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

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.

Endoscopic-assisted microsurgical resection of giant vestibular schwannoma in semi-sitting position

The main objectives of microsurgery for vestibular schwannoma are total tumor removal and preservation of facial and cochlear nerve function. For giant tumors, total tumor removal and facial nerve function preservation are challenging. The semisitting position has some advantages. In this video the authors show the removal of a giant vestibular schwannoma with the patient in a semisitting position. They demonstrate the advantages of the semisitting technique, such as the two-handed microsurgical dissection technique and a clear operative field. Finally, a small residual tumor in the internal auditory canal was removed by endoscopy. The patient’s facial function was House-Brackmann grade I at discharge. The video can be found here: https://stream.cadmore.media/r10.3171/2021.7.FOCVID2176

Comparative Treatment Outcome in T3N0 Glottic Cancer With and Without Vocal Fold Fixation Receiving Radiation Therapy and Concurrent Low-Dose Intra-Arterial Cisplatin Infusion

Objectives: Selective radiotherapy and concomitant intra-arterial cisplatin infusion (m-RADPLAT) with a lower cisplatin dosage have been performed for organ and function preservation in patients with locally advanced squamous cell carcinoma of the larynx (SCC-L), and results showing a lower rate of adverse events have been reported. This study evaluated the treatment outcomes of patients with T3N0 glottic SCC-L with or without vocal fold fixation (VFF) who were treated with m-RADPLAT. Methods: We retrospectively reviewed the data of 33 patients with T3N0 SCC-L who received m-RADPLAT. Results: The vocal fold in patients with VFF 3 months after completing m-RADPLAT resumed normal movement in 15 patients (83%) and persisted fixation in 3 (17%). The 3-year local control, laryngeal cancer-specific survival, and overall survival rates of patients with or without VFF were 88.9% and 86.7%, 94.1% and 93.3%, and 88.9% and 86.7%, respectively. Additionally, the 3-year freedom from laryngectomy, laryngectomy-free survival, and laryngo-esophageal dysfunction-free survival rates of patients with or without VFF were 94.4% and 86.7%, 88.9% and 73.3%, and 83.3% and 73.3%, respectively. Grade 3 or higher toxicities were observed in all patients: leukopenia in 4 patients (12%), neutropenia in 5 (15%), anemia in 2 (6%), thrombocytopenia in 3 (9%), and mucositis in 2 (6%). Conclusions: This study demonstrated that m-RADPLAT yielded VFF improvement and a favorable survival while maintaining laryngeal function not only in patients with T3N0 glottic SCC-L without VFF but also in patients with VFF.

Microsurgical Resection of a Parasellar Meningioma Invading the Cavernous Sinus, Bone, and Optic Canal: 2-Dimensional Operative Video

Parasellar meningiomas, regardless of the initial origin, frequently involve the optic canal and cavernous sinus, leading to visual loss and ocular movement dysfunction.1 Hyperostotic bony invasion to the surrounding skull base is common.2 Visual acuity prognosis can be improved by surgical resection through different technical maneuvers, including opening the optic canal and the preservation of the visual apparatus vascular supply by developing the intra-arachnoidal dissection planes.1,3,4 To achieve radical dissection and reduce recurrences, the extradural invaded bone is thoroughly resected. Likewise, the soft and nonadherent invasive tumor around the cavernous carotid can be extensively removed.1,3,4 New or worsening of the ophthalmoplegia is frequent after cavernous sinus exploration and tumor resection. However, it is usually temporary and improves progressively in 80% of patients.1,3,4 Safely approaching these lesions requires extensive anatomic knowledge through cadaveric dissection and training, allowing us to achieve tumor control, preserve or improve visual function, and avoid or delay irradiation therapy.1,3,4 Pituitary function preservation is also possible in many patients through surgery, which is at higher risk with irradiation. We demonstrate the technical maneuvers through a case of a 49-yr-old woman who presented with a parasellar meningioma involving the cavernous sinus, both optic canals, and extensive bony invasion. The patient consented to the surgery and publication of her images. Image at 1:14 and middle and right image at 1:31 reprinted with permission from Al-Mefty O, Operative Atlas of Meningiomas. Vol 1, ©LWW, 1998. Left image at 1:31 reprinted from Arnautovic et al,5 by permission from JNSPG.

Adjuvant therapy for head and neck cancers

The non-surgical management of head and neck cancer has changed over the last two decades with more emphasis given now to organ preservation and post-treatment organ function. These two concepts do not necessarily go hand in hand but preserving an organ without preserving its function is pointless. In this period, for some head and neck cancers subsites, for example, oropharynx, the treatment model has moved away from primary surgery followed by planned, adjuvant radiotherapy, to one of primary chemoradiotherapy with the objective of greater organ and function preservation. This change in management strategy may be coming under further review now, with the introduction of transoral robotic surgery (TORS), where the treatment model may revert back to primary surgery with the question raised, whether highly selective TORS followed by highly selective adjuvant radiotherapy using the newer radiation technologies and techniques with intensity-modulated radiotherapy or tomotherapy, with or without chemotherapy might optimize tumour control with minimal long-term morbidity.

Immunohistochemical Expression of FOXP3+ Regulatory T Cells in Proteinuric Primary Glomerulopathies

FOXP3+ regulatory T-cell (Tregs) detection in renal allograft biopsies has been associated with a less intense immune response. Data about FOXP3+ Tregs’ presence and role in primary glomerulopathies of native kidneys are minimal. We comparatively studied the immunohistochemical expression of FOXP3+ Tregs, CD4+ and CD3+ T cells in IgA nephropathy (IgAN), focal segmental glomerulosclerosis (FSGS), and membranous glomerulopathy (MGN). We retrospectively reviewed 71 renal biopsies (28 from patients with IgAN, 22 from patients with FSGS and 21 from patients with MGN) performed with proteinuria as the main indication. FOXP3+ Tregs and CD4+ and CD3+ T cells in inflammatory cell infiltrates of the interstitial tissue and periglomerular space were automatically counted using image analysis software. Univariable and multivariable logistic regressions were applied for statistical analysis. Nuclear FOXP3+ immunohistochemical expression was observed in T cells in 64% of IgAN cases, 77% of FSGS cases, and 76% of MGN cases ( p > 0.05 ). Absolute FOXP3+ Tregs count in the interstitial tissue was higher in patients without arteriolar hyalinosis than in those with arteriolar hyalinosis (1.814 ± 2.160 vs. 831 ± 696; p = 0.029 ). In patients with a high FOXP3+/CD4+ ratio in the interstitial tissue, the odds ratio for CKD-EPI eGFR ≥60 ml/min/1.73 m2 at biopsy was 4.80 (95% CI: 1.29–17.91; p = 0.019 ). FOXP3+ Tregs intrarenal infiltration in primary glomerulopathies is common. FOXP3+ Tregs’ increased expression may be associated with milder histological lesions. High FOXP3+/CD4+ ratio in the interstitial tissue may have prognostic significance for renal function preservation.

Neurogenic Bladder in Patients with Mylomeningocele in Pediatric Age

Myelomeningocele (MMC) is congenital nervous system malformation caused by neurulation process failure during pregnancy. The prevalence varies by the continent, region, race, ethnicity and the time when assessed and patients present abnormalities of different organs. One of the most severe complications is renal failure. Aim: Clinical evaluation of patients with MMC in Iraq and answering the question whether our treatment methods lead to renal function preservation. Material and methods: Medical records of 28 patients in the period 2014.2019were evaluated retrospectively. The data included: age, sex, BMI Z-score WHO, place of residence, perinatal history, social situation, physical activity, urodynamic diagnosis, renal function, hydrocephalus diagnosis, and functioning of shunting procedures. Results: They were no statistically significant differences in most studied parameters between boys and girls. Keywords: Meningomyelocele, Epidemiological study, Neurogenic bladder, Renal function

DOES CONCOMITANT ADMINISTRATION OF DEXMEDETOMIDINE AND PROPOFOL PROVIDE MYOCARDIAL PROTECTION AND RENAL FUNCTION PRESERVATION IN COMPARISON TO PROPOFOL ALONE; A RANDOMIZED PROSPECTIVE STUDY

Objective: To ascertain the safety and efficacy of concomitant administration of dexmedetomidine and propofol in maintaining myocardial protection and renal function integrity in comparison to propofol alone in adult cardiac surgical patients. Methodology: A randomized clinical trial was conducted at cardiac center Bahawalpur from June 2018 to January 2020. Study included 64 patients who underwent coronary artery bypass grafting (CABG). Two groups, DP (DEXMEDETOMIDINE (DEX) +Propofol) and P (Propofol alone) were made by allocating 32 patients in each group. Hemodynamic parameters (Heart rate, Diastolic blood pressure (DBP), systolic blood pressure (SBP) and mean arterial pressure (MAP) at different time intervals throughout the surgery were measured, pre and post-operative CKMB, any arrhythmias, events of tachycardia and bradycardia were recorded and renal parameters (urine output immediate post pump and 4 hours post pump, creatinine clearance of day 1 and day 2) were measured. Results: DP group showed stable hemodynamics with values of hemodynamic parameters were lesser and statistically significant than patients in group P (Heart rate (p<.05), DBP (P<.05), SBP (P<.05) and MAP (p<.05). Both groups showed insignificant difference in terms of incidence of arrhythmias (p=0.325), Post-operative CKMB (P=0.512), events of tachycardia (p=0.6) and bradycardia (p=0.5).Immediate post pump urine was statistically significant (p<.05), however, 4-hour post pump urine (p = 0.45), creatinine clearance of day 1 (p = 0.8) and day 2 (p =.092) were comparable. Conclusion: Concomitant administration of dexmedetomidine and propofol provide adequate cardioprotection by maintaining stable hemodynamics in comparison to propofol alone, however they did not prove to be effective renoprotective agents.