Tag: adenoma

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Quality of Life After Endoscopic Surgical Management of Pituitary Adenomas

Neurosurgery 90:81–91, 2022

Patient-reported quality of life (QOL) is a vital metric for surgical success.
OBJECTIVE: To assess the effect of surgery on QOL in the largest prospectively collected, longitudinal cohort of surgically managed pituitary adenomas.
METHODS: A consecutive surgical adenoma cohort (n=304) between late 2016 and mid- 2020 underwent a scheduled overall (Anterior Skull Base Questionnaire-35) and sinonasal- specific (Sinonasal Outcome Test-22) QOL assessment. Scores were stratified by adenoma subtype and analyzed for clinical predictors of QOL changes.
RESULTS: The average age was 53.8 ± 16 yr, and 53% of participants were female. 60.9% of adenomas were nonfunctioning while adrenocorticotropic hormone adenomas (16.4%), growth hormone adenomas (14.1%), and prolactinomas (5.9%) were the most prevalent secreting adenomas. Baseline overall QOL differed between tumor types (P = .006), with adrenocorticotropic hormone adenomas worse than growth hormone adenomas (P = .03) and nonfunctioning pituitary adenomas (NFPA) (P < .001). Sinonasal QOL worsened in the 3 wk after surgery but returned to baseline by 6 wk and beyond. Overall QOL worsened at 3 wk after surgery (P < .001) but significantly improved from baseline by 3 mo (P = .009) and beyond (P < .001). Emotional functioning improved soon after surgery, followed by performance and pain, and then, by 6 mo, physical function and vitality. Predictors of improved QOL were sellar/suprasellar lesions (P = .01), prolactinomas (P = .003), and NFPA (P = .04). Conversely, new postoperative hypopituitarism (P = .04) and larger adenoma volume (P = .04) predicted QOL worsening.
CONCLUSION: QOL is worsened after surgery at early time points. Prolactinomas and NFPA enjoy significant QOL improvements from surgery as early as 3 mo postoperatively. Other functional tumors may experience early benefits in younger patients without hypopituitarism and when isolated to the sellar/suprasellar region. These findings provide valuable information for counseling patients and setting expectations for surgery.

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Endoscopic Transnasal Trans-Sphenoidal Approach for Pituitary Adenomas: A Comparison to the Microscopic Approach Cohort by Propensity Score Analysis

Neurosurgery DOI:10.1093/neuros/nyz201

Despite some evidence for the adoption of endoscopic transnasal transsphenoidal surgery (ETSS) for pituitary adenomas, the advantages of this technique over the traditional approach have not been robustly confirmed.

OBJECTIVE: To compare ETSS with the microscopic sublabial trans-septal transsphenoidal surgery (MTSS) for pituitary adenomas.

METHODS: We retrospectively reviewed 2 cohorts of ETSS and MTSS performed at our institution from 1995 to 2017. Patient characteristics, surgical data, and outcomes were recorded prospectively. We performed a univariate and multivariable analysis to determine the best surgical approach. To improve the quality of the results, we matched the distribution of patient characteristics between groups by propensity score (PS) method.

RESULTS: A total of 187 procedures (90 MTSS, 97 ETSS) were reviewed. We found better results in the ETSS group in terms of gross total resection (P = .002) and hormone-excess secretion control (P=.014). There was also a lower incidence of cerebrospinal fluid leakage (P = .039), transitory diabetes insipidus (P = .028), and postoperative hypopituitarism (P = .045), as well as a shorter hospital length of stay (P < .001). After PS matching, we confirmed by multivariable logistic regression analysis an increased odds ratio of gross total resection for the ETSS (3.910; 95% CI 1.720-8.889; P= .001).

CONCLUSION: By PS method, our results suggest that the ETSS provides advantages over the traditional MTSS approach for tumor resection. Better control of secreting tumors and a lower rate of most complications also support the selection of the ETSS approach for the treatment of pituitary adenomas.

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Withholding Perioperative Steroids in Patients Undergoing Transsphenoidal Resection for Pituitary Disease: Randomized Prospective Clinical Trial to Assess Safety

Neurosurgery, Volume 85, Issue 2, August 2019, Pages E226–E232

Perioperative steroid protocols for patients undergoing transsphenoidal surgery (TSS) for pituitary pathology vary by institution.

OBJECTIVE: To assess the safety of withholding glucocorticoids in patients undergoing TSS.

METHODS: Patients with an intact hypothalamic-pituitary-adrenal (HPA) axis undergoing TSS for a pituitary tumor at the same academic institution between 2012 and 2015 were randomized to either receive 100 mg of intravenous hydrocortisone followed by 0.5 mg of intravenous dexamethasone every 6 h for 4 doses (STER, n = 23) or to undergo surgery without steroids (NOSTER, n = 20). Postoperative cortisol levels were then used to determine the need for glucocorticoids after surgery. Data regarding postoperative cortisol levels, hospital stay length, and complications were collected.

RESULTS: Mean postoperative 8 am cortisol levels were higher in the NOSTER group compared to the STER group (745 ± 359 nmol/L and 386 ± 193 nmol/L, respectively, P = .001) and more patients were discharged on glucocorticoids in the STER group (42% vs 12%, P = .07). There was no difference in the incidence of postoperative complications, including hyperglycemia, diabetes insipidus, or permanent adrenal insufficiency. Permanent adrenal insufficiency occurred in 8% of patients.

CONCLUSION: Perioperative steroids can be safely withheld in patients with an intact HPA axis undergoing TSS. Although administration of perioperative glucocorticoids does not appear to increase the risk of complications, it may interfere with assessment of the HPA axis after surgery.

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Endonasal endoscopic pituitary surgery in the elderly

J Neurosurg 128:429–436, 2018

Pituitary adenomas are benign, slow-growing tumors that cause symptoms either through mass effect or hormone overproduction. The decision to operate on a healthy young person is relatively straightforward. In the elderly population, however, the risks of complications may increase, rendering the decision more complex. Few studies have documented the risks of surgery using the endonasal endoscopic approach in a large number of elderly patients. The purpose of this study was to audit a single center’s data regarding outcomes of purely endoscopic endonasal transsphenoidal resection of pituitary adenomas in elderly patients and to compare them to the current literature.

METHODS A retrospective review of a prospectively acquired database of all endonasal endoscopic surgeries done by the senior authors was queried for patients aged 60–69 years and for those aged 70 years or older. Demographic and radiographic preoperative data were reviewed. Outcomes with respect to extent of resection and complications were examined and compared with appropriate statistical tests.

RESULTS A total of 135 patents were identified (81 aged 60–69 years and 54 aged 70 years or older [70+]). The average tumor diameter was slightly larger for the patients in the 70+ age group (mean [SD] 25.7 ± 9.2 mm) than for patients aged 60–69 years (23.1 ± 9.8 mm, p = 0.056). There was no significant difference in intraoperative blood loss (p > 0.99), length of stay (p = 0.22), or duration of follow-up (p = 0.21) between the 2 groups. There was a 7.4% complication rate in patients aged 60–69 years (3 nasal and 3 medical complications) and an 18.5% complication rate in patients older than 70 years (4 cranial, 3 nasal, 1 visual, and 2 medical complications; p = 0.05 overall and 0.013 for cranial complications). Cranial complications in the 70+ age category included 2 postoperative hematomas, 1 pseudoaneurysm formation, and 1 case of symptomatic subdural hygromas.

CONCLUSIONS Endonasal endoscopic surgery in elderly patients is safe, but there is a graded increase in complication rates with increasing age. The decision to operate on an asymptomatic or mildly symptomatic patient in these age groups should take this increasing complication rate into account. The use of a lumbar drain or lumbar punctures should be weighed against the risk of subdural hematoma in patients with preexisting atrophy.

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Surgical complications after transsphenoidal microscopic and endoscopic surgery for pituitary adenoma: a consecutive series of 506 procedures

Treatment of acromegaly by endoscopic transsphenoidal surgery

Acta Neurochir (2014) 156:441–449

This single-institution, consecutive series of transsphenoidal procedures included all patients in a defined population of 2.6 million inhabitants who underwent surgery during a specific time period.

Objective We sought to determine the surgical complication rate and overall survival rate after transsphenoidal surgery for pituitary adenoma.

Methods All transsphenoidal procedures for histologically verified pituitary adenomas performed between September 2002 and February 2011 at our institution were included in this study. The data were obtained from a prospectively collected database and from reviewing medical records. No patients were lost to follow-up, and the median follow-up time was 28 months.

Results A total of 506 transsphenoidal procedures were performed on 446 patients. There were 268 microscopic and 238 endoscopic procedures involving 352 non-functioning and 154 hormone-secreting adenomas. A total of 73 % of the procedures were primary surgeries, and 27 % were repeat surgeries for tumor recurrence. The overall complication rate was 9.1 %. The three most frequent complications were cerebrospinal fluid (CSF) leakage (4.7 %), meningitis (2 %), and visual deterioration (2 %). Multivariate analyses showed that the overall risk for complications increased with older age, surgery for recurrent tumors, and surgery performed by a low-volume surgeon. There was no significant difference in the overall complication rate between the microsurgical and endoscopic techniques. The rate of surgical mortality was 0.6 %, and the overall survival rates at 1 and 5 years were 95 % and 90 %, respectively. The only negative predictor of survival was older age.

Conclusions Transsphenoidal surgery for pituitary adenomas has a low complication rate and a low rate of mortality. We did not find a significant difference in the complication rate between endoscopic and microscopic techniques.

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Endoscopic Endonasal Transclival Approach to the Jugular Tubercle

Neurosurgery 71[ONS Suppl 1]:ons146–ons159, 2012

The jugular tubercle is a rounded bony prominence that arises from the inferolateral margin of the clivus. In a previous publication, we described the surgical anatomy of the expanded endonasal approach to the jugular tubercle.

OBJECTIVE: To illustrate the translation of laboratory work to the operating room describing the anatomic and technical nuances of the endonasal approach to the jugular tubercle.

METHODS: We review the relevant surgical anatomy needed to perform an endonasal approach to the jugular tubercle, and we select 4 different lesions to illustrate the application of our laboratory findings.

RESULTS: In the first case, exposure and partial drilling of the jugular tubercle was critical to gain an adequate corridor to the meningioma, particularly to its inferolateral margin. This allowed for early devascularization, safe extracapsular dissection, and preservation of surrounding neurovascular structures. In addition, the jugular tubercle was hyperostotic and its resection, along with generous dural removal, provided a grade I Simpson tumor resection. In the second (chondrosarcoma) and third (chordoma) cases, the jugular tubercle was infiltrated by tumor, and consequently its complete resection was essential to achieve total tumor removal. In the last case, an unusual adrenocorticotropic hormone-secreting adenoma recurrence at the jugular tubercle region, the technical modification of the transclival approach presented here was successfully applied to achieve complete resection and Cushing disease remission.

CONCLUSION: The transjugular tubercle variant of the expanded endonasal transclival approach allows for direct access to ventrolateral lesions in the inferior clival/petroclival region with no cerebral or cerebellar retraction, or cranial nerve manipulation during the approach.

 

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Dural invasion in Cushing disease

J Neurosurg 116:272–279, 2012. DOI: 10.3171/2011.8.JNS11456

Dural invasion by adrenocorticotropic hormone (ACTH)-secreting adenomas is a significant risk factor for incomplete resection and recurrence in Cushing disease (CD). Since ACTH-producing adenomas are often the smallest of the various types of pituitary tumors at the time of resection, examining their invasion provides the best opportunity to identify the precise sites of early dural invasion by pituitary adenomas. To characterize the incidence and anatomical distribution of dural invasion by ACTH-secreting adenomas, the authors prospectively and systematically analyzed features of dural invasion in patients with CD.

Methods. The authors prospectively studied consecutive patients with CD undergoing the systematic removal of ACTH-secreting adenoma and histological analysis of the anterior sella dura as well as other sites of dural invasion that were evident at surgery. Clinical, imaging, histological, and operative findings were analyzed.

Results. Eighty-seven patients with CD (58 females and 29 males) were included in the study. Overall, dural invasion by an ACTH-positive adenoma was histologically confirmed in 30 patients (34%). Eighteen patients (60% of dural invasion cases, 21% of all patients) had evidence of cavernous sinus wall invasion (4 of these patients also had other contiguous sites of invasion), and 12 patients (40% of dural invasion cases) had invasion of the sella dura excluding the cavernous sinus wall. Eleven patients (13% all patients) had invasion of the routinely procured anterior sella dura specimen. Preoperative MR imaging revealed an adenoma in 64 patients (74%) but accurately predicted dural invasion in only 4 patients (22%) with cavernous sinus invasion and none of the patients with non–cavernous sinus invasion. Adenomas associated with dural invasion (mean ± SD, 10.9 ± 7.8 mm, range 2–37 mm) were significantly larger than those not associated with dural invasion (5.7 ± 2.1 mm, range 2.5–12 mm; p = 0.0006, Mann- Whitney test).

Conclusions. Dural invasion by ACTH-producing adenomas preferentially occurs laterally into the wall of the cavernous sinus. Preoperative MR imaging infrequently detects dural invasion, including cavernous sinus invasion. Invasion is directly associated with tumor size. To provide a biochemical cure and avoid recurrence after resection, identification and removal of invaded sella dura, including the medial cavernous sinus wall, are necessary.

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