scholarly journals Volumetry in the Assessment of Pituitary Adenoma Resection: Endoscopy versus Microscopy

2018 ◽  
Vol 79 (06) ◽  
pp. 538-544 ◽  
Author(s):  
Anthony Wang ◽  
Ashish Shah ◽  
Charif Sidani ◽  
Brandon Gaynor ◽  
Simon Dockrell ◽  
...  
Keyword(s):  
Pituitary Adenoma ◽  
Pituitary Adenomas ◽  
Residual Tumor ◽  
Extent Of Resection ◽  
Volumetric Analysis ◽  
Complete Resection ◽  
Tumor Control ◽  
Consecutive Series ◽  
Complication Rates ◽  
Recurrence Rates

Background Assessment of the extent of resection after surgical resection of pituitary adenomas is most commonly reported in terms of the presence or absence of residual tumor. A quantitative comparison of volumetric resection between endonasal endoscopy (EE) and microsurgery (MS) has rarely been done. Methods A retrospective analysis was performed on a consecutive series of 154 patients with pituitary adenomas treated by the same surgeon at a single institution. We employed volumetric analysis pre- and postoperatively on two cohorts of pituitary adenoma patients treated through MS (n = 37) versus EE approach (n = 117). Results Volumetric analysis revealed a higher incidence of complete resection (64.4 vs. 56.8%) and mean volume reduction in the EE cohort (92.7 vs. 88.4%), although not significant. Recurrence rates were significantly lower in the EE group (7.7% vs 24.3%, p = 0.015). Subgroup analysis identified that patients with preoperative tumor volumes >1 mL were less likely to recur through EE (7.8 vs. MS: 29.6%; p = 0.0063). A higher incidence of complete resection was also noted in patients with favorable Knosp grades (0–1) (EE: 87.8 vs. MS: 63.2%; p = 0.036). Postoperative complication rates were not significantly different between both techniques. Conclusion Both microscopy and endoscopy are well-tolerated, effective approaches in the treatment of pituitary adenomas. Our series demonstrated that EE may be superior to MS in preventing tumor recurrence and achieving a complete resection in certain subsets of patients. EE provides a slight advantage in tumor control outcomes that may justify the paradigm shift to pure endoscopy at our center.

Estimating Risk of Pituitary Apoplexy after Resection of Giant Pituitary Adenomas

2021 ◽  
Author(s):  
John T. Butterfield ◽  
Takako Araki ◽  
Daniel Guillaume ◽  
Ramachandra Tummala ◽  
Emiro Caicedo-Granados ◽  
...  
Keyword(s):  
Pituitary Adenomas ◽  
Pituitary Apoplexy ◽  
Residual Tumor ◽  
Extent Of Resection ◽  
Morbidity And Mortality ◽  
Surgical Approaches ◽  
Subtotal Resection ◽  
Advantages And Disadvantages ◽  
Cranial Nerve Palsies ◽  
Giant Pituitary Adenomas

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.

scholarly journals Stereotactic radiosurgery for treating meningiomas eligible for complete resection

2021 ◽  
Vol 16 (1) ◽  
Author(s):  
Maximilian I. Ruge ◽  
Juman Tutunji ◽  
Daniel Rueß ◽  
Eren Celik ◽  
Christian Baues ◽  
...  
Keyword(s):  
Adverse Events ◽  
Stereotactic Radiosurgery ◽  
Medical Condition ◽  
Local Tumor Control ◽  
Complete Resection ◽  
Neurological Deficits ◽  
Tumor Control ◽  
Recurrence Rates ◽  
Treatment Volume

Abstract Background For meningiomas, complete resection is recommended as first-line treatment while stereotactic radiosurgery (SRS) is established for meningiomas of smaller size considered inoperable. If the patient´s medical condition or preference excludes surgery, SRS remains a treatment option. We evaluated the efficacy and safety of SRS in a cohort comprising these cases. Methods In this retrospective single-centre analysis we included patients receiving single fraction SRS either by modified LINAC or robotic guidance by Cyberknife for potentially resectable intracranial meningiomas. Treatment-related adverse events as well as local and regional control rates were determined from follow-up imaging and estimated by the Kaplan–Meier method. Results We analyzed 188 patients with 218 meningiomas. The median radiological, and clinical follow-up periods were 51.4 (6.2–289.6) and 55.8 (6.2–300.9) months. The median tumor volume was 4.2 ml (0.1–22), and the mean marginal radiation dose was 13.0 ± 3.1 Gy, with reference to the 80.0 ± 11.2% isodose level. Local recurrence was observed in one case (0.5%) after 239 months. The estimated 2-, 5-, 10- and 15-year regional recurrence rates were 1.5%, 3.0%, 6.6% and 6.6%, respectively. Early adverse events (≤ 6 months after SRS) occurred in 11.2% (CTCEA grade 1–2) and resolved during follow-up in 7.4% of patients, while late adverse events were documented in 14.4% (grade 1–2; one case grade 3). Adverse effects (early and late) were associated with the presence of symptoms or neurological deficits prior to SRS (p < 0.03) and correlated with the treatment volume (p < 0.02). Conclusion In this analysis SRS appears to be an effective treatment for patients with meningiomas eligible for complete resection and provides reliable long-term local tumor control with low rates of mild morbidity.

scholarly journals The Changing Paradigm for the Surgical Treatment of Large Vestibular Schwannomas

2018 ◽  
Vol 79 (S 04) ◽  
pp. S362-S370 ◽  
Author(s):  
Constantin Tuleasca ◽  
Alda Rocca ◽  
Mercy George ◽  
Etienne Pralong ◽  
Luis Schiappacasse ◽  
...  
Keyword(s):  
Functional Outcome ◽  
Residual Tumor ◽  
University Hospital ◽  
Tumor Control ◽  
Subtotal Resection ◽  
Consecutive Series ◽  
Cochlear Function ◽  
Nerve Preservation ◽  
The Past

Objective Planned subtotal resection followed by Gamma Knife surgery (GKS) in patients with large vestibular schwannoma (VS) has emerged during the past decade, with the aim of a better functional outcome for facial and cochlear function. Methods We prospectively collected patient data, surgical, and dosimetric parameters of a consecutive series of patients treated by this method at Lausanne University Hospital during the past 8 years. Results A consecutive series of 47 patients were treated between July 2010 and January 2018. The mean follow-up after surgery was 37.5 months (median: 36, range: 0.5–96). Mean presurgical tumor volume was 11.8 mL (1.47–34.9). Postoperative status showed normal facial nerve function (House–Brackmann I) in all patients. In a subgroup of 28 patients, with serviceable hearing before surgery and in which cochlear nerve preservation was attempted at surgery, 26 (92.8%) retained serviceable hearing. Nineteen had good or excellent hearing (Gardner–Robertson class 1) before surgery, and 16 (84.2%) retained it after surgery. Mean duration between surgery and GKS was 6 months (median: 5, range: 3–13.9). Mean residual volume as compared with the preoperative one at GKS was 31%. Mean marginal dose was 12 Gy (11–12). Mean follow-up after GKS was 34.4 months (6–84). Conclusion Our data show excellent results in large VS management with a combined approach of microsurgical subtotal resection and GKS on the residual tumor, with regard to the functional outcome and tumor control. Longer term follow-up is necessary to fully evaluate this approach, especially regarding tumor control.

scholarly journals Surgery of Insular Nonenhancing Gliomas: Volumetric Analysis of Tumoral Resection, Clinical Outcome, and Survival in a Consecutive Series of 66 Cases

Neurosurgery ◽  
2011 ◽  
Vol 70 (5) ◽  
pp. 1081-1094 ◽  
Author(s):  
Miran Skrap ◽  
Massimo Mondani ◽  
Barbara Tomasino ◽  
Luca Weis ◽  
Riccardo Budai ◽  
...  
Keyword(s):  
Overall Survival ◽  
Survival Rate ◽  
Extent Of Resection ◽  
Volumetric Analysis ◽  
Magnetic Resonance Images ◽  
Neurophysiological Monitoring ◽  
Consecutive Series ◽  
Overall Survival Rate ◽  
The Difference

Abstract BACKGROUND: Despite intraoperative technical improvements, the insula remains a challenging area for surgery because of its critical relationships with vascular and neurophysiological functional structures. OBJECTIVE: To retrospectively investigate the morbidity profile in insular nonenhancing gliomas, with special emphasis on volumetric analysis of tumoral resection. METHODS: From 2000 to 2010, 66 patients underwent surgery. All surgical procedures were conducted under cortical-subcortical stimulation and neurophysiological monitoring. Volumetric scan analysis was applied on T2-weighted magnetic resonance images (MRIs) to establish preoperative and postoperative tumoral volume. RESULTS: The median preoperative tumor volume was 108 cm3. The median extent of resection was 80%. The median follow-up was 4.3 years. An immediate postoperative worsening was detected in 33.4% of cases; a definitive worsening resulted in 6% of cases. Patients with extent of resection of &gt; 90% had an estimated 5-year overall survival rate of 92%, whereas those with extent of resection between 70% and 90% had a 5-year overall survival rate of 82% (P &lt; .001). The difference between preoperative tumoral volumes on T2-weighted MRI and on postcontrast T1-weighted MRI ([T2 − T1] MRI volume) was computed to evaluate the role of the diffusive tumoral growing pattern on overall survival. Patients with preoperative volumetric difference &lt; 30 cm3 demonstrated a 5-year overall survival rate of 92%, whereas those with a difference of &gt; 30 cm3 had a 5-year overall survival rate of 57% (P = .02). CONCLUSION: With intraoperative cortico-subcortical mapping and neurophysiological monitoring, a major resection is possible with an acceptable risk and a significant result in the follow-up.

Tumor control after surgery for spinal myxopapillary ependymomas: distinct outcomes in adults versus children

2013 ◽  
Vol 19 (4) ◽  
pp. 471-476 ◽  
Author(s):  
William B. Feldman ◽  
Aaron J. Clark ◽  
Michael Safaee ◽  
Christopher P. Ames ◽  
Andrew T. Parsa
Keyword(s):  
Recurrence Rate ◽  
Adjuvant Radiotherapy ◽  
Pediatric Patients ◽  
Cauda Equina ◽  
Extent Of Resection ◽  
Gross Total Resection ◽  
Tumor Control ◽  
Recurrence Rates ◽  
Total Resection ◽  
Who Grade

Object Myxopapillary ependymomas (MPEs) are rare WHO Grade I tumors found in the conus medullaris, cauda equina, and filum terminale. Treatment generally consists of resection with or without adjuvant radiotherapy. Evidence-based guidelines for surgical management are lacking due to the rarity of this tumor. Methods An English-language PubMed search was performed using the key words “myxopapillary” and “ependymoma.” Reports describing fewer than 3 patients or those lacking data on the extent of resection or radiotherapy were excluded. A total of 28 articles describing 475 patients met the authors' inclusion criteria. Patients were grouped by extent of resection and whether or not they underwent adjuvant radiotherapy. Differences in recurrence rates were assessed by chi-square test. Results The overall recurrence rate was 15.5% in patients treated by gross-total resection (GTR) and 32.6% in patients treated by subtotal resection (STR), irrespective of whether they underwent adjuvant therapy (p < 0.001). Regardless of the extent of resection, adjuvant radiotherapy was not associated with a decrease in recurrence rates. The overall recurrence rate was 15.6% in patients who underwent GTR and radiotherapy compared with 15.9% in patients who underwent GTR alone (p = 0.58), and it was 29.3% in patients who underwent STR and radiotherapy compared with 35.1% in those who underwent STR alone (p = 0.53). The difference between recurrence rates for patients who underwent GTR alone versus STR and radiotherapy was statistically significant (p = 0.02). Subgroup analysis demonstrated significantly higher recurrence rates in pediatric patients compared with adults (40.5% vs 23.4%, respectively; p = 0.02). Even in the setting of GTR alone, recurrence rates were higher in pediatric patients (65% vs 7.6%; p < 0.001). Conclusions Gross-total resection alone is associated with decreased recurrence rates compared with STR with or without radiotherapy. The authors' results suggest that treatment goals should include attempted GTR whenever possible. The observation that children benefitted from radiation therapy to a greater extent than did adults suggests that biological differences between tumors in these patient populations warrants more rigorous scientific studies.

scholarly journals Nonfunctioning Pituitary Adenoma That Changed to a Functional Gonadotropinoma

2018 ◽  
Vol 2018 ◽  
pp. 1-4
Author(s):  
Gerson Geovany Andino-Ríos ◽  
Lesly Portocarrero-Ortiz ◽  
Carlos Rojas-Guerrero ◽  
Alejandro Terrones-Lozano ◽  
Alma Ortiz-Plata ◽  
...  
Keyword(s):  
Pituitary Adenoma ◽  
Pituitary Adenomas ◽  
Medical Condition ◽  
Case Reports ◽  
Progressive Increase ◽  
Complete Resection ◽  
Point Of View ◽  
Serum Estradiol ◽  
Secondary Amenorrhea ◽  
Nonfunctioning Pituitary Adenoma

Objective. Pituitary adenomas can be classified as clinically functional or silent. Depending on the reviewed literature, these are the first or second place in frequency of the total pituitary adenomas. Even rarer is the presence of a functional gonadotropinoma since only very few case reports exist to date. The conversion of a clinically silent to functional pituitary adenoma is extraordinarily rare; the mechanisms that explain these phenomena are unknown or not fully understood. Methods. We report the case of a woman who initially had a nonfunctional gonadotropinoma and in the course of her medical condition showed biochemical changes in her hormonal pituitary profile compatible with a functional gonadotropinoma. Results. We considered that the patient had a functional gonadotropinoma due to the hyperestrogenemia in the context of secondary amenorrhea, resolving the hyperestrogenemia after almost complete resection of the tumor. Conclusion. It is necessary to point out from a clinical and/or biochemical point of view the change in functionality that a nonfunctional pituitary adenoma may have. In the case of our patient, the suspicion of this change in functionality became evident when we found an increase in the FSH/LH ratio and a progressive increase in serum estradiol concentrations when the patient had amenorrhea.

scholarly journals Comparison of radiosurgery and conventional surgery for the treatment of glomus jugulare tumors

2004 ◽  
Vol 17 (2) ◽  
pp. 22-30 ◽  
Author(s):  
Oren N. Gottfried ◽  
James K. Liu ◽  
William T. Couldwell
Keyword(s):  
Tumor Size ◽  
Treatment Options ◽  
Cerebrospinal Fluid Leak ◽  
Residual Tumor ◽  
Morbidity Rate ◽  
Tumor Control ◽  
Complication Rates ◽  
Glomus Jugulare ◽  
Initial Surgery ◽  
The Mean

Object The optimal management of glomus jugulare tumors remains controversial. Available treatments were once associated with poor outcomes and significant complication rates. Advances in skull base surgery and the delivery of radiation therapy by stereotactic radiosurgery have improved the results obtained using these treatment options. The authors summarize and compare the contemporary outcomes and complications for these therapies. Methods Papers published between 1994 and 2004 that detailed the use of radiosurgery or surgery to treat glomus jugulare tumors were reviewed. Eight radiosurgery series including 142 patients and seven surgical studies including 374 patients were evaluated for neurological outcome, change in tumor size (radiosurgery) or percent of total resection (surgery), recurrences, tumor control, need for further treatment, and complications. The mean age at treatment for patients who underwent surgery and radiosurgery was 47.3 and 56.7 years, respectively. The mean follow-up duration was 49.2 and 39.4 months, respectively. The surgical control rate was 92.1%, with 88.2% of tumors totally resected in the initial surgery. A cerebrospinal fluid leak occurred in 8.3% of patients who underwent surgery and recurrences were found in 3.1%; the mortality rate was 1.3%. Among patients who underwent radiosurgery, tumors diminished in 36.5%, whereas 61.3% had no change in tumor size, and subjective or objective improvements occurred in 39%. Despite the presence of residual tumor in 100% of radiosurgically treated patients, recurrences were found in only 2.1%, the morbidity rate was 8.5%, and there were no deaths. Conclusions Death and recurrences after these treatments are infrequent, and therefore both treatments are considered to be safe and efficacious. Although surgery is associated with higher morbidity rates, it immediately and totally eliminates the tumor. The radiosurgery results are very promising, although the incidence of late recurrence (after 10–20 years) is unknown.

Evaluation of Complications and Costs During Overlapping Transsphenoidal Surgery in the Treatment of Pituitary Adenoma

Neurosurgery ◽  
2018 ◽  
Vol 84 (5) ◽  
pp. 1104-1111 ◽  
Author(s):  
Michael Karsy ◽  
Christian A Bowers ◽  
Jonathan Scoville ◽  
Bornali Kundu ◽  
Mohammed A Azab ◽  
...  
Keyword(s):  
Pituitary Adenoma ◽  
Pituitary Adenomas ◽  
Improve Patient Safety ◽  
Surgical Complication ◽  
Tumor Resection ◽  
Healthcare Delivery ◽  
Complication Rates ◽  
Tumor Type ◽  
Presenting Symptoms ◽  
Transsphenoidal Resection

Abstract BACKGROUND Pituitary adenomas are among the most common primary brain tumors. Recently, overlapping surgery has been curbed in many institutions because of the suggestion there might be more significant adverse events, despite several studies showing that complication rates are equivalent. OBJECTIVE To assess complications and costs associated with overlapping surgery during the transsphenoidal resection of pituitary adenomas. METHODS A single-center, retrospective cohort study was performed to evaluate the cases of patients who underwent a transsphenoidal approach for pituitary tumor resection. Patient, surgical, complication, and cost (value-driven outcome) variables were analyzed. RESULTS A total of 629 patients (302 nonoverlapping, 327 overlapping cases) were identified. No significant differences in age (P = .6), sex (P = .5), tumor type (P = .5), or prior rates of pituitary adenoma resection (P = .5) were seen. Similar presenting symptoms were observed in the 2 groups, and follow-up length was comparable (P = .3). No differences in tumor sizes (P = .5), operative time (P = .4), fat/fascia use (P = .4), or cerebrospinal fluid diversion (P = .8) were seen between groups. The gross total resection rate was not significantly different (P = .9), and no difference in recurrence rate was seen (P = .4). A comparable complication rate was seen between groups (P = .6). No differences in total or subtotal costs were seen either. CONCLUSION The results of this study offer additional evidence that overlapping surgery does not result in worsened complications, lengthened surgery, or increased patient cost for patients undergoing transsphenoidal resection of pituitary adenomas. Thus, studies and policy aiming to improve patient safety and cost should focus on optimizing other aspects of healthcare delivery.

scholarly journals Impact of tumor characteristics and pre- and postoperative hormone levels on hormonal remission following endoscopic transsphenoidal surgery in patients with acromegaly

2020 ◽  
Vol 48 (6) ◽  
pp. E10 ◽  
Author(s):  
Tyler Cardinal ◽  
Martin J. Rutkowski ◽  
Alexander Micko ◽  
Mark Shiroishi ◽  
Chia-Shang Jason Liu ◽  
...  
Keyword(s):  
Pituitary Adenoma ◽  
Medical Therapy ◽  
Pituitary Adenomas ◽  
Transsphenoidal Surgery ◽  
Cranial Nerves ◽  
Elevated Serum ◽  
Tumor Control ◽  
Tumor Diameter ◽  
Endoscopic Endonasal ◽  
Csf Leakage

OBJECTIVEAcromegaly 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.METHODSThe 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.RESULTSThe 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.CONCLUSIONSEndoscopic 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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