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Ruzevick J, Cardinal T, Pangal DJ, Bove I, Strickland B, Zada G. From white to blue light: evolution of endoscope-assisted intracranial tumor neurosurgery and expansion to intraaxial tumors. J Neurosurg 2022:1-6. [PMID: 36681992 DOI: 10.3171/2022.10.jns22489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 10/04/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Intraoperative use of the endoscope to assist in visualization of intracranial tumor pathology has expanded with increasing surgeon experience and improved instrumentation. The authors aimed to study how advancements in endoscopic technology have affected the evolution of endoscope use, with particular focus on blue light-filter modification allowing for discrimination of fluorescent tumor tissue following 5-ALA administration. METHODS A retrospective analysis of patients undergoing craniotomy for tumor resection at a single institution between February 2012 and July 2021 was performed. Patients were included if the endoscope was used for diagnostic tumor cavity inspection or therapeutic assistance with tumor resection following standard craniotomy and microsurgical tumor resection, with emphasis on those cases in which blue light endoscopy was used. Medical records were queried for patient demographics, operative reports describing the use of the endoscope and extent of resection, associations with tumor pathology, and postoperative outcomes. Preoperative and postoperative MR images were reviewed for radiographic extent of resection. RESULTS A total of 52 patients who underwent endoscope-assisted craniotomy for tumor were included. Thirty patients (57.7%) were men and the average age was 52.6 ± 16.1 years. Standard white light endoscopes were used for assistance with tumor resection in 28 cases (53.8%) for tumors primarily located in the ventricular system, parasellar region, and cerebellopontine angle. A blue light endoscope for detection of 5-ALA fluorescence was introduced into our practice in 2014 and subsequently used for assistance with tumor resection in 24 cases (46.2%) (intraaxial: n = 22, extraaxial: n = 2). Beyond the use of the surgical microscope as the primary visualization source, the blue light endoscope was used to directly perform additional tumor resection in 19/21 cases as a result of improved fluorescence detection as compared to the surgical microscope. No complications were associated with the use of the endoscope or with additional resection performed under white or blue light visualization. CONCLUSIONS Endoscopic assistance to visualize intracranial tumors had previously been limited to white light, assisting mostly in the visualization of extraaxial tumors confined to intraventricular and cisternal compartments. Blue light-equipped endoscopes provide improved versatility and visualization of 5-ALA fluorescing tissue beyond the capability of the surgical microscope, thereby expanding its use into the realm of intraaxial tumor resections.
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Affiliation(s)
- Jacob Ruzevick
- Department of Neurological Surgery, The University of Southern California Keck School of Medicine, Los Angeles, California
| | - Tyler Cardinal
- Department of Neurological Surgery, The University of Southern California Keck School of Medicine, Los Angeles, California
| | - Dhiraj J. Pangal
- Department of Neurological Surgery, The University of Southern California Keck School of Medicine, Los Angeles, California
| | - Ilaria Bove
- Department of Neurological Surgery, The University of Southern California Keck School of Medicine, Los Angeles, California
| | - Ben Strickland
- Department of Neurological Surgery, The University of Southern California Keck School of Medicine, Los Angeles, California
| | - Gabriel Zada
- Department of Neurological Surgery, The University of Southern California Keck School of Medicine, Los Angeles, California
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Mahmoodifar S, Pangal DJ, Cardinal T, Craig D, Simon T, Tew BY, Yang W, Chang E, Yu M, Neman J, Mason J, Toga A, Salhia B, Zada G, Newton PK. A quantitative characterization of the spatial distribution of brain metastases from breast cancer and respective molecular subtypes. J Neurooncol 2022; 160:241-251. [DOI: 10.1007/s11060-022-04147-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 09/25/2022] [Indexed: 11/30/2022]
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Pangal DJ, Yarovinsky B, Cardinal T, Cote DJ, Ruzevick J, Attenello FJ, Chang EL, Ye J, Neman J, Chow F, Zada G. The abscopal effect: systematic review in patients with brain and spine metastases. Neurooncol Adv 2022; 4:vdac132. [PMID: 36199973 PMCID: PMC9529003 DOI: 10.1093/noajnl/vdac132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Background The abscopal effect is a rare phenomenon whereby local radiation induces a proposed immune-mediated anti-tumor effect at distant sites. Given the growing use of immunotherapies and systemic immune checkpoint inhibitors in neuro-oncologic practice, we aimed to review prior studies pertaining to this phenomenon in the context of tumor shrinkage both within the central nervous system as well as distant disease sites. Methods A systematic review in accordance with the PRISMA guidelines was conducted to identify all studies which assessed the abscopal effect in patients with treated metastatic cancer to the brain and/or spine. Articles were included if they reported the abscopal effect in patients (case studies) or if the abscopal effect was explicitly analyzed in case series with cohorts of patients with metastatic brain or spine tumors. Laboratory investigations and clinical trials investigating new therapies were excluded. Results Twenty reports met inclusion criteria [16 case reports, 4 case series (n = 160), total n = 174]. Case reports of the abscopal effect were in relation to the following cancers: melanoma (6 patients), breast cancer (3), lung adenocarcinoma (2), non-small-cell lung cancer (2), hepatocellular carcinoma (1), and renal cell carcinoma (1). Eleven patients had irradiation to the brain and 2 to the spine. Patients undergoing whole brain radiotherapy (6) had an average dose of 33.6 Gy over 8-15 fractions, and those undergoing stereotactic radiosurgery (5) had an average dose of 21.5 Gy over 1-5 fractions. One patient had radiation to the body and an intracranial abscopal effect was observed. Most common sites of extracranial tumor reduction were lung and lymph nodes. Ten case studies (57%) showed complete resolution of extra-CNS tumor burden. Median progression-free survival was 13 months following radiation. Four papers investigated incidence of abscopal effects in patients with metastatic melanoma to the brain who received immune checkpoint inhibitor therapy (n = 160); two papers found an abscopal effect in 35% and 52% of patients (n = 16, 21 respectively), and two papers found no evidence of abscopal effects (n = 61, 62). Conclusions Abscopal effects can occur following radiotherapy in patients with brain or spine metastases and is thought to be a result of increased anti-tumor immunity. The potential for immune checkpoint inhibitor therapy to be used in combination with radiotherapy to induce an abscopal effect is an area of active investigation.
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Affiliation(s)
- Dhiraj J Pangal
- USC Brain Tumor Center, Keck School of Medicine, University of Southern California, Los Angeles, California, USA,Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Benjamin Yarovinsky
- Corresponding Author: Dhiraj J. Pangal, BS, USC Department of Neurosurgery, 1200 N State Street, Suite 3300, Los Angeles, CA 90033, USA ()
| | - Tyler Cardinal
- USC Brain Tumor Center, Keck School of Medicine, University of Southern California, Los Angeles, California, USA,Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - David J Cote
- USC Brain Tumor Center, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Jacob Ruzevick
- USC Brain Tumor Center, Keck School of Medicine, University of Southern California, Los Angeles, California, USA,Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Frank J Attenello
- USC Brain Tumor Center, Keck School of Medicine, University of Southern California, Los Angeles, California, USA,Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Eric L Chang
- USC Brain Tumor Center, Keck School of Medicine, University of Southern California, Los Angeles, California, USA,Department of Radiation Oncology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Jason Ye
- USC Brain Tumor Center, Keck School of Medicine, University of Southern California, Los Angeles, California, USA,Department of Radiation Oncology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Josh Neman
- USC Brain Tumor Center, Keck School of Medicine, University of Southern California, Los Angeles, California, USA,Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Frances Chow
- USC Brain Tumor Center, Keck School of Medicine, University of Southern California, Los Angeles, California, USA,Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Gabriel Zada
- USC Brain Tumor Center, Keck School of Medicine, University of Southern California, Los Angeles, California, USA,Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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Kugener G, Pangal DJ, Cardinal T, Collet C, Lechtholz-Zey E, Lasky S, Sundaram S, Markarian N, Zhu Y, Roshannai A, Sinha A, Han XY, Papyan V, Hung A, Anandkumar A, Wrobel B, Zada G, Donoho DA. Utility of the Simulated Outcomes Following Carotid Artery Laceration Video Data Set for Machine Learning Applications. JAMA Netw Open 2022; 5:e223177. [PMID: 35311962 PMCID: PMC8938712 DOI: 10.1001/jamanetworkopen.2022.3177] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
IMPORTANCE Surgical data scientists lack video data sets that depict adverse events, which may affect model generalizability and introduce bias. Hemorrhage may be particularly challenging for computer vision-based models because blood obscures the scene. OBJECTIVE To assess the utility of the Simulated Outcomes Following Carotid Artery Laceration (SOCAL)-a publicly available surgical video data set of hemorrhage complication management with instrument annotations and task outcomes-to provide benchmarks for surgical data science techniques, including computer vision instrument detection, instrument use metrics and outcome associations, and validation of a SOCAL-trained neural network using real operative video. DESIGN, SETTING, AND PARTICIPANTS For this quailty improvement study, a total of 75 surgeons with 1 to 30 years' experience (mean, 7 years) were filmed from January 1, 2017, to December 31, 2020, managing catastrophic surgical hemorrhage in a high-fidelity cadaveric training exercise at nationwide training courses. Videos were annotated from January 1 to June 30, 2021. INTERVENTIONS Surgeons received expert coaching between 2 trials. MAIN OUTCOMES AND MEASURES Hemostasis within 5 minutes (task success, dichotomous), time to hemostasis (in seconds), and blood loss (in milliliters) were recorded. Deep neural networks (DNNs) were trained to detect surgical instruments in view. Model performance was measured using mean average precision (mAP), sensitivity, and positive predictive value. RESULTS SOCAL contains 31 443 frames with 65 071 surgical instrument annotations from 147 trials with associated surgeon demographic characteristics, time to hemostasis, and recorded blood loss for each trial. Computer vision-based instrument detection methods using DNNs trained on SOCAL achieved a mAP of 0.67 overall and 0.91 for the most common surgical instrument (suction). Hemorrhage control challenges standard object detectors: detection of some surgical instruments remained poor (mAP, 0.25). On real intraoperative video, the model achieved a sensitivity of 0.77 and a positive predictive value of 0.96. Instrument use metrics derived from the SOCAL video were significantly associated with performance (blood loss). CONCLUSIONS AND RELEVANCE Hemorrhage control is a high-stakes adverse event that poses unique challenges for video analysis, but no data sets of hemorrhage control exist. The use of SOCAL, the first data set to depict hemorrhage control, allows the benchmarking of data science applications, including object detection, performance metric development, and identification of metrics associated with outcomes. In the future, SOCAL may be used to build and validate surgical data science models.
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Affiliation(s)
- Guillaume Kugener
- Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles
| | - Dhiraj J. Pangal
- Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles
| | - Tyler Cardinal
- Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles
| | - Casey Collet
- Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles
| | - Elizabeth Lechtholz-Zey
- Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles
| | - Sasha Lasky
- Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles
| | - Shivani Sundaram
- Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles
| | - Nicholas Markarian
- Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles
| | - Yichao Zhu
- Department of Computer Science, Viterbi School of Engineering, University of Southern California, Los Angeles
| | - Arman Roshannai
- Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles
| | - Aditya Sinha
- Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles
| | - X. Y. Han
- Department of Operations Research and Information Engineering, Cornell University, Ithaca, New York
| | - Vardan Papyan
- Department of Mathematics, University of Toronto, Toronto, Ontario, Canada
| | - Andrew Hung
- Center for Robotic Simulation and Education, USC Institute of Urology, Keck School of Medicine of the University of Southern California, Los Angeles
| | - Animashree Anandkumar
- Department of Computer Science and Mathematics, California Institute of Technology, Pasadena
| | - Bozena Wrobel
- Department of Otolaryngology, Keck School of Medicine of the University of Southern California, Los Angeles
| | - Gabriel Zada
- Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles
| | - Daniel A. Donoho
- Division of Neurosurgery, Center for Neuroscience, Children’s National Hospital, Washington, DC
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Cardinal T, Pangal D, Strickland BA, Newton P, Mahmoodifar S, Mason J, Craig D, Simon T, Tew BY, Yu M, Yang W, Chang E, Cabeen RP, Ruzevick J, Toga AW, Neman J, Salhia B, Zada G. Anatomical and topographical variations in the distribution of brain metastases based on primary cancer origin and molecular subtypes: a systematic review. Neurooncol Adv 2022; 4:vdab170. [PMID: 35024611 PMCID: PMC8739649 DOI: 10.1093/noajnl/vdab170] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background While it has been suspected that different primary cancers have varying predilections for metastasis in certain brain regions, recent advances in neuroimaging and spatial modeling analytics have facilitated further exploration into this field. Methods A systematic electronic database search for studies analyzing the distribution of brain metastases (BMs) from any primary systematic cancer published between January 1990 and July 2020 was conducted using PRISMA guidelines. Results Two authors independently reviewed 1957 abstracts, 46 of which underwent full-text analysis. A third author arbitrated both lists; 13 studies met inclusion/exclusion criteria. All were retrospective single- or multi-institution database reviews analyzing over 8227 BMs from 2599 patients with breast (8 studies), lung (7 studies), melanoma (5 studies), gastrointestinal (4 studies), renal (3 studies), and prostate (1 study) cancers. Breast, lung, and colorectal cancers tended to metastasize to more posterior/caudal topographic and vascular neuroanatomical regions, particularly the cerebellum, with notable differences based on subtype and receptor expression. HER-2-positive breast cancers were less likely to arise in the frontal lobes or subcortical region, while ER-positive and PR-positive breast metastases were less likely to arise in the occipital lobe or cerebellum. BM from lung adenocarcinoma tended to arise in the frontal lobes and squamous cell carcinoma in the cerebellum. Melanoma metastasized more to the frontal and temporal lobes. Conclusion The observed topographical distribution of BM likely develops based on primary cancer type, molecular subtype, and genetic profile. Further studies analyzing this association and relationships to vascular distribution are merited to potentially improve patient treatment and outcomes.
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Affiliation(s)
- Tyler Cardinal
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Dhiraj Pangal
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Ben A Strickland
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Paul Newton
- Department of Aerospace and Mechanical Engineering, Mathematics and The Ellison Institute for Transformative Medicine of USC, Los Angeles, California, USA
| | - Saeedeh Mahmoodifar
- Department of Physics & Astronomy, University of Southern California, Los Angeles, California, USA
| | - Jeremy Mason
- Department of Urology, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - David Craig
- Department of Translational Genomics, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Thomas Simon
- Department of Translational Genomics, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Ben Yi Tew
- Department of Translational Genomics, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Min Yu
- Broad Stem Cell Center, University of Southern California, Los Angeles, California, USA
| | - Wensha Yang
- Department of Radiation Oncology, University of Southern California, Los Angeles, California, USA
| | - Eric Chang
- Department of Radiation Oncology, University of Southern California, Los Angeles, California, USA
| | - Ryan P Cabeen
- USC Stevens Neuroimaging and Informatics Institute, University of Southern California, Los Angeles, California, USA
| | - Jacob Ruzevick
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Arthur W Toga
- USC Stevens Neuroimaging and Informatics Institute, University of Southern California, Los Angeles, California, USA
| | - Josh Neman
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Bodour Salhia
- Department of Translational Genomics, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Gabriel Zada
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
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Pangal DJ, Kugener G, Cardinal T, Lechtholz-Zey E, Collet C, Lasky S, Sundaram S, Zhu Y, Roshannai A, Chan J, Sinha A, Hung AJ, Anandkumar A, Zada G, Donoho DA. Use of surgical video-based automated performance metrics to predict blood loss and success of simulated vascular injury control in neurosurgery: a pilot study. J Neurosurg 2021; 137:1-10. [PMID: 34972086 DOI: 10.3171/2021.10.jns211064] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 10/06/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Experts can assess surgeon skill using surgical video, but a limited number of expert surgeons are available. Automated performance metrics (APMs) are a promising alternative but have not been created from operative videos in neurosurgery to date. The authors aimed to evaluate whether video-based APMs can predict task success and blood loss during endonasal endoscopic surgery in a validated cadaveric simulator of vascular injury of the internal carotid artery. METHODS Videos of cadaveric simulation trials by 73 neurosurgeons and otorhinolaryngologists were analyzed and manually annotated with bounding boxes to identify the surgical instruments in the frame. APMs in five domains were defined-instrument usage, time-to-phase, instrument disappearance, instrument movement, and instrument interactions-on the basis of expert analysis and task-specific surgical progressions. Bounding-box data of instrument position were then used to generate APMs for each trial. Multivariate linear regression was used to test for the associations between APMs and blood loss and task success (hemorrhage control in less than 5 minutes). The APMs of 93 successful trials were compared with the APMs of 49 unsuccessful trials. RESULTS In total, 29,151 frames of surgical video were annotated. Successful simulation trials had superior APMs in each domain, including proportionately more time spent with the key instruments in view (p < 0.001) and less time without hemorrhage control (p = 0.002). APMs in all domains improved in subsequent trials after the participants received personalized expert instruction. Attending surgeons had superior instrument usage, time-to-phase, and instrument disappearance metrics compared with resident surgeons (p < 0.01). APMs predicted surgeon performance better than surgeon training level or prior experience. A regression model that included APMs predicted blood loss with an R2 value of 0.87 (p < 0.001). CONCLUSIONS Video-based APMs were superior predictors of simulation trial success and blood loss than surgeon characteristics such as case volume and attending status. Surgeon educators can use APMs to assess competency, quantify performance, and provide actionable, structured feedback in order to improve patient outcomes. Validation of APMs provides a benchmark for further development of fully automated video assessment pipelines that utilize machine learning and computer vision.
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Affiliation(s)
- Dhiraj J Pangal
- 1Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Guillaume Kugener
- 1Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Tyler Cardinal
- 1Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Elizabeth Lechtholz-Zey
- 1Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Casey Collet
- 1Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Sasha Lasky
- 1Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Shivani Sundaram
- 1Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Yichao Zhu
- 1Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Arman Roshannai
- 1Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Justin Chan
- 1Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Aditya Sinha
- 1Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Andrew J Hung
- 2Center for Robotic Simulation and Education, USC Institute of Urology, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Animashree Anandkumar
- 3Computing + Mathematical Sciences, California Institute of Technology, Pasadena, California; and
| | - Gabriel Zada
- 1Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Daniel A Donoho
- 4Division of Neurosurgery, Center for Neuroscience, Children's National Medical Center, Washington, DC
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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 2021; 137:1-9. [PMID: 34952511 DOI: 10.3171/2021.9.jns211689] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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Cardinal T, Strickland BA, Bonney PA, Lechtholz-Zey E, Mendoza J, Pangal DJ, Mack W, Giannotta S, Zada G. Disparities in the Surgical Treatment of Cerebrovascular Pathologies: A Contemporary Systematic Review. World Neurosurg 2021; 158:244-257.e1. [PMID: 34856403 DOI: 10.1016/j.wneu.2021.11.106] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 11/23/2021] [Accepted: 11/24/2021] [Indexed: 01/28/2023]
Abstract
INTRODUCTION This systematic review analyzes contemporary literature on racial/ethnic, insurance, and socioeconomic disparities within cerebrovascular surgery in the United States to determine areas for improvement. METHODS We conducted an electronic database search of literature published between January 1990 and July 2020 using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for studies analyzing a racial/ethnic, insurance, or socioeconomic disparity within adult cerebrovascular surgery. RESULTS Of 2873 articles screened for eligibility by title and abstract, 970 underwent full-text independent review by 3 authors. Twenty-seven additional articles were identified through references to generate a final list of 47 included studies for analysis. Forty-six were retrospective reviews and 1 was a prospective observational cohort study, thereby comprising Levels III and IV of evidence. Studies investigated carotid artery stenting (11/47, 23%), carotid endarterectomy (22/47, 46.8%), mechanical thrombectomy (8/47, 17%), and endovascular aneurysm coiling or surgical aneurysm clipping (20/47, 42.6%). Minority and underinsured patients were less likely to receive surgical treatment. Non-White patients were more likely to experience a postoperative complication, although this significance was lost in some studies using multivariate analyses to account for complication risk factors. White and privately insured patients generally experienced shorter length of hospital stay, had lower rates of in-hospital mortality, and underwent routine discharge. Twenty-five papers (53%) reported no disparities within at least one examined metric. CONCLUSIONS This comprehensive contemporary systematic review demonstrates the existence of disparity gaps within the field of adult cerebrovascular surgery. It highlights the importance of continued investigation into sources of disparity and efforts to promote equity within the field.
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Affiliation(s)
- Tyler Cardinal
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA.
| | - Ben A Strickland
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Phillip A Bonney
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Elizabeth Lechtholz-Zey
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Jesse Mendoza
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Dhiraj J Pangal
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - William Mack
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Steven Giannotta
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Gabriel Zada
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
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Lechtholz-Zey E, Bonney PA, Cardinal T, Mendoza J, Strickland BA, Pangal DJ, Giannotta S, Durham S, Zada G. Systematic Review of Racial, Socioeconomic, and Insurance Status Disparities in the Treatment of Pediatric Neurosurgical Diseases in the United States. World Neurosurg 2021; 158:65-83. [PMID: 34718199 DOI: 10.1016/j.wneu.2021.10.150] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/21/2021] [Accepted: 10/22/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Increasing light is being shed on how race, insurance, and socioeconomic status (SES) may be related to outcomes from disease in the United States. To better understand the impact of these health care disparities in pediatric neurosurgery, we performed a systematic review of the literature. METHODS We conducted a systematic review using PRISMA guidelines and MeSH terms involving neurosurgical conditions and racial, ethnic, and SES disparities. Three independent reviewers screened articles and analyzed texts selected for full analysis. RESULTS Thirty-eight studies were included in the final analysis, of which all but 2 were retrospective database reviews. Thirty-four studies analyzed race, 22 analyzed insurance status, and 13 analyzed SES/income. Overall, nonwhite patients, patients with public insurance, and patients from lower SES were shown to have reduced access to treatment and greater rates of adverse outcomes. Nonwhite patients were more likely to present at an older age with more severe disease, less likely to undergo surgery at a high-volume surgical center, and more likely to experience postoperative morbidity and mortality. Underinsured and publicly insured patients were more likely to experience delay in surgical referral, less likely to undergo surgical treatment, and more likely to experience inpatient mortality. CONCLUSIONS Health care disparities are present within multiple populations of patients receiving pediatric neurosurgical care. This review highlights the need for continued investigation into identifying and addressing health care disparities in pediatric neurosurgery patients.
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Affiliation(s)
- Elizabeth Lechtholz-Zey
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Phillip A Bonney
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Tyler Cardinal
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA.
| | - Jesse Mendoza
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Ben A Strickland
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Dhiraj J Pangal
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Steven Giannotta
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Susan Durham
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA; Division of Neurosurgery, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Gabriel Zada
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
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10
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Cardinal T, Bonney PA, Strickland BA, Lechtholz-Zey E, Mendoza J, Pangal DJ, Liu J, Attenello F, Mack W, Giannotta S, Zada G. Disparities in the Surgical Treatment of Adult Spine Diseases: A Systematic Review. World Neurosurg 2021; 158:290-304.e1. [PMID: 34688939 DOI: 10.1016/j.wneu.2021.10.121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/14/2021] [Accepted: 10/15/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Our goal was to systematically review the literature on racial/ethnic, insurance, and socioeconomic disparities in adult spine surgery in the United States and analyze potential areas for improvement. METHODS We conducted a database search of literature published between January 1990 and July 2020 using PRISMA guidelines for all studies investigating a disparity in any aspect of adult spine surgery care analyzed based on race/ethnicity, insurance status/payer, or socioeconomic status (SES). RESULTS Of 2679 articles identified through database searching, 775 were identified for full-text independent review by 3 authors, from which a final list of 60 studies were analyzed. Forty-three studies analyzed disparities based on patient race/ethnicity, 32 based on insurance status, and 8 based on SES. Five studies assessed disparities in access to care, 15 examined surgical treatment, 35 investigated in-hospital outcomes, and 25 explored after-discharge outcomes. Minority patients were less likely to undergo surgery but more likely to receive surgery from a low-volume provider and experience postoperative complications. White and privately insured patients generally had shorter hospital length of stay, were more likely to undergo favorable/routine discharge, and had lower rates of in-hospital mortality. After discharge, white patients reported better outcomes than did black patients. Thirty-three studies (55%) reported no disparities within at least 1 examined metric. CONCLUSIONS This comprehensive systematic review underscores ongoing potential for health care disparities among adult patients in spinal surgery. We show a need for continued efforts to promote equity and cultural competency within neurologic surgery.
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Affiliation(s)
- Tyler Cardinal
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA.
| | - Phillip A Bonney
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Ben A Strickland
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Elizabeth Lechtholz-Zey
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Jesse Mendoza
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Dhiraj J Pangal
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - John Liu
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Frank Attenello
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - William Mack
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Steven Giannotta
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Gabriel Zada
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
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11
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Penn MC, Cardinal T, Zhang Y, Abt B, Bonney PA, Lorenzo P, Lin M, Rosner J, Weiss M, Zada G, Carmichael JD. Cure and Hormonal Control After Prolactinoma Resection: Case Series and Systematic Review. J Endocr Soc 2021; 5:bvab074. [PMID: 34466765 PMCID: PMC8402931 DOI: 10.1210/jendso/bvab074] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Indexed: 11/19/2022] Open
Abstract
Context Surgical management of prolactinomas is an important treatment for patients intolerant of dopamine agonist therapy. However, predictors of postoperative outcomes remain unclear. Object While transsphenoidal surgical resection (TSSR) is important second-line therapy in prolactinoma patients, predictors of surgical cure and biochemical remission following TSSR remain sparse. Methods A retrospective review of prolactinoma patients undergoing TSSR at the USC Pituitary Center from 1995 to 2020 was conducted. Participants were categorized as surgical cure (normalization of serum prolactin without medical treatment), surgical noncure, biochemical control (prolactin normalization with or without adjuvant therapy), and nonbiochemical control. A systematic review of the outcomes of surgically managed prolactinomas was performed. Results The 40 female and 16 male participants had an average age of 35.6 years. Prior treatment included transsphenoidal resection (6, 11%) and dopamine agonist treatment (47, 84%). The 40 macroadenomas and 15 microadenomas exhibited suprasellar extension (24, 43%) and parasellar invasion (20, 36%). Fifteen (27%) were purely intrasellar. Gross total resection was achieved in 25 patients (45%) and subtotal in 26 (46%). Surgical cure was achieved in 25 patients (46%) and biochemical control in 35 (64%). Surgical cure was more likely in smaller, noninvasive tumors, those that were fully resected, and patients with lower preoperative (< 1000 ng/mL) and immediately postoperative (< 7.6 ng/mL) prolactin levels. Ten of 26 patients (38%) undergoing adjuvant therapy achieved biochemical control, which was less likely in men and those with higher preoperative prolactin or invasive tumors. Conclusion Surgical resection of prolactinomas is a safe procedure that, when offered judiciously, can achieve symptom and/or biochemical control in a majority of patients. A variety of predictors may be useful in advising patients on likelihood of postoperative remission.
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Affiliation(s)
- Marisa C Penn
- Department of Neurosurgery, Keck School of Medicine of USC, Los Angeles, California 90033, USA
| | - Tyler Cardinal
- Department of Neurosurgery, Keck School of Medicine of USC, Los Angeles, California 90033, USA
| | - Yanchen Zhang
- Department of Neurosurgery, Keck School of Medicine of USC, Los Angeles, California 90033, USA
| | - Brittany Abt
- Department of Neurosurgery, Keck School of Medicine of USC, Los Angeles, California 90033, USA
| | - Phillip A Bonney
- Department of Neurosurgery, Keck School of Medicine of USC, Los Angeles, California 90033, USA
| | - Patricia Lorenzo
- Division of Endocrinology, Department of Medicine, Keck School of Medicine of USC, Los Angeles, California 90033, USA
| | - Michelle Lin
- Department of Neurosurgery, Keck School of Medicine of USC, Los Angeles, California 90033, USA
| | - Jack Rosner
- Department of Neurosurgery, Keck School of Medicine of USC, Los Angeles, California 90033, USA
| | - Martin Weiss
- Department of Neurosurgery, Keck School of Medicine of USC, Los Angeles, California 90033, USA
| | - Gabriel Zada
- Department of Neurosurgery, Keck School of Medicine of USC, Los Angeles, California 90033, USA.,USC Pituitary Center, Keck School of Medicine of USC, Los Angeles, California 90033, USA
| | - John D Carmichael
- Division of Endocrinology, Department of Medicine, Keck School of Medicine of USC, Los Angeles, California 90033, USA.,USC Pituitary Center, Keck School of Medicine of USC, Los Angeles, California 90033, USA
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12
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Chan J, Pangal DJ, Cardinal T, Kugener G, Zhu Y, Roshannai A, Markarian N, Sinha A, Anandkumar A, Hung A, Zada G, Donoho DA. A systematic review of virtual reality for the assessment of technical skills in neurosurgery. Neurosurg Focus 2021; 51:E15. [PMID: 34333472 DOI: 10.3171/2021.5.focus21210] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 05/19/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Virtual reality (VR) and augmented reality (AR) systems are increasingly available to neurosurgeons. These systems may provide opportunities for technical rehearsal and assessments of surgeon performance. The assessment of neurosurgeon skill in VR and AR environments and the validity of VR and AR feedback has not been systematically reviewed. METHODS A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was conducted through MEDLINE and PubMed. Studies published in English between January 1990 and February 2021 describing the use of VR or AR to quantify surgical technical performance of neurosurgeons without the use of human raters were included. The types and categories of automated performance metrics (APMs) from each of these studies were recorded. RESULTS Thirty-three VR studies were included in the review; no AR studies met inclusion criteria. VR APMs were categorized as either distance to target, force, kinematics, time, blood loss, or volume of resection. Distance and time were the most well-studied APM domains, although all domains were effective at differentiating surgeon experience levels. Distance was successfully used to track improvements with practice. Examining volume of resection demonstrated that attending surgeons removed less simulated tumor but preserved more normal tissue than trainees. More recently, APMs have been used in machine learning algorithms to predict level of training with a high degree of accuracy. Key limitations to enhanced-reality systems include limited AR usage for automated surgical assessment and lack of external and longitudinal validation of VR systems. CONCLUSIONS VR has been used to assess surgeon performance across a wide spectrum of domains. The VR environment can be used to quantify surgeon performance, assess surgeon proficiency, and track training progression. AR systems have not yet been used to provide metrics for surgeon performance assessment despite potential for intraoperative integration. VR-based APMs may be especially useful for metrics that are difficult to assess intraoperatively, including blood loss and extent of resection.
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Affiliation(s)
- Justin Chan
- 1USC Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Dhiraj J Pangal
- 1USC Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Tyler Cardinal
- 1USC Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Guillaume Kugener
- 1USC Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Yichao Zhu
- 1USC Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Arman Roshannai
- 1USC Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Nicholas Markarian
- 1USC Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Aditya Sinha
- 1USC Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Anima Anandkumar
- 2Computing + Mathematical Sciences, California Institute of Technology, Pasadena, California
| | - Andrew Hung
- 3USC Department of Urology, Keck School of Medicine of the University of Southern California, Los Angeles, California; and
| | - Gabriel Zada
- 1USC Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Daniel A Donoho
- 4Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
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13
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Shahrestani S, Cardinal T, Micko A, Strickland BA, Pangal DJ, Kugener G, Weiss MH, Carmichael J, Zada G. Neural network modeling for prediction of recurrence, progression, and hormonal non-remission in patients following resection of functional pituitary adenomas. Pituitary 2021; 24:523-529. [PMID: 33528731 DOI: 10.1007/s11102-021-01128-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/16/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE Functional pituitary adenomas (FPAs) cause severe neuro-endocrinopathies including Cushing's disease (CD) and acromegaly. While many are effectively cured following FPA resection, some encounter disease recurrence/progression or hormonal non-remission requiring adjuvant treatment. Identification of risk factors for suboptimal postoperative outcomes may guide initiation of adjuvant multimodal therapies. METHODS Patients undergoing endonasal transsphenoidal resection for CD, acromegaly, and mammosomatotroph adenomas between 1992 and 2019 were identified. Good outcomes were defined as hormonal remission without imaging/biochemical evidence of disease recurrence/progression, while suboptimal outcomes were defined as hormonal non-remission or MRI evidence of recurrence/progression despite adjuvant treatment. Multivariate regression modeling and multilayered neural networks (NN) were implemented. The training sets randomly sampled 60% of all FPA patients, and validation/testing sets were 20% samples each. RESULTS 348 patients with mean age of 41.7 years were identified. Eighty-one patients (23.3%) reported suboptimal outcomes. Variables predictive of suboptimal outcomes included: Requirement for additional surgery in patients who previously had surgery and continue to have functionally active tumor (p = 0.0069; OR = 1.51, 95%CI 1.12-2.04), Preoperative visual deficit not improved after surgery (p = 0.0033; OR = 1.12, 95%CI 1.04-1.20), Transient diabetes insipidus (p = 0.013; OR = 1.27, 95%CI 1.05-1.52), Higher MIB-1/Ki-67 labeling index (p = 0.038; OR = 1.08, 95%CI 1.01-1.15), and preoperative low cortisol axis (p = 0.040; OR = 2.72, 95%CI 1.06-7.01). The NN had overall accuracy of 87.1%, sensitivity of 89.5%, specificity of 76.9%, positive predictive value of 94.4%, and negative predictive value of 62.5%. NNs for all FPAs were more robust than for CD or acromegaly/mammosomatotroph alone. CONCLUSION We demonstrate capability of predicting suboptimal postoperative outcomes with high accuracy. NNs may aid in stratifying patients for risk of suboptimal outcomes, thereby guiding implementation of adjuvant treatment in high-risk patients.
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Affiliation(s)
- Shane Shahrestani
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
- Department of Medical Engineering, California Institute of Technology, Pasadena, CA, USA.
| | - Tyler Cardinal
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Alexander Micko
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Ben A Strickland
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Dhiraj J Pangal
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Guillaume Kugener
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Martin H Weiss
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - John Carmichael
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Gabriel Zada
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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14
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Cardinal T, Rutkowski MJ, Micko A, Shiroishi M, Jason Liu CS, Wrobel B, Carmichael J, Zada G. Impact of tumor characteristics and pre- and postoperative hormone levels on hormonal remission following endoscopic transsphenoidal surgery in patients with acromegaly. Neurosurg Focus 2021; 48:E10. [PMID: 32480366 DOI: 10.3171/2020.3.focus2080] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 03/31/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Acromegaly is a disease of acral enlargement and elevated serum levels of insulin-like growth factor-1 (IGF-1) and growth hormone (GH), usually caused by a pituitary adenoma. A lack of consensus on factors that reliably predict outcomes in acromegalic patients following endoscopic endonasal transsphenoidal surgery (EETS) warrants additional investigation. METHODS The authors identified 52 patients with acromegaly who underwent an endoscopic endonasal approach (EEA) for resection of a GH-secreting pituitary adenoma. Preoperative and postoperative tumor and endocrinological characteristics such as tumor size, invasiveness, and GH/IGF-1 levels were evaluated as potential indicators of postoperative hormonal remission. Endocrinological remission was defined as postoperative IGF-1 levels at or below the age- and sex-normalized values. RESULTS The 52 patients had a mean age of 50.7 ± 13.4 years and a mean follow-up duration of 24.4 ± 19.1 months. Ten patients (19%) had microadenomas and 42 (81%) had macroadenomas. Five patients (9.6%) had giant adenomas. Forty-four tumors (85%) had extrasellar extension, with 40 (77%) exhibiting infrasellar invasion, 18 (35%) extending above the sella, and 7 (13%) invading the cavernous sinuses. Thirty-six patients (69%) underwent gross-total resection (GTR; mean maximal tumor diameter 1.47 cm), and 16 (31%) underwent subtotal resection (STR; mean maximal tumor diameter 2.74 cm). Invasive tumors were significantly larger, and Knosp scores were negatively correlated with GTR. Thirty-eight patients (73%) achieved hormonal remission after EEA resection alone, which increased to 87% with adjunctive medical therapy. Ninety percent of patients with microadenomas and 86% of patients with macroadenomas achieved hormonal remission. Preoperative IGF-1 and postoperative day 1 (POD1) GH levels were inversely correlated with hormonal remission. Postoperative CSF leakage occurred in 2 patients (4%), and none experienced vision loss, death, or injury to internal carotid arteries or cranial nerves. CONCLUSIONS Endoscopic transsphenoidal resection of GH-secreting pituitary adenomas is a safe and highly effective treatment for achieving hormonal remission and tumor control in up to 87% of patients with acromegaly when combined with postoperative medical therapy. Patients with lower preoperative IGF-1 and POD1 GH levels, with less invasive pituitary adenomas, and who undergo GTR are more likely to achieve postoperative biochemical remission.
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Affiliation(s)
- Tyler Cardinal
- 1Department of Neurosurgery, USC Pituitary Center, Keck School of Medicine of University of Southern California, Los Angeles, California
| | - Martin J Rutkowski
- 1Department of Neurosurgery, USC Pituitary Center, Keck School of Medicine of University of Southern California, Los Angeles, California
| | - Alexander Micko
- 1Department of Neurosurgery, USC Pituitary Center, Keck School of Medicine of University of Southern California, Los Angeles, California.,2Department of Neurosurgery, Medical University of Vienna, Austria
| | - Mark Shiroishi
- 3Department of Radiology, Division of Neuroradiology, Keck School of Medicine of University of Southern California
| | - Chia-Shang Jason Liu
- 3Department of Radiology, Division of Neuroradiology, Keck School of Medicine of University of Southern California
| | - Bozena Wrobel
- 5Department of Otolaryngology, Keck School of Medicine of University of Southern California, Los Angeles, California
| | - John Carmichael
- 1Department of Neurosurgery, USC Pituitary Center, Keck School of Medicine of University of Southern California, Los Angeles, California.,4Department of Medicine, Division of Endocrinology and Diabetes, Keck School of Medicine of University of Southern California; and
| | - Gabriel Zada
- 1Department of Neurosurgery, USC Pituitary Center, Keck School of Medicine of University of Southern California, Los Angeles, California
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15
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Pangal DJ, Baertsch H, Kellman EM, Cardinal T, Brunswick A, Rutkowski M, Strickland B, Chow F, Attenello F, Zada G. Complementary and Alternative Medicine for the Treatment of Gliomas: Scoping Review of Clinical Studies, Patient Outcomes, and Toxicity Profiles. World Neurosurg 2021; 151:e682-e692. [PMID: 33940275 DOI: 10.1016/j.wneu.2021.04.096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 04/21/2021] [Accepted: 04/21/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Complementary and alternative medicine (CAM) are highly used among those diagnosed with glioma. Further research is warranted, however, as it remains important to clearly delineate CAM practices that are unproven, disproven, or promising for future research and implementation. METHODS A systematic review was conducted to identify all articles that investigated the effect of any CAM therapy on survival of patients with newly diagnosed or recurrent glioma. RESULTS Eighteen papers and 4 abstracts pertaining to the effects of ketogenic diet (4), antioxidants (3), hyperbaric oxygen (4), cannabinoids (2), carbogen and nicotinamide (3), mistletoe extract (2), hypocupremia and penicillamine (1), and overall CAM use (3) on overall and progression-free survival in patients with low- and high-grade glioma were identified (Levels of Evidence I-IV). Ketogenic diets, hyperbaric oxygen therapy, and cannabinoids appear to be safe and well tolerated by patients; preliminary studies demonstrate tumor response and increased progression-free survival and overall survival when combined with standard of care therapies. Antioxidant usage exhibit mixed results perhaps associated with glioma grade with greater effect on low-grade gliomas; vitamin D intake was associated with prolonged survival. Conversely, carbogen breathing and hypocupremia were found to have no effect on the survival of patients with glioma, with associated significant toxicity. Most modalities under the CAM umbrella have not been appropriately studied and require further investigation. CONCLUSIONS Despite widespread use, Level I or II evidence for CAM for the treatment of glioma is lacking, representing future research directions to optimally counsel and treat glioma patients.
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Affiliation(s)
- Dhiraj J Pangal
- USC Brain Tumor Center, USC Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA.
| | - Hans Baertsch
- USC Brain Tumor Center, USC Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Eliza M Kellman
- USC Brain Tumor Center, USC Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Tyler Cardinal
- USC Brain Tumor Center, USC Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Andrew Brunswick
- USC Brain Tumor Center, USC Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Martin Rutkowski
- USC Brain Tumor Center, USC Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Ben Strickland
- USC Brain Tumor Center, USC Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Frances Chow
- USC Brain Tumor Center, USC Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Frank Attenello
- USC Brain Tumor Center, USC Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Gabriel Zada
- USC Brain Tumor Center, USC Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
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Abstract
Surgical failure or recurrence of Cushing's disease can be treated with medical therapy, radiotherapy, adrenalectomy, and/or repeat transsphenoidal surgery, all of which have their respective benefits and drawbacks. Redo transsphenoidal surgery has been shown to achieve at least short-term remission in about 40-80% of patients and is associated with low rates of morbidity and near-zero mortality, albeit higher rates of postoperative hypopituitarism, diabetes insipidus, and cerebrospinal fluid leak than initial resection. Despite this, recurrence may ensue in 50% of patients. When selecting patient candidates for reoperation, many predictors of postoperative outcomes have been proposed including imaging characteristics, histopathological staining, intraoperative tumor visualization, and tumor size, however no single predictor consistently predicts outcomes. Redo transsphenoidal surgery should be performed by an experienced pituitary surgeon and patients should be followed at a tertiary care center by a multidisciplinary team consisting of an experienced endocrinologist and neurosurgeon to monitor closely for remission and recurrence.
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Affiliation(s)
- Tyler Cardinal
- USC Pituitary Center, Department of Neurosurgery, Keck School of Medicine of University of Southern California, 1300 N. State Street, Suite 3300, Los Angeles, CA, 90033, USA
| | - Gabriel Zada
- USC Pituitary Center, Department of Neurosurgery, Keck School of Medicine of University of Southern California, 1300 N. State Street, Suite 3300, Los Angeles, CA, 90033, USA
| | - John D Carmichael
- USC Pituitary Center, Department of Neurosurgery, Keck School of Medicine of University of Southern California, 1300 N. State Street, Suite 3300, Los Angeles, CA, 90033, USA; Department of Medicine, Division of Endocrinology and Diabetes, Keck School of Medicine of University of Southern California, 1333 San Pablo Street, BMT-B11, Los Angeles, CA, 90033, USA.
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17
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Cardinal T, Brunswick A, Strickland BA, Micko A, Shiroishi M, Liu CSJ, Wrobel B, Carmichael JD, Zada G. Safety and Effectiveness of the Direct Endoscopic Endonasal Approach for Primary Sellar Pathology: A Contemporary Case Series of More Than 400 Patients. World Neurosurg 2021; 148:e536-e546. [PMID: 33454431 DOI: 10.1016/j.wneu.2021.01.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 01/05/2021] [Accepted: 01/06/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND The direct endoscopic endonasal approach (EEA) has become the primary technique used for resection of sellar pathology, meriting investigation into the risk factors for complications and predictors of postoperative outcomes after direct EEA. METHODS We retrospectively analyzed the patient and tumor characteristics from 404 patients who had undergone direct EEA for sellar pathology at the USC Pituitary Center from September 2011 to December 2019. RESULTS Of the 404 pathologic entities included, 349 (86%) were pituitary adenomas (PAs), 29 (7%) were Rathke cleft cysts, and 26 (6%) were other sellar lesions. The mean lesion diameter was 2.3 cm, with 34 microadenomas (10%) and 315 macroadenomas (90%). Cavernous sinus invasion was present in 39% of the PAs. No patient died. The surgical complications included internal carotid artery injury without neurological sequelae (0.2%), vision loss (0.7%), meningitis (0.7%), cerebrospinal fluid leak (4%), epistaxis (4%), sinusitis (1%), transient cranial nerve paresis (0.5%), and postoperative abscess (0.25%). New hypopituitarism developed in 3%. Gross total resection was achieved in 208 PA cases (58%). Clinical improvement of headaches and visual deficits were reported for 67% and 76% of cases, respectively. Hormonal remission was achieved in 82% of patients with functional PAs. The median hospital stay was 2 days, with 34 patients (8%) readmitted within 30 days and 10 (3%) undergoing early reoperation. Disease recurrence or progression developed in 10% and was less likely in the case of gross total resection and apoplexy. CONCLUSION In the present, large, consecutive, mostly single-surgeon series, the patients experienced clinical improvement in most preoperative symptoms and had low rates of perioperative morbidity. We have demonstrated that direct EEA can be efficiently, safely, and successfully performed by a neurosurgical team.
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Affiliation(s)
- Tyler Cardinal
- USC Pituitary Center, Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.
| | - Andrew Brunswick
- USC Pituitary Center, Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Ben A Strickland
- USC Pituitary Center, Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Alexander Micko
- USC Pituitary Center, Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA; Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Mark Shiroishi
- Division of Neuroradiology, Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Chia-Shang J Liu
- Division of Neuroradiology, Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Bozena Wrobel
- Department of Otolaryngology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - John D Carmichael
- USC Pituitary Center, Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA; Division of Endocrinology and Diabetes, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Gabriel Zada
- USC Pituitary Center, Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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Cardinal T, Collet C, Wedemeyer M, Singer PA, Weiss M, Zada G, Carmichael JD. Postoperative GH and Degree of Reduction in IGF-1 Predicts Postoperative Hormonal Remission in Acromegaly. Front Endocrinol (Lausanne) 2021; 12:743052. [PMID: 34867787 PMCID: PMC8637049 DOI: 10.3389/fendo.2021.743052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 09/30/2021] [Indexed: 11/13/2022] Open
Abstract
PURPOSE Determine predictive factors for long-term remission of acromegaly after transsphenoidal resection of growth hormone (GH)-secreting pituitary adenomas. METHODS We identified 94 patients who had undergone transsphenoidal resection of GH-secreting pituitary adenomas for treatment of acromegaly at the USC Pituitary Center from 1999-2019 to determine the predictive value of postoperative endocrine lab values. RESULTS Patients underwent direct endoscopic endonasal (60%), microscopic transsphenoidal (38%), and extended endoscopic approaches (2%). The cohort was 63% female and 37% male, with average age of 48.9 years. Patients presented with acral enlargement (72, 77%), macroglossia (40, 43%), excessive sweating (39, 42%), prognathism (38, 40%) and frontal bossing (35, 37%). Seventy-five (80%) were macroadenomas and 19 (20%) were microadenomas. Cavernous sinus invasion was present in 45%. Available immunohistochemical data demonstrated GH staining in 88 (94%) and prolactin in 44 (47%). Available postoperative MRI demonstrated gross total resection in 63% of patients and subtotal resection in 37%. Most patients (66%) exhibited hormonal remission at 12 weeks postoperatively. Receiver operating characteristic (ROC) curves demonstrated postoperative day 1 (POD1) GH levels ≥1.55ng/mL predicted failure to remit from surgical resection alone (59% specificity, 75% sensitivity). A second ROC curve showed decrease in corrected insulin-like growth factor-1 (IGF-1) levels of at least 37% prognosticated biochemical control (90% sensitivity, 80% specificity). CONCLUSION POD1 GH and short-term postoperative IGF-1 levels can be used to successfully predict immediate and long-term hormonal remission respectively. A POD1 GH cutoff can identify patients likely to require adjuvant therapy to emphasize clinical follow-up.
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Affiliation(s)
- Tyler Cardinal
- University of Southern California (USC) Pituitary Center, Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, CA, United States
- *Correspondence: Tyler Cardinal,
| | - Casey Collet
- University of Southern California (USC) Pituitary Center, Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, CA, United States
| | - Michelle Wedemeyer
- University of Southern California (USC) Pituitary Center, Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, CA, United States
| | - Peter A. Singer
- University of Southern California (USC) Pituitary Center, Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, CA, United States
- Department of Medicine, Division of Endocrinology and Diabetes, Keck School of Medicine of University of Southern California, Los Angeles, CA, United States
| | | | - Gabriel Zada
- University of Southern California (USC) Pituitary Center, Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, CA, United States
| | - John D. Carmichael
- University of Southern California (USC) Pituitary Center, Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, CA, United States
- Department of Medicine, Division of Endocrinology and Diabetes, Keck School of Medicine of University of Southern California, Los Angeles, CA, United States
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Rutkowski MJ, Chang KE, Cardinal T, Du R, Tafreshi AR, Donoho DA, Brunswick A, Micko A, Liu CSJ, Shiroishi MS, Carmichael JD, Zada G. Development and clinical validation of a grading system for pituitary adenoma consistency. J Neurosurg 2020; 134:1800-1807. [PMID: 32503003 DOI: 10.3171/2020.4.jns193288] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 04/03/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Pituitary adenoma (PA) consistency, or texture, is an important intraoperative characteristic that may dictate operative dissection techniques and/or instruments used for tumor removal during endoscopic endonasal approaches (EEAs). The impact of PA consistency on surgical outcomes has yet to be elucidated. METHODS The authors developed an objective 5-point grading scale for PA consistency based on intraoperative characteristics, including ease of tumor debulking, manipulation, and instrument selection, ranging from cystic/hemorrhagic tumors (grade 1) to calcified tumors (grade 5). The proposed grading system was prospectively assessed in 306 consecutive patients who underwent an EEA for PAs, and who were subsequently analyzed for associations with surgical outcomes, including extent of resection (EOR) and complication profiles. RESULTS Institutional database review identified 306 patients who underwent intraoperative assessment of PA consistency, of which 96% were macroadenomas, 70% had suprasellar extension, and 44% had cavernous sinus invasion (CSI). There were 214 (69.9%) nonfunctional PAs and 92 functional PAs (31.1%). Distribution of scores included 15 grade 1 tumors (4.9%), 112 grade 2 tumors (36.6%), 125 grade 3 tumors (40.8%), 52 grade 4 tumors (17%), and 2 grade 5 tumors (0.7%). Compared to grade 1/2 and grade 3 PAs, grade 4/5 PAs were significantly larger (22.5 vs 26.6 vs 27.4 mm, p < 0.01), more likely to exhibit CSI (39% vs 42% vs 59%, p < 0.05), and trended toward nonfunctionality (67% vs 68% vs 82%, p = 0.086). Although there was no association between PA consistency and preoperative headaches or visual dysfunction, grade 4/5 PAs trended toward preoperative (p = 0.058) and postoperative panhypopituitarism (p = 0.066). Patients with preoperative visual dysfunction experienced greater improvement if they had a grade 1/2 PA (p < 0.05). Intraoperative CSF leaks were noted in 32% of cases and were more common with higher-consistency-grade tumors (p = 0.048), although this difference did not translate to postoperative CSF leaks. Gross-total resection (%) was more likely with lower PA consistency score as follows: grade 1/2 (60%), grade 3 (50%), grade 4/5 (44%; p = 0.045). Extracapsular techniques were almost exclusively performed in grade 4/5 PAs. Assignment of scores showed low variance and high reproducibility, with an intraclass correlation coefficient of 0.905 (95% CI 0.815-0.958), indicating excellent interrater reliability. CONCLUSIONS These findings demonstrate clinical validity of the proposed intraoperative grading scale with respect to PA subtype, neuroimaging features, EOR, and endocrine complications. Future studies will assess the relation of PA consistency to preoperative MRI findings to accurately predict consistency, thereby allowing the surgeon to tailor the exposure and prepare for varying resection strategies.
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Affiliation(s)
| | | | | | - Robin Du
- 1Department of Neurological Surgery
| | | | | | | | | | - Chia-Shang J Liu
- 3Department of Radiology, Keck Medical Center, University of Southern California, Los Angeles, California
| | - Mark S Shiroishi
- 3Department of Radiology, Keck Medical Center, University of Southern California, Los Angeles, California
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Cardinal T, Rutkowski M, Patel T, Shiroishi M, Carmichael JD, Zada G. MON-319 Impact of Tumor Characteristics and Preoperative IGF-1 Levels on Postoperative Hormonal Remission Following Endoscopic Transsphenoidal Surgery in Patients with Acromegaly: A Single-Surgeon Series. J Endocr Soc 2020. [PMCID: PMC7208766 DOI: 10.1210/jendso/bvaa046.994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Introduction: Acromegaly is a potentially fatal neuro-endocrinopathy caused by a growth hormone (GH)-secreting pituitary adenoma (PA). A lack of consensus on factors that reliably predict patient outcomes in acromegalic patients following endoscopic endonasal approaches (EEA) warrants additional investigation. Methods: Pre- and postoperative tumor and endocrinological characteristics from 55 acromegalic patients who underwent EEA for resection of a GH-secreting PA were evaluated as potential predictors of postoperative hormonal remission (defined as age- and sex- normalized IGF-1 levels). Results: The 55 patients included had a mean age of 50.1 ± 13.5 years and a mean follow-up time of 18 ± 17.4 months. Fifty-three patients (96%) presented with dysmorphic craniofacial features, with 22 (40%) presenting with prognathism, 22 (40%) exhibiting frontal bossing, and 18 (33%) presenting with macroglossia. Ten (18%) had microadenomas and 45 (82%) had macroadenomas. Five (9.4%) had giant adenomas. Forty-five (92%) tumors were invasive, with 44 (83%) exhibiting infrasellar invasion, 17 (32%) extending above the sella, and 9 (18%) with cavernous sinus invasion. Thirty-three patients (66%) underwent gross total resection (GTR; mean maximal tumor diameter = 1.52 cm), and 17 (34%) underwent subtotal resection (STR; mean maximal tumor diameter = 2.77 cm). Invasive tumors were significantly larger and Knosp scores were negatively correlated with GTR. Thirty-three patients (65%) achieved hormonal remission after EEA resection alone, which increased to 80% with adjunctive medical therapy. Additionally, 90% of patients who underwent GTR and 63% of patients who underwent STR demonstrated postoperative remission. Six patients (11%) exhibited biochemical remission after postoperative medical therapy with an average time to remission of 5.2 months. These patients all had significantly higher preoperative IGF-1 levels and larger tumors than patients who remitted immediately postoperatively. In all patients preoperative IGF-1 levels were inversely correlated with hormonal remission. Conclusions: This study indicates that endoscopic transsphenoidal resection of growth hormone secreting pituitary adenomas is a safe and highly effective management strategy for achieving hormonal remission and tumor control for patients with acromegaly. When combined with postoperative medical therapy, we observed endocrinological remission rates of 80% based on normalized IGF-1 levels. Our results support the conclusions of current literature that smaller and less invasive tumors are more likely to be fully resected. We additionally suggest that patients with lower preoperative IGF-1 are more likely to undergo postoperative biochemical remission, irrespective of tumor size and invasion.
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Affiliation(s)
| | | | - Tanu Patel
- KECK SCHOOL OF MEDICINE OF USC, Los Angeles, CA, USA
| | | | | | - Gabriel Zada
- KECK SCHOOL OF MEDICINE OF USC, Los Angeles, CA, USA
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Radwanski RE, Winston G, Younus I, Song I, Cardinal T, Mack WJ, Zada G, Greenfield JP, Pannullo SC. Medical Student Neurosurgery Training Camp: Updates Following 2019 Course Expansion. World Neurosurg 2019; 130:561-563. [PMID: 31351935 DOI: 10.1016/j.wneu.2019.07.157] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Ryan E Radwanski
- American Association of Neurological Surgeons Medical Student Chapter, Weill Cornell Medical College, New York, New York, USA
| | - Graham Winston
- American Association of Neurological Surgeons Medical Student Chapter, Weill Cornell Medical College, New York, New York, USA
| | - Iyan Younus
- American Association of Neurological Surgeons Medical Student Chapter, Weill Cornell Medical College, New York, New York, USA
| | - Ivy Song
- American Association of Neurological Surgeons Medical Student Chapter, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Tyler Cardinal
- American Association of Neurological Surgeons Medical Student Chapter, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - William J Mack
- American Association of Neurological Surgeons Medical Student Chapter, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Gabriel Zada
- American Association of Neurological Surgeons Medical Student Chapter, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Jeffrey P Greenfield
- American Association of Neurological Surgeons Medical Student Chapter, Weill Cornell Medical College, New York, New York, USA
| | - Susan C Pannullo
- American Association of Neurological Surgeons Medical Student Chapter, Weill Cornell Medical College, New York, New York, USA
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Petit Y, Park CH, Mok JM, Smetanina E, Chimier B, Duchateau G, Cardinal T, Canioni L, Park SH. Ultrashort laser induced spatial redistribution of silver species and nano-patterning of etching selectivity in silver-containing glasses. Opt Express 2019; 27:13675-13680. [PMID: 31163827 DOI: 10.1364/oe.27.013675] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 04/03/2019] [Indexed: 06/09/2023]
Abstract
Femtosecond laser-induced spatial redistribution of silver species (ions, clusters, and hole centers) in a silver-containing phosphate glass is investigated by correlative means of near-field scanning optical microscopy (NSOM) images, numerical simulations, chemical micro-probe analysis, and nanoscale spatial profiles after soft etching. In particular, we found that the chemical etching selectivity for nanoscale patterning is strongly dependent upon the irradiation of femtosecond laser due to the spatial redistribution of silver species within the affected area. These results strongly indicate that controlling the distribution of silver species by femtosecond laser irradiation may open new routes for surface nanoscale chemical and/or spatial patterning for the fabrication of 2D surface photonic crystals.
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Smetanina EO, Chimier B, Petit Y, Royon A, Cardinal T, Canioni L, Duchateau G. Laser writing of nonlinear optical properties in silver-doped phosphate glass. Opt Lett 2017; 42:1688-1691. [PMID: 28454136 DOI: 10.1364/ol.42.001688] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The formation of both local second- and third-harmonic generations (SHG and THG) induced by a train of femtosecond laser pulses in silver-doped phosphate glasses is addressed. Based on modeling calculations, including various diffusion and kinetic processes, THG is shown to result from the formation of silver clusters. The latter organize into a ring-shape structure, leading to the emergence of a static electric field. By breaking the glass centro-symmetry, this field gives rise to a local effective second-order susceptibility, inducing SHG. Both theoretically predicted SHG and THG evolutions with respect to the number of pulses in the train are in good agreement with experimental observations. In particular, the observed reaching of a maximum in the nonlinear optical responses after a few thousands of pulses is explained by the competition of various physical processes. A cooling of the glass is shown to improve the process efficiency of the laser writing of second-order nonlinearity.
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Lepicard A, Cardinal T, Fargin E, Adamietz F, Rodriguez V, Richardson K, Dussauze M. Micro-structuring the surface reactivity of a borosilicate glass via thermal poling. Chem Phys Lett 2016. [DOI: 10.1016/j.cplett.2016.09.077] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Abstract
GaN quantum dots (QDs) are prepared in a one-step continuous process using anhydrous solvents at supercritical conditions (and temperatures below 450 °C) in short residence times, typically less than 25 s.
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Affiliation(s)
| | - S. Marre
- CNRS
- ICMCB
- UPR 9048
- F-33600 Pessac
- France
| | - A. Garcia
- CNRS
- ICMCB
- UPR 9048
- F-33600 Pessac
- France
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Massera J, Petit L, Cardinal T, Videau JJ, Hupa M, Hupa L. Thermal properties and surface reactivity in simulated body fluid of new strontium ion-containing phosphate glasses. J Mater Sci Mater Med 2013; 24:1407-1416. [PMID: 23512152 DOI: 10.1007/s10856-013-4910-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2012] [Accepted: 03/08/2013] [Indexed: 06/01/2023]
Abstract
In this paper, we investigate the effect of SrO substitution for CaO in 50P₂O₅-10Na₂-(40-x)CaO-xSrO glass system (x from 0 to 40) on the thermal and structural properties and also on the glass reactivity in simulated body fluid (SBF) in order to find new glass candidates for biomedical glass fibers. The addition of SrO at the expense of CaO seems to restrain the leaching of phosphate ions in the solution limiting the reduction of the solution pH. We observed the formation of an apatite layer at the surface of the glasses when in contact with SBF. SrO and MgO were found in the apatite layer of the strontium ion-containing glasses, the concentration of which increases with an increase of SrO content. We think that it is the presence of MgO and SrO in the layer which limits the leaching of phosphate in the solution and thus the glass dissolution in SBF.
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Affiliation(s)
- J Massera
- Process Chemistry Centre, Åbo Akademi University, Biskopsgatan 8, 20500 Turku, Finland.
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Petit Y, Royon A, Marquestaut N, Dussauze M, Fargues A, Veber P, Jubera V, Cardinal T, Canioni L. Two-photon excited fluorescence in the LYB:Eu monoclinic crystal: towards a new scheme of single-beam dual-voxel direct laser writing in crystals. Opt Express 2013; 21:822-833. [PMID: 23388975 DOI: 10.1364/oe.21.000822] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
We report on two-photon excited fluorescence in the oriented Eu(3+)doped LYB monoclinic crystal under femtosecond laser tight focusing. Due to spatial walk-off, the two polarization modes of the incident femtosecond beam simultaneously provide the independent excitation of two distinct focuses, leading to a single-beam dual-voxel nonlinear excitation of fluorescence below material modification threshold. These observations emphasize on the anisotropy of both two-photon absorption as well as fluorescence emission. They demonstrate the localized control of the nonlinear energy deposit, thanks to the adjustment of both the input power and polarization, by properly balancing the injected energy in each voxel. Such approach should be considered for future direct laser writing of waveguides in propagation directions out of the dielectric axes, so as to optimally cope with the highly probable anisotropy of laser-induced material modification thresholds in these crystals. These results open new ways for further potential developments in direct laser writing as the simultaneous inscription of double-line structures for original waveguides processes.
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Affiliation(s)
- Y Petit
- Université Bordeaux, LOMA, UMR 5798, F-33400 Talence, France.
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Assaf BA, Cardinal T, Wei P, Katmis F, Moodera JS, Heiman D. Modified electrical transport probe design for standard magnetometer. Rev Sci Instrum 2012; 83:033904. [PMID: 22462935 DOI: 10.1063/1.3697998] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Making electrical transport measurements on a material is often a time consuming process that involves testing a large number of samples. It is thus inconvenient to wire up and rewire samples onto a sample probe. We therefore present a method of modifying Quantum Design's MPMS SQUID magnetometer transport probe that simplifies the process of sample mounting. One of the difficulties to overcome is the small diameter of the sample space. A small socket is designed and mounted on the probe so that various samples mounted on individual headers can be readily exchanged in the socket. We also present some test results on the topological insulator Bi(2)Te(2)Se using the modified probe.
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Affiliation(s)
- B A Assaf
- Department of Physics, Northeastern University, Boston, Massachusetts 02115, USA
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Petit L, Abel J, Anderson T, Choi J, Nazabal V, Moizan V, Couzi M, Richardson M, Maurel C, Cardinal T, Richardson K. Processing and characterization of new passive and active oxysulfide glasses in the Ge–Ga–Sb–S–O system. J SOLID STATE CHEM 2009. [DOI: 10.1016/j.jssc.2009.07.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Manek-Hönninger I, Boullet J, Cardinal T, Guillen F, Ermeneux S, Podgorski M, Bello Doua R, Salin F. Photodarkening and photobleaching of an ytterbium-doped silica double-clad LMA fiber. Opt Express 2007; 15:1606-1611. [PMID: 19532394 DOI: 10.1364/oe.15.001606] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
We studied the temporal evolution of the photodarkening effect in an Yb-doped silica LMA fiber. The absorption spectra exhibit an increase in absorption in the visible and in the near infrared spectral range when the fiber is exposed to pump light around 980 nm. We show the influence of the photodarkening on the cw lasing properties of the fiber, and demonstrate photobleaching of the same fiber by exposure to UV light at 355 nm. The corresponding absorption spectra and lasing performances are shown and are entirely comparable to those of a new fiber.
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Guillon C, Langot P, Del Fatti N, Vallée F, Kirakosyan AS, Shahbazyan TV, Cardinal T, Treguer M. Coherent acoustic vibration of metal nanoshells. Nano Lett 2007; 7:138-42. [PMID: 17212453 DOI: 10.1021/nl062380d] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Using time-resolved pump-probe spectroscopy, we have performed the first investigation of the vibrational modes of gold nanoshells. The fundamental isotropic mode launched by a femtosecond pump pulse manifests itself in a pronounced time-domain modulation of the differential transmission probed at the frequency of nanoshell surface plasmon resonance. The modulation amplitude is significantly stronger, and the period is longer than that in a gold nanoparticle of the same overall size, in agreement with theoretical calculations. This distinct acoustical signature of nanoshells provides a new and efficient method for identifying these versatile nanostructures and for studying their mechanical and structural properties.
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Affiliation(s)
- C Guillon
- Centre de Physique Moléculaire Optique et Hertzienne CNRS and Université Bordeaux I, 351 cours de la Libération, 33405 Talence, France
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Puhl SM, Maliszewski AF, Varela J, Cardinal T, Tompkins C, Vahdat A. Accuracy of 1-RM Estimation Across Sex and Fitness Groups. Med Sci Sports Exerc 2004. [DOI: 10.1249/00005768-200405001-01694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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