Hybrid fluorescein-guided surgery for pituitary adenoma resection: a pilot study

2020 ◽  
Vol 132 (5) ◽  
pp. 1490-1498 ◽  
Author(s):  
Samuel Romano-Feinholz ◽  
Víctor Alcocer-Barradas ◽  
Alejandra Benítez-Gasca ◽  
Ernesto Martínez-de la Maza ◽  
Cristopher Valencia-Ramos ◽  
...  
Keyword(s):  
Pituitary Adenoma ◽  
Pilot Study ◽  
Pituitary Adenomas ◽  
Tumor Resection ◽  
Scar Tissue ◽  
Spectrophotometric Analysis ◽  
Guided Surgery ◽  
Yellow 560 ◽  
Acth Secreting ◽  
Microscopic Techniques

OBJECTIVEThe authors conducted a pilot study on hybrid fluorescein-guided surgery for pituitary adenoma resection and herein describe the feasibility and safety of this technique.METHODSIn this pilot study, the authors included all consecutive patients presenting with pituitary adenomas, functioning and nonfunctioning. They performed a hybrid fluorescein-guided surgical technique for tumor resection. An endonasal endoscopic approach was used; after exposure of the rostrum of the sphenoid sinus, they administered a bolus of 8 mg/kg of fluorescein sodium (FNa) intravenously, and during resection, they alternated between endoscopic and microscopic techniques to guide the resection under a YELLOW 560 filter.RESULTSThe study included 15 patients, 7 men (47%) and 8 women (53%). Of the pituitary adenomas, 7 (46%) were nonfunctioning, 6 (40%) were GH secreting, 1 (7%) was prolactin secreting, and 1 (7%) was ACTH secreting. There were no FNa-related complications (anaphylactic reactions); yellowish staining of urine, skin, and mucosa was seen in all patients and resolved in a maximum time of 24 hours. After color spectrophotometric analysis, the authors identified a statistical difference in fluorescence among tumor, gland, and scar tissue (p = 0.01).CONCLUSIONSThis is the first study of its kind to describe the feasibility and safety of using FNa to guide the resection of pituitary adenomas. The authors found this technique to be safe and feasible. It may be used to obtain better surgical results, especially for hormone-producing and recurring tumors, as well as for reducing the learning curve in pituitary adenoma surgery.

scholarly journals Ectopic ACTH-secreting pituitary adenoma of the sphenoid sinus: case report of endoscopic endonasal resection and systematic review of the literature

2015 ◽  
Vol 38 (2) ◽  
pp. E10 ◽  
Author(s):  
Justin Seltzer ◽  
Joshua Lucas ◽  
Deborah Commins ◽  
Olga Lerner ◽  
Alexander Lerner ◽  
...  
Keyword(s):  
Pituitary Adenoma ◽  
Pituitary Adenomas ◽  
Sphenoid Sinus ◽  
Cushing Syndrome ◽  
Tumor Resection ◽  
Serum Cortisol ◽  
Total Resection ◽  
Endoscopic Endonasal ◽  
Ectopic Acth ◽  
Acth Secreting

Ectopic pituitary adenomas are exceedingly rare entities that are often misdiagnosed. The resulting delay in diagnosis may be particularly concerning in the case of Cushing syndrome caused by an ectopic adrenocorticotropic hormone (ACTH)–secreting pituitary adenoma. Although the total resection of ectopic adenomas results in rapid and durable remission, persistent Cushing syndrome is often associated with permanently damaging invasive procedures and significantly higher risk of mortality. The authors report the case of a 48-year-old man with ACTH-dependent Cushing syndrome. On the morning before surgery, his serum cortisol measured 51 μg/dl, his ACTH level was 195.7 pg/ml, and his urinary free cortisol level was 2109 μg/day. Serum cortisol was not suppressed with the administration of high-dose dexamethasone. Imaging showed separate masses in both the sphenoid sinus and the pituitary gland, complicating the diagnostic process and requiring pathological assessment of both masses. No other abnormalities were found on thoracic, abdominal, or pelvic scans. Gross-total resection of both lesions was accomplished via an endoscopic endonasal transsphenoidal approach. Pathology confirmed an ectopic ACTH pituitary adenoma of the sphenoid sinus and a Crooke hyaline change of the pituitary gland. The patient achieved stable hormonal remission without significant postoperative complications, returned to full activity within 3 months, and remained disease free nearly 1 year after tumor resection. In a systematic literature review, the authors identified 41 cases of ectopic ACTH-secreting pituitary adenomas, including 18 arising in the sphenoid sinus without direct involvement of the sella. Including the case described here, the total number of ectopic ACTH pituitary adenomas arising in the sphenoid sinus was 19, and the total number of ectopic ACTH pituitary adenomas without regard to location was 42. For the 19 patients with adenomas found in the sphenoid sinus, ages ranged from 16 to 76 years, and there were 15 women and 4 men. The mean and median diameters of the resected sphenoid masses were 13.9 and 8 mm, respectively, with a range of 3–55 mm. Seven were microadenomas (< 1 cm). Fifteen of the 19 cases reported serum ACTH and morning cortisol levels, the means of which were 106.7 pg/ml and 32.5 μg/dl, respectively. Gross-total tumor resection was achieved in all patients except one, and in all of them durable hormonal remission of Cushing syndrome was achieved (mean follow-up time 20 months). Ectopic pituitary adenomas are rare but important causes of Cushing syndrome and related endocrinopathies, particularly because of the rapid onset and severity of symptoms with atypical presentation. Ectopic pituitary adenomas, especially those in the nasal cavity, nasopharynx, or paranasal sinuses, are easily misidentified. Any patient presenting with signs and symptoms of Cushing syndrome without any obvious pituitary adenoma or other sources of hypercortisolemia should be thoroughly screened for an ectopic adenoma. However, as with the case presented here, the coincident existence of a sellar mass should not preclude the possibility of an ectopic source. There should be a high degree of clinical suspicion for any mass in the general area surrounding the sella when evaluating Cushing syndrome.

scholarly journals miR-26a Plays an Important Role in Cell Cycle Regulation in ACTH-Secreting Pituitary Adenomas by Modulating Protein Kinase Cδ

Endocrinology ◽  
2013 ◽  
Vol 154 (5) ◽  
pp. 1690-1700 ◽  
Author(s):  
Erica Gentilin ◽  
Federico Tagliati ◽  
Carlo Filieri ◽  
Daniela Molè ◽  
Mariella Minoia ◽  
...  
Keyword(s):  
Cell Cycle ◽  
Pituitary Adenoma ◽  
Protein Kinase ◽  
Pituitary Adenomas ◽  
Viable Cell Number ◽  
Pituitary Cells ◽  
Human Pituitary ◽  
Human Pituitary Adenoma ◽  
Acth Secreting ◽  
Protein Kinase Cδ

Abstract The functional aftermath of microRNA (miRNA) dysregulation in ACTH-secreting pituitary adenomas has not been demonstrated. miRNAs represent diagnostic and prognostic biomarkers as well as putative therapeutic targets; their investigation may shed light on the mechanisms that underpin pituitary adenoma development and progression. Drugs interacting with such pathways may help in achieving disease control also in the settings of ACTH-secreting pituitary adenomas. We investigated the expression of 10 miRNAs among those that were found as most dysregulated in human pituitary adenoma tissues in the settings of a murine ACTH-secreting pituitary adenoma cell line, AtT20/D16v-F2. The selected miRNAs to be submitted to further investigation in AtT20/D16v-F2 cells represent an expression panel including 5 up-regulated and 5 down-regulated miRNAs. Among these, we selected the most dysregulated mouse miRNA and searched for miRNA targets and their biological function. We found that AtT20/D16v-F2 cells have a specific miRNA expression profile and that miR-26a is the most dysregulated miRNA. The latter is overexpressed in human pituitary adenomas and can control viable cell number in the in vitro model without involving caspase 3/7-mediated apoptosis. We demonstrated that protein kinase Cδ (PRKCD) is a direct target of miR-26a and that miR26a inhibition delays the cell cycle in G1 phase. This effect involves down-regulation of cyclin E and cyclin A expression via PRKCD modulation. miR-26a and related pathways, such as PRKCD, play an important role in cell cycle control of ACTH pituitary cells, opening new therapeutic possibilities for the treatment of persistent/recurrent Cushing's disease.

NCOG-31. GIANT PITUITARY ADENOMA (GPA) SCORE: A NOVEL SCORING SYSTEM TO PREDICT POSTOPERATIVE OUTCOMES OF GIANT PITUITARY ADENOMAS

2021 ◽  
Vol 23 (Supplement_6) ◽  
pp. vi158-vi158
Author(s):  
Syed Ather Enam ◽  
Fauzan Alam Hashmi ◽  
Sanam Mir Ghazi ◽  
Ahsan Ali Khan ◽  
Muhammad Bilal Tariq ◽  
...  
Keyword(s):  
Pituitary Adenoma ◽  
Linear Regression ◽  
Pituitary Adenomas ◽  
Scoring System ◽  
Tumor Resection ◽  
Maximum Diameter ◽  
Giant Pituitary Adenoma ◽  
Giant Pituitary Adenomas ◽  
The Mean ◽  
Suprasellar Extension

Abstract BACKGROUND Giant pituitary adenomas (GPA) are uncommon and highly variable in morphology and extension. There is no scoring system that considers all the dimensions of adenoma invasion. We developed a new Giant Pituitary Adenoma score and report our surgical experience and evaluate outcomes after resection of these tumors in accordance with the preoperative score. METHODS We developed a novel scoring system for classifying giant pituitary adenomas, and 11-year data of GPA surgery at our center was collected retrospectively, based on this scoring system. GPA Score considered tumor’s parasellar extension, encasement of cavernous internal carotid artery (ICA), suprasellar extension &gt; 2 cm, suprasellar extension &gt; 4cm and retrosellar extension. Maximum possible score was 9. The scoring system was applied to 53 patients of GPA who underwent surgical resection between January 1, 2006, and December 2017. The Lundin-Pederson (ABC/2) method was used to calculate the tumor volume both pre- and post-resection and linear regression was used to assess the relationship between extent of tumor resection and GPA score. RESULTS The median age of the study population was 42.08 ± 16.49 years. The mean maximum diameter of the pituitary adenomas was 5.0 cm (range 4.0 cm-8.5cm) while the mean volume of the adenomas was 27.3 cm3 (range 10 cm3-149 cm3). There were 3 cases of score 2, 5 cases of score 3, 13 cases of score 4, 20 cases of score 5, 9 cases of score 6 and 3 cases of score 7. The range of tumor volumes of tumors for scores from 2-7 was 17.3 cm3 to 65.8 cm3 and GPA score was correlated with the percent residual tumor using linear regression that was statistically significant (p= 0.001). CONCLUSION GPA Score is a reliable scoring system to predict the extent and subsequent difficulty in tumor resection in GPA.

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.

Pituitary Adenomas with Changing Phenotype: A Systematic Review

2020 ◽  
Vol 128 (12) ◽  
pp. 835-844
Author(s):  
Fernando Guerrero-Pérez ◽  
Agustina Pia Marengo ◽  
Noemi Vidal ◽  
Carles Villabona
Keyword(s):  
Systematic Review ◽  
Cushing’S Disease ◽  
Pituitary Adenomas ◽  
Tumor Resection ◽  
Cushing's Disease ◽  
Complete Tumor Resection ◽  
Null Cell ◽  
Acth Secreting ◽  
Complete Tumor

Abstract Purpose and Methods Phenotype transformation in pituitary adenomas (PA) is a little known and unexpected clinical phenomenon. We describe two illustrative cases and performed a systematic review of cases reported in literature. Results Case 1: A 24-year-old woman underwent surgery because of Cushing’s disease. A complete tumor resection and hypercortisolism resolution was achieved. Two years later, tumor recurred but clinical and hormonal hypercortisolism were absent. Case 2: A 77-year-old woman underwent surgery due to acromegaly. A complete tumor resection and GH excess remission was achieved. Four years later, tumor recurred but clinical and hormonal acromegaly was ruled out. Search of literature: From 20 patients (including our cases), 75% were female with median age 45 (19) years. Ten patients (50%) had initially functioning PA: 8 switched to NFPA (5 ACTH-secreting PA, 2 prolactinomas and 1 acromegaly) and 2 exchanged to acromegaly from TSH-secreting PA and microprolactinoma. One patient developed a pituitary carcinoma from ACTH-secreting PA. Ten patients (50%) initially had NFPA; 9 developed Cushing’s disease (4 silent corticotroph adenomas, 4 null cell PA and 1 managed conservatively). One patient with silent somatotroph PA changed to acromegaly. Treatments before transformation were surgery (80%), radiotherapy (40%), pharmacological (40%) and in 2 patients switching happened without any treatment. Median follow-up until transformation was 72 months (range 12–276). Conclusion PA can change from functioning to (NF) non-functioning (vice versa) and even exchange their hormonal expression. Clinicians should be aware and a careful lifelong follow-up is mandatory to detect it.

scholarly journals Magmas, a Gene Newly Identified as Overexpressed in Human and Mouse ACTH-Secreting Pituitary Adenomas, Protects Pituitary Cells from Apoptotic Stimuli

Endocrinology ◽  
2010 ◽  
Vol 151 (10) ◽  
pp. 4635-4642 ◽  
Author(s):  
Federico Tagliati ◽  
Erica Gentilin ◽  
Mattia Buratto ◽  
Daniela Molè ◽  
Ettore Ciro degli Uberti ◽  
...  
Keyword(s):  
Pituitary Adenoma ◽  
Pituitary Adenomas ◽  
Mitochondrial Protein ◽  
Pituitary Tumors ◽  
Pituitary Cells ◽  
Subcellular Compartment ◽  
Adenoma Cell ◽  
Macrophage Colony ◽  
Reduced Rate ◽  
Acth Secreting

Pituitary tumors are mostly benign, being locally invasive in 5–35% of cases. Deregulation of several genes has been suggested as a possible alteration underlying the development and progression of pituitary tumors. We here report the identification of a cDNA, corresponding to Magmas gene (mitochondria-associated protein involved in granulocyte-macrophage colony-stimulating factor signal transduction), which is highly expressed in two different ACTH-secreting mouse pituitary adenoma cell lines as compared with normal pituitary as well as in two thirds of 64 examined pituitary adenomas as compared with human normal pituitary. Tim 16, the mitochondrial protein encoded by Magmas, was indeed expressed in a mouse ACTH-secreting pituitary adenoma cell line, AtT-20 D16v-F2 cells, in a subcellular compartment likely corresponding to mitochondria. Magmas silencing determined a reduced rate of DNA synthesis, an accumulation in G1 phase, and a concomitant decrease in S phase in At-T20 D16v-F2 cells. Moreover, Magmas-silenced cells displayed basal caspase 3/7 activity and DNA fragmentation levels similar to control cells, which both increased under proapoptotic stimuli. Our data demonstrate that Magmas is overexpressed in mouse and human ACTH-secreting pituitary adenomas. Moreover, our results show that Magmas protects pituitary cells from apoptosis, suggesting its possible involvement in neoplastic transformation.

Failure of valproic acid to inhibit the growth of an ACTH-secreting pituitary adenoma

1984 ◽  
Vol 105 (4) ◽  
pp. 449-454 ◽  
Author(s):  
Grant Gwinup ◽  
Alan N. Elias ◽  
Benjamin Choi
Keyword(s):  
Valproic Acid ◽  
Pituitary Adenoma ◽  
Pituitary Adenomas ◽  
Chronic Administration ◽  
Pituitary Tumours ◽  
Plasma Acth ◽  
Lower Plasma ◽  
Acid Therapy ◽  
Acth Concentration ◽  
Acth Secreting

Abstract. Di-n-propylacetic acid (valproic acid) has been reported to lower plasma ACTH concentration after both acute and chronic administration of the drug. To date, there is no report on the efficacy of the drug in inducing regression of ACTH-secreting pituitary adenomas. We report herein our findings in a patient with Nelson's syndrome who was treated with valproic acid for over a year. Despite a lowering of her plasma ACTH concentration during therapy with valproic acid, the patient's tumour showed no evidence of regression while she was taking the drug. In view of these findings, valproic acid therapy for ACTH-secreting pituitary tumours needs to be re-evaluated.

scholarly journals Pituitary Adenomas: Presentations and Outcomes in a South Asian Country

2008 ◽  
Vol 35 (2) ◽  
pp. 198-203 ◽  
Author(s):  
Muhammad Shahzad Shamim ◽  
Muhammad Ehsan Bari ◽  
Faraz Khursheed ◽  
Rashid Jooma ◽  
Syed Ather Enam
Keyword(s):  
Pituitary Adenoma ◽  
Pituitary Adenomas ◽  
Hormone Replacement ◽  
Tumor Resection ◽  
Residual Tumor ◽  
Asian Country ◽  
Developed Countries ◽  
P Value ◽  
Tumor Diameter ◽  
Giant Pituitary Adenoma

Objective:: The purpose of this retrospective review of all operated cases of pituitary adenomas in the last decade, is to define the demographic patterns and characteristics of such tumors and to assess surgical outcomes with regards to safety and efficacy of trans–sphenoidal tumor removal in our institution.Methods:Surgically treated pituitary adenomas presenting from 1995 till 2005 were reviewed for different variables. Results were expressed as mean, standard deviation and median for continuous and number with percentage for categorical data. Chi square test was applied to measure differences and significance was taken at p value < 0.05.Results:One hundred and twenty–five patients were operated for pituitary adenoma. Sixty–three percent were male and mean age was 37 years. Sixty percent of the patients presented with headache and/or visual symptoms. Twelve percent presented with pituitary apoplexy and 28% presented with symptoms due to pituitary hyperfunction. Fifty–five percent of patients had functioning and 44% had nonfunctioning adenomas. Mean pre operative tumor diameter from 86 pre op MRI scans was 26.76 mm (3–78 mm). Eighty–four percent of patients underwent trans–sphenoidal tumor resection and three percent had craniotomy. Mean size of post op residual tumor as calculated from 76 available post operative scans was 5.3 mm (range 0–31 mm). 17.6% of the patients required hormone replacement beyond three months and 10% were re–operated. Overall mortality was 1.6%.Conclusion:In Pakistan, patients are more likely to present either with apoplexy or with a giant pituitary adenoma than patients reported from developed countries. Overall, our results have been satisfactory and comparable with the literature.

scholarly journals Cushing Disease Due to Ectopic Pituitary Adenoma.

2019 ◽  
pp. 1-5
Keyword(s):  
Pituitary Adenoma ◽  
Pituitary Adenomas ◽  
Adrenocorticotropic Hormone ◽  
Pituitary Tumors ◽  
Pituitary Stalk ◽  
Cushing Disease ◽  
Ectopic Acth ◽  
Common Cause ◽  
Ectopic Pituitary Adenoma ◽  
Acth Secreting

Abstract Adrenocorticotropic hormone (ACTH) - secreting pituitary adenomas are the most common cause of Cushing disease. A pituitary adenoma is rarely ectopic and suprasellar dependent (ectopic) ACTH -secreting pituitary tumors are extremely rare, with few cases described in the literature. Therefore, this study aimed to report the case of a patient with a diagnosis of Cushing disease because of a suprasellar ACTH-secreting tumor attached to the pituitary stalk, requiring a craniotomy.

Comparison of outcomes between a less experienced surgeon using a fully endoscopic technique and a very experienced surgeon using a microscopic transsphenoidal technique for pituitary adenoma

2016 ◽  
Vol 124 (3) ◽  
pp. 596-604 ◽  
Author(s):  
Hasan A. Zaidi ◽  
Al-Wala Awad ◽  
Michael A. Bohl ◽  
Kristina Chapple ◽  
Laura Knecht ◽  
...  
Keyword(s):  
Pituitary Adenoma ◽  
Endoscopic Surgery ◽  
Pituitary Adenomas ◽  
Transsphenoidal Surgery ◽  
Tumor Resection ◽  
Endoscopic Technique ◽  
Endoscopic Transsphenoidal Surgery ◽  
Experienced Surgeon ◽  
Surgery Technique ◽  
Surgeon Experience

OBJECT The comparative efficacy of microscopic and fully endoscopic transsphenoidal surgery for pituitary adenomas has not been well studied despite the adoption of fully endoscopic surgery by many pituitary centers. The influence of surgeon experience has also not been examined in this setting. The authors therefore compared the extent of tumor resection (EOR) and the endocrine outcomes of 1 very experienced surgeon performing a microscopic transsphenoidal surgery technique with those of a less experienced surgeon using a fully endoscopic transsphenoidal surgery technique for resection of nonfunctioning pituitary adenomas in a concurrent series of patients. METHODS Post hoc analysis was conducted of a cohort of adult patients prospectively enrolled in a pituitary adenoma quality-of-life study between October 2011 and June 2014. Patients were followed up for 6 months after surgery. Patients were treated either by a less experienced surgeon (100 independent cases) who practices fully endoscopic surgery exclusively or by a very experienced surgeon (1800 independent cases) who practices microscopic surgery exclusively. Patient demographic characteristics, tumor characteristics, hypopituitarism, complications, and length of hospital stay were analyzed. Tumor volumes and EOR were determined by formal volumetric analysis involving manual segmentation of MR images performed before surgery and within 6 months after surgery. Logistic regression analysis was used to determine predictors of EOR. RESULTS Fifty-five patients underwent fully endoscopic transsphenoidal surgery, and 80 patients underwent fully microscopic transsphenoidal surgery. The baseline characteristics of the 2 treatment groups were well matched. EOR was similar between the endoscopic and microscopic groups, respectively, as estimated by gross-total resection rate (78.2% vs 81.3%, p = 0.67), percentage of tumor resected (99.2% vs 98.7%, p = 0.42), and volume of residual tumor (0.12 cm3 vs 0.20 cm3, p = 0.41). Multivariate modeling suggested that preoperative tumor volume was the most important predictor of EOR (p = 0.001). No difference was found in the development of anterior gland dysfunction (p > 0.14), but there was a higher incidence of permanent posterior gland dysfunction in the microscopic group (p = 0.04). Combined rates of major complications and unplanned readmissions were lower in the endoscopic group (p = 0.02), but individual complications were not significantly different. CONCLUSIONS A less experienced surgeon using a fully endoscopic technique was able to achieve outcomes similar to those of a very experienced surgeon using a microscopic technique in a cohort of patients with nonfunctioning tumors smaller than 60 cm3. The study raises the provocative notion that certain advantages afforded by the fully endoscopic technique may impact the learning curve in pituitary surgery for nonfunctioning adenomas.

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