Outcomes following transsphenoidal surgical management of incidental pituitary adenomas: a series of 52 patients over a 17-year period

OBJECTIVEIncidental pituitary adenomas (IPAs) are commonly discovered during cranial imaging evaluations obtained for unrelated indications. The optimal management of IPA remains controversial. The authors investigated the outcomes and safety of the surgical treatment of IPAs at their institution.METHODSClinical outcome data for 1692 patients surgically treated for pituitary adenomas at the Keck Medical Center of USC/USC Pituitary Center over a 17-year period (1999–2016) were reviewed to identify all cases with surgically managed IPAs. Clinical characteristics reviewed in this retrospective analysis included patient demographics, endocrine laboratory data, visual field examinations, and MRI results. Intraoperative data reviewed included requirement for CSF leak repair, surgical complications, and estimated extent of resection. Postoperative data collected included pathology results, length of stay, postoperative complications, endocrine outcomes, readmission rates, and long-term outcomes, including extent of resection noted on postoperative imaging studies and tumor progression and/or recurrence.RESULTSFifty-two patients (3.1% of all cases) underwent transsphenoidal surgery for IPA. The median age at surgery was 61 years (range 31–86 years). The most common reasons for neuroimaging included trauma (19%), stroke/transient ischemic attack (15%), and sinonasal disease (15%). Visual field deficits were present in 15% of bedside examinations, and among the 22 patients sent for formal testing, 54.5% were noted to have deficits. Preoperative endocrine function was normal in 69% of patients, which includes 3 patients (5.8%) having isolated hyperprolactinemia consistent with a stalk effect without other hormonal dysfunction. The average maximal tumor diameter was 20.9 mm (8–50 mm; data available in 35 patients). The most common primary indication for surgery was compression of the chiasm or vision loss (52%); other major considerations included tumor growth, a young patient age, and identified endocrine abnormalities. Intraoperative CSF leak repair was performed in 56% of patients, and 1 patient (2%) developed postoperative CSF rhinorrhea treated with lumbar drainage. The median hospital stay was 2 days. There were no deaths or major complications. Three patients (5.8%) developed transient diabetes insipidus. Over a mean follow-up of 61 months, 4 patients (50.0%) reported improved headaches and 6 (54.5%) reported improvement in their visual deficits. Four patients (25%) had improved endocrine function, including one with resumption of menstruation and another with remission of acromegaly. One patient (2.4%) reported new postoperative headache, and none experienced worsened vision. Four patients (10.5%) developed new single-axis hypopituitarism and 1 (2.6%) developed new panhypopituitarism. The overall recurrence/progression rate on neuroimaging was 9.6% at a mean of 80 months.CONCLUSIONSTranssphenoidal resection of IPAs, when appropriate, can be performed safely at experienced treatment centers. Incidental pituitary adenomas should be evaluated and treated as indicated, especially in younger patients at risk for endocrine or visual dysfunction.

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Identification and repair of intraoperative cerebrospinal fluid leaks in endonasal transsphenoidal pituitary surgery: surgical experience in a series of 1002 patients

Journal of Neurosurgery ◽

10.3171/2017.4.jns162451 ◽

2018 ◽

Vol 129 (2) ◽

pp. 425-429 ◽

Cited By ~ 13

Author(s):

Ben A. Strickland ◽

Joshua Lucas ◽

Brianna Harris ◽

Edwin Kulubya ◽

Joshua Bakhsheshian ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Pituitary Adenomas ◽

Transsphenoidal Approach ◽

Csf Leak ◽

Sellar Region ◽

Inclusion Criteria ◽

Csf Rhinorrhea ◽

Sellar Lesions ◽

Sellar Reconstruction ◽

Csf Leaks

OBJECTIVECerebrospinal fluid (CSF) rhinorrhea is among the most common complications following transsphenoidal surgery for sellar region lesions. The aim of this study was to review the authors’ institutional experience in identifying, repairing, and treating CSF leaks associated with direct endonasal transsphenoidal operations.METHODSThe authors performed a retrospective review of cases involving surgical treatment of pituitary adenomas and other sellar lesions at the University of Southern California between December 1995 and March 2016. Inclusion criteria included all pathology of the sellar region approached via a direct microscopic or endoscopic endonasal transsphenoidal approach. Demographics, pathology, intraoperative and postoperative CSF leak rates, and other complications were recorded and analyzed. A literature review of the incidence of CSF leaks associated with the direct endonasal transsphenoidal approach to pituitary lesions was conducted.RESULTSA total of 1002 patients met the inclusion criteria and their cases were subsequently analyzed. Preoperative diagnoses included pituitary adenomas in 855 cases (85.4%), Rathke’s cleft cyst in 94 (9.4%), and other sellar lesions in 53 (5.2%). Lesions with a diameter ≥ 1 cm made up 49% of the series. Intraoperative repair of an identified CSF leak was performed in 375 cases (37.4%) using autologous fat, fascia, or both. An additional 92 patients (9.2%) underwent empirical sellar reconstruction without evidence of an intraoperative CSF leak. Postoperative CSF leaks developed in 26 patients (2.6%), including 13 (1.3% of the overall group) in whom no intraoperative leak was identified. Among the 26 patients who developed a postoperative CSF leak, 13 were noted to have intraoperative leak and underwent sellar repair while the remaining 13 did not have an intraoperative leak or sellar repair. No patients who underwent empirical sellar repair without an intraoperative leak developed a postoperative leak. Eight patients underwent additional surgery (0.8% reoperation rate) for CSF leak repair, and 18 were successfully treated with lumbar drainage or lumbar puncture alone. The incidence of postoperative CSF rhinorrhea in this series was compared with that in 11 other reported series that met inclusion criteria, with incidence rates ranging between 0.6% and 12.1%.CONCLUSIONSIn this large series, half of the patients who developed postoperative CSF rhinorrhea had no evidence of intraoperative CSF leakage. Unidentified intraoperative CSF leaks and/or delayed development of CSF fistulas are equally important sources of postoperative CSF rhinorrhea as the lack of employing effective CSF leak repair methods. Empirical sellar reconstruction in the absence of an intraoperative CSF leak may be of benefit following resection of large tumors, especially if the arachnoid is thinned out and herniates into the sella.

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The incidence of occult endocrinopathies in patients with cancer undergoing immunotherapy in community practice.

Journal of Clinical Oncology ◽

10.1200/jco.2021.39.15_suppl.e14571 ◽

2021 ◽

Vol 39 (15_suppl) ◽

pp. e14571-e14571

Author(s):

Ahmed Abdalla ◽

Aditi Singh ◽

Hussein Gharib ◽

Benjamin Huber ◽

Sindhu Janarthanam Malapati ◽

...

Keyword(s):

Clinical Trials ◽

Testosterone Level ◽

Single Agent ◽

Laboratory Data ◽

Endocrine Function ◽

Hormone Levels ◽

Primary Indication ◽

Number Of Patients ◽

The Mean ◽

Stimulating Hormone

e14571 Background: Immune checkpoint blockade (IO) can induce inflammation of the pituitary, thyroid or adrenal glands. This usually results in non-specific symptoms such as headache, low-energy, nausea and vomiting, which can be difficult to differentiate from symptoms associated with cancer and therapy-related symptoms. Therefore, the exact incidence of endocrinopathies is exceedingly difficult to estimate in community practices. Also, the variable methods of assessment, diagnosis, and monitoring used in different clinical trials make it challenging to precisely measure the incidence of endocrinopathies. Methods: This is a single-center retrospective chart review of patients diagnosed with cancer receiving immunotherapy for cancer treatment who had routine hormone levels checked during their treatment. Data collected includes tumor types and the types of IO agents used. Laboratory data collected included thyroid-stimulating hormone (TSH), testosterone level, follicular stimulating hormone (FSH), luteinizing hormone (LH), cortisol levels. Results: In total, 75 patients were included in the study. The primary indication for IO was lung cancer in 43 patients (57%), genitourinary tumors (12%), melanoma (12%) and head & neck cancers (5.3%). Single-agent nivolumab (39 patients) was the most common IO agent used followed by single-agent pembrolizumab (22 patients), ipilimumab (11 patients), atezolizumab (3 patients), avelumab (1 patient) (There was one patient who got nivolumab initially and then pembrolizumab). Nine patients were treated with ipilimumab/nivolumab combination. The mean number of cycles received was 9.1. The total number of patients who developed at least one abnormal hormone level was 57(76%), with 33 out of 74 (45%) patients had at least one abnormal TSH, 29 out of 44 (66%) patients had at least one abnormal testosterone level, 10 out of 49 (20.4%) patients had at least one abnormal FSH and/or LH level, 36 out of 52 (69%) patients had at least one abnormal cortisol level. The mean number of days from starting IO to develop the first abnormal laboratory result was 106 days. Conclusions: The incidence of endocrinopathy was significantly high in patients receiving IO in this study, which is higher than what is reported in previous clinical trials. This could be due to frequent testing in asymptomatic patients and strict laboratory cut-off values which is not always clinically meaningful. This finding may highlight the importance of routine monitoring of the endocrine function during IO treatment. Routine measurement of hormone levels can detect asymptomatic endocrinopathy which may warrant further work-up and treatment. These findings should be validated in a larger prospective study.

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Spontaneous and medically induced cerebrospinal fluid leakage in the setting of pituitary adenomas: review of the literature

Neurosurgical FOCUS ◽

10.3171/2012.4.focus1268 ◽

2012 ◽

Vol 32 (6) ◽

pp. E2 ◽

Cited By ~ 37

Author(s):

Grace Lam ◽

Vivek Mehta ◽

Gabriel Zada

Keyword(s):

Pituitary Adenoma ◽

Pituitary Adenomas ◽

Somatostatin Analogs ◽

Csf Leak ◽

Cerebrospinal Fluid Leakage ◽

Review Of The Literature ◽

Csf Rhinorrhea ◽

Clinical Scenarios ◽

Csf Leakage ◽

Csf Leaks

Object Spontaneous and medically induced CSF leaks are uncommonly associated with pituitary adenomas. The aim of this study was to further characterize the clinical scenarios most closely associated with this phenomenon. Methods A review of the literature was conducted to identify all cases of nonsurgical CSF leaks associated with pituitary adenomas. The authors aimed to identify associated risk factors and management strategies used to treat these tumors and repair the CSF leak site. Results Fifty-two patients with spontaneous or medically induced CSF leaks in the setting of a pituitary adenoma were identified from 29 articles published from 1980 through 2011. In 38 patients (73%), CSF rhinorrhea developed following initiation of medical therapy, whereas spontaneous CSF leakage developed as the presenting symptom in 14 patients (27%). The patients' mean age was 42.8 years (range 23–68 years). There were 35 males and 17 females. Forty-two patients (81%) had a prolactinoma, with the remaining patients having the following tumors: nonfunctioning pituitary adenoma (6 patients), growth hormone–secreting adenoma (2 patients), mammosomatotroph cell adenoma (1 patient), and ACTH-secreting adenoma (1 patient). Infrasellar tumor invasion into the paranasal sinuses was specifically reported in 56% of patients. The medical agents associated with CSF leakage were dopamine agonists (97%) and somatostatin analogs (3%). The average time from initialization of medical treatment to onset of rhinorrhea was 3.3 months (range 3 days–17 months). Nonsurgical management was successful in 4 patients, including 1 who had successful resolution with a temporary lumbar drain. Forty-six patients (88%) underwent surgical intervention to treat the CSF leak and/or resect the tumor. In 2 patients, surgery was not performed due to medical contraindications or patient preference. Conclusions Nonsurgical development of CSF rhinorrhea may occur in the setting of pituitary adenomas, especially following favorable response of invasive prolactinomas to initiation of dopamine agonist therapy. Additional cases have been reported as the presenting symptom of a pituitary adenoma and are likely to be related to decreased tumor volume due to intrinsic infarction or hemorrhage, ongoing invasion, and/or increases in intracranial pressure. Surgical repair, preferentially via a transsphenoidal approach, is the recommended initial treatment for definitive repair of the CSF leak and achievement of maximal tumor resection.

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Silent corticotroph pituitary adenomas: clinical characteristics, long-term outcomes, and management of disease recurrence

Journal of Neurosurgery ◽

10.3171/2020.10.jns203236 ◽

2021 ◽

pp. 1-8

Author(s):

Ben A. Strickland ◽

Shane Shahrestani ◽

Robert G. Briggs ◽

Anna Jackanich ◽

Sherwin Tavakol ◽

...

Keyword(s):

Pituitary Adenomas ◽

Statistical Significance ◽

Progression Free Survival ◽

Disease Recurrence ◽

Csf Leak ◽

Survival Duration ◽

Tumor Control ◽

Tumor Diameter ◽

Free Survival ◽

Neurological Outcomes

OBJECTIVE Silent corticotroph adenomas (SCAs) are a distinct subtype of nonfunctioning pituitary adenomas (NFAs) that demonstrate positive immunohistochemistry for adrenocorticotropic hormone (ACTH) without causing Cushing’s disease. SCAs are hypothesized to exhibit more aggressive behavior than standard NFAs. The authors analyzed their institution’s surgical experience with SCAs in an effort to characterize rates of invasion, postoperative clinical outcomes, and patterns of disease recurrence and progression. The secondary objectives were to define the best treatment strategies in the event of tumor recurrence and progression. METHODS A retrospective analysis of patients treated at the authors’ institution identified 100 patients with SCAs and 841 patients with NFAs of other subtypes who were treated surgically from 2000 to 2019. Patient demographics, tumor characteristics, surgical and neuroimaging data, rates of endocrinopathy, and neurological outcomes were recorded. Cohorts of patients with SCAs and patients with standard NFAs were compared with regard to these characteristics and outcomes. RESULTS The SCA cohort presented with cranial neuropathy (13% vs 5.7%, p = 0.0051) and headache (53% vs 42.3%, p = 0.042) compared to the NFA cohort, despite similar rates of apoplexy. The SCA cohort included a higher proportion of women (SCA 60% vs NFA 45.8%, p = 0.0071) and younger age at presentation (SCA 50.5 ± 13.3 vs NFA 54.6 ± 14.9 years of age, p = 0.0082). Reoperations were comparable between the cohorts (SCA 16% vs NFA 15.7%, p = 0.98). Preoperative pituitary function was comparable between the cohorts with the exception of higher rates of preoperative panhypopituitarism in NFA patients (2% vs 6.1%, respectively; p = 0.0033). The mean tumor diameter in SCA patients was 24 ± 10.8 mm compared to 26 ± 11.3 mm in NFA patients (p = 0.05). Rates of cavernous sinus invasion were higher in the SCA group (56% vs 49.7%), although this result did not reach statistical significance. There were no significant differences in extent of resection, intraoperative CSF leak rates, endocrine or neurological outcomes, or postoperative complications. Ki-67 rates were significantly increased in the SCA cohort (2.88 ± 2.79) compared to the NFA cohort (1.94 ± 1.99) (p = 0.015). Although no differences in overall rates of progression or recurrence were noted, SCAs had a significantly lower progression-free survival (24.5 vs 51.1 months, p = 0.0011). Among the SCA cohort, progression was noted despite the use of adjuvant radiosurgery in 33% (n = 4/12) of treated tumors. Adequate tumor control was not achieved in half (n = 6) of the SCA progression cohort despite radiosurgery or multiple resections. CONCLUSIONS In this study, to the authors’ knowledge the largest surgical series to assess outcomes in SCAs to date, the findings suggest that SCAs are more biologically aggressive tumors than standard NFAs. The progression-free survival duration of patients with SCAs is only about half that of patients with other NFAs. Therefore, close neuroimaging and clinical follow-up are warranted in patients with SCAs, and residual disease should be considered for early postoperative adjuvant radiosurgery, particularly in younger patients.

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

Journal of Neurosurgery ◽

10.3171/2014.3.jns131679 ◽

2014 ◽

Vol 121 (1) ◽

pp. 75-83 ◽

Cited By ~ 78

Author(s):

Kyle Juraschka ◽

Osaama H. Khan ◽

Bruno L. Godoy ◽

Eric Monsalves ◽

Alexandra Kilian ◽

...

Keyword(s):

Pituitary Adenomas ◽

Transsphenoidal Surgery ◽

Sphenoid Sinus ◽

Tumor Volume ◽

Extent Of Resection ◽

Tumor Diameter ◽

Endoscopic Endonasal ◽

Posterior Extension ◽

Endoscopic Endonasal Transsphenoidal Surgery ◽

Giant Pituitary Adenomas

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

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Surgical outcomes using a medial-to-lateral endonasal endoscopic approach to pituitary adenomas invading the cavernous sinus

Journal of Neurosurgery ◽

10.3171/2014.1.jns131228 ◽

2014 ◽

Vol 120 (5) ◽

pp. 1086-1094 ◽

Cited By ~ 29

Author(s):

Graeme F. Woodworth ◽

Kunal S. Patel ◽

Benjamin Shin ◽

Jan-Karl Burkhardt ◽

Apostolos John Tsiouris ◽

...

Keyword(s):

Cavernous Sinus ◽

Pituitary Adenomas ◽

Extent Of Resection ◽

Endoscopic Approach ◽

Gross Total Resection ◽

Csf Leak ◽

Cranial Neuropathy ◽

Total Resection ◽

Aggressive Approach ◽

Cranial Neuropathies

Object This study details the extent of resection and complications associated with endonasal endoscopic surgery for pituitary tumors invading the cavernous sinus (CS) using a moderately aggressive approach to maximize extent of resection through the medial CS wall while minimizing the risk of cranial neuropathy and blood loss. Tumor in the medial CS was aggressively pursued while tumor in the lateral CS was debulked in preparation for radiosurgery. Methods A prospective surgical database of consecutive endonasal pituitary surgeries with verified CS invasion on intraoperative visual inspection was reviewed. The extent of resection as a whole and within the CS was assessed by an independent neuroradiologist using pre- and postoperative Knosp-Steiner (KS) categorization and volumetrics of the respective MR images. The extent of resection and clinical outcomes were compared for medial (KS 1–2) and lateral (KS 3–4) lesions. Results Thirty-six consecutive patients with pituitary adenomas involving the CS who had surgery via an endonasal endoscopic approach were identified. The extent of resection was 84.6% for KS 1–2 and 66.6% for KS 3–4 (p = 0.04). The rate of gross-total resection was 53.8% for KS 1–2 and 8.7% for KS 3–4 (p = 0.0006). Six patients (16.7%) had preoperative cranial neuropathies, and all 6 had subjective improvement after surgery. Surgical complications included 2 transient postoperative cranial neuropathies (5.6%), 1 postoperative CSF leak (2.8%), 1 reoperation for mucocele (2.8%), and 1 infection (2.8%). Conclusions The endoscopic endonasal “medial-to-lateral” approach permits safe debulking of tumors in the medial and lateral CS. Although rates of gross-total resection are moderate, particularly in the lateral CS, the risk of permanent cranial neuropathy is extremely low and there is a high chance of improvement of preexisting deficits. This approach can also facilitate targeting for postoperative radiosurgery.

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The Use of Methylene Blue Staining Test in Determining the CSF Leaks Location of the Anterior Skull Base

Revista de Chimie ◽

10.37358/rc.18.6.6328 ◽

2018 ◽

Vol 69 (6) ◽

pp. 1376-1377

Author(s):

Razvan Hainarosie ◽

Teodora Ghindea ◽

Irina Gabriela Ionita ◽

Mura Hainarosie ◽

Cristian Dragos Stefanescu ◽

...

Keyword(s):

Methylene Blue ◽

Cerebrospinal Fluid ◽

Intrathecal Injection ◽

Diagnostic Procedures ◽

Blue Staining ◽

Csf Leak ◽

Glucose Content ◽

Csf Rhinorrhea ◽

Cerebrospinal Fluid Rhinorrhea ◽

Csf Leakage

Cerebrospinal fluid rhinorrhea represents drainage of cerebrospinal fluid into the nasal cavity. The first steps in diagnosing CSF rhinorrhea are a thorough history and physical examination of the patient. Other diagnostic procedures are the double ring sign, glucose content of the nasal fluid, Beta-trace protein test or beta 2-transferrin. To establish the exact location of the defect imagistic examinations are necessary. However, the gold standard CSF leakage diagnostic method is an intrathecal injection of fluorescein with the endoscopic identification of the defect. In this paper we analyze a staining test, using Methylene Blue solution, to identify the CSF leak�s location.

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Estimating Risk of Pituitary Apoplexy after Resection of Giant Pituitary Adenomas

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0041-1722993 ◽

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.

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Endonasal endoscopic reoperation for residual or recurrent craniopharyngiomas

Journal of Neurosurgery ◽

10.3171/2016.1.jns152238 ◽

2017 ◽

Vol 126 (2) ◽

pp. 418-430 ◽

Cited By ~ 27

Author(s):

Sivashanmugam Dhandapani ◽

Harminder Singh ◽

Hazem M. Negm ◽

Salomon Cohen ◽

Mark M. Souweidane ◽

...

Keyword(s):

Tumor Volume ◽

Visual Outcome ◽

Extent Of Resection ◽

Endocrine Function ◽

Subtotal Resection ◽

Total Resection ◽

Medical College ◽

The Impact ◽

First Time

OBJECTIVE Craniopharyngiomas can be difficult to remove completely based on their intimate relationship with surrounding visual and endocrine structures. Reoperations are not uncommon but have been associated with higher rates of complications and lower extents of resection. So radiation is often offered as an alternative to reoperation. The endonasal endoscopic transsphenoidal approach has been used in recent years for craniopharyngiomas previously removed with craniotomy. The impact of this approach on reoperations has not been widely investigated. METHODS The authors reviewed a prospectively acquired database of endonasal endoscopic resections of craniopharyngiomas over 11 years at Weill Cornell Medical College, NewYork-Presbyterian Hospital, performed by the senior authors. Reoperations were separated from first operations. Pre- and postoperative visual and endocrine function, tumor size, body mass index (BMI), quality of life (QOL), extent of resection (EOR), impact of prior radiation, and complications were compared between groups. EOR was divided into gross-total resection (GTR, 100%), near-total resection (NTR, > 95%), and subtotal resection (STR, < 95%). Univariate and multivariate analyses were performed. RESULTS Of the total 57 endonasal surgical procedures, 22 (39%) were reoperations. First-time operations and reoperations did not differ in tumor volume, radiological configuration, or patients' BMI. Hypopituitarism and diabetes insipidus (DI) were more common before reoperations (82% and 55%, respectively) compared with first operations (60% and 8.6%, respectively; p < 0.001). For the 46 patients in whom GTR was intended, rates of GTR and GTR+NTR were not significantly different between first operations (90% and 97%, respectively) and reoperations (80% and 100%, respectively). For reoperations, prior radiation and larger tumor volume had lower rates of GTR. Vision improved equally in first operations (80%) compared with reoperations (73%). New anterior pituitary deficits were more common in first operations compared with reoperations (51% vs 23%, respectively; p = 0.08), while new DI was more common in reoperations compared with first-time operations (80% vs 47%, respectively; p = 0.08). Nonendocrine complications occurred in 2 (3.6%) first-time operations and no reoperations. Tumor regrowth occurred in 6 patients (11%) over a median follow-up of 46 months and was not different between first versus reoperations, but was associated with STR (33%) compared with GTR+NTR (4%; p = 0.02) and with not receiving radiation after STR (67% vs 22%; p = 0.08). The overall BMI increased significantly from 28.7 to 34.8 kg/m2 over 10 years. Six months after surgery, there was a significant improvement in QOL, which was similar between first-time operations and reoperations, and negatively correlated with STR. CONCLUSIONS Endonasal endoscopic transsphenoidal reoperation results in similar EOR, visual outcome, and improvement in QOL as first-time operations, with no significant increase in complications. EOR is more impacted by tumor volume and prior radiation. Reoperations should be offered to patients with recurrent craniopharyngiomas and may be preferable to radiation in patients in whom GTR or NTR can be achieved.

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Endonasal endoscopic pituitary surgery in the elderly

Journal of Neurosurgery ◽

10.3171/2016.11.jns162286 ◽

2018 ◽

Vol 128 (2) ◽

pp. 429-436 ◽

Cited By ~ 11

Author(s):

Peter J. Wilson ◽

Sacit B. Omay ◽

Ashutosh Kacker ◽

Vijay K. Anand ◽

Theodore H. Schwartz

Keyword(s):

Elderly Patients ◽

Complication Rate ◽

Pituitary Adenomas ◽

Statistical Tests ◽

The Elderly ◽

Medical Complications ◽

Tumor Diameter ◽

Complication Rates ◽

Pseudoaneurysm Formation ◽

Significant Difference

OBJECTIVEPituitary adenomas are benign, slow-growing tumors that cause symptoms either through mass effect or hormone overproduction. The decision to operate on a healthy young person is relatively straightforward. In the elderly population, however, the risks of complications may increase, rendering the decision more complex. Few studies have documented the risks of surgery using the endonasal endoscopic approach in a large number of elderly patients. The purpose of this study was to audit a single center's data regarding outcomes of purely endoscopic endonasal transsphenoidal resection of pituitary adenomas in elderly patients and to compare them to the current literature.METHODSA retrospective review of a prospectively acquired database of all endonasal endoscopic surgeries done by the senior authors was queried for patients aged 60–69 years and for those aged 70 years or older. Demographic and radiographic preoperative data were reviewed. Outcomes with respect to extent of resection and complications were examined and compared with appropriate statistical tests.RESULTSA total of 135 patents were identified (81 aged 60–69 years and 54 aged 70 years or older [70+]). The average tumor diameter was slightly larger for the patients in the 70+ age group (mean [SD] 25.7 ± 9.2 mm) than for patients aged 60–69 years (23.1 ± 9.8 mm, p = 0.056). There was no significant difference in intraoperative blood loss (p > 0.99), length of stay (p = 0.22), or duration of follow-up (p = 0.21) between the 2 groups. There was a 7.4% complication rate in patients aged 60–69 years (3 nasal and 3 medical complications) and an 18.5% complication rate in patients older than 70 years (4 cranial, 3 nasal, 1 visual, and 2 medical complications; p = 0.05 overall and 0.013 for cranial complications). Cranial complications in the 70+ age category included 2 postoperative hematomas, 1 pseudoaneurysm formation, and 1 case of symptomatic subdural hygromas.CONCLUSIONSEndonasal endoscopic surgery in elderly patients is safe, but there is a graded increase in complication rates with increasing age. The decision to operate on an asymptomatic or mildly symptomatic patient in these age groups should take this increasing complication rate into account. The use of a lumbar drain or lumbar punctures should be weighed against the risk of subdural hematoma in patients with preexisting atrophy.

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