Radiographic and clinical outcomes using intraoperative magnetic resonance imaging for transsphenoidal resection of pituitary adenomas

Abstract

OBJECTIVEThe utility and safety of intraoperative MRI (iMRI) for resection of pituitary adenomas is not clearly established in the context of advances in endoscopic approaches. The goal in this study was to evaluate the safety and efficacy of iMRI for pituitary adenoma resection, with endoscopic transsphenoidal (ETS) versus microscopic transsphenoidal (MTS) approaches.METHODSRadiographic and clinical outcomes of all pituitary adenomas resected using iMRI between 2008 and 2017 at a single institution were retrospectively evaluated.RESULTSOf 212 tumors treated, 131 (62%) underwent further resection based on iMRI findings, resulting in a significant increase in gross-total resection on postoperative MRI compared with iMRI (p = 0.0001) in both ETS and MTS groups. iMRI increased rates of gross-total resection for cavernous sinus invasion Knosp grades 1 and 2, but not in Knosp ≥ 3 across treatment groups (p < 0.0001). The extent of resection on postoperative MRI was significantly correlated with increased progression-free survival (p < 0.0001). Initial hormone remission off medical therapy was achieved in 64%, with a significantly higher rate of remission in tumors resected via the ETS approach (81%) compared with the MTS approach (55%) (p = 0.02). The rate of persistent new hormone deficit was low at 8%, including a 2.8% rate of permanent diabetes insipidus, and 45% of patients had improvement in preoperative hormone deficit following surgery. Serious postoperative complications including CSF leaks requiring reoperation were rare at 1%, with no postoperative infections.CONCLUSIONSThese results suggest that iMRI is a safe and effective method of increasing the extent of resection for pituitary adenomas while preserving hormone function. When paired with the endoscope, iMRI may offer the ability to tailor more aggressive removal of tumors while optimizing pituitary function, resulting in high rates of secretory hormone remission. Secretory tumors and adenomas with Knosp grade < 3 cavernous sinus invasion may benefit most from the use of iMRI.

Impact of Intraoperative Magnetic Resonance Imaging (i-MRI) on Surgeon Decision Making and Clinical Outcomes in Cranial Tumor Surgery

“…Our result in the pituitary group was in contrast to the published data where iMRI-guided additional resection occurred in 30% to 62% of cases with increase GTR of 3% to 20%. 17 25 26 …”

“…STR!GTR 7 (20.6) 7 (30.4) 0 (0) 0 (0) STR!NTR 1 (2.9) 1 (4.3) 0 (0) 0 (0) iMRI-guided additional resection occurred in 30% to 62% of cases with increase GTR of 3% to 20%. 17,25,26 iMRI versus pMRI…”

Magnetic resonance imaging characteristics predict pituitary function in non-functional pituitary macro-adenoma undergoing trans-sphenoidal surgery

“…These results suggest that using preoperative MRI is a safe method leading to the increase in the resection rate of pituitary adenomas. Especially when MRI is combined with endoscopy, it provides the ability to adapt to the removal of tumors while optimizing pituitary function, resulting in a high rate of recovery of secretory hormone [ 25 ].…”

A Preoperative MRI-Based Radiomics-Clinicopathological Classifier to Predict the Recurrence of Pituitary Macroadenoma Within 5 Years

“…The aggressive PMAs were defined as grade of Knosp 3 or 4, and/or Hardy—Wilson Grades 3 or 4 (and/or Hardy—Wilson Stage C or D or E), and/or histological evidence of invasion of cavernous or sphenoid sinus ( 1 ). The patients who experienced subtotal resection were recognized as cases with residual tumor, and the subjects who underwent gross- or near-total resection were regarded as cases without remnants ( 24 , 25 ).…”