Factors Associated with Biochemical Remission after Open Transsphenoidal Surgery for Acromegaly

2013 ◽  
Vol 74 (S 01) ◽  
Author(s):  
Hai Sun ◽  
Jessica Brzana ◽  
Chris Yedinak ◽  
Sakir Gultekin ◽  
Johnny Delashaw ◽  
...  
Keyword(s):  
Transsphenoidal Surgery ◽  
Factors Associated ◽  
Biochemical Remission

scholarly journals Factors Associated with Biochemical Remission after Microscopic Transsphenoidal Surgery for Acromegaly

2013 ◽  
Vol 75 (01) ◽  
pp. 047-052 ◽  
Author(s):  
Hai Sun ◽  
Jessica Brzana ◽  
Chris Yedinak ◽  
Sakir Gultekin ◽  
Johnny Delashaw ◽  
...  
Keyword(s):  
Transsphenoidal Surgery ◽  
Factors Associated ◽  
Biochemical Remission

Determining the utility of intraoperative magnetic resonance imaging for transsphenoidal surgery: a retrospective study

2014 ◽  
Vol 120 (2) ◽  
pp. 346-356 ◽  
Author(s):  
Jan Coburger ◽  
Ralph König ◽  
Klaus Seitz ◽  
Ute Bäzner ◽  
Christian Rainer Wirtz ◽  
...  
Keyword(s):  
Transsphenoidal Surgery ◽  
High Field ◽  
Progression Free Survival ◽  
Residual Tumor ◽  
Conventional Group ◽  
Free Survival ◽  
Kaplan Meier ◽  
Remission Rates ◽  
Biochemical Remission

Object Intraoperative MRI (iMRI) provides updated information for neuronavigational purposes and assessments on the status of resection during transsphenoidal surgery (TSS). The high-field technique additionally provides information about vascular structures at risk and precise information about extrasellar residual tumor, making it readily available during the procedure. The imaging, however, extends the duration of surgery. To evaluate the benefit of this technique, the authors conducted a retrospective study to compare postoperative outcome and residual tumor in patients who underwent conventional microsurgical TSS with and without iMRI. Methods A total of 143 patients were assessed. A cohort of 67 patients who had undergone surgery before introduction of iMRI was compared with 76 patients who had undergone surgery since iMRI became routine in TSS at the authors' institution. Residual tumor, complications, hormone dependency, biochemical remission rates, and improvement of vision were assessed at 6-month follow-up. A volumetric evaluation of residual tumor was performed in cases of parasellar tumor extension. Results The majority of patients in both groups suffered from nonfunctioning pituitary adenomas. At the 6-month follow-up assessment, vision improved in 31% of patients who underwent iMRI-assisted surgery versus 23% in the conventional group. One instance of postoperative intrasellar bleeding was found in the conventional group. No major complications were found in the iMRI group. Minor complications were seen in 9% of patients in the iMRI group and in 5% of those in the conventional group. No differences between groups were found for hormone dependency and biochemical remission rates. Time of surgery was significantly lower in the conventional treatment group. Overall a residual tumor was found after surgery in 35% of the iMRI group, and 41% of the conventional surgery group harbored a residual tumor. Total resection was achieved as intended significantly more often in the iMRI group (91%) than in the conventional group (73%) (p < 0.034). Patients with a planned subtotal resection showed higher mean volumes of residual tumor in the conventional group. There was a significantly lower incidence of intrasellar tumor remnants in the iMRI group than in the conventional group. Progression-free survival after 30 months was higher according to Kaplan-Meier analysis with the use of iMRI, but a statistically significant difference could not be shown. Conclusions The use of high-field iMRI leads to a significantly higher rate of complete resection. In parasellar tumors a lower residual volume and a significantly lower rate of intrasellar tumor remnants were shown with the technique. So far, long-term follow-up is limited for iMRI. However, after 2 years Kaplan-Meier analyses show a distinctly higher progression-free survival in the iMRI group. No significant benefit of iMRI was found for biochemical remission rates and improvement of vision. Even though the surgical time was longer with the adjunct use of iMRI, it did not increase the complication rate significantly. The authors therefore recommend routine use of high-field iMRI for pituitary surgery, if this technique is available at the particular center.

scholarly journals Predictors for remission after transsphenoidal surgery in acromegaly: a Dutch multicenter study

2021 ◽  
Author(s):  
Eva C Coopmans ◽  
Mark R Postma ◽  
Thalijn L C Wolters ◽  
Sebastiaan W F van Meyel ◽  
Romana Netea-Maier ◽  
...  
Keyword(s):  
Multicenter Study ◽  
Transsphenoidal Surgery ◽  
Early Stage ◽  
Primary Treatment ◽  
Postoperative Treatment ◽  
Tumor Diameter ◽  
Total N ◽  
Maximum Tumor Diameter ◽  
Biochemical Remission

Abstract Context Transsphenoidal surgery (TSS) is the primary treatment of choice in acromegaly. It is important to identify patients in whom surgical cure is not attainable at an early stage, both to inform patients on expected treatment outcome and to select those who are more likely to need additional therapy. Objective To identify predictors for remission after TSS in acromegaly. Design Large multicenter study with retrospective data collection from three tertiary neurosurgical referral centers in the Netherlands. Methods We analyzed clinical data since 2000 from three cohorts (Groningen, Nijmegen and Rotterdam, total n=282). Multivariate regression models were used to identify predictors of early biochemical remission (12 weeks-1 year postoperatively) according to the 2010 consensus criteria, long-term remission (age- and sex normalized IGF-1 and the absence of postoperative treatment until last follow-up) and relative IGF-1 and GH reduction. Results A larger maximum tumor diameter (OR 0.91, 95% CI 0.87–0.96, p≤0.0001) was associated with a lower chance of early biochemical remission. A larger maximum tumor diameter (OR 0.93, 95% CI 0.89–0.97, p=0.0022) and a higher random GH concentration at diagnosis (OR 0.98, 95% CI 0.96–0.99, p=0.0053) were associated with a lower chance of long-term remission. Conclusion Maximum tumor diameter and random GH concentration at diagnosis are the best predictors for remission after TSS in acromegaly.

Incidence and risk factors associated with reoperation for sellar hematoma following endoscopic transsphenoidal pituitary surgery

2020 ◽  
Vol 133 (3) ◽  
pp. 702-708 ◽  
Author(s):  
Iyan Younus ◽  
Mina M. Gerges ◽  
Saniya S. Godil ◽  
Rafael Uribe-Cardenas ◽  
Georgiana A. Dobri ◽  
...  
Keyword(s):  
Risk Factors ◽  
Pituitary Adenoma ◽  
Transsphenoidal Surgery ◽  
Severe Headache ◽  
Tumor Diameter ◽  
Median Length ◽  
Factors Associated ◽  
Postoperative Hematoma ◽  
Clot Evacuation ◽  
Suprasellar Extension

OBJECTIVEPostoperative sellar hematoma is an uncommon complication of endonasal endoscopic transsphenoidal surgery (EETS) for pituitary adenoma that often requires emergency surgical evacuation. Sellar hematomas can cause mass effect and compress parasellar structures, leading to clinically significant symptoms such as visual impairment and severe headache. The objective of this study was to determine the incidence and risk factors associated with reoperation for postoperative hematoma after EETS for pituitary adenoma.METHODSThe authors reviewed a prospectively acquired database of EETS for pituitary adenoma over 13 years at Weill Cornell Medicine, NewYork-Presbyterian Hospital and identified cases that required reoperation for confirmed hematoma. They also reviewed clinical and radiographic data of a consecutive series of patients undergoing EETS for pituitary adenoma who did not have postoperative hematoma, which served as the control group. Demographic data and risk factors were compared between the groups using univariate and multivariate analyses via binary logistic regression.RESULTSAmong a cohort of 583 patients undergoing EETS for pituitary adenoma, 9 patients (1.5%) required operation for sellar hematoma evacuation. All 9 patients with reoperation for sellar hematoma presented with worsening in their vision, and severe headache was present in 67%. New postoperative endocrine dysfunction developed in 78%. Clot evacuation improved vision in 88%. The mean time to hematoma evacuation was 4.5 days. The median length of stay for patients with sellar hematoma was 8 days (range 4–210 days) compared with a median length of stay of 3 days (range 1–32 days) for the control patients (p < 0.005). Significant risk factors in univariate analysis were tumor diameter ≥ 30 mm (p < 0.005), suprasellar extension (p < 0.005), tumor volume (p < 0.005), cavernous sinus invasion (p < 0.05), gonadotroph histology (p < 0.05), antiplatelet use (p < 0.05), and elevated BMI (p < 0.05). On multivariate analysis, tumor diameter ≥ 30 mm (OR 4.555, CI 1.30–28.90; p < 0.05) and suprasellar extension (OR 1.048, CI 1.01–1.10; p < 0.05) were found to be the only independent predictors of sellar hematoma. The incidence of hematoma in tumors ≥ 30 mm was 5% (7/139).CONCLUSIONSPostoperative sellar hematoma requiring reoperation is a rare phenomenon after transsphenoidal surgery, often presenting with visual loss and headache. Clot evacuation results in improvement in vision, but long-term endocrinopathy often ensues. Tumor diameter ≥ 30 mm and suprasellar extent are the most reliable risk factors. Close postoperative scrutiny should be given to patients at high risk.

scholarly journals Transsphenoidal Surgery of Invasive Corticotroph Adenomas: Results in A Series of 86 Consecutive Patients

2021 ◽  
Author(s):  
Congxin Dai ◽  
Ming Feng ◽  
Lin Lu ◽  
Bowen Sun ◽  
Yanghua Fan ◽  
...  
Keyword(s):  
Transsphenoidal Surgery ◽  
Remission Rate ◽  
Partial Resection ◽  
Gross Total Resection ◽  
Subtotal Resection ◽  
Total Resection ◽  
Persistent Disease ◽  
Biochemical Remission ◽  
Corticotroph Adenomas

Abstract Objective: Surgery is first-line treatment for corticotroph adenomas. Although most of corticotroph adenomas are noninvasive microadenomas that show expansive growth to surrounding tissues, a small subset of them is locally invasive and difficult to manage. The aim of this study was to evaluate surgical outcome of invasive corticotroph adenomas from a single-center. Patients and Methods: The clinical features and outcomes of CD patients who underwent transsphenoidal surgery (TSS) between January 2000 and September 2019 at Peking Union Medical College Hospital were collected from medical records. The clinical, endocrinological, radiological, histopathological, surgical outcomes and a minimum 12-month follow-up of 86 consecutive CD patients with invasive corticotroph adenomas were retrospectively reviewed. Results: Eighty-six patients with invasive corticotroph adenomas were included in the study. The average age at TSS was 37.7 years (range, 12 to 67 years), with a female-to-male ratio of 3.1:1 (65/21). The median duration of symptoms was 52.6 months (range, 1.0 to 264 months). The average of maximum diameter of tumor was 17.6 mm (range, 4.5–70 mm). All 86 patients with invasive corticotroph adenomas were performed TSS by microscopic or endoscopic approach. Gross-total resection was achieved in 63 patients (73.3%), subtotal resection in 18 (20.9%), and partial resection in 5 (5.8%). After surgery, the overall postoperative immediate remission rate was 48.8% (42/86), 51.2 % (44/86) of patients maintained persistent hypercortisolism. In 42 patients with initial remission, 16.7 % (7/42) of them experienced a recurrence. In these patients with persistent disease and recurrent CD, data about further treatment was available for 30 patients. The radiotherapy was used for 15 patients, and 4 (26.7%) of them achieved biochemical remission. Repeat TSS was performed in 5 patients, and none achieved remission. Medication was administrated in 4 patients, and one of them obtained disease control. Adrenalectomy was performed in 6 patients, and 5 (83.3 %) achieved biochemical remission. At last follow-up, (33.3%) 10 of 30 patients were in remission, and 20 patients still had persistent disease. The remission rate in patients with invasive corticotroph adenomas who underwent gross-total resection and first TSS were significantly higher than that in patients undergoing subtotal resection, partial resection, and a second TSS (all P＜0.05). However, there was no significant difference in the remission rate between patient with different tumor size, Knosp Grade and surgical approaches (P＞0.05).Conclusion: The management of invasive corticotroph adenomas remain a therapeutic challenge due to incomplete resection of invasive and/or a large adenoma. With application of multiple techniques assistance, approximately half of the patients could achieve gross-total resection and biochemical remission via TSS by experienced neurosurgeons. The extent of tumor resection and number of operations were associated with surgical remission rate in invasive corticotroph adenomas. If the remission was not achieved by surgery, other treatments including radiotherapy, medical therapy, and even bilateral adrenalectomy are required.

Long-term outcomes of transsphenoidal surgery for management of growth hormone–secreting adenomas: single-center results

2020 ◽  
Vol 133 (5) ◽  
pp. 1360-1370 ◽  
Author(s):  
Mohammed J. Asha ◽  
Hirokazu Takami ◽  
Carlos Velasquez ◽  
Selfy Oswari ◽  
Joao Paulo Almeida ◽  
...  
Keyword(s):  
Growth Hormone ◽  
Recurrence Rate ◽  
Transsphenoidal Surgery ◽  
Remission Rate ◽  
Repeat Surgery ◽  
Significant Difference ◽  
Remission Rates ◽  
Biochemical Remission

OBJECTIVETranssphenoidal surgery is advocated as the first-line management of growth hormone (GH)–secreting adenomas. Although disease control is defined by strict criteria for biochemical remission, the length of follow-up needed is not well defined in literature. In this report, the authors present their long-term remission rate and identify various predictive factors that might influence the clinical outcome.METHODSThe authors conducted a single-institute retrospective analysis of all transsphenoidal procedures for GH-secreting adenomas performed from January 2000 to June 2016. The primary outcome was defined as biochemical remission according to the 2010 consensus criteria and measured at the 1-year postoperative mark as well as on the last recorded follow-up appointment.Secondary variables included recurrence rate, patterns of clinical presentation, and outcome of adjuvant therapy (including repeat surgery). Subgroup analysis was performed for patients who had biochemical or radiological “discordance”—patients who achieved biochemical remission but with incongruent insulin-like growth factor 1 (IGF-1)/GH or residual tumor on MRI. Recurrence-free survival analysis was conducted for patients who achieved remission at 1 year after surgery.RESULTSEighty-one patients (45 female and 36 male) with confirmed acromegaly treated with transsphenoidal surgery were included. In 62 cases the patients were treated with a pure endoscopic approach and in 19 cases an endoscopically assisted microscopic approach was used.Primary biochemical remission after surgery was achieved in 59 cases (73%) at 1 year after surgery. However, only 41 patients (51%) remained in primary surgical remission (without any adjuvant treatment) at their last follow-up appointment, indicating a recurrence rate of 31% (18 of 59 patients) over the duration of follow-up (mean 100 ± 61 months). Long-term remission rates for pure endoscopic and endoscopically assisted cases were not significantly different (48% vs 52%, p = 0.6). Similarly, no significant difference in long-term remission was detected between primary surgery and repeat surgery (54% vs 33%, p = 0.22).Long-term remission was significantly influenced by extent of resection, cavernous sinus invasion (radiologically as well as surgically reported), and preoperative and early postoperative GH and IGF-1 levels (within 24–48 hours after surgery) as well as by clinical grade, with lower remission rates in patients with dysmorphic features and/or medical comorbidities (grade 2–3) compared to minimally symptomatic or silent cases (grade 1).CONCLUSIONSThe long-term surgical remission rate appears to be significantly less than “early” remission rates and is highly dependent on the extent of tumor resection. The authors advocate a long-term follow-up regimen and propose a clinical grading system that may aid in predicting long-term outcome in addition to the previously reported anatomical factors. The role of repeat surgery is highlighted.

Long-term endocrinological follow-up evaluation in 115 patients who underwent transsphenoidal surgery for acromegaly

1998 ◽  
Vol 89 (3) ◽  
pp. 353-358 ◽  
Author(s):  
Pamela U. Freda ◽  
Sharon L. Wardlaw ◽  
Kalmon D. Post
Keyword(s):  
Transsphenoidal Surgery ◽  
Remission Rate ◽  
Postoperative Radiotherapy ◽  
Term Outcome ◽  
Long Term Outcome ◽  
Content Type ◽  
Biochemical Remission ◽  
Fine Print

Object. The results of surgical therapy for acromegaly were assessed using carefully conducted endocrinological testing in 115 patients who underwent transsphenoidal surgery from 1981 to 1995. Methods. Ninety-nine of the 115 patients could be contacted for follow-up review; in 57 of the patients an endocrinological assessment was performed by the authors. Biochemical cure was strictly defined as a normalization of the insulin-like growth factor(IGF)—I level (obtained in 100 patients) and/or a basal or glucose-suppressed growth hormone (GH) level of 2 ng/ml or less. The mean length of follow up from transsphenoidal surgery to laboratory testing was 5.4 years with a maximum of 15.7 years. After transsphenoidal surgery alone, 61% of the patients achieved a biochemical remission; the remission rate was 88% for patients with microadenomas and 53% for those with macroadenomas. Tumor size and preoperative GH level tended to correlate negatively with outcome of surgery. Early postoperative GH level tended to correlate with long-term outcome; in cases in which the early postoperative GH level was lower than 3 ng/ml, the chance of long-term remission was 89%. Thirty-two patients received postoperative radiotherapy: in 10 (31%) of these patients the disease is currently in remission after surgery and radiotherapy only and in three others the disease is in remission with the addition of medical therapy. The overall complication rate was 6.9% with no cerebrospinal fluid leaks, meningitis, permanent diabetes insipidus, or new hypopituitarism. The overall recurrence rate was low at 5.4%. Conclusions. This series shows, based on IFGF—I measurements and strict GH supression criteria to define remission, that transsphenoidal surgery provides an excellent chance for long-term cure in patients with microadenomas. Surgery alone is successful in most patients with noninvasive macroadenomas; however, most patients with invasive macroadenomas will require adjunctive therapy. Recurrences are uncommon when biochemical remission is clearly documented postoperatively.

Radiosurgery of growth hormone–producing pituitary adenomas: factors associated with biochemical remission

2007 ◽  
Vol 106 (5) ◽  
pp. 833-838 ◽  
Author(s):  
Bruce E. Pollock ◽  
Jeffrey T. Jacob ◽  
Paul D. Brown ◽  
Todd B. Nippoldt
Keyword(s):  
Growth Hormone ◽  
Pituitary Adenomas ◽  
Anterior Pituitary ◽  
Factors Associated ◽  
Factor I ◽  
Upper Limit ◽  
Igf I ◽  
Biochemical Remission ◽  
Age And Sex

Object The authors reviewed outcomes after stereotactic radiosurgery for patients with acromegaly and analyzed factors associated with biochemical remission. Methods Retrospective analysis was performed for 46 consecutive cases of growth hormone (GH)–producing pituitary adenomas treated by radiosurgery between 1991 and 2004. Biochemical remission was defined as a fasting GH less than 2 ng/ml and a normal age- and sex-adjusted insulin-like growth factor–I (IGF-I) level while patients were not receiving any pituitary suppressive medications. The median follow up after radiosurgery was 63 months (range 22–168 months). Twenty-three patients (50%) had biochemical remission documented at a median of 36 months (range 6–63 months) after one radiosurgical procedure. The actuarial rates of biochemical remission at 2 and 5 years after radiosurgery were 11 and 60%, respectively. Multivariate analysis showed that IGF-I levels less than 2.25 times the upper limit of normal (hazard ratio [HR] 2.9, 95% confidence interval [CI] 1.2–6.9, p = 0.02) and the absence of pituitary suppressive medications at the time of radiosurgery (HR 4.2, 95% CI 1.4–13.2, p = 0.01) correlated with biochemical remission. The incidence of new anterior pituitary deficits was 10% at 2 years and 33% at 5 years. Conclusions Discontinuation of pituitary suppressive medications at least 1 month before radiosurgery significantly improved endocrine outcomes for patients with acromegaly. Patients with GH–producing pituitary adenomas should not undergo further radiation therapy or surgery for at least 5 years after radiosurgery because GH and IGF-I levels continue to normalize over that interval.

Prevalence of Signs and Symptoms of Pseudotumor Cerebri Syndrome Before and After Transsphenoidal Surgery for Cushing’s Disease – A Prospective Consecutive Case Series

2020 ◽  
Author(s):  
Torge Huckhagel ◽  
Jörg Flitsch ◽  
Roman Rotermund ◽  
Volker Knospe
Keyword(s):  
Visual Acuity ◽  
Cushing’S Disease ◽  
Transsphenoidal Surgery ◽  
Signs And Symptoms ◽  
Pseudotumor Cerebri ◽  
Cushing's Disease ◽  
Pseudotumor Cerebri Syndrome ◽  
Before And After ◽  
Biochemical Remission

Abstract Introduction Pseudotumor cerebri syndrome (PTCS) has anecdotally been described after successful treatment of Cushing’s disease (CD), but the prevalence following transsphenoidal surgery has not been determined so far in a prospective study. Patients and Methods 41 consecutive adult CD patients were prospectively screened for signs and symptoms of PTCS, headache-related impairment, and ophthalmological features associated with intracranial pressure elevation before surgery and at follow-up (mean 4 months). Results Biochemical remission was achieved in 36 of 41 (87.8%) patients after surgery. The most frequent preoperative complaints were visual acuity impairment (19 cases; 46.3%), headache (13 cases; 31.7%), and ear noise (9 cases; 22.0%). A significant reduction of visual disturbances was seen at follow-up. Overall, CD patients presented with fairly low headache-related emotional and functional restrictions before and after surgery. One of 34 (2.9%) patients with sufficient ophthalmological follow-up showed new-onset papilledema combined with temporary worsening of visual acuity and scotoma. Conclusion Our results suggest a very low frequency of signs and symptoms of PTCS after surgical treatment for CD in adults. This estimate is in line with previous outcomes from retrospective pediatric CD series. Further large-scale studies are needed to determine the actual prevalence of this condition following biochemical remission of CD.

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