Consistency of pituitary adenomas: Amounts of collagen types I and III and the predictive value of T2WI MRI

Abstract BACKGROUND Surgical resection is the primary treatment for nonfunctional (NF) pituitary adenomas, but gross-total resection is difficult to achieve in all cases. NF adenomas overexpress folate receptor alpha (FRα). OBJECTIVE To test the hypothesis that we could target FRα for highly sensitive and specific intraoperative detection of NF adenomas using near-infrared (NIR) imaging. METHODS Fourteen patients with NF pituitary adenoma were infused with the folate analog NIR dye OTL38 preoperatively. NIR fluorescence signal-to-background ratio (SBR) was recorded for each tumor during resection of the adenomas. Extent of surgery was not modified based on the presence or absence of fluorescence. Immunohistochemistry was performed to assess FRα expression in all specimens. Magnetic resonance imaging (MRI) was performed postoperatively to assess residual neoplasm. RESULTS Nine adenomas overexpressed FRα and fluoresced with a NIR SBR of 3.2 ± 0.52, whereas the 5 non-FRα-overexpressing adenomas fluoresced with an SBR of 1.5 ± 0.21. Linear regression demonstrated a significant correlation between intraoperative SBR and the FRα expression (P-value < .001). Analysis of 14 margin samples revealed that the surgeon's impression of the tissue had 83% sensitivity, 100% specificity, 100% positive predictive value, and 89% negative predictive value, while NIR fluorescence had 100% for all values. NIR fluorescence accurately predicted postoperative MRI results in 78% of FRα-overexpressing patients. CONCLUSION Preoperative injection of folate-tagged NIR dye provides strong signal and visualization of NF pituitary adenomas. It is 100% sensitive and specific for detecting margin neoplasm and can predict postoperative MRI findings. Our results suggest that NIR fluorescence may be superior to white-light visualization alone and may improve resection rates in NF pituitary adenomas.

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Assessment of T2-Weighted Coronal Magnetic Resonance Images in the Investigation of Pituitary Lesions

ISRN Radiology ◽

10.1155/2014/650926 ◽

2014 ◽

Vol 2014 ◽

pp. 1-6 ◽

Cited By ~ 1

Author(s):

Ruken Yuksekkaya ◽

Levent Aggunlu ◽

Yusuf Oner ◽

Halil Celik ◽

Sergin Akpek ◽

...

Keyword(s):

Magnetic Resonance ◽

Pituitary Gland ◽

Predictive Value ◽

Pituitary Adenomas ◽

Contrast Material ◽

Magnetic Resonance Images ◽

Intravenous Contrast ◽

Primary Evaluation ◽

Sensitivity Specificity ◽

Accuracy Rates

Magnetic resonance imaging is the most important diagnostic method in the investigation of the pituitary lesions. Our aim is to determine whether T2-weighted coronal images may be helpful in the evaluation of the pituitary gland with suspected pituitary adenomas. One hundred and sixty-seven patients were examined prospectively with T2-weighted coronal and T1-weighted coronal images enhanced with intravenous contrast material. The images were evaluated for the presence, the size, the location, and the ancillary signs including sellar floor erosion or ballooning, infindibulary deviation, convexity of the superior border of the gland, diffuse enlargement of the gland, and the invasion of the cavenous sinuses on both images. In forty-six (28%) patients lesions were revealed on both sequences. In twenty-one (12%) patients the lesions that were revealed on the T1-weighted images were not detected on the T2-weighted images. Positive predictive value, negative predictive value, sensitivity, specificity, and diagnostic accuracy rates of T2-weighted coronal images on the detection of the presence of lesions were 100%, 17.4%, 68.7%, 100%, and 87.4%, respectively. Both T2-weighted coronal and T1-weighted coronal images enhanced with intravenous gadolinium-based contrast material are important in the diagnosis of pituitary adenomas. T2-weighted coronal images could be used as a screening tool for the primary evaluation of the pituitary gland.

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Cyst Type Differentiates Rathke Cleft Cysts From Cystic Pituitary Adenomas

Frontiers in Oncology ◽

10.3389/fonc.2021.778824 ◽

2021 ◽

Vol 11 ◽

Author(s):

Sherwin Tavakol ◽

Michael P. Catalino ◽

David J. Cote ◽

Xian Boles ◽

Edward R. Laws ◽

...

Keyword(s):

Pituitary Adenoma ◽

Cyst Wall ◽

Predictive Value ◽

Pituitary Adenomas ◽

Classification Scheme ◽

Solid Component ◽

Fluid Level ◽

Cystic Neoplasms ◽

Cyst Type

PurposeA classification system for cystic sellar lesions does not exist. We propose a novel classification scheme for these lesions based on the heterogeneity of the cyst wall/contents and the presence of a solid component on imaging.MethodsWe retrospectively reviewed 205 patients’ medical records (2008–2020) who underwent primary surgery for a cystic sellar lesion. Cysts were classified a priori into 1 of 4 cyst types based on the heterogeneity of the cyst wall/contents and the presence of a solid component imaging. There was high interrater reliability. Univariable and multivariable models were used to estimate the ability of cyst type to predict the two most common diagnoses: Rathke cleft cyst (RCC) and cystic pituitary adenoma.ResultsThe frequencies of RCC and cystic pituitary adenoma in our cohort were 45.4% and 36.4%, respectively. Non-neoplastic lesions (e.g., arachnoid cysts and RCC) were more likely to be Type 1 or 2, whereas cystic neoplasms (e.g., pituitary adenomas and craniopharyngiomas) were more likely to be Type 3 or 4 (p<0.0001). Higher cyst types, compared to Type 1, had higher odds of being cystic pituitary adenomas compared to RCCs (OR: 23.7, p=0.033, and 342.6, p <0.0001, for Types 2 and 4, respectively). Lesions with a fluid-fluid level on preoperative MRI also had higher odds of being pituitary adenomas (OR: 12.7; p=0.023). Cystic pituitary adenomas were more common in patients with obesity (OR: 5.0, p=0.003) or symptomatic hyperprolactinemia (OR: 11.5; p<0.001, respectively). The multivariable model had a positive predictive value of 82.2% and negative predictive value of 86.4%.ConclusionWhen applied to the diagnosis of RCC versus cystic pituitary adenoma, higher cystic lesion types (Type 2 & 4), presence of fluid-fluid level, symptomatic hyperprolactinemia, and obesity were predictors of cystic pituitary adenoma. Further validation is needed, but this classification scheme may prove to be a useful tool for the management of patients with common sellar pathology.

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Hormone levels and tumour size response to quinagolide and cabergoline in patients with prolactin-secreting and clinically non-functioning pituitary adenomas: predictive value of pituitary scintigraphy with 123 I-methoxybenzamide

Clinical Endocrinology ◽

10.1046/j.1365-2265.2000.00951.x ◽

2000 ◽

Vol 52 (4) ◽

pp. 437-445 ◽

Cited By ~ 34

Author(s):

Annamaria Colao ◽

Diego Ferone ◽

Secondo Lastoria ◽

Gaetana Cerbone ◽

Antonella Di Sarno ◽

...

Keyword(s):

Predictive Value ◽

Pituitary Adenomas ◽

Tumour Size ◽

Hormone Levels ◽

Non Functioning Pituitary Adenomas

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Early postoperative MRI and detection of residual adenoma after transsphenoidal pituitary surgery

Journal of Neurosurgery ◽

10.3171/2019.11.jns191845 ◽

2020 ◽

pp. 1-10 ◽

Cited By ~ 2

Author(s):

Lea M. Alhilali ◽

Andrew S. Little ◽

Kevin C. J. Yuen ◽

Jae Lee ◽

Timothy K. Ho ◽

...

Keyword(s):

Tumor Growth ◽

Negative Predictive Value ◽

Predictive Value ◽

Pituitary Adenomas ◽

Transsphenoidal Surgery ◽

Residual Tumor ◽

Pituitary Surgery ◽

Intraoperative Assessment ◽

Postoperative Mri ◽

Transsphenoidal Pituitary Surgery

OBJECTIVECurrent practice guidelines recommend delayed (≥ 3 months after operation) postoperative MRI after transsphenoidal surgery for pituitary adenomas, although this practice defers obtaining important information, such as the presence of a residual adenoma, that might influence patient management during the perioperative period. In this study, the authors compared detection of residual adenomas by means of early postoperative (EPO) MRI (< 48 hours postsurgery) with both surgeon intraoperative assessment and late postoperative (LPO) MRI at 3 months.METHODSAdult patients who underwent microscopic transsphenoidal surgery for pituitary adenomas with MRI preoperatively, < 48 hours after the operation, 3 months postoperatively, and yearly for 4 years were included. The presence or absence of residual tumor was assessed intraoperatively by a single surgeon and postoperatively by 2 neuroradiologists blinded to the intraoperative assessment and other postoperative imaging studies. The presence of residual tumor was confirmed by reresection, tumor growth on imaging, or hormonal evidence. Interreader reliability was calculated at each imaging time point. Specificity, sensitivity, positive predictive value, and negative predictive value for EPO and LPO imaging and intraoperative assessment were determined.RESULTSIn total, 102 consecutive patients who underwent microscopic transsphenoidal resection of a pituitary adenoma were included. Eighteen patients (18%) had confirmed residual tumors (12 confirmed by tumor growth, 5 by surgery, and 1 by biochemical evidence of persistent disease). Interreader reliability for detecting residual tumor on EPO MRI was almost perfect (κ = 0.88) and significantly higher than that for LPO MRI (κ = 0.69, p = 0.03). EPO MRI was highly specific for residual tumor (98%), a finding similar to that for intraoperative assessment (99%, p = 0.60) and significantly higher than that for LPO MRI (81%, p < 0.001). Notably, EPO MRI was significantly more sensitive for residual tumor (100%) than both intraoperative assessment (78%, p = 0.04) and LPO MRI (78%, p = 0.04). EPO MRI had a 100% negative predictive value and was used to find 4 residual tumors that were not identified intraoperatively. Residual tumors found on EPO MRI allowed for reresection during the same hospitalization for 3 patients.CONCLUSIONSEPO MRI after transsphenoidal pituitary surgery can be reliably interpreted and has greater sensitivity for detecting residual tumor than intraoperative assessment and LPO MRI. This result challenges current guidelines stating that delayed postoperative imaging is preferable to early imaging. Pituitary surgeons should consider performing EPO MRI either in addition to or instead of delayed imaging.

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Pituitary Adenomas and Invasiveness from Anatomo-Surgical, Radiological, and Histological Perspectives: A Systematic Literature Review

Cancers ◽

10.3390/cancers11121936 ◽

2019 ◽

Vol 11 (12) ◽

pp. 1936 ◽

Cited By ~ 5

Author(s):

Simona Serioli ◽

Francesco Doglietto ◽

Alessandro Fiorindi ◽

Antonio Biroli ◽

Davide Mattavelli ◽

...

Keyword(s):

Molecular Markers ◽

Literature Review ◽

Systematic Literature Review ◽

Predictive Value ◽

Pituitary Adenomas ◽

Comprehensive Analysis ◽

Sellar Region ◽

Histological Findings ◽

Multiple Perspectives ◽

Surgical Data

Invasiveness in pituitary adenomas has been defined and investigated from multiple perspectives, with varying results when its predictive value is considered. A systematic literature review, following PRISMA guidelines, was performed, searching PubMed and Scopus databases with terms that included molecular markers, histological, radiological, anatomical and surgical data on invasiveness of pituitary adenomas. The results showed that differing views are still present for anatomical aspects of the sellar region that are relevant to the concept of invasiveness; radiological and histological diagnoses are still limited, but might improve in the future, especially if they are related to surgical findings, which have become more accurate thanks to the introduction of the endoscope. The aim is to achieve a correct distinction between truly invasive pituitary adenomas from those that, in contrast, present with extension in the parasellar area through natural pathways. At present, diagnosis of invasiveness should be based on a comprehensive analysis of radiological, intra-operative and histological findings.

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Evaluation of Surgical Resection Goal and Its Relationship to Extent of Resection and Patient Outcomes in a Multicenter Prospective Study of Patients With Surgically Treated, Nonfunctioning Pituitary Adenomas: A Case Series

Operative Neurosurgery ◽

10.1093/ons/opz085 ◽

2019 ◽

Vol 18 (1) ◽

pp. 26-33

Author(s):

Andrew S Little ◽

Michael R Chicoine ◽

Daniel F Kelly ◽

Christina E Sarris ◽

Michael A Mooney ◽

...

Keyword(s):

Patient Outcomes ◽

Predictive Value ◽

Pituitary Adenomas ◽

Tumor Resection ◽

Case Series ◽

Residual Tumor ◽

Pituitary Surgery ◽

Extent Of Resection ◽

Subtotal Resection ◽

Nonfunctioning Pituitary Adenomas

Abstract BACKGROUND The influence of the surgeon's preoperative goal regarding the extent of tumor resection on patient outcomes has not been carefully studied among patients with nonfunctioning pituitary adenomas. OBJECTIVE To analyze the relationship between surgical tumor removal goal and patient outcomes in a prospective multicenter study. METHODS Centrally adjudicated extent of tumor resection (gross total resection [GTR] and subtotal resection [STR]) data were analyzed using standard univariate and multivariable analyses. RESULTS GTR was accomplished in 148 of 171 (86.5%) patients with planned GTR and 32 of 50 (64.0%) patients with planned STR (P = .001). Sensitivity, specificity, positive predictive value, and negative predictive value of GTR goal were 82.2, 43.9, 86.5, and 36.0%, respectively. Knosp grade 0-2, first surgery, and being an experienced surgeon were associated with surgeons choosing GTR as the goal (P < .01). There was no association between surgical goal and presence of pituitary deficiency at 6 mo (P = .31). Tumor Knosp grade (P = .004) and size (P = .001) were stronger predictors of GTR than was surgical goal (P = .014). The most common site of residual tumor was the cavernous sinus (29 of 41 patients; 70.1%). CONCLUSION This is the first pituitary surgery study to examine surgical goal regarding extent of tumor resection and associated patient outcomes. Surgical goal is a poor predictor of actual tumor resection. A more aggressive surgical goal does not correlate with pituitary gland dysfunction. A better understanding of the ability of surgeons to meet their expectations and of the factors associated with surgical result should improve prognostication and preoperative counseling.

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Near-Infrared Optical Contrast of Skull Base Tumors During Endoscopic Endonasal Surgery

Operative Neurosurgery ◽

10.1093/ons/opy213 ◽

2018 ◽

Vol 17 (1) ◽

pp. 32-42 ◽

Cited By ~ 8

Author(s):

Jun W Jeon ◽

Steve S Cho ◽

Shayoni Nag ◽

Love Buch ◽

John Pierce ◽

...

Keyword(s):

Skull Base ◽

Predictive Value ◽

Pituitary Adenomas ◽

Near Infrared ◽

Brain Parenchyma ◽

Skull Base Tumors ◽

Endoscopic Endonasal ◽

Endoscopic Techniques ◽

Early Results ◽

Ventral Skull Base

Abstract BACKGROUND Near-infrared (NIR) tumor contrast is achieved through the “second-window ICG” technique, which relies on passive accumulation of high doses of indocyanine green (ICG) in neoplasms via the enhanced permeability and retention effect. OBJECTIVE To report early results and potential challenges associated with the application of second-window ICG technique in endonasal endoscopic, ventral skull-base surgery, and to determine potential predictors of NIR signal-to-background ratio (SBR) using endoscopic techniques. METHODS Pituitary adenoma (n = 8), craniopharyngioma (n = 3), and chordoma (n = 4) patients received systemic infusions of ICG (5 mg/kg) approximately 24 h before surgery. Dual-channel endoscopy with visible light and NIR overlay were photodocumented and analyzed post hoc. RESULTS All tumors (adenoma, craniopharyngioma, chordoma) demonstrated NIR positivity and fluoresced with an average SBR of 3.9 ± 0.8, 4.1 ± 1.7, and 2.1 ± 0.6, respectively. Contrast-enhanced T1 signal intensity proved to be the single best predictor of observed SBR (P = .0003). For pituitary adenomas, the sensitivity, specificity, positive predictive value, and negative predictive value of NIR-guided identification of tumor was 100%, 20%, 71%, and 100%, respectively. CONCLUSION In this preliminary study of a small set of patients, we demonstrate that second-window ICG can provide NIR optical tumor contrast in 3 types of ventral skull-base tumors. Chordomas demonstrated the weakest NIR signal, suggesting limited utility in those patients. Both nonfunctional and functional pituitary adenomas appear to accumulate ICG, but utility for margin detection for the adenomas is limited by low specificity. Craniopharyngiomas with third ventricular extension appear to be a particularly promising target given the clean brain parenchyma background and strong SBR.

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

10.21203/rs.3.rs-1037768/v1 ◽

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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Pituitary function after transsphenoidal surgery including measurement of basal morning cortisol as predictor of adrenal insufficiency

Endocrine Connections ◽

10.1530/ec-21-0155 ◽

2021 ◽

Author(s):

Ida Staby ◽

Jesper Krogh ◽

Marianne Klose ◽

Jonas Baekdal ◽

Ulla Feldt-Rasmussen ◽

...

Keyword(s):

Adrenal Insufficiency ◽

Predictive Value ◽

Pituitary Adenomas ◽

Transsphenoidal Surgery ◽

Tumour Size ◽

Endocrine Function ◽

Pituitary Function ◽

Adrenal Axis ◽

Post Surgery ◽

Basal Cortisol

Introduction: Patients with pituitary adenomas undergoing transsphenoidal surgery require pre- and post-surgery examination of pituitary hormones. There is currently no consensus on how to evaluate the adrenal axis post-surgery. The aims of this study were to investigate factors that may predict postoperative adrenal insufficiency (AI) and to investigate the overall effect of transsphenoidal surgery on the pituitary function. Methods: One-hundred-and-forty-three consecutive patients who had undergone transsphenoidal surgery for pituitary adenomas were included. Data on tumour size, pituitary function pre-surgery, plasma basal cortisol measured within 48 hours post-surgery and pituitary function 6 months post-surgery were collected. Patients with AI prior to surgery, perioperative glucocorticoid treatment, Cushing’s disease and no re-evaluation after 1 month were excluded (n=93) in the basal cortisol analysis. Results: Low plasma basal cortisol post-surgery, tumour size and previous pituitary surgery were predictors of AI (all p<0.05). A basal cortisol cut-off concentration of 300 nmol/L predicted AI 6 months post-surgery with a sensitivity and negative predictive value of 100%, specificity of 81% and positive predictive value of 25%. New gonadal, thyroid and adrenal axis insufficiencies accounted for 2%, 10% and 10%, respectively. The corresponding recovery rates were 17%, 7% and 24%, respectively Conclusion: Transsphenoidal surgery had an overall beneficial effect on pituitary endocrine function. Low basal plasma cortisol measured within 48 hours after surgery, tumour size and previous surgery were identified as risk factors for AI. Measurement of basal cortisol post-surgery may help identifying patients at risk of developing AI.

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