Value of endoscopy for maximizing tumor removal in endonasal transsphenoidal pituitary adenoma surgery

McLaughlin, Nancy; Eisenberg, Amy; Cohan, Pejman; Chaloner, Charlene; Kelly, Daniel F.

doi:10.3171/2012.11.jns112020

Cited by 85 publications

(54 citation statements)

References 51 publications

(73 reference statements)

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“…In our study, the extended approach significantly increased the maneuverability of the instruments and helped us to see the wall of the cavernous sinus better. 24,30 Moreover, with complications in only 17 cases, we had a significantly lower complication rate when compared with other endoscopic series presented in the literature. Only 3% of our cases had anterior pituitary dysfunction and 1% had posterior pituitary dysfunction.…”

Section: Discussionmentioning

confidence: 68%

“…29,42 Although transsphenoidal microsurgery has been considered to be the best surgical approach in the treatment of GH-secreting adenomas, in the last decade endoscopic treatment of sellar lesions proved to be an important option as well. 19,22,30,39 The endoscopic approach has some obvious advantages, including improved surgical visualization, less nasal trauma, increased patient comfort, and potentially better results with respect to total tumor resection. 15,17,19 Important changes have been introduced to the cure criteria for acromegaly.…”

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confidence: 99%

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Treatment of acromegaly by endoscopic transsphenoidal surgery: surgical experience in 214 cases and cure rates according to current consensus criteria

Hazer

Işık

Berker

et al. 2013

JNS

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Object Acromegaly is a disease that has significant morbidity and mortality related to high levels of growth hormone (GH) and insulin-like growth factor–I (IGF-I), and is usually caused by pituitary adenomas. The goal in this study was to investigate the role of endoscopic transsphenoidal surgery and surgical experience in the treatment of GH adenoma cases in relation to surgical results and hormonal cure rates, and to perform a review of the literature. Methods The authors present a retrospective analysis of 214 GH adenoma cases. Restoration of IGF-I levels to normal for age and sex, suppression of GH levels below 0.4 μg/L on the oral glucose tolerance test, and demonstration of the total removal of the tumor on MRI studies obtained after administration of contrast material at the 3-month postoperative follow-up visit were the criteria for cure. Results In total 214 patients with a mean age of 41.9 ± 12 years (range 17–75 years) and a male/female ratio of 106/108 were enrolled in the study. Cure was achieved in 134 (62.6%) of 214 patients. One hundred sixty-nine patients were primary cases, and of these 109 (64.5%) were cured, whereas 61 patients were previously operated cases and of these 25 (41%) were cured. With a 51.1% decrease in the 1st month postoperatively, IGF-I levels were found to be predictive of cure (74.4% sensitivity and 73.7% specificity). Cut-off values for GH levels in predicting cure for the 1st day, 1st week, and 1st month postoperatively were 2.33, 2.05, and 2.25 μg/L, respectively. The cut-off value for surgical experience was 57 for primary surgeries (58.5% cure rate before this cut-off value compared with 72.6% after it; p = 0.025) and 108 for all operations (45.8% vs 79.4%, p = 0.037). Although 28 patients were found to be in remission according to the criteria in 2000, they were not in remission according to the new consensus criteria. Nine of these cases (32.1%) had random GH levels < 1 μg/L at the 1-year follow-up. The 1-year IGF-I and GH levels in these 28 patients showed no significant difference when compared with the cases defined as cured according to the current criteria. Conclusions In acromegaly treatment, transsphenoidal endoscopic surgery performed by an expert senior surgeon and increased surgical experience are important for higher cure rates. Random GH levels < 2.33 μg/L after the 1st day postoperatively and a > 50% decrease in IGF-I levels after the 1st month postoperatively are predictive of cure. Moreover, there is no urgency for additional therapy in patients with GH levels of 0.4–1 μg/L and MRI sequences showing no tumor at the 3-month follow-up, because for these cases remission can be achieved at the 1-year follow-up.

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Section: Discussionmentioning

confidence: 68%

mentioning

confidence: 99%

Treatment of acromegaly by endoscopic transsphenoidal surgery: surgical experience in 214 cases and cure rates according to current consensus criteria

Hazer

Işık

Berker

et al. 2013

JNS

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“…7,9,14 A better understanding of the surgical and patient factors that influence postoperative sinonasal QOL and nasal morbidity may be helpful for improving patient counseling and surgical technique. In this study, we describe an exploratory post hoc analysis of a multicenter QOL study to define predictors of sinonasal morbidity and QOL after endoscopic transsphenoidal surgery.…”

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confidence: 99%

Predictors of sinonasal quality of life and nasal morbidity after fully endoscopic transsphenoidal surgery

Little

Kelly

Milligan

et al. 2015

JNS

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OBJECT Despite the increasing application of endoscopic transsphenoidal surgery for pituitary lesions, the prognostic factors that are associated with sinonasal quality of life (QOL) and nasal morbidity are not well understood. The authors examine the predictors of sinonasal QOL and nasal morbidity in patients undergoing fully endoscopic transsphenoidal surgery. METHODS An exploratory post hoc analysis was conducted of patients who underwent endoscopic pituitary surgery and were enrolled in a prospective multicenter QOL study. End points of the study included patient-reported sinonasal QOL and objective nasal endoscopy findings. Multivariate models were developed to determine the patient and surgical factors that correlated with QOL at 2 weeks through 6 months after surgery. RESULTS This study is a retrospective review of a subgroup of patients studied in the clinical trial “Rhinological Outcomes in Endonasal Pituitary Surgery” (clinical trial no. NCT01504399, clinicaltrials.gov). Data from 100 patients who underwent fully endoscopic transsphenoidal surgery were included. Predictors of a lower postoperative sinonasal QOL at 2 weeks were use of nasal splints (p = 0.039) and female sex at the trend level (p = 0.061); at 3 months, predictors of lower QOL were the presence of sinusitis (p = 0.025), advancing age (p = 0.044), and use of absorbable nasal packing (p = 0.014). Health status (multidimensional QOL) was also predictive at 2 weeks (p = 0.001) and 3 months (p < 0.001) and was the only significant predictor of sinonasal QOL at 6 months (p < 0.001). A Kaplan-Meier analysis was performed to study time to resolution of nasal crusting, mucopurulence, and synechia as observed during nasal endoscopy after surgery. The mean time (± SEM) to absence of nasal crusting was 16.3 ± 2.1 weeks, mucopurulence was 6.2 ± 1.1 weeks, and synechia was 4.4 ± 0.5 weeks. Use of absorbable nasal packing was associated with more severe mucopurulence. CONCLUSIONS Sinonasal QOL following endoscopic pituitary surgery reaches a nadir at 2 weeks and recovers by 3 months postoperatively. Use of absorbable packing and nasal splints, while used in a minority of patients, negatively correlates with early sinonasal QOL. Sinonasal QOL and overall health status are well correlated in the postoperative period, suggesting the important influence of sinonasal QOL on the patient experience.

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“…Transsphenoidal surgery, with either microscopic or endoscopic technique, is currently adopted in more than 95 % of surgical procedures to the sellar area and ca. 97 % of all surgery for the treatment of pituitary adenomas [2][3][4][5][6][7]. The wider and panoramic view offered by the endoscope together with the proposals and contributions of many active groups has expanded its applicability to the removal of different "pure" supradiaphragmatic lesions [8][9][10][11][12][13][14].…”

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confidence: 99%

Size does not matter. The intrigue of giant adenomas: a true surgical challenge

et al. 2014

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Pituitary surgery is an evolving specialty of modern neurosurgery that requires precise anatomical knowledge, technical skill, and integrated appreciation of pituitary pathophysiology. Over the years, this field has made a well-noticed advantage of the evolving ideas and surgical tools, amongst them, the endoscope. This last, with the advent of the concept of minimally invasive and keyhole surgery, gained popularity as the sole visualizing instrument in many neurosurgical approaches, above all those for pituitary lesions. Nowadays, the endoscopic transsphenoidal approach is commonly used in many centers throughout the world under the same indications as the conventional microsurgical technique [1]. Transsphenoidal surgery, with either microscopic or endoscopic technique, is currently adopted in more than 95 % of surgical procedures to the sellar area and ca. 97 % of all surgery for the treatment of pituitary adenomas [2][3][4][5][6][7]. The wider and panoramic view offered by the endoscope together with the proposals and contributions of many active groups has expanded its applicability to the removal of different "pure" supradiaphragmatic lesions [8][9][10][11][12][13][14]. Indeed, the extended endoscopic approach is increasingly adopted for the treatment of pathologies such as craniopharyngiomas, midline skull base meningiomas, chordomas, and other skull base lesions. Though it has been reported that the extended endonasal approach may offer a greater extent of resection also in the case of pituitary macroadenomas with suprasellar symmetric and/or asymmetric extension, recurrent or residual dumbbell-shaped adenomas and/or fibrous macroadenomas, once considered all amenable to open transcranial surgery only [15]. The same principles are valid in cases of giant adenomas, where the extended approach has proved to facilitate, in most instances, a wider lesion exposure just after the dural opening over the sellar-suprasellar space, thus avoiding any retraction of neurovascular structures [16][17][18][19]. However, there are conditions that could render more troublesome the transsphenoidal approach, either related to the anatomy of the surgical route or to the inner features of the lesion itself, i.e., the size of the sella, its degree of ossification, the size and the pneumatization of the sphenoid sinus, and/or carotid arteries position and shape [1,6,20,21].On the other hand, transcranial surgery should be preferred when tumors present with extensive intracranial invasion, with asymmetric lateral development, into the anterior cranial fossa or lateral or posterior extension into the middle and posterior cranial fossa, particularly if major vessel involvement is present and/or whether transsphenoidal surgery has been already unsuccessful, and in these regards, several authors have reported surgical strategy and results, properly addressing indications, pros, and cons [22][23][24].When perceiving this controversial scenario, we moved backward through our series and analyzed the decisionmaking process, i.e., surgica...

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Value of endoscopy for maximizing tumor removal in endonasal transsphenoidal pituitary adenoma surgery

Cited by 85 publications

References 51 publications

Treatment of acromegaly by endoscopic transsphenoidal surgery: surgical experience in 214 cases and cure rates according to current consensus criteria

Treatment of acromegaly by endoscopic transsphenoidal surgery: surgical experience in 214 cases and cure rates according to current consensus criteria

Predictors of sinonasal quality of life and nasal morbidity after fully endoscopic transsphenoidal surgery

Size does not matter. The intrigue of giant adenomas: a true surgical challenge

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