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Lefevre E, Chasseloup F, Hage M, Chanson P, Buchfelder M, Kamenický P. Clinical and therapeutic implications of cavernous sinus invasion in pituitary adenomas. Endocrine 2024:10.1007/s12020-024-03877-2. [PMID: 38761347 DOI: 10.1007/s12020-024-03877-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 05/12/2024] [Indexed: 05/20/2024]
Abstract
Invasion of the cavernous sinus by pituitary adenomas impedes complete surgical resection, compromises biochemical remission, and increases the risk of further tumor recurrence. Accurate preoperative MRI-based diagnosis or intraoperative direct inspection of cavernous sinus invasion are essential for optimal surgical planning and for tailoring postoperative therapeutic strategies, depending on whether a total resection has been achieved, or tumoral tissue has been left in surgically inaccessible locations. The molecular mechanisms underlying the invasive behavior of pituitary adenomas remain poorly understood, hindering the development of targeted therapies. Some studies have identified genes overexpressed in pituitary adenomas invading the cavernous sinus, offering insights into the acquisition of invasive behavior. Their main limitation however lies in comparing purely intrasellar specimens obtained from invasive and non-invasive adenomas. Further, precise anatomical knowledge of the medial wall of the cavernous sinus is crucial for grasping the mechanisms of invasion. Recently, alongside the standard intrasellar surgery, extended endoscopic intracavernous surgical procedures with systematic selective resection of the medial wall of the cavernous sinus have shown promising results for invasive secreting pituitary adenomas. The first- and second-generation somatostatin agonist ligands and cabergoline are used with variable efficacy to control secretory activity and/or growth of intracavernous remnants. Tumor regrowth usually requires surgical reintervention, sometimes combined with radiotherapy or radiosurgery which is applied despite their benign nature. Unraveling the molecular pathways driving invasive behavior of pituitary adenomas and their tropism to the cavernous sinuses is the key for developing efficient innovative treatment modalities that could reduce the need for repeated surgery or radiotherapy.
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Affiliation(s)
- Etienne Lefevre
- INSERM U1185, Physiologie et Physiopathologie Endocriniennes, Université Paris-Saclay, 94276, Le Kremlin-Bicêtre, France.
- Service de Neurochirurgie, AP-HP, Hôpital Pitié-Salpêtrière, 75013, Paris, France.
| | - Fanny Chasseloup
- INSERM U1185, Physiologie et Physiopathologie Endocriniennes, Université Paris-Saclay, 94276, Le Kremlin-Bicêtre, France
- Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des maladies Rares de l'Hypophyse, AP-HP, Hôpital Bicêtre, 94276, Le Kremlin-Bicêtre, France
| | - Mirella Hage
- INSERM U1185, Physiologie et Physiopathologie Endocriniennes, Université Paris-Saclay, 94276, Le Kremlin-Bicêtre, France
| | - Philippe Chanson
- INSERM U1185, Physiologie et Physiopathologie Endocriniennes, Université Paris-Saclay, 94276, Le Kremlin-Bicêtre, France
- Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des maladies Rares de l'Hypophyse, AP-HP, Hôpital Bicêtre, 94276, Le Kremlin-Bicêtre, France
| | - Michael Buchfelder
- Department of Neurosurgery, University Hospital Erlangen, 91054, Erlangen, Germany
| | - Peter Kamenický
- INSERM U1185, Physiologie et Physiopathologie Endocriniennes, Université Paris-Saclay, 94276, Le Kremlin-Bicêtre, France
- Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des maladies Rares de l'Hypophyse, AP-HP, Hôpital Bicêtre, 94276, Le Kremlin-Bicêtre, France
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Gerlach R, Modesti CL, Rampinelli V. Interdisciplinary Management of Skull Base Tumors. Laryngorhinootologie 2024; 103:S28-S42. [PMID: 38697142 DOI: 10.1055/a-2196-8984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2024]
Abstract
OBJECTIVE Endoscopic endonasal skull base surgery has gained acceptance worldwide. Comparative analysis has demonstrated that endoscopic skull base surgery may have advantages for many pathologies of the anterior skull base, e. g., sinonasal malignant tumors; pathologies of the central skull base, e. g., pituitary adenomas, craniopharyngiomas; well-selected cases of planum sphenoidale and tuberculum sellae meningiomas; or for clival lesions, e. g., chordomas, chondrosarcomas, or selected meningiomas. Over the past three decades, interdisciplinary surgical teams, consisting of otolaryngologists and neurosurgeons, have provided detailed anatomical knowledge, suggested new approaches or modifications of established surgical techniques, and offered continued surgical education. METHOD A review of pertinent literature was conducted with an emphasis on interdisciplinary endoscopic surgery of skull base lesions. RESULTS Based on the authors̓ surgical experience in two different interdisciplinary endoscopic skull base centers, the authors classify approaches for endoscopic endonasal skull base surgery, describe indications, and key anatomic landmarks for common pathologies, and highlight surgical techniques to avoid complications. CONCLUSION Interdisciplinary endonasal endoscopic surgery combines surgical expertise, improves resection rates for many pathologies, and minimizes morbidity by reducing the incidence of surgical complications.
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Affiliation(s)
| | - Claudia Lodovica Modesti
- Unit of Otolaryngology and Head and Surgery, ASST Spedali Civili di Brescia, University of Brescia, Italy
| | - Vittorio Rampinelli
- Unit of Otolaryngology and Head and Surgery, ASST Spedali Civili di Brescia, University of Brescia, Italy
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Bander ED, Carnevale JA, Tosi U, Godfrey KJ, Schwartz TH. Lateral Transorbital Endoscope-Assisted Approach to the Cavernous Sinus. Oper Neurosurg (Hagerstown) 2023; 25:359-364. [PMID: 37427936 DOI: 10.1227/ons.0000000000000824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 05/11/2023] [Indexed: 07/11/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Surgical access to the cavernous sinus (CS) poses a unique challenge to the neurosurgeon given the concentration of delicate structures in the confines of a very small anatomic space. The lateral transorbital approach (LTOA) is a minimally invasive, keyhole approach that can provide direct access to the lateral CS. METHODS A retrospective review of CS lesions treated by a LTOA at a single institution was performed between 2020 and 2023. Patient indications, surgical outcomes, and complications are described. RESULTS Six patients underwent a LTOA for a variety of pathologies including a dermoid cyst, schwannoma, prolactinoma, craniopharyngioma, and solitary fibrous tumor. The goals of surgery (ie, drainage of cyst, debulking, and pathological diagnosis) were achieved in all cases. The mean extent of resection was 64.6% (±34%). Half of the patients with preoperative cranial neuropathies (n = 4) improved postoperatively. There were no new permanent cranial neuropathies. One patient had a vascular injury repaired endovascularly with no neurological deficits. CONCLUSION The LTOA provides a minimal access corridor to the lateral CS. Careful case selection and reasonable goals of surgery are critical to successful outcome.
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Affiliation(s)
- Evan D Bander
- Department of Neurosurgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York, USA
| | - Joseph A Carnevale
- Department of Neurosurgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York, USA
| | - Umberto Tosi
- Department of Neurosurgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York, USA
| | - Kyle J Godfrey
- Department of Neurosurgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York, USA
- Department of Ophthalmology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York, USA
| | - Theodore H Schwartz
- Department of Neurosurgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York, USA
- Department of Otolaryngology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York, USA
- Department of Neuroscience, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York, USA
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Corvino S, Villanueva-Solórzano PL, Offi M, Armocida D, Nonaka M, Iaconetta G, Esposito F, Cavallo LM, de Notaris M. A New Perspective on the Cavernous Sinus as Seen through Multiple Surgical Corridors: Anatomical Study Comparing the Transorbital, Endonasal, and Transcranial Routes and the Relative Coterminous Spatial Regions. Brain Sci 2023; 13:1215. [PMID: 37626571 PMCID: PMC10452901 DOI: 10.3390/brainsci13081215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 07/27/2023] [Accepted: 08/16/2023] [Indexed: 08/27/2023] Open
Abstract
Background: The cavernous sinus (CS) is a highly vulnerable anatomical space, mainly due to the neurovascular structures that it contains; therefore, a detailed knowledge of its anatomy is mandatory for surgical unlocking. In this study, we compared the anatomy of this region from different endoscopic and microsurgical operative corridors, further focusing on the corresponding anatomic landmarks encountered along these routes. Furthermore, we tried to define the safe entry zones to this venous space from these three different operative corridors, and to provide indications regarding the optimal approach according to the lesion's location. Methods: Five embalmed and injected adult cadaveric specimens (10 sides) separately underwent dissection and exposure of the CS via superior eyelid endoscopic transorbital (SETOA), extended endoscopic endonasal transsphenoidal-transethmoidal (EEEA), and microsurgical transcranial fronto-temporo-orbito-zygomatic (FTOZ) approaches. The anatomical landmarks and the content of this venous space were described and compared from these surgical perspectives. Results: The oculomotor triangle can be clearly exposed only by the FTOZ approach. Unlike EEEA, for the exposure of the clinoid triangle content, the anterior clinoid process removal is required for FTOZ and SETOA. The supra- and infratrochlear as well as the anteromedial and anterolateral triangles can be exposed by all three corridors. The most recently introduced SETOA allowed for the exposure of the entire lateral wall of the CS without entering its neurovascular structures and part of the posterior wall; furthermore, thanks to its anteroposterior trajectory, it allowed for the disclosure of the posterior ascending segment of the cavernous ICA with the related sympathetic plexus through the Mullan's triangle, in a minimally invasive fashion. Through the anterolateral triangle, the transorbital corridor allowed us to expose the lateral 180 degrees of the Vidian nerve and artery in the homonymous canal, the anterolateral aspect of the lacerum segment of the ICA at the transition zone from the petrous horizontal to the ascending posterior cavernous segment, surrounded by the carotid sympathetic plexus, and the medial Meckel's cave. Conclusions: Different regions of the cavernous sinus are better exposed by different surgical corridors. The relationship of the tumor with cranial nerves in the lateral wall guides the selection of the approach to cavernous sinus lesions. The transorbital endoscopic approach can be considered to be a safe and minimally invasive complementary surgical corridor to the well-established transcranial and endoscopic endonasal routes for the exposure of selected lesions of the cavernous sinus. Nevertheless, peer knowledge of the anatomy and a surgical learning curve are required.
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Affiliation(s)
- Sergio Corvino
- Division of Neurosurgery, Department of Neuroscience and Reproductive and Odontostomatological Sciences, Università di Napoli “Federico II”, 80131 Naples, Italy; (S.C.); (L.M.C.)
- PhD Program in Neuroscience, Department of Neuroscience and Reproductive and Odontostomatological Sciences, Università di Napoli “Federico II”, 80131 Naples, Italy
| | - Pedro L. Villanueva-Solórzano
- Department of Neurosurgery, National Institute of Neurology and Neurosurgery “Manuel Velasco Suarez”, Mexico City 14269, Mexico;
| | - Martina Offi
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli, 00168 Rome, Italy;
- Division of Neurosurgery, Catholic University of Rome, 00153 Rome, Italy
| | - Daniele Armocida
- Neurosurgery Division, Human Neurosciences Department, “Sapienza” University, 00185 Rome, Italy;
| | - Motonobu Nonaka
- Department of Neurosurgery, Kochi University Hospital, 185-1, Oko-cho, Kohasu, Kochi 783-8505, Japan;
| | - Giorgio Iaconetta
- Neurosurgical Clinic A.O.U. “San Giovanni di Dio e Ruggi d’Aragona”, 84131 Salerno, Italy;
| | - Felice Esposito
- Division of Neurosurgery, Department of Neuroscience and Reproductive and Odontostomatological Sciences, Università di Napoli “Federico II”, 80131 Naples, Italy; (S.C.); (L.M.C.)
| | - Luigi Maria Cavallo
- Division of Neurosurgery, Department of Neuroscience and Reproductive and Odontostomatological Sciences, Università di Napoli “Federico II”, 80131 Naples, Italy; (S.C.); (L.M.C.)
| | - Matteo de Notaris
- Neurosurgery Operative Unit, Department of Neuroscience, Coordinator Neuroanatomy Section Italian Society of Neurosurgery, G. Rummo Hospital, 82100 Benevento, Italy;
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Sahin MC, Bozkurt OF, Sahin MM, Celtikci E. Cavernous Sinus capillary hemangioma: Case report and literature review. BRAIN & SPINE 2023; 3:101776. [PMID: 38021022 PMCID: PMC10668058 DOI: 10.1016/j.bas.2023.101776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 06/17/2023] [Accepted: 06/30/2023] [Indexed: 12/01/2023]
Abstract
Introduction Capillary hemangioma of the cavernous sinus is considered a benign vascular skull base tumor. In this case report, a patient with capillary hemangioma located in the cavernous sinus who was operated on with endoscopic endonasal approach is presented. Research question What should be considered when planning the treatment for capillary hemangiomas located in the cavernous sinus? Material and methods The treatment approaches applied in 12 patients with a diagnosis of capillary hemangioma located in the cavernous sinus, reported in the English literature, are reviewed in this article. We presented the clinical and radiological results of the treatments. Results Cavernous sinus capillary hemangiomas are considered benign tumors. However, surgical treatment is preferred in the foreground because of the neurological deficits due to the compression effect caused by the mass. In the case reported by Masman et al. for the first time in the literature in 2021, they provided total excision with the endoscopic endonasal approach in the patient they first diagnosed by taking a biopsy with the endoscopic endonasal approach. In our case report, we provided total excision with endoscopic endonasal transsphenoidal approach. Discussion and conclusion Many factors should be considered when deciding on the treatment method in these patients. Although radiotherapy is quite effective in the treatment of capillary hemangioma, surgery should be preferred, especially in symptomatic patients. In patients who cannot undergo surgery, radiotherapy is very valuable, although the long-term results are not yet known.
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Affiliation(s)
- Mustafa Caglar Sahin
- Gazi University Medical School Department of Neurosurgery, 06560, Ankara, Turkey
| | - Omer Faruk Bozkurt
- Gazi University Medical School Department of Neurosurgery, 06560, Ankara, Turkey
| | - Muammer Melih Sahin
- Gazi University Medical School Department of Otorhinolaryngolog y, 06560, Ankara, Turkey
| | - Emrah Celtikci
- Gazi University Medical School Department of Neurosurgery, 06560, Ankara, Turkey
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Xiao L, Ouyang T, Wu B, Xie S, Tang B, He Y, Ding H, Wu X, Hong T. Subclassification of Knosp Grade 4 Pituitary Adenoma: Bringing Insights Into the Significance of Tumor Growth Pathways. Neurosurgery 2023; 92:213-222. [PMID: 36519865 DOI: 10.1227/neu.0000000000002197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 08/15/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Understanding the growth pathway of Knosp grade 4 pituitary adenoma (KG4PA) has a direct impact on surgical planning and safety for tumor eviction. OBJECTIVE To analyze the different characteristics between KG4PAs with a focus on the tumor growth pathway and its relationship to the cavernous segment of internal carotid artery. METHODS Clinical data from 129 patients with KG4PAs who underwent endoscopic endonasal surgery were retrospectively reviewed. A subclassification scheme was proposed based on the tumor growth pathway and its relevant features. The clinical connotation of the subclassification on surgical outcomes was also analyzed. RESULTS The KG4PAs were classified into 3 types based on the tumor growth pathway and its relevant features: groups A, B, and AB. The gross total resection rate in group A (51.2%) was much lower than that in group B (87.5%) and AB (87%) with a significant difference between the 3 groups ( P = .0004). The overall rate of visual function improvement, preoperative cranial nerve (CN) palsy improvement, and postoperative hormonal remission was 85.1%, 83.3%, and 85.7%, respectively. The rate of transient CN palsy, permanent CN palsy, permanent diabetes insipidus, panhypopituitarism, CSF leakage, and internal carotid artery injury was 7.8%, 3.9%, 4.7%, 2.3%, 1.5%, and 0.7%, respectively. CONCLUSION The subclassification strengthens our understanding of KG4PAs on tumor growth corridors and topographic relations of tumor and cavernous segment of internal carotid artery. Furthermore, the distinction into groups 4A, 4B, and 4AB is of benefits for selecting approaches, predicting risk and avoiding complications, and generating more tailored individualized surgical strategies for KG4PAs with better outcomes.
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Affiliation(s)
- Limin Xiao
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Taohui Ouyang
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Bowen Wu
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Shenhao Xie
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Bin Tang
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yulin He
- Department of Radiology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Han Ding
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Xiao Wu
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Tao Hong
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
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Micko ASG, Keritam O, Marik W, Strickland BA, Briggs RG, Shahrestani S, Cardinal T, Knosp E, Zada G, Wolfsberger S. Dumbbell-shaped pituitary adenomas: prognostic factors for prediction of tumor nondescent of the supradiaphragmal component from a multicenter series. J Neurosurg 2022; 137:609-617. [PMID: 34952511 DOI: 10.3171/2021.9.jns211689] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 09/28/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Dumbbell-shaped pituitary adenomas (DSPAs) are a subgroup of macroadenomas with suprasellar extension that are characterized by a smaller diameter at the level of the diaphragma sellae opening compared with the supradiaphragmal tumor component (SDTC). Hence, DSPAs may be particularly prone to a nondescending suprasellar tumor component and risk for residual tumor or postoperative bleeding. METHODS A multicenter retrospective cohort analysis of 99 patients with DSPA operated on via direct endoscopic endonasal transsphenoidal approach between 2011 and 2020 was conducted. Patient recruitment was performed at two tertiary care centers (Medical University of Vienna and University of Southern California) with expertise in endoscopic skull base surgery. DSPA was defined as having a smaller diameter at the level of the diaphragma sellae compared with the SDTC. RESULTS On preoperative MRI, all DSPAs were macroadenomas (maximum diameter range 17-71 mm, volume range 2-88 cm3). Tumor descent was found in 73 (74%) of 99 patients (group A), and nondescent in 26 (26%) of 99 patients (group B) intraoperatively. DSPAs in group A had a significantly smaller diameter (30 vs 42 mm, p < 0.001) and significantly smaller volume (10 vs 22 cm3, p < 0.001) than those in group B. The ratio of the minimum area at the level of the diaphragmal opening in comparison with the maximum area of the suprasellar tumor component ("neck-to-dome area") was significantly lower in group A than in group B (1.7 vs 2.7, p < 0.001). Receiver operating characteristic curve analysis revealed an area under the curve of 0.75 (95% CI 0.63-0.87). At a cutoff ratio of 1.9, the sensitivity and specificity for a nondescending suprasellar tumor component were 77% and 34%, respectively. CONCLUSIONS In the present study, the neck-to-dome area ratio was of prognostic value for prediction of intraoperative tumor nondescent in DSPAs operated on via a direct endonasal endoscopic approach. Pituitary adenoma SDTC nondescent carried the inherent risk of hemorrhagic transformation in all cases.
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Affiliation(s)
| | - Omar Keritam
- 1Department of Neurosurgery, Medical University of Vienna
| | - Wolfgang Marik
- 2Department of Biomedical Imaging and Image-guided Therapy, Division of Neuroradiology and Musculoskeletal Radiology, Medical University of Vienna, Austria; and
| | - Ben A Strickland
- 3Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Robert G Briggs
- 3Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Shane Shahrestani
- 3Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Tyler Cardinal
- 3Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | | | - Gabriel Zada
- 3Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
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Jung IH, Yoo J, Choi S, Lim SH, Ko J, Roh TH, Hong JB, Kim EH. Endoscopic transorbital approach to the cavernous sinus: Cadaveric anatomy study and clinical application (‡SevEN-009). Front Oncol 2022; 12:962598. [PMID: 36091168 PMCID: PMC9459324 DOI: 10.3389/fonc.2022.962598] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 08/08/2022] [Indexed: 11/13/2022] Open
Abstract
Objective Cavernous sinus (CS) invasion is frequently encountered in the management of skull base tumors. Surgical treatment of tumors in the CS is technically demanding, and selection of an optimal surgical approach is critical for maximal tumor removal and patient safety. We aimed to evaluate the feasibility of an endoscopic transorbital approach (ETOA) to the CS based on a cadaveric study. Methods Five cadaveric heads were used for dissection under the ETOA in the comparison with the endoscopic endonasal approach (EEA) and the microscopic transcranial approach (TCA). The CS was exposed, accessed, and explored, first using the ETOA, followed by the EEA and TCA. A dedicated endoscopic system aided by neuronavigation guidance was used for the procedures. During the ETOA, neurovascular structures inside the CS were approached through different surgical triangles. Results After completing the ETOA with interdural dissection, the lateral wall of the CS was fully exposed. The lateral and posterior compartments of the CS, of which accessibility is greatly limited under the EEA, were effectively approached and explored under the ETOA. The anteromedial triangle was the largest window via which most of the lateral compartment was freely approached. The internal carotid artery and abducens nerve were also observed through the anteromedial triangle and just behind V1. During the ETOA, the approaching view through the supratrochlear and infratrochlear triangles was more directed towards the posterior compartment. After validation of the feasibility and safety based on the cadaveric study, ETOA was successfully performed in a patient with a pituitary adenoma with extensive CS invasion. Conclusions Based on the cadaveric study, we demonstrated that the lateral CS wall was reliably accessed under the ETOA. The lateral and posterior compartments of the CS were effectively explored via surgical triangles under the ETOA. ETOA provides a unique and valuable surgical route to the CS with a promising synergy when used with EEA and TCA. Our experience with a clinical case convinces us of the efficacy of the ETOA during surgical management of skull base tumors with CS-invasion.
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Affiliation(s)
- In-Ho Jung
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, South Korea
- Department of Neurosurgery, Dankook University College of Medicine, Cheonan, South Korea
| | - Jihwan Yoo
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, South Korea
- Brain Tumor Center, Gangnam Severance Hospital, Seoul, South Korea
| | - Seonah Choi
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Seung Hoon Lim
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, South Korea
- Department of Neurosurgery, College of Medicine, Kyung Hee University, Seoul, South Korea
| | - JaeSang Ko
- Department of Ophthalmology, Severance Hospital, Institute of Vision Research, Yonsei University College of Medicine, Seoul, South Korea
- Endoscopic Skull Base Center, Severance Hospital, Seoul, South Korea
| | - Tae Hoon Roh
- Department of Neurosurgery, Ajou University Hospital, Ajou University School of Medicine, Suwon, South Korea
| | - Je Beom Hong
- Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Eui Hyun Kim
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, South Korea
- Endoscopic Skull Base Center, Severance Hospital, Seoul, South Korea
- *Correspondence: Eui Hyun Kim,
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Alali AA, Hanagandi PB, Maralani PJ. Do We Need Gadolinium-Based Contrast Agents for Routine MRI Surveillance of Unoperated Pituitary Macroadenoma? AJNR Am J Neuroradiol 2022; 43:1024-1028. [PMID: 35738673 DOI: 10.3174/ajnr.a7554] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 05/04/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The use of gadolinium-based contrast agents contributes to the cost of MR imaging and prolongs image-acquisition time. There are also recent concerns regarding gadolinium deposition, particularly in patients who require frequent follow-up MRIs. The purpose of this study was to assess whether gadolinium-based contrast agents are needed during MR imaging follow-up for unoperated pituitary macroadenoma. MATERIALS AND METHODS A total of 105 patients with unoperated pituitary macroadenoma who underwent follow-up MR imaging of the sella were included in this retrospective study. The craniocaudal dimension, cavernous sinus invasion grading, and optic pathway compression were assessed independently on coronal T2WI and compared with coronal T1-weighted images with gadolinium-based contrast agents (T1 postcontrast images). The agreement between the T2WI and T1 postcontrast images for the craniocaudal dimension was assessed using the intraclass correlation coefficient; for the cavernous sinus invasion and optic pathway compression, it was assessed using κ statistics. RESULTS There was excellent agreement for the craniocaudal dimensions between T2WI and T1 postcontrast images (intraclass correlation coefficient = 0.96, P < .001; 95% CI, 0.84-0.99). Additionally, there was almost-perfect agreement between cavernous sinus invasion and optic pathway compression between T2WI and T1 postcontrast images, with κ = 0.95 and 0.84, respectively (P < .001). CONCLUSIONS MR imaging of the sella without the use of gadolinium-based contrast agents could potentially be considered for the follow-up of unoperated pituitary macroadenomas. This choice can reduce the MR imaging examination cost and acquisition time and avoids potential adverse effects of gadolinium-based contrast agents.
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Affiliation(s)
- A A Alali
- From the Division of Neuroradiology (A.A.A.), King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - P B Hanagandi
- Department of Medical Imaging (P.B.H.), King Abdulaziz Medical City NGHA, Riyadh, Saudi Arabia
| | - P J Maralani
- Division of Neuroradiology (P.J.M.), Department of Medical Imaging, University of Toronto, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Kelly AP, Greenfield JP, Dobri GA, Schwartz TH. Pediatric pituitary adenomas are more aggressive, more likely to be hormone producing and are more difficult to cure than adult pituitary adenomas: case series and systematic literature review. Childs Nerv Syst 2022; 38:729-738. [PMID: 35048170 DOI: 10.1007/s00381-022-05445-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 01/06/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE Pediatric pituitary adenomas (pPAs) are uncommon. Thus, their presentation and outcomes after treatment are less well-understood than those of pituitary adenomas in adulthood (aPAs). METHODS A retrospective chart review was conducted for all patients who underwent endoscopic endonasal transsphenoidal surgery (EETS) for pPA at NewYork-Presbyterian Hospital/Weill Cornell Medicine (NYP/WCM) from 2005-2020. Eleven patients were identified, and information pertaining to age, sex, adenoma characteristics, procedural details, and outcomes was reviewed. A systematic review of the literature was also performed to compare outcomes of EETS versus microscopic endonasal transsphenoidal surgery (METS) for pPA. RESULTS From 2005-2020, 11 patients underwent EETS for pPA at NYP/WCM. Mean age at operation was 14.9 ± 2.7 years, and 5 patients (45.5%) were male. 10 adenomas (90.9%) were hormone-producing. Of the functional adenomas, 8 (80.0%) were PRL-secreting and 2 (20.0%) were GH-secreting. Maximum adenoma diameter (MAD) ranged from 1.2-5.1 cm, with a median of 1.55 cm. Cavernous sinus invasion (CSI) occurred in 2 patients with macroprolactinoma. Gross total resection (GTR) was achieved in 10 (90.9%). Biochemical remission occurred in 5/10 (50.0%). Post-operative complications were documented in 8 cases (72.7%) and included diabetes insipidus, hypopituitarism, sinusitis, weight gain, cerebrospinal fluid leak, meningitis, and hydrocephalus. Systematic literature review of 105 microscopic and 175 endoscopic cases revealed high frequency of hormone-producing tumors (83.6%) and similar rates of GTR (82.4% vs 85.1%) and biochemical cure (75.8% vs 64.3%). CONCLUSIONS pPAs are more likely to be hormone producing and may be more aggressive and difficult to cure than aPAs. EETS is an effective treatment, although complication rates may be higher than in adult populations.
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Affiliation(s)
- Alexander P Kelly
- Weill Cornell Medical College, Weill Cornell Medicine, New York, NY, USA
| | - Jeffrey P Greenfield
- Department of Neurological Surgery, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, NY, USA
| | - Georgiana A Dobri
- Department of Neurological Surgery, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, NY, USA
| | - Theodore H Schwartz
- Department of Neurological Surgery, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, NY, USA.
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Guan X, Wang Y, Zhang C, Ma S, Zhou W, Jia G, Jia W. Surgical Experience of Transcranial Approaches to Large-to-Giant Pituitary Adenomas in Knosp Grade 4. Front Endocrinol (Lausanne) 2022; 13:857314. [PMID: 35634502 PMCID: PMC9133328 DOI: 10.3389/fendo.2022.857314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 04/04/2022] [Indexed: 11/15/2022] Open
Abstract
Pituitary adenomas in Knosp grade 4 are difficult to resect completely and are generally involved in poor prognosis, because of the close relationship between the tumor and internal carotid. In this study, the authors retrospectively reviewed the outcome of different transcranial approaches in the management of large-to-giant pituitary adenomas in Knosp grade 4. A total of 42 patients with large-to-giant pituitary adenomas in Knosp grade 4, who underwent craniotomy in the Pituitary Disease Subdivision, Department of Neurosurgery, Beijing Tiantan Hospital, between March 2012 and March 2015 were included in this study. Clinical characteristics, surgical methods, complications, and outcomes were evaluated. The median age was 45 years (range, 19-73 years old), and 42.9% of the enrolled cases were men. The mean tumor diameter was 43.6 mm, and the mean volume was 30.9 cm3. 26 patients underwent the frontolateral approach, while 16 cases accepted the frontotemporal approach. Gross total resection was achieved in 11 patients (26.2%), near total in 26 (61.9%), and subtotal in 5 (11.9%). The adenomas were larger, and the distance of the tumor extending to the lateral skull base was also further in the frontotemporal approach cases. The surgical time was shorter, and the bleeding volume was less in the frontolateral approach cases. Subsellar extension was associated with incomplete resection in pituitary macroadenomas of Knosp grade 4. The craniotomy is still an effective treatment for pituitary macroadenomas in Knosp grade 4.
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Affiliation(s)
- Xiudong Guan
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yangyang Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chengkai Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | | | - Wenjianlong Zhou
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Guijun Jia
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Wang Jia
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Neurosurgical Institute, Beijing, China
- *Correspondence: Wang Jia,
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12
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Tao C, Cheng G, Chen Y, Gu P, Hu W. Early outcomes of endoscopic endonasal approach pituitary adenomas resection with minimal nasal injury. Medicine (Baltimore) 2021; 100:e27843. [PMID: 34797319 PMCID: PMC8601292 DOI: 10.1097/md.0000000000027843] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 11/01/2021] [Indexed: 01/05/2023] Open
Abstract
To report the results of a consecutive series of pituitary adenomas resected through endoscopic endonasal approach (EEA) with minimal nasal injury.Retrospectively review tumor characteristics and surgical outcomes of a consecutive series of EEA pituitary adenomas resection performed mainly by a single author between March 2018 and June 2019.A total of 75 endoscopic endonasal approach pituitary adenoma resections were performed by the authors' team. Of the 75 patients, 28 through mononostril EEA, 47 through Binonostril EEA. Hadad-Bassagasteguy vascularized nasoseptal flap was harvested in only 4 (5.3%) patients with a high risk of postoperative cerebrospinal fluid leak, and one side middle turbinate only been resected in 2 (2.7%) patients, other patients preserved bilateral middle turbinate. Of the 75 patients, gross total resection is 74.7%, near-total resection is 16.0%. Endocrinological remission was achieved in 76.9% of GH-secreting adenomas, 61.5% of prolactin-secreting adenomas. The postoperative cerebrospinal fluid leak rate was 2.7%. Two patients had suprasellar hemorrhage, 1 patient had perioperative stroke, 2 patients had permanent diabetes insipidus, no cranial nerve deficits, internal carotid artery injury, anosmia, and death. The sino-nasal function was measured with the Sino-Nasal Outcome Test-22 and visual analog scale for olfaction preoperatively and postoperatively, and there was no statistically significant difference.The EEA is an effective approach to resect pituitary adenomas, the gross total resection and near-total resection rate and endocrinological remission rate are satisfactory. The EEA is a safe approach, as the complication rate is acceptable compared with those reported in the previous series of microscopic and endoscopic approaches. These results can be achieved with minimal nasal injury.
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Magnetic resonance angiographic study of variations in course of paraclival and parasellar internal carotid artery in relation to expanded endonasal endoscopic approaches. Eur Arch Otorhinolaryngol 2021; 279:3459-3465. [PMID: 34652526 DOI: 10.1007/s00405-021-07123-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 10/04/2021] [Indexed: 10/20/2022]
Abstract
AIMS To study the variations in the course of the paraclival and parasellar carotid arteries in normal subjects using magnetic resonance angiography as is relevant from an endoscopic endonasal perspective. METHODS Two hundred MR angiographies of normal subjects were analyzed in a prospective study. The intercarotid distances were measured at fixed points along the paraclival and parasellar segments of the internal carotid artery. The intercarotid spaces thus obtained were categorized into trapezoid, square and hourglass shapes. The angle between the posterior ascending vertical and horizontal bend of the parasellar ICA was also measured and analyzed. RESULTS The trapezoid shape of intercarotid space is the most common (52.5%), followed by the square (35%) and the hourglass (12.5%) shaped spaces. Angle of < 80° between the posterior ascending vertical and horizontal bend of the parasellar ICA was found in 39% of subjects, angle between 80° and 100° was found in 9% subjects, angle > 100° was found in 43% while asymmetric angles on the two sides was found in 9% of subjects. CONCLUSION A thorough understanding of the course of the ICA is important in planning the approach and preventing injury to the ICA.
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Zhang Y, Tu S, Duan L, Fu W, Wang J, Geng S. Classification of Pituitary Adenomas Invading the Cavernous Sinus Assisted by Three-Dimensional Multimodal Imaging and Its Clinical Application. J Neurol Surg B Skull Base 2021; 82:567-575. [PMID: 34513564 DOI: 10.1055/s-0040-1715597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 06/21/2020] [Indexed: 10/23/2022] Open
Abstract
Introduction To help diagnose and evaluate the prognosis of pituitary adenoma with cavernous sinus (CS) invasion and guide endonasal endoscopic surgery (EES) assisted by intraoperative navigation (ION) with three-dimensional multimodal imaging (3D-MMI). We propose a classification of CS invasion based on 3D-MMI. Methods We picked some appropriate cases and reconstructed the 3D-MMI and then classified them into 3 grades according to the stereo relationship among ICA, tumor and CS in 3D-MMI. Then, we applied different strategies according to their grade to remove pituitary adenomas that invaded the CS. Results All 38 patients were divided into 3 grades. Tumors compressing the ICA and CS without CS invasion were divided into grade 1. Tumors encasing the ICA and invading the superior-posterior compartment and/or anterior-inferior compartment but without distinct separation of the ICA and CS lateral wall were deemed as grade 2. Tumors encasing the ICA and filling the lateral compartment of the CS that dissociated the lateral wall from the ICA were deemed as grade 3. The 3D-MMI enabled adequate spatial visualization of the ICA, CS and tumors. All patients were operated on under the guidance of ION with 3D-MMI. Conclusion Classification based on 3D-MMI can better demonstrate the relationships among tumor, ICA and CS in a stereo and multi-angle view, which will have significance in guiding the surgical strategy.
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Affiliation(s)
- Yukun Zhang
- Department of Neurosurgery, Capital Medical University, Beijing Tiantan Hospital, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Department of Neurosurgery, Peking University International Hospital, Beijing, China
| | - Shaohua Tu
- Department of Neurosurgery, Capital Medical University, Beijing Tiantan Hospital, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Lian Duan
- Department of Neurosurgery, Capital Medical University, Beijing Tiantan Hospital, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Weilun Fu
- Department of Neurosurgery, Capital Medical University, Beijing Tiantan Hospital, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jianbo Wang
- Department of Neurosurgery, Capital Medical University, Beijing Tiantan Hospital, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Sumin Geng
- Department of Neurosurgery, Capital Medical University, Beijing Tiantan Hospital, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
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Acitores Cancela A, Rodríguez Berrocal V, Pian H, Martínez San Millán JS, Díez JJ, Iglesias P. Clinical relevance of tumor consistency in pituitary adenoma. Hormones (Athens) 2021; 20:463-473. [PMID: 34148222 DOI: 10.1007/s42000-021-00302-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 05/13/2021] [Indexed: 12/30/2022]
Abstract
PURPOSE To review the clinical relevance of pituitary adenoma (PA) consistency and its relationship to clinical presentation, radiologic and histopathological characteristics, and surgical outcomes. BACKGROUND PA consistency is a critical factor influencing operative planning, surgical outcomes, and patient counseling. There is no validated classification of PA consistency in the literature, and there are no current preoperative variables capable of predicting it. REVIEW We conducted a thorough literature review of the Medline, Embase, Web of Science, and Cochrane Library databases. The inclusion criteria were all articles that described PA consistency and correlated it with preoperative aspects, radiological, pathological, and operative findings, or clinical outcomes. DISCUSSION Although most authors differentiate easily aspirated (soft) tumors from those that are not (fibrous, might require prior fragmentation), there is no universally accepted PA consistency classification. Fibrous PA tends to be hypointense on T2WI and has lower apparent diffusion coefficient (ADC) values. Fibrous tumors seemed to present higher invasion into neighboring structures, including the cavernous sinus. Several articles suggest that dopamine agonists could increase PA consistency and that prior surgery and radiotherapy also make PA more fibrous. The anatomopathological studies identify collagen as being mainly responsible for fibrous consistency of adenomas. CONCLUSIONS Preoperative knowledge of PA consistency affords the neurosurgeon substantial benefit, which clearly appears to be relevant to surgical planning, risks, and surgery outcomes. It could also encourage the centralization of these high complexity tumors in reference centers. Further studies may be enhanced by applying standard consistency classification of the PA and analyzing a more extensive and prospective series of fibrous PA.
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Affiliation(s)
- Alberto Acitores Cancela
- Department of Neurosurgery, Hospital Universitario Ramón Y Cajal, Ctra. de Colmenar Viejo km. 9, 100, 28034, Madrid, Spain.
| | - Víctor Rodríguez Berrocal
- Department of Neurosurgery, Hospital Universitario Ramón Y Cajal, Ctra. de Colmenar Viejo km. 9, 100, 28034, Madrid, Spain
| | - Héctor Pian
- Departments of Neurosurgery and Pathology, Hospital Universitario Ramón Y Cajal, Madrid, Spain
| | | | - Juan José Díez
- Department of Endocrinology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
| | - Pedro Iglesias
- Department of Endocrinology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
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Gómez-Amador JL, Martínez-Anda JJ, Guerrero-Suarez PD, Rosales-Amaya AM, Delgado-Arce JC, Guerrero-López DA. Endoscopic endonasal lateral transellar approach for growth hormone-secreting adenomas with cavernous sinus invasion: Technical note and surgical results. NEUROCIRUGÍA (ENGLISH EDITION) 2021; 32:170-177. [PMID: 34218877 DOI: 10.1016/j.neucie.2020.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 05/27/2020] [Indexed: 10/21/2022]
Abstract
BACKGROUND Cavernous sinus (CS) invasion is found in 15-20% of pituitary adenomas; it represents a poor prognosis factor and a surgical challenge even in experienced pituitary centers. We present our experience and technical note description for surgical management of pituitary adenomas with CS invasion in acromegaly by the transsellar lateral approach with an endoscopic endonasal transsphenoidal route. METHOD prospective case series of patients who underwent endoscopic endonasal surgery for Growing Hormone (GH) producing adenomas with CS invasion treated at the Neurosurgery departments of National Institute of Neurology and Neurosurgery in Mexico City, and of Toluca Medical Center of Social Security Institute of the State of Mexico and Provinces between January 2014 and March 2019. RESULTS Thirty-two of 94 patients with diagnosis of pituitary adenoma treated at our institutions (34%) had acromegaly; thirteen of patients with acromegaly diagnosis met the inclusion criteria for CS invasion. Postoperative images reported gross total resection in 10 patients (76.9%). Mean follow-up time was 28.3 months. Remission criteria were achieved in nine patients (69.2%), with one of these patients (11.1%) having recurrence during follow up. All patients with no biochemical remission had improvement in GH and IGF profiles. Three patients without remission underwent radiosurgery (14Gy), and one patient had remission after the procedure. CONCLUSIONS We consider this to be a safe and efficient approach for tumors invading CS, when surgical team have good experience in endoscopy of the skull base and reconstruction techniques, appropriate instruments are available, and tumor has soft consistency.
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Affiliation(s)
- Juan Luis Gómez-Amador
- Department of Neurosurgery, National Institute of Neurology and Neurosurgery Manuel Velasco Suarez, Insurgentes Sur Av. 3877, Barrio La Fama, Postal Code 14269 Mexico City, Mexico
| | - Jaime Jesús Martínez-Anda
- Neurosurgery Department, Toluca Medical Center of Social Security Institute of the State of Mexico and Provinces Baja Velocidad, Av. 57.5km Mexico - Toluca Highway, Postal Code 52140 Metepec, State of Mexico, Mexico.
| | - Pablo David Guerrero-Suarez
- Neurosurgery Department, Toluca Medical Center of Social Security Institute of the State of Mexico and Provinces Baja Velocidad, Av. 57.5km Mexico - Toluca Highway, Postal Code 52140 Metepec, State of Mexico, Mexico
| | - Arturo Miguel Rosales-Amaya
- Neurosurgery Department, Toluca Medical Center of Social Security Institute of the State of Mexico and Provinces Baja Velocidad, Av. 57.5km Mexico - Toluca Highway, Postal Code 52140 Metepec, State of Mexico, Mexico
| | - Julio Cesar Delgado-Arce
- Neurosurgery Department, Toluca Medical Center of Social Security Institute of the State of Mexico and Provinces Baja Velocidad, Av. 57.5km Mexico - Toluca Highway, Postal Code 52140 Metepec, State of Mexico, Mexico
| | - David Antonio Guerrero-López
- Neurosurgery Department, Toluca Medical Center of Social Security Institute of the State of Mexico and Provinces Baja Velocidad, Av. 57.5km Mexico - Toluca Highway, Postal Code 52140 Metepec, State of Mexico, Mexico
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Experience of Endoscopic Endonasal Approach for 803 Pituitary Tumors With Cavernous Sinus Invasion. J Craniofac Surg 2021; 33:e118-e122. [PMID: 34334752 DOI: 10.1097/scs.0000000000008049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE The aim of this study was to investigate the effectiveness, safety, complications, and prognosis of endoscopic endonasal surgery for pituitary adenomas with cavernous sinus invasion (CSI). METHODS The clinical data of 803 pituitary adenomas with CSI surgeries performed in our single ward between January 1, 2006 and December 31, 2018 were retrospectively reviewed. The resection degree, bone invasion, endocrine examination, complications, and outcome were retrospectively summarized. RESULTS Gross total resection was achieved in 394 patients (49.1%) subtotal resection in 171 patients (21.3%) and partial resection in 238 patients (29.6%). Clinically variable analyses showed that there was a significant correlation between CSI and female, older age, operation history, and non-gross total resection (NGTR). Among the pituitary adenomas with CSI, there was a significant correlation between bone invasive and NGTR, Knosp classification, recurrence. K-M curves showed that young age, larger tumors, bilateral invasion, Grade 4 of Knosp classification, NGTR, and bone invasion were associated with pituitary adenomas regrowth. Multivariate analysis revealed that bone invasion, NGTR, and Grade 4 of Knosp classification were independent risk factors for pituitary adenomas regrowth. There was a significant correlation between CSI and female, older age, operation history, and tumor resection degree. CONCLUSIONS There was a significant correlation between CSI and female, older age, operation history, and tumor resection degree. The patients with CSI and bone invasion were likely to recurrent. Non-gross total resection, bone invasion, and Grade 4 of Knosp classification were independent risk factors for pituitary adenomas regrowth. Endoscopic endonasal surgery is an excellent choice for pituitary adenomas with CSI.
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Ouyang T, Zhang N, Xie S, Tang B, Li J, Xiao L, Zhang F, Wu B, Zhou D, Li M, Hong T. Outcomes and Complications of Aggressive Resection Strategy for Pituitary Adenomas in Knosp Grade 4 With Transsphenoidal Endoscopy. Front Oncol 2021; 11:693063. [PMID: 34235083 PMCID: PMC8255811 DOI: 10.3389/fonc.2021.693063] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 05/20/2021] [Indexed: 11/30/2022] Open
Abstract
Surgery for pituitary adenomas (PAs) with cavernous sinus (CS) invasion in Knosp grade 4 is a great challenge and whether to adopt a conservative or aggressive surgical strategy is controversial. The aim of this study is to provide the outcomes and complications of an aggressive resection strategy for Knosp grade 4 PAs with transsphenoidal endoscopic surgery. Outcomes and complications were retrospectively analyzed in 102 patients with Knosp grade 4 PAs. Among them, primary PAs were seen in 60 patients and recurrent PAs were seen in 42 cases. Gross total resection (GTR) of the entire tumor was achieved in 72 cases (70.6%), subtotal tumor resection (STR) in 18 cases (17.6%), and partial tumor resection (PTR) in 12 cases (11.8%). Additionally, GTR of the tumor within the CS was achieved in 82 patients (80.4%), STR in 17 patients (16.7%), and PTR in 3 patients (2.9%). Statistical analyses showed that both recurrent tumors and firm consistency tumors were adverse factors for complete resection (P<0.05). Patients with GTR of the entire tumor were more likely to have favorable endocrine and visual outcomes than those with incomplete resection (P<0.05). Overall, the most common surgical complication was new cranial nerve palsy (n=7, 6.8%). The incidence of internal carotid artery (ICA) injury and postoperative cerebrospinal fluid (CSF) leakage was 2.0% (n=2) and 5.9% (n=6), respectively. Six patients (5.9%) experienced tumor recurrence postoperatively. For experienced neuroendoscopists, an aggressive tumor resection strategy via transsphenoidal endoscopic surgery may be an effective and safe option for Knosp grade 4 PAs.
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Affiliation(s)
- Taohui Ouyang
- Department of Neurosurgery, the First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Na Zhang
- Department of Neurology, the First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Shenhao Xie
- Department of Neurosurgery, the First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Bin Tang
- Department of Neurosurgery, the First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Junjun Li
- Department of Neurosurgery, Wuhan Union Hospital, Wuhan, China
| | - Limin Xiao
- Department of Neurosurgery, the First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Fabao Zhang
- Department of Radiology, the First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Bowen Wu
- Department of Neurosurgery, the First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Dongwei Zhou
- Department of Neurosurgery, the First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Meihua Li
- Department of Neurosurgery, the First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Tao Hong
- Department of Neurosurgery, the First Affiliated Hospital of Nanchang University, Nanchang, China
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Rutland JW, Delman BN, Feldman RE, Tsankova N, Lin HM, Padormo F, Shrivastava RK, Balchandani P. Utility of 7 Tesla MRI for Preoperative Planning of Endoscopic Endonasal Surgery for Pituitary Adenomas. J Neurol Surg B Skull Base 2021; 82:303-312. [PMID: 34026406 PMCID: PMC8133814 DOI: 10.1055/s-0039-3400222] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Accepted: 09/28/2019] [Indexed: 10/25/2022] Open
Abstract
Objective There is increasing interest in investigating the utility of 7 Tesla (7 T) magnetic resonance imaging (MRI) for imaging of skull base tumors. The present study quantifies visualization of tumor features and adjacent skull base anatomy in a homogenous cohort of pituitary adenoma patients. Methods Eighteen pituitary adenoma patients were scanned at 7 T in this prospective study. All patients had reference standard-of-care clinical imaging at either 3 T (7/18, 39%) or 1.5 T (11/18, 61%). Visualization of tumor features and conspicuity of arteries and cranial nerves (CNs) was rated by an expert neuroradiologist on 7 T and clinical field strength MRI. Overall image quality and severity of image artifacts were also characterized and compared. Results Ability to visualize tumor features did not differ between 7 T and lower field MRI. Cranial nerves III, IV, and VI were better detected at 7 T compared with clinical field strength scans. Cranial nerves III, IV, and VI were also better detected at 7 T compared with only 1.5 T, and CN III was better visualized at 7 T compared with 3 T MRI. The ophthalmic arteries and posterior communicating arteries (PCOM) were better detected at 7 T compared with clinical field strength imaging. The 7 T also provided better visualization of the ophthalmic arteries compared with 1.5 T scans. Conclusion This study demonstrates that 7 T MRI is feasible at the skull base and identifies various CNs and branches of the internal carotid artery that were better visualized at 7 T. The 7 T MRI may offer important preoperative information that can help to guide resection of pituitary adenoma and reduce operative morbidity.
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Affiliation(s)
- John W. Rutland
- Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, New York, United States
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Bradley N. Delman
- Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, New York, United States
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Rebecca E. Feldman
- Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Nadejda Tsankova
- Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Hung-Mo Lin
- Department of Population Health Science and Policy, Mount Sinai Hospital, New York, New York, United States
| | - Francesco Padormo
- Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, New York, United States
- Department of Medical Physics, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Raj K. Shrivastava
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Priti Balchandani
- Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, New York, United States
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Park K, Park KH, Park HR, Lee JM, Kim YH, Kim DY, Won TB, Kong SH, Kim JH, Shin CS, Paek SH. Long-term Outcome of Microscopic Transsphenoidal Surgery for Prolactinomas as an Alternative to Dopamine Agonists. J Korean Med Sci 2021; 36:e97. [PMID: 33876586 PMCID: PMC8055511 DOI: 10.3346/jkms.2021.36.e97] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 01/27/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Although long-term dopamine agonist (DA) therapy is recommended as a first-line treatment for prolactinoma, some patients may prefer surgical treatment because of the potential adverse effects of long-term medication, or the desire to become pregnant. This study aimed to determine whether surgical treatment of prolactinomas could be an alternative to DA therapy. METHODS In this retrospective study, 96 consecutive patients (74 female, 22 male) underwent primary pituitary surgery without long-term DA treatment for prolactinomas at a single institution from 1990 to 2010. All patients underwent primary surgical treatment in the microscopic transsphenoidal approach (TSA). RESULTS The median age and median follow-up period were 31 (16-73) years and 139.1 (12.2-319.6) months, respectively. An initial overall remission was accomplished in 47.9% (46 of 96 patients, 33 macroadenomas, and 13 microadenomas) of patients. DA dose reduction was achieved in all patients after TSA. A better remission rate was independently predicted by lower diagnostic prolactin levels and by a greater extent of surgical resection. Overall remission at the last follow-up was 33.3%, and the overall recurrence rate was 30.4%. The permanent complication rate was 3.1%, and there was no mortality. CONCLUSION TSA can be considered a safe and potentially curative treatment for selective microprolactinomas as an alternative to treatment with a long-term DA.
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Affiliation(s)
- Kawngwoo Park
- Department of Neurosurgery, Gachon University Gil Medical Center, Incheon, Korea
| | - Kwang Hyon Park
- Department of Neurosurgery, Chungnam National University Hospital, Daejeon, Korea
| | - Hye Ran Park
- Department of Neurosurgery, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Jae Meen Lee
- Department of Neurosurgery, Pusan National University Hospital, Busan, Korea
| | - Yong Hwy Kim
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Dong Young Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Tae Bin Won
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Sung Hye Kong
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Jung Hee Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Chan Soo Shin
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Sun Ha Paek
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea.
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21
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Erkan B, Barut O, Akbas A, Akpinar E, Akdeniz YS, Tanriverdi O, Gunaldi O. Results of Endoscopic Surgery in Patients with Pituitary Adenomas : Association of Tumor Classification Grades with Resection, Remission, and Complication Rates. J Korean Neurosurg Soc 2021; 64:608-618. [PMID: 33853298 PMCID: PMC8273775 DOI: 10.3340/jkns.2020.0207] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 10/07/2020] [Indexed: 11/27/2022] Open
Abstract
Objective The endoscopic endonasal transsphenoidal approach is a widely-used method for the surgical treatment of pituitary adenomas. We aimed to evaluate the results of endoscopic surgery by comparing preoperative classification methods and investigating their relationship with postoperative resection and remission rates and complications.
Methods We retrospectively reviewed the medical records of 236 patients (118 males) who underwent surgery for pituitary adenomas. Preoperative Knosp classification, tumor size (TS), suprasellar extension (SSE), postoperative resection and remission rates, and complications were evaluated.
Results The follow-up period was 3 months to 6 years. The patients’ ages ranged between 16 and 84 years. Endocrinologically, 114 patients (48.3%) had functional adenoma (FA), and 122 patients (51.7%) had non-functional adenoma (NFA). Among the FA group, 92 (80.7%) showed remission. A statistically significant difference was found between patients with and without remission in terms of the Knosp, TS, and SSE classifications (p<0.01). Knosp, TS, and SSE classification grades were found to be correlated with the resection rates (p<0.01). Meningitis was seen in seven patients (3.0%), diabetes insipidus in 16 (6.9%; permanently in two [0.9%]), and rhinorrhea in 19 (8.1%). Thirty-six patients (15.3%) developed pituitary insufficiency and received hormone replacement therapy.
Conclusion The resection categories and remission rates of FAs were directly proportional to the adenoma sizes and Knosp grades, while the degree of suprasellar growth further complicated resection and remission rates. Adenoma sizes less than 2 cm and SSEs less than 1 cm are associated with favorable remission and resection rates.
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Affiliation(s)
- Buruc Erkan
- Department of Neurosurgery, Umraniye Research & Training Hospital, Health Sciences University, Istanbul, Turkey
| | - Ozan Barut
- Department of Neurosurgery, Bakirkoy Research & Training Hospital for Psychiatry, Neurology, and Neurosurgery, Health Sciences University, Istanbul, Turkey
| | - Ahmet Akbas
- Department of Neurosurgery, Taksim Research & Training Hospital, Health Sciences University, Istanbul, Turkey
| | - Ebubekir Akpinar
- Department of Neurosurgery, Bakirkoy Research & Training Hospital for Psychiatry, Neurology, and Neurosurgery, Health Sciences University, Istanbul, Turkey
| | - Yasemin Sefika Akdeniz
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Health Sciences University, Istanbul, Turkey
| | - Osman Tanriverdi
- Department of Neurosurgery, Bakirkoy Research & Training Hospital for Psychiatry, Neurology, and Neurosurgery, Health Sciences University, Istanbul, Turkey
| | - Omur Gunaldi
- Department of Neurosurgery, Bakirkoy Research & Training Hospital for Psychiatry, Neurology, and Neurosurgery, Health Sciences University, Istanbul, Turkey
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22
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Cheng J, Nie D, Li B, Gui S, Li C, Zhang Y, Zhao P. CircNFIX promotes progression of pituitary adenoma via CCNB1 by sponging miR-34a -5p. Mol Cell Endocrinol 2021; 525:111140. [PMID: 33359304 DOI: 10.1016/j.mce.2020.111140] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 12/18/2020] [Indexed: 02/06/2023]
Abstract
Previous studies have shown that CCNB1 affects the invasiveness of pituitary adenomas, and it is of great significance to find the upstream mechanism of regulating CCNB1.In this study, we explored a significantly overexpressed circRNA in invasive pituitary adenomas. Based on bioinformatics analysis and mechanism experiments, we determined that circNFIX (has-circ_0005660) affects cell invasion, migration and proliferation in pituitary adenomas by sponging miR-34a-5p through CCNB1. In pituitary adenoma tissues, the expression of circNFIX and CCNB1 was upregulated, while miR-34a-5p expression was downregulated. The silencing of circNFIX or overexpression of miR-34a-5p inhibited cell invasion, migration and proliferation. Inhibition of miR-34a-5p expression reversed the inhibitory effect of circNFIX silencing on the progression of pituitary adenoma. In conclusion, CircNFIX affects cell invasion, migration, and proliferation in pituitary adenomas by sponging miR-34a-5p through CCNB1. Therefore, circNFIX is expected to serve as a potential target for the treatment of pituitary adenomas.
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Affiliation(s)
- Jianhua Cheng
- Neurosurgical Department, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
| | - Ding Nie
- Neurosurgical Department, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
| | - Bin Li
- Department of Cell and Biology, Beijing Neurosurgical Institute, Beijing, 100070, China
| | - SongBai Gui
- Neurosurgical Department, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
| | - ChuZhong Li
- Department of Cell and Biology, Beijing Neurosurgical Institute, Beijing, 100070, China
| | - YaZhuo Zhang
- Department of Cell and Biology, Beijing Neurosurgical Institute, Beijing, 100070, China
| | - Peng Zhao
- Neurosurgical Department, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China.
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23
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Zhu H, Li B, Li C, Liu C, Wang X, Gui S, Zhao P, Bai J, Cao L, Zhang Y. The clinical features, recurrence risks and surgical strategies of bone invasive pituitary adenomas. Clin Neurol Neurosurg 2020; 201:106455. [PMID: 33395618 DOI: 10.1016/j.clineuro.2020.106455] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 12/16/2020] [Accepted: 12/23/2020] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Bone invasive pituitary adenomas (BIPAs) show obvious malignant behaviour. The aim of this study was to analyse the clinical features, prognosis, recurrence risks and surgical strategies of BIPAs. PATIENTS AND METHODS Clinical charts and radiological information were reviewed retrospectively in 107 consecutive cases of BIPAs. Transnasal endoscopic surgery was adopted with the goal of removing tumours. Scheduled follow-up was performed. RESULTS Clinical variable analyses revealed a significant correlation between bone invasive range and sex, tumour volume and tumour regrowth. Gross total resection, subtotal resection and partial resection were achieved in 26 cases (24.3 %), 28 cases (26.2 %) and 53 cases (49.5 %), respectively. There was a significant correlation between nongross total resection and female sex, young age, large tumour volume, bone invasive range, tumour regrowth and functional pituitary adenomas in BIPAs. The tumour regrowth rates at 3 years, 5 years and 10 years were 45.3 %, 76.3 % and 97.5 %, respectively. Kaplan-Meier curve analysis showed that tumour volume, bone invasion range, age, recurrent tumours and tumour resection degree were associated with BIPA regrowth. Multivariate analysis showed that tumour resection degree, bone invasive range, and tumour diameter were independent risk factors for BIPA regrowth. CONCLUSION BIPAs have the characteristics of high surgical risk, low GTR rate and high recurrence rate. There was a significant correlation between bone invasive range and sex, tumour volume and tumour regrowth in BIPAs. Bone invasive range is an independent risk factor for BIPA regrowth.
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Affiliation(s)
- Haibo Zhu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
| | - Bin Li
- Beijing Neurosurgical Institute, Capital Medical University, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
| | - Chuzhong Li
- Beijing Neurosurgical Institute, Capital Medical University, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China; Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China; Beijing Institute for Brain Disorders Brain Tumour Center, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China; China National Clinical Research Center for Neurological Diseases, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
| | - Chunhui Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
| | - Xinsheng Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
| | - Songbai Gui
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
| | - Peng Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
| | - Jiwei Bai
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
| | - Lei Cao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
| | - Yazhuo Zhang
- Beijing Neurosurgical Institute, Capital Medical University, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China; Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China; Beijing Institute for Brain Disorders Brain Tumour Center, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China; China National Clinical Research Center for Neurological Diseases, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China.
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24
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Solari D, D'Avella E, Bove I, Cappabianca P, Cavallo LM. Extended endonasal approaches for pituitary adenomas. J Neurosurg Sci 2020; 65:160-168. [PMID: 33245222 DOI: 10.23736/s0390-5616.20.05120-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Pituitary adenomas with significant extension beyond the sellar boundary, large size, asymmetrical shape and subarachnoid space invasion, although rare, represent a therapeutic challenge. The invasiveness of the tumor itself often limits the potential for complete tumor resection and increases the likelihood of intraoperative or postoperative complications, regardless of the approach. The extended endoscopic endonasal approach has been proposed as a valid alternative to the transcranial route for the treatment of certain pituitary adenomas not suitable to the standard transsphenoidal approach. Thanks to the wide and close up view provided by the endoscope via the appropriate expanded bone removal at the skull base, this technique offers, in an adequate working space, a safe exposure of the tumor and surrounding anatomical structures, at the supra-, para-, and retro-sellar areas. It stands clear that the primary goal of this approach remains the maximum allowed resection with preservation of neurological and endocrine functions. Herein, we debate the extended endoscopic endonasal technique for the treatment of pituitary adenomas, with the aim of underlying its indications, pitfalls, advantages, and limitations.
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Affiliation(s)
- Domenico Solari
- Division of Neurosurgery, Department of Neurosciences and Reproductive and Odontostomatological Sciences, Federico II University, Naples, Italy
| | - Elena D'Avella
- Division of Neurosurgery, Department of Neurosciences and Reproductive and Odontostomatological Sciences, Federico II University, Naples, Italy
| | - Ilaria Bove
- Division of Neurosurgery, Department of Neurosciences and Reproductive and Odontostomatological Sciences, Federico II University, Naples, Italy
| | - Paolo Cappabianca
- Division of Neurosurgery, Department of Neurosciences and Reproductive and Odontostomatological Sciences, Federico II University, Naples, Italy -
| | - Luigi M Cavallo
- Division of Neurosurgery, Department of Neurosciences and Reproductive and Odontostomatological Sciences, Federico II University, Naples, Italy
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25
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Peto I, Abou-Al-Shaar H, White TG, Abunimer AM, Kwan K, Zavadskiy G, Wagner K, Black K, Eisenberg M, Bruni M, Dehdashti AR. Sources of residuals after endoscopic transsphenoidal surgery for large and giant pituitary adenomas. Acta Neurochir (Wien) 2020; 162:2341-2351. [PMID: 32700080 DOI: 10.1007/s00701-020-04497-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 07/14/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Giant and large pituitary adenomas (PA) constitute a specific subset of PAs, with gross total resection (GTR) rates frequently not exceeding 50%. Both an anatomical inaccessibility and an inadequate tumor visualization are thought to play a role. This study analyzes risk factors for postoperative residuals after endoscopic transsphenoidal pituitary surgery for large and giant pituitary adenomas. METHODS A retrospective analysis of patients with giant and large PA operated between 2015 and 2018 was performed. RESULTS Forty patients (13 females, 27 males) were included in the analysis (30 large and 10 giant PAs). The mean MRI follow-up time was 5.9 ± 6.54 months. Overall, GTR was achieved in 29 patients (72.5%), subtotal resection in 9 (22.5%), and the inconclusive result was in 2 (5%). Unexpected residuals represented 7 (77.7%) of all 9 residual tumors. The most frequent intraoperative factor associated with unexpected residual tumors was improper identification of residual tumor due to obstruction of view in 2 (28.5%) cases and inability to distinguish normal tissue from tumor in the other two (28.5%). Sub-analysis based on tumor size revealed that with large PAs, GTR was achieved in 25 (83.3%), STR in 4 (13.3%), and inconclusive in 1 (3.3%) patient. In patients with giant PAs, GTR was achieved in 4 (40%), STR in 5 (50%), and inconclusive in 1 (10%). Analysis of preoperative factors showed a significant association of residual tumors with larger suprasellar AP distance (p = 0.041), retrosellar extension (p = 0.007), and higher Zurich Score (p = 0.029). CONCLUSION Large and giant PAs are challenging lesions with high subtotal resection rates. Suprasellar AP distance, retrosellar extension, and higher Zurich Score seem to be significant predictors of degree of resection in these tumors. Improving the intraoperative ability to distinguish tumor from a normal tissue might further decrease the number of unexpected residuals.
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Affiliation(s)
- Ivo Peto
- Department of Neurosurgery, Hofstra Northwell School of Medicine, Manhasset, NY, 11030, USA.
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL, 33606, USA.
| | - Hussam Abou-Al-Shaar
- Department of Neurosurgery, Hofstra Northwell School of Medicine, Manhasset, NY, 11030, USA
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Timothy G White
- Department of Neurosurgery, Hofstra Northwell School of Medicine, Manhasset, NY, 11030, USA
| | - Abdullah M Abunimer
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kevin Kwan
- Department of Neurosurgery, Hofstra Northwell School of Medicine, Manhasset, NY, 11030, USA
| | | | - Katherine Wagner
- Department of Neurosurgery, Hofstra Northwell School of Medicine, Manhasset, NY, 11030, USA
| | - Karen Black
- Department of Neuroradiology, North Shore University Hospital, Hofstra Northwell School of Medicine, Manhasset, NY, USA
| | - Mark Eisenberg
- Department of Neurosurgery, Hofstra Northwell School of Medicine, Manhasset, NY, 11030, USA
| | - Margherita Bruni
- Department of Otolaryngology, New York Head & Neck Institute, New York, NY, USA
| | - Amir R Dehdashti
- Department of Neurosurgery, Hofstra Northwell School of Medicine, Manhasset, NY, 11030, USA.
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26
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Lee WJ, Cho KR, Choi JW, Kong DS, Seol HJ, Nam DH, Lee JI. Gamma Knife Radiosurgery as a Primary Treatment for Nonfunctioning Pituitary Adenoma Invading the Cavernous Sinus. Stereotact Funct Neurosurg 2020; 98:371-377. [PMID: 32937617 DOI: 10.1159/000508737] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 05/11/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Surgical resection of nonfunctioning pituitary adenoma (NFPA) invading the cavernous sinus (CS) remains a challenging and significant factor associated with incomplete resection. The residual tumor in CS is usually treated with adjuvant stereotactic radiosurgery (SRS), but there is little information concerning SRS as an initial treatment for CS-invading NFPA. In this study, we investigated the tumor control rate and clinical outcomes of the patients who received primary gamma knife radiosurgery (GKRS) for CS-invading NFPA. METHODS This was a single-institute retrospective analysis of 11 patients. CS invasion of tumor was categorized using the modified Knosp grading system. The median tumor volume and maximal diameter were 1.6 cm3 (range 0.4-6.5) and 17.2 mm (range 11.6-23.3), respectively. The median clinical follow-up period was 48.5 months (range 16.4-177.8). The median prescription dose at tumor margin was 15 Gy (range 11-25) and median prescription isodose was 50% (range 45-50). The maximum radiation dose to optic chiasm and optic nerve were 7.2 Gy (range 3.4-9.2) and 7.5 Gy (range 4.5-11.5), respectively. RESULTS Tumor control was achieved in all patients. The median tumor volume and maximal diameter at last follow-up were 0.4 cm3 (range 0.1-2.3) and 11.4 mm (range 4.7-19.5), respectively. The median volume reduction rate was 52% (range 33-88). Six patients showed downgrading of modified Knosp grade after GKRS. No patients developed GKRS-related complications such as hypopituitarism or visual disturbance. CONCLUSIONS SRS may be an alternative primary treatment option for CS-invading NFPA if there is no urgent and absolute indication for surgery such as optic apparatus compression.
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Affiliation(s)
- Won Jae Lee
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kyung-Rae Cho
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jung-Won Choi
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Doo-Sik Kong
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Ho Jun Seol
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Do-Hyun Nam
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jung-Il Lee
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea,
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27
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Li C, Zhu H, Zong X, Wang X, Gui S, Zhao P, Bai J, Liu C, Cao L, Li Z, Zhang Y. Experience of trans-nasal endoscopic surgery for pituitary tumors in a single center in China: Surgical results in a cohort of 2032 patients, operated between 2006 and 2018. Clin Neurol Neurosurg 2020; 197:106176. [PMID: 32905978 DOI: 10.1016/j.clineuro.2020.106176] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 07/06/2020] [Accepted: 08/20/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVES This study was conducted to investigate complications and outcome by endonasal endoscopic approach in our single center. PATIENTS AND METHODS The clinical data of 2032 pituitary adenoma surgeries performed in our ward between January 2006 and December 2018 were retrospectively reviewed. The GTR (gross total resection) rate, hormonal control, complications, and tumor recurrence rate were retrospectively analyzed. RESULTS There were 628 (83.5 %) preoperative headache patients, 513 (68.9 %) visual acuity and visual field impaired patients, 218 (66.4 %) endocrine symptom patients and 26 (53.1 %) SIADH (syndrome of inappropriate secretion of antidiuretic hormone) patients experienced improvement after surgery. GTR was achieved in 1627 patients (80.1 %) and NGTR (non-gross total resection) in 405 patients (19.9 %). Clinically variable analyses revealed a significant correlation between GTR and Knosp's grades, large tumor volume, bone-invasive and recurrent tumors. Postoperative complications mainly included 34 (1.7 %) CSF (cerebral spinal fluid) leak, 72 (3.5 %) pituitary insufficiency, 30 (1.5 %) meningitis, 20 (0.98 %) cranial nerve deficits, 5 (0.25 %) hematoma, 5 (0.25 %) patients with internal carotid artery injury, and other complications mainly included nasal complications occurred in 168 patients (8.6 %). Overall, there were 3 deaths (0.15 %) occurred in our series. Univariate analysis showed that larger tumors, invasion, bone invasive, recurrent tumors and NGTR were associated with tumor regrowth. Multivariate analysis showed that NGTR and invasion were independent risk factors for tumor regrowth. CONCLUSIONS NGTR and invasion were independent risk factors for tumor regrowth. Endoscopic surgery is an excellent choice for pituitary adenomas. It has the advantages of being minimally invasive, safe, and efficacious.
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Affiliation(s)
- Chuzhong Li
- Beijing Neurosurgical Institute, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China; Department of Neurosurgery, Beijing Tiantan Hospital Affiliated to Capital Medical University, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China; Beijing Institute for Brain Disorders Brain Tumor Center, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China; China National Clinical Research Center for Neurological Diseases, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
| | - Haibo Zhu
- Department of Neurosurgery, Beijing Tiantan Hospital Affiliated to Capital Medical University, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
| | - Xuyi Zong
- Department of Neurosurgery, Beijing Tiantan Hospital Affiliated to Capital Medical University, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
| | - Xinsheng Wang
- Department of Neurosurgery, Beijing Tiantan Hospital Affiliated to Capital Medical University, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
| | - Songbai Gui
- Department of Neurosurgery, Beijing Tiantan Hospital Affiliated to Capital Medical University, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
| | - Peng Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital Affiliated to Capital Medical University, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
| | - Jiwei Bai
- Department of Neurosurgery, Beijing Tiantan Hospital Affiliated to Capital Medical University, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
| | - Chunhui Liu
- Department of Neurosurgery, Beijing Tiantan Hospital Affiliated to Capital Medical University, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
| | - Lei Cao
- Department of Neurosurgery, Beijing Tiantan Hospital Affiliated to Capital Medical University, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
| | - Zhenye Li
- Department of Neurosurgery, Beijing Tiantan Hospital Affiliated to Capital Medical University, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
| | - Yazhuo Zhang
- Beijing Neurosurgical Institute, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China; Department of Neurosurgery, Beijing Tiantan Hospital Affiliated to Capital Medical University, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China; Beijing Institute for Brain Disorders Brain Tumor Center, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China; China National Clinical Research Center for Neurological Diseases, No.119, South Fourth Ring West Road, Fengtai District, Beijing, 100070, China.
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28
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Gómez-Amador JL, Martínez-Anda JJ, Guerrero-Suarez PD, Rosales-Amaya AM, Delgado-Arce JC, Guerrero-López DA. Endoscopic endonasal lateral transellar approach for growth hormone-secreting adenomas with cavernous sinus invasion: Technical note and surgical results. Neurocirugia (Astur) 2020; 32:S1130-1473(20)30081-6. [PMID: 32690399 DOI: 10.1016/j.neucir.2020.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 05/07/2020] [Accepted: 05/27/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Cavernous sinus (CS) invasion is found in 15-20% of pituitary adenomas; it represents a poor prognosis factor and a surgical challenge even in experienced pituitary centers. We present our experience and technical note description for surgical management of pituitary adenomas with CS invasion in acromegaly by the transsellar lateral approach with an endoscopic endonasal transsphenoidal route. METHOD prospective case series of patients who underwent endoscopic endonasal surgery for Growing Hormone (GH) producing adenomas with CS invasion treated at the Neurosurgery departments of National Institute of Neurology and Neurosurgery in Mexico City, and of Toluca Medical Center of Social Security Institute of the State of Mexico and Provinces between January 2014 and March 2019. RESULTS Thirty-two of 94 patients with diagnosis of pituitary adenoma treated at our institutions (34%) had acromegaly; thirteen of patients with acromegaly diagnosis met the inclusion criteria for CS invasion. Postoperative images reported gross total resection in 10 patients (76.9%). Mean follow-up time was 28.3 months. Remission criteria were achieved in nine patients (69.2%), with one of these patients (11.1%) having recurrence during follow up. All patients with no biochemical remission had improvement in GH and IGF profiles. Three patients without remission underwent radiosurgery (14Gy), and one patient had remission after the procedure. CONCLUSIONS We consider this to be a safe and efficient approach for tumors invading CS, when surgical team have good experience in endoscopy of the skull base and reconstruction techniques, appropriate instruments are available, and tumor has soft consistency.
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Affiliation(s)
- Juan Luis Gómez-Amador
- Department of Neurosurgery, National Institute of Neurology and Neurosurgery Manuel Velasco Suarez, Insurgentes Sur Av. 3877, Barrio La Fama, Postal Code 14269 Mexico City, Mexico
| | - Jaime Jesús Martínez-Anda
- Neurosurgery Department, Toluca Medical Center of Social Security Institute of the State of Mexico and Provinces Baja Velocidad, Av. 57.5km Mexico - Toluca Highway, Postal Code 52140 Metepec, State of Mexico, Mexico.
| | - Pablo David Guerrero-Suarez
- Neurosurgery Department, Toluca Medical Center of Social Security Institute of the State of Mexico and Provinces Baja Velocidad, Av. 57.5km Mexico - Toluca Highway, Postal Code 52140 Metepec, State of Mexico, Mexico
| | - Arturo Miguel Rosales-Amaya
- Neurosurgery Department, Toluca Medical Center of Social Security Institute of the State of Mexico and Provinces Baja Velocidad, Av. 57.5km Mexico - Toluca Highway, Postal Code 52140 Metepec, State of Mexico, Mexico
| | - Julio Cesar Delgado-Arce
- Neurosurgery Department, Toluca Medical Center of Social Security Institute of the State of Mexico and Provinces Baja Velocidad, Av. 57.5km Mexico - Toluca Highway, Postal Code 52140 Metepec, State of Mexico, Mexico
| | - David Antonio Guerrero-López
- Neurosurgery Department, Toluca Medical Center of Social Security Institute of the State of Mexico and Provinces Baja Velocidad, Av. 57.5km Mexico - Toluca Highway, Postal Code 52140 Metepec, State of Mexico, Mexico
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29
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Transsphenoidal resection for pituitary adenoma in elderly versus younger patients: a systematic review and meta-analysis. Acta Neurochir (Wien) 2020; 162:1297-1308. [PMID: 32221730 DOI: 10.1007/s00701-020-04300-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 03/19/2020] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Pituitary adenomas (PA) are common intracranial tumors. In the context of the aging of the population, the question is whether postsurgical outcomes are comparable to the younger ones. The primary objective of the present study was to review published resection and recurrence rates after transsphenoidal resection. The secondary aim was to evaluate visual improvement and complication rates. METHODS The authors searched PubMed and Medline databases, of published English series, with no time frame limit, evaluating outcomes of transsphenoidal resection in populations aged more or less than 65, 70, and 80 years. We performed a systematic review and meta-analysis. RESULTS Median overall resection rates for younger population was 70.7% (range 54-76.8) and for elderly one was 65.7% (range 16.6-78.2) (two-sample t test, p = 0.35). The only statistically significant difference for gross total resection rates (GTR) favored patients aged less than 80 (p = 0.01). There was no statistically significant difference among recurrence rates. There was a statistically significant difference for visual improvement favoring patients aged more than 80 (p = 0.03). For the age groups of less versus more than 70, there was a statistically significant difference for overall complication rate favoring younger groups (p < 0.05). CONCLUSION Present data shows GTR rates favoring younger patients. Recurrence rates remain similar over the mean follow-up period. Moreover, visual improvement favors patients aged more than 80. Overall complication rates favor patients younger than 70, which might be also related to additional comorbidities, frequently present in seniors. Transsphenoidal surgery is safe and effective even for older patients.
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Younus I, Gerges MM, Dobri GA, Ramakrishna R, Schwartz TH. Readmission after endoscopic transsphenoidal pituitary surgery: analysis of 584 consecutive cases. J Neurosurg 2019; 133:1242-1247. [PMID: 31561225 DOI: 10.3171/2019.7.jns191558] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 07/01/2019] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Hospital readmission is a key component in value-based healthcare models but there are limited data about the 30-day readmission rate after endonasal endoscopic transsphenoidal surgery (EETS) for pituitary adenoma. The objective of this study was to determine the incidence and identify factors associated with 30-day readmission after EETS for pituitary adenoma. METHODS The authors analyzed a prospectively acquired database of patients who underwent EETS for pituitary adenoma from 2005 to 2018 at NewYork-Presbyterian Hospital, Weill Cornell Medicine. Clinical, socioeconomic, and radiographic data were reviewed for cases of unplanned readmission within 30 days of surgery and, as a control group, for all other patients in the series who were not readmitted. Statistical significance was determined with an alpha < 0.05 using Pearson's chi-square and Fisher's exact tests for categorical variables and the independent-samples t-test for continuous variables. RESULTS Of 584 patients undergoing EETS for pituitary adenoma, 27 (4.6%) had unplanned readmission within 30 days. Most readmissions occurred within the first week after surgery, with a mean time to readmission of 6.6 ± 3.9 days. The majority of readmissions (59%) were for hyponatremia. These patients had a mean sodium level of 120.6 ± 4.6 mEq/L at presentation. Other causes of readmission were epistaxis (11%), spinal headache (11%), sellar hematoma (7.4%), CSF leak (3.7%), nonspecific headache (3.7%), and pulmonary embolism (3.7%). The postoperative length of stay was significantly shorter for patients who were readmitted than for the controls (2.7 ± 1.0 days vs 3.9 ± 3.2 days; p < 0.05). Patients readmitted for hyponatremia had an initial length of stay of 2.6 ± 0.9 days, the shortest of any cause for readmission. The mean BMI was significantly lower for readmitted patients than for the controls (26.4 ± 3.9 kg/m2 vs 29.3 ± 6.1 kg/m2; p < 0.05). CONCLUSIONS Readmission after EETS for pituitary adenoma is a relatively rare phenomenon, with delayed hyponatremia being the primary cause. The study results demonstrate that shorter postoperative length of stay and lower BMI were associated with 30-day readmission.
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Affiliation(s)
| | - Mina M Gerges
- Departments of2Neurosurgery
- 6Department of Neurosurgery, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Georgiana A Dobri
- Departments of2Neurosurgery
- 4Neuroscience, and
- 5Endocrinology, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York; and
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Cohen-Cohen S, Gardner PA, Alves-Belo JT, Truong HQ, Snyderman CH, Wang EW, Fernandez-Miranda JC. The medial wall of the cavernous sinus. Part 2: Selective medial wall resection in 50 pituitary adenoma patients. J Neurosurg 2019; 131:131-140. [PMID: 30192191 DOI: 10.3171/2018.5.jns18595] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 05/02/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Pituitary adenomas often invade the medial wall of the cavernous sinus (CS), but this structure is generally not surgically removed because of the risk of vascular and cranial nerve injury. The purpose of this study was to report the surgical outcomes in a large series of cases of invasive pituitary adenoma in which the medial wall of the CS was selectively removed following an anatomically based, stepwise surgical technique. METHODS The authors' institutional database was reviewed to identify cases of pituitary adenoma with isolated invasion of the medial wall, based on an intraoperative evaluation, in which patients underwent an endoscopic endonasal approach with selective resection of the medial wall of the CS. Cases with CS invasion beyond the medial wall were excluded. Patient complications, resection, and remission rates were assessed. RESULTS Fifty patients were eligible for this study, 15 (30%) with nonfunctional adenomas and 35 (70%) with functional adenomas, including 16 growth hormone-, 10 prolactin-, and 9 adrenocorticotropic hormone (ACTH)-secreting tumors. The average tumor size was 2.3 cm for nonfunctional and 1.3 cm for functional adenomas. Radiographically, 11 cases (22%) were Knosp grade 1, 23 (46%) Knosp grade 2, and 16 (32%) Knosp grade 3. Complete tumor resection, based on intraoperative impression and postoperative MRI, was achieved in all cases. The mean follow-up was 30 months (range 4-64 months) for patients with functional adenomas and 16 months (range 4-30 months) for those with nonfunctional adenomas. At last follow-up, complete biochemical remission (using current criteria) without adjuvant treatment was seen in 34 cases (97%) of functional adenoma. No imaging recurrences were seen in patients who had nonfunctional adenomas. A total of 57 medial walls were removed in 50 patients. Medial wall invasion was histologically confirmed in 93% of nonfunctional adenomas and 83% of functional adenomas. There were no deaths or internal carotid artery injuries, and the average blood loss was 378 ml. Four patients (8%) developed a new, transient cranial nerve palsy, and 2 of these patients required reoperation for blood clot evacuation and fat graft removal. There were no permanent cranial nerve palsies. CONCLUSIONS The medial wall of the CS can be removed safely and effectively, with minimal morbidity and excellent resection and remission rates. Further follow-up is needed to determine the long-term results of this anatomically based technique, which should only be performed by very experienced endonasal skull base teams.
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Affiliation(s)
- Salomon Cohen-Cohen
- Departments of1Neurological Surgery and.,3Department of Neurological Surgery, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | | | | | | | - Carl H Snyderman
- 2Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and
| | - Eric W Wang
- 2Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and
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Micko A, Oberndorfer J, Weninger WJ, Vila G, Höftberger R, Wolfsberger S, Knosp E. Challenging Knosp high-grade pituitary adenomas. J Neurosurg 2019; 132:1739-1746. [PMID: 31151112 DOI: 10.3171/2019.3.jns19367] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 03/04/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Parasellar growth is one of the most important prognostic variables of pituitary adenoma surgery, with adenomas regarded as not completely resectable if they invade the cavernous sinus (CS) but potentially curable if they displace CS structures. This study was conducted to correlate surgical treatment options and outcomes to the different biological behaviors (invasion vs displacement) of adenomas with parasellar extension into the superior or inferior CS compartments or completely encasing the carotid artery (Knosp high grades 3A, 3B, and 4). METHODS This was a retrospective cohort analysis of 106 consecutive patients with Knosp high-grade pituitary adenomas with parasellar extension who underwent surgery via a primary endoscopic transsphenoidal approach between 2003 and 2017. Biological tumor characteristics (surgical status of invasiveness and tumor texture, 2017 WHO classification, proliferation rate), extent of resection, and complication rate were correlated with parasellar extension grades 3A, 3B, and 4 on preoperative MRI studies. RESULTS Invasiveness was significantly less common in grade 3A (44%) than in grade 3B (72%, p = 0.037) and grade 4 (100%, p < 0.001) adenomas. Fibrous tumor texture was significantly more common in grade 4 (52%) compared to grade 3A (20%, p = 0.002), but not compared to grade 3B (28%) adenomas. Functioning macroadenomas had a significantly higher rate of invasiveness than nonfunctioning adenomas (91% vs 55%, p = 0.002). Mean proliferation rate assessed by MIB-1 was > 3% in all groups but without significant difference between the groups (grade 3A, 3.2%; 3B, 3.9%; 4, 3.7%). Rates of endocrine remission/gross-total resection were significantly higher in grade 3A (64%) than in grade 3B (33%, p = 0.021) and grade 4 (0%, p < 0.001) adenomas. In terms of complication rates, no significant difference was observed between grades. CONCLUSIONS According to the authors' data, the biological behavior of pituitary adenomas varies significantly between parasellar extension patterns. Adenomas with extension into the superior CS compartment have a lower rate of invasive growth than adenomas extending into the inferior CS compartment or encasing the carotid artery. Consequently, a significantly higher rate of remission can be achieved in grade 3A than in grade 3B and grade 4 adenomas. Therefore, the distinction into grades 3A, 3B, and 4 is of importance for prediction of adenoma invasion and surgical treatment considerations.
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Affiliation(s)
| | | | | | - Greisa Vila
- 3Department of Internal Medicine III, Clinical Division of Endocrinology and Metabolism, and
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Lamos EM, Munir KM. Cushing disease: highlighting the importance of early diagnosis for both de novo and recurrent disease in light of evolving treatment patterns. Endocr Pract 2019; 20:945-55. [PMID: 25100372 DOI: 10.4158/ep14068.ra] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To highlight and summarize current literature on Cushing disease (CD)-related morbidity and mortality, focusing on residual complications after "cure" and the changing role of pharmacologic therapy in CD. METHODS Current journal articles on the consequences of untreated or undertreated CD, CD recurrence, and recent trends in CD treatment were collected from PubMed searches and analyzed in combination in view of the authors' clinical experience. RESULTS Timely recognition and treatment of de novo and recurrent CD remains a singular clinical challenge. Chronic excess cortisol exposure leads to potentially irreversible sequelae and death, stressing the importance of early diagnosis and treatment. Disease relapse after primary pituitary adenomectomy is prevalent and recurrence may manifest decades after initial surgery. Increased risk for mortality and hypercortisolism-related complications in postsurgical CD patients may indicate persistent subclinical disease and further underscores the need for cautious, ongoing observation and testing. Potential long-term pharmacologic treatment options (e.g., pasireotide, mifepristone) have recently emerged that may provide biochemical and symptomatic remission for those with refractory CD, or those for whom surgery is contraindicated. CONCLUSION Delays in CD diagnosis, management, and follow-up are common and lead to increased adverse metabolic complications and mortality. Rapid recognition and treatment as well as vigilant monitoring are therefore essential. After surgical treatment, some patients may suffer from persistent subclinical CD that remains difficult to detect with routine testing. Although long-term pharmacologic treatment has historically been limited by adverse reactions or escape from response, new treatments may offer more options for patients with refractory disease.
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Affiliation(s)
- Elizabeth M Lamos
- Division of Endocrinology, Diabetes, and Nutrition, University of Maryland School of Medicine, Baltimore, Maryland
| | - Kashif M Munir
- Division of Endocrinology, Diabetes, and Nutrition, University of Maryland School of Medicine, Baltimore, Maryland
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Serra C, Staartjes VE, Maldaner N, Muscas G, Akeret K, Holzmann D, Soyka MB, Schmid C, Regli L. Predicting extent of resection in transsphenoidal surgery for pituitary adenoma. Acta Neurochir (Wien) 2018; 160:2255-2262. [PMID: 30267209 DOI: 10.1007/s00701-018-3690-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 09/21/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND The extent of resection (EOR) is a crucial outcome parameter in transsphenoidal pituitary surgery (TSS), and is linked to endocrinological outcome, postoperative morbidity, and mortality. We aimed to build a robust, quantitative, and easily reproducible imaging score able to predict EOR in TSS. METHODS The ratio (R) between the maximum horizontal adenoma diameter and intercarotid distance at the horizontal C4 segment was used to stratify our patient series in four classes: class I R ≤ 0.75, class II 0.75 < R ≤ 1.25, and class III R ≥ 1.25. Class IV included adenomas which completely encased the internal carotid artery. The resulting score was internally validated for robustness. RESULTS One hundred sixteen patients were included in the study, of which 96 (83%) for derivation and 20 (17%) for validation. EOR showed significant differences between grades (grade I, 100%; II, 97.9%; III, 94.2%; IV, 87.2%; all P < 0.05). The same applied to residual volume (RV) (grade I, 0 cm3; II, 0.08 cm3; III, 1.11 cm3; IV, 1.63 cm3; all P < 0.05). Differences in gross total resection (GTR) were statistically significant among classes I, II, and III (P < 0.05). The incidence of residual adenoma in the cavernous sinus increased also constantly from grade I up to grade IV although a significant difference was only found between grades III and II (P = 0.004). The score performed equally well in the validation cohort. Inter-observer agreement was high, with intraclass correlation coefficients > 0.89 for measurement of both the horizontal tumor diameter and the ICD among two independent raters (P < 0.001). CONCLUSIONS The proposed score is a simple and reproducible tool which reliably predicts surgical outcome including EOR, RV, and GTR of pituitary adenoma patients undergoing TSS.
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Affiliation(s)
- Carlo Serra
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland.
| | - Victor E Staartjes
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Nicolai Maldaner
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Giovanni Muscas
- Department of Neurosurgery, Tuscany School of Neurosurgery, University of Firenze, Florence, Italy
| | - Kevin Akeret
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - David Holzmann
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Michael B Soyka
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Christoph Schmid
- Department of Endocrinology and Diabetes, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Luca Regli
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
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Toda M, Kosugi K, Ozawa H, Ogawa K, Yoshida K. Surgical Treatment of Cavernous Sinus Lesion in Patients with Nonfunctioning Pituitary Adenomas via the Endoscopic Endonasal Approach. J Neurol Surg B Skull Base 2018; 79:S311-S315. [PMID: 30210983 DOI: 10.1055/s-0038-1667123] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 06/10/2018] [Indexed: 10/28/2022] Open
Abstract
Objective The main purpose of this article is to assess the effectiveness and safety of surgery via the endoscopic endonasal approach (EEA) for cavernous sinus (CS) lesion in patients with nonfunctioning pituitary adenomas (NFPA). Design Retrospective study. Setting Keio University Hospital. Participants Thirty patients who underwent CS surgery via the EEA between 2009 and 2017 for Knosp grade 4 NFPA with pre- and postoperative magnetic resonance imaging available for volumetric analysis. Main Outcome Measures Clinical presentation, extent of resection, and surgical complications. Results Gross total and near total resection of CS tumors was achieved in 12/30 (40%) cases of Knosp grade 4 NFPA. The average resection rate of CS lesions in these 30 patients was 73.5%; 77.3% in primary cases and 70.1% in recurrent cases that did not vary significantly. Preoperative visual disturbance and oculomotor nerve palsy improved in 12/19 (63.1%) and ⅗ (60%) cases, respectively. Complications associated with CS via the EEA were postoperative cerebrospinal leakage (1/30, 3.3%), meningitis (1/30, 3.3%), and transient cranial nerve palsy (2/30, 6.7%). These complications except a case of mild transient abducens nerve palsy occurred in recurrent cases with subdural lesions. Conclusions Although the optimal management of CS lesions in NFPA is controversial, debulking via the EEA is an effective and safe option that improves neurological symptoms and enables effective adjuvant radiotherapy. Recurrent cases with subdural invasion are technically challenging, even using the EEA, and special care is required to avoid complications.
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Affiliation(s)
- Masahiro Toda
- Department of Neurosurgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Kenzo Kosugi
- Department of Neurosurgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Hiroyuki Ozawa
- Department of Otorhinolaryngology, Head and Neck Surgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Kaoru Ogawa
- Department of Otorhinolaryngology, Head and Neck Surgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Kazunari Yoshida
- Department of Neurosurgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
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Zhu H, Guo J, Shen Y, Dong W, Gao H, Miao Y, Li C, Zhang Y. Functions and Mechanisms of Tumor Necrosis Factor-α and Noncoding RNAs in Bone-Invasive Pituitary Adenomas. Clin Cancer Res 2018; 24:5757-5766. [DOI: 10.1158/1078-0432.ccr-18-0472] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Revised: 05/07/2018] [Accepted: 07/02/2018] [Indexed: 11/16/2022]
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Kawasaki T, Kurosaki Y, Fukuda H, Kinosada M, Ishibashi R, Handa A, Chin M, Yamagata S. Flexible endoscopically assisted evacuation of acute and subacute subdural hematoma through a small craniotomy: preliminary results. Acta Neurochir (Wien) 2018; 160:241-248. [PMID: 29192373 DOI: 10.1007/s00701-017-3399-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 11/13/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND The first choice to treat acute subdural hematoma (SDH) is a large craniotomy under general anesthesia. However, increasing age or comorbid burden of the patients may render invasive treatment strategy inappropriate. These medically frail patients with SDH may benefit from a combination of small craniotomy and endoscopic hematoma removal, which is less invasive and even available under local anesthesia. Although hematoma evacuation with a rigid endoscope for acute or subacute SDHs has been reported in the literature, use of a flexible endoscope may have distinct advantages. In this article, we attempted to clarify the utility of small craniotomy evacuation with a flexible endoscope for acute and subacute SDH in the elderly patients. METHOD Between November 2013 and September 2016, a total of 17 patients with acute SDH (15 patients), subacute SDH (1 patient), or acute aggravation of chronic SDH (1 patient) underwent hematoma evacuation with a flexible endoscope at our hospital and were enrolled in this retrospective study. Either under local or general anesthesia, the SDH was removed with a flexible suction tube with the aid of the flexible endoscope through the small craniotomy (3 × 4 cm). Hematoma evacuation rate, improvement of clinical symptoms, and procedure-related complications were evaluated. RESULTS Hematoma evacuation rate was satisfactory, and statistically significant clinical improvement was observed in postoperative Glasgow Coma Scale in all cases compared to the preoperative assessment. No procedure-related hemorrhagic complications were observed. CONCLUSIONS The results reported here suggest that small craniotomy evacuation with a flexible endoscope is a safe, effective, and minimally invasive treatment for acute and subacute SDH in selected cases.
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Fernandez-Miranda JC, Zwagerman NT, Abhinav K, Lieber S, Wang EW, Snyderman CH, Gardner PA. Cavernous sinus compartments from the endoscopic endonasal approach: anatomical considerations and surgical relevance to adenoma surgery. J Neurosurg 2017; 129:430-441. [PMID: 28862552 DOI: 10.3171/2017.2.jns162214] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Tumors with cavernous sinus (CS) invasion represent a neurosurgical challenge. Increasing application of the endoscopic endonasal approach (EEA) requires a thorough understanding of the CS anatomy from an endonasal perspective. In this study, the authors aimed to develop a surgical anatomy-based classification of the CS and establish its utility for preoperative surgical planning and intraoperative guidance in adenoma surgery. METHODS Twenty-five colored silicon-injected human head specimens were used for endonasal and transcranial dissections of the CS. Pre- and postoperative MRI studies of 98 patients with pituitary adenoma with intraoperatively confirmed CS invasion were analyzed. RESULTS Four CS compartments are described based on their spatial relationship with the cavernous ICA: superior, posterior, inferior, and lateral. Each compartment has distinct boundaries and dural and neurovascular relationships: the superior compartment relates to the interclinoidal ligament and oculomotor nerve, the posterior compartment bears the gulfar segment of the abducens nerve and inferior hypophyseal artery, the inferior compartment contains the sympathetic nerve and distal cavernous abducens nerve, and the lateral compartment includes all cavernous cranial nerves and the inferolateral arterial trunk. Twenty-nine patients had a single compartment invaded, and 69 had multiple compartments involved. The most commonly invaded compartment was the superior (79 patients), followed by the posterior (n = 64), inferior (n = 45), and lateral (n = 23) compartments. Residual tumor rates by compartment were 79% in lateral, 17% in posterior, 14% in superior, and 11% in inferior. CONCLUSIONS The anatomy-based classification presented here complements current imaging-based classifications and may help to identify involved compartments both preoperatively and intraoperatively.
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Affiliation(s)
| | - Nathan T Zwagerman
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center; and
| | - Kumar Abhinav
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center; and
| | - Stefan Lieber
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center; and
| | - Eric W Wang
- 2Department of Otolaryngology, University of Pittsburgh, Pennsylvania
| | - Carl H Snyderman
- 2Department of Otolaryngology, University of Pittsburgh, Pennsylvania
| | - Paul A Gardner
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center; and
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Kuan EC, Yoo F, Patel PB, Su BM, Bergsneider M, Wang MB. An Algorithm for Sellar Reconstruction Following the Endoscopic Endonasal Approach: A Review of 300 Consecutive Cases. J Neurol Surg B Skull Base 2017; 79:177-183. [PMID: 29868324 DOI: 10.1055/s-0037-1606293] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Accepted: 07/15/2017] [Indexed: 12/17/2022] Open
Abstract
Objectives/Hypotheses The endoscopic endonasal approach (EEA) is the workhorse endoscopic procedure for sellar and parasellar pathology. Various reconstruction techniques have been reported following EEA surgery, ranging from no reconstruction to vascularized flaps. We review our institution's experience with sellar reconstruction following EEA and propose an evidence-based algorithm. Design Retrospective review. Setting Tertiary academic medical center. Participants Patients who underwent endoscopic EEA surgery for sellar or parasellar pathology between March 1, 2013 and August 31, 2016. Main Outcome Measures Patient demographic and clinicopathologic data were collected. Outcome measures included intraoperative and postoperative cerebrospinal fluid (CSF) leak rates and extent of resection (gross or subtotal). Results Three hundred consecutive patients were included. Depending on the presence and grade of intraoperative CSF leak, cases were reconstructed using either a free mucosal graft (FMG) or nasoseptal flap (NSF). Intraoperative and postoperative CSF leak rates were 30.7% and 2.3%, respectively. Multivariable logistic regression found that intraoperative CSF leak was associated with recurrent disease (odds ratio [OR] 2.47, p = 0.004), with no apparent predictors of postoperative CSF leak. Conclusions Based on this large series, we propose the following algorithm for sellar reconstruction: FMG for no CSF leak; fat graft + FMG ± rigid fixation for low-grade leaks; and fat graft + NSF ± rigid fixation for high-grade leaks.
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Affiliation(s)
- Edward C Kuan
- Department of Head and Neck Surgery, David Geffen School of Medicine at the University of California, Los Angeles (UCLA) Medical Center, Los Angeles, California, United States
| | - Frederick Yoo
- Department of Head and Neck Surgery, David Geffen School of Medicine at the University of California, Los Angeles (UCLA) Medical Center, Los Angeles, California, United States
| | - Pratik B Patel
- Department of Head and Neck Surgery, David Geffen School of Medicine at the University of California, Los Angeles (UCLA) Medical Center, Los Angeles, California, United States
| | - Brooke M Su
- Department of Head and Neck Surgery, David Geffen School of Medicine at the University of California, Los Angeles (UCLA) Medical Center, Los Angeles, California, United States
| | - Marvin Bergsneider
- Department of Neurosurgery, David Geffen School of Medicine at the University of California, Los Angeles (UCLA) Medical Center, Los Angeles, California, United States
| | - Marilene B Wang
- Department of Head and Neck Surgery, David Geffen School of Medicine at the University of California, Los Angeles (UCLA) Medical Center, Los Angeles, California, United States
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Negm HM, Al-Mahfoudh R, Pai M, Singh H, Cohen S, Dhandapani S, Anand VK, Schwartz TH. Reoperative endoscopic endonasal surgery for residual or recurrent pituitary adenomas. J Neurosurg 2017; 127:397-408. [DOI: 10.3171/2016.8.jns152709] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVERegrowth of the lesion after surgical removal of pituitary adenomas is uncommon unless subtotal resection was originally achieved in the first surgery. Treatment for recurrent tumor can involve surgery or radiotherapy. Locations of residual tumor may vary based on the original approach. The authors evaluated the specific sites of residual or recurrent tumor after different transsphenoidal approaches and describe the surgical outcome of endoscopic endonasal transsphenoidal reoperation.METHODSThe authors analyzed a prospectively collected database of a consecutive series of patients who had undergone endoscopic endonasal surgeries for residual or recurrent pituitary adenomas after an original transsphenoidal microscopic or endoscopic surgery. The site of the recurrent tumor and outcome after reoperation were noted and correlated with the primary surgical approach. The chi-square or Fisher exact test was used to compare categorical variables, and the Mann-Whitney U-test was used to compare continuous variables between surgical groups.RESULTSForty-one patients underwent surgery for residual/recurrent pituitary adenoma from 2004 to 2015 at Weill Cornell Medical College. The previous treatment was a transsphenoidal microscopic (n = 22) and endoscopic endonasal (n = 19) surgery. In 83.3% patients (n = 30/36) there was postoperative residual tumor after the initial surgery. A residual tumor following endonasal endoscopic surgery was less common in the sphenoid sinus (10.5%; 2/19) than it was after microscopic transsphenoidal surgery (72.7%; n =16/22; p = 0.004). Gross-total resection (GTR) was achieved in 58.5%, and either GTR or near-total resection was achieved in 92.7%. Across all cases, the average extent of resection was 93.7%. The rate of GTR was lower in patients with Knosp-Steiner Grade 3–4 invasion (p < 0.0005). Postoperative CSF leak was seen in only one case (2.4%), which stopped with lumbar drainage. Visual fields improved in 52.9% (n = 9/17) of patients and were stable in 47% (n = 8/17). Endocrine remission was achieved in 77.8% (n = 14/18) of cases, 12 by surgery alone and 2 by adjuvant medical (n = 1) and radiation (n = 1) therapy. New diabetes insipidus occurred in 4.9% (n = 2/41) of patients—in one of whom an additional single anterior hormonal axis was compromised—and 9.7% (n = 4/41) of patients had a new anterior pituitary hormonal insufficiency.CONCLUSIONSEndonasal endoscopic reoperation is extremely effective at removing recurrent or residual pituitary adenomas that remain after a prior surgery, and it may be preferable to radiation therapy particularly in symptomatic patients. Achievement of GTR is less common when lateral cavernous sinus invasion is present. The locations of residual/recurrent tumor were more likely sphenoidal and parasellar following a prior microscopic transsphenoidal surgery and sellar following a prior endonasal endoscopic surgery.
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Affiliation(s)
- Hazem M. Negm
- Departments of 1Neurological Surgery,
- 4Department of Neurosurgery, Menoufia University, Menoufia, Egypt
| | - Rafid Al-Mahfoudh
- Departments of 1Neurological Surgery,
- 5South East Neurosurgery and Spinal Surgery, Brighton and Sussex University Hospitals NHS Trust, East Sussex, United Kingdom
| | - Manish Pai
- Departments of 1Neurological Surgery,
- 6Tata Main Hospital, Jamshedpur, India
| | - Harminder Singh
- Departments of 1Neurological Surgery,
- 9Stanford University School of Medicine, Stanford, California
| | - Salomon Cohen
- Departments of 1Neurological Surgery,
- 7Department of Neurosurgery, National Institute of Neurology and Neurosurgery, “Manuel Velasco Suarez,” Mexico City, Mexico
| | - Sivashanmugam Dhandapani
- Departments of 1Neurological Surgery,
- 8Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India; and
| | | | - Theodore H. Schwartz
- Departments of 1Neurological Surgery,
- 2Otolaryngology, and
- 3Neuroscience, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York
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Koutourousiou M, Vaz Guimaraes Filho F, Fernandez-Miranda JC, Wang EW, Stefko ST, Snyderman CH, Gardner PA. Endoscopic Endonasal Surgery for Tumors of the Cavernous Sinus: A Series of 234 Patients. World Neurosurg 2017; 103:713-732. [PMID: 28450229 DOI: 10.1016/j.wneu.2017.04.096] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 04/13/2017] [Accepted: 04/15/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Cavernous sinus (CS) tumors often are considered inoperable. We present our experience with endoscopic endonasal surgery (EES) and compare the outcomes for different tumor. METHODS EES (medial or lateral approach) was used in 234 patients with CS tumors. The cohort included 175 (75%) pituitary adenomas and 59 (25%) nonadenomatous lesions. RESULTS Presenting symptoms were significantly different between the 2 groups, with cranial neuropathies occurring mainly in nonadenomas (P < 0.0001). The overall gross total tumor resection rate from the CS was 37.3% (37.1% in adenomas, 38.1% in non-adenomas). In total, preexisting cranial nerve (CN) dysfunction improved in 56.4% of the patients. After treatment completion (including radiation of residual tumor), 83.3% of acromegalic patients, 50% of prolactinomas and 33.3% of Cushing's disease, were in remission. Visual loss improved in 86.8% of adenomas and in 70.8% of nonadenomas. Intracavernous CN palsies improved in 77.3% of adenomas and 42.4% of nonadenomas. New permanent CN palsies occurred in 7 nonadenomas, which is significantly greater than in adenomas (P = 0.007). The leak rate of cerebrospinal fluid was 6.3% for adenomas and 11.9% for nonadenomas. Four patients suffered an internal carotid artery injury with no neurologic sequelae in 3 cases and 1 death (0.4%). CONCLUSIONS EES provides an easily accessible midline corridor to the CS with equivalent or superior results to transcranial approaches in the management of select tumors. Symptomatology due to CS invasion is more likely to improve in pituitary adenomas and the rate of surgical complications is greater in nonadenomas. Using a team approach, the overall mortality due to vascular injury is low.
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Affiliation(s)
- Maria Koutourousiou
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA; Department of Neurological Surgery, University of Louisville, Louisville, Kentucky, USA
| | | | - Juan C Fernandez-Miranda
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Eric W Wang
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Susan Tonya Stefko
- Department of Ophthalmology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Carl H Snyderman
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Paul A Gardner
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
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42
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Esquenazi Y, Essayed WI, Singh H, Mauer E, Ahmed M, Christos PJ, Schwartz TH. Endoscopic Endonasal Versus Microscopic Transsphenoidal Surgery for Recurrent and/or Residual Pituitary Adenomas. World Neurosurg 2017; 101:186-195. [PMID: 28185971 DOI: 10.1016/j.wneu.2017.01.110] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 01/22/2017] [Accepted: 01/26/2017] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Surgery for recurrent/residual pituitary adenomas is increasingly being performed through endoscopic surgery. Whether this new technology has altered the indications and outcomes of surgery is unknown. We conducted a systematic review and meta-analysis of published studies to compare the indications and outcomes between microscopic and endoscopic approaches. METHODS A PubMed search was conducted (1985-2015) to identify surgical series of endoscopic endonasal and microscopic transsphenoidal resection of residual or recurrent pituitary adenomas. Data were extracted regarding tumor characteristics, surgical treatment, extent of resection, endocrine remission, visual outcome, and complications. RESULTS Twenty-one studies met inclusion criteria. A total of 292 patients were in the endoscopic group, and 648 patients were in the microscopic group. Endoscopic cases were more likely nonfunctional (P < 0.001) macroadenomas (P < 0.001) with higher rates of cavernous sinus invasion (P = 0.012). The pooled rate of gross total tumor resection was 53.5% for the endoscopic group and 46.6% for the microscopic group. Endocrine remission was achieved in 53.0% and 46.7% of patients, and visual improvement occurred in 73.2% and 49.6% for the endoscopic and microscopic groups. Cerebrospinal fluid leak and pituitary insufficiency were higher in the endoscopic group. CONCLUSION This meta-analysis indicates that the use of the endoscope to reoperate on residual or recurrent adenomas has only led to modest increases in resection rates. However, larger more complex cases are being tackled, so direct comparisons are misleading. The most dramatic change has been in visual improvement along with modest increases in risk. Reoperation for recurrent or residual adenomas is a safe and effective treatment option.
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Affiliation(s)
- Yoshua Esquenazi
- Vivian L. Smith Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA.
| | - Walid I Essayed
- Department of Neurosurgery, Weill Cornell Medical College, Cornell University, New York-Presbyterian Hospital, New York, New York, USA
| | - Harminder Singh
- Department of Neurosurgery, Weill Cornell Medical College, Cornell University, New York-Presbyterian Hospital, New York, New York, USA; Department of Neurological Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Elizabeth Mauer
- Healthcare Policy and Research, Division of Biostatistics and Epidemiology, Weill Cornell Medical College, New York, New York, USA
| | - Mudassir Ahmed
- Department of Neurosurgery, Weill Cornell Medical College, Cornell University, New York-Presbyterian Hospital, New York, New York, USA
| | - Paul J Christos
- Department of Neurological Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Theodore H Schwartz
- Department of Neurosurgery, Weill Cornell Medical College, Cornell University, New York-Presbyterian Hospital, New York, New York, USA; Department of Otolaryngology, Weill Cornell Medical College, Cornell University, New York-Presbyterian Hospital, New York, New York, USA; Department of Neuroscience, Weill Cornell Medical College, Cornell University, New York-Presbyterian Hospital, New York, New York, USA
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43
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Ajlan A, Achrol AS, Albakr A, Feroze AH, Westbroek EM, Hwang P, Harsh GR. Cavernous Sinus Involvement by Pituitary Adenomas: Clinical Implications and Outcomes of Endoscopic Endonasal Resection. J Neurol Surg B Skull Base 2017; 78:273-282. [PMID: 28603683 DOI: 10.1055/s-0036-1598022] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 11/30/2016] [Indexed: 10/20/2022] Open
Abstract
Background Parasellar invasion of pituitary adenomas (PAs) into the cavernous sinus (CS) is common. The management of the CS component of PA remains controversial. Objective The objective of this study was to analyze CS involvement in PA treated with endoscopic endonasal approaches, including incidence, surgical risks, surgical strategies, long-term outcomes, and our treatment algorithm. Methods We reviewed a series of 176 surgically treated PA with particular attention to CS involvement and whether the CS tumor was approached medial or lateral to the internal carotid artery. Results The median duration of follow-up was 36 months. Macroadenomas and nonfunctional adenomas represented 77 and 60% of cases, respectively. CS invasion was documented in 23% of cases. CS involvement was associated with a significantly diminished odds of gross total resection (47 vs. 86%, odds ratio [OR]: 5.2) and increased the need for subsequent intervention (4 vs. 40%, OR: 14.4). Hormonal remission was achieved in 15% of hormonally active tumors. Rates of surgical complication were similar regardless of CS involvement. Conclusion Our tailored strategy beginning with a medial approach and adding lateral exposure as needed resulted in good outcomes with low morbidity in nonfunctional adenomas. Functional adenomas involving the CS were associated with low rates of hormonal remission necessitating higher rates of additional treatment.
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Affiliation(s)
- Abdulrazag Ajlan
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, United States.,Department of Neurosurgery, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Achal S Achrol
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, United States
| | - Abdulrahman Albakr
- Department of Neurosurgery, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Abdullah H Feroze
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, United States
| | - Erick M Westbroek
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Peter Hwang
- Department of Otolaryngology, Stanford University School of Medicine, California, United States
| | - Griffith R Harsh
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, United States
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44
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Dhandapani S, Singh H, Negm HM, Cohen S, Anand VK, Schwartz TH. Cavernous Sinus Invasion in Pituitary Adenomas: Systematic Review and Pooled Data Meta-Analysis of Radiologic Criteria and Comparison of Endoscopic and Microscopic Surgery. World Neurosurg 2016; 96:36-46. [DOI: 10.1016/j.wneu.2016.08.088] [Citation(s) in RCA: 83] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 08/19/2016] [Accepted: 08/20/2016] [Indexed: 11/28/2022]
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45
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Hwang J, Seol HJ, Nam DH, Lee JI, Lee MH, Kong DS. Therapeutic Strategy for Cavernous Sinus-Invading Non-Functioning Pituitary Adenomas Based on the Modified Knosp Grading System. Brain Tumor Res Treat 2016; 4:63-69. [PMID: 27867914 PMCID: PMC5114194 DOI: 10.14791/btrt.2016.4.2.63] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 06/09/2016] [Accepted: 06/29/2016] [Indexed: 12/05/2022] Open
Abstract
Background Non-functioning pituitary adenomas (NFPA) invading into the cavernous sinus are surgically challenging. To decrease recurrence rate, surgeon makes a strong endeavor to resect tumor gross totally. However, gross total resection (GTR) is difficult to achieve with cavernous sinus invasion. Recently, a new classification system for cavernous invasion of pituitary adenomas was suggested. The aim of this study is to validate this new classification system and to identify limitations and considerations in designing treatment strategies for patients with NFPA involving the cavernous sinus. Methods Between January 2000 and January 2012, 275 patients who underwent operation for NFPA were enrolled in the study. Median age was 50 years (15–79 years). There were 145 males and 130 females. The median follow-up duration was 4 years (range 1–12.5 years). Results Related to extent of tumor removal, GTR was obtained in 184 patients (66.9%), near total resection (NTR) was obtained in 45 patients (16.3%), and sub-total resection (STR) was obtained in 46 patients (16.7%) of a total 275 patients. There were statistically significant differences between the extent of resection and the new Knosp classification (p<0.001). In the high-grade group of the new Knosp classification, there was no difference in recurrence between patients who underwent GTR or NTR only and those who underwent STR with adjuvant radiation therapy (p=0.515). Conclusion In case of high risk of surgical complications, STR with adjuvant radiation therapy can be considered as an alternative strategy for safe treatment of cavernous-invading adenomas.
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Affiliation(s)
- Juyoung Hwang
- Department of Neurosurgery, Endoscopic Skull Base Surgery Clinic, Brain Tumor Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ho Jun Seol
- Department of Neurosurgery, Endoscopic Skull Base Surgery Clinic, Brain Tumor Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Do-Hyun Nam
- Department of Neurosurgery, Endoscopic Skull Base Surgery Clinic, Brain Tumor Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung-Il Lee
- Department of Neurosurgery, Endoscopic Skull Base Surgery Clinic, Brain Tumor Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Min Ho Lee
- Department of Neurosurgery, Endoscopic Skull Base Surgery Clinic, Brain Tumor Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Doo-Sik Kong
- Department of Neurosurgery, Endoscopic Skull Base Surgery Clinic, Brain Tumor Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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46
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Theodosopoulos PV, Cebula H, Kurbanov A, Cabero AB, Osorio JA, Zimmer LA, Froelich SC, Keller JT. The Medial Extra-Sellar Corridor to the Cavernous Sinus: Anatomic Description and Clinical Correlation. World Neurosurg 2016; 96:417-422. [PMID: 27659813 DOI: 10.1016/j.wneu.2016.09.046] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 09/08/2016] [Accepted: 09/09/2016] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The zenith of surgical interest in the cavernous sinus peaked in the 1980s, as evidenced by reports of 10 surgical triangles that could access the contents of the lateral sellar compartment (LSC). However, these transcranial approaches later became marginalized, first by radiosurgery's popularity and lower morbidity, and then by clinical potential of endoscopic corridors noted in several qualitative studies. Our anatomic study, taking a contemporary look at the medial extra-sellar corridor, gives a detailed qualitative-quantitative analysis for its use with increasingly popular endoscopic endonasal approaches to the cavernous sinus. METHODS In 20 cadaveric specimens, we re-examined the anatomic landmarks of the medial corridor into the LSC with qualitative descriptions and measurements. An illustrative case highlights a recurrent symptomatic pituitary adenoma that invaded the cavernous sinus approached through the medial corridor. RESULTS The corridor's shape varied from tetrahedron to hexahedron. Comparing right and left sides, width averaged 3.6 ± 4.5 mm and 4.0 ± 4.4 mm, and height averaged 2.3 mm and 2.1 mm, respectively. About 35% of sides showed ample space for access into the cavernous sinus. Our case report of successful outcome lends support for the safety and efficacy of this endoscopic approach. CONCLUSIONS Our re-examination of this particular surgical access into the LSC refines the understanding of the medial extra-sellar corridor as a main endoscopic access route to this compartment. Achieving safe access to the contents of the LSC, this 11th triangle is clinically relevant and potentially superior for select lesions in this region.
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Affiliation(s)
- Philip V Theodosopoulos
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Helene Cebula
- Department of Neurosurgery, Lariboisiere University Hospital, Paris, France
| | - Almaz Kurbanov
- Department of Neurosurgery, University of Cincinnati (UC) College of Medicine, Cincinnati, Ohio, USA
| | - Arnau Benet Cabero
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Joseph A Osorio
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Lee A Zimmer
- Department of Otolaryngology Head and Neck Surgery, University of Cincinnati (UC) College of Medicine, Cincinnati, Ohio, USA; Brain Tumor Center at UC Neuroscience Institute, Cincinnati, Ohio, USA
| | | | - Jeffrey T Keller
- Department of Neurosurgery, University of Cincinnati (UC) College of Medicine, Cincinnati, Ohio, USA; Brain Tumor Center at UC Neuroscience Institute, Cincinnati, Ohio, USA; Mayfield Clinic, Cincinnati, Ohio, USA.
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47
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Farrell CJ, Nyquist GG, Farag AA, Rosen MR, Evans JJ. Principles of Pituitary Surgery. Otolaryngol Clin North Am 2016; 49:95-106. [PMID: 26614830 DOI: 10.1016/j.otc.2015.09.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Since the description of a transnasal approach for treatment of pituitary tumors, transsphenoidal surgery has undergone continuous development. Hirsch developed a lateral endonasal approach before simplifying it to a transseptal approach. Cushing approached pituitary tumors using a transsphenoidal approach but transitioned to the transcranial route. Transsphenoidal surgery was not "rediscovered" until Hardy introduced the surgical microscope. An endoscopic transsphenoidal approach for pituitary tumors has been reported and further advanced. We describe the principles of pituitary surgery including the key elements of surgical decision making and discuss the technical nuances distinguishing the endoscopic from the microscopic approach.
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Affiliation(s)
- Christopher J Farrell
- Department of Neurological Surgery, Thomas Jefferson University, 909 Walnut Street, 2nd Floor, Philadelphia, PA 19107, USA.
| | - Gurston G Nyquist
- Department of Otolaryngology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Alexander A Farag
- Department of Otolaryngology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Marc R Rosen
- Department of Otolaryngology, Thomas Jefferson University, Philadelphia, PA, USA
| | - James J Evans
- Department of Neurological Surgery, Thomas Jefferson University, 909 Walnut Street, 2nd Floor, Philadelphia, PA 19107, USA
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48
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Patrona A, Patel KS, Bander ED, Mehta A, Tsiouris AJ, Anand VK, Schwartz TH. Endoscopic endonasal surgery for nonadenomatous, nonmeningeal pathology involving the cavernous sinus. J Neurosurg 2016; 126:880-888. [PMID: 27128582 DOI: 10.3171/2015.8.jns15275] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Surgery within the cavernous sinus (CS) remains a controversial topic because of the delicate and complex anatomy. The risk also varies with tumor consistency. Softer tumors such as pituitary adenomas are more likely to be surgically treated, while firm tumors such as meningiomas are often treated with radiosurgery. However, a wide range of pathologies that can involve the CS are amenable to surgery. The authors describe and analyze their results using endonasal endoscopic "medial-to-lateral" approaches for nonadenomatous, nonmeningeal tumors, in relation to the degree of invasion within the CS. METHODS A prospectively acquired database of consecutive endoscopic approaches for tumors with verified intraoperative CS invasion was reviewed. Pituitary adenomas and meningiomas were excluded. Degree of invasion of the CS was classified using the Knosp-Steiner (KS) grading system as well as the percentage of cavernous carotid artery (CCA) encasement. Extent of resection of the entire tumor and of the CS component was assessed by independent neuroradiologists using volumetric measurements of the pre- and postoperative MRI studies. Demographic data and complications were noted. RESULTS Fifteen patients (mean age 51.1 years who received endoscopic surgery between 2007 and 2013 met the selection criteria. There were 11 malignant tumors, including chordoma, chondrosarcoma, hemangiopericytoma, lymphoma, and metastatic cancer, and 4 benign tumors, including 3 cavernous hemangiomas and 1 dermoid. All cases were discussed before treatment in a tumor board. Adjuvant treatment options included chemotherapy and radiotherapy. The mean pre- and postoperative tumor volumes were 12.74 ml and 3.86 ml. Gross-total resection (GTR; ie, resection greater than 95%) was the goal in 13 cases and was achieved in 6 patients (46%) while in addition 5 patients had a greater than 80% resection. Gross-total resection in the CS was accomplished in 55% of the tumors with KS Grades 1-2 and in 16.6% of the tumors with KS grades 3-4, respectively. Likewise, GTR was accomplished in 55% of the tumors with CCA encasement under 75% and in 14.3% of the lesions with CCA encasement over 75%, irrespective of tumor volume and underlying pathology. There were 18 preexisting cranial neuropathies involving cranial nerves III-VI, of which 9 fully resolved, 4 improved, and 3 remained unchanged; 2 of these worsened with tumor recurrence. Surgical complications included 1 transient new cranial nerve VI palsy associated with Horner's syndrome and 1 case of panhypopituitarism. There were no postoperative CSF leaks and no infections. The mean extended follow-up was 34.4 months. CONCLUSIONS Endonasal endoscopic approaches can play a role in the management of nonmeningeal, nonadenomatous tumors invading the CS, either through biopsy, debulking, or GTR. An advantage of this method is the relief of preexisting cranial neuropathies with low risk for new neurological deficit. Extent of resection within the CS varies with KS grade and degree of carotid encasement irrespective of the underlying pathology. The goals of surgery should be clearly established preoperatively in consultation with radiation and medical oncologists.
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Affiliation(s)
- Aikaterini Patrona
- Department of Neurosurgery, Medizinische Hochschule Brandenburg, Ruppiner Kliniken, Neuruppin, Germany; and
| | | | | | | | | | - Vijay K Anand
- Otolaryngology, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York
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49
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Morphological Characteristics of the Sphenoid Sinus and Endoscopic Localization of the Cavernous Sinus. J Craniofac Surg 2016. [PMID: 26221856 DOI: 10.1097/scs.0000000000001964] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
The aim of this study was to investigate the relationship between the morphological characteristics of the sphenoid sinus and endoscopic localization of the cavernous sinus (CS) using an extended endoscopic endonasal transsphenoidal approach. Thirty sides of CS in 15 adult cadaver heads were dissected to simulate the extended endoscopic endonasal transsphenoidal approach, and the morphology of the sphenoid sinus and anatomic structures of CS were observed. The opticocarotid recess (OCR), ophthalmomaxillary recess (V1V2R), and maxillomandibular recess (V2V3R) in the lateral wall of the sphenoid sinus were presented in 16 sides (53.3%), 6 sides (20%), and 4 sides (13.3%) of the 30 sides, respectively. OCR is a constant anatomic landmark in endoscopy and coincides with the anterior portion of the clinoidal triangle. The C-shaped internal carotid artery (ICA) in the lateral wall of the sphenoid sinus was presented in 11 sides (36.7%), the upper one-third of which corresponds to the middle portion of the clinoidal triangle, and the lower two-thirds of which correlates to the supratrochlear triangle, infratrochlear triangle, and ophthalmic nerve in CS, around which the medial, lateral, and anteroinferior interspaces are distributed. From a front-to-behind perspective, the C-shaped ICA consists of inferior horizontal segment, anterior vertical segment, clinoidal segment as well as partial subarachnoid segment of the ICA. OCR and C-shaped ICA in the lateral wall of the sphenoid sinus are the 2 reliable anatomic landmarks in the intraoperative location of the parasellar region of CS.
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50
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Bao X, Deng K, Liu X, Feng M, Chen CC, Lian W, Xing B, Yao Y, Wang R. Extended transsphenoidal approach for pituitary adenomas invading the cavernous sinus using multiple complementary techniques. Pituitary 2016; 19:1-10. [PMID: 26267303 DOI: 10.1007/s11102-015-0675-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE Transsphenoidal surgery is the treatment of choice for most pituitary adenomas (PA), except prolactinomas. Difficulties achieving radical resection with this method are encountered in patients with PAs invading the cavernous sinus (CS), due to the inability of the standard transsphenoidal approach to expose all tumors adequately. This study analyzed methods to resect PAs invading the CS and factors influencing the degree of tumor resection and occurrence of complications. METHODS Outcomes were retrospectively analyzed in 52 patients with PA invading the CS who underwent surgery via the extended transsphenoidal approach utilizing multiple techniques, including microscopy, endoscopy, neuronavigation, and intraoperative Doppler ultrasonography. RESULTS Gross-total resection (GTR) was achieved in 33 patients (63.5 %). GTR rate was significantly higher in patients with Knosp Grade 3 than Knosp Grade 4 (92.3 vs. 53.8 %) and in patients undergoing initial surgery than reoperation (77.1 vs. 35.3 %). One patient (2.9 %) undergoing initial surgery experienced transient cranial nerve palsy, without other postoperative complications. Postoperative complications were significantly higher after reoperation. Firm tumor consistency was significantly more frequent in patients undergoing reoperation than initial surgery (52.9 vs. 8.6 %). CONCLUSION Extended transsphenoidal surgery incorporating multiple complementary techniques was highly effective for PAs invading the CS. Postoperative complications rates were relatively low, especially for patients undergoing initial surgery and those with Knosp Grade 3 tumors. Total resection of PAs invading the CS remains challenging, especially in patients undergoing reoperation or having firm tumors.
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Affiliation(s)
- Xinjie Bao
- Department of Neurosurgery, Pituitary Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Kan Deng
- Department of Neurosurgery, Pituitary Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaohai Liu
- Department of Neurosurgery, Pituitary Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ming Feng
- Department of Neurosurgery, Pituitary Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Clark C Chen
- Division of Neurosurgery, Center for Theoretic and Applied Neuro-Oncology, University of California, San Diego, CA, USA
| | - Wei Lian
- Department of Neurosurgery, Pituitary Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bing Xing
- Department of Neurosurgery, Pituitary Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yong Yao
- Department of Neurosurgery, Pituitary Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Renzhi Wang
- Department of Neurosurgery, Pituitary Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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