Reported outcomes in transsphenoidal surgery for pituitary adenomas: a systematic review

First-in-human pilot study of snapshot multispectral endoscopy for delineation of pituitary adenoma

Significance

The definitive treatment for pituitary adenoma is transsphenoidal surgical resection. Conventional white light imaging shows limited contrast between the adenoma and the pituitary gland, and only the tissue surface is visualized, leaving a pressing unmet need for improved intraoperative adenoma delineation to preserve pituitary function during surgery.

Aim

To evaluate the potential of multispectral imaging to enhance visualization of adenoma during transsphenoidal resection.

Approach

A multispectral camera based on a spectrally resolved detector array was coupled to a standard 4-mm rigid endoscope for in vivo imaging, such that the camera head could easily be switched with the standard of care camera head during surgery.

Results

The multispectral imaging (MSI) endoscope was deployed during transsphenoidal surgery, and usable data were obtained from 12 patients. MSI was able to distinguish between an adenoma and a healthy pituitary based on the spectral angle with the reference spectrum of blood.

Conclusions

The MSI endoscope holds the potential to differentiate adenoma tissue and healthy pituitary. With further development, MSI endoscopy could enable real-time label-free delineation of tumors during surgery, based on quantitative thresholds, which should contribute to improving the completeness of resection, while helping to preserve the pituitary gland, preventing serious life-changing complications.

Suprasellar Anterior-Posterior Diameter Optimizes the Use of Intraoperative MRI in Patients Undergoing Endoscopic Pituitary Surgery

BACKGROUND AND OBJECTIVES

Intraoperative MRI (iMRI) has been demonstrated to improve the extent of resection of pituitary neuroendocrine tumors resected using endoscopic endonasal approaches. We sought to establish if preoperative clinicoradiological parameters could be used to predict which patients are most likely to benefit from iMRI and thus allow more efficient use of this technology.

METHODS

A prospectively maintained surgical database of all endoscopic pituitary tumor resections with iMRI guidance performed between May 2017 and September 2023 was accessed. Data were collected on clinical and radiological parameters that may predict reintervention after iMRI. Logistic regression models were constructed to assess the relationship between predictor variables and reintervention after iMRI.

RESULTS

Seventy-three patients were included in the study. After review of the iMRI, 24/73 (33%) patients underwent surgical reintervention. The combined rate of gross total resection/near total resection was 64/73 (88%). The rate of biochemical cure of endocrine disease after surgery for a hormonally active tumor was 15/21 (71%). On univariate logistic regression analysis, the only factor significantly associated with reintervention after iMRI was the suprasellar anterior-posterior diameter (odds ratio 1.1, 95% CI 1.01-1.2, P = .030).

CONCLUSION

Suprasellar anterior-posterior diameter ≥15 mm predicts the requirement for reintervention after endoscopic resection of pituitary neuroendocrine tumor. Use of this easily obtained radiological parameter will allow iMRI to be used in those patients who are most likely to benefit.

Reported baseline variables in transsphenoidal surgery for pituitary adenoma over a 30 year period: a systematic review

PURPOSE

Heterogeneous reporting in baseline variables in patients undergoing transsphenoidal resection of pituitary adenoma precludes meaningful meta-analysis. We therefore examined trends in reported baseline variables, and degree of heterogeneity of reported variables in 30 years of literature.

METHODS

A systematic review of PubMed and Embase was conducted on studies that reported outcomes for transsphenoidal surgery for pituitary adenoma 1990-2021. The protocol was registered a priori and adhered to the PRISMA statement. Full-text studies in English with > 10 patients (prospective), > 500 patients (retrospective), or randomised trials were included.

RESULTS

178 studies were included, comprising 427,659 patients: 52 retrospective (29%); 118 prospective (66%); 9 randomised controlled trials (5%). The majority of studies were published in the last 10 years (71%) and originated from North America (38%). Most studies described patient demographics, such as age (165 studies, 93%) and sex (164 studies, 92%). Ethnicity (24%) and co-morbidities (25%) were less frequently reported. Clinical baseline variables included endocrine (60%), ophthalmic (34%), nasal (7%), and cognitive (5%). Preoperative radiological variables were described in 132 studies (74%). MRI alone was the most utilised imaging modality (67%). Further specific radiological baseline variables included: tumour diameter (52 studies, 39%); tumour volume (28 studies, 21%); cavernous sinus invasion (53 studies, 40%); Wilson Hardy grade (25 studies, 19%); Knosp grade (36 studies, 27%).

CONCLUSIONS

There is heterogeneity in the reporting of baseline variables in patients undergoing transsphenoidal surgery for pituitary adenoma. This review supports the need to develop a common data element to facilitate meaningful comparative research, trial design, and reduce research inefficiency.

Dexmedetomidine in Patients Undergoing Transsphenoidal Resection of Pituitary Adenoma: An Updated Systematic Review and Meta-Analysis of Randomized Placebo-Controlled Trials

Dexmedetomidine has been widely studied in many surgical settings, with possible benefits in lowering anesthetic requirements, improving perioperative hemodynamic stability, and improving postoperative outcomes. This systematic review aims to evaluate the effects of dexmedetomidine in patients undergoing transsphenoidal resection of pituitary adenoma, shedding light on its potential as an adjunctive agent in anesthesia for this specific surgical population. In this review, we searched PubMed, Cochrane Library, Scopus, Web of Science, and Google Scholar from inception to July 20, 2023. A total of six randomized clinical trials (RCTs) investigating the effects of dexmedetomidine versus placebo in patients undergoing transsphenoidal resection of pituitary adenoma were included in this review. The outcomes of interest were extracted from the included studies as mean difference (MD) and standard deviation (SD), then analyzed using the Review Manager (RevMan, RevMan International Inc., New York, USA) software. Our literature search process retrieved 274 records. Of them, six studies were included in the meta-analysis. There was a significant difference between the dexmedetomidine group compared to the placebo group in terms of heart rate at the end of the surgery (MD = -16.5; CI = [-25.36 to -7.64]; P value = 0.0003) and after extubation (MD = -16.81; CI = [-23.18 to -10.43]; P values < 0.00001). Furthermore, dexmedetomidine significantly reduced the mean arterial blood pressure (MAP) at after both intubation and extubation (MD = -9.11 and -21.5; CI = [-13.56 to -4.65] and [-30.93 to -12.06]; P values < 0.00001). This systematic review and meta-analysis demonstrated that dexmedetomidine appears to have several potential benefits in patients undergoing transsphenoidal resection of pituitary adenoma. The use of dexmedetomidine was associated with reductions in heart rate, mean arterial blood pressure, blood loss, and duration of surgery, while showing no significant difference in propofol dose or time to extubation of the trachea.

Functioning Endocrine Outcome after Endoscopic Endonasal Transsellar Approach for Pituitary Neuroendocrine Tumors

BACKGROUND

The endoscopic endonasal approach (EEA) is a well-established technique for the treatment of pituitary neuroendocrine tumor Preservation of normal gland tissue is crucial to retain effective neuroendocrine pituitary function. The aim of this paper is to analyze pituitary endocrine secretion after EEA for pituitary neuroendocrine tumor to identify potential predictors of functioning gland recovery.

METHODS

Patients who underwent an exclusive EEA for pituitary neuroendocrine tumors between October 2014 and November 2019 were reviewed. Patients were divided into groups according to postoperative pituitary function (Group 1, unchanged; group 2, recovering; group 3, worsening).

RESULTS

Among the 45 patients enrolled, 15 presented a silent tumor and showed no hormonal impairment, and 30 patients presented pituitary dysfunction. A total of 19 patients (42.2%) were included in group 1, 12 (26.7%) patients showed pituitary function recovery after surgery (group 2), and 14 patients (31.1%) exhibited the onset of new pituitary deficiency postoperatively (group 3). Younger patients and those with functioning tumor were more likely to have complete pituitary hormonal recovery (p = 0.0297 and p = 0.007, respectively). No predictors of functional gland worsening were identified.

CONCLUSION

EEA for pituitary neuroendocrine tumor is a reliable and safe technique regarding postoperative hormonal function. Preserving pituitary function after tumor resection should be a primary goal in a minimally invasive approach.