Diabetes insipidus after endoscopic transsphenoidal surgery: multicenter experience and development of the SALT score

Exploring factors behind Arginine-Vasopressine deficiency in endoscopic endonasal surgery for PitNET: a single-center analysis of 349 patients

Arginine-Vasopressine deficiency (AVP-D), formerly known as Central Diabetes Insipidus, is a well-known complication in surgery for sellar/parasellar masses. Although less frequent in endoscopic series than transcranial and microscopic transsphenoidal ones, AVP-D has been variably related to different factors. Focusing the work on pituitary Neuroendocrine Tumors (PitNET), all patients who were treated endoscopically at a single centre were retrospectively reviewed to analyze the occurrence of this complication. Patient's characteristics, radiological information, and operative data were collected for patients who underwent surgery for PitNET at the same Institution by a single surgeon in the period 2016-2022. AVP-D was diagnosed in the presence of new-onset hypotonic polyuria with or without hypernatremia and was defined persistent if required a treatment with desmopressine/DDAVP for more than 6 months. Out of 349 patients (mean age at surgery 57.5 years old) 44 (12.6%) developed AVP-D (25 transient and 19 permanent). Younger age, the presence of an intraoperative CSF leak, the maximum diameter of the lesion, its suprasellar extension (considering the presence of a visual deficit), consistency of the lesion (distinguishing 4 classes, soft, soft-fibrous, fibrous and fibrous-firm), the extent of resection and the functioning status showed some relationship at univariate analysis (p < 0.05) with this complication. Larger diameter and longer operative time were seen more frequently in permanent AVP-D. A more solid intraoperative consistency with the presence of adherences (class 4 vs. class 1, OR 11.14, 95%CI 1.20-103.4) and the appearance of an intraoperative CSF-leak (OR 8.27, 95%CI 3.92-17.47) maintained a statistical significance in the multivariate logistic regression, with an older age being a protective factor in developing this deficiency (OR 0.96, 95%CI 0.95-0.99). The recognition of factors that can predict the onset of AVP-D with a certain degree of accuracy enables the entire staff to pay greater attention to the patient at risk in the postoperative period, thus preventing AVP-D complications.

Long-term clinical outcome of 103 patients with acromegaly after pituitary surgery

PURPOSE

Acromegaly is a rare disease that can be challenging to treat due to residual pituitary adenoma after surgery or variable response to medical treatments. The primary aim of the study was to evaluate the path of treatment and long-term outcome of acromegaly after pituitary surgery.

METHODS

Patients with acromegaly who had undergone surgery for a growth hormone-producing pituitary neuroendocrine tumor also known as a pituitary adenoma, at Sahlgrenska University Hospital between 1994 and 2019 were included in the study. Medical records from diagnosis to the end of study (November 2022) were reviewed for surgical outcome and treatment patterns related to acromegaly.

RESULTS

In the cohort of 103 patients, 111 surgeries were performed. Mean follow-up duration was 12.7 (range: 0-37) years. Lesions were identified as a macroadenoma in 76 (76.8%) cases. At post-surgical follow-up until discharge from hospital, surgical complications and new pituitary hormone deficiency or syndrome of inappropriate antidiuretic hormone secretion occurred in 37% of cases. At 1-year post-surgery follow-up, 50% of evaluable patients achieved biochemical control of acromegaly. Of the 96 patients who had follow-up > 1 year, 53 (51.5%) had no additional medication for acromegaly after surgery until end of their follow-up. From diagnosis to the end of follow-up, 53 patients received medical therapy and seven were treated with radiotherapy.

CONCLUSION

About half of the patients had biochemical control of acromegaly 1-year post-surgery. Treatment patterns reflected the complexity of post-surgical management and provided an overview of the long-term clinical progression in patients with acromegaly following pituitary surgery.

Risk Factors for Development of Diabetes Insipidus and Syndrome of Inappropriate Antidiuretic Hormone Secretion after Transsphenoidal Resection of Pituitary Adenoma

Background  We aimed to determine the incidence and risk factors for development of diabetes insipidus (DI) and syndrome of inappropriate antidiuretic hormone secretion (SIADH) after transsphenoidal hypophysectomy (TSH) for resection of a pituitary adenoma. Methods  This was a retrospective study of 403 adult patients undergoing TSH for pituitary adenoma. Clinical variables, tumor characteristics, and operative factors were collected. Incidences of DI and SIADH were determined, including timing in the perioperative period. Independent predictors of developing DI and SIADH were identified using multivariable logistic regression. Results  Following TSH, 21.3% of patients developed DI at a mean 2.6 days and 7.4% developed SIADH at a mean 4.7 days. DI was negatively associated with older age (odds ratio [OR] = 0.98, 95% confidence interval [CI]: 0.96-0.99, p  = 0.029). DI was positively associated with female sex (OR = 2.26, 95% CI: 1.24-4.11, p  = 0.008), increase in anteroposterior tumor size (OR = 1.54, 95% CI: 1.11-2.13, p  = 0.010), intraoperative cerebrospinal fluid (CSF) leak (OR = 2.29, 95% CI: 1.25-4.19, p  = 0.008), and every 100 mL of estimated blood loss (EBL) (OR = 1.18, 95% CI: 1.01-1.39, p  = 0.046). Development of SIADH was positively associated with intraoperative CSF leak (OR = 3.56, 95% CI: 1.24-10.21, p  = 0.018) on multivariate analysis. Conclusion  DI and SIADH occur in the minority of patients undergoing TSH, but vigilance for their development must be maintained for days after the surgery. Development of DI after TSH is multifactorial, having possible patient-specific risk factors and risk related to the complexity of surgical dissection, reflected by tumor size, intraoperative CSF leak, and EBL. Development of SIADH could be associated with intraoperative CSF leak occurrence.

Analysis of factors influencing the occurrence of diabetes insipidus following neuroendoscopic transsphenoidal resection of pituitary adenomas and risk assessment

Objective

Studies have revealed a higher prevalence of diabetes insipidus in patients following resection of pituitary adenoma surgery. By comprehensively analysing the clinical history of patients undergoing endoscopic transnasal sphenoidal resection for pituitary adenomas, the factors influencing development of postoperative diabetes insipidus were investigated and a predictive model was developed to assess its risk.

Methods

A retrospective analysis was conducted on the medical records of 281 patients with pituitary adenomas who underwent neuroendoscopic transsphenoidal resection at our institution between October 2020 and October 2022. The Mann-Whitney U test, chi-square test, and logistic regression analysis were used to identify the independent factors that potentially contribute to the development of postoperative diabetes insipidus. Additionally, a nomogram was constructed to evaluate the predicted risk of postoperative diabetes insipidus in patients with pituitary adenomas.

Results

Diabetes insipidus occurred in 100 (35.59 %) of the 281 enrolled patients. The results of the multifactorial logistic regression analysis revealed that diabetes, hypertension, cardiopathy, preoperative serum cortisol level, cerebrospinal fluid leakage, and tumour texture independently influenced the occurrence of postoperative diabetes insipidus (P < 0.05). A nomogram was developed to evaluate the risk of postoperative diabetes insipidus in patients with pituitary adenoma.

Conclusions

Multiple independent risk factors associated with the patient and tumour were identified in predicting diabetes insipidus. Early recognition of these risk factors may contribute to the prevention or reduction of diabetes insipidus incidence following pituitary adenoma surgery.

Anterior-posterior diameter is a key driver of resectability and complications for pituitary adenomas with suprasellar extension in endoscopic transsphenoidal surgery

BACKGROUND

As endoscopic transsphenoidal approaches are more routinely selected for progressively larger pituitary adenomas with parasellar extension, understanding potential anatomical factors that limit resection and contribute to complications is becoming increasingly important for tailoring a surgical approach. This study aimed to reevaluate existing predictive tools for resectability in pituitary adenomas specifically with suprasellar extension, and furthermore identify any additional measurable features that may be more useful in preoperative planning.

METHODS

A single-center retrospective chart review of adult patients who underwent endoscopic transsphenoidal surgery for pituitary adenomas with suprasellar extension from 2015 to 2020 was performed. Preoperative MRIs were systematically assessed to assign a Knosp classification, a Zurich Pituitary Score (ZPS), and for dimensional measurements of the suprasellar aspect of the lesions. Univariate comparisons and multivariate regression models were employed to assess the influence of these factors on extent of resection and postoperative complications.

RESULTS

Of the 96 patients with suprasellar pituitary adenomas who underwent endoscopic transsphenoidal surgery, 74 patients (77%) had a gross total resection (GTR). Neither Knosp grade nor ZPS score, even when dichotomized, demonstrated an association with GTR (Knosp 3A-4 versus Knosp 0-2, p = 0.069; ZPS III-IV versus ZPS I-II, p = 0.079). Multivariate regression analysis identified suprasellar anterior-posterior tumor diameter (SSAP) as the only significant predictor of extent of resection in this cohort (OR 0.951, 95% CI 0.905-1.000, p = 0.048*). A higher SSAP also had the strongest association with intraoperative CSF leaks (p = 0.0012*) and an increased overall rate of postoperative complications (p = 0.002*). Further analysis of the regression model for GTR suggested an optimal cut point value for SSAP of 23.7 mm, above which predictability for failing to achieve GTR carried a sensitivity of 89% and a specificity of 41%.

CONCLUSIONS

This study is unique in its examination of endoscopic transsphenoidal surgical outcomes for pituitary adenomas with suprasellar extension. Our findings suggest that previously established grading systems based on lateral extension into the cavernous sinus lose their predictive value in lesions with suprasellar extension and, more specifically, with increasing suprasellar anterior-posterior diameter.

Presenting characteristics, histological subtypes and outcomes of adult central nervous system tumours: retrospective review of a surgical cohort

Introduction

The most recent local study on the incidence of histological subtypes of all brain and spinal tumours treated surgically was published in 2000. In view of the outdated data, we investigated the presenting characteristics, histological subtypes and outcomes of adult patients who underwent surgery for brain or spinal tumours at our institution.

Methods

A single-centre retrospective review of 501 patients who underwent surgery for brain or spinal tumours from 2016 to 2020 was conducted. The inclusion criteria were (a) patients who had a brain or spinal tumour that was histologically verified and (b) patients who were aged 18 years and above at the time of surgery.

Results

Four hundred and thirty-five patients (86.8%) had brain tumours and 66 patients (13.2%) had spinal tumours. Patients with brain tumours frequently presented with cranial nerve palsy, headache and weakness, while patients with spinal tumours frequently presented with weakness, numbness and back pain. Overall, the most common histological types of brain and spinal tumours were metastases, meningiomas and tumours of the sellar region. The most common complications after surgery were cerebrospinal fluid leak, diabetes insipidus and urinary tract infection. In addition, 15.2% of the brain tumours and 13.6% of the spinal tumours recurred, while 25.7% of patients with brain tumours and 18.2% of patients with spinal tumours died. High-grade gliomas and metastases had the poorest survival and highest recurrence rates.

Conclusion

This study serves as a comprehensive update of the epidemiology of brain and spinal tumours and could help guide further studies on brain and spinal tumours.

A Machine Learning-Based Prediction of Diabetes Insipidus in Patients Undergoing Endoscopic Transsphenoidal Surgery for Pituitary Adenoma

BACKGROUND

Diabetes insipidus (DI) is a common complication after endoscopic transsphenoidal surgery (TSS) for pituitary adenoma (PA), which affects the quality of life in patients. Therefore, there is a need to develop prediction models of postoperative DI specifically for patients who undergo endoscopic TSS. This study establishes and validates prediction models of DI after endoscopic TSS for patients with PA using machine learning algorithms.

METHODS

We retrospectively collected information about patients with PA who underwent endoscopic TSS in otorhinolaryngology and neurosurgery departments between January 2018 and December 2020. The patients were randomly split into a training set (70%) and a test set (30%). The 4 machine learning algorithms (logistic regression, random forest, support vector machine, and decision tree) were used to establish the prediction models. Area under the receiver operating characteristic curves were calculated to compare the performance of the models.

RESULTS

A total of 232 patients were included, and 78 patients (33.6%) developed transient DI after surgery. Data were randomly divided into a training set (n = 162) and a test set (n = 70) for development and validation of the model, respectively. The area under the receiver operating characteristic curve was highest in the random forest model (0.815) and lowest in the logistic regression model (0.601). Invasion of pituitary stalk was the most important feature for model performance, closely followed by macroadenomas, size classification of PA, tumor texture, and Hardy-Wilson suprasellar grade.

CONCLUSIONS

Machine learning algorithms identify preoperative features of importance and reliably predict DI after endoscopic TSS for patients with PA. Such a prediction model may enable clinicians to develop individualized treatment strategy and follow-up management.

Predictors of the Spontaneous Resolution of Central Diabetes Insipidus Following Endoscopic Endonasal Surgery for Craniopharyngioma

OBJECTIVE

Central diabetes insipidus (CDI) is the most common complication of endoscopic endonasal surgery (EES) for craniopharyngioma. However, some cases of CDI could spontaneously resolve during the follow-up period. Hence, this study aimed to determine the predictive factors for the spontaneous resolution of CDI.

METHODS

Data of patients with CDI who underwent EES for craniopharyngioma between February 2009 and June 2021 were retrospectively reviewed. All patients were divided into 2 groups based on the resolution of CDI during follow-up: the recovery and no recovery groups. The baseline characteristic, surgical, and follow-up results of patients were compared.

RESULTS

We identified 84 patients with CDI (35 in the recovery group and 49 in the no recovery group). A direct comparison showed that retaining the pituitary stalk (57.1% vs. 14.3%, P = 0.000) and no-hypothalamic injury (HI) (68.6% vs. 20.4%, P = 0.000) were more common in the recovery group, whereas hydrocephalus at diagnosis (8.6% vs. 46.9%, P = 0.000) was significantly more common in the no recovery group. Subsequently, we found through univariate and multivariate analysis that the spontaneous resolution of CDI was associated with hydrocephalus at diagnosis (yes vs. no: odds ratio [OR], 0.198; P = 0.045), pituitary stalk injury (retaining vs. sectioning: OR, 7.055; P = 0.004), and the Hong et al HI pattern (mild-HI vs. no-HI: OR, 0.183; P = 0.038; unilateral-HI vs. no-HI: OR, 0.147; P = 0.017; bilateral-HI vs. no-HI: OR, 0.154; P = 0.044).

CONCLUSIONS

Hydrocephalus at diagnosis, pituitary stalk injury, and the Hong et al HI pattern might be predictors of the spontaneous resolution of CDI following EES for craniopharyngioma.

Quality of life and surgical outcomes in incidental pituitary adenomas undergoing endoscopic endonasal resection

OBJECTIVE

Incidental, asymptomatic pituitary adenomas require nuanced, shared decision-making, which is limited by a poor understanding of their natural history and effects on quality of life (QOL). A greater understanding of the effects of surgery would inform evidence-based care.

METHODS

A multicenter review of consecutive pituitary adenomas resected via an endoscopic endonasal approach (EEA) between late 2016 and mid-2021 was performed, with prospective, longitudinal QOL assessment (at 3 and 6 weeks and at 3, 6, and 12 months) postoperatively using the 35-item Anterior Skull Base Questionnaire.

RESULTS

Of 366 adenomas resected during the study period, 52 (14.2%) were incidentally discovered, of which 51 (98.1%) were macroadenomas. Preoperative QOL in patients with these incidentalomas was better than in those with adenomas presenting with endocrinopathy (p < 0.01), visual failure (p = 0.02), or headache (p = 0.03). Surgery was performed due to visual field deficits (13.5%, n = 7); ophthalmoplegia (1.9%, n = 1); radiological compression or contact of the optic apparatus (63.5%, n = 33); functional status (growth hormone-secreting tumor) (5.8%, n = 3); and clinically significant growth (15.4%, n = 8). Surgical outcomes were excellent, with vision improved in 100% (7/7) and complete resection in 84.6% (44/52). There were 2 (3.8%) cases of new cortisol deficiency, 3 (5.8%) cases of transient postoperative diabetes insipidus, and 4 (7.7%) cases of postoperative hyponatremia. There were no perioperative complications and no cases of postoperative CSF leakage. QOL transiently decreased during the first 3 weeks after surgery, then improved to above baseline levels by 3 months (p = 0.03) and continued to improve throughout the first postoperative year (p = 0.03). All surgical indications demonstrated an overall mean improvement in QOL at 3 months. QOL benefits were not affected by age or tumor size.

CONCLUSIONS

Resection of pituitary adenomas via the EEA provided a tangible benefit for patients within 3 months. Surgery via the EEA is safe, effective, and beneficial for patients with pituitary incidentalomas meeting accepted criteria for intervention.

The HACKD Score-Predicting Extent of Resection of Pituitary Macroadenomas Through an Endoscopic Endonasal Transsphenoidal Approach

BACKGROUND

Predicting extent of resection before pituitary surgery is imperative for operative planning and patient counseling. In the era of endoscopic endonasal transsphenoidal surgery (EEA), a specific, reliable tool for predicting resection of macroadenomas would have widespread applications.

OBJECTIVE

To identify factors that predict resection of pituitary macroadenomas through the EEA.

METHODS

A prospectively maintained, multicenter database of 277 consecutive macroadenomas resected through the EEA was analyzed. Multivariate logistic regression identified predictors of gross total resection (GTR). A simple scoring system, the Hardy, Age, Clival, Knosp, Depth (HACKD) Score, was developed and tested.

RESULTS

GTR was achieved in 82.3% (228/277) of cases. Older than 50 years (odds ratio [OR] 2.96, P = .01), clival extension (OR 5.87, P < .01), Hardy grade C or D suprasellar extension (OR 3.91, P = .01), Knosp grade 3 or 4 cavernous sinus invasion (OR 7.62, P < .01), and tumor depth >20 mm (OR 5.14, P < .01) were all associated with subtotal resection. The HACKD score, awarding 1 point each for Hardy grade C or D, and older than 50 years, and 2 points each for clival extension, Knosp grades 3 or 4, and tumor depth >20 mm, demonstrated excellent discriminative ability (AUROC 0.887, 95% CI: 0.839-0.934). The rate of GTR progressively decreased with a higher HACKD score. Rates of GTR were 95.8% (182/190) for low (HACKD ≤2), 59.5% (44/74) for moderate (HACKD 3-5), and 15.4% (2/13) for high (HACKD 6+) HACKD scores.

CONCLUSION

The HACKD score is a simple and accurate tool based on the largest study analyzing predictors of GTR in pituitary macroadenomas operated through the EEA.

Surgical outcomes and longitudinal quality of life after endoscopic endonasal surgery for anterior skull base meningioma

OBJECTIVE

The objective of this study was to establish the effect of endoscopic endonasal surgery on longitudinal quality of life (QOL) in patients with anterior skull base meningioma.

METHODS

A prospectively collected cohort of consecutively operated anterior skull base meningiomas was analyzed. All cases were performed using the endoscopic endonasal approach (EEA). Sinonasal-specific and overall QOL were measured using the 22-Item Sinonasal Outcome Test and the Anterior Skull Base Questionnaire longitudinally (at 3 weeks, 6 weeks, and 3, 6, and 12 months) across the first postoperative year. The relationship between surgical and QOL outcomes to clinical and radiological characteristics was analyzed using multivariate regression.

RESULTS

Fifty cases were available, with a mean age of 61.5 years and female predominance (74.0%). Visual dysfunction and headache were the most common presenting symptoms, and tumors commonly took origin from the planum (46.0%), tuberculum (44.0%), and olfactory groove (24.0%). Median tumor volume was 4.6 cm3. Visual improvement was noted in 73.1% of cases with preoperative field deficits, while nonimprovement was associated with greater tumor height (p = 0.04). Gross-total resection was not possible in patients with 360° vessel encasement and high-grade cavernous sinus extension with ophthalmoplegia. Postoperative diabetes insipidus was observed only in cases with suprasellar extension. Sinonasal-specific QOL worsened transiently after surgery but returned to baseline levels after 3 weeks. Olfaction and taste scores returned to preoperative baseline scores within the year. Overall QOL at presentation was worse in those with larger tumors (p = 0.04) and visual failure (p = 0.04) and better in those presenting with headache (p = 0.04). Transient worsening of QOL was seen in the first 3 weeks, which returned to baseline by 6 weeks, and then improved to above preoperative levels at 6 months and beyond. Worse QOL at baseline (p = 0.01) and visual improvement (p = 0.01) predicted QOL improvement after surgery.

CONCLUSIONS

Longitudinal QOL in anterior skull base meningioma has been examined for the first time. Endoscopic endonasal surgery improves overall QOL after a transient 3-week worsening due to the sinonasal morbidity of the approach. Visual function is intimately tied to QOL, with worse vision associated with worse preoperative QOL, and QOL improving in parallel with visual restoration after surgery. The EEA is associated with better visual outcomes and should be the preferred approach in accessible tumors.

Quality of Life in Craniopharyngioma: A Systematic Review

BACKGROUND

Craniopharyngiomas are morbid tumors that significantly reduce patients' quality of life (QoL). The lifelong burden of endocrine, visual, hypothalamic, and limbic dysfunction can have disastrous consequences for the physical and psychosocial health of patients. Elucidating the factors that influence QoL could guide therapeutic interventions to improve patient well-being.

METHODS

A systematic review was performed in accordance with the PRISMA (preferred reporting items for systematic reviews and meta-analyses) statement using the PubMed and Medline databases. Studies that had reported patient QoL using validated metrics in both adult and pediatric populations were included. Bias and methodological rigor were assessed using the MINORS (methodological index for nonrandomized studies) criteria.

RESULTS

A total of 25 studies, including 2025 patients, were available for review. Most studies were small, retrospective, cohort studies with a high risk of bias. The QoL of the patients with craniopharyngioma was lower than that of the general population. Hypothalamic involvement was consistently the strongest predictor of QoL. Endocrinopathy contributed to morbidity but could be ameliorated by hormone replacement therapy. Social and emotional dysregulation and a poor memory are common complaints after surgery, and iatrogenic damage to the infundibulum, hypothalamus, limbic system, and frontal lobes might underlie these concerns. Sleep-wake cycle dysfunction and hypothalamic obesity are serious consequences of hypothalamic damage.

CONCLUSIONS

An experienced multidisciplinary team is necessary to optimally manage the complex cases of these patients. The poor QoL of patients with craniopharyngioma is multifactorial. However, the contribution of iatrogenesis is not insubstantial. Improved surgical techniques, focusing on hypothalamic preservation, and adjuvant treatment options are required to improve the well-being of these patients.

Surgical outcomes and quality of life in Rathke's cleft cysts undergoing endoscopic transsphenoidal resection: a multicentre study and systematic review of the literature

OBJECTIVE

To establish the effect of endoscopic endonasal surgery (EES) on quality-of-life (QoL) in symptomatic Rathke cleft cyst (RCC).

METHODS

Analysis of 38 patients with RCC treated by EES, with regular overall (ASBQ-35) and sinonasal-specific (SNOT-22) QoL assessment during the first postoperative year. A systematic literature review of large case series was performed with pooled analysis.

RESULTS

In our series, mean age was 53.6 years with a female predominance (73.7%). Larger cysts were seen in males (p < 0.01), those with hypogonadism (p = 0.04), and visual dysfunction (p = 0.04). Complete normalisation of vision was seen in 83.3%. Persistence of visual dysfunction postoperatively was associated with diabetes (p = 0.005), hypertension (p = 0.02), suprasellar only location (p = 0.001), and monocular field cut (p = 0.02). Surgery did not significantly effect hormonal function. Sinonasal QoL transiently worsened after surgery, resolving within 3 weeks. A parallel transient worsening of overall QoL normalised by 6 weeks, and remained at preoperative baseline thereafter. These results were comparable to the literature, where 76.4% demonstrated improvement of vision and 13.1% had recurrence after treatment. There was no significant difference in outcomes between EES and microscopic approaches.

CONCLUSIONS

We report longitudinal QoL outcomes in RCC for the first time. Vision commonly improves with surgery, but endocrinopathy is likely to persist. Microvascular risk-factors may compromise visual improvement. Surgery causes a transient worsening of sinonasal symptoms that resolves within 3-6 weeks, but patients may not experience significant improvement in QoL within the first postoperative year.

Predicting the Need for Desmopressin Treatment During Inpatient and After Discharge Following Endoscopic Sellar Surgery

Introduction

Postoperative diabetes insipidus (DI) is a common complication following endoscopic sellar surgery. However, the requirement of desmopressin treatment for patients with DI are heterogenous. Although the predictors of postoperative DI have been reported, whether these patients required desmopressin treatment remained uninvestigated. Predicting the need of desmopressin can benefit clinical decision making more directly than predicting the occurence of postoperative DI. This study aimed to identify variables that predict the need for desmopressin treatment following sellar surgery.

Methods

Patients undergoing endoscopic sellar surgery between 2016 and 2019 were retrospectively reviewed. Twenty-three variables, characterized as potential predictors for requiring desmopressin treatment, were analyzed. To assess the capability to generalize the identified predictors, external validation with receiver operating characteristic (ROC) analysis was performed using a second series from 2019 to 2020.

Results

Postoperative DI occurred in 40 of 159 included patients. Twelve patients required inpatient desmopressin treatment and 20 patients needed desmopressin prescription after discharge. The potential predictors of requiring any desmopressin use included higher peak sodium (Na) level (p = 0.007), lower minimum Na level (p = 0.043), and higher peak urine output (p = 0.006), but these were not supported by external validation. The predictors of requiring desmopressin after discharge included higher peak Na (p = 0.040) and minimum Na levels (p = 0.048), which were supported by external ROC validation showing areas under curve of 0.787, 0.611, and 0.898 for peak Na (p = 0.036), minimum Na (p = 0.460), and peak Na – minimum Na levels (p < 0.001), respectively. A criterion of peak Na ≥ 150 mmol/L or peak Na – minimum Na ≥ 10 predicted the need of desmopressin prescription after discharge. A postoperative management algorithm was proposed.

Conclusion

The required treatments for patients with postoperative DI following endoscopic sellar surgery are heterogenous. Elevated peak Na and large peak Na—minimum Na levels in the perioperative period predicted requiring desmopressin after hospital discharge. Patients with peak Na <150 mmol/L and peak Na—minimum Na <10 can be safely discharged without desmopressin prescription.

Masked diabetes insipidus in pituitary metastasis from breast cancer after thalamic biopsy: a case report

Background

Symptomatic pituitary metastasis is rare; furthermore, it can result in diabetes insipidus and panhypopituitarism. Since diabetes insipidus is masked by concurrent panhypopituitarism, it can impede the diagnosis of pituitary dysfunction.

Case presentation

A 68-year-old Japanese female suffering from pituitary and thalamic metastases caused by untreated breast cancer, underwent a biopsy targeting the thalamus, not the pituitary. She lacked prebiopsy pituitary dysfunction symptoms; however, these symptoms unexpectedly occurred after biopsy. Diabetes insipidus was masked by corticosteroid insufficiency, and she showed normal urinary output and plasma sodium levels. Upon commencement of glucocorticoid replacement therapy, the symptoms of diabetes insipidus appeared.

Conclusions

In this case, thalamic biopsy, as opposed to pituitary biopsy, was performed to preserve pituitary function. However, pituitary dysfunction could not be avoided. Caution is necessary for asymptomatic patients with pituitary metastases as invasive interventions, such as surgery, may induce pituitary dysfunction. Moreover, with respect to masked diabetes insipidus, there is a need to carefully consider pituitary dysfunction to avoid misdiagnosis and delayed treatment.

Quality of Life After Endoscopic Surgical Management of Pituitary Adenomas

BACKGROUND

Patient-reported quality of life (QOL) is a vital metric for surgical success.

OBJECTIVE

To assess the effect of surgery on QOL in the largest prospectively collected, longitudinal cohort of surgically managed pituitary adenomas.

METHODS

A consecutive surgical adenoma cohort (n = 304) between late 2016 and mid-2020 underwent a scheduled overall (Anterior Skull Base Questionnaire-35) and sinonasal-specific (Sinonasal Outcome Test-22) QOL assessment. Scores were stratified by adenoma subtype and analyzed for clinical predictors of QOL changes.

RESULTS

The average age was 53.8 ± 16 yr, and 53% of participants were female. 60.9% of adenomas were nonfunctioning while adrenocorticotropic hormone adenomas (16.4%), growth hormone adenomas (14.1%), and prolactinomas (5.9%) were the most prevalent secreting adenomas. Baseline overall QOL differed between tumor types (P = .006), with adrenocorticotropic hormone adenomas worse than growth hormone adenomas (P = .03) and nonfunctioning pituitary adenomas (NFPA) (P < .001). Sinonasal QOL worsened in the 3 wk after surgery but returned to baseline by 6 wk and beyond. Overall QOL worsened at 3 wk after surgery (P < .001) but significantly improved from baseline by 3 mo (P = .009) and beyond (P < .001). Emotional functioning improved soon after surgery, followed by performance and pain, and then, by 6 mo, physical function and vitality. Predictors of improved QOL were sellar/suprasellar lesions (P = .01), prolactinomas (P = .003), and NFPA (P = .04). Conversely, new postoperative hypopituitarism (P = .04) and larger adenoma volume (P = .04) predicted QOL worsening.

CONCLUSION

QOL is worsened after surgery at early time points. Prolactinomas and NFPA enjoy significant QOL improvements from surgery as early as 3 mo postoperatively. Other functional tumors may experience early benefits in younger patients without hypopituitarism and when isolated to the sellar/suprasellar region. These findings provide valuable information for counseling patients and setting expectations for surgery.

Frailty does not preclude surgical success after endoscopic transsphenoidal surgery for pituitary adenomas

INTRODUCTION

Frailty is a state of physiological vulnerability that negatively influences surgical outcomes. The effect of frailty on pituitary adenoma surgery, however, is not clear, and patients may be wrongly denied surgery because they are "too frail". We examined the effects of frailty on surgical outcome and quality-of-life (QoL) in patients undergoing endoscopic transsphenoidal resection of pituitary adenomas.

METHODS

A prospective, consecutive cohort of surgically managed pituitary adenoma was analysed. Frailty was defined by the 5-factor modified Frailty Index (mFI-5) and the Charlson Comorbidity Index (CCI). QoL was measured by the anterior skull base questionnaire (ASBQ) and sinonasal outcomes test (SNOT).

RESULTS

Of 304 patients with pituitary adenomas, 42 (13.8%) were frail (mFI5 of > 1). Frail patients tended to have smaller adenomas (p < 0.0001) with less suprasellar extension (p < 0.0001). Both overall (ASBQ) and sinonasal-specific (SNOT) QoL were not affected by frailty on multivariate analysis. Endocrine and visual outcomes were similarly not worsened by frailty. Overall, medical complications were uncommon, and perioperative morbidity or mortality was not significantly greater in the frail group.

CONCLUSION

Frail patients experience the same QoL benefits from surgery as their non-frail counterparts, and have equivalently successful visual and endocrine outcomes. Frailty should not be seen as a barrier to successful surgical management of pituitary adenomas.

Predictors of visual and endocrine outcomes after endoscopic transsphenoidal surgery for pituitary adenomas

Surgery for pituitary adenoma is indicated for relief of mass effect and control of endocrinopathy. Setting benchmarks for visual and hormonal outcomes is important for monitoring performance of surgical centres, while understanding the preoperative factors that predict endocrine cure and visual improvement facilitates tailored counselling for patients prior to surgery. A prospective, consecutive cohort of surgically managed (endoscopic transsphenoidal) pituitary adenoma (n = 304) were analysed. Preoperative and postoperative endocrine and visual field assessments were performed and compared to demographic, imaging and pathological data. Larger adenomas tended to have preoperative endocrine deficiency (p < 0.001) and visual field defects (p < 0.001). The largest tumours did not experience normalisation of their endocrinopathy or visual fields with surgery. Of the adenomas with normal preoperative endocrine function, 92.0% (126/137) maintained this postoperatively; only 2 of the 11 patients with new hypopituitarism required long-term hormone replacement. Functional tumour cure was achieved in 65.2% (86/116) after surgery; 74.4% (32/43) of acromegalics and 70.0 (35/50) of Cushing's disease patients achieved hormonal control. All patients with isolated hyperprolactinaemia from stalk effect normalised with surgery, while only 15.9% (7/44) with hypopituitarism recovered normal endocrine function. New hypopituitarism was predicted by younger age and functional adenoma, particularly Cushing's disease. Resolution of endocrinopathy was less likely with reoperative cases and those with cavernous sinus invasion (Knosp grade > 2) or preoperative ophthalmoplegia. One-third of the cohort (102/304, 33.6%) had a preoperative field cut, most commonly an incomplete (51.0%) or complete (31.4%) bitemporal hemianopsia. Only two patients (2/304, 0.7%) had visual field worsening after surgery, while 71.6% (73/102) experienced partial or complete resolution of their field cut after surgery. Complete resolution of visual field defect was predicted by younger age and incomplete bitemporal hemianopsia. Surgery is a safe and effective therapy for pituitary adenomas. Nearly all patients experience improvement in visual fields, especially the young and those with incomplete bitemporal defects. Reoperative cases and those with cavernous sinus involvement (high Knosp grade/ophthalmoplegia) are less likely to have resolution of endocrinopathy. Visual worsening, new ophthalmoplegia or endocrinopathy were rare complications of surgery.