The long-term significance of microscopic dural invasion in 354 patients with pituitary adenomas treated with transsphenoidal surgery

2002 ◽  
Vol 96 (2) ◽  
pp. 195-208 ◽  
Author(s):  
Björn P. Meij ◽  
Maria-Beatriz S. Lopes ◽  
Dilantha B. Ellegala ◽  
Tord D. Alden ◽  
Edward R. Laws
Keyword(s):  
Pituitary Adenoma ◽  
Pituitary Adenomas ◽  
Transsphenoidal Surgery ◽  
Tumor Tissue ◽  
Pituitary Surgery ◽  
Mr Images ◽  
Content Type ◽  
Pituitary Disease ◽  
The Mean ◽  
Fine Print

Object. Pituitary adenomas are considered benign tumors; however, they may infiltrate surrounding tissues including the dura mater. In this paper the authors analyze the clinical significance of microscopically confirmed dural invasion by comparing a range of variables (age and sex of patients, adenoma type, adenoma size on magnetic resonance [MR] images, remission, residual pituitary disease, recurrence, survival, and disease-free interval after surgery) between patients with noninvasive adenomas and those with invasive ones. Methods. Between 1992 and 1997 dural specimens were obtained in 354 patients with pituitary adenomas who underwent transsphenoidal surgery performed by the senior author (E.R.L.). Dural specimens were examined using routine histological methods and assessed for invasion by pituitary adenoma tissue. The dura was invaded by the pituitary adenoma in 161 patients (45.5%), and in 192 patients (54.5%) no evidence of dural invasion was found. Dural invasion was present significantly more frequently in the repeated surgery group (69%, 55 patients) than in the primary transsphenoidal surgery group (41%, 291 patients). The mean age of patients undergoing primary transsphenoidal surgery was significantly older in cases of invasive adenomas (50 years) compared with cases of noninvasive adenomas (43 years), and these age differences also correlated with adenoma size. Women tend to develop clinically evident, smaller adenomas at a younger age than men. Of the patients with pituitary adenomas that were 20 mm or smaller, 117 (76%) of 154 were women, whereas of the patients with adenomas that were larger than 20 mm, 74 (54%) of 137 were men. The frequency of dural invasion increased with increasing size of the pituitary adenoma as measured on MR images. In 291 patients who underwent primary pituitary surgery, the frequency of dural invasion according to adenoma size was 24% (≤ 10 mm), 35% (> 10 to ≤ 20 mm), 55% (> 20 to ≤ 40 mm), and 70% (> 40 mm). In patients who underwent primary transsphenoidal surgery, dural invasion was present in more than 50% of those with nonfunctioning adenomas and in 30 to 35% of patients with endocrinologically active adenomas. The mean diameter of the gonadotrophic adenomas and null-cell adenomas was significantly larger than that of each of the endocrinologically active adenomas. In 58 (20%) of 291 patients who underwent primary pituitary surgery there was residual pituitary disease postsurgery, and 20% of this subset of patients showed clinical improvement to such an extent that no further management was recommended. After pituitary surgery, residual tumor tissue was demonstrable significantly more frequently in patients with invasive adenomas than in those with noninvasive adenomas. Recurrences after initial remission (cure) of pituitary disease occurred in 18 (8.8%) of 205 patients between 2 and 79 months after primary pituitary surgery (median 25 months). The recurrence rate was not related to dural invasion in a consistent or significant fashion. Seven patients died between 14 and 79 months after pituitary surgery and all had invasive adenomas identified on gross observation at surgery and on microscopy. The survival rate was slightly but significantly decreased for patients with invasive adenomas (91%) compared with patients with noninvasive adenomas (100%) at 6 years postsurgery. Conclusions. The principal significance of dural invasion by pituitary adenoma is the persistence of tumor tissue after transsphenoidal surgery (incomplete adenomectomy; 20% in primary pituitary tumor resections). The increase in adenoma size with time and the concurrent development of dural invasion are the major factors that determine an incomplete adenomectomy. When the adenoma remains restricted to the sellar compartment or shows only moderate suprasellar extension, dural invasion may not yet have developed and conditions for complete selective adenomectomy are improved.

Gamma knife radiosurgery for pituitary adenomas

2000 ◽  
Vol 93 (supplement_3) ◽  
pp. 19-22 ◽  
Author(s):  
Masahiro Izawa ◽  
Motohiro Hayashi ◽  
Kohtarou Nakaya ◽  
Hiroyuki Satoh ◽  
Taku Ochiai ◽  
...  
Keyword(s):  
Pituitary Adenoma ◽  
Tumor Growth ◽  
Gamma Knife ◽  
Pituitary Adenomas ◽  
Gamma Knife Radiosurgery ◽  
Single Institution ◽  
Hormone Production ◽  
Content Type ◽  
The Mean ◽  
Fine Print

Object. The purpose of this study was the analysis of a large series of patients treated with gamma knife radiosurgery for pituitary adenoma in a single institution. Methods. One hundred eight patients with pituitary adenomas were treated over the last 7 years. Seventy-four patients have been followed for more than 6 months and form the basis of this report. Conclusions. Twenty-three patients harbored nonfunctioning adenomas, and 56 harbored functioning adenomas. The mean margin dose was 22.5 Gy (nonfunctioning adenomas, 19.5 Gy; functioning adenomas, 23.8 Gy). Control of tumor growth was achieved in 91%. A significant decrease of excessive hormone production was seen in 80% of patients, and the endocrinological normalization rate was 30.3%. Postradiosurgical complications were seen in 2.5%.

Hyperprolactinemia, intrasellar pituitary tissue pressure, and the pituitary stalk compression syndrome

1987 ◽  
Vol 67 (2) ◽  
pp. 192-196 ◽  
Author(s):  
Peter D. Lees ◽  
John D. Pickard
Keyword(s):  
Pituitary Adenoma ◽  
Transsphenoidal Surgery ◽  
Pituitary Stalk ◽  
Consecutive Series ◽  
Tissue Pressure ◽  
Content Type ◽  
Compression Syndrome ◽  
The Mean ◽  
Intrasellar Pressure ◽  
Fine Print

✓ The intrasellar pressure has been studied in a consecutive series of 24 patients undergoing transsphenoidal surgery for pituitary adenoma. The mean intrasellar pressure for the group was 23 ± 2.5 mm Hg (± standard error of the mean), with a mean pulse pressure of 3.5 ± 1 mm Hg. The waveform partly resembled the arterial configuration. The results are correlated with the radiological and endocrinological features of the tumors. A hypothesis is proposed to explain the mechanism of hyperprolactinemia associated with the pituitary stalk compression syndrome.

Long-term results of gamma knife surgery for growth hormone—producing pituitary adenoma: is the disease difficult to cure?

2005 ◽  
Vol 102 (Special_Supplement) ◽  
pp. 119-123 ◽  
Author(s):  
Tatsuya Kobayashi ◽  
Yoshimasa Mori ◽  
Yukio Uchiyama ◽  
Yoshihisa Kida ◽  
Shigeru Fujitani
Keyword(s):  
Growth Hormone ◽  
Gamma Knife ◽  
Pituitary Adenomas ◽  
Gamma Knife Surgery ◽  
Long Term Results ◽  
Content Type ◽  
The Mean ◽  
Dose Radiation ◽  
Fine Print

Object. The authors conducted a study to determine the long-term results of gamma knife surgery for residual or recurrent growth hormine (GH)—producing pituitary adenomas and to compare the results with those after treatment of other pituitary adenomas. Methods. The series consisted of 67 patients. The mean tumor diameter was 19.2 mm and volume was 5.4 cm3. The mean maximum dose was 35.3 Gy and the mean margin dose was 18.9 Gy. The mean follow-up duration was 63.3 months (range 13–142 months). The tumor resolution rate was 2%, the response rate 68.3%, and the control rate 100%. Growth hormone normalization (GH < 1.0 ng/ml) was found in 4.8%, nearly normal (< 2.0 ng/ml) in 11.9%, significantly decreased (< 5.0 ng/ml) in 23.8%, decreased in 21.4%, unchanged in 21.4%, and increased in 16.7%. Serum insulin-like growth factor (IGF)—1 was significantly decreased (IGF-1 < 400 ng/ml) in 40.7%, decreased in 29.6%, unchanged in 18.5%, and increased in 11.1%, which was almost parallel to the GH changes. Conclusions. Gamma knife surgery was effective and safe for the control of tumors; however, normalization of GH and IGF-1 secretion was difficult to achieve in cases with large tumors and low-dose radiation. Gamma knife radiosurgery is thus indicated for small tumors after surgery or medication therapy when a relatively high-dose radiation is required.

Localization of pituitary adenomas by using intraoperative ultrasoound pituitary in patients with Cushing's disease and no demonstrable tumor on magnetic resonance imaging

1998 ◽  
Vol 89 (6) ◽  
pp. 927-932 ◽  
Author(s):  
Joe C. Watson ◽  
Thomas H. Shawker ◽  
Lynnette K. Nieman ◽  
Hetty L. DeVroom ◽  
John L. Doppman ◽  
...  
Keyword(s):  
Magnetic Resonance ◽  
Mr Imaging ◽  
Cushing’S Disease ◽  
Pituitary Adenomas ◽  
Pituitary Surgery ◽  
Intraoperative Ultrasonography ◽  
Cushing's Disease ◽  
Content Type ◽  
Negative Findings ◽  
Fine Print

Object. Pituitary surgery has been reported to produce remission of Cushing's disease with preservation of pituitary function in only 60 to 70% of patients. The inability to identify an adenoma accounts for most failed sellar explorations. Most negative surgical explorations occur in patients in whom magnetic resonance (MR) imaging of the pituitary demonstrates normal findings, which happens in at least 35 to 45% of patients with Cushing's disease. Methods. To examine the usefulness of intraoperative ultrasonography (IOUS) for identifying an adenoma in patients with no demonstrable tumor (negative findings) on pituitary MR imaging, we prospectively assessed the results of IOUS in 68 patients with a negative (59 patients) or equivocal (nine patients) MR image from a consecutive series of 107 patients with Cushing's disease (64%). We compared surgical findings and outcomes in these 68 patients with a group of 68 patients with Cushing's disease and negative findings on MR imaging in whom IOUS was not available. Intraoperative ultrasonography localized a tumor in 47 (69%) of 68 patients with negative findings on MR imaging. Surprisingly, the size of the adenomas that were detected with IOUS compared with the size of those not detected did not differ (6.8 ± 3.4 mm compared with 6.1 ± 2.8 mm [mean ± standard deviation], respectively [p = 0.5]). In four patients, no adenoma was found at surgery or in the pathological specimen (“true negative”). In eight patients, nine abnormalities detected by IOUS that were suspected adenomas were negative on exploration (“false positive”). Thus, IOUS has a sensitivity of 73% and a positive predictive value of 84% for detecting pituitary adenomas in patients with Cushing's disease and negative findings on MR imaging. Compared with the 68 patients who did not undergo IOUS, remission after surgery was improved (61 patients [90%] compared with 57 patients [84%]), the number of tumors found on exploration was increased (61 tumors compared with 51 tumors; p = 0.02), and the number of hemihypophysectomies was decreased (five compared with 15; p = 0.02) with IOUS. When the groups were compared after excluding patients with prior pituitary surgery, tumors were found in 91% versus 72% (p = 0.008), and remission occurred in 95% versus 87% of patients, respectively, in the groups that had or did not have IOUS. Conclusions. The IOUS is a sensitive imaging modality when used in patients with Cushing's disease in whom findings on pituitary MR imaging are negative. The improved ability to detect and localize these tumors by using IOUS positively affects surgical outcome.

Long-term surgical outcome in 16 patients with thyrotropin pituitary adenoma

2000 ◽  
Vol 93 (2) ◽  
pp. 194-200 ◽  
Author(s):  
Naoko Sanno ◽  
Akira Teramoto ◽  
R. Yoshiyuki Osamura
Keyword(s):  
Cavernous Sinus ◽  
Pituitary Adenomas ◽  
Transsphenoidal Surgery ◽  
Term Outcome ◽  
Long Term Outcome ◽  
Content Type ◽  
Primary Hyperthyroidism ◽  
Fine Print

Object. Thyrotropin-secreting pituitary adenomas are rare lesions of the endocrinological system. Although introduction of a hypersensitive radioimmunoassay for thyrotropin enables the recognition of inappropriate secretion of this hormone, the aforementioned lesions remain uncommon and unfamiliar to most neurosurgeons. It has been reported previously that surgical cure of thyrotropin-secreting adenomas is more difficult than in other functional adenomas because of the large size and invasive features of the former. However, the long-term outcome after surgery has not been well documented. The authors report on a surgical series of 16 patients with thyrotropin adenoma and the results of long-term follow up.Methods. Sixteen patients ages 23 to 62 years (12 women and four men) underwent transsphenoidal removal of thyrotropin adenomas between 1983 and 1999. These patients had the syndrome of inappropriate thyrotropin secretion (SITS) with pituitary mass lesions. Four of the patients had undergone previous subtotal thyroidectomy and/or radioiodine thyroid ablation, and 11 had been treated with antithyroid medication. Radiological investigations demonstrated macroadenomas in 14 patients, and 10 of those had cavernous sinus invasion. Surgical findings showed unusually fibrous and firm tumors in 13 (81.2%) of 16 patients. Preoperative octreotide administration was revealed to be effective for serum thyrotropin reduction as well as tumor shrinkage. Transsphenoidal surgery was performed with no morbidity resulting. Surgical remission was achieved in 10 (62.5%) of 16 patients, and total remission was achieved in 14 patients (87.5%) with a combination of additional radiation or medical therapy. In the other two patients, SITS persisted because of tumor rests in the cavernous sinus. Therefore, radiation and/or antithyroid therapy was administered. In the mean follow-up period of 7.5 years (range 11 months–15.8 years), no recurrence of tumor was observed on magnetic resonance images, whereas recurrence of SITS was found in two patients with no tumor regrowth. In addition, coexistent primary hyperthyroidism was found in two other patients despite remission of SITS after surgery.Conclusions. Transsphenoidal surgery can achieve a good long-term outcome in patients with thyrotropin-secreting pituitary adenomas if surgery is performed before these become larger, invasive tumors. In the authors' experience, thyrotropin-secreting adenomas are fibrous and firm, which makes it difficult to achieve surgical remission. In addition, even satisfactory resection of the tumor sometimes results in recurrence of SITS or hyperthyroid symptoms due to coexistent primary hyperthyroidism. It is emphasized that a careful follow-up review is necessary after surgery, especially in patients with a long preoperative history of hyperthyroidism.

Thickening of sphenoid sinus mucosa during the acute stage of pituitary apoplexy

2001 ◽  
Vol 95 (5) ◽  
pp. 897-901 ◽  
Author(s):  
Kazunori Arita ◽  
Kaoru Kurisu ◽  
Atushi Tominaga ◽  
Kazuhiko Sugiyama ◽  
Fusao Ikawa ◽  
...  
Keyword(s):  
Transsphenoidal Surgery ◽  
Sphenoid Sinus ◽  
Pituitary Apoplexy ◽  
Sella Turcica ◽  
Acute Stage ◽  
Mr Images ◽  
Content Type ◽  
Subepithelial Layer ◽  
Sinus Mucosa ◽  
Fine Print

✓ The authors treated two patients with pituitary apoplexy in whom magnetic resonance (MR) images were obtained before and after the episode. Two days after the apoplectic episodes, MR imaging demonstrated marked thickening of the mucosa of the sphenoid sinus that was absent in the previous studies. The relevance of this change in the sphenoid sinus was investigated. Retrospective evaluations were performed using MR images obtained in 14 consecutive patients with classic pituitary apoplexy characterized by acute onset of severe headache. The mucosa of the sphenoid sinus had thickened predominantly in the compartment just beneath the sella turcica, in nine of 11 patients, as ascertained on MR images obtained within 7 days after the onset of apoplectic symptoms. This condition improved spontaneously in all four patients who did not undergo transsphenoidal surgery. The sphenoid sinus mucosa appeared to be normal on MR images obtained from three patients at the chronic stage (> 3 months after onset). The incidence of sphenoid sinus mucosal thickening during the acute stage was significantly higher in the patients with apoplexy than that in the 100 patients without apoplexy. A histological study conducted in four patients who underwent transsphenoidal surgery during the early stage showed that the subepithelial layer of the sphenoid sinus mucous membrane was obviously swollen. The sphenoid sinus mucosa thickens during the acute stage of pituitary apoplexy. This thickening neither indicates infectious sinusitis nor rules out the choice of the transsphenoidal route for surgery.

Salvage retreatment after failure of radiosurgery in patients with arteriovenous malformations

2003 ◽  
Vol 98 (2) ◽  
pp. 337-341 ◽  
Author(s):  
Kelly D. Foote ◽  
William A. Friedman ◽  
Thomas L. Ellis ◽  
Frank J. Bova ◽  
John M. Buatti ◽  
...  
Keyword(s):  
Treatment Failure ◽  
Initial Treatment ◽  
Primary Treatment ◽  
Size Reduction ◽  
Cure Rate ◽  
Mr Images ◽  
Content Type ◽  
The Mean ◽  
Fine Print

Object. The goal of this study was to evaluate the outcomes of patients who underwent repeated radiosurgery to treat a residual intracranial arteriovenous malformation (AVM) after an initial radiosurgical treatment failure. Methods. The authors reviewed the cases of 52 patients who underwent repeated radiosurgery for residual AVM at the University of Florida between December 1991 and June 1998. In each case, residual arteriovenous shunting persisted longer than 36 months after the initial treatment; the mean interval between the first and second treatment was 41 months. Each AVM nidus was measured at the time of the original treatment and again at the time of retreatment, and the dosimetric parameters of the two treatments were compared. After retreatment, patients were followed up and their outcomes were evaluated according to a standard posttreatment protocol for radiosurgery for AVMs. The mean original lesion volume was 13.8 cm3 and the mean volume at retreatment was 4.7 cm3, for an average volume reduction of 66% after the initial treatment failure. Only two AVMs (3.8%) failed to demonstrate size reduction after the primary treatment. The median doses on initial and repeated treatment were 12.5 and 15 Gy, respectively. Five patients were lost to follow up and five refused neuroimaging follow up. One patient died of a hemorrhage shortly after retreatment. Of the remaining 41 patients, 24 had evidence of cure, 15 on angiographic studies and nine on magnetic resonance (MR) images. Seventeen had evidence of treatment failure, 10 on angiographic studies and seven on MR images. By angiographic criteria alone, the cure rate after retreatment was 60%, whereas according to angiographic and MR imaging results, the cure rate was 59%. Conclusions. Although initial radiosurgical treatment failed to obliterate the AVM in these 52 patients, it did produce a substantial therapeutic effect (volume reduction). This size reduction commonly allowed higher doses to be delivered during radiosurgical retreatment. The results show rates of angiographically confirmed cure comparable to primary treatment and a low incidence of complications, indicating that salvage radiosurgical retreatment is a safe and effective therapy in cases of failed AVM radiosurgery.

Delayed hyponatremia after transsphenoidal surgery for pituitary adenoma

1995 ◽  
Vol 83 (2) ◽  
pp. 363-367 ◽  
Author(s):  
Daniel F. Kelly ◽  
Edward R. Laws ◽  
Damirez Fossett
Keyword(s):  
Pituitary Adenoma ◽  
Antidiuretic Hormone ◽  
Intravenous Administration ◽  
Serum Sodium ◽  
Transsphenoidal Surgery ◽  
Fluid Restriction ◽  
Content Type ◽  
Inappropriate Secretion ◽  
Average Serum ◽  
Fine Print

✓ Hyponatremia, usually attributed to the syndrome of inappropriate secretion of antidiuretic hormone, typically occurs in a delayed fashion following transsphenoidal removal of a pituitary adenoma. In a series of 99 consecutive patients who underwent transsphenoidal surgery for pituitary adenoma, nine patients developed delayed hyponatremia, seven of whom were symptomatic. Of these seven patients, four had been discharged from the hospital and required readmission on postoperative Day 7 to 9. In the nine patients who developed hyponatremia, on the average, serum sodium levels began to fall on Day 4 and reached a nadir on Day 7 (mean serum sodium nadir 123 mmol/L). The development of delayed hyponatremia was associated with the presence of a macroadenoma in eight of the nine patients. Seven of the nine patients had serum sodium levels less than 130 mmol/L and required treatment. One patient was treated with fluid restriction alone and six were treated with both fluid restriction and intravenous urea therapy. Twenty-four and 48 hours after urea administration, serum sodium levels rose by an average of 6 and 10 mmol/L, respectively, and at discharge, levels averaged 136 mmol/L. Intravenous administration of urea provides a rapid yet safe means of correcting symptomatic hyponatremia when fluid restriction alone is inadequate. In this article, the authors discuss the pathogenesis of delayed hyponatremia.

Transsphenoidal extracapsular approach to pituitary tumors

1986 ◽  
Vol 64 (1) ◽  
pp. 16-20 ◽  
Author(s):  
Nobuo Hashimoto ◽  
Hajime Handa ◽  
Tatsuhito Yamagami
Keyword(s):  
Pituitary Adenomas ◽  
Transsphenoidal Surgery ◽  
Pituitary Tumors ◽  
Hormonal Control ◽  
Arachnoid Membrane ◽  
Content Type ◽  
Tumor Capsule ◽  
Suprasellar Extension ◽  
Fine Print ◽  
Transsphenoidal Resection

✓ Two years' experience with an extracapsular transsphenoidal approach to pituitary adenomas is presented. Some pituitary tumors contain an inordinate amount of connective tissue that often makes transsphenoidal resection difficult. By opening the tumor capsule and adjacent arachnoid membrane, such tumors with suprasellar extension can be safely removed. In some cases of functioning adenoma, resection of the diaphragma sellae and adjacent arachnoid membrane results in hormonal control. Among 62 cases of transsphenoidal surgery for pituitary adenomas, eight cases required this procedure. The surgical procedure is described and the cases are summarized. The indication and limitations of this procedure are discussed.

Serum prolactin in patients with hypothalamus and pituitary disorders

1981 ◽  
Vol 55 (2) ◽  
pp. 194-199 ◽  
Author(s):  
Per Olov Lundberg ◽  
Per Olof Osterman ◽  
Leif Wide
Keyword(s):  
Pituitary Adenoma ◽  
Pituitary Adenomas ◽  
Single Case ◽  
Geometric Mean ◽  
High Serum ◽  
Serum Prolactin ◽  
Content Type ◽  
Sellar Tumor ◽  
Very High ◽  
Fine Print

✓ Serum prolactin concentrations were studied in 115 patients with anatomically defined disorders in the hypothalamo-pituitary region. Fifty of the patients had expansively growing pituitary adenomas; in 17 of them (13 females and four males) the prolactin values were slightly raised (15 to 100 µg/liter), and in 13 (11 females and two males) they were over 100 µg/liter. The frequency of elevated prolactin values was higher for females than for males. Fifteen patients with invasively growing pituitary adenomas had very high serum prolactin levels (range 1230 to 31,500 µg/liter, geometric mean 3150 µg/liter). In a single case of malignant pituitary adenoma, the serum prolactin was at the lower level of detection. Of 49 further patients with suprasellar meningiomas, craniopharyngiomas, or other expansive or destructive lesions of the hypothalamus and sellar region, 15 had slightly raised prolactin values (maximum 114 µg/liter). Eight of these 49 patients had sellar destruction, with a roentgenological picture similar to that in patients with invasive pituitary adenomas. Among these eight patients, the maximum prolactin value was 67 µg/liter. It is concluded that moderately raised serum prolactin values (up to 100 µg/liter) in a patient with a sellar tumor does not prove that the tumor is a prolactinoma. A serum prolactin value of 100 to 1000 µg/liter strongly indicates a prolactin-producing tumor. In a patient with sellar destruction, a serum prolactin value of over 1000 µg/liter is proof that the destruction is caused by an invasive pituitary adenoma.

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