Usefulness of Intraoperative Computed Tomography on Extent of Resection of Large and Giant Pituitary Adenomas. Experience from a Developing Country

Abstract Background Pituitary apoplexy after resection of giant pituitary adenomas is a rare but often cited morbidity associated with devastating outcomes. It presents as hemorrhage and/or infarction of residual tumor in the postoperative period. Because of its rarity, its incidence and consequences remain ill defined. Objective The aim of this study is to estimate the rate of postoperative pituitary apoplexy after resection of giant pituitary adenomas and assess the morbidity and mortality associated with apoplexy. Methods A systematic review of literature was performed to examine extent of resection in giant pituitary adenomas based on surgical approach, rate of postoperative apoplexy, morbidities, and mortality. Advantages and disadvantages of each approach were compared. Results Seventeen studies were included in quantitative analysis describing 1,031 cases of resection of giant pituitary adenomas. The overall rate of subtotal resection (<90%) for all surgical approaches combined was 35.6% (95% confidence interval: 28.0–43.1). Postoperative pituitary apoplexy developed in 5.65% (n = 19) of subtotal resections, often within 24 hours and with a mortality of 42.1% (n = 8). Resulting morbidities included visual deficits, altered consciousness, cranial nerve palsies, and convulsions. Conclusion Postoperative pituitary apoplexy is uncommon but is associated with high rates of morbidity and mortality in subtotal resection cases. These findings highlight the importance in achieving a maximal resection in a time sensitive fashion to mitigate the severe consequences of postoperative apoplexy.

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Analysis of Related Factors of Tumor Recurrence or Progression After Transnasal Sphenoidal Surgical Treatment of Large and Giant Pituitary Adenomas and Establish a Nomogram to Predict Tumor Prognosis

Frontiers in Endocrinology ◽

10.3389/fendo.2021.793337 ◽

2021 ◽

Vol 12 ◽

Author(s):

Yike Chen ◽

Feng Cai ◽

Jing Cao ◽

Feng Gao ◽

Yao Lv ◽

...

Keyword(s):

Risk Factors ◽

Pituitary Adenomas ◽

Tumor Recurrence ◽

Extent Of Resection ◽

Partial Resection ◽

Smoking History ◽

Ki 67 ◽

Multiple Factors ◽

Giant Pituitary Adenomas ◽

Tumor Prognosis

BackgroundPituitary adenoma (PA) is a benign neuroendocrine tumor caused by adenohypophysial cells, and accounts for 10%-20% of all primary intracranial tumors. The surgical outcomes and prognosis of giant pituitary adenomas measuring ≥3 cm in diameter differ significantly due to the influence of multiple factors such as tumor morphology, invasion site, pathological characteristics and so on. The aim of this study was to explore the risk factors related to the recurrence or progression of giant and large PAs after transnasal sphenoidal surgery, and develop a predictive model for tumor prognosis.MethodsThe clinical and follow-up data of 172 patients with large or giant PA who underwent sphenoidal surgery at the Second Affiliated Hospital of Zhejiang University School of Medicine from January 2011 to December 2017 were retrospectively analyzed. The basic clinical information (age, gender, past medical history etc.), imaging features (tumor size, invasion characteristics, extent of resection etc.), and histopathological characteristics (pathological results, Ki-67, P53 etc.) were retrieved. SPSS 21.0 software was used for statistical analysis, and the R software was used to establish the predictive nomogram.ResultsSeventy out of the 172 examined cases (40.7%) had tumor recurrence or progression. The overall progress free survival (PFS) rates of the patients at 1, 3 and 5 years after surgery were 90.70%, 79.65% and 59.30% respectively. Log-rank test indicated that BMI (P < 0.001), Knosp classification (P < 0.001), extent of resection (P < 0.001), Ki-67 (P < 0.001), sphenoidal sinus invasion (P = 0.001), Hardy classification (P = 0.003) and smoking history (P = 0.018) were significantly associated with post-surgery recurrence or progression. Cox regression analysis further indicated that smoking history, BMI ≥25 kg/m2, Knosp classification grade 4, partial resection and ≥3% Ki-67 positive rate were independent risk factors of tumor recurrence or progression (P < 0.05). In addition, the nomogram and ROC curve based on the above results indicated significant clinical value.ConclusionThe postoperative recurrence or progression of large and giant PAs is related to multiple factors and a prognostic nomogram based on BMI (≥25 kg/m2), Knosp classification (grade 4), extent of resection (partial resection) and Ki-67 (≥3%) can predict the recurrence or progression of large and giant PAs after transnasal sphenoidal surgery.

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Endoscopic Endonasal Transsphenoidal Approach to Large and Giant Pituitary Adenomas: Institutional Experience and Predictors of Extent of Resection

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0033-1336147 ◽

2013 ◽

Vol 74 (S 01) ◽

Cited By ~ 1

Author(s):

Kyle Juraschka ◽

Boris Krischek ◽

Eric Monsalves ◽

Alex Kilian ◽

Aisha Ghare ◽

...

Keyword(s):

Pituitary Adenomas ◽

Extent Of Resection ◽

Transsphenoidal Approach ◽

Endoscopic Endonasal ◽

Institutional Experience ◽

Giant Pituitary Adenomas

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Endoscopic endonasal transsphenoidal approach to large and giant pituitary adenomas: institutional experience and predictors of extent of resection

Journal of Neurosurgery ◽

10.3171/2014.3.jns131679 ◽

2014 ◽

Vol 121 (1) ◽

pp. 75-83 ◽

Cited By ~ 78

Author(s):

Kyle Juraschka ◽

Osaama H. Khan ◽

Bruno L. Godoy ◽

Eric Monsalves ◽

Alexandra Kilian ◽

...

Keyword(s):

Pituitary Adenomas ◽

Transsphenoidal Surgery ◽

Sphenoid Sinus ◽

Tumor Volume ◽

Extent Of Resection ◽

Tumor Diameter ◽

Endoscopic Endonasal ◽

Posterior Extension ◽

Endoscopic Endonasal Transsphenoidal Surgery ◽

Giant Pituitary Adenomas

Object While the use of endoscopic approaches has become increasingly accepted in the resection of pituitary adenomas, limited evidence exists regarding the success of this technique for patients with large and giant pituitary adenomas. This study reviews the outcomes of a large cohort of patients with large and giant pituitary adenomas who underwent endoscopic endonasal transsphenoidal surgery at the authors' institution and focuses on identifying factors that can predict extent of resection and hence aid in developing guidelines and indications for the use of endoscopic endonasal transsphenoidal surgery versus open craniotomy approaches to large and giant pituitary adenomas. Methods The authors reviewed 487 patients who underwent endoscopic endonasal transsphenoidal resection of sellar masses. From this group, 73 consecutive patients with large and giant pituitary adenomas (defined as maximum diameter ≥ 3 cm and tumor volume ≥ 10 cm3) who underwent endoscopic endonasal transsphenoidal surgery between January 1, 2006, and June 6, 2012, were included in the study. Clinical presentation, radiological studies, laboratory investigations, tumor pathology data, clinical outcomes, extent of resection measured by volumetric analysis, and complications were analyzed. Results The mean preoperative tumor diameter in this series was 4.1 cm and the volume was 18 cm3. The average resection rate was 82.9%, corresponding with a mean residual volume of 3 cm3. Gross-total resection was achieved in 16 patients (24%), near-total in 11 (17%), subtotal in 24 (36%), and partial in 15 (23%). Seventy-three percent of patients experienced improvement in visual acuity, while 24% were unchanged. Visual fields were improved in 61.8% and unchanged in 5.5%. Overall, 27 patients (37%) experienced a total of 32 complications. The most common complications were sinusitis (14%) and CSF leak (10%). Six patients underwent subsequent radiation therapy because of aggressive tumor histopathology. No deaths occurred in this cohort of patients. Statistically significant predictors of extent of resection included highest Knosp grade (p = 0.001), preoperative tumor volume (p = 0.025), preoperative maximum tumor diameter (p = 0.002), hemorrhagic component (p = 0.027), posterior extension (p = 0.001), and sphenoid sinus invasion (p = 0.005). Conclusions Endoscopic endonasal transsphenoidal surgery is an effective treatment method for patients with large and giant pituitary adenomas, which results in high (> 80%) rates of resection and improvement in visual function. It is not associated with high rates of major complications and is safe when performed by experienced surgeons. The preoperative Knosp grade, tumor volume, tumor diameter, hemorrhagic components on MRI, posterior extension, and sphenoid sinus invasion may allow a prediction of extent of resection and in these patients a staged operation may be required to maximize extent of resection.

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Primary Endoscopic Endonasal Management of Giant Pituitary Adenomas: Outcome and Pitfalls from a Large Prospective Multicenter Experience

Cancers ◽

10.3390/cancers13143603 ◽

2021 ◽

Vol 13 (14) ◽

pp. 3603

Author(s):

Salvatore Chibbaro ◽

Francesco Signorelli ◽

Davide Milani ◽

Helene Cebula ◽

Antonino Scibilia ◽

...

Keyword(s):

Pituitary Adenomas ◽

Anterior Pituitary ◽

Extent Of Resection ◽

Incomplete Resection ◽

Pituitary Insufficiency ◽

Recurrence Rates ◽

Endoscopic Endonasal ◽

Multi Stage ◽

Clinical And Radiological Outcome ◽

Giant Pituitary Adenomas

Purpose: To evaluate factors influencing clinical and radiological outcome of extended endoscopic endonasal transtuberculum/transplanum approach (EEA-TTP) for giant pituitary adenomas (GPAs). Methods: We recruited prospectively all consecutive GPAs patients undergoing EEA-TTP between 2015 and 2019 in 5 neurosurgical centers. Preoperative clinical and radiologic features, visual and hormonal outcomes, extent of resection (EoR), complications and recurrence rates were recorded and analyzed. Results: Of 1169 patients treated for pituitary adenoma, 96 (8.2%) had GPAs. Seventy-eight (81.2%) patients had visual impairment, 12 (12.5%) had headaches, 3 (3.1%) had drowsiness due to hydrocephalus, and 53 (55.2%) had anterior pituitary insufficiency. EoR was gross or near-total in 46 (47.9%) and subtotal in 50 (52.1%) patients. Incomplete resection was associated with lateral suprasellar, intraventricular and/or cavernous sinus extension and with firm/fibrous consistence. At the last follow-up, all but one patient (77, 98.7%) with visual deficits improved. Headache improved in 8 (88.9%) and anterior pituitary function recovered in 27 (50.9%) patients. Recurrence rate was 16.7%, with 32 months mean recurrence-free survival. Conclusions: EEA-TTP is a valid option for GPAs and seems to provide better outcomes, lower rate of complications and higher EoR compared to one- or multi-stage microscopic, non-extended endoscopic transsphenoidal, and transcranial resections.

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Treatment strategies for giant pituitary adenomas in the era of endoscopic transsphenoidal surgery: a multicenter series

Journal of Neurosurgery ◽

10.3171/2021.1.jns203982 ◽

2021 ◽

pp. 1-10

Author(s):

Alexander Micko ◽

Matthew S. Agam ◽

Andrew Brunswick ◽

Ben A. Strickland ◽

Martin J. Rutkowski ◽

...

Keyword(s):

Pituitary Adenomas ◽

Transsphenoidal Surgery ◽

Treatment Strategies ◽

Extent Of Resection ◽

Gross Total Resection ◽

Total Resection ◽

Endoscopic Transsphenoidal Surgery ◽

Group A ◽

Giant Pituitary Adenomas ◽

Group B

OBJECTIVE Given the anatomical complexity and frequently invasive growth of giant pituitary adenomas (GPAs), individually tailored approaches are required. The aim of this study was to assess the treatment strategies and outcomes in a large multicenter series of GPAs in the era of endoscopic transsphenoidal surgery (ETS). METHODS This was a retrospective case-control series of 64 patients with GPAs treated at two tertiary care centers by surgeons with experience in ETS. GPAs were defined by a maximum diameter of ≥ 4 cm and a volume of ≥ 10 cm3 on preoperative isovoxel contrast-enhanced MRI. RESULTS The primary operation was ETS in all cases. Overall gross-total resection rates were 64% in round GPAs, 46% in dumbbell-shaped GPAs, and 8% in multilobular GPAs (p < 0.001). Postoperative outcomes were further stratified into two groups based on extent of resection: group A (gross-total resection or partial resection with intracavernous remnant; 21/64, 33%) and group B (partial resection with intracranial remnant; 43/64, 67%). Growth patterns of GPAs were mostly round (11/14, 79%) in group A and multilobular (33/37, 89%) in group B. In group A, no patients required a second operation, and 2/21 (9%) were treated with adjuvant radiosurgery. In group B, early transcranial reoperation was required in 6/43 (14%) cases due to hemorrhagic transformation of remnants. For the remaining group B patients with remnants, 5/43 (12%) underwent transcranial surgery and 12/43 (28%) underwent delayed second ETS. There were no deaths in this series. Severe complications included stroke (6%), meningitis (6%), hydrocephalus requiring shunting (6%), and loss or distinct worsening of vision (3%). At follow-up (mean 3 years, range 0.5–16 years), stable disease was achieved in 91% of cases. CONCLUSIONS ETS as a primary treatment modality to relieve mass effect in GPAs and extent of resection are dependent on GPA morphology. The pattern of residual pituitary adenoma guides further treatment strategies, including early transcranial reoperation, delayed endoscopic transsphenoidal/transcranial reoperation, and adjuvant radiosurgery.

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