Surgical Treatment Of Pituitary Adenomas Research Articles

Association between county-level socioeconomic status and the incidence of and surgical treatment for pituitary adenoma.

The objective of this study was to evaluate the association between county-level socioeconomic status (SES) and the incidence of and surgical treatment for pituitary adenoma (PA). Using the Centers for Disease Control and Prevention's National Program of Cancer Registries and the National Cancer Institute's Surveillance, Epidemiology, and End Results database, the authors identified the average annual age-adjusted incidence rates and calculated odds ratios (ORs) for surgical treatment of PA, stratified by a county-level index for SES, race/ethnicity, metropolitan status, and other confounders. From 2006 to 2018, 167,121 PA cases were identified. There was no significant trend in the incidence of PA by county-level SES overall (incidence rate ratio [IRR] 0.98, 95% CI 0.96-1.00, p = 0.05, comparing highest to lowest quintile of SES). Among Asian or Pacific Islander (API; IRR 0.82, 95% CI 0.71-0.95, p = 0.007) and American Indian/Alaska Native (AIAN) participants (IRR 0.82, 95% CI 0.71-0.95, p = 0.009), the incidence of PA was statistically significantly lower with higher SES, while among Black individuals, the incidence of PA was higher with higher SES (IRR 1.10, 95% CI 1.05-1.15, p < 0.001, comparing 5th to 1st quintile of SES). Higher SES quintile was associated with surgical treatment of PA (OR 1.04, 95% CI 0.99-1.09, comparing highest to lowest quintile, p value for trend = 0.02). Males were more likely than females to undergo surgery (OR 1.50, 95% CI 1.47-1.53, p < 0.001), and Black (OR 0.89, 95% CI 0.86-0.91, p < 0.001) and AIAN individuals (OR 0.88, 95% CI 0.78-0.99, p = 0.04) were less likely to undergo surgery than White individuals, whereas API individuals were more likely to undergo surgery (OR 1.15, 95% CI 1.09-1.21, p < 0.001). Higher county-level SES in the US was associated with a higher incidence of PA among Black individuals, but not among White individuals, while API and AIAN individuals had a lower PA incidence with higher SES. After multivariable adjustment, higher county-level SES was associated with surgical treatment of PA, and White and API individuals were significantly more likely to undergo surgery than Black or AIAN individuals.

A Preoperative Nomogram for Prediction of Postoperative Hypocortisolism in Patients with Pituitary Adenomas: A Single-Center Retrospective Cohort Study

Patients with pituitary adenomas (PAs) are at an increased risk preoperatively and postoperatively for hypopituitarism. Postoperative hypocortisolism is associated with increased mortality and morbidity as well as poor quality of life. However, research about the risk factors for postoperative hypocortisolism is limited, and a predictive nomogram for postoperative hypocortisolism has not yet been developed. We aimed to investigate the predictive factors for postoperative hypocortisolism and construct a dynamic online nomogram. Our database included 438 consecutive PA patients who were hospitalized and treated with transsphenoidal surgery by experienced neurosurgeons from the different medical teams in the Neurosurgery Department, Jinling Hospital, between January 2018 and October 2020. The final study group included 238 eligible patients. Data on possible predictors, including age, sex, treatment history of PAs, preoperative signs and symptoms, primary recurrence subtype, and clinical subtypes, were collected. Univariable and multivariable logistic regression analyses were applied to identify independent predictors, which were included in constructing the nomogram model. The calibration curve and receiver operating characteristic curve were computed to evaluate the predictive performance of the nomogram model. The incidence of postoperative hypocortisolism was 12.08%. Three preoperative predictors were identified to construct the nomogram: surgical type (microscopic or endoscopic, with endoscopic surgery proven to be the protective factor) (odds ratio, 0.24; 95% confidence interval [CI], 0.093-0.610; P= 0.003), prothrombin time (odds ratio, 2.40; 95% CI, 1.332-4.326; P= 0.004), and basophil cell count (odds ratio, 5.25; 95% CI, 1.270-21.816; P= 0.022,). The area under the curve of receiver operating characteristic curve for the constructed nomogram was 0.749 (95% CI, 0.640-0.763); a well-fixed calibration curve was generated for the nomogram model. An interactive web-based dynamic nomogram application was also constructed. In this study, surgical type, prothrombin time, and basophil cell count were the most relevant predictive factors for postoperative hypocortisolism. A predictive nomogram that can preoperatively assess the risk of hypocortisolism after surgical treatment of PAs was developed. This nomogram could be helpful in identifying high-risk patients who require close monitoring of serum cortisol levels and initiating clinical procedures for patients requiring cortisol administration therapy as a lifesaving strategy.

Acromegaly in the differential diagnosis of hearing loss

Acromegaly is a multifactorial neuroendocrine disease caused by hyperproduction of growth hormone (GH). In more than 95% of cases the reason of acromegaly the GH-secreting pituitary adenoma. In patients with this neuroendocrine disease, a slowly developing complex of symptom can manifest with concomitant pathological conditions, including auditory function disordersDiagnostic difficulties of acromegaly at the ambulatory stage determine the importance of doctor`s awareness in different medical specialties.Here we demonstrate a clinical case of the improvement of the auditory function due to combined surgical and medical treatment of a patient with the pituitary macroadenoma, acromegaly and hearing loss.Anamnesis features: a patient with an active stage of acromegaly and a pituitary macroadenoma measuring 57x35x32 mm with ante-, supra-, infra-, parasellar spread, (Knosp III(D), Knosp IV(S) noted a violation of auditory function. She was consulted by an otolaryngologist, sensorineural hearing loss on the right of the 3rd degree was diagnosed, on the left of the 1st degree. The patient underwent surgical treatment of pituitary adenoma, noted a significant improvement in auditory function in the early postoperative period. Six months later, repeated audiometry was performed, marked regression of hearing damage was noted.The case described by us indicates the reversibility of a rare complication of acromegaly - hearing loss and the importance of an interdisciplinary approach in the management of patients with this pathology.

Успешный исход беременности и родов после хирургического лечения аденомы гипофиза в I триместре (клиническое наблюдение)

The authors present a clinical case of partial hypopituitarism developed in a 31-year-old patient during the first trimester of pregnancy after the surgical treatment of hemorrhagic pituitary adenoma. The onset of the diseases was recorded on the 12th week of pregnancy and was characterized by such specific clinical manifestations as severe headache, multiple spells of vomiting, diplopia and right-sided ptosis. The contrast-enhanced MRI revealed a pituitary adenoma with a "fresh" hemorrhage and the destruction of anterior wall and floor of the sella turcica, and the invasion into the sphenoid and right cavernous sinuses. The patient underwent emergency surgery – the endoscopic endonasal approach for total resection of pituitary adenoma. Hypopituitarism manifestations identified in the postoperative period were relieved by hormone replacement therapy. A timely diagnosis and prompt decision on the surgical treatment of pituitary adenoma, as well as a multidisciplinary team approach to patient care ensured the appropriate management of the underlying disease, successful pregnancy, childbirth outcome and high maternal quality of life. KEYWORDS: pituitary adenoma, pregnancy, management practices, hemorrhage, pituitary apoplexy, hypopituitarism, surgical treatment. FOR CITATION: Barakina O.V., Markova T.N., Ismailova S.G. et al. Successful pregnancy and delivery outcome after the surgical treatment of pituitary adenoma in the first trimester of pregnancy (a clinical case). Russian Journal of Woman and Child Health. 2022;5(4):326–331 (in Russ.). DOI: 10.32364/2618-8430-2022-5-4-326-331.

Development of a preoperative index-based nomogram for the prediction of hypokalemia in patients with pituitary adenoma: a retrospective cohort study.

ObjectiveTo develop and validate a preoperative index-based nomogram for the prediction of hypokalemia in patients with pituitary adenoma (PA).MethodsThis retrospective cohort study included 205 patients with PAs between January 2013 and April 2020 in the Sun Yat-sen Memorial Hospital, Guangzhou, China. The patients were randomly classified into either a training set (N = 143 patients) and a validation set (N = 62 patients) at a ratio of 7:3. Variables, which were identified by using the LASSO regression model were included for the construction of a nomogram, and a logistic regression analysis was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs) in the training set. The area under the curve (AUC) was used to evaluate the performance of the nomogram for predicting hypokalemia. Multivariate logistic regression analysis with a restricted cubic spline analysis was conducted to identify a potential nonlinear association between the preoperative index and hypokalemia.ResultsThe incidence of hypokalemia was 38.05%. Seven preoperative indices were identified for the construction of the nomogram: age, type of PA, weight, activated partial thromboplastin time, urea, eosinophil percentage, and plateletocrit. The AUCs of the nomogram for predicting hypokalemia were 0.856 (95% CI [0.796–0.915]) and 0.652 (95% CI [0.514–0.790]) in the training and validation sets, respectively. Restricted cubic splines demonstrated that there was no nonlinear association between hypokalemia and the selected variables.ConclusionIn this study, we constructed a preoperative indices-based nomogram that can assess the risk of hypokalemia after the surgical treatment of pituitary adenomas. This nomogram may also help to identify high risk patients who require close monitoring of serum potassium.

Results of Endoscopic Surgery in Patients with Pituitary Adenomas : Association of Tumor Classification Grades with Resection, Remission, and Complication Rates.

ObjectiveThe endoscopic endonasal transsphenoidal approach is a widely-used method for the surgical treatment of pituitary adenomas. We aimed to evaluate the results of endoscopic surgery by comparing preoperative classification methods and investigating their relationship with postoperative resection and remission rates and complications. MethodsWe retrospectively reviewed the medical records of 236 patients (118 males) who underwent surgery for pituitary adenomas. Preoperative Knosp classification, tumor size (TS), suprasellar extension (SSE), postoperative resection and remission rates, and complications were evaluated. ResultsThe follow-up period was 3 months to 6 years. The patients’ ages ranged between 16 and 84 years. Endocrinologically, 114 patients (48.3%) had functional adenoma (FA), and 122 patients (51.7%) had non-functional adenoma (NFA). Among the FA group, 92 (80.7%) showed remission. A statistically significant difference was found between patients with and without remission in terms of the Knosp, TS, and SSE classifications (p<0.01). Knosp, TS, and SSE classification grades were found to be correlated with the resection rates (p<0.01). Meningitis was seen in seven patients (3.0%), diabetes insipidus in 16 (6.9%; permanently in two [0.9%]), and rhinorrhea in 19 (8.1%). Thirty-six patients (15.3%) developed pituitary insufficiency and received hormone replacement therapy. ConclusionThe resection categories and remission rates of FAs were directly proportional to the adenoma sizes and Knosp grades, while the degree of suprasellar growth further complicated resection and remission rates. Adenoma sizes less than 2 cm and SSEs less than 1 cm are associated with favorable remission and resection rates.

Ultrasound Doppler examination in the surgical treatment of pituitary adenomas with cavernous sinus extension

Objective: To determine the effectiveness of intraoperative Doppler ultrasound in the surgical treatment of pituitary adenomas with invasive parasellar growth into the cavernous sinus Knosp 3 and Knosp 4. Material and Methods. During 2009–2017, 71 patients with pituitary adenomas (PA) with extension into the cavernous sinus Knosp 3 and Knosp 4 were retrospectively reviewed. According to the size PA were divided into pituitary macroadenomas, (from 10 to 40 mm) in 45 (63.4%) patients, and giant PA (over 40 mm) – in 26 (36.6%) patients. Cavernous sinus invasion Knosp 3 and 4 was identified in 47 (66.2%) and 24 (33.8%) patients respectively. Non-secreting PA - 43 (60.5%) patients and hormone-secreting PA - 28 patients (39.4%). Endoscopic endonasal trassphenoidal (EET) approach was used in all cases. Laterally expanded EET (LEEET) approach was used in 29 cases. Intraoperative Doppler ultrasound (IDUS) was used in 36 (51%) cases. Results. Intraoperative Doppler ultrasound was used in cases of Knosp 3 extension in 23 (32.4%) cases and in Knosp 4 - in 13 (18.3%) cases. Gross total resection, including extension into the cavernous sinus using IDUS was achieved in 22 (62.7%) patients. In cases where IDUS was not used, gross total resection was achieved in 19 (52.7%) cases. In cases where the IDUS was not used, recurrence rate was 7.3%, with IDUS - 5%. Biochemical remission was achieved in 22 (78.6%) cases. Liquorrhea nasalis after surgery was observed in 6 (8.4%) cases, meningoencephalitis - in 1 (1.4%) case, oculomotor palsy -3 (4.2%) cases. Conclusions. Intraoperative Doppler ultrasound is an informative method that provides safe resection of pituitary adenomas with cavernous sinus extension with a low level of possible postoperative complications. Parasellar extension of Pituitary adenomas into the cavernous sinus Knosp 4 significantly reduces the possibility of gross total resection. However, the use of intraoperative ultrasound makes it possible to determine safe boundaries for manipulation both medially and laterally from the internal carotid artery, increasing the level of radicality and the duration of clinical remission. Intraoperative Doppler ultrasound during endoscopic endonasal transsphenoidal surgery of pituitary adenomas with parasellar extension allows to identify the internal carotid artery in the tumor stroma with the existing changed skull base anatomy. Dura incision under intraoperative Doppler ultrasound reduces the risk of internal carotid artery injury.

Morphological Aspects of Acute Renal Injury in Cardiac Surgery

Summary. The use of endoscopic transsphenoidal access is an effective and safe method for the surgical treatment of pituitary adenomas (PA). In endoscopic transsphenoidal surgeries, there is a need to control intracranial pressure (ICP) for reposition and expansion of the tumor capsule. Currently, the main method for reducing ICP in transsphenoidal surgery is installation of an external lumbar drainage, which is associated with a number of complications.Aim of study. To improve the results of surgical treatment of patients with arterial hypertension using hypertonic saline solution.Material and methods. A clinical and anatomical analysis of material from 27 deceased patients who were treated in the cardiac surgery department of the Institute was carried out. Valve replacement was performed in 11 patients, aortic replacement - 2, valves and aorta - 7, combined operations - 7. The patient’s records, autopsy protocols, results of histological examination of surgical and autopsy material were studied. Already on the next day after surgery, an increase in serum creatinine by more than 25% was noted under the conditions of CBR. Morphological examination of the kidneys revealed acute pathological processes - necrosis of nephrocytes of the convoluted tubules in 59.3% of cases and dystrophic changes in 40.7% of cases against the background of chronic pathology (nephrosclerosis, vascular atherosclerosis, glomerulosclerosis, pyelonephritis, secondary contracted kidney). After coronary angiography with a radiopaque contrast agent (RCA), signs of excretory nephrosis were noted, often with fixation of the RCA in the loop of Henle, with tubulorexis and the formation of cell casts.

Efficacy of Hypertonic Saline Solution to Achieve Persistent Intraoperative Intracranial Hypotension in Endoscopic Endonasal Transsphenoidal Surgery

Abstract. The use of endoscopic transsphenoidal access is an effective and safe method for the surgical treatment of pituitary adenomas (PA). In endoscopic transsphenoidal surgeries, there is a need to control intracranial pressure (ICP) for reposition and expansion of the tumor capsule. Currently, the main method for reducing ICP in transsphenoidal surgery is installation of an external lumbar drainage, which is associated with a number of complications.Aim of study. To improve the results of surgical treatment of patients with hypertension using hypertonic saline solution (HSS).Material and methods. The study included 89 patients, who were devided into two groups: Group A — control group (n=25), where the lumbar drainage was installed for invasive intraoperative measurement of the dynamics of ICP parameters at the main stages of the operation (HSS was not administered in these patients); Group B — study group (n=64), where the efficacy of non­invasive regulation of the tumor capsule position using intravenous HSS was assessed, in addition, lumbar drainage was installed in 25 patients of group B, as well as in group A, for invasive measurement of ICP (the dynamics of ICP changes at the main stages of the operation was measured), and the dynamics of changes in the electrolyte composition of the plasma during the first days after the administration of the HSS was monitored as well.Results. In Group B, there was a more significant decrease in ICP in the course of HSS (on average by 22.49 mm Hg) compared to Group A, where the decrease in ICP was 14.23–8,46 mm Hg (from 13.62±1.36 mm Hg, p&lt;0.05). After intravenous administration of HSS, the plasma composition changed as expected (the concentrations of Na+ and Cl­ increased on average to 150±0.71 mmol/L and 118.3±1.06 mmol/L, respectively, which slightly exceeded the average statistical norm, K + slightly decreased within the average statistical norm), during the first day there was a normalization of the above laboratory parameters .This technique was used to obtain patent No. 2669924 “A method for regulating the position of a tumor capsule in endoscopic transsphenoidal surgery of pituitary adenoma”.Conclusion. The use of HSS is a safe non­invasive technique for expansion of the tumor capsule during operations to remove pituitary adenomas using transsphenoidal endoscopic access. It should be noted that this method is most appropriate in situations not associated with the risk of developing intraoperative liquorrhea.

Defining the timing and role of acute postoperative imaging in pituitary adenoma surgery: clinical study.

The ideal timing of postoperative imaging after pituitary adenoma surgery has yet to be determined. We reviewed our pituitary database to determine whether timing of routine postoperative imaging has significantly changed patients' clinical course or outcomes. Retrospective chart review of patients undergoing resection of pituitary adenoma at our university center between 2012 and 2017 was performed. Timing and indication for postoperative imaging, findings of immediate and delayed postoperative imaging, as well as re-operations and radiosurgery details were recorded. Visual functions such as acuity and visual fields were used as clinical outcome indicators. Statistical analysis was run using Microsoft Excel. Five hundred and nineteen patients were identified; 443 had imaging data in our system and were included in the study. Early (< 90 days) MRIs were obtained in 71 patients and late (≥ 90 days) in 372 patients. We found statistical differences in our demographic groups including larger tumors in the early MRI group (early mean 12.33 cm3, late mean 4.64 cm3, p < 0.001) and higher Knosp grade (p = 0.0006). We found a significant difference in rates of return to the OR (16.9% in the early group and 4.84% in the late group; p < 0.001). There was a significant difference in the rate of residual identified on first postoperative MRI: 52.11% in the early group and 29.57% in the late group (p < 0.001). There was no difference in visual outcomes between the patient cohorts. After surgical treatment of pituitary adenoma, MRI obtained before 3 months is associated with higher rates of return to OR but no difference in long-term clinical outcomes. Due to cost efficiency, we argue for a delayed first postoperative MRI. The timing of MRI should also be governed by other factors such as large pituitary macroadenomas or postoperative complications. We recommend a consistent institutional protocol for determining the most cost-effective follow-up of postoperative pituitary patients.

P.055 Epidemiologic features of pituitary adenoma patients requiring surgical treatment: large North American patient population based study

Background: The surgical treatment of pituitary adenoma has evolved greatly over the decades. In order to better understand the patient population and their surgical treatment, we conducted an institutional review for pituitary adenoma surgery using the endoscopic endonasal trans-sphenoidal (EETS) approach. Methods: A retrospective review of all EETS cases for pituitary tumor resection was performed between November 2009 and June 2016. Patient characteristics, tumor type, endocrine data, operation characteristics were extracted from medical records. Preoperative MRI images were reviewed. The SIPAP classification was applied to the pituitary tumors. Postoperative patient data were extracted for the available follow-up period. Results: 232 cases were identified. Functional tumors were present in 29% of the cohort. Complete excision was most common for functioning tumors (49%) compared to nonfunctioning tumors (26%). There were no major vascular injuries. Hormone replacement with cortisol was required transiently in 70% of patients, with thyroid hormone replacement occurring in 40% of the cohort. Conclusions: From this large North American cohort nearly 30% of operated pituitary tumors were functioning. More commonly, these tumors were completely resected compared to the nonfunctioning group. The most commonly replaced hormone following EETS surgery was cortisol and this was largely transient.

Endonasal endoscopic surgery in pituitary adenomas: Surgical results in a series of 86 consecutive patients

IntroductionThe endoscopic endonasal approach has become the gold standard for the surgical treatment of pituitary adenomas. ObjectivesThe aim of this study is to present the results obtained in our hospital in purely endoscopic surgery of pituitary adenomas. MethodsFrom February 2011 to August 2016, we conducted a prospective study on a series of 86 patients with pituitary adenoma, all of whom underwent surgery with a purely endoscopic endonasal approach. The ‘four hands-two nostrils’ technique was performed in all cases by a surgical team composed of an ENT surgeon and a neurosurgeon. Mean follow-up was 32 months. All patients were evaluated according to clinical, radiological and endocrinological criteria. ResultsIn our series, 53% were women and 47% men. The age ranged from 14 to 84 years of age, with a mean of 54 years of age. The most common initial symptom was visual deficit (42%), followed by hormonal hyperfunction (21%), with acromegaly being the most common clinical syndrome. The most common tumours were non-functioning tumours (73%), while GH-secreting tumours (65%) were the most common functioning adenoma. Regarding tumour size, 76% were macroadenomas, 11% microadenomas and 13% giant adenomas. Approximately 63% of the adenomas exhibited suprasellar extension and 37% involved invasion of the cavernous sinus (Knosp grade ≥3). Total excision was achieved in 77% of the cases. After the intervention, visual improvement was achieved in 91% and remission of endocrine hyperfunction in up to a 73% of cases. The most common complication was anterior pituitary insufficiency of at least one axis (9%). There were no cases of postoperative cerebrospinal fluid fistula. ConclusionsIn terms of surgical quality, our results are similar to those of published series, and demonstrate the efficacy and safety of the endoscopic endonasal approach as the surgical treatment of choice for pituitary adenomas. However, further studies with a higher sample size are necessary to obtain clinically significant results.

Endoscopic Endonasal Trans-sphenoidal Approach: Minimally Invasive Surgery for Pituitary Adenomas.

Endoscopic endonasal trans-sphenoidal surgery has become the gold standard for the surgical treatment of pituitary adenomas and many other pituitary lesions. Refinements in surgical techniques, technological advancements, and incorporation of neuronavigation have rendered this surgery minimally invasive. The complication rates of this surgery are very low while excellent results are consistently obtained through this approach. This paper focuses on the step-by-step surgical approach to pituitary adenomas, which is based on personal experience, and details the results obtained with this minimally invasive surgery.

Endoscopic Endonasal Trans-sphenoidal Approach: Minimally Invasive Surgery for Pituitary Adenomas

Endoscopic endonasal trans-sphenoidal surgery has become the gold standard for the surgical treatment of pituitary adenomas and many other pituitary lesions. Refinements in surgical techniques, technological advancements, and incorporation of neuronavigation have rendered this surgery minimally invasive. The complication rates of this surgery are very low while excellent results are consistently obtained through this approach. This paper focuses on the step-by-step surgical approach to pituitary adenomas, which is based on personal experience, and details the results obtained with this minimally invasive surgery.

The specific features of endonasal transsphenoidal approach in surgical treatment of pituitary adenoma

Benign pituitary gland tumors (or adenomas) constitute the vast majority of all chiasmosellar tumors. There are various approaches in surgical treatment of the sella turcica pathology. Endonasal transsphenoidal approach is the method of preference. Choosing the approach to the skull base, the surgeon should carefully study the results of magnetic resonance imaging and computer-aided tomography. If there are anatomic features preventing the approach to the operated area, first of all the patient undergoes the correction of these structures. The surgical excision of pituitary adenoma through endonasal access is conditionally divided into three stages: nasal, sphenoidal and sellar. The final stage of surgical treatment is the stage-by-stage plastic surgery of the bottom of sella turcica with the layer-by-layer implantation of glue compositions and sealing the intracranial space. 12 patients diagnosed with pituitary adenoma with infra- and suprasellar growth were examined at the Chairs of Otorhinolaryngology and Neurosurgery with the participation of cytological laboratories. All the patients were examined by an otorhinolaryngologist on the 7th, 30th and 90th days after surgery. Endoscopic visualization of the surgical intervention area was performed and cytological examination of the nasal cavity secretion was made at the indicated time intervals. Therefore, it has been found that the reactive inflammatory phenomena associated with irrigation therapy were stopped by the 30th-40th day after the surgery. In 8 patients the treatment was supplemented with local antibacterial therapy, which provided the removal of the reactive inflammatory phenomena in the surgical intervention area. Therefore, all patients after endonasal transsphenoidal removal of pituitary adenoma are recommended the 30-day otorhinolaryngologists’ follow-up with the purpose of control of regeneration processes dynamics.

Identification and repair of intraoperative cerebrospinal fluid leaks in endonasal transsphenoidal pituitary surgery: surgical experience in a series of 1002 patients.

OBJECTIVE Cerebrospinal fluid (CSF) rhinorrhea is among the most common complications following transsphenoidal surgery for sellar region lesions. The aim of this study was to review the authors' institutional experience in identifying, repairing, and treating CSF leaks associated with direct endonasal transsphenoidal operations. METHODS The authors performed a retrospective review of cases involving surgical treatment of pituitary adenomas and other sellar lesions at the University of Southern California between December 1995 and March 2016. Inclusion criteria included all pathology of the sellar region approached via a direct microscopic or endoscopic endonasal transsphenoidal approach. Demographics, pathology, intraoperative and postoperative CSF leak rates, and other complications were recorded and analyzed. A literature review of the incidence of CSF leaks associated with the direct endonasal transsphenoidal approach to pituitary lesions was conducted. RESULTS A total of 1002 patients met the inclusion criteria and their cases were subsequently analyzed. Preoperative diagnoses included pituitary adenomas in 855 cases (85.4%), Rathke's cleft cyst in 94 (9.4%), and other sellar lesions in 53 (5.2%). Lesions with a diameter ≥ 1 cm made up 49% of the series. Intraoperative repair of an identified CSF leak was performed in 375 cases (37.4%) using autologous fat, fascia, or both. An additional 92 patients (9.2%) underwent empirical sellar reconstruction without evidence of an intraoperative CSF leak. Postoperative CSF leaks developed in 26 patients (2.6%), including 13 (1.3% of the overall group) in whom no intraoperative leak was identified. Among the 26 patients who developed a postoperative CSF leak, 13 were noted to have intraoperative leak and underwent sellar repair while the remaining 13 did not have an intraoperative leak or sellar repair. No patients who underwent empirical sellar repair without an intraoperative leak developed a postoperative leak. Eight patients underwent additional surgery (0.8% reoperation rate) for CSF leak repair, and 18 were successfully treated with lumbar drainage or lumbar puncture alone. The incidence of postoperative CSF rhinorrhea in this series was compared with that in 11 other reported series that met inclusion criteria, with incidence rates ranging between 0.6% and 12.1%. CONCLUSIONS In this large series, half of the patients who developed postoperative CSF rhinorrhea had no evidence of intraoperative CSF leakage. Unidentified intraoperative CSF leaks and/or delayed development of CSF fistulas are equally important sources of postoperative CSF rhinorrhea as the lack of employing effective CSF leak repair methods. Empirical sellar reconstruction in the absence of an intraoperative CSF leak may be of benefit following resection of large tumors, especially if the arachnoid is thinned out and herniates into the sella.

Observation on curative effect of two kinds of surgical methods of pituitary adenoma resection

Objective: To compare the clinical data of pituitary adenoma resection with pterional approach and transsphenoidal approach, to analyze its advantages and disadvantages, and to provide reference for clinical diagnosis and treatment. Methods: From March 2010 to March 2014, 54 patients with pituitary adenoma were randomly divided into microscopy pterional group (31 cases) and microscopy nasal sphenoid sinus group (23 cases). Using a microscope under the pterional approach and a single nasal sphenoid sinus approach to the surgical operation of the microscope. The results showed that the operation time, intraoperative blood loss, hospitalization time, effective resection rate and postoperative complications (mainly after a transient diabetes insipidus and transient electrolyte disorder) were observed. Hormone levels and the patient's 1-year follow-up results of the comparison. Results: There was no significant difference in the clinical data between the two groups. The average operative time (121.3 ± 19.4) min in the pterional group was significantly higher than that in the nasal sphenoid sinus group (78.5 ± 7.8) mL compared with the nasal sphenoid sinus group (50.3 ± 3.2) mL, statistically significant (P 0.05), and the postoperative complications (including one hyperthyroidism and transient electrolyte imbalance) occurred no significant difference. All patients 1 year follow-up results can be seen, the two groups of long-term efficacy are better. Comparison between different type of tumors showed that there were some changes when pterional pterional and transphenoidal pre-surgery and post-surgery, secretion of PRL are [(387.3 ± 100.8) ng / mL vs (145.3 ± 27.4) ng / mL] and [(390.2±133.7) ng/ml vs (148.4±57.2) ng/ml]、GH [(63.4±5.7) ng/ml vs (10.6±2.4) ng/ml] and [(65.6±6.2) ng/ml vs (12.4±1.6)ng/ml]、ACTH[(202.9±73.7)ng/l vs (38.5±4.6) ng/l] and [(206.8±78.6) ng/l vs (35.6±2.5) ng/l], the difference was significant (P 0.05). Conclusion: There is no significant difference in the curative effect of two groups of surgical treatment of pituitary adenoma. The operation time and operation blood loss of pituitary adenoma resection are superior to those of pterional infusion, which is minimally invasive, safe and effective, the clinical efficacy of the exact, worthy of further promotion.

Analysis of the clinical curative effect of neural endoscopic nasal adjustment surgical treatment for pituitary adenomas

Objective To explore the clinical curative effect of neural endoscopic nasal adjustment surgical treatment for pituitary adenomas. Methods The clinical data of 176 patients with pituitary adenoma were retrospectively analyzed.82 patients in group A used microscopic surgery treatment, 94 cases were treated by nerve endoscopic treatment(group B). The operation time, postoperative hospital stay time, the cutting rate, hormone levels, recovery rate and complications were compared between the two groups. Results In group A, the operation time, postoperative hospitalization time, the whole cut were (103.5±21.5)min, (7.8±1.1)d, 78 cases, those of group B were (109.1±25.8)min, (5.2±1.0)d, 91 cases, the operation time, whole cut of the two groups had no statistically significant differences(t=1.551, χ2=0.034, all P>0.05). The postoperative hospitalization time of group A was longer than that of group B, the difference was statistically significant(t=16.422, P 0.05). In group A, the transient diabetes insipidus, nasal symptoms, complications were higher than those in the control group, the differences were statistically significant(χ2=10.746, P 0.05). Conclusion Neural endoscopic nasal adjustment of surgical treatment of pituitary adenoma and the microscopic surgery has similar clinical curative effect, but has a lower incidence of complications and shorter postoperative hospital stay. Key words: Prolactinoma; Neuroendoscopy

Visual pathway impairment by pituitary adenomas: quantitative diagnostics by diffusion tensor imaging.

OBJECTIVE Despite ample experience in surgical treatment of pituitary adenomas, little is known about objective indices that may reveal risk of visual impairment caused by tumor growth that leads to compression of the anterior visual pathways. This study aimed to explore diffusion tensor imaging (DTI) as a means for objective assessment of injury to the anterior visual pathways caused by pituitary adenomas. METHODS Twenty-three patients with pituitary adenomas, scheduled for transsphenoidal tumor resection, and 20 healthy control subjects were included in the study. A minimum suprasellar tumor extension of Grade 2-4, according to the SIPAP (suprasellar, infrasellar, parasellar, anterior, and posterior) scale, was required for inclusion. Neuroophthalmological examinations, conventional MRI, and DTI were completed in all subjects and were repeated 6 months after surgery. Quantitative assessment of chiasmal lift, visual field defect (VFD), and DTI parameters from the optic tracts was performed. Linear correlations, group comparisons, and prediction models were done in controls and patients. RESULTS Both the degree of VFD and chiasmal lift were significantly correlated with the radial diffusivity (r = 0.55, p < 0.05 and r = 0.48, p < 0.05, respectively) and the fractional anisotropy (r = -0.58, p < 0.05 and r = -0.47, p < 0.05, respectively) but not with the axial diffusivity. The axial diffusivity differed significantly between controls and patients with VFD, both before and after surgery (p < 0.05); however, no difference was found between patients with and without VFD. Based on the axial diffusivity and fractional anisotropy, a prediction model classified all patients with VFD correctly (sensitivity 1.0), 9 of 12 patients without VFD correctly (sensitivity 0.75), and 17 of 20 controls as controls (specificity 0.85). CONCLUSIONS DTI could detect pathology and degree of injury in the anterior visual pathways that were compressed by pituitary adenomas. The correlation between radial diffusivity and visual impairment may reflect a gradual demyelination in the visual pathways caused by an increased tumor effect. The low level of axial diffusivity found in the patient group may represent early atrophy in the visual pathways, detectable on DTI but not by conventional methods. DTI may provide objective data, detect early signs of injury, and be an additional diagnostic tool for determining indication for surgery in cases of pituitary adenomas.

Surgical treatment of pituitary adenomas in childhood and adolescence

Objective: To investigate the clinical characteristics and treatment of pituitary adenomas of childhood and adolescence. Methods: Thisarticle was a retrospective study of 140 pituitary adenomas of childhood and adolescence that was admitted into Peking Union Medical College Hospital from December 1987 to December 2014, whose clinical manifestations, hormone secretions, images, pathological types, surgical complications and follow-ups were studied. Results: A total of 58 (41.4%) males and 82 females (58.6%) were included, whose mean age was 12.5 years old (age range from 7 to 18). As for the type of tumors, ACTH adenoma, PRL adenoma, GH adenoma, non-functional adenoma and multiple-secreting adenoma accounted for 35.7%, 25.7%, 12.2%, 25.7% and 0.7%, respectively. Microadenoma accounted for 33.6% of total patients, while macroadenoma and giant adenoma accounted for 60.0% and 6.4% respectively. 19.3% of adenomas in our study wereinvasive. Transsphenoidal approach surgery was commonly used and accounted for 97.9% of cases in our study, 2 of which used intraoperative navigation assistance. Total resection was achieved in 93.6% of patients, and the rest achieved subtotal resection. 108 (77.1%) patients got full term follow-up until 1 year after surgery, and tumor recurred in 14 patients (13.0%). Conclusions: ACTH-secreting adenoma is the most common pituitary adenoma in childhood and adolescence which need surgical treatment. Transsphenoidal approach surgery is the most commonly used surgical procedure. The recurrence rate is about 13%, and the patients need regular examination of pituitary hormones and image study to confirm the recurrence.