Blood culture bottles for culturing cerebrospinal fluid in cases of bacterial meningitis caused by Enterococcus faecalis: A case report.

Pathogen identification is essential for the treatment of bacterial meningitis. However, cerebrospinal fluid (CSF) culture tests are often negative when antimicrobial agents are administered before CSF is collected. Therefore, it is necessary to improve the culturing process for such samples. Here, we report a case of bacterial meningitis where the causative bacteria were detected by inoculating that patient's CSF samples into blood culture bottles. A 52-year-old man developed a fever and headache after undergoing transnasal transsphenoidal surgery for a nonfunctioning pituitary neuroendocrine tumor. He was suspected of having a wound infection, for which he was treated with cefozopran and vancomycin. A CSF test was also performed, owing to persistent fever, and bacterial meningitis was suspected. Although conventional CSF culture tests were negative, CSF cultures using blood culture bottles detected Enterococcus faecalis. The antimicrobial agents were therefore changed to ampicillin and gentamicin, after which the patient's meningitis improved. The blood culture bottles used contained adsorbed polymer beads with antimicrobial neutralizing properties, which likely contributed to the isolation of the bacteria. In addition to conventional cultures, ones done in blood culture bottles may be useful for diagnosing bacterial meningitis via CSF samples-particularly in cases where antimicrobial agents have already been administered.

Optic tract edema in craniopharyngioma as a predictor of BRAFV600E mutation presence.

OBJECTIVE: the advent of BRAF inhibitors for preoperative treatment of craniopharyngioma has necessitated the identification of BRAFV600E status. Hence, we investigated predictors of BRAFV600E mutation in craniopharyngiomas. METHODS: this retrospective study utilized data from 30 patients who were newly diagnosed with craniopharyngioma between 2011 and 2021. Magnetic resonance imaging (MRI) and computed tomography were performed within 1 week prior to surgery. Genetic analysis for BRAF mutation was performed using the Oncomine next-generation sequencing panel or Sanger sequencing. The relationship between BRAF mutation and demographic data, endocrinological function and tumour characteristics on imaging was assessed. RESULTS: tumour tissue carried the BRAFV600E mutation in nine patients. There was no significant difference in age, sex, or presence of hormonal dysfunction amongst patients with and without the BRAFV600E mutation in the tumour. Most tumours with the BRAFV600E mutation were histologically categorized as papillary craniopharyngioma (P = 0.0005), and were solid (P = 0.0002) and supra-diaphragmatic (P = 0.0033) on MRI. BRAFV600E tumours were more frequently associated with optic tract edema than wild-type tumour s (55.6 vs. 0%, P = 0.0009) and all tumour s with optic tract edema carried the BRAFV600E mutation. Optic tract edema was not associated with tumour volume, cysts, or preoperative pituitary function. CONCLUSIONS: in craniopharyngiomas, the presence of optic tract edema can predict the presence of BRAFV600E mutation with a positive predictive value of 100%. The finding should be verified in larger prospective cohorts and multivariate regression analysis.

Characteristics and therapeutic strategies of brain and cranial radiation-induced sarcoma: analysis of 165 cases from our case experience and comprehensive review.

BACKGROUND: Radiation-induced sarcoma (RIS) is among the neoplasms potentially caused by radiation therapy (RT) for brain tumors. However, the clinical characteristics of and ideal treatment for RIS are unclear. We analysed our case experience and conducted a comprehensive literature review to reveal the characteristics of brain and cranial RIS. METHODS: We analysed 165 cases of RIS from the literature together with the RIS case treated at our institution. In each case, the latency period from irradiation to the development of each RIS and the median overall survival (OS) of the patients was analysed by Kaplan-Meier analysis. Spearman's correlation test was used to determine the relationship between the latency period and radiation dose or age at irradiation. RESULTS: The mean age at the development of RIS was 39.63 ± 17.84 years. The mean latency period was 11.79 ± 8.09 years. No factors associated with early development of RIS were detected. The median OS was 11 months, with fibrosarcoma showing significantly shorter OS compared with osteosarcoma and other sarcomas (p = 0.0021), and intracranial RIS showing a worse prognosis than extracranial RIS (p < 0.0001). Patients treated with surgery (p < 0.0001) and postoperative chemotherapy (p = 0.0157) for RIS presented significantly longer OS, whereas RT for RIS was not associated with a survival benefit. CONCLUSIONS: Although prognosis for RIS is universally poor, pathological characteristics and locations are associated with worse prognosis. Surgery and chemotherapy may be the ideal treatment strategies for RIS.

Differences in invasiveness and recurrence rate among nonfunctioning pituitary neuroendocrine tumors depending on tumor subtype.

PURPOSE: To clarify the invasiveness to surrounding structures and recurrence rate of each subtype of nonfunctioning pituitary neuroendocrine tumor (Pit-NETs) according to the WHO 2022 classification. METHODS: This retrospective study utilized data from 292 patients with nonfunctioning Pit-NETs treated with initial transsphenoidal surgery. Recurrence was evaluated on 113 patients who were available for a magnetic resonance imaging follow-up ≥ 60 months. All tumors were assessed by immunohistochemical staining for Pit-1, T-PIT, and GATA3. Invasiveness to surrounding structures was evaluated based on intraoperative findings. RESULTS: Cavernous sinus invasion was found in 47.5% of null cell tumors, 50.0% of Pit-1 lineage tumors, 31.8% of corticotroph tumors, and 18.3% of gonadotroph tumors. Dura mater defects in the floor of sellar turcica, indicating dural invasion, were found in 44.3% of null cell tumors, 36.4% of corticotroph tumors, 16.7% of Pit-1 lineage tumors, and 17.3% of gonadotroph tumors. In logistic regression analysis, Pit-1 (OR 5.90, 95% CI 1.71-20.4, P = 0.0050) and null tumors (OR 4.14, 95% CI 1.86-9.23, P = 0.0005) were associated with cavernous sinus invasion. Recurrence was found in 8 (4.9%) patients, but without significant differences between tumor subtypes. The presence of cavernous sinus invasion was correlated with recurrence (HR = 1.95, 95% CI 1.10-3.46, P = 0.0227). CONCLUSION: Among nonfunctioning Pit-NETs, Pit-1 lineage tumors tend to invade the cavernous sinus, corticotroph tumors may produce dura mater defects, and null cell tumors tend to cause both. Pit-NETs with cavernous sinus invasion require a careful attention to recurrence.

Predictive factors of postoperative diabetes insipidus in 333 patients undergoing transsphenoidal surgery for non-functioning pituitary adenoma.

PURPOSE: Diabetes insipidus (DI) following transsphenoidal surgery (TSS) is a common complication. Although postoperative DI often occurs in patients with craniopharyngioma and Rathke's cleft cyst, postoperative DI in patients with non-functioning pituitary adenoma (NFPA) has not been fully examined. We clarified the clinical characteristics and magnetic resonance imaging (MRI) findings predicting postoperative DI in NFPAs. METHODS: A total of 333 patients undergoing initial TSS for NFPA were included in this retrospective study. Hyperintensity (HI) in the posterior pituitary lobe was evaluated on preoperative T1-weighted MRI. Based on the findings of HI patients were divided into three groups as follows: HI was not detected (Disappearance group), HI located intrasellarly (Intrasellar group), and HI located suprasellarly (Suprasellar group). RESULTS: The overall rate of DI was 21.9%, including permanent DI in 0.6%. DI occurred at postoperative day 1 (72.6%) or day 2 (19.2%) and improved within 7 days in most cases (87.7%). Univariable and multivariable analyses showed that the predictive factors of DI were a younger age (odds ratio [OR] 0.97, 95% confidence interval [CI] 0.95-0.99, P = 0.0037) and larger tumor diameter (OR 1.04, 95% CI 1.01-1.08, P = 0.0155). The rate of DI was highest in the Disappearance group (43.8%) followed by the Intrasellar group (26.0%). The OR was 2.17 in the Intrasellar group compared with the Suprasellar group (95% CI 1.17-4.02, P = 0.0141). CONCLUSIONS: Factors predicting DI following TSS for NFPA were a younger age, larger tumor size, and the location of intrasellar HI on preoperative T1-weighted MRI.

Influence of growth hormone therapy on germinoma survivors.

PURPOSE: Due to the effectiveness of growth hormone therapy (GHT), the number of cancer survivors receiving GHT has increased. Previous studies had indicated that GHT was not associated with the increasing risks of tumor recurrence and development with second neoplasm (SN) in cancer survivors. However, to date, research on those risks in germinoma survivors is still limited. The aim of this study is to evaluate the impact of GHT in relation to tumor recurrence and development with SN in pure germinoma survivors. METHODS: This retrospective cohort study was approved by the Ethical Committee for Epidemiology of our institution. Seventy-three consecutive patients who underwent a biopsy of the lesion and were diagnosed with pure germinoma were retrospectively studied. They (median age, 15.0 years) were followed up more than 1 year after biopsy (median follow-up period, 14.3 years). The following data was obtained from the medical records of the patients: age, sex, preoperative magnetic resonance imaging findings, hormonal replacement, and events including tumor recurrence and/or SN. RESULTS: In our patient series, 16 patients (21.9%) who were more likely to have neurohypophysial lesion and receive multiple hormonal therapies had received GHT. No significant differences in the rates of tumor recurrence and development with SN were observed between the patients who had and had not received GHT. Moreover, the recurrence-free survival and overall survival rates were not different between the patients who had and had not received GHT. CONCLUSIONS: GHT did not increase the risks of tumor recurrence and development with SN in pure germinoma survivors.

Usefulness of critical flicker fusion frequency measurement and its laterality for evaluating compressive optic neuropathy due to pituitary neuroendocrine tumors.

Critical flicker fusion frequency (CFF) is a short but sensitive method for evaluating optic nerve function. We measured CFF in patients with pituitary neuroendocrine tumors (Pit-NETs) to assess its usefulness. Data from 184 patients with nonfunctioning Pit-NETs, who had been treated with transsphenoidal surgery and had no medical history of eye diseases, was used in this retrospective study. Visual acuity decline (VAD) was defined as > 0.10 reduction in logMAR visual acuity and CFF decline (CFD) was defined as CFF value < 35 Hz. Visual field defect (VFD) was evaluated by automated perimetry on a Humphrey visual field analyzer. Potential associations between abnormal test results and tumor height from the suprasellar were analyzed. Contact between the optic nerve or chiasma and the tumor was present and absent in 161 and 23 patients, respectively. In patients showing contact, the difference in CFF between the left and right eyes was larger (p = 0.0008), and the optimal cutoff value using the receiver operating characteristic curve was 3 Hz. Therefore, ≥ 3 Hz was considered positive for CFF laterality (CFL), the most prevalent condition. Tumor height was lower in patients with CFL positivity compared to those with VAD or VFD (p < 0.01). The prevalence of test abnormalities was the highest for small tumors compared to those of other tests. Changes in CFL permit early detection of Pit-NETs. Our results indicate that CFF laterality can be seen in the early stages of compressive optic neuropathy due to Pit-NET.

Multivariate risk factor analysis and literature review of postoperative deterioration in Karnofsky Performance Scale score in elderly patients with skull base meningioma.

OBJECTIVE Elderly patients are particularly at risk for severe morbidity following surgery. Among the various risk factors, age and skull base location of meningioma are known to be poor prognostic factors in meningioma surgery. The authors conducted this study to analyze significant preoperative risk factors in elderly patients with skull base meningioma. METHODS A total of 265 elderly patients (≥ 65 years old) with meningioma were surgically treated at the authors' institute and affiliated hospitals between 2000 and 2016, and these cases were reviewed. Among them, 57 patients with skull base meningioma were evaluated. Among the various risk factors, the authors analyzed age, sex, Karnofsky Performance Scale (KPS) score, American Society of Anesthesiologists score, and tumor size, location, and pathology. Body mass index (BMI) and serum albumin were investigated as the frailty factors. The authors also reviewed 11 surgical studies of elderly patients ≥ 60 years old with meningioma. RESULTS The mean age was 72.4 ± 5.7 years, and 42 patients were female (73.6%). The mean size of meningioma was 36.6 ± 14.8 mm at the maximum diameter, and the mean follow-up period was 31.1 ± 31.5 months. (The continuous variables are expressed as the mean ± SD.) Histopathological investigation revealed a higher incidence (71.9%) of WHO Grade I. The rates of deterioration after surgery, at 3 months, and at 1 year were 33.3%, 37.3%, and 39.1%, respectively. Univariate analysis revealed location, preoperative KPS score, BMI level 2, and serum albumin level (p = 0.010, 0.017, 0.0012, and 0.0019, respectively) to be poor prognostic factors. Multivariate analysis revealed that location (p = 0.038) and BMI (p = 0.035) were risk factors for KPS score deterioration immediately after surgery. According to the 11 papers reviewed, the median rate (25th-75th percentile) of skull base-related location was 43.5% (39.6-47.75); for asymptomatic status the mean was 24%; and for mortality at 3 months and 1 year the medians were 6.3% (0.7-7.1) and 8% (4.8-9.4), respectively. CONCLUSION Careful preoperative assessment based on the frailty concept was essential for better outcome in elderly patients with skull base meningioma. The BMI is appropriate as a quantitative factor for measure of frailty, particularly in elderly individuals with skull base meningioma. Further prospective randomized controlled trials are necessary to validate frailty as a preoperative risk factor. Not only patient selection but also surgical timing was an important factor.

Changes in quality of life in patients with acromegaly after surgical remission - A prospective study using SF-36 questionnaire.

Patients with acromegaly have a compromised quality of life (QOL). Modern surgical techniques have improved the surgical cure rate. However, there are no prospective studies reporting postoperative changes in QOL among patients cured solely by surgery. The aim of the present study was to determine the effect of surgery on QOL using the 36-item short form health survey (SF-36) questionnaire. SF-36 scores comprise 3 components: the physical component summary (PCS), the mental component summary (MCS) and role-social component summary (RCS). Included in this prospective cohort were 41 patients with acromegaly who underwent surgery alone and achieved postoperative normalization of insulin-like growth factor-1. All participants completed the SF-36 preoperatively and 1 year postoperatively. Preoperatively, RCS and 4 subscale scores (role physical, social functioning, role emotional, mental health) were below the set standards for the normal population. Postoperatively, the PCS and RCS scores did not change significantly, but the MCS score improved significantly (from 48.1 ± 11.3 to 51.7 ± 8.9, p=0.03). Further we compared the QOL of 26 patients whose nadir GH level was < 0.4 µg/L during postoperative oral glucose tolerance testing (complete remission group) with that of 15 patients whose nadir GH level was ≥ 0.4 µg/L (partial remission group). There were no significant differences between these groups in terms of PCS, MCS, RCS, or any subscale scores. In conclusion, surgical remission mostly improved the participants' mental condition. There was no difference in QOL between patients who achieved the new remission criteria and those who did not.

[A Case of Intradural Retroclival Chordoma].

A 67-year-old woman was referred to our department with a retroclival lesion including a cyst on MRI. MRI revealed a lesion appearing as an isointense region on a diffusion-weighted image(DWI). Gadolinium(Gd)-DTPA T1-WI showed heterogeneous enhancement of the lesion in the prepontine cistern. Computed tomography(CT)revealed an isodense lesion with no invasion into the clival bone. Based on a preoperative diagnosis of retroclival chordoma, extended trans-sphenoidal surgery(TSS)was performed by a direct endoscopic endonasal approach via the left nostril. We found a round dural defect with a diameter of 5 mm, through which the tumor was incarcerated. However, the tumor had no connection to the clival bone. The lesion was totally removed and histologically diagnosed as a chordoma. Furthermore, the clival bone included no tumor cells. Based on those radiological and histological findings, we diagnosed the lesion as an intradural retroclival chordoma. We should consider intradural retroclival chordoma as a candidate for the differential diagnosis of a retroclival lesion without clival bone invasion.

Solitary Langerhans cell histiocytosis located in the neurohypophysis with a positive titer HCG-ß in the cerebrospinal fluid.

INTRODUCTION: Beta-human chorionic gonadotropin (HCG-ß) is considered to be a useful tumor marker for germ cell tumors (GCTs); however, various tumors other than GCTs, including cystic pituitary adenomas, Rathke's cleft cysts, and craniopharyngiomas, were reported to express HCG-ß. CASE REPORT: We herein present the case of a 5-year-old boy who presented with polyuria and had a solitary lesion in the neurohypophysis with a positive HCG-ß titer in the cerebrospinal fluid. Under a preoperative diagnosis of germinoma, a biopsy was performed from the posterior pituitary lobe via the transsphenoidal endoscopic approach and the histological diagnosis was revealed to be Langerhans cell histiocytosis (LCH). CONCLUSIONS: The finding of a slightly positive HCG-ß titer in the cerebrospinal fluid (CSF) cannot exclude the possibility of LCH, and we strongly recommend a histological diagnosis for the diagnosis of a solitary neurohypophysial lesion.

Clinical features and natural course of acromegaly in patients with discordance in the nadir GH level on the oral glucose test and the IGF-1 value at 3 months after adenomectomy.

Discordant GH and IGF-1 levels after adenomectomy are well recognized in acromegalics. The aim of this study was to evaluate the clinical features and natural course of postoperative acromegaly associated with discordant GH and IGF-1 levels over a postoperative period. A total of 69 acromegalics underwent surgery with at least 1 year of follow-up and received 75-g oral glucose tolerance tests (OGTTs) at 3 months postoperatively. The patients were categorized into four groups according to the postoperative nadir GH levels and IGF-1 levels: controlled group (normal GH and normal IGF-1), high-IGF-1 group (normal GH and high IGF-1), high-GH group (high GH and normal IGF-1), and uncontrolled group (high GH and high IGF-1). The incidence of discordant GH and IGF-1 levels was 27.5%: high-IGF-1 group = 10.1% (n = 7) and high-GH group = 17.4% (n = 12). All patients in the high-IGF-1 group exhibited a decline in the IGF-1 level after surgery, with normalization observed in 71.4% of the patients without additional treatment (median 23 months). These subjects had preoperatively high IGF-1 levels despite not demonstrating higher GH levels than the patients in the controlled group. On the other hand, four patients in the high-GH group exhibited an elevated nadir GH level higher than 1.0 µg/L on repeated OGTTs after 3 months, and one patient experienced a recurrence of acromegaly. Patients in the high-IGF-1 group require no additional treatments, and their IGF-1 levels are likely to normalize within a few years. However, patients in the high-GH group should be carefully followed due to the possibility of recurrence.

Diffusion-weighted imaging and the apparent diffusion coefficient on 3T MR imaging in the differentiation of craniopharyngiomas and germ cell tumors.

The apparent diffusion coefficient (ADC) on diffusion-weighted imaging (DWI) plays an important role in diagnosing intracranial tumors and predicting the histopathological grade of the tumor. However, the differences in the ADC values between craniopharyngiomas and germ cell tumors (GCTs) have not been clarified. We therefore evaluated the DWI and ADC values at b = 1000 and b = 4000 s/mm(2) on 3T magnetic resonance (MR) imaging and assessed the possibility of differentiating between craniopharyngiomas and GCTs. We retrospectively reviewed 19 patients with craniopharyngioma and 24 patients with GCT who underwent surgery and received a histopathological diagnosis. Thirty-four patients underwent DWI with b = 1000 and b = 4000 s/mm(2) and nine patients underwent periodically rotated overlapping parallel lines with enhanced reconstruction (PROPELLER) DWI with b = 1000 s/mm(2). The ADC was determined by manually placing regions of interests (ROIs) in the respective tumor regions on the ADC maps and is expressed as the minimum (ADC(MIN)), mean (ADC(MEAN)), and maximum (ADC(MAX)) absolute values. The craniopharyngiomas showed lower intensity on DWI at b = 1000 and b = 4000 s/mm(2) than the GCTs. Furthermore, the craniopharyngiomas demonstrated significantly high ADC values (ADC(MIN), ADC(MEAN), and ADC(MAX)) in comparison with the GCTs on DWI at b = 1000 and b = 4000 s/mm(2). The logistic discriminant analysis clarified the advantage of ADC(MIN) at b = 4000 s/mm(2) in differentiating between craniopharyngiomas and GCTs compared with the other ADC values. DWI and the ADC values may help clinicians to differentiate between craniopharyngiomas and GCTs. The ADC(MIN) at b = 4000 s/mm(2) is particularly useful for differentiation.

Impact of subclinical haemorrhage on the pituitary gland in patients with pituitary adenomas.

OBJECTIVE: Advanced magnetic resonance imaging (MRI) and optical instruments for surgery frequently demonstrate subclinical haemorrhage in pituitary adenomas; however, the effects of subclinical haemorrhage on pituitary glands remain unclear. We sought to clarify the pituitary function in patients with subclinical pituitary adenoma haemorrhage (SPAH). DESIGN/PATIENTS: Between January 2006 and December 2012, we retrospectively reviewed 328 consecutive patients who underwent surgery for pituitary adenoma. SPAH was defined as an intratumoral haemorrhage based on both 3 tesla MRI and operative findings, with no clinical symptoms of acute pituitary adenoma apoplexy. The pituitary dysfunction assessed using pre- and postoperative provocative tests was investigated in patients categorized into three groups: nonapoplectic adenoma, adenoma with SPAH and adenoma with clinical apoplexy. MEASUREMENTS: The main outcome measure was the incidence of pituitary dysfunction. RESULTS: The overall incidence of nonapoplectic adenomas, adenomas with SPAH and adenomas with clinical apoplexy was 82·3%, 14·3% and 3·4%, respectively. Clinical pituitary apoplexy frequently occurred in male patients with large nonfunctioning adenomas, causing pituitary dysfunction. Contrastingly, the incidence of SPAH was significantly higher in the patients with prolactinoma (P = 0·0260), including those with relatively small adenomas (P = 0·0007). No medications, such as dopamine agonists or somatostatin analogues, were observed to affect the occurrence of SPAH. No deterioration of the pituitary function was observed in the SPAH patients in comparison with the patients with nonapoplectic adenoma, and the size of the haematoma occupying the pituitary adenoma did not exhibit any relationships with the deterioration of the pituitary function. Furthermore, SPAH caused no deterioration of the pituitary function after a surgery based on the postoperative provocation tests. CONCLUSIONS: Subclinical pituitary adenoma haemorrhage does not cause any added dysfunction in pituitary glands. Signs of haemorrhage in pituitary adenomas do not necessitate immediate tumour decompression surgery, if there are no symptoms of acute haemorrhage.

Pituitary adenomas in childhood and adolescence with a focus on intratumoral hemorrhage.

Pituitary adenomas in childhood and adolescence are relatively rare. In the present study we investigated intratumoral hemorrhage in pituitary adenomas and examined cases of intratumoral hemorrhage using adult patients for comparison. From 1975 to 2012, 38 consecutive patients operated for pituitary adenoma and one patient treated with medication alone, were enrolled in this study. Their ages were less than 18 years old at the initial diagnosis (mean age 15.3 ± 2.9 years). The comparison group consisted of 209 consecutive adult patients (>18 years old). The incidence and characteristics of intratumoral hemorrhage in pituitary adenomas were evaluated, based on magnetic resonance imaging (MRI) findings (28 cases) and on operative findings. The incidence of pituitary adenomas in childhood and adolescence was 38/1,073 (3.5 %) patients operated. Functioning pituitary adenomas (82.1 %) were common and non-functioning pituitary adenomas (17.9 %) were rare. Although no significant difference in tumor size was found and Knosp grade did not differ between young (≤18 years old) and adult (>18 years old) patients, indications of intratumoral hemorrhage on MRI was common in young patients (42.9 %). Based on both MRI and operative findings, intratumoral hemorrhage was significantly more likely to occur in young patients, compared with adult patients.

Transsphenoidal surgical treatment of pituitary adenomas in patients aged 80 years or older.

To know the clinical characteristics of pituitary adenomas in the elderly patients aged 80 years or older who were surgically treated. From 1995 through 2012, 907 patients underwent surgery for the pituitary adenomas at Kagoshima- and Hiroshima University hospitals in Japan. Ten (1.1%) patients were aged 80 years or older. We retrospectively assessed the clinical characteristics including preoperative comorbidities, manifestations, neuroimaging findings, and endocrinologic features of these ten patients. The subjects included eight males and two females. Their ages ranged from 80 to 86 with mean of 83.1 years. Of these, besides one case of growth hormone-producing adenoma, others were clinically nonfunctioning adenoma. Six patients had modest comorbidities such as hypertension, cardiovascular diseases, diabetes mellitus, or chronic kidney dysfunction, and all patients were classified into grade 2-3 on American Society of Anesthesiologists' Physical Status grading. Transsphenoidal surgery was performed in all due to visual disturbance in eight, diabetes mellitus as an intercurrent illness of acromegaly in one, and for the purpose of preventing visual disturbance in one patient who had an adenoma impinging optic chiasm but still had normal visual field. The surgeries provided sufficient decompression of the optic pathways and improved visual disorder in all. In an acromegalic male, his comorbidities considerably improved. No permanent surgical morbidity ensued. More than three axes of anterior pituitary hormones were preoperatively impaired in all, which were rarely recovered. Transsphenoidal surgery is safe and efficient treatment way for patients aged 80 years or older with pituitary adenomas with chiasmatic symptoms when the patients' general condition is well preserved and pituitary hormonal deficiency is adequately replaced.

A case of petrous apex cholesterol granuloma successfully treated with endoscopic endonasal surgery.

A transcranial approach in combination with a transpetrosal setting has been the mainstream of surgical treatment of cholesterol granulomas in the petrous apex. However, endoscopic endonasal surgery has become a choice of treatment for these lesions with recent advancements in surgical techniques and instruments. We report a successful case of cholesterol granuloma managed with endoscopic endonasal surgery. A 45-year-old woman, who had a long-standing history of otitis media, presented with left abducens nerve palsy and discomfort around the left eye. Magnetic resonance (MR) imaging showed a large cystic lesion, suggesting cholesterol granuloma, in the left middle fossa abutting the cavernous sinus and lateral wall of the sphenoid sinus. We chose an endoscopic endonasal approach to drain the contents of the cyst because the lesion protruded into the left sphenoid sinus. The sphenoid sinus was widely opened and the cyst wall was fenestrated with the assistance of an image guidance navigation system. Postoperative MR images confirmed the complete collapse of the cyst. She has been free from symptoms since the operation.

Pseudocapsular resection to prevent recurrence in nonfunctioning pituitary neuroendocrine tumors: a retrospective, single-center study with more than 5 years of follow-up.

OBJECTIVE: Pseudocapsular resection is a well-recognized, useful approach to achieve endocrinological remission in functioning pituitary neuroendocrine tumors (PitNETs). However, its advantage in nonfunctioning PitNETs (NF-PitNETs) has not been established. This study aimed to clarify the contribution of pseudocapsular resection to the prevention of NF-PitNET recurrence in long-term follow-up. METHODS: This retrospective study included 132 patients who underwent total tumor removal and were followed for more than 5 years after surgery. The patients were categorized into those who underwent total pseudocapsular resection (n = 67) and those who did not (n = 65). The nonpseudocapsule (nonpseudocap) resection group included patients who underwent partial pseudocapsular resection and those in whom the pseudocapsule was not resected, did not exist, or could not be identified during surgery. The main outcome measures were the tumor recurrence rate and site of recurrence. RESULTS: In the nonpseudocap resection group, 2 patients (3.1%) had tumor recurrence in the cavernous sinus and 5 (7.7%) had tumor recurrence in the pituitary fossa. In the pseudocapsule (pseudocap) resection group, only 2 patients (3.0%) had tumor recurrence in the cavernous sinus and 0 patients had tumor recurrence in the pituitary fossa. Tumor recurrence in the pituitary fossa was more likely to occur in the nonpseudocap resection group than in the pseudocap resection group (p = 0.0267). Multivariate regression analysis revealed that pseudocapsular resection was a significant factor for reducing the tumor recurrence rate in the pituitary fossa (p = 0.0107). CONCLUSIONS: Pseudocapsular resection may reduce the rate of tumor recurrence and improve the management of NF-PitNETs in long-term follow-up.

Characteristics of radiation-induced brain tumors: case series and systematic review.

OBJECTIVE: Radiation therapy (RT) improves the outcome of patients with cancer but introduces the risk of radiation-induced neoplasms in cancer survivors. The most common radiation-induced brain tumors (RIBTs) are gliomas (RIGs), meningiomas (RIMs), and sarcomas (RISs). To investigate the characteristics of these RIBTs, the authors conducted a comprehensive review and analysis of their case series and relevant cases from the literature. METHODS: Sixteen patients in the case series and 941 patients from the literature who previously underwent cranial irradiation were included in this study. The age at irradiation for primary disease was recorded, and the latency period from irradiation to the development of RIBT and the median overall survival (OS) of patients with RIBTs were analyzed using the Kaplan-Meier method. Patients were stratified by age at the time of irradiation (pediatric vs nonpediatric) and the irradiation dose (higher vs lower dose), and latency and OS were compared using the log-rank test. RESULTS: Among patients with RIBTs, 23.4% underwent radiation at < 5 years of age, and 46.6% underwent RT in the 1st decade of life. The median ages at cranial irradiation were 8.4 (IQR 4.1-16) years in patients with RIMs, 9 (IQR 5-23) years in patients with RIGs, and 27.7 (IQR 13.8-40) years in patients with RISs. The median latency period from irradiation to the development of RIM was significantly longer than that to the development of RIG and RIS (RIM: 20 years, RIG: 9 years, RIS: 10 years; p < 0.0001). The latency period was shorter in the nonpediatric patient group with RIMs (p = 0.047). The OS was significantly longer in patients with RIMs than in those with RIGs and RISs (RIM: not reached, RIG: 11 months, RIS: 11 months; p < 0.0001). The OS of patients with RIMs and RIGs was significantly shorter in patients who received higher radiation doses (p = 0.0095 and p = 0.0026, respectively). CONCLUSIONS: The prognosis was poor and worse for patients with RIGs and RISs than for those with RIMs, and patients with RIBTs who underwent higher-dose irradiation for primary disease had poor prognoses. Because RIBTs develop more than a decade after cranial irradiation, long-term follow-up is crucial.

Severe growth hormone deficiency is rare in surgically-cured acromegalics.

Growth hormone deficiency (GHD) in surgically-cured acromegalics has been reported to negatively affect their metabolic condition and quality of life (QOL). The incidence of GHD, its causes, and its effects on their physio-psychological condition remain to be examined in detail. We performed a retrospective study to investigate GH secretory function in surgically-cured acromegalics, prognostic factors of GHD, and its impact on QOL. The study population consisted of 72 acromegalics who were determined to be surgically cured according to the Cortina consensus criteria. We recorded the incidence of impaired GH secretory function based on the peak GH level during postoperative insulin tolerance test (ITT) which lowered their nadir blood sugar to under 50 mg/dL. Their QOL was evaluated by SF-36. In surgically-cured acromegalics, the incidence of severe GHD (peak GH during ITT ≦ 3.0 µg/L) was 12.5 % (9/72). The preoperative tumor size was significantly larger in patients with severe GHD than without severe GHD (21.9 ± 9.0 vs. 15.5 ± 7.1 mm, p = 0.017). The peak GH levels during postoperative ITT were statistically correlated with the physical but not the mental component summary of the SF-36 score. The incidence of GHD was 12.5 % in our surgically-cured acromegalics. As some QOL aspects are positively related with peak GH levels during postoperative ITT, efforts should be made to preserve pituitary function in acromegalic patients undergoing adenomectomy.