Computed Tomography on Extent of Resection of Large and Giant Pituitary Adenomas. Experience from a Developing Country. World Neurosurg 2021; 157:13-20. [PMID: 34619403 DOI: 10.1016/j.wneu.2021.09.114] [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: 08/18/2021] [Revised: 09/25/2021] [Accepted: 09/27/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND AND OBJECTIVE The literature on the use of intraoperative computed tomography (iCT) is sparse. We provide our experience of the usefulness of iCT in extent of resection in large and giant pituitary adenomas. METHODS A retrospective review was performed of cases using the endonasal endoscopic technique in which iCT was used. Demographic factors, number of scans, and impact on the extent of resection are reported, with visual acuity and field changes. Tumors were graded according to the Hardy classification. Patients with cavernous sinus invasion were excluded. RESULTS All patients received a perioperative computed tomography scan with our iCT scanner. Thirty patients are reported, including 14 large and 16 giant pituitary adenomas, including 14 nonfunctional and 16 growth hormone-secreting tumors. The overall gross total resection (GTR), near-total resection, and subtotal resection rates were 83.3%, 16.7%, and 3.3%, respectively. iCT scanning detected residual in 13 of 30 patients, including 4 with 14 large (29%) and 9 with 16 (56.3%) giant adenomas promoting further surgery. iCT use improved GTR from 43.8% to 81.3% in giant adenomas and from 71% to 86% in large adenomas. Of the 13 patients in whom iCT detected residual disease, none required >2 iCT scans. No intraoperative complications were observed. CONCLUSIONS iCT can improve extent of resection in large and giant pituitary adenomas and facilitate maximum safe resection such as GTR or near-total resection in patients where such should be attempted. iCT use may reduce iatrogenic complications and has select financial benefits in our patients' socioeconomic demographics. However, further prospective controlled studies are required to affirm our conclusions.
Collapse
Affiliation(s)
- Mohammad Ashraf
- Wolfson School of Medicine, University of Glasgow, Glasgow, United Kingdom; Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital Lahore, Pakistan.
| | - Usman Ahmad Kamboh
- Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital Lahore, Pakistan
| | - Muhammad Asif Raza
- Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital Lahore, Pakistan
| | - Naseer Ul Haq
- Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital Lahore, Pakistan
| | - Nabeel Choudhary
- Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital Lahore, Pakistan
| | - Kashif Ali Sultan
- Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital Lahore, Pakistan
| | - Syed Shahzad Hussain
- Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital Lahore, Pakistan
| | - Naveed Ashraf
- Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital Lahore, Pakistan
| |
Collapse
|
6
|
Determinants of Surgical Remission in Prolactinomas: A Systematic Review and Meta-Analysis. World Neurosurg 2021; 154:e349-e369. [PMID: 34325023 DOI: 10.1016/j.wneu.2021.07.035] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 07/07/2021] [Accepted: 07/08/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Prolactin-secreting tumors respond well to medical management, with a few patients requiring surgery. We conducted a systematic review and meta-analysis to study the determinants of surgical remission in these tumors. METHODS We searched PubMed to identify eligible studies reporting postoperative remission in patients treated with transsphenoidal surgery for prolactinoma. Primary outcomes included postoperative remission, follow-up remission, and recurrence. Postoperative and follow-up remission were defined as normoprolactinemia at <1 year and >1 year after operation, respectively. Recurrence was defined as hyperprolactinemia after initial normalization of prolactin levels. Odds ratios (ORs) were calculated, stratified by radiologic size, tumor extension, and tumor invasion, and analyzed using a random-effects model meta-analysis. RESULTS Thirty-five studies were included. Macroadenomas were associated with lower rates of postoperative remission (OR, 0.20; 95% confidence interval [CI], 0.16-0.24) and lower rates of remission at follow-up (OR, 0.11; 95% CI, 0.053-0.22). Postoperative remission was less likely in tumors with extrasellar or suprasellar extension (OR, 0.16; 95% CI, 0.06-0.43) and tumors with cavernous sinus invasion (OR, 0.03; 95% CI, 0.01-0.13). Female gender and absence of preoperative dopamine agonist treatment were also associated with higher remission rates. Across the included studies, there was considerable heterogeneity in each primary outcome (postoperative remission, I2 = 94%; follow-up remission, I2 = 86%; recurrence, I2 = 68%). CONCLUSIONS Transsphenoidal surgery for prolactinomas may be particularly effective in small, noninvasive, treatment-naive tumors and may provide a viable first-line alternative to dopamine agonist therapy in such patients.
Collapse
|
7
|
Zhang F, He Q, Luo G, Long Y, Li R, Ding L, Zhang X. The combination of 13N-ammonia and 11C-methionine in differentiation of residual/recurrent pituitary adenoma from the pituitary gland remnant after trans-sphenoidal Adenomectomy. BMC Cancer 2021; 21:837. [PMID: 34284745 PMCID: PMC8290571 DOI: 10.1186/s12885-021-08574-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 07/07/2021] [Indexed: 11/30/2022] Open
Abstract
Background This study aimed to assess the clinical usefulness of 13N-ammonia and 11C- Methionine (MET) positron emission tomography (PET)/ computed tomography (CT) in the differentiation of residual/recurrent pituitary adenoma (RPA) from the pituitary gland remnant (PGR) after trans-sphenoidal adenomectomy. Methods Between June 2012 and December 2019, a total of 19 patients with a history of trans-sphenoidal adenomectomy before PET/CT scans and histological confirmation of RPA after additional surgery in our hospital were enrolled in this study. Images were interpreted by visual evaluation and semi-quantitative analysis. In semi-quantitative analysis, the maximum standard uptake value (SUVmax) of the target and gray matter was measured and the target uptake/gray matter uptake (T/G) ratio was calculated. Results The T/G ratios of 13N-ammonia were significantly higher in PGR than RPA (1.58 ± 0.69 vs 0.63 ± 1.37, P < 0.001), whereas the T/G ratios of 11C-MET were obviously lower in PGR than RPA (0.78 ± 0.35 vs 2.17 ± 0.54, P < 0.001). Using the canonical discriminant analysis, we calculated the predicted accuracy of RPA (100%), PGR (92.9%), and the overall predicted accuracy (96.43%). Conclusions The combination of 13N-ammonia and 11C-MET PET/CT is valuable in the differentiation of RPA from PGR after trans-sphenoidal adenomectomy.
Collapse
Affiliation(s)
- Fangling Zhang
- Department of Radiology, Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-sen University & Guangdong Provincial Key Laboratory of Stomatology, 56#, Cemetery west Road, Guangzhou, Guangdong Province, 510055, People's Republic of China
| | - Qiao He
- Department of Medical Imaging, The First Affiliated Hospital, Sun Yat-sen University, 58#, Zhongshan Er Road, Guangzhou, Guangdong Province, 510080, People's Republic of China
| | - Ganhua Luo
- Department of Medical Imaging, The First Affiliated Hospital, Sun Yat-sen University, 58#, Zhongshan Er Road, Guangzhou, Guangdong Province, 510080, People's Republic of China
| | - Yali Long
- Department of Medical Imaging, The First Affiliated Hospital, Sun Yat-sen University, 58#, Zhongshan Er Road, Guangzhou, Guangdong Province, 510080, People's Republic of China
| | - Ruocheng Li
- Department of Medical Imaging, The First Affiliated Hospital, Sun Yat-sen University, 58#, Zhongshan Er Road, Guangzhou, Guangdong Province, 510080, People's Republic of China
| | - Lei Ding
- Department of Medical Imaging, The First Affiliated Hospital, Sun Yat-sen University, 58#, Zhongshan Er Road, Guangzhou, Guangdong Province, 510080, People's Republic of China.
| | - Xiangsong Zhang
- Department of Medical Imaging, The First Affiliated Hospital, Sun Yat-sen University, 58#, Zhongshan Er Road, Guangzhou, Guangdong Province, 510080, People's Republic of China.
| |
Collapse
|
8
|
Agrawal N, Ioachimescu AG. Prognostic factors of biochemical remission after transsphenoidal surgery for acromegaly: a structured review. Pituitary 2020; 23:582-594. [PMID: 32602066 DOI: 10.1007/s11102-020-01063-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
PURPOSE Biochemical control is the main determinant of survival, clinical manifestations and comorbidities in acromegaly. Transsphenoidal selective adenomectomy (TSA) is the initial treatment of choice with reported biochemical remission rates varying between 32 and 85%. Understanding the limiting factors is essential for identification of patients who require medical treatment. METHODS We reviewed the English literature published in Medline/Pubmed until Dec 31, 2019 to identify eligible studies that described outcomes of TSA as primary therapy and performed analyses to determine the main predictors of remission. RESULTS Most publications reported single-institution, retrospective studies. The following preoperative parameters were consistently associated with lower remission rates: cavernous sinus invasion by imaging, larger tumor size and higher GH levels. Young age and preoperative IGF-1 levels were predictive in some studies. When controlled for covariates, the best single preoperative predictor was cavernous sinus invasion, followed by preoperative GH levels. Conversely, low GH level in the first few days postoperatively was a robust predictor of durable remission. The influence of tumor histology (sparsely granular pattern, co-expression of prolactin and proliferation markers) on surgical remission remains to be established. Few studies developed predictive models that yielded much higher predictive values than individual parameters. CONCLUSION Surgical outcome prognostication systems could be further generated by machine learning algorithms in order to support development and implementation of personalized care in patients with acromegaly.
Collapse
Affiliation(s)
- Nidhi Agrawal
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, NYU School of Medicine, 550 First Avenue, New York City, NY, 10016, USA
| | - Adriana G Ioachimescu
- Department of Medicine and Neurosurgery, Emory University School of Medicine, 1365 B Clifton Road B-2200, Northeast, B6209, Atlanta, GA, 30322, USA.
| |
Collapse
|
9
|
Minniti G, Paolini S, Rea MLJ, Isidori A, Scaringi C, Russo I, Osti MF, Cavallo L, Esposito V. Stereotactic reirradiation with temozolomide in patients with recurrent aggressive pituitary tumors and pituitary carcinomas. J Neurooncol 2020; 149:123-130. [PMID: 32632895 DOI: 10.1007/s11060-020-03579-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 06/29/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To evaluate the efficacy of a second course of fractionated stereotactic radiotherapy (re-SRT) and temozolomide (TMZ) as salvage treatment option in patients with aggressive pituitary tumors (APTs) and pituitary carcinomas (PCs). PATIENTS AND METHODS Twenty-one patients with recurrent or progressive APTs (n = 17) and PCs (n = 4) who received combined TMZ and re-SRT, 36 Gy/18fractions or 37.5 Gy/15fractions, were retrospectively evaluated. TMZ was given at a dose of 75 mg/m2 given concurrently to re-SRT, and then 150-200 mg/m2/day for 5 days every 4 weeks or 50 mg/m2 daily for 12 months. Local control (LC) and overall survival (OS) were calculated from the time of re-SRT by Kaplan-Meier method. RESULTS With a median follow-up of 27 months (range 12-58 months), 2-year and 4-year LC rates were 73% and 65%, respectively; 2-year and 4-year survival rates were 82% and 66%, respectively. A complete response was achieved in 2 and partial response in 11 patients. Six patients recurred with a median time to progression of 14 months. O(6)-Methylguanine-DNA methyltransferase (MGMT) status and tumor volume emerged as prognostic factors. Grade 3 radiation-related toxicities occurred in 3 (14%) patients. Grade 2 or 3 hematologic toxicities during chemotherapy occurred in 8 (38%) patients. CONCLUSION Re-SRT and TMZ is a safe treatment offering high LC in patients with progressive APTs and PCs. The potential advantages of combined chemoradiation as up-front or salvage treatment need to be explored in prospective trials.
Collapse
Affiliation(s)
- Giuseppe Minniti
- Department of Medicine, Surgery and Neurosciences, University of Siena, Policlinico Le Scotte, 53100, Siena, Italy. .,IRCCS Neuromed, Pozzilli, IS, Italy.
| | | | - Marie Lise Jaffrain Rea
- Biotechnological and Applied Clinical Sciences Department, University of L'Aquila, L'Aquila, Italy
| | - Andrea Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Claudia Scaringi
- UPMC Hillman Cancer Center, San Pietro Hospital FBF, Rome, Italy
| | - Ivana Russo
- UPMC Hillman Cancer Center, Villa Maria, Mirabella, AV, Italy
| | | | - Luigi Cavallo
- Division of Neurosurgery, Università degli Studi di Napoli "Federico II", Naples, Italy
| | | |
Collapse
|
10
|
Chen S, Xu S, Lin F, Zhang X, Liu F, Dong M, Li X, Ma X. Endoscopic surgical treatment of Cushing's disease: A single-center experience of cauterization of peritumoral tissues. Exp Ther Med 2019; 18:4420-4426. [PMID: 31777545 PMCID: PMC6862633 DOI: 10.3892/etm.2019.8075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 09/24/2018] [Indexed: 11/23/2022] Open
Abstract
Endoscopic transsphenoidal surgery is a form of treatment for Cushing's disease that is initially preferred compared with other types of treatment. Peritumoral tissue is inactivated by cauterization if a clear border of the lesion cannot be identified. In order to compare the surgical outcomes and post-operative complications between patients who underwent inactivation (cauterization of peritumoral tissues is referred to as inactivation) and those who did not, the medical records of patients treated between January 2010 and June 2016 were retrospectively reviewed. Furthermore, the results of conventional examinations performed in order to diagnose and locate the tumors, including neuroimaging, high-dose dexamethasone suppression tests and/or bilateral inferior petrosal sinus sampling, were collected. A total of 79 consecutive patients with Cushing's disease were included in the present analysis. Inactivation of peritumoral tissue had been applied in 35 (44.3%) of the cases. A gross total resection was achieved in 73 (92.4%) of the cases, while partial resection had been performed in the remaining six (7.6%). Early post-operative endocrinological remission was attained in 71 (89.8%) of the patients. A total of seven cases suffered from hypopituitarism, while cerebrospinal fluid rhinorrhea and brain stem infarction were recorded in four cases and one case, respectively. During the follow-up, the duration of which ranged between 11 and 62 months, recurrence was documented in five patients, as determined by endocrinal examinations. All of the cases that were initially treated unsuccessfully and those with recurrence achieved endocrinological remission following radiotherapy. Enhanced pituitary magnetic resonance imaging revealed no further enlargement of tumors during follow-up. The extent of endocrinological remission, recurrence and post-operative complications did not significantly differ between patients who underwent inactivation and those who did not. In conclusion, inactivation of peritumoral tissue by cauterization achieved satisfactory results in patients with intricate lesions, however it is comparable to conventional procedures.
Collapse
Affiliation(s)
- Songyu Chen
- Department of Neurosurgery, Shanghai Tenth People's Hospital, Tongji University, Shanghai 200072, P.R. China.,Department of Neurosurgery, Qilu Hospital of Shandong University, Jinan, Shandong 250012, P.R. China.,Brain Science Research Institute, Shandong University, Jinan, Shandong 250012, P.R. China
| | - Shujun Xu
- Department of Neurosurgery, Qilu Hospital of Shandong University, Jinan, Shandong 250012, P.R. China.,Brain Science Research Institute, Shandong University, Jinan, Shandong 250012, P.R. China
| | - Fuxin Lin
- Department of Neurosurgery, Qilu Hospital of Shandong University, Jinan, Shandong 250012, P.R. China.,Brain Science Research Institute, Shandong University, Jinan, Shandong 250012, P.R. China.,Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fujian Medical University, Fuzhou, Fujian 350004, P.R. China
| | - Xin Zhang
- Department of Neurosurgery, Qilu Hospital of Shandong University, Jinan, Shandong 250012, P.R. China.,Brain Science Research Institute, Shandong University, Jinan, Shandong 250012, P.R. China
| | - Fuqiang Liu
- Department of Endocrinology, Qilu Hospital of Shandong University, Jinan, Shandong 250012, P.R. China
| | - Ming Dong
- Department of Endocrinology, Qilu Hospital of Shandong University, Jinan, Shandong 250012, P.R. China
| | - Xingang Li
- Department of Neurosurgery, Qilu Hospital of Shandong University, Jinan, Shandong 250012, P.R. China.,Brain Science Research Institute, Shandong University, Jinan, Shandong 250012, P.R. China
| | - Xiangyu Ma
- Department of Neurosurgery, Qilu Hospital of Shandong University, Jinan, Shandong 250012, P.R. China.,Brain Science Research Institute, Shandong University, Jinan, Shandong 250012, P.R. China
| |
Collapse
|
11
|
Abstract
Radiation therapy (RT) is an effective treatment for patients with either nonfunctioning or secreting pituitary adenomas unsuccessfully treated by surgery and/or medical therapy, resulting in local control of 90-95% at 5-10 years and variable normalization of hormonal hypersecretion for patients with GH-, ACTH-, and prolactin-secreting adenomas in the range of 40-80% at 5 years; however, its use has been limited because of concerns regarding potential late toxicity of radiation and delayed efficacy in normalization of hormone hypersecretion. In the last decades, there have been advances in all aspects of radiation treatment, including more accurate immobilization, imaging, treatment planning and dose delivery. RT has evolved with the development of highly conformal stereotactic techniques and new planning and dose delivery techniques, including intensity-modulated radiotherapy (IMRT) and volumetric modulated arc therapy (VMAT). All these new techniques allow precise and sharply focused radiation delivery reducing the dose to surrounding critical neurovascular and brain structures, and potentially limiting the long-term consequences of radiation treatments. In this review, we present a critical analysis of the more recent available literature on the use of RT in patients with both nonfunctioning and secreting pituitary adenomas, focussing particularly on the risk/benefit ratio of modern radiation techniques.
Collapse
Affiliation(s)
- Giuseppe Minniti
- Radiation Unit, UPMC Hillman Cancer Center, San Pietro Hospital, Rome, Italy.
| | - John Flickinger
- Department of Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| |
Collapse
|
12
|
Abstract
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.
Collapse
Affiliation(s)
- Jürgen Honegger
- Department of Neurosurgery, University of Tuebingen, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany.
| | - Florian Grimm
- Department of Neurosurgery, University of Tuebingen, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
| |
Collapse
|
13
|
Taghvaei M, Sadrehosseini SM, Ardakani JB, Nakhjavani M, Zeinalizadeh M. Endoscopic Endonasal Approach to the Growth Hormone–Secreting Pituitary Adenomas: Endocrinologic Outcome in 68 Patients. World Neurosurg 2018; 117:e259-e268. [DOI: 10.1016/j.wneu.2018.06.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 06/01/2018] [Accepted: 06/02/2018] [Indexed: 12/14/2022]
|
14
|
Babu H, Ortega A, Nuno M, Dehghan A, Schweitzer A, Bonert HV, Carmichael JD, Cooper O, Melmed S, Mamelak AN. Long-Term Endocrine Outcomes Following Endoscopic Endonasal Transsphenoidal Surgery for Acromegaly and Associated Prognostic Factors. Neurosurgery 2018; 81:357-366. [PMID: 28368500 DOI: 10.1093/neuros/nyx020] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 01/13/2017] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Long-term remission rates from endoscopic transsphenoidal surgery for acromegaly and their relationship to prognostic indicators of disease aggressiveness are not well documented. OBJECTIVE To investigate long-term remission rates in patients with acromegaly after endoscopic transsphenoidal surgery, and correlate this with molecular and radiographic markers of disease aggressiveness. METHODS We identified all patients undergoing endoscopic transsphenoidal surgery for acromegaly from 2005 to 2013 at Cedars-Sinai Pituitary Center. Hormonal remission was established by normal insulin-like growth factor (IGF)-1, basal serum growth hormone <2.5 ng/mL, and growth hormone suppression to <1 ng/mL following oral glucose tolerance test. Oral glucose tolerance test was performed at 3 months after surgery, and then as indicated. IGF-1 was measured at 3 months and then at least annually. We evaluated tumor granularity, nuclear expression of p21, Ki67 index, and extent of cavernous sinus invasion, and correlated these with remission status. RESULTS Fifty-eight patients that underwent surgery had follow-up from 38 to 98 months (mean 64 ± 32.2 months). There were 21 microadenomas and 37 macroadenomas. Three months after surgery 40 of 58 patients (69%) were in biochemical remission. Four additional patients were in remission at 6 months after surgery, and 1 patient had recurrence within the first year after surgery. At last follow-up, 43 of 44 (74.1%) of patients remained in remission. Cavernous sinus invasion by tumor predicted failure to achieve remission. CONCLUSIONS Prognostic markers of disease aggressiveness other than cavernous sinus invasion did not correlate with surgical outcome. Long-term remission after surgery alone was achieved in 74% of patients, indicating long-term efficacy of endoscopic surgery.
Collapse
Affiliation(s)
- Harish Babu
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, Cali-fornia
| | - Alicia Ortega
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, Cali-fornia.,Division of Endocrinology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Miriam Nuno
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, Cali-fornia.,Division of Endocrinology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Aaron Dehghan
- Division of Endocrinology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Aaron Schweitzer
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, Cali-fornia
| | - H Vivien Bonert
- Division of Endocrinology, Cedars-Sinai Medical Center, Los Angeles, California
| | - John D Carmichael
- Division of Endocrinology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Odelia Cooper
- Division of Endocrinology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Shlomo Melmed
- Division of Endocrinology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Adam N Mamelak
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, Cali-fornia
| |
Collapse
|
15
|
Guo Z, Liu C, Hou H, Li R, Su J, Zhang F, Xing G, Qian L, Qiu J, Xie Y, Zhu N. Preoperative Computed Tomography (CT) Evaluation of Anatomical Abnormalities in Endonasal Transsphenoidal Approach in Pituitary Adenoma. Med Sci Monit 2018; 24:1268-1275. [PMID: 29497027 PMCID: PMC5844192 DOI: 10.12659/msm.904402] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND This study aimed to retrospectively analyze patient clinical data to investigate the effects of computed tomography (CT) reconstruction and the measurement of abnormal structures in the endonasal sphenoidal sinus approach on the operative effects in patients undergoing pituitary adenoma resection. MATERIAL AND METHODS The records of 53 patients who underwent pituitary adenoma resection via the endonasal transsphenoidal approach in the Neurosurgery Department of Tai'an City Central Hospital from December 2010 to June 2016 were analyzed retrospectively. All cases showed anatomical abnormalities in the endonasal transsphenoidal approach that were detected by conventional CT scans. The clinical data of the patients were reviewed. After review, 26 patients who underwent preoperative CT reconstruction and measurement of abnormal structures before surgery were included in the observation group (CT reconstruction group), and 27 patients who did not undergo CT reconstruction and measurement of abnormal structures were included in the control group. Data on intraoperative blood loss, surgical time, hospital stay, and postoperative complications were collected to assess the quality of the surgery. RESULTS Compared with the control group, the observation group showed less blood loss (p<0.001), a shorter operation time (p<0.001), fewer postoperative complications (p<0.001), and a shorter hospital stay (p<0.001). CONCLUSIONS Preoperative CT reconstruction and measurement of abnormal structures in patients undergoing pituitary adenoma resection by the endonasal transsphenoidal approach can improve operative quality and reduce complications.
Collapse
Affiliation(s)
- Zhengyi Guo
- Taian City Central Hospital, Taian, Shandong, China (mainland)
| | - Chunli Liu
- Taian City Central Hospital, Taian, Shandong, China (mainland)
| | - Haifeng Hou
- Taishan Medical University, Taian, Shandong, China (mainland)
| | - Ruiying Li
- Taian City Central Hospital, Taian, Shandong, China (mainland)
| | - Jichun Su
- Taian City Central Hospital, Taian, Shandong, China (mainland)
| | - Fuyong Zhang
- Taian City Central Hospital, Taian, Shandong, China (mainland)
| | - Guoqiang Xing
- Taian City Central Hospital, Taian, Shandong, China (mainland)
| | - Linlin Qian
- Taian City Central Hospital, Taian, Shandong, China (mainland)
| | - Jianfeng Qiu
- Taishan Medical University, Taian, Shandong, China (mainland)
| | - Yuanzhong Xie
- Taian City Central Hospital, Taian, Shandong, China (mainland)
| | - Ningxi Zhu
- Taian City Central Hospital, Taian, Shandong, China (mainland)
| |
Collapse
|
16
|
Microsurgical versus endoscopic transsphenoidal resection for acromegaly: a systematic review of outcomes and complications. Acta Neurochir (Wien) 2017; 159:2193-2207. [PMID: 28913667 DOI: 10.1007/s00701-017-3318-6] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 08/28/2017] [Indexed: 12/16/2022]
Abstract
PURPOSE The aim of this systematic review is to evaluate the long-term endocrine outcomes and postoperative complications following endoscopic vs. microscopic transsphenoidal resection (TSR) for the treatment of acromegaly. METHODS A literature review was performed, and studies with at least five patients who underwent TSR for acromegaly, reporting biochemical remission criteria and long-term remission outcomes were included. Data extracted from each study included surgical technique, perioperative complications, biochemical remission criteria, and long-term remission outcomes. RESULTS Fifty-two case series from 1976 to 2016 met the inclusion criteria, comprising 4375 patients. Thirty-six reports were microsurgical (n = 3144) and 13 were endoscopic (n = 940). Three studies compared microsurgical (n = 111) to endoscopic TSR outcomes (n = 180). The overall initial and long-term remission rates were 58.2 vs. 57.4% and 69.2 vs. 70.2% for the microsurgical and endoscopic groups, respectively. For microadenomas, the initial and long-term remission rates were 77.6 vs. 82.2% and 76.9 vs. 73.5% for microsurgical and endoscopic approaches, respectively. For macroadenomas, the initial and long-term remission rates were 46.9 vs. 60.0% and 40.2 vs. 61.5% for microsurgical and endoscopic approaches, respectively. The rates of postoperative CSF leak were 3.0 vs. 2.3% for the microscopic and endoscopic groups, respectively. The rates of hypopituitarism and transient diabetes insipidus were 6.7 vs. 6.4% and 9.0 vs. 7.8% for the microscopic and endoscopic groups, respectively. CONCLUSIONS Both endoscopic and microsurgical approaches for TSR of growth hormone-secreting adenomas are viable treatment options for patients with acromegaly, and yield similarly high rates of remission under the most current consensus criteria.
Collapse
|
17
|
Erfe JM, Perry A, McClaskey J, Inzucchi SE, James WS, Eid T, Bronen RA, Mahajan A, Huttner A, Santos F, Spencer D. Long-term outcomes of tissue-based ACTH-antibody assay-guided transsphenoidal resection of pituitary adenomas in Cushing disease. J Neurosurg 2017; 129:629-641. [PMID: 29027854 DOI: 10.3171/2017.3.jns162245] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Cushing disease is caused by a pituitary micro- or macroadenoma that hypersecretes adrenocorticotropic hormone (ACTH), resulting in hypercortisolemia. For decades, transsphenoidal resection (TSR) has been an efficacious treatment but with certain limitations, namely precise tumor localization and complete excision. The authors evaluated the novel use of a double-antibody sandwich assay for the real-time quantitation of ACTH in resected pituitary specimens with the goals of augmenting pathological diagnosis and ultimately improving long-term patient outcome. METHODS This study involved a retrospective review of records and an analysis of assay values, pathology slides, and MRI studies of patients with Cushing disease who had undergone TSR in the period from 2009 to 2014 and had at least 1 year of follow-up in coordination with an endocrinologist. In the operating room, biopsy specimens from the patients had been analyzed for tissue ACTH concentration. Additional samples were simultaneously sent for frozen-section pathological analysis. The ACTH assay performance was compared against pathology assessments of surgical tumor samples using receiver operating characteristic (ROC) analysis and against pre- and postoperative MRI studies. RESULTS Fourteen patients underwent TSR with guidance by ACTH-antibody assay and pathological assessment of 127 biopsy samples and were followed up for an average of 3 years. The ACTH threshold for discriminating adenomatous from normal tissue was 290,000 pg/mg of tissue, based on jointly maximized sensitivity (95.0%) and specificity (71.3%). Lateralization discordance between preoperative MRI studies and surgical visualization was noted in 3 patients, confirming the impression that MRI alone may not achieve optimal localization. A majority of the patients (85.7%) attained long-term disease remission based on urinary free cortisol levels, plasma cortisol levels, and long-term corticosteroid therapy. Comparisons of patient-months of remission and treatment failure showed that the remission rate in the study sample statistically exceeds the rate in historical controls (71.9%; p = 0.0007, Fisher's exact test). Long-term unexpected hormonal deficiencies were statistically similar between study patients (29%) and those in a meta-analysis (25%; p = 0.7596, Fisher's exact test). CONCLUSIONS These preliminary findings reflect the promising potential of tissue-based ACTH-antibody-guided assay for improving the cure rates of Cushing disease patients undergoing TSR. Further studies with larger sample sizes, further refinements of assay interpretation, and longer-term follow-ups are needed.
Collapse
Affiliation(s)
- J Mark Erfe
- 1Yale School of Medicine, New Haven, Connecticut
| | - Avital Perry
- 2Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota
| | - John McClaskey
- 3Department of Pathology, Mount Sinai Hospital, New York, New York; and
| | | | | | | | | | | | | | | | | |
Collapse
|
18
|
Endoscopic Transsphenoidal Approach for Surgical Treatment of Growth Hormone Secreting Pituitary Adenoma: Endocrinological Outcome in 49 Patients Based on 2010 Consensus Criteria for Remission - Preliminary Result. ARCHIVES OF NEUROSCIENCE 2017. [DOI: 10.5812/archneurosci.14131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
19
|
Abstract
PURPOSE Surgical extraction of as much tumour mass as possible is considered the first step of treatment in acromegaly in many centers. In this article the potential benefits, disadvantages and limitations of operative acromegaly treatment are reviewed. METHODS Pertinent literature was selected to provide a review covering current indications, techniques and results of operations for acromegaly. RESULTS The rapid reduction of tumour volume is an asset of surgery. To date, in almost all patients, minimally invasive, transsphenoidal microscopic or endoscopic approaches are employed. Whether a curative approach is feasible or a debulking procedure is planned, can be anticipated on the basis of preoperative magnetic resonance imaging. The radicality of adenoma resection essentially depends on localization, size and invasive character of the tumour. The normalization rates of growth hormone and IGF-1 secretion, respectively, depend on tumour-related factors such as size, extension, the presence or absence of invasion and the magnitude of IGF-1 and growth hormone oversecretion. However, also surgeon-related factors such as experience and patient load of the centers have been shown to strongly affect surgical results and the rate of complications. As compared to most medical treatments, surgery is relatively cheap since the costs occur only once and not repeatedly. There are several new technical gadgets which aid in the surgical procedure: navigation and variants of intraoperative imaging. CONCLUSIONS For the mentioned reasons, current algorithms of acromegaly management suggest an initial operation, unless the patients are unfit for surgery, refuse an operation or only an unsatisfactory resection is anticipated. A few suggestions are made when a re-operation could be considered.
Collapse
Affiliation(s)
- Michael Buchfelder
- Department of Neurosurgery, University Hospital Erlangen, Schwabachanlage 6, 91054, Erlangen, Germany.
| | - Sven-Martin Schlaffer
- Department of Neurosurgery, University Hospital Erlangen, Schwabachanlage 6, 91054, Erlangen, Germany
| |
Collapse
|
20
|
Different Volumetric Measurement Methods for Pituitary Adenomas and Their Crucial Clinical Significance. Sci Rep 2017; 7:40792. [PMID: 28098212 PMCID: PMC5241871 DOI: 10.1038/srep40792] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 12/09/2016] [Indexed: 02/08/2023] Open
Abstract
Confirming the status of residual tumors is crucial. In stationary or spontaneous regression cases, early treatments are inappropriate. The long-used geometric calculation formula is 1/2 (length × width × height). However, it yields only rough estimates and is particularly unreliable for irregularly shaped masses. In our study, we attempted to propose a more accurate method. Between 2004 and 2014, 94 patients with pituitary tumors were enrolled in this retrospective study. All patients underwent transsphenoidal surgery and received magnetic resonance imaging (MRI). The pre- and postoperative volumes calculated using the traditional formula were termed A1 and A2, and those calculated using the proposed method were termed O1 and O2, respectively. Wilcoxon signed rank test revealed no significant difference between the A1 and O1 groups (P = 0.1810) but a significant difference between the A2 and O2 groups (P < 0.0001). Significant differences were present in the extent of resection (P < 0.0001), high-grade cavernous sinus invasion (P = 0.0312), and irregular shape (P = 0.0116). Volume is crucial in evaluating tumor status and determining treatment. Therefore, a more scientific method is especially useful when lesions are irregularly shaped or when treatment is determined exclusively based on the tumor volume.
Collapse
|
21
|
Efficacy of Microsurgical Sublabial Approach (MSA) Versus Endoscopic Endonasal Approach (EEA) for the Treatment of Pituitary Adenomas Based on Radiological and Hormonal Outcome. ACTA NEUROCHIRURGICA. SUPPLEMENT 2017; 124:101-106. [PMID: 28120060 DOI: 10.1007/978-3-319-39546-3_16] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND The purpose of this study was to compare the surgical efficacy of the microsurgical sublabial approach (MSA) versus the endoscopic endonasal approach (EEA) for the treatment of pituitary adenomas, based on short-term (12 months) radiological and endocrinological follow-up. METHODS One hundred and fourteen patients affected by pituitary adenoma were enrolled at our Unit between January 2007 and February 2012; 72 were treated with MSA, and 42 with EEA. The preoperative parameters considered were: type of lesion (secreting or nonsecreting), lesion size, presence of intralesional hemorrhage, lesion perimeter (nodular vs. uniform), intrasellar vs. suprasellar, involvement of cavernous sinus, and osteodural infiltration. Hormonal assays and magnetic resonance imaging (MRI) scans were performed at 12 months after the surgical procedure. RESULTS Univariate analysis of the data documented a statistically significant difference in favor of MSA for the subgroups of secreting adenomas (90.9 % vs. nonsecreting 48.3 %), microadenomas (100 % vs. macroadenomas 57.1 %), adenomas without osteodural infiltration (87.5 % vs. 55.5 % with the infiltration) or those without intralesional hemorrhage (75 % vs. 45.9 % with the hemorrhage), and growth hormone (GH) adenomas (88.8 % vs. 43.7 %). Multivariate analysis confirmed the greater effectiveness of MSA for the treatment of micro-secreting adenomas. CONCLUSIONS Recent advances in the EEA for treating pituitary adenomas could lead to this modality replacing the microsurgical technique. In our experience the MSA allowed us to achieve better results in the treatment of microadenomas.
Collapse
|
22
|
Tampourlou M, Trifanescu R, Paluzzi A, Ahmed SK, Karavitaki N. THERAPY OF ENDOCRINE DISEASE: Surgery in microprolactinomas: effectiveness and risks based on contemporary literature. Eur J Endocrinol 2016; 175:R89-96. [PMID: 27207245 DOI: 10.1530/eje-16-0087] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Accepted: 03/11/2016] [Indexed: 11/08/2022]
Abstract
Microprolactinomas are the most common pituitary adenomas. In symptomatic patients, dopamine agonists are the first-line treatment of choice; when cabergoline is used, biochemical control rates between 85 and 93% have been reported. Long-term treatment is needed in most of the cases with compliance, patient convenience, and potential adverse effects representing areas requiring attention. Based on the literature published in the past 15 years, transsphenoidal surgery can lead to normal prolactin in the postoperative period in usually 71-100% of the cases with very low postoperative complication rates. Surgical expertise is the major determinant of the outcomes, and it may be a cost-effective option in young patients with life expectancy greater than 10 years (provided it is performed by experienced surgeons at high volume centers with confirmed optimal outcomes). Larger series of patients with adequate follow-up could further validate the place of transsphenoidal surgery (particularly through the endoscopic approach for which long-term results are currently limited) in the management algorithm of patients with microprolactinoma.
Collapse
Affiliation(s)
- Metaxia Tampourlou
- Institute of Metabolism and Systems ResearchUniversity of Birmingham, Centre for EndocrinologyDiabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Raluca Trifanescu
- Department of EndocrinologyCarol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | | | - Shahzada K Ahmed
- Department of OtorhinolaryngologyUniversity Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
| | - Niki Karavitaki
- Institute of Metabolism and Systems ResearchUniversity of Birmingham, Centre for EndocrinologyDiabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| |
Collapse
|
23
|
Cohen-Inbar O, Xu Z, Schlesinger D, Vance ML, Sheehan JP. Gamma Knife radiosurgery for medically and surgically refractory prolactinomas: long-term results. Pituitary 2015; 18:820-30. [PMID: 25962347 DOI: 10.1007/s11102-015-0658-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Prolactinomas are the most common functioning pituitary adenomas. Dopamine agonists (DA) are generally very effective in treating prolactinomas by inducing tumor volume regression and endocrine remission. A minority of patients do not respond to DA or are intolerant because of side-effects. Microsurgical resection when possible is the next treatment option, but cavernous sinus, dural, or bone involvement may not allow for complete resection. OBJECTIVE We reviewed the outcome of patients with medically and surgically refractory prolactinomas treated with Gamma Knife radiosurgery (GKRS) during a 22 years follow-up period. METHODS We reviewed the patient database at the University of Virginia Gamma Knife center during a 25-year period (1989-2014), identifying 38 patients having neurosurgical, radiological and endocrine follow-up. RESULTS Median age at GKRS treatment was 43 years. Median follow-up was 42.3 months (range 6-207.9). 55.3 % (n = 21) were taking a dopamine agonist at time of GKRS. 63.2 % (n = 24) had cavernous sinus tumor invasion. Endocrine remission (normal serum prolactin off of a dopamine agonist) was achieved in 50 % (n = 19). GKRS induced hypopituitarism occurred in 30.3 % (n = 10). Cavernous sinus involvement was shown to be a significant negative prognosticator of endocrine remission. Taking a dopamine agonist drug at the time of GKRS showed a tendency to decrease the probability for endocrine remission. CONCLUSION GKRS for refractory prolactinomas can lead to endocrine remission in many patients. Hypopituitarism is the most common side effect of GKRS.
Collapse
Affiliation(s)
- Or Cohen-Inbar
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, 22908, USA.
| | - Zhiyuan Xu
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, 22908, USA
| | - David Schlesinger
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, 22908, USA
| | - Mary Lee Vance
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, 22908, USA
- Department of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, 22908, USA.
| |
Collapse
|
24
|
Fathalla H, Cusimano MD, Di Ieva A, Lee J, Alsharif O, Goguen J, Zhang S, Smyth H. Endoscopic versus microscopic approach for surgical treatment of acromegaly. Neurosurg Rev 2015; 38:541-8; discussion 548-9. [PMID: 25666392 DOI: 10.1007/s10143-015-0613-7] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Revised: 10/10/2014] [Accepted: 11/16/2014] [Indexed: 11/30/2022]
Abstract
Transsphenoidal surgery in the setting of acromegaly is quite challenging due to increased soft tissue mass, bony overgrowth, and bleeding. There is a debate on the endoscopic versus microscopic approach for these patients. The purpose of our study is to compare the outcomes for acromegaly after transsphenoidal surgery using both techniques. Retrospective review of 65 acromegalic patients who underwent transsphenoidal surgery in our department. Clinical remission was defined as resolution of typical acromegalic symptoms. Radiological resection was defined by volumetric criteria, and biochemical remission was defined as by the 2010 consensus on the criteria for remission of acromegaly. There was no significant difference in age, preoperative endocrine status, percent of macro adenomas, suprasellar, or infrasellar extension between both groups. Patients were assigned to both groups based on our existing referral pattern. Endoscopic approach was performed in 42 patients, while the microscopic approach was performed in 23 patients. No significant difference in remission rates was found between both groups (45.2 vs. 34.7 %, p = 0.40). The endoscopic group, however, had a significantly higher rate of gross total resections (61 vs. 42 %, p = 0.05). There was also a trend towards higher rates of gross total resections when cavernous sinus was present (48 vs. 14.2 %, p = 0.09). Postoperative diabetes insipidus occurred more in microscopic patients (34.7 vs. 17 %, p = 0.05), otherwise there was no significant difference in rates of complications. The median follow-up period was 56.6 months (range 6-156, mean 66.1). There is no significant difference in the rates of biochemical remission between the endoscopic and microscopic techniques. The endoscope technique, however, seems to be superior in achieving gross total resection especially with tumors invading the cavernous sinus.
Collapse
Affiliation(s)
- Hussein Fathalla
- Division of Neurosurgery, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada,
| | | | | | | | | | | | | | | |
Collapse
|
25
|
Comparison of (68)Ga DOTATATE to 18F-FDG uptake is useful in the differentiation of residual or recurrent pituitary adenoma from the remaining pituitary tissue after transsphenoidal adenomectomy. Clin Nucl Med 2015; 39:605-8. [PMID: 24873787 DOI: 10.1097/rlu.0000000000000457] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
AIM The evaluation of the remaining pituitary tissue and recurrent or residual tumor after the pituitary adenoma resection is difficult. However, it is essential to assess the size of the recurrent tumor and remaining pituitary reserve before resurgery. This study aimed to distinguish the remaining pituitary tissue from pituitary adenoma with Ga 1,4,7,10-tetraazacyclododecane-N,N',N″,N″'-tetraacetic acid-D-Phe,Tyr3-octreotate (DOTATATE) and F-FDG PET imaging in patients status post transsphenoidal adenomectomy. METHODS Thirty-five patients with suspected recurrent/residual pituitary tumors were retrospectively evaluated. All of these patients underwent DOTATATE and FDG PET/CT within 1 week before additional surgery. The DOTATATE and FDG uptake levels were compared. The image findings were then compared with pathology results after the additional surgery. RESULTS Residual or recurrent pituitary adenoma were confirmed pathologically in all 35 patients. One recurrent pituitary adenoma did not have either DOTATATE or FDG uptake. In the remaining 34 adenomas, 33 had higher FDG uptake than DOTATATE uptake. In comparison, DOTATATE had significant higher uptake than FDG in the remaining pituitary tissues in all cases. CONCLUSIONS Different degree of uptake of Ga DOTATATE and F-FDG PET/CT in the remaining pituitary tissue and recurrent/residual pituitary tumor indicated that combined analysis of Ga DOTATATE and F-FDG PET/CT might be of clinical value in differentiating recurrent/residual pituitary adenoma from the remaining pituitary tissue.
Collapse
|
26
|
Tanei T, Nagatani T, Nakahara N, Watanabe T, Nishihata T, Nielsen ML, Takebayashi S, Hirano M, Wakabayashi T. Use of high-field intraoperative magnetic resonance imaging during endoscopic transsphenoidal surgery for functioning pituitary microadenomas and small adenomas located in the intrasellar region. Neurol Med Chir (Tokyo) 2014; 53:501-10. [PMID: 23883562 DOI: 10.2176/nmc.53.501] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The usefulness of 1.5-T high-field intraoperative magnetic resonance (iMR) imaging during transsphenoidal surgery for functioning pituitary adenomas was retrospectively evaluated based on long-term endocrine remission from the records of 14 patients who underwent transsphenoidal surgery with iMR imaging for functioning pituitary microadenomas and small adenomas located in the intrasellar region. The maximum tumor diameter was 9.3 ± 2.6 mm. Patients were diagnosed with acromegaly (n = 7), prolactinoma (n = 4), and Cushing's disease (n = 3). If iMR imaging detected tumor remnants after resection, the resection cavity was reexamined and further resection was performed. Postoperative endocrine follow-up period was mean 33.7 ± 13.3 months. Tumor remnants were detected after the first resection in seven patients. Further resection was performed in five of these patients, and three achieved long-term endocrine remission. As a result, the overall long-term endocrine remission rate was 78.5% (11/14), instead of the 57.1% (8/14) that would be expected if iMR imaging had not been performed. Long-term endocrine remission had a tendency to be associated with the absence of tumor remnants on the final iMR images, but this was not significant (p = 0.09). Long-term endocrine remission was associated with presence of tumor remnants in the cavernous sinus on the final iMR images (p = 0.03). High-field iMR imaging is useful for depicting tumor remnants after resection, and increased the long-term endocrine remission rate for patients with functioning pituitary microadenomas and small adenomas.
Collapse
Affiliation(s)
- Takafumi Tanei
- Department of Neurosurgery, Nagoya Central Hospital, Nagoya, Aichi, Japan.
| | | | | | | | | | | | | | | | | |
Collapse
|
27
|
Abstract
PURPOSE The current article looks at some of the factors associated with pituitary adenomas displaying unusually aggressive biological and clinical behaviour in patients with acromegaly. METHODS This was a retrospective, narrative review of previously published evidence chosen at the authors' discretion and presented from the perspective of a Latin American case study. FINDINGS AND CONCLUSIONS Although most pituitary tumors in acromegalic patients are benign and non-aggressive many can behave more aggressively, compromising local surrounding structures. These lesions tend to respond poorly to somatostatin analogs, have a higher risk of recurrence after surgery and, thus, a worse prognosis. Patients with more aggressive tumors constitute a particular challenge, as they often require several therapeutic approaches and may be difficult to manage, especially when options are restricted due to limited resources.
Collapse
Affiliation(s)
- Carmen A. Carrasco
- Departamento de Endocrinología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Mônica Gadelha
- Endocrinology Section, Hospital Universitário Clementino Fraga Filho, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Marcos Manavela
- Division of Endocrinology, Hospital de Clínicas, University of Buenos Aires, Av. Córdoba 2351, 1120 Buenos Aires, Argentina
| | - Oscar D. Bruno
- Division of Endocrinology, Hospital de Clínicas, University of Buenos Aires, Av. Córdoba 2351, 1120 Buenos Aires, Argentina
| |
Collapse
|
28
|
Huan C, Lu C, Xu GM, Qu X, Qu YM. Retrospective Analysis of Cushing's Disease with or without Hyperprolactinemia. Int J Endocrinol 2014; 2014:919704. [PMID: 25506361 PMCID: PMC4259137 DOI: 10.1155/2014/919704] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Accepted: 10/27/2014] [Indexed: 11/18/2022] Open
Abstract
Objective. We compared the characteristics of patients with Cushing's disease alone with those of patients with Cushing's disease and hyperprolactinemia. Methods. Eighty-four patients were enrolled between 2002 and 2011, in a hospital in China. Clinical, endocrinological, and histopathological data, MRI scans, and surgical outcomes were reviewed throughout the follow-up period. Results. Patients with Cushing's disease and hyperprolactinemia had a younger age at diagnosis (30.28 ± 14.23 versus 36.08 ± 10.91 years; P = 0.037) and a larger adenoma maximal diameter (2.44 ± 1.32 versus 1.44 ± 1.05 cm; P < 0.001) than patients with Cushing's disease alone. Menstrual disorders (P = 0.027) and visual field defects (P = 0.021) were more common and progressive obesity (P = 0.009) and hypertension (P < 0.001) were less common in patients with Cushing's disease and hyperprolactinemia. The rate of normalization of hormonal levels was lower (41.7% versus 91.7%; P < 0.001) and the recurrence rate was higher (36.1% versus 8.3%; P < 0.001) in patients with Cushing's disease and hyperprolactinemia. Conclusions. Careful long-term follow-up is needed of patients with Cushing's disease and hyperprolactinemia.
Collapse
Affiliation(s)
- Cheng Huan
- Department of Neurosurgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan 250000, China
| | - Chao Lu
- Department of Laboratory Medicine, Shandong Provincial Hospital Affiliated to Shandong University, Jinan 250000, China
| | - Guang-ming Xu
- Department of Neurosurgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan 250000, China
| | - Xin Qu
- Department of Intensive Care Unit, Shandong Provincial Hospital Affiliated to Shandong University, Jinan 250000, China
| | - Yuan-ming Qu
- Department of Neurosurgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan 250000, China
- *Yuan-ming Qu:
| |
Collapse
|
29
|
Shin SS, Tormenti MJ, Paluzzi A, Rothfus WE, Chang YF, Zainah H, Fernandez-Miranda JC, Snyderman CH, Challinor SM, Gardner PA. Endoscopic endonasal approach for growth hormone secreting pituitary adenomas: outcomes in 53 patients using 2010 consensus criteria for remission. Pituitary 2013. [PMID: 23179961 DOI: 10.1007/s11102-012-0440-6] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
We report the outcomes of the endoscopic endonasal approach (EEA) for resection of growth hormone secreting pituitary adenomas using 2010 consensus criteria. We also assess outcomes with additional medical therapy and radiosurgery (RS) for patients not achieving remission with EEA alone. A retrospective review of 53 patients who had follow up endocrinologic data at least 3 months post-surgery was performed among patients who were treated by EEA between 1998 and 2012. Data were analyzed for remission using GH and IGF-I levels based on 2010 consensus criteria. We also analyzed the outcomes using 2000 consensus criteria for ease in comparison to prior studies of outcomes of surgery for acromegaly. In this series of mostly large (88.2% macroadenomas), invasive (46.9% Hardy-Wilson C, D, E) adenomas, there were 27 patients (50.9%) who achieved remission after EEA only. For patients who had no remission with EEA alone, RS and/or medical therapy were used and 37 patients (69.8 %) achieved remission overall. Statistical analysis showed larger tumor size, Hardy Stages C, D, E and Knosp Scores 3, 4 to be predictive against remission for EEA only and EEA with other modalities. The volume of residual tumor after EEA was not found to be predictive of remission with additional therapies. We used stringent consensus criteria from 2010 in a series which included a high proportion of invasive GH secreting adenomas to show that EEA alone or combined with other modalities results in comparable remission rates to earlier studies which used less strict criteria, while retaining low complication rates.
Collapse
Affiliation(s)
- Samuel S Shin
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
30
|
Hazer DB, Işık S, Berker D, Güler S, Gürlek A, Yücel T, Berker M. Treatment of acromegaly by endoscopic transsphenoidal surgery: surgical experience in 214 cases and cure rates according to current consensus criteria. J Neurosurg 2013; 119:1467-77. [DOI: 10.3171/2013.8.jns13224] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Acromegaly is a disease that has significant morbidity and mortality related to high levels of growth hormone (GH) and insulin-like growth factor–I (IGF-I), and is usually caused by pituitary adenomas. The goal in this study was to investigate the role of endoscopic transsphenoidal surgery and surgical experience in the treatment of GH adenoma cases in relation to surgical results and hormonal cure rates, and to perform a review of the literature.
Methods
The authors present a retrospective analysis of 214 GH adenoma cases. Restoration of IGF-I levels to normal for age and sex, suppression of GH levels below 0.4 μg/L on the oral glucose tolerance test, and demonstration of the total removal of the tumor on MRI studies obtained after administration of contrast material at the 3-month postoperative follow-up visit were the criteria for cure.
Results
In total 214 patients with a mean age of 41.9 ± 12 years (range 17–75 years) and a male/female ratio of 106/108 were enrolled in the study. Cure was achieved in 134 (62.6%) of 214 patients. One hundred sixty-nine patients were primary cases, and of these 109 (64.5%) were cured, whereas 61 patients were previously operated cases and of these 25 (41%) were cured. With a 51.1% decrease in the 1st month postoperatively, IGF-I levels were found to be predictive of cure (74.4% sensitivity and 73.7% specificity). Cut-off values for GH levels in predicting cure for the 1st day, 1st week, and 1st month postoperatively were 2.33, 2.05, and 2.25 μg/L, respectively.
The cut-off value for surgical experience was 57 for primary surgeries (58.5% cure rate before this cut-off value compared with 72.6% after it; p = 0.025) and 108 for all operations (45.8% vs 79.4%, p = 0.037). Although 28 patients were found to be in remission according to the criteria in 2000, they were not in remission according to the new consensus criteria. Nine of these cases (32.1%) had random GH levels < 1 μg/L at the 1-year follow-up. The 1-year IGF-I and GH levels in these 28 patients showed no significant difference when compared with the cases defined as cured according to the current criteria.
Conclusions
In acromegaly treatment, transsphenoidal endoscopic surgery performed by an expert senior surgeon and increased surgical experience are important for higher cure rates. Random GH levels < 2.33 μg/L after the 1st day postoperatively and a > 50% decrease in IGF-I levels after the 1st month postoperatively are predictive of cure. Moreover, there is no urgency for additional therapy in patients with GH levels of 0.4–1 μg/L and MRI sequences showing no tumor at the 3-month follow-up, because for these cases remission can be achieved at the 1-year follow-up.
Collapse
Affiliation(s)
- Derya Burcu Hazer
- 1Department of Neurosurgery, Muğla Sıtkı Koçman University Faculty of Medicine, Muğla
| | - Serhat Işık
- 2Department of Endocrinology and Metabolism, Ministry of Health, Ankara Numune Research and Training Hospital, Ankara; and
| | - Dilek Berker
- 2Department of Endocrinology and Metabolism, Ministry of Health, Ankara Numune Research and Training Hospital, Ankara; and
| | - Serdar Güler
- 3Department of Endocrinology, Faculty of Medicine, Hitit University, Çorum
| | | | | | - Mustafa Berker
- 6Neurosurgery, Hacettepe University Faculty of Medicine, Ankara, Turkey
| |
Collapse
|
31
|
Abstract
This article presents management options for the patient with acromegaly after noncurative surgery. The current evidence for repeat surgery, adjuvant medical therapy with somatostatin analogues, dopamine agonists, the growth hormone receptor antagonist pegvisomant, combination medical therapy, and radiotherapy in the context of persistent postoperative disease are summarized. The relative advantages and disadvantages of each of these treatment modalities are explored, and a general treatment algorithm that integrates these modalities is proposed.
Collapse
Affiliation(s)
- Nestoras Mathioudakis
- Johns Hopkins University School of Medicine, Division of Endocrinology & Metabolism, Department of Medicine, Baltimore, MD 21287, USA
| | | |
Collapse
|
32
|
Roelfsema F, Biermasz NR, Pereira AM. Clinical factors involved in the recurrence of pituitary adenomas after surgical remission: a structured review and meta-analysis. Pituitary 2012; 15:71-83. [PMID: 21918830 PMCID: PMC3296023 DOI: 10.1007/s11102-011-0347-7] [Citation(s) in RCA: 229] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
To study the currently available data of recurrence rates of functioning and nonfunctioning pituitary adenomas following surgical cure and to analyze associated predisposing factors, which are not well established. A systematic literature search was conducted using Medline, Embase, Web of Science and the Cochran Library for studies reporting data on recurrence of pituitary adenoma after surgery, in nonfunctioning adenoma (NF), prolactinoma (PRL) acromegaly (ACRO) and Cushing's disease (CUSH). Of 557 initially retrieved potential relevant studies 143 were selected. Recurrence in NFA was defined as reappearance of tumor on MRI or CT. Increase of hormone levels above normal limits as set by the authors after initial remission was used to indicate recurrence in the functioning tumor types. Remission percentage was lowest in NFA compared with other tumor types (P < 0.001). Surgery-related hypopituitarism was more frequent in CUSH than in the other tumors (P < 0.001). Recurrence, expressed as percentage of the cured population or as ratio of recurrence and total patient years of follow-up was highest in PRL (P < 0.001). The remission percentage did not improve over 3 decades of publications, but there was a modest decrease in recurrence rate (P = 0.04). Recurrences peaked between 1 and 5 years after surgery. Most of the studies with a sufficient number of recurrences did not apply multivariate statistics, and mentioned at best associated factors. Age, gender, tumor size and invasion were generally unrelated to recurrence. For functioning adenomas a low postoperative hormone concentration was a prognostically favorable factor. In NFA no specific factor predicted recurrence. Recurrence rate differs between pituitary adenomas, being highest in patients with prolactinoma, with the highest incidence of recurrence between 1 and 5 years after surgery in all adenomas. Patients with NFA have a lower chance of remission than patients with functioning adenomas. The postoperative basal hormone level is the most important predictor for recurrence in functioning adenomas, while in NFA no single convincing factor could be identified.
Collapse
Affiliation(s)
- Ferdinand Roelfsema
- Department of Endocrinology and Metabolic Diseases, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands.
| | | | | |
Collapse
|
33
|
Lee CC, Lee ST, Chang CN, Pai PC, Chen YL, Hsieh TC, Chuang CC. Volumetric measurement for comparison of the accuracy between intraoperative CT and postoperative MR imaging in pituitary adenoma surgery. AJNR Am J Neuroradiol 2011; 32:1539-44. [PMID: 21700793 DOI: 10.3174/ajnr.a2506] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE To improve the resection rate of unexpected residual pituitary tumor under image guidance, iCT provides a less time-consuming and more convenient approach of promising the safety of the trans-sphenoidal surgery. However, iCT was thought to have worse image quality than MR imaging. This study was designed to determine the predictive concordance of iCT with standard postoperative high-strength MR imaging for the detection of residual tumors. MATERIALS AND METHODS From February to December 2009, 33 patients with pituitary macroadenomas were enrolled in this prospective study. All patients received endoscopic trans-sphenoidal surgery for tumor removal and underwent iCT before the surgery finished. If an accessible tumor remnant was suspected and resectable, the surgery was continued. To assess the accuracy of intraoperative evaluation of tumor resection, the intraoperative findings were compared with MR imaging findings obtained 2 to 3 months after surgery by individually calculating the residual tumor volume. RESULTS There were no statistically significant differences in the comparison between iCT and postoperative MR imaging findings (P > .05), and the predictive rates were also high (R(2) value >0.9). The GTR rate in the case of the noninvasive and fresh cases was 89% (17/19). The overall GTR rate was 58% (19/33), the second-look rate was 21% (7/33), and only one-fourth of the recurrent cases reached GTR. CONCLUSIONS The extent of resection in trans-sphenoidal surgery can be reliably assessed by iCT. Compared with postoperative MR imaging findings, the findings in this study provided quantitative evidence that iCT not only holds significant promise for maximizing the extent of tumor resection but also eliminates the unnecessary blind surgical manipulation, thus increasing the safety of the procedure.
Collapse
Affiliation(s)
- C-C Lee
- Department of Neurosurgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan, Republic of China
| | | | | | | | | | | | | |
Collapse
|
34
|
Tanaka S, Link MJ, Brown PD, Stafford SL, Young WF, Pollock BE. Gamma knife radiosurgery for patients with prolactin-secreting pituitary adenomas. World Neurosurg 2011; 74:147-52. [PMID: 21300006 DOI: 10.1016/j.wneu.2010.05.007] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2010] [Accepted: 04/30/2010] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To evaluate the efficacy of stereotactic radiosurgery (SRS) for patients with prolactin (PRL)-secreting pituitary adenomas that were refractory to medical management. METHODS Retrospective review of 22 patients treated with SRS from 1994 until 2006. All patients were either intolerant or their tumors were unresponsive to dopamine agonist therapy. Nine patients (41%) had undergone prior transsphenoidal surgery. The median serum PRL concentration before SRS was 88.4 ng/mL (range, 25-943). The median treatment volume was 2.2 cm(3) (range, 0.4-29.0); the median margin radiation dose was 25 Gy (range, 16-30). The median endocrinologic follow-up was 60 months (range, 16-129). RESULTS Tumor control after SRS was 100%. Serum PRL concentration was significantly lower (median, 28.4 ng/mL) (P = 0.006) at last follow-up, but the 4-year actuarial rate of biochemical remission off medications was only 17%. No tested variable was associated with biochemical remission off medications. Overall, four patients (18%) had biochemical remission off medications and clinical improvement, three patients (14%) had normal serum PRL concentrations and clinical improvement on dopamine agonist therapy, seven patients (32%) had improved symptoms off medications but continued to have elevated serum PRL levels, and eight patients (36%) continued to be symptomatic with elevated PRL levels either on (n = 3) or off (n = 5) dopamine agonist therapy. The incidence of new anterior pituitary deficits was 42% at 4 years. CONCLUSIONS SRS was effective in controlling tumor growth for patients with PRL-secreting pituitary adenomas, and the majority of patients were clinically improved.
Collapse
Affiliation(s)
- Shota Tanaka
- Department of Neurological Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | | | | | | | | | | |
Collapse
|
35
|
Theodosopoulos PV, Leach J, Kerr RG, Zimmer LA, Denny AM, Guthikonda B, Froelich S, Tew JM. Maximizing the extent of tumor resection during transsphenoidal surgery for pituitary macroadenomas: can endoscopy replace intraoperative magnetic resonance imaging? J Neurosurg 2010; 112:736-43. [PMID: 19835472 DOI: 10.3171/2009.6.jns08916] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Endoscopic approaches to pituitary tumors have become an effective alternative to traditional microscopic transsphenoidal approaches. Despite a proven potential to decrease unexpected residual tumor, intraoperative MR (iMR) imaging is infrequently used even in the few operating environments in which such technology is available. Its use is prohibitive because of its cost, increased complexity, and longer operative times. The authors assessed the potential of intrasellar endoscopy to replace the need for iMR imaging without sacrificing the maximum extent of resection. METHODS In this retrospective study, 27 consecutive patients underwent fully endoscopic resection of pituitary macroadenomas. Intrasellar endoscopy was used to determine the presence of residual tumor within the sella turcica and tumor cavity. Intraoperative MR imaging was used to identify rates of unexpected residual tumor and the need for further tumor resection. RESULTS Intraoperative estimates of the extent of tumor resection were correct in 23 patients (85%). Of 4 patients with unacceptable tumor residuals, 3 underwent further tumor resection. After iMR imaging, the rate of successful completion of the planned extent of resection increased to 26 patients (96%). Rates of both endocrinopathy reversal and postoperative complications were consistent with previously published results for microscopic and endoscopic resection techniques. CONCLUSIONS The findings in this study provided quantitative evidence that intrasellar endoscopy has significant promise for maximizing the extent of tumor resection and is a useful adjunct to surgical approaches to pituitary tumors, particularly when iMR imaging is unavailable. A larger prospective study on the extent of resection following endoscopic transsphenoidal surgery would strengthen these findings.
Collapse
Affiliation(s)
- Philip V Theodosopoulos
- Department of Neurosurgery, Brain Tumor Center at the University of Cincinnati Neuroscience Institute and University of Cincinnati College of Medicine, Cincinnati, Ohio 45267-0515, USA.
| | | | | | | | | | | | | | | |
Collapse
|
36
|
Ceylan S, Koc K, Anik I. Endoscopic endonasal transsphenoidal approach for pituitary adenomas invading the cavernous sinus. J Neurosurg 2010; 112:99-107. [PMID: 19480546 DOI: 10.3171/2009.4.jns09182] [Citation(s) in RCA: 96] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
In this report, the authors describe their experience with surgical access to the cavernous sinus via a fully transnasal endoscopic approach in 20 cases. Clinical and endocrinological follow-up are discussed.
Methods
The authors used an endoscopic transsphenoidal approach in 192 patients with pituitary adenomas between September 1997 and January 2008, adding a cavernous sinus approach in 20 patients with invasive tumors during the last 5 years of this period. Parasellar extension of the tumor was measured according to the Knosp Scale. Radical tumor removal was achieved in 13 (65%) of 20 patients, and subtotal removal in 7 (35%). The authors used recently defined cavernous sinus approaches in the first 14 cases, including the paraseptal approach in 6, middle turbinectomy in 7, and contralateral middle turbinectomy in 1 case. Combined approaches rather than defined standard cavernous sinus approaches were used in 4 cases and an extended approach in 2.
Results
The tumors included nonsecretory adenomas in 5 cases (25%), growth hormone–secreting adenomas in 7 (35%), prolactin-secreting adenomas in 4 (20%), and adrenocorticotropic hormone–secreting adenomas in 4 cases (20%). Normal growth hormone and insulin-like growth factor 1 levels were achieved in 4 patients (57%) with growth hormone adenomas, and remission criteria were obtained in 3 patients with prolactinomas and 3 patients with adrenocorticotropic hormone–secreting adenomas.
Conclusions
Compared with transcranial and microscopic transsphenoidal surgery, endoscopic transsphenoidal surgery offers a wide exposure for cavernous sinus medial wall adenomas that enables removal of the adenoma from the medial cavernous sinus wall. Because of the necessity for multidisciplinary treatment to achieve satisfactory results, Gamma Knife surgery and medical therapy should be supplementary treatment options after endoscopic transsphenoidal surgery.
Collapse
|
37
|
Fully endoscopic transsphenoidal surgery for functioning pituitary adenomas. ACTA ACUST UNITED AC 2009; 72:336-40. [DOI: 10.1016/j.surneu.2009.04.012] [Citation(s) in RCA: 134] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2009] [Accepted: 04/09/2009] [Indexed: 11/21/2022]
|
38
|
Zhang HW, Sun W, Yang J, Yan CX, Yu CJ. Diagnosis and treatment of pituitary microadenoma: report of 80 cases. Neurol Res 2008; 30:587-93. [PMID: 18647498 DOI: 10.1179/174313208x310287] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVE To analyse and discuss the diagnosis and treatment of pituitary microadenoma. SUBJECTS AND METHODS Eighty cases of pituitary microadenoma treated with transsphenoidal approach in our department were analysed retrospectively during the last 2 years. RESULTS During following-up of 13.0+/-3.2 months, neither remained tumor was found except one patients with microprolactinoma, nor recurrence. Diabetes insipidus occurred in 19 patients, among which 15 patients recovered in 1 week, three in 1 month and one in 7 months. The adrenocorticotrophic hormone deficiency was found in nine of 63 patients with PRL-, GH- and non-functioning microadenoma (12%), but hypoadrenalemia recovered in all patients. Among these nine patients, seven recovered in 3 months and two in 6 months. Dysosphesia occurred in 32 cases: 30 recovered in 1 month and two in 4 months. Thirteen of 15 patients (86.7%) with ACTH-secreting microadenoma achieved chemical remission judged by plasma cortisol levels<or=2 microg/dl within 72 hours of surgery. During the mean 13.0 months of follow-up, the symptoms of amenorrhea, galactorrhea, headache, obesity and sexual disturbance were improved greatly. In total, 93.7% (45/48) of patients had normal post-operative PRL levels in the patients who had no pre-operative treatment history of long time medical therapy and large dose medical therapy in short time. CONCLUSIONS (1) Transsphenoidal surgery (TSS) is safe and effective treatment for pituitary microadenoma; (2) TSS is considered to be definitive treatment for ACTH- and GH-secreting microadenoma once the diagnosis is established; (3) in order to obtain better effects, TSS could be offered as first-line treatment for patients with locally non-invasive PRL-secreting microadenoma (tumor larger than 3 mm in diameter) and non-functioning microadenoma.
Collapse
Affiliation(s)
- Hong-Wei Zhang
- Department of Neurosurgery, Brain Sciences Institute of Beijing, and Fuxing Hospital affiliated to the Capital Medical University, Beijing 100038, China
| | | | | | | | | |
Collapse
|
39
|
Yoshida D, Nomura R, Teramoto A. Regulation of cell invasion and signalling pathways in the pituitary adenoma cell line, HP-75, by reversion-inducing cysteine-rich protein with kazal motifs (RECK). J Neurooncol 2008; 89:141-50. [PMID: 18493720 DOI: 10.1007/s11060-008-9606-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2008] [Accepted: 04/22/2008] [Indexed: 10/22/2022]
Abstract
Degradation and remodelling of the extracellular matrix has been investigated, with the main focus on the balance between matrix metalloproteinases (MMP) and tissue inhibitor of metalloproteinases (TIMP). Recent reports disclose the presence of a novel MMP-inhibiting cell membrane-anchored glycoprotein designated 'reversion-inducing cysteine-rich protein with Kazal motifs' (RECK). Our main aim in this study was to elucidate the role of RECK in cell invasion of pituitary adenomas and its contribution to signal transduction. The function of RECK in cell invasion was investigated by comparing data obtained from full-length RECK clone transfection and gene silencing with RECK mRNA-targeting siRNA. RECK expression was confirmed using real-time RT-PCR and Western blotting. Levels of matrix metalloproteinases (MMP-2 and -9) and TIMP-1 were measured by zymography and reverse zymography, respectively. Cell invasion was examined with a 3-D invasion assay. The signal cascade was investigated by cDNA microarray analysis. As expected, expression of RECK was elevated upon cDNA transfection, and diminished using siRNA. We observed elevation of MMP-2 and -9 expression and consequent 3-D cell invasion in cells under-expressing RECK. However, TIMP expression was not affected by RECK. Analysis with cDNA microarray revealed that RECK additionally upregulates growth hormone-releasing hormone receptor (GHRHR) and latrophilin 2 at the transcriptional level. Our findings collectively suggest that RECK regulates the cell signalling pathway, playing a critical neuroendocrinological role in the pituitary adenoma cell line.
Collapse
Affiliation(s)
- Daizo Yoshida
- Department of Neurosurgery, Nippon Medical School, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan.
| | | | | |
Collapse
|
40
|
Rambaldini GM, Butalia S, Ezzat S, Kucharczyk W, Sawka AM. Clinical predictors of advanced sellar masses. Endocr Pract 2007; 13:609-14. [PMID: 17954416 DOI: 10.4158/ep.13.6.609] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To identify clinical variables associated with the presence of a structurally advanced sellar mass (ASM). METHODS We performed a retrospective study of patients referred for evaluation of suspected new pituitary disease or sellar mass to the Endocrine Oncology Unit of Mount Sinai Hospital in Toronto, Ontario, Canada. By multivariate analysis, we examined predictors of a structurally ASM (a sellar lesion with any of the following characteristics: diameter of >or=1 cm on magnetic resonance imaging [MRI], optic chiasmal compression on MRI, or clinical or biochemical evidence of hypopituitarism). RESULTS Data from 152 patients were analyzed. Of the 152 sellar masses, 142 (93%) were pituitary adenomas. An ASM was noted in 85 of the 152 patients (56%). In the final multivariate model, male sex (odds ratio [OR], 6.23; 95% confidence interval [CI], 2.84 to 13.56; P<0.001) and self-reported visual field defect (OR, 3.62; 95% CI, 1.07 to 12.25; P = 0.039) were significantly independently associated with the presence of an ASM. The presence of new or changed headaches also tended to be associated with an ASM (OR, 2.11; 95% CI, 0.96 to 4.64; P = 0.063). Age and self-reported galactorrhea were not independently associated with the presence of an ASM and were conditionally removed from the final model. CONCLUSION In patients with suspected sellar or pituitary disease, male sex and self-reported visual field defects independently predict the presence of an ASM. New or changed headaches also tend to be related to the presence of an ASM. The presence of predictors of an ASM should prompt expedited sellar MRI and biochemical evaluation.
Collapse
Affiliation(s)
- Gloria M Rambaldini
- Department of Medicine, York Central Hospital, Richmond Hill, Ontario, Canada
| | | | | | | | | |
Collapse
|
41
|
Hanson JM, Teske E, Voorhout G, Galac S, Kooistra HS, Meij BP. Prognostic factors for outcome after transsphenoidal hypophysectomy in dogs with pituitary-dependent hyperadrenocorticism. J Neurosurg 2007; 107:830-40. [DOI: 10.3171/jns-07/10/0830] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The aim of this study was to determine prognostic factors for outcome after transsphenoidal hypophysectomy in dogs with pituitary-dependent hyperadrenocorticism (PDH).
Methods
One veterinary neurosurgeon performed transsphenoidal hypophysectomies in 181 dogs with PDH over a 12-year period. Survival analysis was performed with the Kaplan–Meier method. Prognostic factors were analyzed with the univariate Cox proportional hazard analysis followed by stepwise multivariate analysis. The log-rank test was used to assess disease-free fractions in three groups categorized according to early postoperative urinary corticoid/creatinine (C/C) ratios.
Results
Multivariate analysis revealed that old age, large pituitary size, and high preoperative concentrations of plasma adrenocorticotropic hormone were associated with an increased risk of PDH-related death. In addition, large pituitary size, thick sphenoid bone, high C/C ratio, and high concentration of plasma α-melanocyte–stimulating hormone (α-MSH) before surgery were associated with an increased risk of disease recurrence in the dogs that went into remission after hypophysectomy. Disease-free fractions were significantly higher in dogs with postoperative urinary C/C ratios in the lower normal range (< 5 × 10−6) than in dogs with postoperative C/C ratios in the upper normal range (5–10 × 10−6).
Conclusions
The results of this study indicate that pituitary size, sphenoid bone thickness, plasma α-MSH concentration, and preoperative level of urinary cortisol excretion are predictors of long-term remission after transsphenoidal hypophysectomy for PDH in dogs. Urinary C/C ratios measured 6 to 10 weeks after surgery can be used as a guide for predicting the risk of tumor recurrence.
Collapse
Affiliation(s)
| | - Erik Teske
- 1Department of Clinical Sciences of Companion Animals; and
| | - George Voorhout
- 2Division of Diagnostic Imaging, Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands
| | - Sara Galac
- 1Department of Clinical Sciences of Companion Animals; and
| | | | - Björn P. Meij
- 1Department of Clinical Sciences of Companion Animals; and
| |
Collapse
|
42
|
Bademci G. Pitfalls in the management of Cushing’s disease. J Clin Neurosci 2007; 14:401-8; discussion 409. [PMID: 17386367 DOI: 10.1016/j.jocn.2006.10.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2006] [Revised: 10/11/2006] [Accepted: 10/25/2006] [Indexed: 10/23/2022]
Abstract
Cushing's disease is caused by functional corticotroph adenomas of the pituitary gland, most commonly noninvasive microadenomas. Transsphenoidal microsurgery is an effective means of control for patients with adrenocorticotrophic hormone-producing microadenomas. However, a wide variation of clinical outcomes and recurrence rates has been reported. The major causes of surgical failure in the treatment of Cushing's disease lies in inadequate preoperative evaluation, unsuccessful identification of the adenoma and inexperience of the surgeon. Furthermore, appropriate use of combination therapy, including surgery, radiotherapy, radiosurgery and adrenalectomy can improve the outcome. For optimal results in this rare disease, endocrinological, radiological and surgical procedures should be co-ordinated in a specialized center. In this review, factors affecting preoperative evaluation, surgical success and outcome are outlined in the light of current knowledge.
Collapse
Affiliation(s)
- Gulsah Bademci
- Department of Neurosurgery, University of Kirikkale, Kirikkale, Turkey.
| |
Collapse
|
43
|
Abstract
Prolactinomas account for approximately 40% of all pituitary adenomas and are an important cause of hypogonadism and infertility. The ultimate goal of therapy for prolactinomas is restoration or achievement of eugonadism through the normalization of hyperprolactinemia and control of tumor mass. Medical therapy with dopamine agonists is highly effective in the majority of cases and represents the mainstay of therapy. Recent data indicating successful withdrawal of these agents in a subset of patients challenge the previously held concept that medical therapy is a lifelong requirement. Complicated situations, such as those encountered in resistance to dopamine agonists, pregnancy, and giant or malignant prolactinomas, may require multimodal therapy involving surgery, radiotherapy, or both. Progress in elucidating the mechanisms underlying the pathogenesis of prolactinomas may enable future development of novel molecular therapies for treatment-resistant cases. This review provides a critical analysis of the efficacy and safety of the various modes of therapy available for the treatment of patients with prolactinomas with an emphasis on challenging situations, a discussion of the data regarding withdrawal of medical therapy, and a foreshadowing of novel approaches to therapy that may become available in the future.
Collapse
Affiliation(s)
- Mary P Gillam
- Division of Endocrinology, Metabolism, and Molecular Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611, USA
| | | | | | | |
Collapse
|