Harvey Cushing's attempt at the first human pituitary transplantation

Functional Restoration of Pituitary after Pituitary Allotransplantation into Hypophysectomized Rats

Long-term hormone replacement therapy due to panhypopituitarism can lead to serious complications and thus, pituitary transplantation is considered a more desirable. We investigated functional restoration after allotransplatation of the pituitary gland. We transplanted extracted pituitary gland into the omentum of an hypophysectomized rat. Two experiments were performed: (1) to confirm the hypophysectomy was successful and (2) to assess functional restoration after pituitary transplantation. Pituitary hormone level and weight change were consecutively assessed. Electron microscopic (EM) examinations were performed to identify morphological changes at 3 days after transplantation. We confirmed that pituitary gland was properly extracted from 6 rats after sacrifice. The findings showed (1) a weight loss of more than 3% or (2) a weight change of less than 2% along with a decreased growth hormone (GH) level by more than 80% at 2 weeks post-hypophysectomy. A further four rats underwent pituitary transplantation after hypophysectomy and were compared with the previously hypophysectomized rats. All showed rapid weight gain during the two weeks after transplantation. The thyroid-stimulating hormone, prolactin, and GH levels were restored at one week post-transplantation and maintained for 10 weeks. Hypophyseal tissue architecture was maintained at 3 days after transplantation, as indicated by EM. These data suggest that a transplanted pituitary gland can survive in the omentum with concomitant partial restoration of anterior pituitary hormones.

Neurosurgical Interactive Teaching Series: Multidisciplinary Educational Approach

OBJECTIVE

The goal of this manuscript is to investigate the effects of a multidisciplinary multinational web-based teaching conference on trainee education, research, and patient care.

METHODS

We present the structure, case selection, and presentation of our educational lectures. We retrospectively reviewed our database to gather data on the number of presentations, type of presentation, and the pathology diagnosis from November 11, 2016 until February 28, 2020. To investigate attendee satisfaction, we analyzed our yearly continuing medical education evaluation survey results to report the impact that this series may have had on our attendees. We assigned a numeric value to the answers, and the mean overall scores were compared through an analysis of variance. Further analysis on specific questions was performed with a Fisher exact test.

RESULTS

We have hosted 150 lectures, in which we have presented 208 neurosurgical cases corresponding to 133 general session, 59 pituitary, and 16 spine cases, as well as 28 distinct lectures by guest speakers from institutions across the globe. We received 61 responses to our yearly continuing medical education evaluations over the course of 3 years. On these evaluations, we have maintained an excellent overall rating from 2017-2019 (two-sided P > 0.05) and received significantly less suggestions to improve the series comparing 2017 with 2019 (two-sided, P= 0.04).

CONCLUSIONS

As the world of medicine is constantly changing, we are in need of developing new tools to enhance our ability to relay knowledge through accredited and validated methods onto physicians in training, such as the implementation of structured, multidisciplinary, case-based lectures as presented in this manuscript.

Functional survival of rat pituitary gland in hypothermic storage for pituitary transplantation

PURPOSE

Deteriorated pituitary function can lead to serious complications that might need lifelong hormone replacement therapy. However, long-term hormone administration can have significant adverse effects. Thus, it would be more desirable to restore pituitary function by pituitary transplantation. In this study, we investigated functional preservation of extracted pituitary gland in special preservation solution under hypothermic condition for pituitary transplantation.

METHODS

We obtained nineteen pituitary glands from 250-300 g male Sprague-Dawley rats via parapharyngeal approach. These extracted glands were divided into three pieces and stored in histidine-tryptophan-ketoglutarate (HTK) solution at 4 °C and compared to their corresponding glands stored in phosphate buffer saline (PBS). Light and electron microscopic examinations were performed to identify morphological changes of pituitary gland at 0,3, and 7 days after storage. TUNEL assay to confirm cell viability, and adenosine-triphosphate (ATP) concentration were also serially examined.

RESULTS

Tissue architecture and cellular viability of specimens preserved in HTK solution for 3 days were considerably maintained and similar to those in normal pituitary gland (0 day specimen). In contrast, specimens stored in PBS were markedly destroyed after 3 days of storage. After 7 days of storage, significant degeneration occurred in tissues stored in both HTK and PBS. However, tissue architecture was preserved more in specimens stored in HTK solution than those stored in PBS. ATP concentration decreased more rapidly in specimens stored in PBS solution, but there was no statistical significance (p= 0.055).

CONCLUSIONS

Extracted rat pituitary gland supplemented with special preservation solution could be preserved for 3 days under hypothermic condition.

Walter E. Dandy: his contributions to pituitary surgery in the context of the overall Johns Hopkins Hospital experience

BACKGROUND

Walter E. Dandy (1886-1946) was an outstanding neurosurgeon who spent his entire career at the Johns Hopkins Hospital. After graduating from medical school in 1910, he completed a research fellowship in the Hunterian laboratory with Harvey Cushing and then joined the Department of Surgery as resident, rising to the rank professor in 1931. Dandy made several contributions that helped building the neurosurgical specialty, most famously the introduction of pneumo-ventriculography to image brain lesions for which he received a Nobel prize nomination. He also performed many pituitary surgeries, although his role in this area is less known and overshadowed by that of Cushing's.

PURPOSE

This retrospective cohort study was designed to unveil Dandy's pituitary work and place it in the context of the overall pituitary surgeries performed at the Johns Hopkins Hospital.

METHODS

Pituitary surgery data were obtained by screening the paper and electronic surgical pathology records of the Department of Pathology, as well as the general operating room log books of the Johns Hopkins Hospital housed in the Chesney Medical Archives.

RESULTS

A total of 3211 pituitary surgeries associated with a pathological specimen were performed between February 1902 and July 2017 in 2847 patients. Most of the surgeries (2875 of 3211 89%) were done by 21 neurosurgeons. Dandy ranks 4th as number of surgeries, with 287 pituitary operations in 35 years of activity. He averaged 8 pituitary surgeries per year, a rate that positions him 6th among all Hopkins neurosurgeons. With the exception of his first operation done in July 1912 while Cushing was still at Hopkins, Dandy approached the pituitary gland transcranially, rather than transphenoidally. The majority of Dandy's pituitary patients had a pathological diagnosis of pituitary adenomas, followed by craniopharyngiomas and sellar cysts. In the decades Dandy operated, pituitary surgeries represented 0.56% of the total Johns Hopkins surgeries, a percentage significantly greater (p < 0.001) than the 0.1% observed in modern days. Dandy's pituitary clinical work was matched by important experimental studies done in the early stages of his career.

CONCLUSIONS

This study highlights the role of Dandy as an important contributor to advance our understanding of pathophysiology and treatment of pituitary diseases.

Efficacy of transsphenoidal surgery in achieving biochemical cure of growth hormone-secreting pituitary adenomas among patients with cavernous sinus invasion: a systematic review and meta-analysis

OBJECTIVES

Growth hormone-secreting pituitary adenomas in adults can result in severe craniofacial disfigurement and potentially fatal medical complications. Surgical resection leading to remission of the disease is dependent on complete surgical resection of the tumor. Lesions that invade the cavernous sinus may not be safely accessible via an endonasal transsphenoidal surgery (TSS), and the rates of biochemical remission of patients with residual disease vary widely in the literature. We conducted a meta-analysis to examine the prevalence of biochemical remission after TSS among patients with growth hormone-secreting pituitary adenomas with and without cavernous sinus invasion.

METHODS

Embase, PubMed, and Cochrane Library databases were searched for relevant publications. Fourteen studies with 972 patients with biochemically confirmed growth hormone-secreting pituitary adenomas were included in the meta-analysis.

RESULTS

The overall remission prevalence under a fixed-effect model was 47.6% (95% CI = 40.8-54.4%) for patients with invasive macroadenomas (I² = 74.6%, p < 0.01); 76.4% (95% CI = 72.2-80.1%) for patients with non-invasive macroadenomas (I² = 59.6%, p = 0.03); and 74.2% (95% CI = 66.3-80.7%) for patients with non-invasive microadenomas (I² = 36.4, p = 0.10). The significant difference among the three groups resulted from the difference between patients with or without cavernous sinus invasion (p = 0.01) and not from the size of adenomas among those without cavernous sinus invasion (p = 0.66).

DISCUSSION

The prevalence of biochemical remission in patients with cavernous sinus invasion was lower than in patients without cavernous sinus invasion after TSS for acromegaly.

Early hypospadias repair: the contributions of Harvey Cushing

PURPOSE

The early evolution of surgical reconstructive techniques has been well documented in the literature. However, a review of the Johns Hopkins hospital surgical files revealed an interesting participant in early hypospadias repair: Harvey Cushing (1869-1939).

METHODS

Following IRB approval, we reviewed the surgical records from 1896 to 1912 and selected from among his non-neurosurgical patients, one case of first-stage hypospadias repair.

RESULTS

Cushing operated upon the 21-year-old patient, performing a first-stage repair of hypospadias, in conjunction with a repair of a right inguinal hernia. The patient was discharged following a second stage operation. At that time, the patient was in good condition and was voiding appropriately. There was no further follow-up.

CONCLUSION

The repair of hypospadias evolved through the work of European surgeons, from the mid-eighth century through the early nineteenth century. The case we report here illustrates Cushing's early work in the fields of urologic and plastic surgery.

Sellar door: Harvey Cushing's entry into the pituitary gland, the unabridged Johns Hopkins experience 1896-1912

OBJECTIVE

To review the original surgical records from the Johns Hopkins Hospital, and analyze the records of patients Cushing treated for pituitary disorders from 1896 to 1912.

METHODS

Following IRB approval, and through the courtesy of the Alan Mason Chesney Archives, we reviewed the original surgical files from the Johns Hopkins Hospital. Patients presenting with pituitary-related symptoms, who underwent surgical treatment directed at the pituitary gland, were selected for further review.

RESULTS

Thirty-seven patients who underwent surgical intervention for pituitary disorders were found. Of these patients, 12 were mentioned only briefly in Cushing's 1912 monograph, whereas 6 were not described at all. The remaining 19 were documented by Cushing in his 1912 monograph. Cushing used three main surgical approaches to the pituitary: transsphenoidal, transcranial, and the subfrontal "omega incision." There were 6 inpatient deaths. The mean time to last follow-up was 41.0 months. At follow-up, headache was the most common unresolved symptom.

CONCLUSION

This review highlights Cushing's accomplishments in the surgical treatment of suspected pituitary pathology during his early career as a young attending at Johns Hopkins Hospital. It reveals new information about patients whom Cushing did not include in his publications detailing his surgical experience at the Johns Hopkins Hospital.

On the shoulders of giants: Harvey Cushing's experience with acromegaly and gigantism at the Johns Hopkins Hospital, 1896-1912

A review of Dr. Cushing's surgical cases at Johns Hopkins Hospital revealed new information about his early operative experience with acromegaly. Although in 1912 Cushing published selective case studies regarding this work, a review of all his operations for acromegaly during his early years has never been reported. We uncovered 37 patients who Cushing treated with surgical intervention directed at the pituitary gland. Of these, nine patients who presented with symptoms of acromegaly, and one with symptoms of gigantism were selected for further review. Two patients underwent transfrontal 'omega incision' approaches, and the remaining eight underwent transsphenoidal approaches. Of the 10 patients, 6 were male. The mean age was 38.0 years. The mean hospital stay was 39.4 days. There was one inpatient death during primary interventions (10%) and three patients were deceased at the time of last follow-up (33%). The mean time to death, calculated from the date of the primary surgical intervention, and including inpatient and outpatient deaths, was 11.3 months. The mean time to last follow-up, calculated from the day of discharge, was 59.3 months. At the time of last follow-up, two patients reported resolution of headache; four patients reported continued visual deficits, and two patients reported ongoing changes in mental status. This review analyzes the outcomes for 10 patients who underwent surgical intervention for acromegaly or gigantism, and offers an explanation for Cushing's transition from the transfrontal "omega incision" to the transsphenoidal approach while practicing at the Johns Hopkins Hospital.