Giant pituitary adenoma: histological types, clinical features and therapeutic approaches

Treatment-resistant Cushing disease and acromegaly in a young woman: A case of functional pituitary macroadenoma

Cushing disease and acromegaly are common endocrine disorders caused by excessive cortisol and growth hormone production, respectively. Both conditions can co-occur due to functioning pituitary adenomas, which are typically benign pituitary gland tumors. This report discusses a 30-year-old woman with hyperpituitarism leading to treatment-resistant Cushing disease and acromegaly caused by a functional pituitary macroadenoma. A 30-year-old woman presented with a history of excessive weight gain, facial puffiness, fatigue, persistent headaches, and visual disturbances. Clinical examination revealed features consistent with Cushing disease and acromegaly, including a moon face, central obesity, and large hands and feet-the ophthalmologic evaluation identified bitemporal hemianopia, suggesting optic chiasm compression. Laboratory results showed elevated ACTH, IGF-1, and prolactin levels, alongside confirmed hypercortisolism. The patient also had secondary diabetes mellitus and galactorrhea-initial treatment with octreotide provided limited benefit, with persistent hormone elevations and insufficient symptom control. The patient underwent endonasal endoscopic transsphenoidal resection of the pituitary macroadenoma, leading to marked symptomatic and hormonal improvements. This underscores the diagnostic challenge and treatment complexity of such cases. Early diagnosis is critical for optimizing outcomes in patients with hyperpituitarism and mitigating complications. This case highlights the importance of multidisciplinary management and the necessity of long-term follow-up to monitor for recurrence and ensure sustained remission.

Refining Endoscopic and Combined Surgical Strategies for Giant Pituitary Adenomas: A Tertiary-Center Evaluation of 49 Cases over the Past Year

Background/Objectives: Giant pituitary adenomas (GPAs) pose significant surgical challenges due to their large size, parasellar/suprasellar extensions, and proximity to critical neurovascular structures. Although the endoscopic endonasal approach (EEA) is preferred for pituitary tumors, achieving gross total resection (GTR) in GPAs remains difficult. Additional transcranial approaches may improve resection rates while minimizing morbidity. This study evaluates the impact of endoscopic and combined surgical approaches on resection outcomes using a classification system previously defined in GPA patients treated over the past year. Methods: Among 517 pituitary adenomas treated in our clinic between September 2023 and September 2024, 49 GPA patients underwent endoscopic endonasal, transcranial, or combined surgery. Their medical records and surgical videos were retrospectively reviewed. Data included demographics, symptoms, imaging, surgical details, and follow-up outcomes. Tumor resection rates were analyzed based on the "landmark-based classification", considering radiological and pathological features and surgical approach. Results: The mean age was 45.5 years (female/male: 14/35). Zone distribution was 8 (Zone 1), 21 (Zone 2), and 20 (Zone 3). GTR was achieved in 34.6%, near-total resection in 36.7%, and subtotal resection in 28.5%. Endoscopic surgery was performed in 41 patients, combined surgery in 7, and a transcranial approach in 1. Complications included diabetes insipidus (9/49), cerebrospinal fluid leakage (2/49), apoplexy (2/49), hypocortisolism (3/49), epidural hematoma (1/49), and epistaxis (1/49). Conclusions: While EEA is effective for Zone 1 and 2 GPAs, Zone 3 tumors often require combined or transcranial approaches for better resection. A multimodal strategy optimizes tumor removal while minimizing morbidity. Individualized surgical planning based on tumor classification is crucial for improving outcomes.

Preoperative assessment of tumor consistency and gross total resection in pituitary adenoma: Radiomic analysis of T2-weighted MRI and interpretation of contributing radiomic features

Background

Preoperative knowledge of tumor consistency and the likelihood of gross total resection (GTR) would greatly benefit planning of pituitary adenoma surgery, however, no reliable methods currently exist.

Objectives

To evaluate the utility of radiomic analysis of MRI for predicting tumor consistency and GTR. To explore the interpretability of contributing radiomic features.

Methods

Patients undergoing first endoscopic surgery for pituitary macroadenomas were included. Tumor consistency was assessed intraoperatively, GTR was assessed based on postoperative MRI. Radiomic features were extracted from axial T2-weighted MRI. Low-variability and highly intercorrelated features were removed. Random Forest Classifiers were optimized using 70 % of patient data and evaluated on the remaining 30 %. Relative feature importance was assessed using the Gini-Simpson index.

Results

542 patients were included. GTR was achieved in 325 (60.0 %) cases, firm tumors were encountered in 122 (22.5 %) cases. There was a significant correlation between GTR and tumor consistency (67.1 % vs. 35.2 %, p < 0.001). 1688 radiomic variables were extracted, 442 were removed due to low variance and 699 due to high intercorrelation. The consistency prediction model achieved an accuracy of 81.6 % and utilized 32 features, GTR prediction model achieved 79.1 % accuracy using 73 features.

Conclusions

Radiomic analysis demonstrated significant potential for preoperative evaluation of pituitary adenomas. Texture and intensity-based features were the primary contributors to consistency prediction. However, the explanation of these features was insufficient. GTR prediction was predominantly driven by shape-related features. Our findings highlight the challenges of linking radiomic features to underlying tissue properties and emphasize the need for cautious interpretation.

Giant and irregular pituitary neuroendocrine tumors surgery: comparison of simultaneous combined endoscopic endonasal and transcranial and purely endoscopic endonasal surgery at a single center

BACKGROUND

Surgical management of giant and irregular pituitary neuroendocrine tumors (GIPitNETs) presents a significant challenge in neurosurgery. While endoscopic endonasal surgery (EES) is a widely used approach for PitNETs, GIPitNETs with extensive intracranial extension pose challenges for purely EES. We use simultaneous combined endoscopic endonasal and transcranial surgery (CECS) for the treatment of this type of tumor. Currently, there is limited research comparing CECS to EES for GIPitNETs. This study aims to compare the efficacy and short outcome of CECS and purely EES in the management of GIPitNETs to better understand the advantages and limitations of each surgical approach.

METHODS

The data of GIPitNETs patients who underwent surgery between March 2018 and May 2023 at a single center were retrospectively reviewed. All included cases were divided into CECS and EES groups according to the treatment modality received. The baseline characteristics and tumor imaging features of patients were compared between the groups, as well as surgical results, perioperative complications, and last follow-up outcomes.

RESULTS

A total of 50 patients met the inclusion criteria, with 27 undergoing CECS and 23 EES. CECS achieved a significantly higher GTR rate compared to EES (66.7% vs. 13.0%, p < 0.0001). CECS had longer operation times and hospital stays, but both approaches had similar rates of complications, including intracranial infection, CSF leakage, new pituitary dysfunction, postoperative diabetes insipidus, and vascular infarction. CECS reduces the risk of postoperative bleeding. Tumor recurrence and reoperation were significantly more common in the EES group.

CONCLUSIONS

CECS is a safe and effective surgical approach for GIPitNETs, leading to higher rates of GTR, comparable complication rates, and reduced risk of postoperative bleeding when compared to purely EES. EES was associated with more tumor recurrence. Further long-term follow-up data is needed to validate these findings.

Clinical Features and Hormonal Profile of Macroprolactinomas Presenting With the Hook Effect: A Systematic Review

OBJECTIVE

An assay artifact known as the "hook effect" causes spuriously low serum prolactin levels. This systematic review aimed to examine clinical reports on the "hook effect" in patients with macroprolactinomas to describe associated clinical features.

METHODS

We systematically searched multiple databases from database inception to April 16, 2024 for case reports, case series, or observational studies of macroprolactinomas presenting with the hook effect. Original data for hook effect cases from our institution were also included. Data pertaining to patient and tumor characteristics were extracted for data analysis.

RESULTS

A total of 61 macroprolactinoma patients demonstrating the hook effect were analyzed. The mean (standard deviation) age was 40.0 years (15.7 years) with no statistically significant difference between genders. Seventy percent of the patients were male. The smallest reported macroprolactinoma volume demonstrating the hook effect was 3.4 cm³ with its largest dimension measuring 2.9 cm. Mean pre- and postdilution serum prolactin levels were 108.1 ng/mL and 38 526.9 ng/mL, respectively. Ophthalmologic symptoms were the most commonly reported manifestations, (80.9%), followed by headaches (66.0%). Galactorrhea was reported in 4 out of 15 females and in none of the males. Central hypogonadism (63.6%) and central hypothyroidism (44.1%) were the most common associated pituitary hormonal deficiencies. No significant gender differences were noted in tumor size or serum prolactin levels.

CONCLUSION

Clinical characteristics of macroprolactinomas that demonstrate the hook effect greatly resemble those that do not, underscoring the need to perform dilution studies of prolactin in all patients with pituitary macroadenomas with normal or mildly elevated serum prolactin.

Endoscope-assisted transcranial surgery for complex pituitary adenoma: a retrospective case series study with propensity score matching

Surgical treatment of complex pituitary adenomas (PAs) presents a significant challenge. Here in, we compared the surgical outcomes between patients undergoing endoscope-assisted transcranial surgery and microscopic regimens to assess the safety and efficacy of endoscope-assisted transcranial surgery in treating complex PA. This retrospective case-control study was conducted at the First Affiliated Hospital of Soochow University, China. Clinical data were retrospectively analysed between January 2018 and January 2023. The primary outcome was gross total resection (GTR), and the secondary outcomes included recurrence, residual tumour volume, and patient status. Propensity score matching was used to account for group differences. We enrolled 73 patients, of whom 29 underwent endoscope-assisted transcranial surgery, and 44 underwent transcranial microscopic surgery. Compared with the microscopic regimen group, the endoscope-assistedgroup had higher postoperative Karnofsky Performance Scale (KPS) scores (p = 0.031), higher GTR rates (GTR: 79.3% vs. 50%, p = 0.023), and smaller tumour residual volume (residual tumour volume: 0.15 vs. 0.94, p = 0.029). After propensity score matching, the endoscope-assistedregimen was associated with increased odds of GTR rate, compared with the microscopic regimen (odds ratio: 3.65, 95% confidence interval: 1.06-12.54, p = 0.040). KPS score improvement at discharge was more evident in the endoscope-assisted group than in non-combined group. The endoscope-assisted transcranial surgery regimen offered increased GTR rates, higher postoperative KPS score, and less residual tumour than the non-combined regimen did, highlighting endoscope-assistedtherapy as the more favourable treatment approach for patients with complex PA.

Comparison of Surgical Modalities for Giant Pituitary Adenoma: A Systematic Review and Meta-Analysis of 1413 Patients

BACKGROUND AND OBJECTIVES

Giant pituitary adenomas (GPAs) are a challenging clinical entity, composing 5% to 15% of all pituitary adenomas. While the endoscopic endonasal transsphenoidal (EET) approach has surpassed the microsurgical transsphenoidal (MT) and transcranial (TC) approaches as the first-line surgical modality in most institutions, a systematic review comparing the 3 approaches has not been undertaken since 2012. Given growing adoption of EET and development of novel operative techniques over the past decade, an updated comparison of GPA surgical modalities is warranted.

METHODS

We identified all studies related to the surgical management of GPAs in PubMed, Embase, and Web of Science from inception to December 31, 2021. End points assessed included gross total resection (GTR) rates, postoperative visual improvement, mortality, and perioperative complications.

RESULTS

After screening of 1701 studies, we identified 45 studies on the surgical management of GPAs for meta-analysis. Thirty-one used the EET approach (n = 1413), 11 studies used the MT approach (n = 601), and 10 used the TC approach (n = 416). The cumulative number of patients treated by EET did not exceed that of patients treated by the TC or MT approaches until 2014 and 2015, respectively. Despite patients undergoing EET having the highest average tumor diameter, pooled rates for GTR were significantly higher for EET (42%) than MT (33%, P < .001) and TC (8%, P < .001) and EET similarly exhibited superior rates of visual improvement (85%) than MT (73%, P < .001) and TC (56%, P < .001). Mortality rates were comparable between EET (0.6%) and MT (1.6%), but EET had significantly lower mortality than TC (2.7%, P < .001). Compared with MT, EET had lower rates of hypopituitarism (8.5% vs 14.9%, P = .012) but higher rates of diabetes insipidus (3.1% vs 0.5%, P = .001).

CONCLUSION

In an updated meta-analysis of 1413 patients with GPA, EET resection conferred significantly higher rates of visual improvement and GTR, when compared with the MT and TC approaches.

Automatic pituitary adenoma segmentation and identification of cavernous sinus invasion via multitask learning

AIM

This study aimed to develop a multitask deep learning model for pituitary macroadenoma (PMA) segmentation and identification of cavernous sinus (CS) invasion.

MATERIALS AND METHODS

A total of 926 patients with PMAs (n=816 from Institution 1 for model training and n=110 from Institution 2 for model validation) were included. Manual segmentation for tumor and bilateral internal carotid arteries was conducted on coronal contrast-enhanced T1-weighted imaging images using ITK-SNAP. Two performing neurosurgeons evaluated the CS invasion during the operation. A Multi-Task Multiaxis-Attention UNet (MTMAU-Net) framework that combined segmentation and CS invasion classification tasks was proposed. Dice similarity coefficient and 95% Hausdorff distance (HD95) were used to evaluate the segmentation performance. Accuracy and area under the curve (AUC) were used to assess the classification performance.

RESULTS

Compared with several single-task models, MTMAU-Net model achieved higher Dice coefficient (90.84±0.55%) and lower HD95 values (2.13±0.37 mm) in segmentation tasks and performed better in the classification task (accuracy: 88.05±2.84%, AUC: 0.89±0.08). Compared with the Knosp grading system, this model showed overall consistent performance (accuracy: 88.05% vs 87.68%) and outperformed human grading evaluation at Knosp grade 3 (83.33% vs 57.62%). MTMAU-Net showed great capability of generalization in both segmentation (Dice coefficient: 83.71±5.93%) and classification tasks (accuracy: 84.55%, AUC: 0.87) in the validation cohort.

CONCLUSION

MTMAU-Net outperformed single-task models in PMA segmentation and CS invasion classification and showed advantages over the Knosp grading system in identifying CS invasion, which might guide clinicians to make appropriate surgical strategies.

CLINICAL TRIAL REGISTRATION

This study is registered at the Chinese Clinical Trial Registration Center with registration number ChiCTR210047614.

The expression of VDACs and Bcl2 family genes in pituitary adenomas: clinical correlations and postsurgical outcomes

Introduction

Pituitary adenomas (PAs) are benign tumors with high prevalence and, occasionally, aggressive course. The tumorigenesis of these lesions is not completely understood at the molecular level. BAK1 and BAX proteins play fundamental roles in apoptosis and seem to interact with VDAC proteins, whose expressions have been markedly altered in cancer, impacting their prognosis.

Objective

to evaluate the gene expression of VDAC1, VDAC2, BAK1 and BAX and their association with clinical and imaging characteristics in PA.

Methods

Clinical-epidemiological data were collected from 117 tumor samples from patients affected by PA. Invasiveness was assessed by the Knosp scale. Gene expression was examined by real-time PCR. Relative expression analysis was performed by 2^(-DDCt) method.

Results

The sample was mainly composed of women (69/117 - 57.2%). Tumor subtypes observed were Non-Functioning (NF) (73/117 - 62.4%), Acromegaly (24/117 - 20.5%) and Cushing's Disease (CD) (20/117 - 17.1%). Compared to normal tissue, there was a significant reduction in VDAC1 expression in the Acromegaly (p=0.029) and NF (p=0.002) groups. BAX expression was lower in all groups (p <0.001; p=0.007; P =0.005). No difference was found in VDAC2 and BAK1 expression, compared to normal pituitary. Overexpression of VDAC2 occurred in PAs with post-surgical regrowth (p=0.042). A strongly negative correlation was observed in BAX and BAK1 expression in CD.

Conclusion

The results indicated that downregulations of VDAC1 and BAX may be related to resistance to apoptosis. In contrast, overexpression of VDAC2 in regrowing PAs suggests an antiapoptotic role for this gene. In summary, the genes evaluated might be involved in the biopathology of PAs.

Combined simultaneous transsphenoidal and transcranial regimen improves surgical outcomes in complex giant pituitary adenomas: a longitudinal retrospective cohort study

BACKGROUND

Surgical treatment of complex giant pituitary adenomas (GPAs) presents significant challenges. The efficacy and safety of combining transsphenoidal and transcranial approaches for these tumors remain controversial. In this largest cohort of patients with complex GPAs, we compared the surgical outcomes between those undergoing a combined regimen and a non-combined regimen. We also examined the differences in risks of complications, costs, and logistics between the two groups, which might offer valuable information for the appropriate management of these patients.

PATIENTS AND METHODS

This was a multicenter retrospective cohort study conducted at 13 neurosurgical centers. Consecutive patients who received a combined or non-combined regimen for complex GPAs were enrolled. The primary outcome was gross total resection, while secondary outcomes included complications, surgical duration, and relapse. A propensity score-based weighting method was used to account for differences between the groups.

RESULTS

Out of 647 patients [298 (46.1%) women, mean age: 48.5 ± 14.0 years] with complex GPAs, 91 were in the combined group and 556 were in the noncombined group. Compared with the noncombined regimen, the combined regimen was associated with a higher probability of gross total resection [50.5% vs. 40.6%, odds ratio (OR): 2.18, 95% confidence interval (CI): 1.30-3.63, P = 0.003]. The proportion of patients with life-threatening complications was lower in the combined group than in the non-combined group (4.4% vs. 11.2%, OR: 0.25, 95% CI: 0.08-0.78, P = 0.017). No marked differences were found between the groups in terms of other surgical or endocrine-related complications. However, the combined regimen exhibited a longer average surgery duration of 1.3 h ( P < 0.001) and higher surgical costs of 22,000 CNY (~ 3,000 USD, P = 0.022) compared with the noncombined approach.

CONCLUSIONS

The combined regimen offered increased rates of total resection and decreased incidence of life-threatening complications, which might be recommended as the first-line choice for these patients.

Giant Clinically Non-Functioning Pituitary Adenoma Presenting as New Onset Generalized Tonic‒Clonic Seizures: A Case Report

Background

Giant Clinically Non-Functioning Pituitary Adenomas (GCNFPA) are pituitary neuroendocrine tumours spanning beyond 4 cm in diameter without clinically apparent secretory function. They elicit insidious growth pertaining to its asymptomatic nature and present at large sizes from mass effect. Certain clinical features such as headache and visual disturbances are common presentations of GCNFPAs owing to their size, while others such as seizures are extremely rare.

Case Report

A 63-year-old woman presented with back-to-back generalized tonic clonic seizures to the A&E and was treated with Levetiracetam. Following initial normal blood investigations, a visual field analysis revealed a bitemporal upper quadrantanopia and further evaluation using MRI found a giant pituitary lesion with suprasellar extension through the third ventricle into the lateral ventricles with significant mass effect. She underwent neuro-navigation guided endonasal transsphenoidal subtotal resection 2 weeks later. The histological diagnosis of null cell adenoma with a Ki67 of 3% was made. At 3 months of follow-up, she is symptom free and monitored with serial MRIs.

Conclusion

Seizures are an uncommon presentation of GCNFPAs limited to a few case reports. This illustrates the importance of careful evaluation of patient presentations to correctly diagnose pituitary neoplasms and prioritizing symptom relief in choosing surgical approaches.

Clinical presentation and surgical outcomes of very large and giant pituitary adenomas: 80 cases in a cohort study of 306 patients with pituitary adenomas

PURPOSE

To identify differences in the presentation and surgical outcomes between very large (30-39 mm) and giant (≥ 40 mm) (LARGE group) pituitary adenomas (PAs) compared to the smaller group (< 30 mm) (non-LARGE group).

METHODS

Eighty patients with very large (n = 44) or giant (n = 36) PAs and 226 patients in the non-LARGE group who underwent tumor resection by pituitary surgery between 2008 and 2023 were studied. Hormonal, radiological, ophthalmological, and pathological data, and surgical outcomes were evaluated.

RESULTS

Preoperatively, patients of the LARGE group presented more frequently with visual impairment (82.5% vs. 22.1%, P < 0.001) and with pituitary apoplexy (15.0% vs. 2.7%, P < 0.001) than the non-LARGE group. Moreover, the LARGE group were more commonly associated with preoperative panhypopituitarism (28.8% vs. 6.2%, P < 0.001). This group presented cavernous sinus invasion more frequently (71.3% vs. 23.9%, P < 0.001). The non-LARGE group achieved surgical cure more often than the LARGE group (79.7% vs. 50.0%, P < 0.001), and the rate of major complications was higher in the latest (8.8% vs. 1.3%, P < 0.004).

CONCLUSIONS

PAs ≥ 30 mm are most frequently accompanied by hormonal dysfunction, cavernous sinus invasion, and visual impairment. All this implies lower resection rates and higher postoperative complications than the smaller adenomas, posing a real surgical challenge.

Factors Limiting Complete Resection in the Subarachnoid Space in Endoscopic Surgery for Giant Pituitary Adenoma

OBJECTIVES

Giant pituitary adenomas (>4 cm, GPAs) have presented great challenges to surgeons because the residual tumor in the subarachnoid space can cause hemorrhage or vessel injury following apoplexy. This study aimed to investigate the factors limiting surgical success in endoscopic skull base surgery (ESS) for GPAs.

METHODS

ESS was performed on 67 consecutive patients with GPAs from 2010 to 2020. We retrospectively analyzed the clinical and radiologic features and surgical outcomes. Correlations between the tumor characteristics and extent of resection were statistically presented with odds ratios (ORs).

RESULTS

Preoperative visual and hormonal impairments were present in 59 (88.1%) and 55 patients (82.1%), respectively. Gross total resection (GTR) was achieved in 58.2% of patients, and the tumor remained on the lateral side of the subarachnoid space or the cavernous sinus when complete resection failed. The tumor volume, maximal diameter, multilobulated shape, cavernous sinus invasion, posterior fossa extension, and extent of suprasellar lateral extension of tumors were significantly correlated with incomplete resection. In tumors with subarachnoid lateral extension, greater distances from the medial wall of the proximal cavernous internal carotid artery to the most lateral tumor significantly increased the risk of incomplete resection for the suprasellar lateral portion of the tumor, with an OR of 1.21.

CONCLUSIONS

Considerable surgical planning in ESS for GPAs is crucial for complete resection and patient safety. We elucidated that lateral extension of tumors in the subarachnoid space hindered the surgical success of the suprasellar portion of the tumor.

Surgical Strategies in the Treatment of Giant Pituitary Adenomas

BACKGROUND AND OBJECTIVES

The management of giant pituitary adenomas (GPAs) is challenging due to associated endocrinopathies and the close proximity of these tumors to critical structures, such as the optic nerves, structures of the cavernous sinus, and hypothalamus. The objective of this review article was to summarize the current management strategies for giant pituitary adenomas, including the role of open and endoscopic surgical approaches and the role of medical and radiation therapy in conjunction with surgery.

METHODS

We conducted a retrospective review of GPAs operated at our institute between January 2010 and March 2023. Surgical approaches, extent of resection, and associated complications were documented. Furthermore, we conducted a thorough literature review to identify relevant studies published in the past decade, which were incorporated along with insights gained from our institutional case series of GPAs to analyze and integrate both the existing knowledge base and our institution's firsthand experience in the management of GPAs.

RESULTS

A total of 46 giant pituitary adenomas (GPAs) were operated on, using various surgical approaches. Transsphenoidal approach was used in 25 cases and a staged approach using transsphenoidal and pterional was used in 15 cases. Other approaches included transcortical-transventricular, transcallosal, pterional/orbitozygomatic, and subfrontal approaches. Complications and technical nuances were reported.

CONCLUSION

The management of giant pituitary adenomas remains complex, often involving several modalities-open or endoscopic resection, radiosurgery, and medical management of both the tumor and associated endocrinopathies. Surgical resections are often challenging procedures that require careful consideration of several factors, including patient characteristics, tumor location, and size, and the experience and skill of the surgical team.

Clinical characteristics and therapeutic outcomes of acromegalic patients with giant growth hormone-secreting pituitary adenomas: a single-center study of 67 cases

PURPOSE

Acromegalic patients with giant growth hormone-secreting pituitary adenomas (GHPAs) (≥ 40 mm) are relatively rare, and their clinical characteristics and treatment outcome data are limited. This study aims to analyze the clinical practice experience of giant GHPAs.

METHODS

Sixty-seven acromegalic patients with giant GHPAs and 67 patients with macro GHPAs (10-39 mm), matched for age and gender from the same hospital during the same period, were retrospectively recruited. The clinical characteristics, treatment, and outcomes were analyzed.

RESULTS

Enlargement of the extremities and facial features were the most common symptoms in most patients (92.5%). Compared with the macroadenoma group, more frequent visual impairment (86.6% vs. 25.4%, P < 0.001) and gonadal axis dysfunction (49.3% vs. 34.3%, P = 0.008), higher preoperative fasting GH, nadir GH after OGTT and IGF-1 levels, and a higher proportion of extrasellar tumor invasion were seen in the giant adenoma group. As the adenoma size increases, the total resection rate decreases, and postoperative complications and multimodal treatment strategies increase significantly. Fasting and nadir GH levels remained higher at 1 week postoperatively, and there were more surgical complications and cases of anterior hypopituitarism in the giant group. After a median follow-up of 36 months, 12 patients (36.4%) in the giant GHPA group and 17 (36.2%) in the macro GHPA group achieved biochemical remission. Other factors such as age of onset, age of diagnosis, delayed diagnosis time, metabolic complications, p53 positive rate, and Ki-67 index showed no significant difference between the two groups.

CONCLUSIONS

With aggressive multimodal therapy, the biochemical remission rate of acromegalic patients with giant GHPAs is comparable to that of patients with macro adenoma. However, postoperative complications and hypopituitarism need to be closely monitored.

How we do it: the double keyhole micro-endoscopic combined complex pituitary adenoma surgery

BACKGROUND

Surgical removal of complex pituitary adenomas (PA) is a technically challenging procedure. To ensure safe and efficient surgery, we employ the micro-endoscopic combination technique.

METHOD

In this study, we present our approach to the removal of a complex PA using the micro-endoscopic combination strategy. We describe our surgical setup and workflow in detail.

CONCLUSION

Our experience with this case highlights the effectiveness of the micro-endoscopic combination technique in the management of complicated skull base surgeries with good teamwork and cooperation.

Long-term Follow-up of 84 Patients With Giant Prolactinomas-A Swedish Nationwide Study

PURPOSE

To describe the clinical presentation and treatment outcomes in a nationwide cohort of patients with giant prolactinomas.

METHODS

Register-based study of patients with giant prolactinomas [serum prolactin (PRL) > 1000 µg/L, tumor diameter ≥40 mm] identified in the Swedish Pituitary Register 1991-2018.

RESULTS

Eighty-four patients [mean age 47 (SD ±16) years, 89% men] were included in the study. At diagnosis, the median PRL was 6305 µg/L (range 1450-253 000), the median tumor diameter was 47 mm (range 40-85), 84% of the patients had hypogonadotropic hypogonadism, and 71% visual field defects. All patients were treated with a dopamine agonist (DA) at some point. Twenty-three (27%) received 1 or more additional therapies, including surgery (n = 19), radiotherapy (n = 6), other medical treatments (n = 4), and chemotherapy (n = 2). Ki-67 was ≥10% in 4/14 tumors. At the last follow-up [median 9 years (interquartile range (IQR) 4-15)], the median PRL was 12 µg/L (IQR 4-126), and the median tumor diameter was 22 mm (IQR 3-40). Normalized PRL was achieved in 55%, significant tumor reduction in 69%, and combined response (normalized PRL and significant tumor reduction) in 43%. In the primary DA-treated patients (n = 79), the reduction in PRL or tumor size after the first year predicted the combined response at the last follow-up (P < .001 and P = .012, respectively).

CONCLUSION

DAs effectively reduced PRL and tumor size, but approximately 1 patient out of 4 needed multimodal treatment. Our results suggest that the response to DA after 1 year is useful for identifying patients who need more careful monitoring and, in some cases, additional treatment.

Endoscopic endonasal approach for resection of giant nonfunctional pituitary adenoma

The giant pituitary adenoma (GPA)> 4 cm is considered a surgical challenging pathology and associated with higher surgical complications compared to non-giant pituitary adenoma [1]. These tumors are invasive and had extension to nearby neurovascular structures including cranial nerves and internal carotid artery. Endoscopic endonasal approach (EEA) is increasingly used in the last two decades, however tumors with significant height extension in the supraseller region makes surgeons in favor of transcranial approaches or combined approaches [2]. The accompanied symptoms arise from compression of neighboring structures as well as hypopituitarism [3]. In this video we present 65 year old male with PMH significant for HTN who presented with 2-3 months retro-orbital headaches, confusion, gait instability, urinary/fecal incontinence, found to have 5.1 × 2.1 × 2 cm sellaer-suprasellar mass compressing the floor of the third ventricle, mammillary body, and optic apparatus. The mass was associated with hydrocephalus. The endoscopic endonasal skull base approach (trans-sellar, transtubercular) was performed with significant tumor resection without a need for trans cranial approach. A titanium clips was used to reconstruct the diaphragma sella which was very helpful technique to change high flow CSF leak to low flow. The postoperative course of the patient was smooth with improved gait, memory, and vision. He was kept on a hormonal replacement for hypopituitarism.

Two- and three-dimensional endoscopic endonasal surgery of large and giant pituitary adenomas-outcome analysis of a series of 62 patients from a single pituitary center

To analyze the perioperative course and clinical outcome of patients with large (lPA) and giant (gPA) pituitary adenoma who underwent endoscopic endonasal transsphenoidal surgery (EETS) using either two-dimensional (2D-E) or three-dimensional (3D-E) endoscopic systems. Single-center retrospective study of consecutive patients with lPA and gPA who underwent EETS between November 2008 and January 2023. LPA were defined as ≥ 3 cm and < 4 cm in diameter in at least one dimension and a volume of ≥ 10ccm; gPA were defined as larger than 4 cm in diameter and with a greater volume than 10ccm. Patient data (age, sex, endocrinological and ophthalmological status) and tumor data (histology, tumor volume, size, shape, cavernous sinus invasion according to the Knosp classification) were analyzed. 62 patients underwent EETS. 43 patients were treated for lPA (69.4%) and 19 patients for gPA (30.6%). 46 patients (74.2%) underwent surgical resection using 3D-E and 16 patients 2D endoscopy (25.8%). Statistical results are referred to the comparison between 3D-E and 2D-E. Patients' age ranged from 23-88 years (median 57), 16 patients were female (25.8%), 46 male (74.2%). Complete tumor resection was possible in 43.5% (27/62), partial resection in 56.5% (35/62). Resection rates did not differ between 3D-E (27 patients [43.5%]) and 2D-E (7 patients [43.8%], (p = 0.985). Visual acuity improved in 30 of 46 patients with preoperative deficit (65.2%). In the 3D-E group 21 of 32 patients (65.7%) improved, compared to 9 of 14 patients in the 2D-E group (64.3%). Improvement of visual field was achieved in 31 of 50 patients (62.0%; 22 of 37 patients in the 3D-E group [59.4%] and 9 of 13 patients in the 2D-E group [69.2%]). CSF leak was the most frequent complication and occurred in 9 patients (14.5%, [8 patients 17.4% 3D-E]) without statistical significance. Other surgical complications like postoperative bleeding, infection (meningitis) and deterioration of visual acuity and field were detected without statistical difference. New pituitary anterior lobe dysfunction was observed in 30 of 62 patients (48.4%, 8 patients [50.0%] in the 2D-E group and 22 patients [47.8%] in the 3D-E group). A transient deficit of posterior lobe was detected in 22.6% (14/62). No patient died within 30 days of surgery. Although 3D-E may improve surgical dexterity, in this series of lPA and gPA it was not associated with higher resection rates compared to 2D-E. However, 3D-E visualization during resection of large and giant PA is safe and feasible and patient's clinical outcome is not different compared to 2D-E.

Correlation of Pituitary Descent and Diabetes Insipidus After Transsphenoidal Pituitary Macroadenoma Resection

BACKGROUND

Endoscopic transsphenoidal surgery remains the technique of choice for resection of pituitary adenoma. Postoperative diabetes insipidus (DI) is most often transient and observed in 1.6% to 34% of patients, whereas permanent DI has been reported in 0% to 2.7% of patients. The proposed mechanism was the transduction of traction forces exerted by the surgeon on the descended diaphragma sellae and through the pituitary stalk.

OBJECTIVE

To quantify and correlate the degree of pituitary gland descent with postoperative DI.

METHODS

Of 374 patients who underwent transsphenoidal resection of a pituitary adenoma between 2010 and 2020 at our institution, we report a cohort of 30 patients (Group A) DI. We also report a matched cohort by tumor volume of 30 patients who did not develop DI (Group B). We quantified the tension on the pituitary stalk by calculating pituitary descent interval (PDI) by comparing preoperative and postoperative position of the pituitary gland and using Pythagoras' formula where , with craniocaudal (CC) and anterior-posterior (AP) representing measurements of pituitary translation in respective directions after resection.

RESULTS

Patients who developed DI had significantly greater pituitary gland translations in the craniocaudal (23.0 vs 16.3 mm, P = .0015) and anteroposterior (2.4 vs 1.5 mm, P = .0168) directions. Furthermore, Group A had a statistically greater PDI, which was associated with development of DI (23.2 vs 16.6 mm, P = .0017).

CONCLUSION

We were able to quantify pituitary descent and subsequent tension on the pituitary stalk, while also associating it with development of postoperative DI after pituitary adenoma resection.

Acromegaly complicated with fulminant pituitary apoplexy: clinical characteristic analysis and review of literature

PURPOSE

To retrospectively summarize the clinical features of acromegaly complicated with fulminant pituitary apoplexy and analyze the prognostic factors to guide early identification and timely treatment of such patients.

METHODS

A retrospective analysis was carried out to summarize the clinical manifestations, hormone changes, imaging, treatment and follow-up of ten patients with acromegaly complicated with fulminant pituitary apoplexy admitted to our hospital from February 2013 to September 2021.

RESULTS

The mean age of the ten patients (five males and five females) at the time of pituitary apoplexy was 37.1 ± 13.4 years old. There were nine cases with sudden severe headaches and five cases with visual impairment. All patients had pituitary macroadenomas, of which six cases with Knosp grade ≥3. The level of GH/IGF-1 hormone after pituitary apoplexy was lower compared with pre-apoplexy, and 1 patient reached biochemical remission spontaneously. Seven patients underwent transsphenoidal pituitary surgery after apoplexy and one patient was treated with long-acting somatostatin analog. The biochemical remission rate was 37.5% in eight patients immediately after treatment and 50% at the last follow-up. Patients with Knosp grade ≥3 were less likely to achieve biochemical remission than those with Knosp grade <3 (16.7% vs. 100%, p = 0.048), and patients who achieved biochemical remission had a smaller maximum tumor diameter [20.1 (20.1,28.0) mm vs. 44.0 (44.0,60) mm, p = 0.016].

CONCLUSION

Acromegaly complicated with fulminant pituitary apoplexy remains a diagnostic and therapeutic challenge.

Analysis of the Prognostic and Immunological Role of HSPB1 in Pituitary Adenoma: A Potential Target for Therapy

Background and Objectives: The diagnosis and treatment of pituitary adenomas with cavernous sinus invasion pose significant challenges for clinicians. The objective of this study is to investigate the expression profile and prognostic value of HSPB1 (heat shock protein beta-1) in pituitary adenomas with invasive and non-invasive features. Additionally, we aim to explore the potential relationship between HSPB1 expression and immunological functions in pituitary adenoma. Materials and Methods: A total of 159 pituitary adenoma specimens (73 invasive tumours and 86 non-invasive tumours) underwent whole-transcriptome sequencing. Differentially expressed genes and pathways in invasive and non-invasive tumours were analysed. HSPB1 was subjected to adequate bioinformatics analysis using various databases such as TIMER, Xiantao and TISIDB. We investigated the correlation between HSPB1 expression and immune infiltration in cancers and predicted the target drug of HSPB1 using the TISIDB database. Results: HSPB1 expression was upregulated in invasive pituitary adenomas and affected immune cell infiltration. HSPB1 was significantly highly expressed in most tumours compared to normal tissues. High expression of HSPB1 was significantly associated with poorer overall survival. HSPB1 was involved in the regulation of the immune system in most cancers. The drugs DB11638, DB06094 and DB12695 could act as inhibitors of HSPB1. Conclusions: HSPB1 may serve as an important marker for invasive pituitary adenomas and promote tumour progression by modulating the immune system. Inhibitors of HSPB1 expression are currently available, making it a potential target for therapy in invasive pituitary adenoma.

Aggressive pituitary tumors (PitNETs)

The majority of anterior pituitary tumors behave benignly, that is, they grow slowly and do not metastasize, and were therefore called adenomas. However, they would frequently invade adjacent structures, leading to recurrence. One of the misleading assumptions in their previous classification was the simplistic distinction made between adenoma and carcinoma. In the upcoming WHO 2022 classification, a new terminology will be introduced: pituitary neuroendocrine tumor (PitNET) which is consistent with that used for other neuroendocrine neoplasms. In general, aggressive PitNETs are invasive and proliferative tumors with frequent recurrences, resistant to conventional treatments, and yet virtually without metastases. At present, no single morphological or histological marker has been shown as yet to reliably predict their aggressive behavior. In terms of treatment, temozolomide (TMZ) had been considered promising and the sole therapeutic option for aggressive and malignant PitNETs following failure of standard therapies. However, recent reports have disclosed that TMZ does not provide long-term control of many aggressive PitNETs. A further multidisciplinary approach is necessary for both reliable prediction and successful management of aggressive PitNETs.

Remission, complications, and overall survival in transsphenoidal pituitary surgery-a Swedish single-center experience of 578 patients

BACKGROUND

Surgical treatment of pituitary lesions causing hormonal overproduction or mass effect is standard procedure. There are few reports on the results and complications related to these surgeries from Northern Europe. Our aim was to evaluate the outcome and complications of a single tertiary surgical center over more than a decade.

METHODS

This was a retrospective study on all patients that underwent pituitary surgery from 1st of January 2005 to 31st of December 2017. The analysis included type of lesion, surgical method, pre- and postoperative need for hormonal substitution, hormonal outcome, complications to surgery, survival, need for revision surgery, or stereotactic radiation. Appropriate statistical analyses were made to evaluate surgical results, complications, and survival.

RESULTS

Five hundred seventy-eight patients were included in the study. Remission was achieved in 58% of patients with GH-producing and 94% of ACTH-releasing adenomas. Sixty-six percent had no preoperative hormonal substitution compared to 39% postoperatively. Rhinosinusitis (10%) was the most commonly reported postoperative complication followed by leakage of cerebrospinal fluid (8%) and meningitis (4%). Standardized mortality rate for the study population was higher (p = 0.18) when compared to the general population.

CONCLUSION

Our results regarding remission rates and complications are in comparison with previous studies. Surgery of pituitary lesion can be considered a safe and efficient surgery. We noted lower rates of CSF leakage in the later part of the study period and believe that this, in part, was an effect by the introduction of a multidisciplinary surgical skull base team and increased surgical experience.

Staged surgery for irregular giant pituitary adenomas: A report of two cases

The resection of giant pituitary adenomas is one of the most challenging brain surgeries, especially when the giant pituitary adenomas have an irregular shape or irregular growth position. The purpose of the present study is to propose staged surgery for irregular giant pituitary adenomas through a retrospective analysis of two cases. The cases of two patients with irregular giant pituitary adenomas who underwent staged surgery are retrospectively analyzed. In one case, a 51-year-old male was hospitalized after 2 months of memory loss. Brain MRI showed that the pituitary adenoma was paginated and located in the sellar and right suprasellar regions, with a size of ~6.15×6.11×5.69 cm. In the second case, a 60-year-old male had a history of intermittent vertigo for 10 years and paroxysmal amaurosis for 1 year. Brain MRI showed that the pituitary adenoma grew laterally and eccentrically, and was located in the sellar region, with a size of ~4.35×3.96×3.07 cm. Both patients underwent staged surgery; more specifically, the tumors were totally removed through two-stage surgery. In the first-stage operation, most of the tumor was removed by the microscopic transcranial approach, while in the second-stage operation, the residual tumor was removed by the endoscopic transsphenoidal approach. Both patients recovered well without obvious postoperative complications after staged surgery. There was no recurrence during the follow-up. Staged surgery is characterized by only treating tumors in the visual field and achieving a total tumor resection, which has the advantages of a high tumor resection rate, high safety and fewer postoperative complications. Staged surgery is especially suitable for irregular giant pituitary adenomas with an irregular shape or irregular growth position.

Giant growth hormone-secreting pituitary adenomas from the endocrinologist's perspective

OBJECTIVES

Since giant (≥40 mm) GH-secreting pituitary adenomas are rarely encountered, data on their characteristics and treatment outcomes are limited. We aimed to investigate the characteristics of giant GH-secreting pituitary adenomas and to compare their clinical, biochemical, imaging and histopathological features with non-giant macroadenomas.

MATERIALS AND METHODS

We have evaluated 15 (six female/nine male) and 57 (29 female/28 male) patients with acromegaly in giant and <40 mm adenoma groups, respectively. Patients with <40 mm adenoma were further divided into subgroups with adenoma size 20-29 mm and 30-39 mm.

RESULTS

In giant adenoma group, median (IQR) preoperative maximal diameter of adenoma was 40 mm (5 mm), median preoperative GH level was 40 (153.4) ng/mL and median baseline IGF-1 level was 2.19 (1.88) × ULN for age and sex. The number of surgeries was significantly higher in giant adenoma group (median 2, IQR 2) in which 66.7% of patients underwent repeated surgeries (p = 0.014). Residual tumor was detected after last operation in all patients with giant adenoma. Total number of treatment modalities administered postoperatively increased as adenoma size increased (p = 0.043). After a median follow-up duration of 10 years (IQR 10), hormonal remission was achieved in six patients (40%) of giant adenoma group, while the rate of hormonal remission in non-giant adenoma group was 37%. Although preoperative GH and IGF-1 levels and Ki-67 index tended to be higher with increasing adenoma size, there was no statistically significant difference between groups in terms of these variables, as well as age, sex and invasion status.

CONCLUSION

Hormonal remission rates of acromegaly patients with ≥20 mm pituitary macroadenoma were comparable. However, giant GH-secreting pituitary adenomas require an aggressive multimodal treatment approach.

Endoscopic transcranial transdiaphragmatic approach in a single-stage surgery for giant pituitary adenomas

Background

The treatment for giant pituitary adenomas (GPAs, maximal diameter >4 cm) remains challenging, with remarkable mortality and morbidity, and there is no consensus on the optimal surgical approach. Gross total resection (GTR) for GPAs is difficult to achieve through a single transsphenoidal or transcranial approach. Any residual tumor is at risk for postoperative apoplexy. In this study, we propose a new surgical technique for resecting the GPAs in a sing-stage transcranial surgery.

Methods

A retrospective review of 4 patients with complicated GPAs, who had been treated via an endoscopic transcranial transdiaphragmatic approach in a single-stage surgery after routine transcranial resection, was performed. The following data was analyzed: clinical characteristics, preoperative imaging studies, resection rate, perioperative morbidity and mortality, as well as postoperative outcomes.

Results

All patients had nonfunctioning GPAs and preoperative visual disturbances. In three patients, GTR was achieved, and in one patient, near-total resection (90%-100% of the tumor) was achieved. Three patients attained improved postoperative visual function, while one patient's vision remained unchanged. One patient suffered a deficiency in adrenocorticotropic hormone along with thyroid-stimulating hormone, and one patient developed diabetes insipidus. Notably, none of the patients suffered cerebrospinal fluid leakage. However, one patient developed an epidural hematoma and underwent decompressive craniectomy.

Conclusions

The endoscopic transcranial transdiaphragmatic approach in a single-stage surgery can be efficiently and safely performed for maximal excision of GPAs with extensive suprasellar extension. Furthermore, relative to the conventional combined or staged approaches, this innovative surgical strategy provides neurosurgeons with a clear operative field with reduced invasiveness.

Preoperative Peripapillary Retinal Nerve Fiber Layer Thickness as the Prognostic Factor of Postoperative Visual Functions After Endoscopic Transsphenoidal Surgery for Pituitary Adenoma

Purpose

To evaluate the prognostic ability of preoperative peripapillary retinal nerve fiber layer thickness (pRNFLT) for predicting postoperative visual functions, including the visual field index (VFI) and visual acuity (VA), of subjects with pituitary adenoma (PA) who were treated with endoscopic transsphenoidal surgery for pituitary adenoma (ETSS-PA) exclusively.

Subjects and Methods

This 11-year retrospective study was performed at a single institution in Thailand. Sixty-six eyes of 33 subjects who had a PA compressing the anterior visual pathway and were treated with ETSS-PA alone were included. The pRNFLT was measured globally and in the four quadrants preoperatively, using optical coherence tomography. Multivariable analysis and area under the curve (AUC) were used to demonstrate the prognostic ability of preoperative pRNFLT for postoperative visual functions (> 1 month but < 6 months after ETSS-PA).

Results

The mean postoperative VFI and median postoperative VA were 79.45% ± 24.24% and 0.14 [interquartile range: 0.02, 0.40] logarithm of the minimum angle of resolution. Among the 56 eyes with a reliable postoperative VFI, thicker preoperative temporal (odds ratio, 1.18; p = 0.024) and inferior (odds ratio, 1.07; p = 0.013) pRNFLT values were associated with a postoperative VFI > 90%. The strongest association occurred with the preoperative temporal pRNFLT (AUC = 0.821, 95% CI: 0.720-0.923) with a cut-off value of 60 µm. Multivariable analysis for all 66 eyes showed that thicker preoperative inferior-quadrant pRNFLT (odds ratio, 1.05; p = 0.001) was associated with a postoperative VA of at least 20/25. The strongest performance was found with the preoperative inferior pRNFLT (AUC = 0.732, 95% CI: 0.615-0.849) with a cut-off value of 105 µm.

Conclusion

Preoperative pRNFLT offers clinical utility for predicting visual functions after ETSS-PA. Temporal pRNFLT ≥ 60 µm and inferior pRNFLT ≥105 µm predicted postoperative VFI > 90% and postoperative VA better than or equal to 20/25, respectively.

Radiation Therapy for Recurrent or Residual Pituitary Macroadenoma Invading Extrasellar Structures

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.

Relationship with the diaphragm to predict the surgical outcome in large and giant pituitary adenomas

Objective

Large and giant pituitary adenomas (L- and G-PAs) continue to remain a surgical challenge. The diaphragm may have a role in determining the shape of the tumor and therefore influencing the extent of resection. Our study aims to analyze our surgical series of L- and G-PAs according to their relationship with the diaphragm and invasion of cavernous sinus (CS).

Material and methods

We performed a retrospective analysis of our surgical series of patients operated for L- and G-PAs. We categorized the tumors into four grades according to their relationship with the diaphragm: grade 1 (supradiaphragmatic component with a wide incompetent diaphragm), grade 2 (purely infra-diaphragmatic tumor with a competent diaphragm), grade 3 (dumbbell-shape tumors), and grade 4 (multilobulated tumor with invasion of the subarachnoid space).

Results

A total of 37 patients were included in our analysis. According to our classification, 43.3% of patients had grade 1 tumors, 27% had grade 2, 5.4% had grade 3, and 24.3% had grade 4 tumors. CS invasion was confirmed intraoperatively in 17 out of 37 patients (46%). The gross total resection (GTR) was obtained in 19% of the cases, near-total resection in 46%, and subtotal resection in 35%. All the patients who achieved GTR had grade 1 tumors and the lowest rate of CS invasion (p < 0.01).

Conclusion

Radiological evaluation of the tumor relationship with the diaphragm, invasion of CS, and invasion of the subarachnoid space are crucial to plan the surgical strategy and maximize the possibilities of achieving GTR in L- and G-PAs.

Effect of facility volume on giant pituitary adenoma neurosurgical outcomes

OBJECTIVE

Giant pituitary adenomas (PAs), defined as 4 cm or greater at their maximum diameter, are commonly treated with neurosurgical intervention as the first-line therapy. However, existing studies are from high-volume institutions whose outcomes may not be representative of many cancer centers. In the present study, the authors use a large cancer registry to evaluate demographics, national treatment trends, and outcomes by facility volume to address knowledge gaps for this uncommon tumor.

METHODS

The National Cancer Database was queried for adult patients with PAs who had undergone resection from 2004 to 2016. Univariate and multivariate logistic regression modeling was used to evaluate the prognostic impact of covariates on short-term outcomes including 30-day readmission (30R), 30-day mortality (30M), 90-day mortality (90M), and prolonged length of inpatient hospital stay (LOS). Propensity score matching was used for validation.

RESULTS

Among the 39,030 patients who met the study inclusion criteria, 3696 giant PAs were identified. These tumors had higher rates of subtotal resection (55% vs 24%, p < 0.001), adjunctive radiotherapy (15% vs 5%, p < 0.001), and hormonal therapy (8% vs 4%, p < 0.001) than nongiant PAs. The giant PAs also had worse 30M (0.6% vs 3.1%, p < 0.001), 90M (1.0% vs 5.0%, p < 0.001), 30R (4.0% vs 6.3%, p < 0.001), and LOS (22.2% vs 42.1%, p < 0.001). On multivariate analysis for giant PA, decreased tumor size, younger age, race other than African American, lower comorbidity score, and high-volume facility (HVF; defined as ≥ 2.5 giant PA cases per year) were statistically significant predictors of favorable outcomes. Specifically, 30M, 90M, 30R, and LOS were decreased by 50%, 43%, 55%, and 32%, respectively, when giant PAs were treated at HVFs (each p < 0.05). HVFs more often used the endoscopic approach (71% vs 46%, p < 0.001) and less adjuvant radiotherapy (11% vs 16%, p < 0.001). Propensity score matching validated 30M, 30R, and LOS outcome differences in a cohort of 1056 patients.

CONCLUSIONS

This study provides evidence of superior outcomes when giant PAs are treated at HVFs. These results likely reflect the relation between physician experience and outcomes for these uncommon tumors, which suggests the need for institutional collaboration as a potential goal in their surgical management.

Analysis of neuroendoscopy for the treatment of macroadenomas and giant pituitary adenomas

Objective

This study investigated the use and effectiveness of endoscopic transnasal, transsphenoidal surgery, a minimally invasive method for the treatment of macroadenomas and giant pituitary a denomas, in a medical setting. The surgical results of 429 patients who received neuroendoscopic treatment of macroadenomas or giant pituitary adenomas were evaluated, and the experiences and lessons learned from treatment complications were assessed.

Patients and methods

From January 2012 to December 2021, 429 patients with macroadenomas or giant pituitary adenomas, including 60 patients with giant adenomas (diameter ≥4 cm) and 369 patients with macroadenomas (diameter 1–4 cm), received a 3D head CT, a MRI with contrast enhancement, and an endocrinology examination prior to surgery. Preoperative clinical and radiological features, visual measurements, hormone levels, length of stay, length of surgery, postoperative stay, visual and hormone outcomes, resection range, complication and recurrence rates, and routine patient information were recorded. The patients were followed up for 6–72 months (median = 40 months).

Results

Of 429 patients with macroadenomas or giant pituitary adenomas who received neuroendoscopic treatment, 348 (81.12%) had gross-total resections (GTR), 53 (12.35%) had near-total resections (NTR), and 28 (6.53%) had subtotal resections. There were 138 cases of post-operative diabetes insipidus (32.17%), including 7 cases of permanent diabetes insipidus (1.63%), 16 cases of nasal hemorrhage (3.73%), 39 cases of intraoperative cerebrospinal fluid leakage (9.09%), 4 cases of intracranial infection (0.9%), 16 cases of hypophysis (3.7%), and 15 cases of anosmia (3.50%). The clinical symptoms and endocrinology indices of the patients improved after surgery, and all patients were discharged 5–18 days (8.36 ± 2.65) postop.

Conclusion

Neuroendoscopy is a safe operation with a short recovery period and hospital stay and is thus an effective method to treat macroadenomas and giant pituitary adenomas. Preoperative evaluation and prediction can help to accurately address possible intraoperative situations and improve GTR.

Molecular Markers of Telomerase Complex for Patients with Pituitary Adenoma

Pituitary adenoma (PA) is the most common benign tumor of the pituitary gland. The pathogenesis of most PA is considered as a multifactorial process, that involves genetic mutations, alterations in gene transcription, and epigenetic factors. Their interaction promotes tumorigenesis. The processes are increasingly focused on changes in telomere length. Our study enrolled 126 patients with PA and 368 healthy subjects. DNA samples from peripheral blood leukocytes were purified by the DNA salting-out method. The RT-PCR carried out SNPs and relative leukocyte telomere lengths (RLTL). ELISA determined the level of TEP1 in blood serum. Binary logistic regression revealed that TERC rs35073794 is likely associated with increased odds of PA development and macro-PA development. It is also associated with decreased odds of active PA, non-invasive PA, and PA without relapse development. Also, we discovered that PA patients with at least one G allele of the TEP1 gene polymorphism rs1713418 have lower serum TEP1 levels than healthy individuals (p = 0.035). To conclude, the study revealed that TERC rs35073794 might be a potential biomarker for PA development.

Low-rank fusion convolutional neural network for prediction of remission after stereotactic radiosurgery in patients with acromegaly: a proof-of-concept study

Artificial intelligence approaches to analyze pathological images (pathomic) for outcome prediction have not been sufficiently considered in the field of pituitary research. A total of 5,504 Hematoxylin & Eosin-stained pathology image tiles from 58 acromegalic patients with a good or poor outcome were integrated with other clinical and genetic information to train a low-rank fusion convolutional neural network (LFCNN). The model was externally validated in 1,536 patches from an external cohort. The primary outcome was the time to the first endocrine remission after SRS. The median time of initial endocrine remission was 43 months [IQR: 13-60 months] after SRS, and the 24-month initial cumulative remission rate was 57.9% [IQR: 46.4-72.3%]. The patient-wise accuracy of the LFCNN model in predicting the primary outcome was 92.9% in the internal test dataset, and the sensitivity and specificity were 87.5% and 100.0%, respectively. The LFCNN model was a strong predictor of initial cumulative remission in the training cohort (HR 9.58, 95% CI 3.89-23.59; p < 0.001) and was higher than that of established prognostic markers. The predictive value of LFCNN model was further validated in an external cohort (HR 9.06, 95% CI 1.14-72.25; p = 0.012). In this proof-of-concept study, clinically and genetically useful prognostic markers were integrated with digital images to predict endocrine outcomes after SRS in patients with active acromegaly. The model considerably outperforms established prognostic markers and can potentially be used by clinicians to improve decision-making regarding adjuvant treatment choices. This article is protected by copyright. All rights reserved.

Estimating Risk of Pituitary Apoplexy after Resection of Giant Pituitary Adenomas

Background Pituitary apoplexy after resection of giant pituitary adenomas is a rare but often cited morbidity associated with devastating outcomes. It presents as hemorrhage and/or infarction of residual tumor in the postoperative period. Because of its rarity, its incidence and consequences remain ill defined.

Objective The aim of this study is to estimate the rate of postoperative pituitary apoplexy after resection of giant pituitary adenomas and assess the morbidity and mortality associated with apoplexy.

Methods A systematic review of literature was performed to examine extent of resection in giant pituitary adenomas based on surgical approach, rate of postoperative apoplexy, morbidities, and mortality. Advantages and disadvantages of each approach were compared.

Results Seventeen studies were included in quantitative analysis describing 1,031 cases of resection of giant pituitary adenomas. The overall rate of subtotal resection (<90%) for all surgical approaches combined was 35.6% (95% confidence interval: 28.0–43.1). Postoperative pituitary apoplexy developed in 5.65% (n = 19) of subtotal resections, often within 24 hours and with a mortality of 42.1% (n = 8). Resulting morbidities included visual deficits, altered consciousness, cranial nerve palsies, and convulsions.

Conclusion Postoperative pituitary apoplexy is uncommon but is associated with high rates of morbidity and mortality in subtotal resection cases. These findings highlight the importance in achieving a maximal resection in a time sensitive fashion to mitigate the severe consequences of postoperative apoplexy.

A new comprehensive grading for giant pituitary adenomas: SLAP grading

AimGiant pituitary adenomas are difficult to resect due to multicompartmental extension. We developed a new grading system for giant pituitary adenomas (GPAs) considering possible extension in superior, lateral, anterior, and posterior (SLAP) directions. We also related the degree of resection to the SLAP grading.MethodsA review of case files and radiological images of patients with the GPAs defined as pituitary adenomas with a size of more than 4 cm in any dimension was done. The extent of the tumour was noted and scored as per the SLAP system. The maximum total score is 10 and represents a large tumour with maximum extensions in all directions. The subtotal resection (STR) was defined as a residual tumour volume of more than 10%. The association between individual and total score on the degree of resection was determined.ResultsA total of 103 cases of GPAs were analyzed. All patients had a suprasellar (S) extension. The lateral (L) extension was seen in 97.3% of cases. The anterior (A) extension was seen in 28 (27.2%) cases. The posterior (P) extension was seen in 45 (43.7%). Forty-eight (46.6%) had a total score of 5 or more. The STR was achieved in 64 (62.2%) cases. On regression analysis, a total score of ≥5 was associated with odds of 5.02 (1.69-14.93), p-value 0.004 for STR.ConclusionThe SLAP grading is a comprehensive grading system that can be applied easily to the GPAs and gives a complete picture of the extension of the tumour.

LncRNA growth arrest specific transcript 5 inhibits the growth of pituitary neuroendocrine tumors via miR-27a-5p/cylindromatosis axis

The long noncoding RNA growth arrest-specific transcript 5 (GAS5) has been reported to function as a suppressor in many cancers. However, the role and mechanism of lncRNA GAS5 in pituitary neuroendocrine tumors (PitNETs) remain unclear. Here, we found that lncRNA GAS5 and cylindromatosis (CYLD) expression was downregulated in invasive PitNET tissues and was negatively correlated with miR-27a-5p expression. LncRNA GAS5 overexpression inhibited proliferation of PitNETs cell line MMQ and GH3 cells and induced cell apoptosis, simultaneously, inhibited miR-27a-5p expression and increased CYLD expression. Moreover, miR-27a-5p mimic significantly decreased the luciferase activities of lncRNA GAS5 and CYLD luciferase reporter vector and downregulated CYLD expression, while miR-27a-5p inhibitor increased the expression of CYLD in MMQ and GH3 cells. Furthermore, RNA-immunoprecipitation assay revealed the direct binding between lncRNA GAS5 and miR-27a-5p. Additionally, miR-27a-5p mimic or silenced CYLD attenuated the effect of lncRNA GAS5 on MMQ and GH3 cell proliferation. In vivo lncRNA GAS5 overexpression inhibited GH3 cell tumor growth, while miR-27a-5p mimic or silenced CYLD attenuated the effect of lncRNA GAS5 on GH3 cell tumor growth. These results suggest that lncRNA GAS5 acts as an endogenous sponge by binding miR-27a-5p to increase the expression of its target gene CYLD, thereby inhibits PitNETs cell proliferation and tumor growth.

Magnetic resonance imaging finding of coexistence of bilateral paraclinoid aneurysms in a patient with a nonfunctioning macroadenoma, simultaneous resection, and clipping: illustrative case

BACKGROUND

Unruptured incidental intracranial aneurysm can coexist with pituitary adenoma, however, the occurrence is extremely rare. Timely diagnosis of asymptomatic intracranial aneurysms with pituitary adenoma may lead to planning a tailored surgical strategy to deal with both pathologies simultaneously. A case of a patient who underwent transcranial resection of a pituitary adenoma with clipping of two mirror aneurysms is reported.

OBSERVATIONS

A 55-year-old female presented with deterioration of visual acuity that progressed over 1 year, as well as presence of right eyelid ptosis. Magnetic resonance imaging of the head showed the presence of an intrasellar pituitary macroadenoma. Bilateral paraclinoid aneurysms were documented to be in contact with the pituitary tumor. The patient underwent surgery with simultaneous aneurysm clipping and tumor resection through a standard pterional approach with intradural clinoidectomy. The aneurysms were successfully clipped after the tumoral debulking. After clipping, the pseudocapsule was fully resected.

LESSONS

Various treatment options are available. Although endovascular securing of the aneurysms prior to the tumor resection would be ideal, in cases in which this resource is not readily available at all times, the surgeon must be prepared to solve pathologies with an elevated level of complexity.

Neurological Presentation of Giant Pituitary Tumour Apoplexy: Case Report and Literature Review of a Rare but Life-Threatening Condition

Background: Giant pituitary adenomas are benign intracranial tumours with a diameter ≥4 cm. Even if hormonally non-functional, they may still cause local extension, leading to symptoms that include mostly gland dysfunction, mass effects, and, much less frequently, apoplexy due to haemorrhage or infarction. Neurological presentation of giant pituitary tumour apoplexy is even more rare and has not been systematically reviewed. Case Presentation: An 81-year-old woman was admitted to the Emergency Department because of acute onset headache, bilateral visual deficit, and altered consciousness. Computed tomography showed a giant mass lesion (>5.5 cm diameter) expanding upward to the suprasellar cistern, optic chiasm, and third ventricle, over-running the sphenoid sinus, and with lateral invasion of the cavernous sinus. Laboratory investigations revealed central adrenal and hypothyroidism insufficiency, while magnetic resonance imaging confirmed a voluminous suprasellar tumour (~6 cm diameter), with signs of pituitary tumour apoplexy. Neurological manifestations and gland-related deficits improved after hormonal replacement therapy with a high dose of intravenous hydrocortisone, followed by oral hydrocortisone and levo-thyroxine. The patient declined surgical treatment and follow-up visit. Conclusions: Giant pituitary tumour apoplexy is a rare but potentially life-threatening condition. Prompt diagnosis and multidisciplinary management may allow a remarkable clinical improvement, as seen in this case.

Endoscopic vs. microscopic transsphenoidal surgery outcomes in 514 nonfunctioning pituitary adenoma cases

Transsphenoidal surgery remains the preference choice for patients with nonfunctioning pituitary tumors at present, but the superiority of surgical modalities is still debated. Moreover, the efficacy of microscopic and endoscopic transsphenoidal surgery has not been fully studied. Therefore, the present study was designed to compare the postoperative outcomes of the two widely used approaches worldwide. This retrospective study included 514 patients with the first transsphenoidal pituitary adenoma resection in Shandong Provincial Hospital from January 2015 to July 2020 and compared the outcomes of microscope transsphenoidal surgery (MTSS) and endoscopy transsphenoidal surgery (ETSS). A total of 514 patients were included in this study, of whom 210 received the ETSS and 304 received the MTSS. The patients in two groups were similar in terms of postoperative hyponatremia (p = 0.229), diabetes insipidus (p = 0.264), the recovery of hormonal axis (p < 0.05), and extent of resection (EOR) (p = 0.067). ETSS was more likely to cause cerebrospinal fluid leakage than MTSS (p = 0.017, 3.6% vs. 8.6%). CSF leakage might be related to tumor size (95% CI = 1.305-2.766, p = 0.001), and the surgeon's transsphenoidal surgery volume < 300 was also a risk factor (95% CI = 1.396-9.067, p = 0.008). The effect of different surgeries on postoperative vision improvement was statistically difference in univariate analysis (p = 0.048) but not after adjustment for confounders (p = 0.112). Furthermore, there were statistical difference in EOR between MTSS and ETSS when adenomas were performed suprasellar extension (p = 0.037) or optic chiasm compression (p = 0.045). Both techniques are valid for the treatment of nonfunctional adenomas. But CSF leakage is more likely after ETSS. In addition, ETSS is more conducive to resection of nonfunctional adenomas with suprasellar extension or optic chiasm compression.

Metastatic breast cancer masquerading as a pituitary macroadenoma: A case report

The purpose of this manuscript is to report a case of symptomatic breast cancer metastasis to the pituitary gland, a described yet exceedingly rare phenomenon. A 52-year-old woman with a known history of stage-IV breast cancer treated 3 years prior with chemotherapy presented to the emergency department with 2 weeks of right-sided periorbital headache and 1 week of right-sided ptosis. Magnetic resonance imaging showed a 1.9 cm × 2.8 cm × 2.8 cm mass in the pituitary with mass effect on the right optic chiasm. Endocrine laboratory studies were largely normal, including prolactin, thyroid-stimulating hormone, insulin-like growth factor, and a minimally decreased cortisol. She underwent endoscopic transnasal transsphenoidal resection 4 days later to remove the mass without complication. Postoperative pathologic studies were positive for breast cancer metastasis, and she was subsequently started on adjuvant radiation and oral chemotherapy. While breast cancer metastases to the sella have been described in the literature before, symptomatic spread to the pituitary represents a small percentage of all breast cancer metastases, and we thus feel is worthy of further discussion.

Transsphenoidal Surgery of Giant Pituitary Adenoma: Results and Experience of 239 Cases in A Single Center

BACKGROUND

Transsphenoidal surgery (TSS) is first-line treatment for giant pituitary adenomas (PAs). Although PA is a benign neuroendocrine tumor that originates from adenohypophysial cells, the surgical outcomes and prognosis of giant PAs differ significantly due to multiple factors such as tumor morphology, invasion site, pathological characteristics and so on. The aim of this study was to evaluate surgical outcomes of giant PAs in a single-center cohort.

METHODS

The clinical features and outcomes of 239 patients with giant PA who underwent sphenoidal surgery at the Second Affiliated Hospital of Zhejiang University School of Medicine from January 2015 to October 2021 were collected from medical records. The basic clinical information (age, gender, function etc.), surgical procedure, imaging features (maximum diameter, invasion characteristics, tumor shape etc.) and histopathological characteristics (pathological results, Ki-67, P53 etc.) were retrospectively reviewed. SPSS 25.0 and Stata 12.0 software were used for statistical analysis.

RESULTS

A total of 239 patients with giant PAs underwent TSS, of which 168 surgeries (70.29%) were endoscopic endonasal transsphenoidal (EETS) and 71 (29.71%) were microscopic transsphenoidal (MTS). The mean preoperative maximum diameter in the cohort was 45.64 mm. Gross-total resection was achieved in 46 patients (19.25%), near-total in 56 (23.43%), subtotal in 68 (28.45%), and partial in 69 (28.87%) patients. The maximum tumor diameter and Knosp grade were the significant factors that limited the extent of the resection of giant PAs. A total of 193 patients (80.75%) experienced surgical complications, and the most common complications were postoperative diabetes insipidus (DI) (91, 38.08%), intracranial infection (36, 15.06%) and cerebrospinal fluid (CSF) leaks (37, 15.48%). In addition, there was a significant difference in the incidence of CSF leaks between the neuroendoscopy group and the microscopic group (P < 0.05).

CONCLUSION

The management of giant PAs remains a therapeutic challenge due to their large size and postoperative complications. The maximum diameter and Knosp grade of giant PAs significantly limited the extent of resection, which warrants a reasonable surgical plan.

Surgery for acromegaly: Indications and goals

Acromegaly is a disease that occurs secondary to high levels of GH, most often from a hormone-secreting pituitary adenoma, with multisystem adverse effects. Diagnosis includes serum GH and IGF-1 levels, and obtaining an MRI pituitary protocol to assess for a functional pituitary adenoma. Attempted gross total resection of the GH-secreting adenoma is the gold standard in treatment for patients with acromegaly for a goal of biochemical remission. Medical and radiation therapies are available when patients do not achieve biochemical cure after surgical therapy.

Pituitary Adenoma Surgery Survey: Neurosurgical Centers and Pituitary Adenomas

OBJECTIVE

Pituitary adenoma surgery has evolved rapidly in recent decades. This study aims to determine current practice across a wide range of European neurosurgical centers.

METHODS

A list of eligible departments performing pituitary adenoma surgery was created. The survey consisted of 58 questions. For analysis, the departments were divided into four subgroups: academic/nonacademic, high-volume/low-volume, "mainly endoscopic/mainly microscopic practice," and geographical regions.

RESULTS

Data from 254 departments from 34 countries were obtained. In 108 centers (42.5%), <30 pituitary adenomas were operated per year. Twenty (7.9%) centers performed >100 adenoma surgeries per year. Number of neurosurgeons performing endonasal surgeries are as follows: 1 in 24.9% of centers and 2 in 49.8% of centers. All residents assisted endonasal surgeries in 126 centers (49.8%). In 28 centers (21.1%), all residents performed endonasal surgery under supervision during residency. In 141 centers (56.8%), the endoscopic approach was used in >90% of the surgeries. Regular pituitary board (either weekly or once a month) meetings were held in 147 centers (56.3%). Nonfunctioning adenomas represent >70% of pituitary caseload in 149 centers (58.7%).

CONCLUSIONS

In our survey, most centers perform less than 100 surgeries for pituitary adenomas. In most centers, pituitary surgeries are performed by one or two neurosurgeons. Residents have a limited exposure to this type of surgery, and the formal pituitary board is not a standard. Nonfunctioning adenomas make up most of surgically treated adenomas. This study can serve as a benchmark for further analyses of pituitary adenoma centers in Europe.

Outcome of giant pituitary tumors requiring surgery

OBJECTIVE

The management of giant pituitary tumors is complex, with few publications and recommendations. Consequently, patient's care mainly relies on clinical experience. We report here a first large series of patients with giant pituitary tumors managed by a multidisciplinary expert team, focusing on treatments and outcome.

METHODS

A retrospective cohort study was conducted. Giant pituitary tumors were defined by a main diameter > 40mm. Macroprolactinomas sensitive to dopamine agonists were excluded. All patients were operated by a single neurosurgical team. After surgery, multimodal management was proposed, including hormone replacement, radiotherapy and anti-tumor medical therapies. Outcome was modeled using Kaplan-Meyer representation. A logistic regression model was built to identify the risk factors associated with surgical complications.

RESULTS

63 consecutive patients presented a giant adenoma, most often with visual defects. Patients were operated once, twice or three times in 59%, 40% and 1% of cases respectively, mainly through endoscopic endonasal approach. Giant adenomas included gonadotroph, corticotroph, somatotroph, lactotroph and mixed GH-PRL subtypes in 67%, 14%, 11%, 6% and 2% of patients respectively. Vision improved in 89% of patients with prior visual defects. Severe surgical complications occurred in 11% of patients, mainly for tumors > 50 mm requiring microscopic transcranial approach. Additional radiotherapy was needed for 29% of patients, 3 to 56 months after first surgery. For 6% of patients, Temozolomide treatment was required, 19 to 66 months after first surgery.

CONCLUSIONS

Giant pituitary tumors require multimodal management, with a central role of surgery. Most often, tumor control can be achieved by expert multidisciplinary teams.