scholarly journals Somatotroph Adenomas have a Predilection to Invade the Cavernous Sinus and Resection of the Medial Wall of the Cavernous Sinus Offers the Highest Potential for Biochemical Remission in Acromegaly

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. A648-A649
Author(s):  
Ahmed Mohyeldin ◽  
Laurence Katznelson ◽  
Juan Fernandez-Miranda
Keyword(s):  
Positive Predictive Value ◽  
Cavernous Sinus ◽  
Predictive Value ◽  
Pituitary Adenomas ◽  
Medial Wall ◽  
Null Cell ◽  
Intraoperative Evaluation ◽  
Remission Rates ◽  
Biochemical Remission ◽  
Wall Invasion

Abstract Recurrence and remission rates vary widely among different histological subtypes of pituitary adenoma. Invasion of the medial wall of the cavernous sinus is a known mechanism that may account for such failed clinical outcomes as its removal has long been considered unattainable. The use of modern endoscopic techniques allows for direct intraoperative evaluation of invasion and resection of the medial wall of the cavernous sinus with low morbidity when performed by highly experienced surgeons. In this retrospective study we evaluated 105 consecutive primary pituitary adenomas operated by a single surgeon including 28 corticotroph, 27 gonadotroph, 24 somatotroph, 15 lactotroph, 5 null-cell, 5 plurihormonal, and 1 dual adenoma; 53 caused hypersecretory syndromes, specifically acromegaly (30), hyperprolactinemia (15) and Cushing’s disease (8). In each case, we performed meticulous intraoperative inspection of the medial wall with its surgical removal when invasion was suspected, regardless of functional status. Medial wall resection was performed in 46% of pituitary adenomas, and 38/48 walls confirmed pathologic evidence of invasion rendering a positive predictive value of intraoperative evaluation of medial wall invasion of 79%. Furthermore, we show for the first time that the rate of medial wall invasion among pathological subtypes is dramatically different. Somatotroph tumors invaded the medial wall much more often than other adenoma subtypes, 83% intraoperatively and 71% histologically, followed by plurihormonal tumors (40%) and gonadotrophs (33%), both with intraoperative positive predictive value of 100%. The least likely to invade were corticotroph, at a rate of 32% intraoperatively and 21% histologically, and null-cell adenomas at 0%. Removal of the medial wall caused no permanent morbidity with no carotid artery injuries and 2 patients with transient diplopia. We report that resecting the medial wall of the cavernous sinus in acromegaly offers the highest potential for biochemical remission with average postoperative day 1 GH levels at 0.96 ug/l and early surgical remission rates at 90% (100% with adjuvant therapy) based on normalization of IGF-1 levels 3 to 6 months after surgery; these results are significantly better than previously reported but longer follow-up is required for definitive conclusions. Our findings may explain the failed biochemical remission rates seen in acromegaly and illustrate the relevance of advanced surgical techniques for successful outcomes in pituitary surgery.

Imaging and Demographic Characteristics Associated with Invasion of the Medial Wall of the Cavernous Sinus in Patients with Invasive Pituitary Adenomas

2019 ◽  
Author(s):  
Ezequiel Goldschmidt ◽  
Salomon Cohen-Cohen ◽  
Federico Angriman ◽  
Carl Snyderman ◽  
Eric Wang ◽  
...  
Keyword(s):  
Cavernous Sinus ◽  
Pituitary Adenomas ◽  
Demographic Characteristics ◽  
Medial Wall

scholarly journals SAT-398 The Use of Imaging in Primary Hyperparathyroidism

2020 ◽  
Vol 4 (Supplement_1) ◽  
Author(s):  
David Tyler Broome ◽  
Robert Naples ◽  
Richard Bailey ◽  
James F Bena ◽  
Joseph Scharpf ◽  
...  
Keyword(s):  
Primary Hyperparathyroidism ◽  
Positive Predictive Value ◽  
Predictive Value ◽  
Remission Rate ◽  
Imaging Modality ◽  
Statistical Significance ◽  
Preoperative Localization ◽  
Imaging Modalities ◽  
Remission Rates ◽  
Operative Findings

Abstract Primary hyperparathyroidism is characterized by excessive dysregulated production of parathyroid hormone (PTH) by 1 or more abnormal parathyroid glands. Preoperative localization is important for surgical planning in primary hyperparathyroidism. Previously, it had been published that ultrasound (sensitivity of 76.1%, positive predictive value of 93.2%) and nuclear scintigraphy (Sestamibi-SPECT) (sensitivity of 78.9%, and a positive predictive value of 90.7%) are first line imaging modalities1. Currently, the imaging modality of choice varies according to region and institutional protocol. The aim of this study was to evaluate the imaging modality that is associated with an improved remission rate based on concordance with operative findings. A secondary aim was to determine the effect of additive imaging on remission rates. This was an IRB-approved retrospective review of 2657 patients with primary hyperparathyroidism undergoing surgery at a tertiary referral center from 2004–2017. Analyses were performed with SAS software using a 95% confidence interval (p<0.05) for statistical significance. After excluding re-operative and familial cases, 2079 patients met study criteria. There were 422 (20.3%) male and 1657 (79.7%) female patients with a mean age of 66 (+12.2) years, of which 1723 (82.9%) of patients were white and 294 (14.1%) patients were black. Ultrasound (US) was performed in 1891 (91.9%), sestamibi with SPECT (sestamibi/SPECT) in 1945 (93.6%), and CT in 98 (4.7%) patients. Of these, 1721 (82.8%) had combined US and sestamibi/SPECT. US was surgeon-performed in 94.2% of cases and 89.9% of the patients underwent a four gland exploration. Overall, US concordance was 52.4%, sestamibi/SPECT was 45.5%, and CT was 45.9%.US and sestamibi/SPECT both had an improved remission rate if concordant with operative findings, while CT had no effect (US p=0.04; sestamibi/SPECT p=0.01; CT p=0.50). The overall remission rate was 94% (CI=0.93–0.95), however, increasing the number of imaging modalities performed did not increase the remission rate (p=0.76) or concordance with operative findings (p=0.05). Despite having low concordance rates, US and sestamibi/SPECT that agreed with operative findings were associated with higher remission rates. Therefore, when imaging is to be used for localization, our data support the use of US and sestamibi/SPECT as the initial imaging modalities of choice for preoperative localization. 1Kuzminski SJ, Sosa JA, Hoang JK. Update in Parathyroid Imaging. Magn Reson Imaging Clin N Am. 2018;26(1): 151–166.

Removal of the Medial Wall of the Cavernous Sinus for Functional Pituitary Adenomas: A Technical Report and Pathologic Significance

2019 ◽  
Vol 126 ◽  
pp. 53-58 ◽  
Author(s):  
Yuichi Nagata ◽  
Kazuhito Takeuchi ◽  
Taiki Yamamoto ◽  
Takayuki Ishikawa ◽  
Teppei Kawabata ◽  
...  
Keyword(s):  
Cavernous Sinus ◽  
Pituitary Adenomas ◽  
Medial Wall ◽  
Technical Report

scholarly journals The medial wall of the cavernous sinus. Part 2: Selective medial wall resection in 50 pituitary adenoma patients

2019 ◽  
Vol 131 (1) ◽  
pp. 131-140 ◽  
Author(s):  
Salomon Cohen-Cohen ◽  
Paul A. Gardner ◽  
Joao T. Alves-Belo ◽  
Huy Q. Truong ◽  
Carl H. Snyderman ◽  
...  
Keyword(s):  
Pituitary Adenoma ◽  
Cavernous Sinus ◽  
Cranial Nerve ◽  
Tumor Resection ◽  
Medial Wall ◽  
Long Term Results ◽  
Fat Graft ◽  
Cranial Nerve Palsies ◽  
Remission Rates

OBJECTIVEPituitary adenomas often invade the medial wall of the cavernous sinus (CS), but this structure is generally not surgically removed because of the risk of vascular and cranial nerve injury. The purpose of this study was to report the surgical outcomes in a large series of cases of invasive pituitary adenoma in which the medial wall of the CS was selectively removed following an anatomically based, stepwise surgical technique.METHODSThe authors’ institutional database was reviewed to identify cases of pituitary adenoma with isolated invasion of the medial wall, based on an intraoperative evaluation, in which patients underwent an endoscopic endonasal approach with selective resection of the medial wall of the CS. Cases with CS invasion beyond the medial wall were excluded. Patient complications, resection, and remission rates were assessed.RESULTSFifty patients were eligible for this study, 15 (30%) with nonfunctional adenomas and 35 (70%) with functional adenomas, including 16 growth hormone–, 10 prolactin-, and 9 adrenocorticotropic hormone (ACTH)–secreting tumors. The average tumor size was 2.3 cm for nonfunctional and 1.3 cm for functional adenomas. Radiographically, 11 cases (22%) were Knosp grade 1, 23 (46%) Knosp grade 2, and 16 (32%) Knosp grade 3. Complete tumor resection, based on intraoperative impression and postoperative MRI, was achieved in all cases. The mean follow-up was 30 months (range 4–64 months) for patients with functional adenomas and 16 months (range 4–30 months) for those with nonfunctional adenomas. At last follow-up, complete biochemical remission (using current criteria) without adjuvant treatment was seen in 34 cases (97%) of functional adenoma. No imaging recurrences were seen in patients who had nonfunctional adenomas. A total of 57 medial walls were removed in 50 patients. Medial wall invasion was histologically confirmed in 93% of nonfunctional adenomas and 83% of functional adenomas. There were no deaths or internal carotid artery injuries, and the average blood loss was 378 ml. Four patients (8%) developed a new, transient cranial nerve palsy, and 2 of these patients required reoperation for blood clot evacuation and fat graft removal. There were no permanent cranial nerve palsies.CONCLUSIONSThe medial wall of the CS can be removed safely and effectively, with minimal morbidity and excellent resection and remission rates. Further follow-up is needed to determine the long-term results of this anatomically based technique, which should only be performed by very experienced endonasal skull base teams.

scholarly journals Characterization of Gonadotroph Pituitary Adenomas Based on the Recent 2017 WHO Pituitary Tumor Classification

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. A640-A641
Author(s):  
Aviva Cohn ◽  
Chloe Yang Ling Li ◽  
Samantha Elena Hoffman ◽  
Ana Paula Abreu-Metzger ◽  
Joseph Castlen ◽  
...  
Keyword(s):  
Transcription Factor ◽  
Transcription Factors ◽  
Cavernous Sinus ◽  
Tumor Size ◽  
Pituitary Adenomas ◽  
World Health ◽  
Pituitary Hormone ◽  
Pituitary Insufficiency ◽  
Null Cell ◽  
Cavernous Sinus Invasion

Abstract Introduction: More than 20% of pituitary adenomas are nonfunctional, the majority of which are of gonadotroph origin. Whereas previously, immunohistochemistry of pituitary hormones was used to classify adenoma subtypes, in 2017 the World Health Organization (WHO) reclassified pituitary adenomas using transcription factor expression in addition to immunohistochemistry. With this change, clinically nonfunctional gonadotroph adenomas can be distinguished among: (1) those staining for the transcription factor SF-1 and gonadotropins FSH and/or LH (FSH/LH+), (2) those that stain for SF-1 but not for FSH or LH (FSH/LH- SF1+), and (3) true null cell adenomas. It is unclear whether these three subgroups behave similarly clinically, or if they have distinct manifestations or outcomes. Our aim was to characterize these subgroups in regard to tumor size, recurrence and pituitary insufficiency. Methods: In a retrospective chart review, 71 patients from 2017-2020 who presented to the hospital for transsphenoidal resection of clinically nonfunctioning pituitary adenomas were reviewed. All patients with pituitary adenomas that stained positive for SF-1 and negative for T-PIT and PIT-1, and tumors that were negative for all three transcription factors were evaluated. Those lacking clinical data were excluded. Clinical characteristics examined include: demographics, tumor size, invasion of cavernous sinus, and hormone deficiencies. Results: Of the 71 pituitary tumors, 45% (n=32) stained positive for the beta subunit FSH and/or LH (FSH/LH+) and SF-1, 44% (n=31) stained for SF-1 with negative pituitary hormone stains (FSH/LH- SF1+), and 11% (n=8) were negative for all transcription factors and hormones (true null). All tumors were macroadenomas (>1 cm). While there were >50% males in the FSH/LH+ and FSH/LH- SF1+ groups, in the true null group only 25% of patients were male. Most patients were >50 years old in all 3 groups (81% FSH/LH+, 75% FSH/LH- SF1+, 88% true null). The prevalence of cavernous sinus involvement was 36% in both groups that stained for SF-1, but was 62% in the true null group. Both SF-1+ groups had similar tumor sizes and prevalence of panhypopituitarism (15-21%), but there were more episodes of recurrence since last known follow up in the FSH/LH- SF1+ group (20%), compared to FSH/LH+ tumors (7%). The true null group had ≥50% rates for both panhypopituitarism and recurrence. Conclusions: In this study, we highlighted the category of FSH/LH- SF1+ gonadotroph adenomas and compared these to FSH/LH+ and true null cell tumors. Based on clinical features, FSH/LH- SF1+ gonadotroph adenomas are similar to FSH/LH+ staining pituitary adenomas in regard to age, sex, size, and degree of cavernous sinus invasion, although there were more recurrences in the FSH/LH- SF1+ group. Though less common, our cohort suggests more aggressive tendencies in the true null group compared to SF-1 staining tumors.

scholarly journals The Role of T-box Transcription Factor in a Pituitary Adenoma Diagnostic Algorithm

2020 ◽  
Author(s):  
William C. McDonald ◽  
Kelsey N. McDonald ◽  
Jordan A. Helmer ◽  
Bridget Ho ◽  
Amber Wang ◽  
...  
Keyword(s):  
Transcription Factor ◽  
Predictive Value ◽  
Pituitary Adenomas ◽  
Adrenocorticotropic Hormone ◽  
Classification Tree ◽  
Null Cell ◽  
Steroidogenic Factor 1 ◽  
Cluster Analyses ◽  
T Box

Context.— We previously examined pituitary adenomas with immunohistochemical (IHC) stains for steroidogenic factor 1, Pit-1, anterior pituitary hormones, cytokeratin CAM 5.2, and the α-subunit of human chorionic gonadotropin and found that a screening panel comprising stains for steroidogenic factor 1, Pit-1, and adrenocorticotropic hormone successfully classified most cases and reduced the overall number of stains required. Objectives.— To examine the potential role of IHC stain for T-box transcription factor (Tpit) in the classification of our series of pituitary adenomas and to update our screening panel as necessary. Design.— We collected 157 pituitary adenomas from 2 institutions and included these in tissue microarrays. Immunostains for Tpit were scored in a blinded fashion using the Allred system. Adenomas were assigned to a gold standard class based on IHC pattern followed by application of available clinical and serologic information. Test characteristics were calculated. Correlation analyses, cluster analyses, and classification tree analyses were used to see whether IHC staining patterns reliably reflected adenoma class. Results.— Of the cases collected, 147 (93.6%) had sufficient material for Tpit analysis. IHC stain for Tpit identified 8 null cell adenomas (all nonfunctioning clinically) as silent corticotrophs; Tpit stains showed better sensitivity, specificity, positive predictive value, and negative predictive value than IHC for adrenocorticotropic hormone and cytokeratin CAM 5.2. Correlation analyses continued to show the expected relationships among IHC stains. Cluster analyses showed grouping of adenomas into clinically consistent groups. Classification tree analysis underscored the central role of transcription factor IHC stains, including Tpit, in adenoma classification. Conclusions.— Substitution of Tpit stain for the adrenocorticotropic hormone stain improves our prior algorithm by reducing the number of false-negatives and false-positives. As a result, fewer adenomas are classified as null cell adenoma, and more adenomas are classified as silent corticotroph adenoma.

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