Advances in the Imaging of Pituitary Tumors

Evaluation of high-resolution pituitary dynamic contrast-enhanced MRI using deep learning-based compressed sensing and super-resolution reconstruction

OBJECTIVE

This study aims to assess diagnostic performance of high-resolution dynamic contrast-enhanced (DCE) MRI with deep learning-based compressed sensing and super-resolution (DLCS-SR) reconstruction for identifying microadenomas.

MATERIALS AND METHODS

This prospective study included 126 participants with suspected pituitary microadenomas who underwent DCE MRI between June 2023 and January 2024. Four image groups were derived from single-scan DCE MRI, which included 1.5-mm slice thickness images using DLCS-SR (1.5-mm DLCS-SR images), 1.5-mm slice thickness images with deep learning-based compressed sensing reconstruction (1.5-mm DLCS images), 1.5-mm routine images, and 3-mm slice thickness images using DLCS-SR (3-mm DLCS-SR images). Diagnostic criteria were established by incorporating laboratory findings, clinical symptoms, medical histories, previous imaging, and certain pathologic reports. Two readers assessed the diagnostic performance in identifying pituitary abnormalities and microadenomas. Diagnostic agreements were assessed using κ statistics, and intergroup comparisons for microadenoma detection were performed using the DeLong and McNemar tests.

RESULTS

The 1.5-mm DLCS-SR images (κ = 0.746-0.848) exhibited superior diagnostic agreement, outperforming 1.5-mm DLCS (κ = 0.585-0.687), 1.5-mm routine (κ = 0.449-0.487), and 3-mm DLCS-SR images (κ = 0.347-0.369) (p < 0.001 for all). Additionally, the performance of 1.5-mm DLCS-SR images in identifying microadenomas [area under the receiver operating characteristic curve (AUC), 0.89-0.94] surpassed that of 1.5-mm DLCS (AUC, 0.83-0.87; p = 0.042 and 0.011, respectively), 1.5-mm routine (AUC, 0.76-0.78; p < 0.001), and 3-mm DLCS-SR images (AUC, 0.72-0.74; p < 0.001).

CONCLUSION

The findings revealed superior diagnostic performance of 1.5-mm DLCS-SR images in identifying pituitary abnormalities and microadenomas, indicating the clinical-potential of high-resolution DCE MRI.

KEY POINTS

Question What strategies can overcome the resolution limitations of conventional dynamic contrast-enhanced (DCE) MRI, and which contribute to a high false-negative rate in diagnosing pituitary microadenomas? Findings Deep learning-based compressed sensing and super-resolution reconstruction applied to DCE MRI achieved high resolution while improving image quality and diagnostic efficacy. Clinical relevance DCE MRI with a 1.5-mm slice thickness and high in-plane resolution, utilizing deep learning-based compressed sensing and super-resolution reconstruction, significantly enhances diagnostic accuracy for pituitary abnormalities and microadenomas, enabling timely and effective patient management.

Identifying research priorities for pituitary adenoma surgery: an international Delphi consensus statement

PURPOSE

Pituitary surgery is the mainstay treatment for most pituitary adenomas, but many questions remain about perioperative and long-term management and outcomes. This study aimed to identify the most pressing research priorities in pituitary surgery with input from patients, caregivers, and healthcare professionals.

METHODS

An initial survey of patients, caregivers, and healthcare professionals assembled priorities related to preoperative care, surgical techniques, and postoperative management in pituitary surgery. Priorities were thematically grouped into summary priorities, and those answered by existing evidence were omitted following a literature review. An interim survey asked patients, caregivers, and healthcare professionals to select their top 10 priorities from the remaining list. The highest-ranked priorities advanced to a consensus meeting, where the top 10 questions were prioritized.

RESULTS

In the initial survey, 147 participants-60.5% of whom were patients, caregivers, or patient support group representatives-submitted 785 priorities, which were then condensed into 52 summary priorities. After a literature review, 33 unanswered priorities were included in the interim survey, completed by 155 respondents, of whom 54.2% were patients, caregivers, or patient support group representatives. The top-ranked priorities were discussed by 14 participants (7 patients and 7 healthcare professionals) during a consensus meeting. The top 10 priorities covered a variety of themes including enhancing diagnosis and management of pituitary adenomas, advancing surgical techniques and technologies, optimizing the prediction of outcomes and complications, and improving patient support and follow-up.

CONCLUSIONS

The top 10 research priorities in pituitary surgery aim to align researchers and direct funding in order to maximize impact and champion patient representation.

Identifying Subgroups with Rapid Tumor Growth Rate in Adult Pituitary Neuroendocrine Tumors: A Comprehensive Analysis of Clinical and Imaging Features

OBJECTIVE

To comprehensively investigate the clinical and imaging features associated with the tumor growth rate (TGR) of pituitary neuroendocrine tumors (PitNETs).

METHODS

The tumor volume was assessed using magnetic resonance imaging. The potential growth-related parameters were compared among different TGR subgroups. Logistic regression analysis and receiver operating characteristic curves were used to identify risk factors and evaluate their diagnostic accuracy for rapid TGR, respectively.

RESULTS

The study included 81 patients with PitNETs who met the inclusion criteria. Receiver operating characteristic curves were used to determine the optimal cut-off values for age and tumor volume at initial diagnosis. The factors significantly associated with rapid TGR were age <55 years, T2 heterogeneity, and Knosp grade ≥3 (P < 0.05). No significant differences were found among other clinical and imaging subgroups. Multivariate regression analysis confirmed that these factors increased the risk of rapid TGR (P < 0.05). The area under the curve for predicting rapid TGR using age <55 years, T2 heterogeneity, Knosp grade ≥3, and a combined model of these factors were 0.677 (95% confidence interval [CI], 0.564-0.777), 0.705 (95% CI, 0.593-0.801), 0.680 (95% CI, 0.567-0.780), and 0.834 (95% CI, 0.735-0908), respectively. Additionally, the expression of cell lineage-specific transcription factors and Ki-67 exhibited a significant correlation with age <55 years and T2 heterogeneity; however, no association was observed with Knosp grade.

CONCLUSIONS

The TGR of PitNETs is associated with age, T2 heterogeneity, and Knosp grade. Integrating these factors improves the accuracy of prediction for TGR. Therefore, understanding the TGR in PitNETs can provide valuable evidence for tailoring individualized treatment strategies for patients.

Transsphenoidal Surgery for Pituitary Tumors

Transsphenoidal surgery for the treatment of pituitary masses in cats and dogs has become a more established treatment over the last 2 decades. Although expert centers and surgeons that provide this service remain limited, the patient population presented for pituitary surgery increases with wider availability of advanced imaging, together with more challenging cases. In this review, the current state of hypophysectomy is described with future challenges and opportunities.

Lateralization outcomes of bilateral inferior petrosal sinus sampling: desmopressin vs CRH

PURPOSE

Bilateral inferior petrosal sinus sampling (BIPSS) is the gold standard for localizing ACTH-dependent Cushing's syndrome (CS). While corticotropin-releasing hormone (CRH) was initially used for stimulation, desmopressin has become a common alternative. This research evaluates desmopressin's effectiveness in lateralizing Cushing's disease (CD) during BIPSS compared to CRH stimulation.

METHODS

The study included 33 individuals with ACTH-dependent CS who underwent BIPSS and had diagnoses confirmed by endoscopic endonasal transsphenoidal pituitary surgery (EETPS). Fourteen participants underwent BIPSS with CRH and 19 with desmopressin. A comparative analysis was conducted.

RESULTS

BIPSS accurately lateralized 76% of cases, specifically, 71% with CRH and 79% with desmopressin (p = 0.2). For tumors < 6 mm on MRI, overall accuracy was 82%, namely, 75% with CRH and 90% with desmopressin (p = 0.4). IPSS achieved 100% accuracy in the four cases with no lesion on preoperative MRI.

CONCLUSION

This study demonstrates no significant difference in lateralization accuracy between desmopressin and CRH for IPSS. In challenging cases, especially those with microadenomas or non-lesional CD, desmopressin with IPSS aids in preoperative lateralization.

Identification of Prolactinoma in Pituitary Neuroendocrine Tumors Using Radiomics Analysis Based on Multiparameter MRI

This study aims to investigate the feasibility of preoperatively predicting histological subtypes of pituitary neuroendocrine tumors (PitNETs) using machine learning and radiomics based on multiparameter MRI. Patients with PitNETs from January 2016 to May 2022 were retrospectively enrolled from four medical centers. A cfVB-Net network was used to automatically segment PitNET multiparameter MRI. Radiomics features were extracted from the MRI, and the radiomics score (Radscore) of each patient was calculated. To predict histological subtypes, the Gaussian process (GP) machine learning classifier based on radiomics features was performed. Multi-classification (six-class histological subtype) and binary classification (PRL vs. non-PRL) GP model was constructed. Then, a clinical-radiomics nomogram combining clinical factors and Radscores was constructed using the multivariate logistic regression analysis. The performance of the models was evaluated using receiver operating characteristic (ROC) curves. The PitNET auto-segmentation model eventually achieved the mean Dice similarity coefficient of 0.888 in 1206 patients (mean age 49.3 ± SD years, 52% female). In the multi-classification model, the GP of T2WI got the best area under the ROC curve (AUC), with 0.791, 0.801, and 0.711 in the training, validation, and external testing set, respectively. In the binary classification model, the GP of T2WI combined with CE T1WI demonstrated good performance, with AUC of 0.936, 0.882, and 0.791 in training, validation, and external testing sets, respectively. In the clinical-radiomics nomogram, Radscores and Hardy' grade were identified as predictors for PRL expression. Machine learning and radiomics analysis based on multiparameter MRI exhibited high efficiency and clinical application value in predicting the PitNET histological subtypes.

Advancement in perioperative management of pituitary adenomas-Current concepts and best practices

Pituitary adenomas are very common representing 18.1% of all brain tumors and are the second most common brain pathology. Transsphenoidal surgery is the mainstay of treatment for all pituitary adenomas except for prolactinomas which are primarily treated medically with dopamine agonists. A thorough endocrine evaluation of pituitary adenoma preoperatively is crucial to identify hormonal compromise caused by the large sellar mass, identifying prolactin-producing tumors and comorbidities associated with Cushing and acromegaly to improve patient care and outcome. Transsphenoidal surgery is relatively safe in the hands of experienced surgeons, but still carries a substantial risk of causing hypopituitarism that required close follow-up in the immediate postoperative period to decrease mortality. A multidisciplinary team approach with endocrinologists, ophthalmologists, and neurosurgeons is the cornerstone in the perioperative management of pituitary adenomas.

Neuro-ophthalmic evaluation and management of pituitary disease

Neuro-ophthalmic evaluation is a crucial component of the diagnostic and prognostic assessment of pituitary disease and compressive chiasmopathy, and can inform the timing of vision-restoring tumour resection surgery. The most common disease affecting the pituitary with neuro-ophthalmic implications are pituitary adenomas. Neuro-ophthalmic manifestations include decreased vision, abnormal colour vision and impaired visual field or diplopia. The recognition of these syndromes is critical to achieve early diagnosis and treatment and to improve prognosis. The pattern of vision loss in chiasmal compression is determined by the anatomical relationship between the pituitary lesion and optic chiasm, and potential visual field defects include bitemporal deficits, junctional scotomas, monocular cecocentral defects, and incongruous homonymous hemianopias. Rarer neuro-ophthalmic manifestations of pituitary disease include ophthalmoplegia, nystagmus, and obstructive hydrocephalus. There is growing evidence that demonstrates the strong diagnostic utility of optical coherence tomography (OCT) parameters in detecting the presence of compressive chiasmopathy, as well as the prognostic ability to predict the rate and degree of visual recovery following decompression surgery. Long-term neuro-ophthalmic monitoring is critical for detecting delayed vision loss following resection surgery, which may represent tumour recurrence or secondary complications.

Growth hormone receptor antagonist pegvisomant and its role in the medical therapy of growth hormone excess

Pegvisomant is a growth-hormone (GH) receptor antagonist that prevents the formation of the active heterotrimer of the dimerised GH receptor and the GH molecule necessary for downstream signal transduction. Over the past 20 years, it has become a key therapeutic option for physicians treating syndromes of GH/IGF-1 excess. Sufficient longitudinal follow-up data suggest that it can be deemed both safe and effective. It is the drug with the greatest potential for achieving an amelioration of the biochemical effects of GH excess with a corresponding normalisation of IGF-1 levels; however, insufficient dose titration has lessened real-world therapeutic outcomes. Theoretical concerns about stimulating tumour growth have been resolved as this has not been observed, while derangement of liver enzymes and local skin-related adverse reactions may occur in a minority of the patients. It may be a particularly impactful medication for the treatment of children, young people, and those with inherited disorders of GH excess, where other treatment modalities often fail. Combination therapy of pegvisomant with first- and second-generation somatostatin receptor ligands or with dopamine agonists remains an ongoing area of interest and research. High cost remains a barrier to the use of pegvisomant in many settings.

Real-world experience with 11C-methionine positron emission tomography in the management of acromegaly

BACKGROUND

L-[methyl-11C]-methionine-positron emission tomography (Met-PET) is a potentially important imaging adjunct in the diagnostic workup of pituitary adenomas, including somatotroph tumors. Met-PET can identify residual or occult disease and make definitive therapies accessible to a subgroup of patients who would otherwise require lifelong medical therapy. However, existing data on its use are still limited to small case series. Here, we report the largest single-center experience (n = 61) in acromegaly.

METHODS

A total of 189 cases of acromegaly were referred to our national Met-PET service in the last 12 years. For this analysis, we have reviewed outcomes in those 61 patients managed exclusively by our multidisciplinary team (single center, single surgeon). Referral indications were as follows: indeterminate magnetic resonance imaging (MRI; n = 38, 62.3%), occult residual (n = 14, 23.0%), (radio-)surgical planning (n = 6, 9.8%), and occult de novo tumor (n = 3, 4.9%).

RESULTS

A total of 33/61 patients (54.1%) underwent PET-guided surgery. Twenty-four of 33 patients (72.7%) achieved complete biochemical remission following (re-)surgery. Insulin-like growth factor 1 levels were reduced to <2 × upper limit of normal (ULN) in 6 of the remaining 9 cases, 3 of whom achieved levels of <1.1 × ULN compared with mean preoperative levels of 2.4 × ULN (SD 0.8) for n = 9. Only 3 patients developed single new hormonal deficits (gonadotropic/thyrotropic insufficiency). There were no neurovascular complications after surgery.

CONCLUSION

In patients with persistent/recurrent acromegaly or occult tumors, Met-PET can facilitate further targeted intervention (surgery/radiosurgery). This led to complete remission in most cases (24/33) or significant improvement with comparatively low risk of complications. L-[methyl-11C]-methionine-positron emission tomography should therefore be considered in all patients who are potential candidates for further surgical intervention but present no clear target on MRI.

Current and Future Advances in Surgical Therapy for Pituitary Adenoma

The vital physiological role of the pituitary gland, alongside its proximity to critical neurovascular structures, means that pituitary adenomas can cause significant morbidity or mortality. While enormous advancements have been made in the surgical care of pituitary adenomas, numerous challenges remain, such as treatment failure and recurrence. To meet these clinical challenges, there has been an enormous expansion of novel medical technologies (eg, endoscopy, advanced imaging, artificial intelligence). These innovations have the potential to benefit each step of the patient's journey, and ultimately, drive improved outcomes. Earlier and more accurate diagnosis addresses this in part. Analysis of novel patient data sets, such as automated facial analysis or natural language processing of medical records holds potential in achieving an earlier diagnosis. After diagnosis, treatment decision-making and planning will benefit from radiomics and multimodal machine learning models. Surgical safety and effectiveness will be transformed by smart simulation methods for trainees. Next-generation imaging techniques and augmented reality will enhance surgical planning and intraoperative navigation. Similarly, surgical abilities will be augmented by the future operative armamentarium, including advanced optical devices, smart instruments, and surgical robotics. Intraoperative support to surgical team members will benefit from a data science approach, utilizing machine learning analysis of operative videos to improve patient safety and orientate team members to a common workflow. Postoperatively, neural networks leveraging multimodal datasets will allow early detection of individuals at risk of complications and assist in the prediction of treatment failure, thus supporting patient-specific discharge and monitoring protocols. While these advancements in pituitary surgery hold promise to enhance the quality of care, clinicians must be the gatekeepers of the translation of such technologies, ensuring systematic assessment of risk and benefit prior to clinical implementation. In doing so, the synergy between these innovations can be leveraged to drive improved outcomes for patients of the future.

The utility of PET for detecting corticotropinomas in Cushing disease: a scoping review

While magnetic resonance imaging (MRI) is the current standard imaging method for diagnosing and localizing corticotropinomas in Cushing disease, it can fail to detect adenomas in up to 40% of cases. Recently, positron emission tomography (PET) has shown promise as a diagnostic tool to detect pituitary adenomas in Cushing disease. We perform a scoping review to characterize the uses of PET in diagnosing Cushing disease, with a focus on describing the types of PET investigated and defining PET-positive disease. A scoping review was conducted following the PRISMA-ScR guidelines. Thirty-one studies fulfilled our inclusion criteria, consisting of 10 prospective studies, 8 retrospective studies, 11 case reports, and 2 illustrative cases with a total of 262 patients identified. The most commonly utilized PET modalities in prospective/retrospective studies were FDG PET (n = 5), MET PET (n = 5), 68 Ga-DOTATATE PET (n = 2), 13N-ammonia PET (n = 2), and 68 Ga-DOTA-CRH PET (n = 2). MRI positivity ranged from 13 to 100%, while PET positivity ranged from 36 to 100%. In MRI-negative disease, PET positivity ranged from 0 to 100%. Five studies reported the sensitivity and specificity of PET, which ranged from 36 to 100% and 50 to 100%, respectively. PET shows promise in detecting corticotropinomas in Cushing disease, including MRI-negative disease. MET PET has been highly investigated and has demonstrated excellent sensitivity and specificity. However, preliminary studies with FET PET and 68 Ga-DOTA-CRH PET show promise for achieving high sensitivity and specificity and warrant further investigation.

A False Pituitary Tumor

A false pituitary tumor describes pituitary enlargement due to intracranial hypotension. Reported previously primarily in the neurological literature, we present this case referred to endocrinology for evaluation of a pituitary mass. A 24-year-old male was referred to endocrinology for evaluation of pituitary enlargement without a hypo-enhancing lesion on magnetic resonance imaging (MRI). The main symptom reported was headache that was worse in the standing position and in the afternoon. He had no symptoms or signs of pituitary mass-effect, or hormone excess or deficiencies. Past medical history was relevant for a history of nerve schwannoma status post resection with subsequent spinal fusion. Biochemical evaluation of pituitary hormones was normal. Upon review of his pituitary MRI, other abnormalities seen were suggestive of intracranial hypotension. Based on his history and imaging findings, he was diagnosed with intracranial hypotension causing a "false pituitary tumor" rather than pituitary enlargement or abnormality. Further evaluation revealed multiple spinal leaks that were patched. His symptoms subsided within a few days of repair. Endocrinologists should be aware of the possible misdiagnosis of a pituitary mass due to intracranial hypotension.

Measuring pituitary tumor volume: a comparison of the simplified and non-simplified ellipsoid equation with the 3D planimetric volume assessment

PURPOSE

The ellipsoid equation came in an attempt to facilitate the estimation of tumor volume, by measuring the height, width, and anteroposterior length of the lesion. The estimated tumor volume can sometimes be different between methods, thus, it is of extreme interest to evaluate if the methods are significantly different, as well as to discuss the main limitations of each one.

METHODS

This is an observational, analytical, cross-sectional study. A systematic review of the literature was also performed in order to discuss the results observed in the present study.

RESULTS

A total of 82 patients (43 males and 39 females) ranging in age from 15 to 78 years (mean 47.95 ± 14.76) were included in the study. Seven patients were classified as Knosp grade 0 (8.5%), 36 Knosp grade 1 (44%), 14 Knosp grade 2 (17%), 20 Knosp grade 3 (24.4%), 5 Knosp grade 4 (6.1%). The tumor volume estimated by 3D planimetric assessment, non-simplified ellipsoid equation, and simplified ellipsoid formula averaged 10.68 cm³, 10.36 cm³, and 9.9 cm³ respectively.

CONCLUSION

A simplified form of the ellipsoid equation increases the divergence between the measurement obtained in planimetry, and should be discouraged, in view of the new automated methods of performing quick calculations using periodic digits. The non-simplified form underestimated the tumor volume by 2.9% on average but did so regularly. In clinical practice, measurement should be accompanied by an evaluation of tumor morphology.

Diagnosis and Management of Pituitary Adenomas: A Review

Importance

Pituitary adenomas are neoplasms of the pituitary adenohypophyseal cell lineage and include functioning tumors, characterized by the secretion of pituitary hormones, and nonfunctioning tumors. Clinically evident pituitary adenomas occur in approximately 1 in 1100 persons.

Observations

Pituitary adenomas are classified as either macroadenomas (≥10 mm) (48% of tumors) or microadenomas (<10 mm). Macroadenomas may cause mass effect, such as visual field defects, headache, and/or hypopituitarism, which occur in about 18% to 78%, 17% to 75%, and 34% to 89% of patients, respectively. Thirty percent of pituitary adenomas are nonfunctioning adenomas, which do not produce hormones. Functioning tumors are those that produce an excess of normally produced hormones and include prolactinomas, somatotropinomas, corticotropinomas, and thyrotropinomas, which produce prolactin, growth hormone, corticotropin, and thyrotropin, respectively. Approximately 53% of pituitary adenomas are prolactinomas, which can cause hypogonadism, infertility, and/or galactorrhea. Twelve percent are somatotropinomas, which cause acromegaly in adults and gigantism in children, and 4% are corticotropinomas, which secrete corticotropin autonomously, resulting in hypercortisolemia and Cushing disease. All patients with pituitary tumors require endocrine evaluation for hormone hypersecretion. Patients with macroadenomas additionally require evaluation for hypopituitarism, and patients with tumors compressing the optic chiasm should be referred to an ophthalmologist for formal visual field testing. For those requiring treatment, first-line therapy is usually transsphenoidal pituitary surgery, except for prolactinomas, for which medical therapy, either bromocriptine or cabergoline, is usually first line.

Conclusions and Relevance

Clinically manifest pituitary adenomas affect approximately 1 in 1100 people and can be complicated by syndromes of hormone excess as well as visual field defects and hypopituitarism from mass effect in larger tumors. First-line therapy for prolactinomas consists of bromocriptine or cabergoline, and transsphenoidal pituitary surgery is first-line therapy for other pituitary adenomas requiring treatment.

Usefulness of subtraction images for accurate diagnosis of pituitary microadenomas in dynamic contrast-enhanced magnetic resonance imaging

BACKGROUND

Dynamic contrast-enhanced magnetic resonance imaging (MRI) is the modality of choice for the diagnosis of pituitary microadenomas; however, it may be associated with a relatively high false-negative rate, especially in small lesions.

PURPOSE

To evaluate the usefulness of subtraction images for enhancing the visual detection of pituitary microadenomas.

MATERIAL AND METHODS

In total, 50 patients with clinically established diagnosis hyperprolactinemia, acromegaly, and Cushing's disease were enrolled. Ten patients referred for brain MRI for reasons other than pituitary abnormality were selected as control group. Routine dynamic MRI of the pituitary gland and obtained subtraction MRI scans were scrutinized separately on different sessions by an experienced radiologist blinded to the study design and patient's data. The investigator's opinion on the presence or absence of a lesion and lesion size were collected.

RESULTS

In patients with pituitary microadenoma, dynamic MRI images were reported positive in 42 (84%) patients and negative in 8 (16%). Subtraction images were described as positive in all patients (100%)-including all patients with negative dynamic MRI-and the difference was statistically significant (P=0.016). Undetected lesions on dynamic MRI had a mean size of 2.84 ± 1.79 mm (median= 2.20 mm, interquartile range=1.62-4.62 mm) and a significant inverse correlation was noted between lesion size and negative report of dynamic MRI (P=0.018). Brain MRI scans in the control group were reported negative for pituitary microadenoma in both dynamic contrast-enhanced and subtraction images.

CONCLUSION

Subtraction images can successfully identify all lesions detectable with conventional dynamic MRI as well as improving visualization of lesions undetected on dynamic MRI, especially in small lesions.

Costs and Its Determinants in Pituitary Tumour Surgery

PURPOSE

Value-based healthcare (VBHC) provides a framework to improve care by improving patient outcomes and reducing healthcare costs. To support value-based decision making in clinical practice we evaluated healthcare costs and cost drivers in perioperative care for pituitary tumour patients.

METHODS

We retrospectively assessed financial and clinical data for surgical treatment up to the first year after surgery of pituitary tumour patients treated between 2015 and 2018 in a Dutch tertiary referral centre. Multivariable regression analyses were performed to identify determinants of higher costs.

RESULTS

271 patients who underwent surgery were included. Mean total costs (SD) were €16339 (13573) per patient, with the following cost determinants: surgery time (€62 per minute; 95% CI: 50, 74), length of stay (€1331 per day; 95% CI 1139, 1523), admission to higher care unit (€12154 in total; 95% CI 6413, 17895), emergency surgery (€10363 higher than elective surgery; 95% CI: 1422, 19305) and postoperative cerebrospinal fluid leak (€14232; 95% CI 9667, 18797). Intradural (€7128; 95% CI 10421, 23836) and combined transsphenoidal/transcranial surgery (B: 38494; 95% CI 29191, 47797) were associated with higher costs than standard. Further, higher costs were found in these baseline conditions: Rathke's cleft cyst (€9201 higher than non-functioning adenoma; 95% CI 1173, 17230), giant adenoma (€19106 higher than microadenoma; 95% CI 12336, 25877), third ventricle invasion (€14613; 95% CI 7613, 21613) and dependent functional status (€12231; 95% CI 3985, 20477). In patients with uncomplicated course, costs were €8879 (3210) and with complications €17551 (14250).

CONCLUSIONS

Length of hospital stay, and complications are the main drivers of costs in perioperative pituitary tumour healthcare as were some baseline features, e.g. larger tumors, cysts and dependent functional status. Costs analysis may correspond with healthcare resource utilization and guide further individualized care path development and capacity planning.

The clinical outcomes of imaging modalities for surgical management Cushing's disease - A systematic review and meta-analysis

INTRODUCTION

Cushing's disease presents major diagnostic and management challenges. Although numerous preoperative and intraoperative imaging modalities have been deployed, it is unclear whether these investigations have improved surgical outcomes. Our objective was to investigate whether advances in imaging improved outcomes for Cushing's disease.

METHODS

Searches of PubMed and EMBASE were conducted. Studies reporting on imaging modalities and clinical outcomes after surgical management of Cushing's disease were included. Multilevel multivariable meta-regressions identified predictors of outcomes, adjusting for confounders and heterogeneity prior to investigating the effects of imaging.

RESULTS

166 non-controlled single-arm studies were included, comprising 13181 patients over 44 years.The overall remission rate was 77.0% [CI: 74.9%-79.0%]. Cavernous sinus invasion (OR: 0.21 [CI: 0.07-0.66]; p=0.010), radiologically undetectable lesions (OR: 0.50 [CI: 0.37-0.69]; p<0.0001), previous surgery (OR=0.48 [CI: 0.28-0.81]; p=0.008), and lesions ≥10mm (OR: 0.63 [CI: 0.35-1.14]; p=0.12) were associated with lower remission. Less stringent thresholds for remission was associated with higher reported remission (OR: 1.37 [CI: 1.1-1.72]; p=0.007). After adjusting for this heterogeneity, no imaging modality showed significant differences in remission compared to standard preoperative MRI.The overall recurrence rate was 14.5% [CI: 12.1%-17.1%]. Lesion ≥10mm was associated with greater recurrence (OR: 1.83 [CI: 1.13-2.96]; p=0.015), as was greater duration of follow-up (OR: 1.53 (CI: 1.17-2.01); p=0.002). No imaging modality was associated with significant differences in recurrence.Despite significant improvements in detection rates over four decades, there were no significant changes in the reported remission or recurrence rates.

CONCLUSION

A lack of controlled comparative studies makes it difficult to draw definitive conclusions. Within this limitation, the results suggest that despite improvements in radiological detection rates of Cushing's disease over the last four decades, there were no changes in clinical outcomes. Advances in imaging alone may be insufficient to improve surgical outcomes.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42020187751.

Consensus on diagnosis and management of Cushing's disease: a guideline update

Cushing's disease requires accurate diagnosis, careful treatment selection, and long-term management to optimise patient outcomes. The Pituitary Society convened a consensus workshop comprising more than 50 academic researchers and clinical experts to discuss the application of recent evidence to clinical practice. In advance of the virtual meeting, data from 2015 to present about screening and diagnosis; surgery, medical, and radiation therapy; and disease-related and treatment-related complications of Cushing's disease summarised in recorded lectures were reviewed by all participants. During the meeting, concise summaries of the recorded lectures were presented, followed by small group breakout discussions. Consensus opinions from each group were collated into a draft document, which was reviewed and approved by all participants. Recommendations regarding use of laboratory tests, imaging, and treatment options are presented, along with algorithms for diagnosis of Cushing's syndrome and management of Cushing's disease. Topics considered most important to address in future research are also identified.

New types of localization methods for adrenocorticotropic hormone-dependent Cushing's syndrome

The management of endogenous Cushing's syndrome (CS) typically involves two key steps: (i) confirmation of autonomous hypercortisolism and (ii) localization of the cause to guide treatment. Adrenocorticotropic hormone (ACTH)-dependent CS is most commonly due to a pituitary corticotrope tumor which may be so small as to evade detection on conventional magnetic resonance imaging (MRI). Although biochemical testing (e.g., corticotropin stimulation; dexamethasone suppression) can provide an indication of the likely origin of ACTH excess, bilateral inferior petrosal sinus catheterization offers greater accuracy to distinguish pituitary-driven CS [Cushing's Disease (CD)] from the ectopic ACTH syndrome [EAS, e.g., due to a bronchial or pancreatic neuroendocrine tumor (NET)]. In patients with CD, 40-50% may not have a pituitary adenoma (PA) readily visualized on standard clinical MRI. In these subjects, alternative MR sequences (e.g., dynamic, volumetric, fluid attenuation inversion recovery) and higher magnetic field strength (7T > 3T > 1.5T) may aid tumor localization but carry a risk of identifying coincidental (non-causative) pituitary lesions. Molecular imaging is therefore increasingly being deployed to detect small ACTH-secreting PA, with hybrid imaging [e.g., positron emission tomography (PET) combined with MRI] allowing precise anatomical localization of sites of radiotracer (e.g., ¹¹C-methionine) uptake. Similarly, small ACTH-secreting NETs, missed on initial cross-sectional imaging, may be detected using PET tracers targeting abnormal glucose metabolism (e.g., ¹⁸F-fluorodeoxyglucose), somatostatin receptor (SSTR) expression (e.g., ⁶⁸Ga-DOTATATE), amine precursor (e.g., ¹⁸F-DOPA) or amino acid (e.g., ¹¹C-methionine) uptake. Therefore, modern management of ACTH-dependent CS should ideally be undertaken in specialist centers which have an array of cross-sectional and functional imaging techniques at their disposal.

Endoscopic Surgery for Pituitary Tumors

Endoscopic transsphenoidal surgery for pituitary adenoma is a safe and highly effective first-line treatment that is well tolerated by patients. Potential complications are plenty, and there is a large variation in complexity of surgery. This article presents the philosophy, surgical techniques, and outcomes of a high-volume pituitary adenoma center. Three surgical videos illustrate some procedures. The experience has reinforced the authors' belief that experience and surgical volume are key to high quality of care.