Radiologic follow-up of non-functioning pituitary adenomas: rationale and cost effectiveness.

Patients with non-functioning pituitary adenomas (NFPAs) are followed-up with serial endocrine, ophthalmologic and radiological assessment. There is a lack of evidence based guidance regarding the frequency and duration of radiological assessment during follow-up. We retrospectively analysed the details of follow-up radiological scanning in a cohort of patients diagnosed with NFPAs in an attempt to devise a rational and cost effective scanning schedule for use in routine clinical practice. 49 patients were identified using the hospital endocrine register. A detailed review of the case notes and follow up scans was undertaken. The data was analysed using descriptive statistics and Kaplan-Meier survival analysis using SPSS ver 13.0 (SPSS Inc. Chicago, IL). The time in which the tumor size in the followed up patients reached a state of 'no change' which persisted for at least two further scans was calculated. 41 patients, followed up for a median duration of 70 months were ultimately analysed. 33 patients had surgery while eight were conservatively managed. The time taken by 50% of tumors to achieve a steady state of 'no change' in tumor size on scans was 30 months. 90% of tumours achieved this state in 88 months. Surgical management did not significantly influence the time required to attain the steady state on a Kaplan-Meier analysis (Log rank test P = 0.06). NFPAs need extended follow-up since late recurrences after treatment are known. Routine radiologic follow up may be uneconomical after the steady state is achieved. Regular Goldmann perimetry beyond this time may be of greater use in selecting patients who actually need repeat surgical debulking. This method of follow up is likely to be more cost effective and reduce the number of scans performed.

Emergency head CT scans: can neurosurgical registrars be relied upon to interpret them?

Neurosurgical registrars are frequently called upon by A&E staff and physicians to interpret emergency head CT (computed tomography) scans out of hours. This appears to reflect the reduced threshold for scanning patients and the nonavailability of a radiologist to report these scans. This study was undertaken to assess the safety of such practices. Five neurosurgical registrars, blinded to each other and to the radiology reports, interpreted 50 consecutive emergency head CT scans (both trauma and nontrauma) from the hospital's imaging system as a pilot study. These were initially graded as normal or abnormal. Abnormal scans were assessed for the presence of an intracranial bleed, pneumocephalus, skull fractures, cerebral contusions, mass effect, midline shift, ischaemia or hydrocephalus. The agreement of the observers' recordings with the report issued or approved by a consultant radiologist was evaluated using SPSS Version 13.0. Four of the five registrars assessed a further 150 scans in a similar manner to complete the study. There was a good general agreement between the formal reports and the neurosurgical registrars' identification of normal scans (average Kappa 0.79). The radiology reports and the registrars also agreed well on the presence or absence of intracranial blood, contusions and pneumocephalus (Kappa value > 0.70). The agreement was poorer for ischaemia, mass lesions (other than intracranial haematomas), grey white differentiation, evidence of raised intracranial pressure and midline shift (Kappa < 0.5). Neurosurgical registrars compared well with radiologists when it came to assessing emergency head CT scans as normal or detecting a surgical lesion. The agreement was poorer on subtle abnormalities. The practice of neurosurgical registrars informally 'reporting' on emergency head CT scans cannot be recommended.

Abscess formation within a Rathke's cleft cyst.

We report and discuss the rare case of a pituitary abscess forming within a Rathke's cleft cyst (RCC). A 66-year-old gentleman presented with visual deterioration and symptoms suggestive of hypopituitarism. The patient underwent transsphenoidal debulking of the lesion whereupon purulent material was discovered. Histological examination was suggestive of RCC together with numerous neutrophils characteristic of abscess. Microbiological culture of the material grew Staphylococcus aureus. The patient was treated for a RCC abscess and received antibiotics and endocrine replacement therapy. The patient has been followed up for 2 years without recurrence. Although uncommon, we recommend the consideration of RCC abscess as a differential diagnosis of a pituitary mass lesion as clinical presentation and radiological assessment are not specific in identifying these lesions preoperatively.

Treating high grade gliomas in the elderly: the end of ageism?

Introduction Treating high grade gliomas in the elderly is a challenge for multidisciplinary teams. Most studies on this topic exclude patients aged >65 and a Karnofsky Performance Status (KPS) score of <70, a group most likely to have a poor outcome. We undertook this study to analyze the outcomes in a cohort of patients which included such patients. Methods Ours was a retrospective cohort study. About 71 consecutive patients with high grade gliomas, who were seen in the neurooncology clinic in 2004, were included. The case records of these patients were scrutinized for the demographic, clinical data, follow-up and survival. The cohort was divided into two groups; Age > or =65 and age <65 for analysis. The factors influencing survival were analyzed using the Cox's proportional hazards model in each group. Results In the age group > or =65 years, patients treated with a radical resection +/- adjuvant therapy had a lower risk of death (hazard ratio 0.14, 95%CI 0.04-0.51, P = 0.003) when compared to patients undergoing a biopsy +/- adjuvant therapy and palliative treatment. In the group <65 years, the greater the age, greater was the risk of death (hazard ratio 2.05, 95%CI 1.13-3.73, P = 0.01). The median survival was 12 months in the group <65 years and 5 months in age > or =65 years (P = 0.001). In the group > or =65 years, those patients who had radical resection +/- adjuvant treatment had a median survival of 7 months as compared to 3 months in the patients who had biopsy +/- adjuvant treatment (P = 0.003). KPS, presence of co-morbidities, duration of symptoms, location of the lesion and sex were not found to be significant independent predictors of survival in our study. Conclusions Age is an important predictor of survival in younger patients, however in the elderly treatment matters most. Elderly patients undergoing radical surgery +/- adjuvant treatment had a longer median survival as compared to the elderly patients undergoing a biopsy +/- adjuvant treatment. KPS was not found to be a significant independent predictor of survival probably because of underrepresentation of patients with poor KPS. Radical treatment should not be denied to elderly patients who are deemed fit as the outcome is significantly better.