Radiological Knosp, Revised-Knosp, and Hardy-Wilson Classifications for the Prediction of Surgical Outcomes in the Endoscopic Endonasal Surgery of Pituitary Adenomas: Study of 228 Cases.

Marta Araujo-Castro,Carlos Vior,Víctor Rodríguez Berrocal,Alberto Acitores Cancela,Eider Pascual-Corrales

doi:10.3389/fonc.2021.807040

Abstract

PurposeTo evaluate which radiological classification, Knosp, revised-Knosp, or Hardy–Wilson classification, is better for the prediction of surgical outcomes in the endoscopic endonasal transsphenoidal (EET) surgery of pituitary adenomas (PAs).MethodsThis is a retrospective study of patients with PAs who underwent EET PA resection for the first time between January 2009 and December 2020. Radiological cavernous sinus invasiveness was defined as a Knosp or revised-Knosp grade >2 or a grade E in the Hardy–Wilson classification.ResultsA total of 228 patients with PAs were included. Cavernous sinus invasion was evident in 35.1% and suprasellar extension was evident in 74.6%. Overall, surgical cure was achieved in 64.3% of patients. Surgical cure was lower in invasive PAs than in non-invasive PAs (28.8% vs. 83.1%, p < 0.0001), and the risk of major complications was higher (13.8% vs. 3.4%, p = 0.003). The rate of surgical cure decreased as the grade of Knosp increased (p < 0.001), whereas the risk of complications increased (p < 0.001). Patients with Knosp 3B PAs tended to achieve surgical cure less commonly than Knosp 3A PAs (30.0% vs. 56.0%, p = 0.164). Similar results were observed based on the invasion and extension of Hardy–Wilson classification (stage A–C 83.1% vs. E 28.8% p < 0.0001, grade 0–II 81.1% vs. III–IV 59.7% p = 0.008). The Knosp classification offered the greatest diagnostic accuracy for the prediction of surgical cure (AUC 0.820), whereas the invasion Hardy–Wilson classification lacked utility for this purpose (AUC 0.654).ConclusionThe Knosp classifications offer a good orientation for the estimation of surgical cure and the risk of complications in patients with PAs submitted to EET surgery. However, the invasion Hardy–Wilson scale lacks utility for this purpose.

Highlights

Pituitary surgery aims to eliminate excess hormone production in functioning pituitary adenomas (PAs), avoid or ameliorate tumor mass effects, preserve both pituitary function and adjacent nerve structures, and eliminate or reduce the risk of future recurrences [1]
In 1993, Knosp et al described the classical radiological classification of cavernous sinus invasion based on the relations of the PAs with the line between the supraclinoid internal carotid artery (ICA) and intra-cavernous ICA on coronal magnetic resonance imaging (MRI) [7]
Forty patients were medically treated before surgery

Summary

Introduction

Pituitary surgery aims to eliminate excess hormone production in functioning pituitary adenomas (PAs), avoid or ameliorate tumor mass effects, preserve both pituitary function and adjacent nerve structures, and eliminate or reduce the risk of future recurrences [1]. The operative approach of PAs is guided by the size and location of the tumor and its relation to surrounding anatomical structures. This way, invasion of cavernous sinus is a known limiting factor in the achievement of complete surgical resection and could lead to a higher risk of postoperative surgical complications [2,3,4]. Later studies have found that the revised-Knosp classification [3], which includes the differentiation between superior or inferior cavernous sinus compartment invasion in grades 3A and 3B, provides a better prediction of gross total resection and endocrine remission in functioning PAs [10]. To the best of our knowledge, no previous studies have compared the Hardy–Wilson, Knosp, and revised-Knosp classifications for the prediction of surgical cure and complications in PA surgery and analyzed the correlation of these radiological scales with histological findings

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