Suprasellar Extension Research Articles

Predictive value of OCT and MRI for postoperative visual recovery in patients with chiasmal compressive lesions.

We aimed to investigate the predictive value of retinal thickness measured by optical coherence tomography (OCT) and mass biometrics measured using magnetic resonance image (MRI) for visual recovery after surgery for removal of a mass compressing the optic chiasm. Consecutive patients who showed typical temporal visual field defect (VFD) with respect to the vertical meridian due to a chiasmal compressive mass and who underwent mass removal surgery were recruited. Ophthalmic examination was performed preoperatively and postoperatively. Retinal thickness was measured by the Cirrus OCT. The height and size of the mass and suprasellar extension (SSE) in both the sagittal and coronal planes were evaluated. Patients were divided into two groups based on the improvement in VFD (mean deviation [MD] change ≥ 5 dB: group R; others: group NR) and clinical characteristics were compared. Fifteen patients were included in the study. Eight (53.3%) patients were allocated into group R and others (7 patients, 46.7%) into group NR. Age, sex, initial visual acuity, initial MD was not different between the two groups. The retinal thicknesses were not different while tumor height, volume, and both sagittal and coronal SSE were significantly different between the two groups. (p = 0.029, 0.014, <0.001, and <0.001, respectively) All MRI parameters showed significant predictive value for the degree of MD recovery. MRI showed better predictive value than OCT in predicting postoperative VFD recovery in patients with temporal VFDs due to chiasmal compressive disorder.

Predictors of early visual outcome after endoscopic trans sphenoidal excision of pituitary adenomas

BACKGROUND: Endoscopic transsphenoidal excision has revolutionized the surgical management of pituitary macroadenoma. There had been several retrospective studies on the factors determining the visual outcome after surgical excision of pituitary adenoma, but very few prospective studies were published in this context. This is a prospective study of the factors predicting visual outcome following endoscopic transsphenoidal excision of pituitary adenoma. Various factors like age, duration of visual symptoms, the volume of the tumour, suprasellar extension, parasellar extension, type of adenoma, pituitary apoplexy, completion of excision, fundoscopic changes, and preoperative visual deficits were studied. METHODS: Single centre prospective observational study done between November 2016 to December 2018. Thirty patients with pituitary macroadenoma who underwent trans nasal endoscopic excision were studied with preoperative and postoperative visual impairment score (VIS) and the visual outcome was categorized as a good outcome if there was more than 5% improvement in VIS and as worse otherwise. Various predictors that may influence the outcome were statistically compared. RESULTS: 83.3% of patients (n=25) showed improvement in their vision at 6months follow-up. Overall visual outcome (considering both parameters visual acuity and visual field together) was dependent on suprasellar extension (P=0.01), completion of excision (P=0.004), and primary optic atrophy (P=0.018). On subgroup analysis recovery in visual acuity was significantly determined by the preoperative tumour volume(P=0.041), suprasellar extension (P=0.006), completion of excision(P=0.003), and primary optic atrophy (P=0.013). The improvement in the field of vision depended on the severity of preoperative field defects (P=0.04) and completion of excision (P=0.01). CONCLUSIONS: The factors predicting the early visual outcome were the suprasellar extension, completion of excision, preoperative field deficits, and primary optic atrophy. This study highlights the importance of early and proper intervention in pituitary adenomas managed surgically to procure the desired result.

Coexisting Prolactin-Secreting Macroadenoma, Hypopituitarism and Type 1 Diabetes Mellitus in a Young Adult Male Patient

The association between type 1 diabetes mellitus (DM) and pituitary prolactinoma is rarely reported in the literature. Herein we present a 23-year-old male patient with co-existing type 1 DM, pituitary macro-prolactinoma and panhypopituitarism secondary to mass effect. The patient presented with generalised symptoms including fatigability, cold hands, decreased insulin requirement secondary to frequent hypoglycaemic episodes two weeks following the diagnosis of type 1 DM. Initial blood workup showed evidence of possible secondary hypothyroidism. The full pituitary profile screen showed profound anterior hypopituitarism with a prolactin level of 67,168 miu/L (normal range 86-324 miu/L). Pituitary MRI showed macroadenoma, 37mm in size, with a suprasellar cystic extension but no chiasmal compression. It was treated medically with cabergoline and a repeat pituitary MRI after eight weeks of initiating treatment showed a 4-mm reduction in the size of the adenoma, and prolactin level decreased to 6,794 miu/L. The case was discussed at the Neurosurgical MDT and the outcome was to continue to monitor while on cabergoline. This case report is the second in the literature, which documented the association between type 1 DM and pituitary prolactinoma in adolescents. These patients might not present with the classical clinical features of hyperprolactinemia, and instead, they present with frequent hypoglycaemia and decreased insulin requirement due to secondary adrenal insufficiency as a consequence of the mass effect of the prolactinoma. Furthermore, non-specific symptoms, such as generalised tiredness and fatiguability, despite reasonable blood sugar control, in young patients with type 1 DM should trigger screening for all anterior pituitary hormones to exclude hypopituitarism.

Pituitary Metastasis of Papillary Thyroid Carcinoma: The First Case in Thailand

Pituitary metastasis (PM) is uncommon. Papillary thyroid carcinoma (PTC) causing PM is very rare, with only 16 case reports around the world. The authors present a case of PM from PTC who also harbored lung and bone metastases. At the same time as PTC diagnosis, a sellar mass with suprasellar extension, compressing the optic pathway, and a precentral sulcus leptomeningeal lesion were identified. Although the patient had no complaint of related symptoms other than panhypopituitarism, eye examination demonstrated a typical visual field defect. Surgical decompression by endoscopic transsphenoidal surgery encountered a highly vascularized tumor. Histopathology confirmed the diagnosis of the PM from PTC. The patient received subsequent radiation and radioactive iodotherapy. At six months after surgery, she was able to live independently. A short summary of previous case reports of PTC to pituitary gland is provided. Keywords: Thyroid carcinoma; Papillary; Pituitary; Sellar; Metastasis; Pituitary gland; Endoscopic transsphenoidal surgery

Clinical presentation and magnetic resonance imaging characteristics of lymphocytic hypophysitis: a systematic review with meta-analysis.

This meta-analysis was performed to analyze the clinical presentation, magnetic resonance imaging (MRI) characteristics, and the management of lymphocytic hypophysitis (LYH). Four different databases were searched from January 2010 to December 2020, two researchers independently conducted literature screening, data extraction, and quality evaluation. We used a random effects meta-analysis to calculate summary relative risks with 95% CI. This meta-analysis showed that the percentage of women among LYH patients was 78%. LYH was associated with pregnancy in 15% of female patients, with headache (49%) and symptoms of central diabetes insipidus (CDI) (45%) being the most frequent presentation. In 24% of LYH patients, there was an association with another autoimmune disease. The incidence of secondary hypogonadism, secondary hypoadrenalism, secondary hypothyroidism, and growth hormone deficit was 54%, 49%, 43%, and 22%, respectively. Pituitary contrast enhancement (63%), symmetrical pituitary enlargement (60%), thickening of the pituitary stalk (58%), sella mass or suprasellar extension (58%), and loss of posterior pituitary hyperintensity (50%) were typical MRI findings. Regarding LYH treatment, the percentage of patients who had observation or hormone replacement, steroid therapy, and surgery was 43%, 36%, and 34%, respectively. It is of great significance to fully understand the clinical characteristics of lymphocytic hypophysitis, reduce missed diagnosis and misdiagnosis, avoid unnecessary surgery and maintain normal pituitary function.

Factors Predicting Neuroendocrine Recovery Following Transsphenoidal Surgery in Pituitary Apoplexy Patients

Pituitary apoplexy is a rare clinical syndrome. Only a few studies have examined factors associated with recovery of neuroendocrine functions following transsphenoidal surgery. This study aimed to identify factors associated with neuroendocrine recovery following surgery for pituitary apoplexy. The records of pituitary apoplexy patients who underwent transsphenoidal surgery at Songklanagarind Hospital between January 2005 and December 2020 were retrospectively reviewed. The primary outcomes were the recoveries of preoperative visual acuity (VA), visual field, cranial nerve function, and pituitary hormone deficits. Using logistic regression analysis, various factors were analyzed for their associations with recovery of neuroendocrine functions. The study included 98 patients. Multivariate analysis showed that older age and greater suprasellar extension were associated with no recovery of VA (P= 0.042 and P= 0.018, respectively). Only 33% of patients aged >55 years and suprasellar extension of lesion ≥25 mm gained recovery of VA, while 100% of patients with neither of these factors had recovery. Underlying hypertension was associated with no recovery of preoperative visual field defect (P= 0.027). Wilson-Hardy classification-invasion grades 3-4 and lower preoperative serum prolactin level were associated with no recovery from preoperative hypoadrenalism and hypothyroidism (P= 0.016 and P=0.007, respectively). Older age, higher suprasellar extension, and hypertension were poor prognostic factors for visual recovery. Wilson-Hardy inferior invasion grade 3-4 and lower preoperative serum prolactin level were poor prognostic factors for recovery from hypopituitarism. Stratifying patients according to these prognostic factors may assist in selecting patients for surgery.

Intraoperative Cerebrospinal Fluid Leak Graded by Esposito Grade Is a Predictor for Diabetes Insipidus After Endoscopic Endonasal Pituitary Adenoma Resection

Diabetes insipidus (DI) is a well-known complication of transsphenoidal surgery. However, the risk factors for DI remain controversial. We conducted a retrospective study of patients who underwent endoscopic transsphenoidal surgery for pituitary adenoma at our institution during a 5-year period. The patients were divided into a DI group and a non-DI group. Logistic regression analyses were used to identify risk factors for postoperative DI. In subgroup analysis, the DI group was divided into transient DI and permanent DI groups, and perioperative factors were compared between groups. Of 101 patients, 58 were in the non-DI group (57.4%) and 43 were in the DI group (42.6%). Permanent DI occurred in 7 patients (6.9%). In univariate analyses, statistically significant risk factors were suprasellar extension, tumor functionality, and intraoperative cerebrospinal fluid leaks by Esposito grade. In multivariate logistic regression analysis, Esposito grade was the only statistically significant risk factor (P= 0.015). The frequency of DI increased as the Esposito grade increased (P= 0.0002 for the trend). In subgroup analysis, postoperative nadir sodium concentration was lower in the permanent DI group (128.1 ± 2.78 mmol/L) than in the transient DI group (135 ± 1.22 mmol/L; P= 0.035), and the optimal cutoff value was 124.5 mmol/L, with a sensitivity of 57.1% and a specificity of 91.7% (area under the curve= 0.76, P= 0.034). Intraoperative cerebrospinal fluid leak by Esposito grade is associated with postoperative DI. These data can be applied to help identify high-risk patients who need more aggressive follow-up and fluid management.

Rathke’s Cleft Cyst Abscess—An Unusual Guest in The Sella

AbstractAbscess formation within a Rathke's cleft cyst (RCC) is extremely rare, particularly at a young age. We report the case of a young girl with abscess formation in RCC. A 21-year-old female presented with headache, vomiting, visual deterioration and features suggestive of hypopituitarism. She had bitemporal hemianopia with impairment of visual acuity. MRI revealed a cystic lesion in the sella with suprasellar extension and peripheral rim enhancement. On the basis of history and imaging, this was indistinguishable from more commonly encountered pituitary pathology. She underwent transsphenoidal decompression, which revealed yellowish purulent material that when cultured grew Staphylococcus epidermidis. Histological examination revealed numerous neutrophils and cyst wall lining with features characteristic of RCC. Postoperatively, she received antibiotics and replacement therapy for hypopituitarism. Three months later, she experienced deterioration in visual fields. Considering persistent disease, she underwent redo surgery which revealed similar findings. Postsurgery, pituitary MRI revealed an empty sella syndrome. Thereafter, follow-up for 1 year was stable with permanent diabetes insipidus and multiple pituitary hormone deficiency on supplementation. Although uncommon, we recommend considering RCC abscess as a differential diagnosis of a pituitary mass lesion, as predicting its presence can be difficult preoperatively. Persistent or recurrent disease is common in these cases, so timely diagnosis and adequate surgical drainage leads to lower morbidity and mortality.

NCOG-31. GIANT PITUITARY ADENOMA (GPA) SCORE: A NOVEL SCORING SYSTEM TO PREDICT POSTOPERATIVE OUTCOMES OF GIANT PITUITARY ADENOMAS

Abstract BACKGROUND Giant pituitary adenomas (GPA) are uncommon and highly variable in morphology and extension. There is no scoring system that considers all the dimensions of adenoma invasion. We developed a new Giant Pituitary Adenoma score and report our surgical experience and evaluate outcomes after resection of these tumors in accordance with the preoperative score. METHODS We developed a novel scoring system for classifying giant pituitary adenomas, and 11-year data of GPA surgery at our center was collected retrospectively, based on this scoring system. GPA Score considered tumor’s parasellar extension, encasement of cavernous internal carotid artery (ICA), suprasellar extension &amp;gt; 2 cm, suprasellar extension &amp;gt; 4cm and retrosellar extension. Maximum possible score was 9. The scoring system was applied to 53 patients of GPA who underwent surgical resection between January 1, 2006, and December 2017. The Lundin-Pederson (ABC/2) method was used to calculate the tumor volume both pre- and post-resection and linear regression was used to assess the relationship between extent of tumor resection and GPA score. RESULTS The median age of the study population was 42.08 ± 16.49 years. The mean maximum diameter of the pituitary adenomas was 5.0 cm (range 4.0 cm-8.5cm) while the mean volume of the adenomas was 27.3 cm3 (range 10 cm3-149 cm3). There were 3 cases of score 2, 5 cases of score 3, 13 cases of score 4, 20 cases of score 5, 9 cases of score 6 and 3 cases of score 7. The range of tumor volumes of tumors for scores from 2-7 was 17.3 cm3 to 65.8 cm3 and GPA score was correlated with the percent residual tumor using linear regression that was statistically significant (p= 0.001). CONCLUSION GPA Score is a reliable scoring system to predict the extent and subsequent difficulty in tumor resection in GPA.

P.168 Prediction of Pituitary Adenoma Recurrence using the SIPAP Classification

Background: Pituitary tumor recurrence following endoscopic endonasal transsphenoidal surgery (EETS) has been reported widely. We evaluated a modified score using the SIPAP classification system, combining the suprasellar and paraseller extension scores of the pituitary tumor, to determine its impact on adenoma recurrence. Methods: A retrospective cohort study design with patient characteristics, tumor type, endocrine, operation, imaging data collected. Preoperative MRI images were reviewed and SIPAP classification applied. Postoperative data were extracted for the follow-up period available for each patient.The suprasellar score and the highest parasellar scoring from both sides were numerically summed in a bilateral suprasellar and parasellar (SaP) score and combined to make 4 grades. Results: 276 patients were identified, 56.5% of the cohort was male. The mean cohort age was 54 years old.The mean follow up period was 32 months. Patient perioperative tumor grade according to SaP classification and recurrence rate was: Grade 1: 11%: Grade 2: 10%; Grade 3: 15%; Grade 4: 22%. The results followed a pattern of logarithmic curve. Conclusions: The SaP classification was useful in determining the pituitary tumor expected recurrence following EETS. The advanced tumors had the highest recurrence rates. Use of the SaP score may allow for more accurate preoperative counselling of patients with pituitary adenoma.

The clinical course of Rathke's cleft cysts in pediatric patients: impact on growth and pubertal development.

.Rathke’s cleft cysts (RCCs) are non-neoplastic epithelial lesions in the sellar or suprasellar regions. RCCs are usually asymptomatic; however, some patients experience headaches, visual disturbances, and endocrine disorders. The best treatment for associated endocrinopathy remains elusive. We aimed to investigate the clinical course, magnetic resonance imaging findings, and response to therapy in 10 pediatric patients with RCCs and endocrinopathy. Growth impairment and precocious puberty were observed to be prevalent. One patient with suprasellar extension of RCC underwent surgery, while the others were treated medically. Of the nine patients, seven patients showed stable cyst size, while two patients displayed reduction in cyst size. Hormone replacement and gonadotropin suppression therapy were found to be effective. Imaging and endocrine follow-ups are warranted because of the potential for changes in the cyst size and hormonal changes.

Association of PTTG1 expression with invasiveness of non-functioning pituitary adenomas

BackgroundPituitary tumor transforming gene 1 (PTTG1), paired-like homeodomain 2 (PITX2), and galectin-3 have been widely studied as predictive biomarkers for various tumors and are involved in tumorigenesis and tumor progression. We evaluated the usefulness of PTTG1, PITX2, and galectin-3 as predictive biomarkers for invasive non-functioning pituitary adenomas (NFPAs) by determining the relationship between the expressions of these three proteins and the invasiveness of the NFPAs. We also investigated whether PTTG1, E-cadherin, and Ki-67, which are known to be related to each other, show a correlation with NFPA features.MethodsA retrospective study was conducted on 87 patients with NPFAs who underwent surgical removal. The NFPAs were classified into three groups based on magnetic resonance imaging findings of suprasellar extension and cavernous sinus invasion. Immunohistochemical staining for PTTG1, PITX2, galectin-3, E-cadherin, and Ki-67 was performed on tissue microarrays.ResultsPTTG1 expression showed a statistically significant correlation with the invasiveness of NFPAs, whereas PITX2 and galectin-3 did not have a relationship with the invasiveness of NFPAs. Moreover, there was no association among PTTG1, E-cadherin, and Ki-67 expression.ConclusionsPTTG1 has the potential to serve as a predictive biomarker for invasive NFPA. Furthermore, this study may serve as a reference for the development of PTTG1-targeted therapeutic agents.

S2926 Craniopharyngioma-Induced Hypothalamic Obesity and a Red Herring Known as Binimetinib

Introduction: Craniopharyngioma suprasellar extensions damage hypothalamic nuclei resulting in obesity. Binimetinib can reduce the size of craniopharyngiomas by 30%, but also contributes to an increase in adipose and muscle mass. Here is a case of hypothalamic obesity causing weight regain post sleeve gastrectomy (LSG) being successfully treated with a GLP-1 receptor agonist to decrease her weight and Hba1c. Case Description/Methods: A 26-year-old female patient with a BMI of 29 presents to the clinic with a craniopharyngioma-induced mass effect and panhypopituitarism. She had undergone transsphenoidal resections, external beam radiation, chemotherapy, gamma knife, and a ventriculoperitoneal shunt. Due to hypothalamic nucleus injury, she developed hyperphagia with a BMI of 36 kg/m2 and NAFLD-induced cirrhosis. She had a sleeve gastrectomy and reduced her BMI to 26. Her medications include desmopressin, insulin, levothyroxine, hydrocortisone, and recently started on binimetinib. She rapidly regained weight now with a BMI of 29. Abnormal labs include an Hba1c 9.7 g/dL, PT 15.6, INR 1.4, platelets 50, AST 51 u/L and ALT 48 u/L. MRI of her brain with contrast confirmed the suprasellar extension of the craniopharyngioma impinging on the hypothalamus (Figure 1). An esophagram demonstrated the patency of her LSG. After starting 1.8 mg of liraglutide, she lost 20 lbs with a BMI of 27 and dropped her Hba1c to 6.1 g/dL in 4 months. Discussion: Carniopharyngiomas can result in obesity due to damage to regulatory medial hypothalamic nuclei, specifically the arcuate nucleus, paraventricular nucleus, and the ventromedial nucleus. This occurs secondary to tumor mass effects, surgical resection of tumor, or from exposure to radiation >51Gy. This leads to leptin resistance causing hyperphagia, hyperinsulinemia, and decreased energy expenditure causing rapid and stubborn weight gain. A selective inhibitor of MEK, binimetinib, increases the muscle mass and muscle fiber size through inhibition of C26 and IL6, leading to an average muscle gain of 2.3 kg/100 days and 4.2% increase in adipose tissue. Radiation treatment in doses ≥ 54 Gy leads to an increased visceral fat and insulin resistance. Treatment includes a roux-en-y gastric bypass, GLP-1 receptor agonists, and metformin. GLP-1s have also recently shown improvement in NASH resolution. Identification of medication side effects and incorporation of weight loss medications can non-invasively treat hypothalamic obesity weight gain and prevent weight regain.Figure 1.: MRI depicting suprasellar extension of the craniopharyngioma into the hypothalamus.

Transsphenoidal Endoscopic versus Microscopic Approach in Treatment of Pituitary Adenomas: CSF Leak and GTR Systematic review

Abstract Background Pituitary adenomas (PAs) are the second most common brain tumors, 10% to 20% of all primary brain tumors. Transsphenoidal approach is now the gold standard for treatment of PAs either microscopic or endoscopic. Aim of the Work to analyze the collective outcomes from studies comparing the microscopic transsphenoidal surgery (MTS) with the endoscopic transsphenoidal surgery (ETS) regarding gross total resection (GTR) and postoperative cerebrospinal fluid (CSF) leak. Patients and Methods we searched PubMed, Google scholar search engine, Cochrane database of systematic reviews, EMBASE and science Direct, using the following keywords “Pituitary adenoma/tumor, endoscopy or endoscopic, microscopy or microscopic, gross total/subtotal/near total/radicular resection/excision, hypophysectomy, debulking, CSF leak/leakage ". The mentioned databases were searched for studies published during period from the 1st of Jan 2015 to 31 Aug. 2020. Results Total number of patients in included studies was 1211 of which 621 (51.3%) underwent endoscopic surgery and 590 (48.7%) underwent microscopic surgery. Of 990 patient analysed for GTR, it was achieved in 334 patients (69.4%) in endoscopic group compared with 287 patients (56.4%) in microscopic group. Of 1211 patients, Postoperative CSF leak developed in 30 patients (5.7%) compared with 32 patients (4.7%) in endoscopic and microscopic group respectively. Conclusion GTR was found to be slightly higher in the endoscopic group especially in cases of suprasellar and lateral cavernous extensions. CSF leak showed no significant difference between the two groups.

Do We Need Intraoperative Magnetic Resonance Imaging in All Endoscopic Endonasal Pituitary Adenoma Surgery Cases? A Retrospective Study.

There are previous reports investigating effectiveness of intraoperative magnetic resonance imaging (IO-MRI) in pituitary adenoma surgery but there is no clear data in the literature recommending when there is no need of intraoperative scan. This retrospective analysis was based on determining which patients does not need any IO-MRI scan following endoscopic endonasal pituitary adenoma surgery. Patients with functional or non-functional pituitary adenomas that were operated via endoscopic endonasal approach (EEA) between June 2017 and May 2019 were enrolled. Patients younger than 18 years old, patients who did not underwent IO-MRI procedure or not operated via EEA were excluded from the study. Hence, this study is designed to clarify if IO-MRI is useful in both functional and non-functional pituitary adenomas, functional adenomas did not split into subgroups. A total of 200 patients treated with pituitary adenoma were included. In Knosp Grade 0 – 2 group, primary surgeon’s opinion and IO-MRI findings were compatible in 150 patients (98.6%). In Knosp Grade 3 – 4 correct prediction were performed in 32 (66.6%) patients. When incorrectly predicted Knosp Grade 3 – 4 patients (n = 16) was analyzed, in 13 patients there were still residual tumor in cavernous sinus and in 3 patients there were no residual tumor. Fisher’s exact test showed there is a statistically significant difference of correct prediction between two different Knosp Grade groups (two-tailed P < 0.0001). Eighteen patients had a residual tumor extending to the suprasellar and parasellar regions which second most common site for residual tumor. Our findings demonstrate that there is no need of IO-MRI scan while operating adenomas limited in the sellae and not invading the cavernous sinus. However, we strongly recommend IO-MRI if there is any suprasellar and parasellar extension and/or cavernous sinus invasion.

3D Printing-Assisted Skull Base Tumor Surgeries: An Institutional Experience.

Three-dimensional (3D) printing technology in neurosurgery has gained popularity nowadays. Skull base contains many major neurovascular structures in a confined space, along with anatomical variations making surgical approaches to this region challenging. 3D-printed model of skull base tumors consists of the patient's bony skull base, actual tumor dimensions, and surrounding major neurovascular structures. We included a total number of five patients with skull base tumors (one case of planum sphenoidale meningioma, two cases of sellar tumor with suprasellar extension, and two cases of cerebellopontine angle tumor) and 3D-printed tumor model of each of them. These models were used for preoperative simulation and served as very true to life training tool. These help in increasing the efficacy of the surgeon, improves surgical safety and ergonomics. They were also used for patient counselling, educating about the disease, the surgical procedure, and associated risks.

Magnetic Resonance Imaging (MRI) Evaluation of Sellar Region Tumors with Histopathological Correlation

MRI is a complex, rapidly evolving modality which has assumed an increasingly important role in the diagnosis of Sellar region tumors. It is now the preferred modality for the definitive evaluation and follow-up of the most sellar region tumors. Using different pulse sequence small lesion can be detected even without contrast. Gd-DTPA provides valuable information in MR imaging sellar region tumors, particularly in pre-operative evaluation. This study was conducted to elucidate the accuracy of MRI in pre-operative evaluation of sellar region tumors and its validity by determining sensitivity, specificity, positive and negative predictive value with histopathological correlation. This cross sectional observational study was carried out in the department of radiology and imaging in collaboration with department of Neurosurgery, Dhaka Medical college Hospital, Dhaka during the period of January 2008 to April 2009. MRI of brain was done on 42 patients referred for evaluation of sellar region tumors. The following result and observation were obtained. The age range of the patient was 20 to 80 years. The mean age (HSE) was 34.31(+2.80). Maximum patients were in age group 20-30 years and male-female ratio was 1.8:1. Most sellar region tumor located in the intrasellar with suprasellar extension. Out of 42 patients 37 (88%) patients were truly diagnosed by MRI as sellar region tumors. The sensitivity of MRI to diagnosed macro adenoma was 81.25%, specificity 80.76%, positive predictive value 72.2%, negative predictive value 87.5%, accuracy 80.95%. This study finds that MRI is a valid imaging modality in the diagnosis of pituitary adenoma and sellar region tumor.&#x0D; Bangladesh Med J. 2020 Sept; 49(3) : 1-10

Determinants of Surgical Remission in Prolactinomas: A Systematic Review and Meta-Analysis

Prolactin-secreting tumors respond well to medical management, with a few patients requiring surgery. We conducted a systematic review and meta-analysis to study the determinants of surgical remission in these tumors. We searched PubMed to identify eligible studies reporting postoperative remission in patients treated with transsphenoidal surgery for prolactinoma. Primary outcomes included postoperative remission, follow-up remission, and recurrence. Postoperative and follow-up remission were defined as normoprolactinemia at <1 year and >1 year after operation, respectively. Recurrence was defined as hyperprolactinemia after initial normalization of prolactin levels. Odds ratios (ORs) were calculated, stratified by radiologic size, tumor extension, and tumor invasion, and analyzed using a random-effects model meta-analysis. Thirty-five studies were included. Macroadenomas were associated with lower rates of postoperative remission (OR, 0.20; 95% confidence interval [CI], 0.16-0.24) and lower rates of remission at follow-up (OR, 0.11; 95% CI, 0.053-0.22). Postoperative remission was less likely in tumors with extrasellar or suprasellar extension (OR, 0.16; 95% CI, 0.06-0.43) and tumors with cavernous sinus invasion (OR, 0.03; 95% CI, 0.01-0.13). Female gender and absence of preoperative dopamine agonist treatment were also associated with higher remission rates. Across the included studies, there was considerable heterogeneity in each primary outcome (postoperative remission, I2= 94%; follow-up remission, I2= 86%; recurrence, I2= 68%). Transsphenoidal surgery for prolactinomas may be particularly effective in small, noninvasive, treatment-naive tumors and may provide a viable first-line alternative to dopamine agonist therapy in such patients.

Identification of the Extradural and Intradural Extension of Pituitary Adenomas to the Suprasellar Region: Classification, Surgical Strategies, and Outcomes.

ObjectiveSuprasellar pituitary adenomas (PAs) can be located in either extradural or intradural spaces, which impacts surgical strategies and outcomes. This study determined how to distinguish these two different types of PAs and analyzed their corresponding surgical strategies and outcomes.MethodsWe retrospectively analyzed 389 patients who underwent surgery for PAs with suprasellar extension between 2016 to 2020 at our center. PAs were classified into two main grades according to tumor topography and their relationships to the diaphragm sellae (DS) and DS-attached residual pituitary gland (PG). Grade 1 tumors were located extradurally and further divided into grades 1a and 1b, while grade 2 tumors were located intradurally.ResultsOf 389 PAs, 292 (75.1%) were surrounded by a bilayer structure formed by the DS and the residual PG and classified as grade 1a, 63 (16.2%) had lobulated or daughter tumors resulting from the thinning or absence of the residual PG and subsequently rendering the bilayer weaker were classified as Grade 1b, and the remaining 34 (8.7%) PAs that broke through the DS or traversed the diaphragmic opening and encased suprasellar neurovascular structures were classified as Grade 2. We found that the gross total removal of the suprasellar part of grade 1a, 1b, and 2 PAs decreased with grading (88.4%, 71.4%, and 61.8%, respectively). The rate of major operative complications, including cerebrospinal fluid leakage, hemorrhage, and death, increased with grading.ConclusionsIt is essential to identify whether PAs with suprasellar extension are located extradurally or intradurally, which depends on whether the bilayer structure is intact. PAs with an intact bilayer structure were classified as grade 1. These were extradural and usually had good surgical outcomes and lower complications. PAs with no bilayer structure surrounding them were classified as grade 2. These were intradural, connected to the cranial cavity, and had increased surgical complications and a lower rate of gross total removal. Different surgical strategies should be adopted for extradural and intradural PAs.

Primary Endoscopic Endonasal Management of Giant Pituitary Adenomas: Outcome and Pitfalls from a Large Prospective Multicenter Experience.

Simple SummaryGiant pituitary adenomas are highly invasive tumors whose treatment is challenging. Surgery is their management mainstay. However, there is no consensus about the type of approach. Open transcranial, microscopic, and endoscopic trans-sphenoidal approaches have all been employed, alone or in combination. Extended endoscopic endonasal techniques may represent a versatile and safe one-stage approach. Our research aimed at evaluating prospectively their applicability, effectiveness, and safety in a multicenter series, to acquire further evidence toward its use in the treatment of those challenging lesions. Ninety-six patients were recruited and followed-up for 52.4 months on average. Most of them (81.2%) presented with visual deficits and >50% had various degrees of adenohypophysis insufficiency. Resection of at least 75% of initial volume was achieved in all cases, with 98.7% visual improvement, >50% endocrine deficit recovery and a permanent complication rate of 4.2%, indicating extended endoscopic endonasal approaches as a valuable treatment option.Purpose: To evaluate factors influencing clinical and radiological outcome of extended endoscopic endonasal transtuberculum/transplanum approach (EEA-TTP) for giant pituitary adenomas (GPAs). Methods: We recruited prospectively all consecutive GPAs patients undergoing EEA-TTP between 2015 and 2019 in 5 neurosurgical centers. Preoperative clinical and radiologic features, visual and hormonal outcomes, extent of resection (EoR), complications and recurrence rates were recorded and analyzed. Results: Of 1169 patients treated for pituitary adenoma, 96 (8.2%) had GPAs. Seventy-eight (81.2%) patients had visual impairment, 12 (12.5%) had headaches, 3 (3.1%) had drowsiness due to hydrocephalus, and 53 (55.2%) had anterior pituitary insufficiency. EoR was gross or near-total in 46 (47.9%) and subtotal in 50 (52.1%) patients. Incomplete resection was associated with lateral suprasellar, intraventricular and/or cavernous sinus extension and with firm/fibrous consistence. At the last follow-up, all but one patient (77, 98.7%) with visual deficits improved. Headache improved in 8 (88.9%) and anterior pituitary function recovered in 27 (50.9%) patients. Recurrence rate was 16.7%, with 32 months mean recurrence-free survival. Conclusions: EEA-TTP is a valid option for GPAs and seems to provide better outcomes, lower rate of complications and higher EoR compared to one- or multi-stage microscopic, non-extended endoscopic transsphenoidal, and transcranial resections.