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

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.

Estimating Risk of Pituitary Apoplexy after Resection of Giant Pituitary Adenomas

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.

Results of a prospective multicenter controlled study comparing surgical outcomes of microscopic versus fully endoscopic transsphenoidal surgery for nonfunctioning pituitary adenomas: the Transsphenoidal Extent of Resection (TRANSSPHER) Study

2020 ◽  
Vol 132 (4) ◽  
pp. 1043-1053 ◽  
Author(s):  
Andrew S. Little ◽  
Daniel F. Kelly ◽  
William L. White ◽  
Paul A. Gardner ◽  
Juan C. Fernandez-Miranda ◽  
...  
Keyword(s):  
Endoscopic Surgery ◽  
Surgical Outcomes ◽  
Pituitary Adenomas ◽  
Transsphenoidal Surgery ◽  
Tumor Resection ◽  
Extent Of Resection ◽  
Endoscopic Technique ◽  
Controlled Study ◽  
Nonfunctioning Pituitary Adenomas ◽  
Microscopic Surgery

OBJECTIVEMany surgeons have adopted fully endoscopic over microscopic transsphenoidal surgery for nonfunctioning pituitary tumors, although no high-quality evidence demonstrates superior patient outcomes with endoscopic surgery. The goal of this analysis was to compare these techniques in a prospective multicenter controlled study.METHODSExtent of tumor resection was compared after endoscopic or microscopic transsphenoidal surgery in adults with nonfunctioning adenomas. The primary end point was gross-total tumor resection determined by postoperative MRI. Secondary end points included volumetric extent of tumor resection, pituitary hormone outcomes, and standard quality measures.RESULTSSeven pituitary centers and 15 surgeons participated in the study. Of the 530 patients screened, 260 were enrolled (82 who underwent microscopic procedures, 177 who underwent endoscopic procedures, and 1 who cancelled surgery) between February 2015 and June 2017. Surgeons who used the microscopic technique were more experienced than the surgeons who used the endoscopic technique in terms of years in practice and number of transsphenoidal surgeries performed (p < 0.001). Gross-total resection was achieved in 80.0% (60/75) of microscopic surgery patients and 83.7% (139/166) of endoscopic surgery patients (p = 0.47, OR 0.8, 95% CI 0.4–1.6). Volumetric extent of resection, length of stay, surgery-related deaths, and unplanned readmission rates were similar between groups (p > 0.2). New hormone deficiency was present at 6 months in 28.4% (19/67) of the microscopic surgery patients and 9.7% (14/145) of the endoscopic surgery patients (p < 0.001, OR 3.7, 95% CI 1.7–7.7). Microscopic surgery cases were significantly shorter in duration than endoscopic surgery cases (p < 0.001).CONCLUSIONSExperienced surgeons who performed microscopic surgery and less experienced surgeons who performed endoscopic surgery achieved similar extents of tumor resection and quality outcomes in patients with nonfunctioning pituitary adenomas. The endoscopic technique may be associated with lower rates of postoperative pituitary gland dysfunction. This study generally supports the transition to endoscopic pituitary surgery when the procedure is performed by proficient surgeons, although both techniques yield overall acceptable surgical outcomes.■ CLASSIFICATION OF EVIDENCE Type of question: therapeutic; study design: prospective cohort trial; evidence: class III.Clinical trial registration no.: NCT02357498 (clinicaltrials.gov)

scholarly journals Pituitary surgery and volumetric assessment of extent of resection: a paradigm shift in the use of intraoperative magnetic resonance imaging

2016 ◽  
Vol 40 (3) ◽  
pp. E17 ◽  
Author(s):  
Carlo Serra ◽  
Jan-Karl Burkhardt ◽  
Giuseppe Esposito ◽  
Oliver Bozinov ◽  
Athina Pangalu ◽  
...  
Keyword(s):  
Pituitary Adenomas ◽  
Pituitary Surgery ◽  
Extent Of Resection ◽  
Gross Total Resection ◽  
Subtotal Resection ◽  
Consecutive Series ◽  
High Definition ◽  
Total Resection ◽  
Entire Cohort ◽  
Volumetric Assessment

OBJECTIVE The aim of this study was to quantitatively assess the role of intraoperative high-field 3-T MRI (3T-iMRI) in improving the gross-total resection (GTR) rate and the extent of resection (EOR) in endoscopic transsphenoidal surgery (TSS) for pituitary adenomas. METHODS Radiological and clinical data from a prospective database were retrospectively analyzed. Volumetric measurements of adenoma volumes pre-, intraoperatively, and 3 months postoperatively were performed in a consecutive series of patients who had undergone endoscopic TSS. The quantitative contribution of 3T-iMRI was measured as a percentage of the additional rate of GTR and of the EOR achieved after 3T-iMRI. RESULTS The cohort consisted of 50 patients (51 operations) harboring 33 nonfunctioning and 18 functioning pituitary adenomas. Mean adenoma diameter and volume were 21.1 mm (range 5–47 mm) and 5.23 cm3 (range 0.09–22.14 cm3), respectively. According to Knosp's classification, 10 cases were Grade 0; 8, Grade 1; 17, Grade 2; 12, Grade 3; and 4, Grade 4. Gross-total resection was the surgical goal (targeted [t]GTR) in 34 of 51 operations and was initially achieved in 16 (47%) of 34 at 3T-iMRI and in 30 (88%) of 34 cases after further resection. In this subgroup, the EOR increased from 91% at 3T-iMRI to 99% at the 3-month MRI (p < 0.05). In the 17 cases in which subtotal resection (STR) had been planned (tSTR), the EOR increased from 79% to 86% (p < 0.05) and GTR could be achieved in 1 case. Intrasellar remnants were present in 20 of 51 procedures at 3T-iMRI and in only 5 (10%) of 51 procedures after further resection (median volume 0.15 cm3). Overall, the use of 3T-iMRI led to further resection in 27 (53%) of 51 procedures and permitted GTR in 15 (56%) of these 27 procedures; thus, the GTR rate in the entire cohort increased from 31% (16 of 51) to 61% (31 of 51) and the EOR increased from 87% to 95% (p < 0.05). CONCLUSIONS The use of high-definition 3T-iMRI allowed precise visualization and quantification of adenoma remnant volume. It helped to increase GTR and EOR rates in both tGTR and tSTR patient groups. Moreover, it helped to achieve low rates of intrasellar remnants. These data support the use of 3T-iMRI to achieve maximal, safe adenoma resection.

scholarly journals C.02 Delayed new-onset hormone dysfunction following complete and incomplete resection of nonfunctioning pituitary adenomas

2017 ◽  
Vol 44 (S2) ◽  
pp. S12-S12
Author(s):  
J Han ◽  
AL Hebb ◽  
SA Imran ◽  
DB Clarke
Keyword(s):  
Pituitary Adenomas ◽  
Tumor Recurrence ◽  
Tumor Resection ◽  
Residual Tumor ◽  
Incomplete Resection ◽  
Inclusion Criteria ◽  
Nonfunctioning Pituitary Adenomas ◽  
One Year ◽  
Complete Tumor

Background: Post-operative delayed hormone dysfunction (DHD) in patients with nonfunctioning pituitary adenomas (NFPA) is highly variable and is predicted based on limited evidence. This study was undertaken to assess the likelihood of developing new DHD and its relation to the extent of tumor resection and recurrence. Methods: Four hundred fifty-five prospectively collected patient files were reviewed from our Program’s database. Inclusion criteria: NFPA; underwent surgery; and minimum follow-up of two years. Tumor recurrence was correlated with DHD (starting one year post-operatively) based on standardized annual imaging and hormone testing. Results: Eighty-nine patients met our inclusion criteria: 39 males and 50 females; mean follow-up was 4.3yrs (ranging from 2 to 11yrs). With no post-op residual tumor, the probability of developing DHD was only 7% by six years; no patient in this group developed DHD after three years of follow-up. In contrast, by six years, the probability of DHD was 33% in patients with residual stable tumor, and 54% in those with tumor recurrence/growth. Conclusions: By six years, approximately one third of patients with incomplete resection, and over half with tumor regrowth, will likely develop DHD. In contrast, the risk of DHD with complete tumor resection is <10% and, when seen, occurs within three years of surgery.

scholarly journals Ten years’ experience with intraoperative MRI-assisted transsphenoidal pituitary surgery

2020 ◽  
Vol 48 (6) ◽  
pp. E14
Author(s):  
Michal Hlaváč ◽  
Andreas Knoll ◽  
Benjamin Mayer ◽  
Michael Braun ◽  
Georg Karpel-Massler ◽  
...  
Keyword(s):  
Pituitary Adenomas ◽  
Cox Regression ◽  
Tumor Resection ◽  
Residual Tumor ◽  
Pituitary Surgery ◽  
Intraoperative Mri ◽  
Target Tissue ◽  
Cox Regression Analysis ◽  
Transsphenoidal Pituitary Surgery ◽  
Additional Resection

OBJECTIVEMany innovations have been introduced into pituitary surgery in the quest to maximize the extent of tumor resection. Because of the deep and narrow surgical corridor as well as the heterogeneity of confronted pathologies, anatomical orientation and identification of the target tissue can become difficult. Intraoperative MRI (iMRI) may have the potential to increase extent of resection (EOR) in transsphenoidal pituitary surgery. Furthermore, it may simplify anatomical orientation and risk assessment in difficult cases. Here, the authors evaluated the additional value of iMRI for the resection of pituitary adenomas performed in the past 10 years in their department.METHODSThey performed a retrospective single-center analysis of patients treated for pituitary adenoma in their department after the introduction of iMRI between 2008 and 2018. Of 495 transsphenoidal approaches, 300 consecutive MRI-assisted surgeries for pituitary adenomas encompassing 294 patients were selected for further analysis. Microscopic, endoscopic, or endoscope-assisted microscopic transsphenoidal approaches were distinguished. EOR as well as additional resection following iMRI was evaluated via detailed volumetric analysis. Patients were stratified according to the Knosp adenoma classification. Furthermore, demographic data, clinical symptoms, endocrine outcome, and complications were evaluated. Univariable and multivariable Cox regression analyses of progression-free survival (PFS) were performed.RESULTSPituitary adenomas classified as Knosp grades 0–2 were found in 60.3% of cases (n = 181). The most common tumors were nonfunctioning adenomas (75%). Continued resection following iMRI significantly increased EOR (7.5%, p < 0.001) and the proportion of gross-total resections (GTRs) in transsphenoidal pituitary surgery (54% vs 68.3%, p < 0.001). Additional resection after iMRI was performed in 37% of cases. Only in the subgroup of patients with Knosp grades 0–2 adenomas treated with the microsurgical technique was additional resection significantly more common than in the endoscopic group (p = 0.039). Residual tumor volume, Knosp grade, and age were confirmed as independent predictors of PFS (p < 0.001, p = 0.021, and p = 0.029, respectively) in a multivariable Cox regression analysis. Improvement of visual field deficits was documented in 78.6% of patients whose optic apparatus had been affected preoperatively. Revision surgery was done in 7.3% of cases; in 5.6% of cases, it was performed for cerebrospinal fluid fistula.CONCLUSIONSIn this series, iMRI led to the detection of a resectable tumor remnant in a high proportion of patients, resulting in a greater EOR and higher proportion of GTRs after continued resection in microsurgical and endoscopic transsphenoidal resection of pituitary adenomas. The volume of residual tumor was the most important predictor of PFS. Given the study data, the authors postulated that every bit of removed tumor serves the patient and increases their chances of a favorable outcome.

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

2020 ◽  
pp. 1-10 ◽  
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.

scholarly journals Dual-Use Intraoperative MRI in Glioblastoma Surgery: Results of Resection, Histopathologic Assessment, and Surgical Site Infections

2019 ◽  
Vol 80 (06) ◽  
pp. 413-422 ◽  
Author(s):  
Johannes Wach ◽  
Claudia Goetz ◽  
Kasra Shareghi ◽  
Torben Scholz ◽  
Volker Heßelmann ◽  
...  
Keyword(s):  
Positive Predictive Value ◽  
Negative Predictive Value ◽  
Predictive Value ◽  
Intraoperative Imaging ◽  
Tumor Resection ◽  
Surgical Site Infections ◽  
Residual Tumor ◽  
Extent Of Resection ◽  
Neurosurgical Procedures ◽  
Dual Use

Abstract Background To achieve maximal resection in glioblastoma (GBM) surgery, intraoperative imaging is important. An intraoperative magnetic resonance imaging (iMRI) suite used for both diagnostic and intraoperative imaging is considered being a reasonable concept for modern hospital management. It is still discussed if the dual use increases the risk of surgical site infections (SSI). This article assesses the rate of gross total resection (GTR), extent of resection (EOR), and histopathology after iMRI-guided resections in patients with GBM. The rate of surgical site infections (SSIs) is evaluated. Methods In all, 79 patients with GBM were operated on with iMRI. Additional resection was performed if iMRI depicted contrast enhancing tissue suggestive of residual tumor. GTR and EOR were determined by segmentation and volumetric analysis of the MR images. SSIs and the role of intravenous only or intravenous plus intrathecal antibiotics were evaluated. Statistical analysis was performed to detect the sensitivity, specificity, positive predictive value, and negative predictive value of iMRI-guided extended resections. Pearson's two-tailed chi-square test was performed to evaluate the rates of GTR and variables associated with SSI. Results GTR was achieved in 59 patients (74.68%). Rate of GTR was 35.44% before iMRI and additional resections (p < 0.0001). Mean EOR was 96.27%. Positive predictive value for tumor cells in the additionally resected tissue was 88.6%, negative predictive value was 100%, sensitivity was 100%, and specificity was 70. 6%. Rate of SSIs was 5.06% (n = 4). Two superficial SSIs, one subdural empyema and one cerebritis, were seen. SSI rates with parenteral only and additional intrathecal antibiotics were 0% and 8%, respectively (p = 0.133). Conclusion Increase of extent of tumor resection using iMRI is evident. SSI rate is within the normal range of neurosurgical procedures. A dual-use iMRI suite is a safe concept.

scholarly journals Venous Thromboembolism Anticoagulation Prophylaxis Timing in Patients Undergoing Craniotomy for Tumor

2021 ◽  
Vol 2 (1) ◽  
Author(s):  
Hanna Algattas ◽  
Spencer E Talentino ◽  
Bradley Eichar ◽  
Abraham A Williams ◽  
Joseph M Murphy ◽  
...  
Keyword(s):  
Venous Thromboembolism ◽  
Clinical Judgment ◽  
Tumor Resection ◽  
The Elderly ◽  
Extent Of Resection ◽  
Subtotal Resection ◽  
Hemorrhagic Complication ◽  
Increased Risk ◽  
Hemorrhagic Complications ◽  
Prophylactic Anticoagulation

ABSTRACT BACKGROUND Prophylactic anticoagulation helps prevent postoperative venous thromboembolism (VTE) and time to initiation postcraniotomy has relied on clinical judgment and practice patterns. OBJECTIVE To compare risks of postoperative VTE and hemorrhage among patients undergoing tumor resection with initiation of prophylactic anticoagulation on postoperative day 1 (POD1) vs POD2. METHODS Adult patients undergoing craniotomy for tumor between 2008 and 2018 were retrospectively reviewed. Outcomes were recorded from the Electronic medical record (EMR) including deep vein thrombosis (DVT), pulmonary embolism (PE), and hemorrhage. RESULTS Of a total of 1168 patients undergoing craniotomy, 225 initiated anticoagulation on POD1 and 389 initiated on POD2. Of the 171 glioblastoma (GBM) cases, 64 initiated on POD1 and 107 on POD2. There were 9 DVTs (1.5%), 1 PE (0.20%), overall VTE rate of 1.6%, and 7 hemorrhagic complications (1.10%), 4 being clinically significant. The GBM cohort contained 4 DVTs (2.3%) and 3 hemorrhagic complications (1.80%). There was no increased risk of VTE or hemorrhage with anticoagulation initiated on POD2 compared to POD1 in either cohort. Multivariate analysis in both cohorts did not reveal a significant association between DVT, PE, or hemorrhagic complications with age, body mass index, GBM pathology, or extent of resection. Interestingly, glioma patients older than 70 with subtotal resection had a higher likelihood of suffering intracranial hemorrhage when anticoagulation was started on POD1 (odds ratio 12.98). CONCLUSION Risk of VTE or hemorrhagic complication did not significantly differ with prophylactic anticoagulation started on POD1 vs POD2. Early anticoagulation may certainly be considered in high risk cases; however, 1 group where risk may outweigh benefit is the elderly glioma population receiving a subtotal resection.

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