Endoscopic Endonasal Pituitary Transposition for a Transdorsum Sellae Approach to the Interpeduncular Cistern

2008 ◽  
Vol 62 (suppl_1) ◽  
pp. ONS57-ONS74 ◽  
Author(s):  
Amin B. Kassam ◽  
Daniel M. Prevedello ◽  
Ajith Thomas ◽  
Paul Gardner ◽  
Arlan Mintz ◽  
...  
Keyword(s):  
Pituitary Gland ◽  
Diabetes Insipidus ◽  
Medical Center ◽  
Pituitary Function ◽  
Total Resection ◽  
Endoscopic Endonasal ◽  
Interpeduncular Cistern ◽  
Petroclival Meningiomas ◽  
Expanded Endonasal Approach ◽  
Function Preservation

Abstract Objective: The interpeduncular cistern, including the retroinfundibular area, is one of the most challenging regions to approach surgically. The pituitary gland and the infundibu-lum guard the region when an endonasal route is undertaken. Superior transposition of the pituitary gland and infundibulum is described as a functional means to access this complex region through a fully endoscopic, completely transnasal route. Methods: Ten consecutive patients in whom a pituitary transposition was performed during an expanded endonasal approach at the University of Pittsburgh Medical Center for resection of retroinfundibular lesions were reviewed. The series consisted of seven men and three women with a mean age of 44.4 years. Pathology consisted of four craniopharyngiomas, four chordomas, and two petroclival meningiomas. Results: Five patients (50%) underwent total resection of the tumor, three patients (30%) underwent near total resection (>95% removal), and two patients (20%) had partial resection of petroclival meningiomas with the goal of optic apparatus decompression. All four patients with visual deficits recovered their vision completely. There was no neurological deterioration. Eight patients had normal pituitary function preoperatively, seven of whom (87.5%) had confirmed function preservation postoperatively, with one of these patients experiencing transient diabetes insipidus. The remaining patient with a hypothalamic craniopharyngioma underwent complete resection with obligatory panhypopituitarism and diabetes insipidus. Conclusion: Endoscopic endonasal transposition of the pituitary gland and its stalk can provide a valuable corridor to the retroinfundibular space and interpeduncular cistern with pituitary function preservation in the majority of patients. This approach should only be pursued once significant experience with endoscopic endonasal approaches has been acquired.

Endoscopic endonasal transcavernous posterior clinoidectomy with interdural pituitary transposition

2014 ◽  
Vol 121 (1) ◽  
pp. 91-99 ◽  
Author(s):  
Juan C. Fernandez-Miranda ◽  
Paul A. Gardner ◽  
Milton M. Rastelli ◽  
Maria Peris-Celda ◽  
Maria Koutourousiou ◽  
...  
Keyword(s):  
Pituitary Gland ◽  
Cavernous Sinus ◽  
Venous Drainage ◽  
Surgical Anatomy ◽  
Medial Wall ◽  
Endoscopic Endonasal ◽  
Interpeduncular Cistern ◽  
Working Space ◽  
Petroclival Meningiomas ◽  
Extradural Approach

Object The object of this paper was to describe the surgical anatomy and technical nuances of the endonasal transcavernous posterior clinoidectomy approach with interdural pituitary transposition and to report the clinical outcome of this technical modification. Methods The surgical anatomy of the proposed approach was studied in 10 colored silicon-injected anatomical specimens. The medical records of 12 patients that underwent removal of the posterior clinoid(s) with this technique were reviewed. Results The natural anatomical corridor provided by the cavernous sinus is used to get access to the posterior clinoid by mobilizing the pituitary gland in an interdural fashion. The medial wall of the cavernous sinus is preserved intact and attached to the gland during its medial and superior mobilization. This provides protection to the gland, allowing for preservation of its venous drainage pathways. The inferior hypophyseal artery is transected to facilitate the manipulation of the medial wall of the cavernous sinus and pituitary gland. This approach was successfully performed in all patients, including 6 with chordomas, 5 with petroclival meningiomas, and 1 with an epidermoid tumor. No patient in this series had neurovascular injury related to the posterior clinoidectomy. There were no instances of permanent hypopituitarism or diabetes insipidus. Conclusions The authors introduce a surgical variant of the endoscopic endonasal posterior clinoidectomy approach that does not require intradural pituitary transposition and is more effective than the purely extradural approach. The endoscopic endonasal transcavernous approach facilitates the removal of prominent posterior clinoids increasing the working space at the lateral recess of the interpeduncular cistern, while preserving the pituitary function.

scholarly journals The learning curve in endoscopic endonasal resection of craniopharyngiomas

2016 ◽  
Vol 41 (6) ◽  
pp. E9 ◽  
Author(s):  
Varun R. Kshettry ◽  
Hyunwoo Do ◽  
Khaled Elshazly ◽  
Christopher J. Farrell ◽  
Gurston Nyquist ◽  
...  
Keyword(s):  
Learning Curve ◽  
Diabetes Insipidus ◽  
Neurological Complications ◽  
Csf Leak ◽  
Categorical Variables ◽  
Total Resection ◽  
Endoscopic Endonasal ◽  
Visual Improvement ◽  
Early Cohort ◽  
Over Time

OBJECTIVE There is a paucity of literature regarding the learning curve associated with performing endoscopic endonasal cranial base surgery. The purpose of this study was to determine to what extent a learning curve might exist for endoscopic endonasal resection in cases of craniopharyngiomas. METHODS A retrospective review was performed for all endoscopic endonasal craniopharyngioma resections performed at Thomas Jefferson University from 2005 to 2015. To assess for a learning curve effect, patients were divided into an early cohort (2005–2009, n = 20) and a late cohort (2010–2015, n = 23). Preoperative demographics, clinical presentation, imaging characteristics, extent of resection, complications, tumor control, and visual and endocrine outcomes were obtained. Categorical variables and continuous variables were compared using a 2-sided Fisher's exact test and t-test, respectively. RESULTS Only the index operation performed at the authors' institution was included. There were no statistically significant differences between early and late cohorts in terms of patient age, sex, presenting symptoms, history of surgical or radiation treatment, tumor size or consistency, hypothalamic involvement, or histological subtype. The rate of gross-total resection (GTR) increased over time from 20% to 65% (p = 0.005), and the rate of subtotal resection decreased over time from 40% to 13% (p = 0.078). Major neurological complications, including new hydrocephalus, meningitis, carotid artery injury, or stroke, occurred in 6 patients (15%) (8 complications) in the early cohort compared with only 1 (4%) in the late cohort (p = 0.037). CSF leak decreased from 40% to 4% (p = 0.007). Discharge to home increased from 64% to 95% (p = 0.024). Visual improvement was high in both cohorts (88% [early cohort] and 81% [late cohort]). Rate of postoperative panhypopituitarism and permanent diabetes insipidus both increased from 50% to 91% (p = 0.005) and 32% to 78% (p = 0.004), which correlated with a significant increase in intentional stalk sacrifice in the late cohort (from 0% to 70%, p < 0.001). CONCLUSIONS High rates of near- or total resection and visual improvement can be achieved using an endoscopic endonasal approach for craniopharyngiomas. However, the authors did find evidence for a learning curve. After 20 cases, they found a significant decrease in major neurological complications and significant increases in the rates of GTR rate and discharge to home. Although there was a large decrease in the rate of postoperative CSF leak over time, this was largely attributable to the inclusion of very early cases prior to the routine use of vascularized nasoseptal flaps. There was a significant increase in new panhypopituitarism and diabetes insipidus, which is attributable to increase rates of intentional stalk sacrifice.

scholarly journals Preserve or sacrifice the stalk? Endocrinological outcomes, extent of resection, and recurrence rates following endoscopic endonasal resection of craniopharyngiomas

2019 ◽  
Vol 131 (4) ◽  
pp. 1163-1171 ◽  
Author(s):  
Edgar G. Ordóñez-Rubiano ◽  
Jonathan A. Forbes ◽  
Peter F. Morgenstern ◽  
Leopold Arko ◽  
Georgiana A. Dobri ◽  
...  
Keyword(s):  
Diabetes Insipidus ◽  
Extent Of Resection ◽  
Endocrine Function ◽  
Subtotal Resection ◽  
Type I ◽  
Pituitary Insufficiency ◽  
Recurrence Rates ◽  
Total Resection ◽  
Endoscopic Endonasal ◽  
Operative Notes

OBJECTIVEGross-total resection (GTR) of craniopharyngiomas (CPs) is potentially curative and is often the goal of surgery, but endocrinopathy generally results if the stalk is sacrificed. In some cases, GTR can be attempted while still preserving the stalk; however, stalk manipulation or devascularization may cause endocrinopathy and this strategy risks leaving behind small tumor remnants that can recur.METHODSA retrospective review of a prospective cohort of patients who underwent initial resection of CP using the endoscopic endonasal approach over a period of 12 years at Weill Cornell Medical College, NewYork-Presbyterian Hospital, was performed. Postresection integrity of the stalk was retrospectively assessed using operative notes, videos, and postoperative MRI. Tumors were classified based on location into type I (sellar), type II (sellar-suprasellar), and type III (purely suprasellar). Pre- and postoperative endocrine function, tumor location, body mass index, rate of GTR, radiation therapy, and complications were reviewed.RESULTSA total of 54 patients who had undergone endoscopic endonasal procedures for first-time resection of CP were identified. The stalk was preserved in 33 (61%) and sacrificed in 21 (39%) patients. GTR was achieved in 24 patients (73%) with stalk preservation and 21 patients (100%) with stalk sacrifice (p = 0.007). Stalk-preservation surgery achieved GTR and maintained completely normal pituitary function in only 4 (12%) of 33 patients. Permanent postoperative diabetes insipidus was present in 16 patients (49%) with stalk preservation and in 20 patients (95%) following stalk sacrifice (p = 0.002). In the stalk-preservation group, rates of progression and radiation were higher with intentional subtotal resection or near-total resection compared to GTR (67% vs 0%, p < 0.001, and 100% vs 12.5%, p < 0.001, respectively). However, for the subgroup of patients in whom GTR was achieved, stalk preservation did not lead to significantly higher rates of recurrence (12.5%) compared with those in whom it was sacrificed (5%, p = 0.61), and stalk preservation prevented anterior pituitary insufficiency in 33% and diabetes insipidus in 50%.CONCLUSIONSWhile the decision to preserve the stalk reduces the rate of postoperative endocrinopathy by roughly 50%, nevertheless significant dysfunction of the anterior and posterior pituitary often ensues. The decision to preserve the stalk does not guarantee preserved endocrine function and comes with a higher risk of progression and need for adjuvant therapy. Nevertheless, to reduce postoperative endocrinopathy attempts should be made to preserve the stalk if GTR can be achieved.

Expanded Endonasal Endoscopic Surgery in Suprasellar Craniopharyngiomas: A Retrospective Analysis of 43 Surgeries Including Recurrent Cases

2019 ◽  
Vol 17 (2) ◽  
pp. 132-142 ◽  
Author(s):  
Ivan Radovanovic ◽  
Amir R Dehdashti ◽  
Mazda K Turel ◽  
Joao Paulo Almeida ◽  
Bruno L Godoy ◽  
...  
Keyword(s):  
Diabetes Insipidus ◽  
Endoscopic Surgery ◽  
Anterior Pituitary ◽  
Cohort Analysis ◽  
Cerebrospinal Fluid Leak ◽  
Pituitary Insufficiency ◽  
Total Resection ◽  
Endoscopic Endonasal ◽  
Repeat Surgery ◽  
Endonasal Endoscopic Surgery

AbstractBACKGROUNDThe role of expanded endonasal endoscopic surgery for primary and recurrent craniopharyngioma is not yet fully established.OBJECTIVETo report and evaluate our experience with the endoscopic endonasal approach (EEA) for the resection of primary and recurrent craniopharyngiomas.METHODSThis is a retrospective cohort analysis of 43 consecutive EEA procedures in 40 patients operated from September 2006 to February 2012 for suprasellar craniopharyngiomas. In 21 patients (48.8%) the disease was recurrent. We have assessed the surgical results, visual, endocrinological, and functional outcomes and resection rates in this patient cohort.RESULTSAt presentation, 31 (72.1%) patients had visual deficits, 15 patients (34.9%) complained of headaches, 25 patients (58.1%) had anterior pituitary insufficiency, and 14 (32.5%) had diabetes insipidus. Total resection was achieved in 44.2% surgeries, of which 77.3% were in primary lesions and 9.5% in recurrent lesions (P < .001). Vision improved in 92.6% patients and worsened in 2.3%. Complications other than vision were encountered in 25.6% including 9/43 cerebrospinal fluid leak, 2/43 meningitis. A total of 51.9% of patients with preoperative residual anterior pituitary function had new anterior pituitary deficiencies and 42.8% had new diabetes insipidus. There was no mortality. Six patients (14%) had recurrence of disease during the follow-up period (mean 56.8 mo), 5 of which required repeat surgery.CONCLUSIONThe EEA can be integrated in the overall management of both primary and recurrent craniopharyngiomas with good results; however, in our series recurrent surgery was associated with significantly lower rates of gross total resection.

scholarly journals Preoperative preparation of patients with pituitary gland disorders

2011 ◽  
Vol 58 (2) ◽  
pp. 91-96 ◽  
Author(s):  
Vesna Malenkovic ◽  
Ljiljana Gvozdenovic ◽  
Branko Milakovic ◽  
Vera Sabljak ◽  
Nebojsa Ladjevic ◽  
...  
Keyword(s):  
Pituitary Gland ◽  
Diabetes Insipidus ◽  
Endocrine System ◽  
Perioperative Period ◽  
Pituitary Hormones ◽  
Pituitary Function ◽  
Suppressive Therapy ◽  
Primary Therapy ◽  
Preoperative Preparation ◽  
Surgical Interventions

This paper presents the most common disorders of pituitary function: acromegaly, hypopituitarism, diabetes insipidus and syndrome similar to diabetes insipidus, in terms of their importance in preoperative preparation of patients. Pituitary function manages almost the entire endocrine system using the negative feedback mechanism that is impaired by these diseases. The cause of acromegaly is a pituitary adenoma, which produces growth hormone in adults. Primary therapy of acromegaly is surgical, with or without associated radiotherapy. If a patient with acromegaly as comorbidity prepares for non-elective neurosurgical operation, then it requires consultation with brain surgeons for possible delays of that operation and primary surgical treatment of pituitary gland. If operative treatment of pituitary gland is carried out, the preoperative preparation (for other surgical interventions) should consider the need for perioperative glucocorticoid supplementation. Panhypopituitarism consequences are different in children and adults and the first step in diagnosis is to assess the function of target organs. Change of electrolytes and water occurs in the case of pituitary lesions in the form of central or nephrogenic diabetes insipidus as a syndrome of inappropriate secretion of antidiuretic hormone (SIADH). Preoperative preparation of patients with pituitary dysfunction should be multidisciplinary, whether it is a neurosurgical or some other surgical intervention. The aim is to evaluate the result of insufficient production of pituitary hormones (hypopituitarism), excessive production of adenohypophysis hormones (acromegaly, Cushing?s disease and hyperprolactinemia) and the influence of pituitary tumours in surrounding structures (compression syndrome) and to determine the level of perioperative risk. Pharmacological suppressive therapy of the hyperfunctional pituitary disorders can have significant interactions with drugs used in the perioperative period.

Long-term outcomes in the treatment of pediatric skull base chordomas in the endoscopic endonasal era

2020 ◽  
pp. 1-10
Author(s):  
Michael M. McDowell ◽  
Nathan T. Zwagerman ◽  
Eric W. Wang ◽  
Carl H. Snyderman ◽  
Elizabeth C. Tyler-Kabara ◽  
...  
Keyword(s):  
Local Recurrence ◽  
Skull Base ◽  
Medical Center ◽  
Spinal Metastases ◽  
Total Resection ◽  
Ki 67 ◽  
Endoscopic Endonasal ◽  
Increased Risk ◽  
Skull Base Chordomas

OBJECTIVEPediatric skull base chordoma is a rare entity that is traditionally considered to display aggressive behavior with an increased risk of recurrence. There is an absence of literature examining outcomes in the pediatric population in general and using the endoscopic endonasal approach (EEA).METHODSThe authors retrospectively reviewed all patients with skull base chordomas presenting by the age of 18 years to the Children’s Hospital of Pittsburgh or the University of Pittsburgh Medical Center from 2004 to 2019. Clinical outcomes, the number and location of recurrences, and progression-free survival time were determined.RESULTSTwenty patients met the study criteria. The most common presenting complaints were diplopia (n = 7), headache (n = 6), and swallowing difficulty (n = 4). Three cases were incidentally discovered. Twelve patients underwent single-stage EEA alone, 2 patients had two-stage EEA, and 6 patients had combined EEA with open far-lateral or extreme-lateral approaches. Fourteen patients underwent gross-total resection (GTR), and 6 patients had near-total resection. Larger tumors were more likely to require staging or a combined approach (86% vs 7%) and were less likely to receive GTR (33% vs 86%) but had comparable recurrence and mortality rates. Five patients developed CSF leaks requiring reoperation, 2 patients developed a permanent abducens nerve palsy, 1 patient suffered an internal carotid artery injury, 1 patient developed an epidural hematoma, and 1 patient developed a subdural empyema. Four (20%) patients had recurrence during follow-up (mean radiographic follow-up 59 months and mean time to local recurrence 19 months). Two patients with recurrence underwent further resection, and 1 patient elected to stop treatment. Both patients who underwent repeat resection experienced a second recurrence, one of whom elected to stop treatment. Both patients who died had an elevated Ki-67 (p = 0.039), one of whom developed de-differentiated histology. A third patient died of progressive spinal metastases without local recurrence and is one of 2 patients who developed postoperative spinal metastases. Both patients whose tumors became de-differentiated progressed from tumors with an initial Ki-67 of 15 or greater (p = 0.035) and received prior radiotherapy to the bulk tumor (p = 0.03).CONCLUSIONSThe majority of pediatric skull base chordomas, when managed at a specialized center with a goal of GTR, may have a better outcome than traditionally believed. Elevated Ki-67 rates may predict poor outcome and progression to de-differentiation.

Long-Term Outcomes of Pituitary Gland Preservation in Pituitary Macroadenoma Apoplexy: Case Series and Review of the Literature

2019 ◽  
Author(s):  
John Robert Souter ◽  
Ignacio Jusue-Torres ◽  
Kurt Grahnke ◽  
Ewa Borys ◽  
Chirag Patel ◽  
...  
Keyword(s):  
Pituitary Gland ◽  
Medical Center ◽  
Tumor Resection ◽  
Case Series ◽  
Endocrine Function ◽  
Retrospective Case ◽  
Endoscopic Endonasal ◽  
Neurological Improvement ◽  
Presenting Symptoms ◽  
Significant Difference

Abstract Introduction For patients presenting with neurological changes from pituitary tumor apoplexy, urgent surgical intervention is commonly performed for diagnosis, tumor resection, and optic apparatus decompression. Although identification and preservation of the pituitary gland during the time of surgery can be challenging, it may lead to improve endocrine outcomes. Methods A retrospective case series of all patients with macroadenomas presenting with apoplexy at Loyola University Medical Center from 2016 to 2018 was studied. Demographic, radiographic, and intraoperative characteristics were collected including age, gender, comorbidities, presenting symptoms, preoperative size of pituitary adenoma, Knosp's grade, Hardy's grade, identification and/or preservation of the gland, pre- and postoperative hormonal levels, intraoperative and/or postoperative complications, and follow-up time. Results A total of 68 patients underwent endoscopic endonasal surgery for resection of a macroadenoma. Among them, seven (10.2%) presented with apoplexy; five patients were male and two were female and presenting symptoms and signs included headache (100%), endocrinopathies (57%), visual acuity deficit (71%), visual field deficit (71%), and oculomotor palsy (57%). A gross-total resection rate was achieved in 86% of patients. Among them, 71% of patients obtained complete symptomatic neurological improvement. A statistically significant difference between gender and endocrine function was found, as no females and all males required some form of postoperative hormonal supplementation (p = 0.047). Conclusion Endoscopic endonasal resection of macroadenomas with sparing of the pituitary gland in the setting of apoplexy is safe and effective. Preservation of the normal gland led to no posterior pituitary dysfunction, and a statistically significant difference between gender and postoperative endocrinopathy was identified. Further studies with larger samples sizes are warranted.

scholarly journals Bilateral coagulation of inferior hypophyseal artery and pituitary transposition during endoscopic endonasal interdural posterior clinoidectomy: do they affect pituitary function?

2019 ◽  
Vol 131 (1) ◽  
pp. 141-146 ◽  
Author(s):  
Huy Q. Truong ◽  
Hamid Borghei-Razavi ◽  
Edinson Najera ◽  
Ana Carolina Igami Nakassa ◽  
Eric W. Wang ◽  
...  
Keyword(s):  
Endocrine Function ◽  
Pituitary Function ◽  
Posterior Pituitary ◽  
Endoscopic Endonasal ◽  
Interpeduncular Cistern ◽  
Pituitary Dysfunction ◽  
Surgical Access ◽  
Bright Spots ◽  
Cavernous Carotid Artery ◽  
Surgical Manipulation

OBJECTIVEThe endoscopic endonasal transcavernous approach with interdural pituitary transposition provides surgical access to the posterior clinoids and interpeduncular cistern. Prior to posterior clinoidectomy, selective coagulation and transection of the inferior hypophyseal artery (IHA) is recommended to prevent uncontrolled tearing of the artery and its avulsion from the wall of the cavernous carotid artery. The authors’ preliminary experience has shown that unilateral sacrifice of the IHA caused no permanent endocrine dysfunction. In this study, they investigated the pituitary function in the setting of bilateral sacrifice of IHAs and pituitary transposition.METHODSAll patients with normal preoperative pituitary function who underwent endoscopic endonasal bilateral posterior clinoidectomy with bilateral IHA sacrifice between March 2010 and December 2016 were included and retrospectively evaluated. All data regarding pituitary function were collected. The degree of pituitary gland manipulation was estimated based on tumor size on preoperative MRI. An angle between a line from the point where the gland meets the floor of the sella to the highest point of the tumor and the horizontal plane of the sellar floor, or access angle, was also measured. Posterior pituitary bright spots on pre- and postoperative T1-weighted MRI were also reported.RESULTSTwenty patients had bilateral transcavernous posterior clinoidectomies with coagulation of both IHAs. There were 13 chordomas, 3 epidermoid cysts, 2 chondrosarcomas, 1 meningioma, and 1 hemangiopericytoma. The mean follow-up was 19 months (range 13–84 months). Two patients experienced transient diabetes insipidus (DI) requiring desmopressin, which resolved before hospital discharge. One patient (with chordoma) developed delayed permanent DI, and a second patient (with hemangiopericytoma) developed permanent DI and panhypopituitarism. The access angle was higher in the group with pituitary dysfunction (47.25° compared to 33.81°; p = 0.07). Posterior pituitary bright spots were preserved in 75% of cases with normal postoperative endocrine function.CONCLUSIONSThe endoscopic endonasal transcavernous approach to the interpeduncular cistern with pituitary transposition and bilateral sacrifice of the IHAs does not cause pituitary dysfunction in a majority of patients. When endocrine deficit occurs, it appears to be more likely to have been caused by surgical manipulation than loss of blood supply. This finding confirms clinically the crucial concept of interarterial anastomosis of pituitary vasculature proposed by anatomists.

Long-term tumor control after endoscopic endonasal resection of craniopharyngiomas: comparison of gross-total resection versus subtotal resection with radiation therapy

2021 ◽  
pp. 1-9
Author(s):  
Saniya S. Godil ◽  
Umberto Tosi ◽  
Mina Gerges ◽  
Andrew L. A. Garton ◽  
Georgiana A. Dobri ◽  
...  
Keyword(s):  
Radiation Therapy ◽  
Diabetes Insipidus ◽  
Endocrine Function ◽  
Gross Total Resection ◽  
Tumor Control ◽  
Subtotal Resection ◽  
Total Resection ◽  
Endoscopic Endonasal

OBJECTIVE Surgical management of craniopharyngiomas (CPAs) is challenging. Controversy exists regarding the optimal goals of surgery. The purpose of this study was to compare the long-term outcomes of patients who underwent gross-total resection with the outcomes of those who underwent subtotal resection of their CPA via an endoscopic endonasal approach. METHODS From a prospectively maintained database of all endoscopic endonasal approaches performed at Weill Cornell Medicine, only patients with CPAs with > 3 years of follow-up after surgery were included. The primary endpoint was radiographic progression. Data were collected on baseline demographics, imaging, endocrine function, visual function, and extent of resection. RESULTS A total of 44 patients with a mean follow-up of 5.7 ± 2.6 years were included. Of these patients, 14 (31.8%) had prior surgery. GTR was achieved in 77.3% (34/44) of all patients and 89.5% (34/38) of patients in whom it was the goal of surgery. Preoperative tumor volume < 10 cm3 was highly predictive of GTR (p < 0.001). Radiation therapy was administered within the first 3 months after surgery in 1 (2.9%) of 34 patients with GTR and 7 (70%) of 10 patients with STR (p < 0.001). The 5-year recurrence-free/progression-free survival rate was 75.0% after GTR and 25.0% after STR (45% in subgroup with STR plus radiotherapy; p < 0.001). The time to recurrence after GTR was 30.2 months versus 13 months after STR (5.8 months in subgroup with STR plus radiotherapy; p < 0.001). Patients with GTR had a lower rate of visual deterioration and higher rate of return to work or school compared with those with STR (p = 0.02). Patients with GTR compared to STR had a lower rate of CSF leakage (0.0% vs 30%, p = 0.001) but a higher rate of diabetes insipidus (85.3% vs 50%, p = 0.02). CONCLUSIONS GTR, which is possible to achieve in smaller tumors, resulted in improved tumor control, better visual outcome, and better functional recovery but a higher rate of diabetes insipidus compared with STR, even when the latter was supplemented with postoperative radiation therapy. GTR should be the goal of craniopharyngioma surgery, when achievable with minimal morbidity.

scholarly journals Effect of Distance from Target on Hypopituitarism After Stereotactic Radiosurgery for Pituitary Adenomas

2021 ◽  
Author(s):  
Natasha Ironside ◽  
Harrison Snyder ◽  
Zhiyuan Xu ◽  
David Schlesinger ◽  
Ching-Jen Chen ◽  
...  
Keyword(s):  
Pituitary Gland ◽  
Stereotactic Radiosurgery ◽  
Predictive Value ◽  
Pituitary Adenomas ◽  
Anterior Pituitary ◽  
Pituitary Function ◽  
Anterior Pituitary Function ◽  
Function Preservation ◽  
Hypothalamic Pituitary Axis

Abstract IntroductionDelayed hypopituitarism is the most common complication after stereotactic radiosurgery (SRS) for pituitary adenomas. The aim of this study was to investigate the relationship between the distance from the hypothalamic-pituitary axis to the treatment target and anterior pituitary function preservation after SRS. MethodsBetween 2007 and 2020, consecutive adult patients who underwent single-session SRS for pituitary adenomas with ³6 months of follow-up were included. Distance measurements between hypothalamic-pituitary axis structures and the SRS target volume were quantified on MRI. The primary outcome was anterior pituitary function preservation. Outcomes were compared using multivariable regression and area under the receiver operator characteristic curve (AUROC) analyses. ResultsThe study cohort comprised 224 patients, who were categorized by preservation (n=168) and no preservation (n=56) of anterior pituitary function after SRS. Independent predictors of anterior pituitary function preservation were a greater distance between the center of the pituitary gland and center of the SRS target (OR=1.101 [1.000–1.213], p=0.050), and a shorter clinical follow-up duration (OR=0.985 [0.977–0.993], p<0.0001). The adjusted AUROC for the distance from the center of the pituitary gland and center of the SRS target in predicting anterior pituitary function preservation was 0.595. The sensitivity, specificity, positive predictive value and negative predictive value in predicting anterior pituitary function preservation at the optimal cut-off distance of 15mm were 30.0%, 88.0%, 89.9% and 26.2%, respectively.ConclusionsGreater distance between the normal pituitary gland and the SRS target is associated with anterior pituitary function preservation and increasing this distance should be a goal of adenoma resection. Larger prospective, multi-center studies are necessary to corroborate this finding and establish the effects of distance on hypopituitarism after SRS for pituitary adenomas.

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