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Cushing's disease (CD) is characterized by endogenous hypercortisolism that is associated with increased mortality and morbidity. Due to high recurrence rates in CD, the determination of high-risk patients is of paramount importance. In this study, we aimed to determine recurrence rates and clinical, laboratory, and histological predictors of recurrence in a high volume single-center. This retrospective study included 273 CD patients operated in a single pituitary center between 1997 and 2020. The patients with early postoperative remission were further grouped according to recurrence status (recurrent and sustained remission groups). Demographic, radiologic, laboratory, pathologic, and follow-up clinical data of the patients were analyzed and compared between groups. The recurrence rate was 9.6% in the first 5 years; however, the overall recurrence rate was 14.2% in this study. Higher preoperative basal ACTH levels were significantly correlated with CD recurrence even with ACTH levels adjusted for tumor size, Ki-67 levels, and tumoral invasion. Recurrence rates were significantly higher in patients with ACTH levels higher than 55 pg/ml, tumor diameter>9.5 mm, and if adrenal axis recovery was before 6 months. The severity of hypercortisolism, morbidities, and demographic factors except age were not predictive factors of recurrence. Based on our study data, younger age at diagnosis, a diagnosis of osteoporosis, higher preoperative ACTH levels, larger tumor size, invasive behavior, higher Ki 67 index, and early recovery of the adrenal axis during the postoperative period attracted attention as potential predictors of recurrent disease.
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Síndrome de Cushing , Hipersecreção Hipofisária de ACTH , Adulto , Humanos , Seguimentos , Resultado do Tratamento , Estudos Retrospectivos , Hipersecreção Hipofisária de ACTH/diagnóstico , Hipersecreção Hipofisária de ACTH/cirurgia , Recidiva Local de Neoplasia/cirurgia , Hormônio AdrenocorticotrópicoRESUMO
PURPOSE: Sellar metastases are rare lesions. Recent improvements in diagnosis and treatment strategies have prolonged survival but increased the probability of metastatic tumors. Evaluation with clinical symptomatology and meticulous laboratory examination is crucial. We present our multicenter national study on sellar metastases to evaluate and underline the main clinical, endocrine, and radiological considerations regarding the diagnosis and endonasal endoscopic management of such rare lesions. METHODS: A medical literature-based retrospective study was planned across 13 neurosurgical centers in Turkey, where a data survey was conducted to collect information regarding sellar metastases surgically treated using the endoscopic endonasal approach, including clinical presentation, radiographic features, primary tumor origin, histopathological confirmation, time to metastasis, treatment, and patient outcomes. RESULTS: Between 2010 and 2020, 54 patients (22 women [40.7%] and 32 men [59.3%]) who underwent surgery with the endonasal endoscopic approach and had pathologically proven sellar metastases (overall incidence, 0.54%) were included. Of the patients, 59.3% had no known malignancy and presented with new-onset symptoms, 79.6% reported headache, 51.9% complained of some degree of visual deficits, and 50% had cranial nerve symptoms. Tissue biopsy was performed in 7.4% of the patients, whereas gross or subtotal resection was achieved in the remaining patients. CONCLUSION: To our knowledge, this is the largest series of patients surgically treated with the endonasal endoscopic approach for sellar metastases. For these patients, the treatment focus should be on management modalities for increasing quality of life instead radical treatment options with survival benefit.
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Neoplasias Hipofisárias , Qualidade de Vida , Masculino , Humanos , Feminino , Estudos Retrospectivos , Resultado do Tratamento , Nariz/cirurgia , Endoscopia , Neoplasias Hipofisárias/cirurgiaRESUMO
OBJECTIVE: Optic pathway gliomas (OPGs) constitute approximately 3-5% of childhood intracranial tumors. In this study, the authors presented their experience of using the endoscopic endonasal approach to treat patients with OPG located in the chiasma-hypothalamic region and aimed to use the infrachiasmatic corridor in the endoscopic endonasal approach as an alternative to the transcranial approach in the surgical necessity of OPGs. METHODS: We retrospectively analyzed the data of ten patients diagnosed with OPG histopathologically among 3757 cases who underwent endoscopic endonasal surgery between August 1997 and March 2021 at Kocaeli University Faculty of Medicine Pituitary Research Center and Department of Neurosurgery. Mean follow-up period 48.5 months. During the postoperative follow-up period, 3 of these 10 patients underwent reoperation due to tumor recurrence. Combined (endoscopic endonasal approach + transcranial approach) approach was applied to 2 patients in the same session. Surgical and clinical outcomes were evaluated in detail. RESULTS: Ten patients with a mean patient age of 20.6 ± 11.4 were included in this study. The most common complaint was visual impairment. After surgery, improvement in visual impairment was observed in five patients. No increase in postoperative visual impairment was observed in any of the patients. Postoperative panhypopituitarism was not observed in any of the patients. STR resection was performed in 5 patients and NTR resection in 5 patients. No additional treatment was required during follow-up in 4 of 5 patients who underwent NTR. A total of 6 patients received postoperative radiotherapy treatment. CONCLUSIONS: In gliomas located in the chiasma-hypothalamic region, appropriate patient selection and endoscopic endonasal surgical treatment may contribute to the elimination of symptoms due to the mass effect of the tumor. It may also contribute to keeping the disease under control with targeted adjuvant therapies by clarifying the pathological diagnosis of the lesion.
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Neuroendoscopia , Glioma do Nervo Óptico , Neoplasias Hipofisárias , Humanos , Estudos Retrospectivos , Recidiva Local de Neoplasia/patologia , Endoscopia , Glioma do Nervo Óptico/diagnóstico por imagem , Glioma do Nervo Óptico/cirurgia , Transtornos da Visão/cirurgia , Resultado do Tratamento , Neoplasias Hipofisárias/diagnóstico por imagem , Neoplasias Hipofisárias/cirurgia , Neoplasias Hipofisárias/patologiaRESUMO
OBJECT: The infrachiasmatic corridor is the most important surgical access route for craniopharyngiomas and was identified and used in clinical series. The aims of this study were to describe the characteristics that assist dissection and resection rates in endoscopic surgery of solid, cystic, and recurrent cases and their importance in the infrachiasmatic corridor in endoscopic surgery. METHODS: One hundred operations on 84 patients with pathologically identified craniopharyngioma were included in the study. The MRI findings were evaluated, and the location of the lesions was classified as (1) infrasellar; (2) sellar; or (3) suprasellar. In the sagittal plane, we measured the longest diameter of cystic and solid components and the height of chiasm-sella. Images were assessed for the extent of resection and were classified as gross total resection. This was deemed as the absence of residual tumor and subtotal resection, which had residual tumor. RESULTS: The infrasellar location was reported in 7/84 (8.3%) patients, the sellar location in 8/84 (9.5%), and the suprasellar location in 69/84 (82.1%) patients. The narrow and high chiasm-sella were observed in 28/69 (40.5%) and 41/69 patients (59.4%), respectively. The mean distance of the chiasm-sella was 9.46± 3.76. Gross total tumor resection was achieved in 60/84 (71.4%) and subtotal tumor resection was performed in 24/84 (28.6%) patients. The results revealed that suprasellar location (OR: 0.068; p = 0.017) and recurrent cases (OR: 0.011; p<0.001) were negative predictive factors on GTR. Increasing the experience (OR: 42,504; p = 0.001) was a positive predictor factor for GTR. CONCLUSION: An EETS approach that uses the infrachiasmatic corridor is required for skull base lesions extending into the suprasellar area. The infrachiasmatic corridor can determine the limitations of endoscopic craniopharyngioma surgery. This corridor is a surgical safety zone for inferior approaches.
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Craniofaringioma , Neoplasias Hipofisárias , Craniofaringioma/diagnóstico por imagem , Craniofaringioma/cirurgia , Endoscopia , Humanos , Neuroendoscopia , Nariz , Neoplasias Hipofisárias/diagnóstico por imagem , Neoplasias Hipofisárias/cirurgia , Estudos Retrospectivos , Base do Crânio , Resultado do TratamentoRESUMO
INTRODUCTION: The relationship between growth hormone (GH)/insulin-like growth factor 1 (IGF-1) and glucocorticoids (GC) was examined in various studies. Long-term GC treatment was shown to decrease GH concentration and, interestingly, to increase IGF-1 concentration. We performed a retrospective study in order to examine how preoperative IGF-1 concentrations vary within the reference range and if tertiles of age- and sex-adjusted normal IGF-1 are predictive for early postoperative remission in the patients with Cushing's Disease (CD). PATIENTS AND METHODS: Patients diagnosed with CD were retrospectively evaluated. After the exclusion of 67 patients, a final cohort of 250 CD patients were included. Age- and sex-adjusted normal IGF-1 levels were divided into tertiles (T1, T2 and T3). Early postoperative remission was defined as a nadir morning cortisol concentration measured within the first 3 consecutive days following surgery of less than 5 µg/dL (138 nmol/L). RESULTS: Early postoperative remission rate was the lowest in T1 and highest in T3; 49.1% (n = 28) versus 77.3% (n = 75), p = .001, respectively. Binary logistic regression analysis showed the remission rate in T3 was three times higher than that in T1 (p = .003). Cortisol and ACTH concentration were significantly higher and GH concentrations were significantly lower in T1 compared to those in the other two tertiles. CONCLUSIONS: As the first study evaluating the correlation between early postoperative remission rate in patients with CD and the tertiles of normal age- and sex-adjusted IGF-1 levels, we have shown that higher IGF-1 levels could predict better outcome in CD.
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Fator de Crescimento Insulin-Like I/metabolismo , Avaliação de Resultados em Cuidados de Saúde , Hipersecreção Hipofisária de ACTH/sangue , Hipersecreção Hipofisária de ACTH/cirurgia , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Valores de Referência , Indução de Remissão , Estudos RetrospectivosRESUMO
An extended endoscopic transsphenoidal approach is required for skull base lesions extending to the suprasellar area. Inferior approach using the infrachiasmatic corridor allows access to the lesions through the tumor growth that is favorable for the extended transsphenoidal approaches. Infrachiasmatic corridor is a safer route for the inferior approaches that is made up by basal arachnoid membrane and Liliequist's membrane with its leaves (diencephalic and mesencephalic leaf). This area extends from the optic canal and tuberculum sella to the corpus mamillare. We performed extended endoscopic approach using the infrachiasmatic corridor in 52 cases, including tuberculum sella meningiomas (n:23), craniopharyngiomas (n:16), suprasellar Rathke's cleft cyst (n:6), pituitary adenoma (n:2), fibrous dysplasia (n:1), infundibular granulosa cell tumor (n:2), and epidermoid tumor (n:2). Total resection was achieved in 17 of 23 (74%) with tuberculum sellae meningioma using infrachiasmatic approach. Twenty patients presented with visual disorders and 14 of them improved. There were two postoperative cerebrospinal fluid (CSF) leakages and one transient diabetes insipidus and one permanent diabetes insipidus. Sixteen patients were operated on by the infrachiasmatic approach for craniopharyngiomas. Improvement was reached in seven of eight patients presented with visual disorders. Complete tumor resection was performed in 10 of 16 cases and cyst aspiration in 4 cases, and there were remnants in two cases. Postoperative CSF leakage was seen in two patients. Infrachiasmatic corridor provides an easier and safer inferior route for the removal of middle midline skull base lesions in selected cases.
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Craniofaringioma/cirurgia , Neoplasias Meníngeas/cirurgia , Meningioma/cirurgia , Neuroendoscopia , Neoplasias Hipofisárias/cirurgia , Neoplasias da Base do Crânio/cirurgia , Adulto , Idoso , Cistos do Sistema Nervoso Central/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Neuroendoscopia/métodos , Procedimentos Neurocirúrgicos/métodosAssuntos
Granulomatose com Poliangiite/complicações , Hipopituitarismo , Hipófise , Prednisolona/administração & dosagem , Rituximab/administração & dosagem , Tiroxina , Idoso , Antirreumáticos/administração & dosagem , Biópsia/métodos , Endoscopia/métodos , Feminino , Humanos , Hiperprolactinemia/diagnóstico , Hiperprolactinemia/etiologia , Hipopituitarismo/etiologia , Hipopituitarismo/patologia , Hipopituitarismo/fisiopatologia , Hipopituitarismo/terapia , Imageamento por Ressonância Magnética/métodos , Hipófise/diagnóstico por imagem , Hipófise/patologia , Tiroxina/sangue , Tiroxina/uso terapêutico , Resultado do TratamentoRESUMO
OBJECTIVE: As surgical techniques become less invasive, the use of endoscopy in brain surgery supports this trend. Numerous endoscopic surgical approaches have been defined, especially for skull base diseases. The current study summarizes our experience of using the rarely reported endoscopic transnasal transdiaphragmatic approach through the existing hole in the diaphragma sella to access lesions extending into the suprasellar region. METHODS: Our surgical team performed 4876 endoscopic endonasal surgeries between August 1997 and December 2022 at the Department of Neurosurgery, Pituitary Research Center, Faculty of Medicine, Kocaeli University. The study retrospectively analyzed data from 11 patients who had undergone endoscopic transnasal transdiaphragmatic surgery since January 2020. Preoperative and postoperative magnetic resonance imaging, pituitary function examination, and clinical observation were carried out. RESULTS: The mean age of the patients was 31.1 ± 10.7 years and the female/male ratio was 6:5. Pathologic subtypes observed included breast cancer metastasis (n = 1), adrenocorticotropic hormone-secreting adenoma (n = 4), growth hormone-secreting adenoma (n = 3), craniopharyngioma (n = 2), and Rathke cleft cyst (n = 1). The mean postoperative hospital stay was 4.7 ± 1.1 days and none of the patients showed cerebrospinal fluid leakage during this period. CONCLUSIONS: The endoscopic transnasal transdiaphragmatic approach may be considered an alternative to the conventional extended endoscopic transnasal approach in patients with lesions extending into the suprasellar region. The main strength of this method is that it facilitates suprasellar region access through a small dural incision and bone defect in the base of the skull. As a result, it also reduces the risk of postoperative cerebrospinal fluid leakage and associated complications.
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Adenoma , Neuroendoscopia , Neoplasias Hipofisárias , Humanos , Masculino , Feminino , Adulto Jovem , Adulto , Neuroendoscopia/métodos , Estudos Retrospectivos , Neoplasias Hipofisárias/diagnóstico por imagem , Neoplasias Hipofisárias/cirurgia , Neoplasias Hipofisárias/patologia , Endoscopia/métodos , Adenoma/diagnóstico por imagem , Adenoma/cirurgia , Vazamento de Líquido Cefalorraquidiano/cirurgia , Resultado do TratamentoRESUMO
Objectives: To evaluate the performances of machine learning using semantic and radiomic features from magnetic resonance imaging data to distinguish cystic pituitary adenomas (CPA) from Rathke's cleft cysts (RCCs). Materials and Methods: The study involved 65 patients diagnosed with either CPA or RCCs. Multiple observers independently assessed the semantic features of the tumors on the magnetic resonance images. Radiomics features were extracted from T2-weighted, T1-weighted, and T1-contrast-enhanced images. Machine learning models, including Support Vector Machines (SVM), Logistic Regression (LR), and Light Gradient Boosting (LGB), were then trained and validated using semantic features only and a combination of semantic and radiomic features. Statistical analyses were carried out to compare the performance of these various models. Results: Machine learning models that combined semantic and radiomic features achieved higher levels of accuracy than models with semantic features only. Models with combined semantic and T2-weighted radiomics features achieved the highest test accuracies (93.8%, 92.3%, and 90.8% for LR, SVM, and LGB, respectively). The SVM model combined semantic features with T2-weighted radiomics features had statistically significantly better performance than semantic features only (p = 0.019). Conclusion: Our study demonstrates the significant potential of machine learning for differentiating CPA from RCCs.
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BACKGROUND AND OBJECTIVES: The widespread use of endoscope and increased surgical experiences in pituitary adenomas (PAs) has raised the expectations for higher resection and cure rates. The subject that will meet this expectation in all types of adenomas is the capsule and its dissection. The purpose of this study was to go beyond the commonly mentioned pseudocapsule definition for small-sized adenomas in previous studies and to describe the capsule structure in different morphologies present in pituitary adenomas of all sizes. This includes detailing the nuances of capsular dissection (CD) and presenting postoperative surgical outcomes through the experiences of a high-volume tertiary center. METHODS: In our center, 534 patients underwent endoscopic trans-sphenoidal surgery because of pituitary adenoma in 2022 by the same surgeon. The data of the patients were examined retrospectively. The surgical techniques applied were grouped as adenoma resection only, capsular resection after internal debulking, and direct extracapsular resection. RESULTS: CD was performed in 275 (51.5%) patients. The gross total resection (GTR) rate in nonsecretory adenomas with and without CD was 90.7% (97/107) and 90.7% (97/107), respectively. The remission rate in secretory adenomas with and without CD was 81.0% (136/168) and 44.0% (67/152), respectively. When the patients were examined in 2 groups as those who underwent CD and those who did not, the application of CD had a positive predictive value in terms of GTR/remission (P: .036). Capsule thickness was not found to be statistically significant depending on tumor subtype, size, and aggressiveness, but capsule thickness was statistically significant in terms of total capsular resection (P: .045). CONCLUSION: The morphology of the capsule, tumor size/subtype/consistency, and patient-specific factors are crucial for the selection of the surgical technique to be applied. It is possible to increase the GTR/remission rates in adenomas of all sizes by capsule dissection. Moreover, performing CD does not contribute significantly to the development of potential complications in such cases.
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OBJECTIVE: Craniopharyngiomas are locally invasive neoplasms, and they cause potential lifelong morbidity because of their tendency for local recurrence. Despite advancements in endoscopic techniques, gross-total resection (GTR) of tumors with invasion or adhesion to important surrounding anatomical structures is extremely difficult. The authors present a single-center study that evaluated the impact of the endoscopic endonasal approach (EEA) on the surgical outcomes of pediatric craniopharyngiomas, the factors affecting the resection rate, and recurrence. METHODS: A total of 44 pediatric patients (age ≤ 18 years) who were treated via the EEA for craniopharyngioma from August 1997 to June 2022, as well as their 53 operations, were included in this study. The preoperative radiological configuration and surgical data of these cases were assessed. Also, preoperative and postoperative clinical (endocrinologic, neurological, and ophthalmological), hypothalamic, physical and social development, and neurocognitive assessment data were described. RESULTS: In total, 37 cases (69.8%) had no history of operation beforehand. The most common symptoms at presentation were endocrine disturbances (98.1%), headache without vomiting (84.3%), and visual disturbance (51%). Cases were classified as infrasellar (1.9%), sellar (32.1%), sellar-suprasellar (52.8%), and suprasellar (13.2%) localization. GTR was achieved in 34/53 cases (64.1%). The rate of GTR was higher in infrasellar and sellar tumors compared with sellar-suprasellar and suprasellar tumors (p = 0.003), and preoperative hypothalamic involvement was associated with lower likelihood of GTR (p = 0.024). Moreover, with experience, the rate of GTR increased (p = 0.037). Postoperative complications, other than endocrine impairment, occurred in 10/53 cases (18.9%). The mean duration of follow-up was 53.57 months. At follow-up, 21/53 (39.6%) cases presented with tumor recurrence. The 5-year progression-free survival (PFS) rate was 48.5%. There was a statistically significant difference between the GTR and other-than-GTR groups in terms of PFS (p < 0.001). According to univariate analysis, smaller tumor (p = 0.017), infrasellar and sellar localization (p = 0.031), and GTR (p < 0.001) were significantly associated with decreased rate of recurrence. Also, there was a statistically significant association between the recurrence rate and adhesion strength of the tumor (p < 0.001). CONCLUSIONS: This retrospective cohort study revealed surgical indications for EEA, as well as factors affecting the resection rate, recurrence, and quality of life during the follow-up period of the included cases. The authors believe that GTR should be the goal for craniopharyngioma treatment, but the authors' treatment approach was to provide a balance between radical surgery with maximum safety and adjuvant treatment for long-term disease control.
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Craniofaringioma , Neoplasias Hipofisárias , Humanos , Criança , Adolescente , Craniofaringioma/diagnóstico por imagem , Craniofaringioma/cirurgia , Craniofaringioma/patologia , Seguimentos , Estudos Retrospectivos , Neoplasias Hipofisárias/diagnóstico por imagem , Neoplasias Hipofisárias/cirurgia , Neoplasias Hipofisárias/patologia , Qualidade de Vida , Recidiva Local de Neoplasia/cirurgia , Recidiva Local de Neoplasia/patologia , Intervalo Livre de ProgressãoRESUMO
BACKGROUND: Pseudocapsules were first identified in pituitary adenoma surgery in 1936. Since then, the distinction between pituitary capsules and pseudocapsules has been unclear, and the definitions of these entities have varied. In this study, pituitary capsules and extracapsular dissection were examined retrospectively, intra- and extrapseudocapsular resection was evaluated, and dissection of the pituitary adenoma and pseudocapsule was examined prospectively. METHODS: Between January 2009 and May 2012, endoscopic transsphenoidal pituitary surgery was performed on 224 patients in the Department of Neurosurgery, Kocaeli University Faculty of Medicine, Turkey. Data for 174 patients were analyzed retrospectively between January 2009 and December 2011, and 50 patients treated between December 2011 and May 2012 were included in a prospective study. RESULTS: In the retrospective phase of the study, capsules were examined in 21 of the 174 patients on whom extracapsular resection had been performed. In the 50 cases treated between December 2011 and May 2012, dissection of the pituitary capsule, adenohypophysis, and pseudocapsule was performed. In 30 patients in the prospective phase of the study, pseudocapsules were identified during intraoperative endoscopic observation. Remission was achieved in 28 of 33 functioning adenomas in the prospective study. The mean follow-up period in this group was 13 months. CONCLUSION: The endoscopic and histopathological evidence provided in this study demonstrates that the pituitary capsule and pseudocapsule are distinct structures. In addition, it is also shown that extracapsular dissection can be performed in functioning adenomas that invade the suprasellar region. Significantly higher rates of total resection and higher remission rates were observed in cases where extra- and intrapseudocapsular dissection was required.
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Adenoma , Endoscopia/métodos , Procedimentos Neurocirúrgicos , Neoplasias Hipofisárias/patologia , Adenoma/cirurgia , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Neurocirúrgicos/métodos , Neoplasias Hipofisárias/cirurgia , Estudos Prospectivos , Resultado do TratamentoRESUMO
OBJECTIVE: The classically recommended first-line therapy for microprolactinomas is medical therapy. In the presence of drug resistance and intolerance after the use of dopamine agonists or when the patients prefer surgery instead of medication, surgical treatment is considered as second-line treatment. The high hormonal remission and low complication rates after surgery for microprolactinomas suggest that the surgical outcome of endoscopic surgeries may be better than medical therapy in well-selected patients. This study reports a large series of patients with microprolactinoma treated by endoscopic transnasal approach and evaluates the efficiency of surgical treatment. METHODS: Our study is a retrospective cohort analysis of patients with microprolactinoma operated on by an endoscopic transnasal approach between August 1997 and February 2022 by an experienced pituitary surgeon in a single tertiary center. Inclusion criteria for microprolactinoma were based on increased prolactin levels, microadenoma (<10 mm in diameter) on pituitary magnetic resonance imaging, and histopathologically verified lactotroph adenoma. RESULTS: The mean follow-up was 74.90 months (range, 6-207). The postoperative day 1 remission rate was 85.7% and the long-term remission rate was 74.3%. The long-term remission rates of the patients in the preference group were significantly higher than those of the patients in the resistant or intolerance group (P = 0.002). Patients who used dopamine agonists for more than 3 years had a lower remission rate compared with patients who used dopamine agonists for a shorter period or who did not use it (P = 0.01). The surgical complication rate was 4.76%. CONCLUSIONS: According to our findings, endoscopic transnasal surgery performed by an experienced neurosurgeon in well-selected patients with microprolactinoma can be offered with cure rates superior to medical therapy and may be an alternative first-line treatment option to dopamine agonists.
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Neoplasias Hipofisárias , Prolactinoma , Humanos , Prolactinoma/diagnóstico por imagem , Prolactinoma/tratamento farmacológico , Prolactinoma/cirurgia , Neoplasias Hipofisárias/diagnóstico por imagem , Neoplasias Hipofisárias/tratamento farmacológico , Neoplasias Hipofisárias/cirurgia , Agonistas de Dopamina/uso terapêutico , Estudos Retrospectivos , Resultado do TratamentoRESUMO
AIM: To determine the limits, to show the effect of tumor consistency on resection rates and to present the sinonasal morbidity rate in patients with tuberculum sellae meningiomas who underwent endoscopic endonasal approach. MATERIAL AND METHODS: We reviewed the medical data, radiological images, and surgical videos of the patients with pathologically confirmed meningiomas originating from the tuberculum sellae and they were operated via endoscopic endonasal approach between August 1997 and December 2020. We used our endoscopic classification based on infrachiasmatic corridor. In this classification, tumors were divided into those within the infrachiasmatic corridor and proximity of the optic nerve, internal carotid artery, and anterior artery complex and those outside the infrachiasmatic corridor. RESULTS: Gross total resection was achieved in 45/60 (75%) patients. We found that tumor consistency was statistically significant on resection rates. Simultaneously, tumor median diameters on the anteroposterior (≤21.15 mm), transverse (≤19.75 mm), and superoinferior (≤15 mm) axes were statistically significant on resection rates. CONCLUSION: In summary, the most important factor in selecting the surgical technique is the tumor size. Infrachiasmatic corridor boundaries are the limitations of endoscopic approach. These limitations can change based on surgeon's experience. Also, tumor consistency is a factor that affecting degree of tumor resection rates.
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Neoplasias Meníngeas , Meningioma , Neuroendoscopia , Neoplasias da Base do Crânio , Humanos , Meningioma/diagnóstico por imagem , Meningioma/cirurgia , Meningioma/patologia , Neoplasias Meníngeas/diagnóstico por imagem , Neoplasias Meníngeas/cirurgia , Neoplasias Meníngeas/patologia , Neuroendoscopia/métodos , Resultado do Tratamento , Nariz/patologia , Sela Túrcica/diagnóstico por imagem , Sela Túrcica/cirurgia , Neoplasias da Base do Crânio/diagnóstico por imagem , Neoplasias da Base do Crânio/cirurgiaRESUMO
We assessed the potential retinal microcirculation alterations for postoperative visual recovery in sellar/paraseller tumor patients with Optical Coherence Tomography Angiography (OCT-A). Two hundred ten eyes with sellar/parasellar tumor for which preoperative and postoperative (3 months) MRI Scans, Visual Acuity Test, Optical Coherence Tomography (OCT), OCT-A and, Visual Field Test data were available, besides 92 healthy eyes were evaluated. In the preoperative phase, significant reductions were observed in retinal vascular densities in various regions, including the Superficial Retinal Capillary Plexus (SRCP) (whole: p < 0.001, fovea: p = 0.025, parafovea: p < 0.001), Deep Retinal Capillary Plexus (DRCP) (whole: p < 0.001, fovea: p = 0.003, parafovea: p < 0.001), Peripapillary Vascular Density (PVD) (whole: p = 0.045, peripapillary: p < 0.001, nasal: p < 0.001, inferior: p < 0.001, temporal: p < 0.001), and Retinal Nerve Fiber Layer (RNFL) (nasal: p = 0.024, inferior: p < 0.001, temporal: p < 0.001, superior: p < 0.001) compared to the healthy control group. After surgery, the postoperative data of patients without chiasmal distortion were compared to their preoperative data. In the postoperative evaluation, significant increases were observed in vascular densities in patients without chiasmal distortion in the SRCP (whole: p < 0.001, parafovea: p = 0.045), DRCP (whole: p = 0.007, fovea: p = 0.006, parafovea: p = 0.040), PVD (peripapillary: p = 0.010, inferior: p < 0.001, temporal: p < 0.001, superior: p < 0.001), and RNFL (nasal: p = 0.011, inferior: p = 0.034, temporal: p = 0.046, superior: p = 0.011). Furthermore, significant associations were observed in the ROC analysis between the postoperative Visual Field Mean Deviation (VFMD) and SRCP (whole AUC = 0.793, p < 0.001, cut-off = 51.45, parafovea AUC = 0.820, p < 0.001, cut-off = 53.95), DRCP (whole AUC = 0.818, p < 0.001, cut-off = 55.95, parafovea AUC = 0.820, p < 0.001, cut-off = 59.05), PVD (temporal AUC = 0.692, p < 0.001, cut-off = 55.10), and RNFL (whole AUC = 0.690, p = 0.001, cut-off = 119.5, inferior AUC = 0.712, p < 0.001, cut-off = 144.75). These findings indicate a potential role of pre and post-operative OCT-A measurements in the assessment of surgical timing and postoperative visual recovery in patients with or without optic chiasm distortion.
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Neoplasias , Tomografia de Coerência Óptica , Humanos , Descompressão Cirúrgica , Vértebras Lombares , Angiografia , Retina/diagnóstico por imagemRESUMO
AIM: To demonstrated demyelination and remyelination of the optic nerve histologically by electron microscopy in an experimental model similar to the compression of pituitary adenomas on the optic chiasm. MATERIAL AND METHODS: The rats were fixed to a stereotaxic device under deep anesthesia, and a balloon catheter was placed under the optic chiasm through a burr hole which was in front of the bregma in accordance with the brain atlas of rats. The animals were divided into five groups (n=8): control, mild compression demyelination, severe compression demyelination, mild compression remyelination, severe compression remyelination. The fine structures of the tissues obtained were evaluated using electron microscopy. RESULTS: We found a significant difference in the severity of degeneration when comparing group 1 with group 5 (p < 0.001); there was no degeneration in group 1 rats and severe degeneration in all of the group 5 rats. Oligodendrocytes were found in all rats in group 1 and none of the rats in no group 2. The nuclei were preserved in the group 1 rats but damaged in all of the group 5 rats. There were no lymphocytes or erythrocytes in group 1 and all positives in group 5. CONCLUSION: This technique, which induced degeneration without causing damage to the optic nerve with toxic or chemical agents, revealed Wallerian degeneration similar to tumoral compression. After compression relief, the optic nerve remyelination process can be better understood, particularly for sellar lesions. In our opinion, this model may guide future experiments to identify protocols to induce and accelerate remyelination.
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Doenças Desmielinizantes , Remielinização , Ratos , Animais , Quiasma Óptico/patologia , Nervo Óptico/patologia , Doenças Desmielinizantes/induzido quimicamente , Doenças Desmielinizantes/patologia , Modelos TeóricosRESUMO
OBJECTIVE: Pediatric pituitary adenomas are rare lesions and account for approximately 3% of all supratentorial tumors in children. There is a paucity of reports on endoscopic transsphenoidal surgery in children. The aim of this study was to assess the early/late outcomes of endoscopic pediatric pituitary adenoma surgery at a high-volume tertiary center, as well as to characterize the factors associated with aggressive growth, including the histopathological features. METHODS: Between August 1997 and June 2022, a total of 3256 patients underwent endoscopic transsphenoidal surgery for pituitary adenoma at the Department of Neurosurgery and Pituitary Research Center of the Kocaeli University School of Medicine. Of these, 70 (2.1%) pediatric patients (25 males, 45 females) (age ≤18 years) with a pathological diagnosis of pituitary adenoma were retrospectively reviewed. RESULTS: The mean age of patients was 15.5 ± 2.3 years. Among the hormone-secreting adenomas, 19 (34.5%) were adrenocorticotrophic hormone secreting, 13 (23.6%) were growth hormone secreting, 19 (34.5%) were prolactin secreting, and 4 (7.2%) were both growth hormone-prolactin secreting. Gross total resection was achieved in 93.3% of nonfunctional tumors. The early/late surgical remission rates for hormone-secreting adenomas were 61.5%/46.1% (mean follow-up: 63.7 ± 49.3 months) for acromegaly, 78.9%/68.4% (47.8 ± 51.0 months) for Cushing disease, 57.8%/31.5% (72.2 ± 59.5 months) for prolactinoma, and 25%/25% (35.2 ± 31.4 months) for growth hormone-prolactin-secreting adenomas. Five sparsely granulated corticotroph tumors, 5 sparsely granulated somatotroph tumors, and 11 densely granulated lactotroph tumors were classified as aggressive histopathological subtypes. CONCLUSIONS: The unique characteristics of the pediatric population and the aggressiveness of the disease in this population pose considerable therapeutic challenges. To increase treatment success, current adjuvant therapies that are appropriate for the morphological and biological characteristics of the tumor are required in addition to surgical treatment.
Assuntos
Adenoma , Neoplasias Hipofisárias , Masculino , Feminino , Humanos , Criança , Adolescente , Neoplasias Hipofisárias/cirurgia , Neoplasias Hipofisárias/patologia , Estudos Retrospectivos , Prolactina , Adenoma/cirurgia , Adenoma/patologia , Hormônio do Crescimento , Resultado do TratamentoRESUMO
OBJECTIVE: Giant pituitary adenoma is considered a challenging pathology for surgery owing to its complications and low resection rate. In this study, the authors present their experience of using the endoscopic endonasal approach to treat patients with giant pituitary adenoma, and they aimed to develop a classification system for prediction of extent of resection. METHODS: The institutional medical records of patients diagnosed with giant pituitary adenoma who underwent endoscopic endonasal transsphenoidal surgery between August 1997 and December 2019 were retrospectively reviewed. Surgical and clinical outcomes were evaluated in detail. The effects of tumor characteristics on extent of resection were analyzed. The findings were used to develop two classification systems that could preoperatively predict extent of resection. Morphological score was based on tumor characteristics, and landmark-based classification was defined according to surgical zones based on neurovascular landmarks. The effects of change in surgical strategy, which aimed to maximize tumor resection and capsule dissection, on rates of resection and complications were evaluated before and after 2017. RESULTS: This study included 205 patients, with a mean patient age of 46.95 years and mean preoperative tumor diameter of 46.56 mm. Gross-total resection (GTR) was achieved in 35.12% of patients, near-total resection (NTR) in 39.51%, and subtotal resection (STR) in 25.36%. Extent of resection differed significantly between the grades and zones of the classification systems (p < 0.001 for both). Among patients with grade 3 tumor, 75.75% of patients achieved STR, 21.21% achieved NTR, and 3.03% achieved GTR. Among patients with zone 3 tumor, 65.75% achieved STR, 32.87% achieved NTR, and 1.36% achieved GTR. Both grade 3 and zone 3 indicated limited extent of resection. The mean (range) follow-up duration was 50.16 (9-247) months. Postoperative recovery of at least one hormone axis was seen in 15.24% of patients with pituitary deficiency, and development of new hormonal deficiency was observed in 22.43% of patients. Complications included permanent diabetes insipidus (7.80%), cerebrospinal fluid leakage (3.90%), postoperative apoplexy (3.90%), meningitis (3.41%), and epistaxis (3.41%). The surgical mortality rate was 1.46%. Among 85 patients treated before 2017, 27.05% of patients achieved GTR, 37.64% achieved NTR, and 35.29% achieved STR; among 120 patients treated after 2017, 40.83% achieved GTR, 40.83% achieved NTR, and 18.33% achieved STR. Seven patients in the pre-2017 cohort had postoperative apoplexy versus only 1 patient in the post-2017 cohort. There were no statistically significant differences between the two periods in terms of the incidence rates of other complications. CONCLUSIONS: Capsule dissection and GTR are valuable for preventing serious complications and reducing recurrence of giant adenoma. Treatment of giant pituitary adenoma may be better managed with the help of a classification system that provides information about extent of resection that can be achieved with an endoscopic approach.
Assuntos
Adenoma , Neoplasias Hipofisárias , Acidente Vascular Cerebral , Adenoma/patologia , Humanos , Pessoa de Meia-Idade , Neoplasias Hipofisárias/patologia , Estudos Retrospectivos , Acidente Vascular Cerebral/complicações , Resultado do TratamentoRESUMO
Hypophysitis (HP) is a rare disease which develops secondary to chronic or acute inflammation of the pituitary gland and may cause symptoms related to pituitary dysfunction and mass compression. Lymphocytic HP is the most common subtype of primary HP, while xanthomatous HP (XHP) is considered the rarest form, with 35 reported cases, to date. A 35-year-old woman was initially admitted to a Gynecology clinic with a 2-year history of amenorrhea and headache. She was started on cabergoline 0.5 mg twice a week for macroprolactinoma. Due to persistent amenorrhea with low gonadotropins, she was referred to our Endocrinology clinic. Her pituitary function profile revealed panhypopituitarism and a 13×11×12 mm sized sellar mass with diffuse enhancement which sustained toward the infundibulum and dura was observed on the gadolinium-enhanced pituitary MRI. The patient underwent an endoscopic endonasal transsphenoidal approach for tumor resection and thick yellowish fluid draining from the lesion was observed. The histopathological diagnosis was reported as a rupture of an Rathke's cleft cyst and an XHP. The surgery did not improve the symptoms/pituitary functions, however, headache recovered immediately after the first dose of high dose methylprednisolone treatment. The inflammatory process in a xanthomatous lesion may actually be a secondary response to mucous fluid content release from a ruptured cyst, thus recommended to classify XHP as secondary hypophysitis. Since the differentiation of XHP from other pituitary tumors may be challenging preoperatively, surgery is the major diagnostic tool and also, the most recommended therapeutic option.
RESUMO
OBJECTIVE: To analyze surgical outcomes and tumor characteristics of 49 patients with thyrotropin-secreting pituitary adenoma, a rare functional pituitary adenoma subtype with challenging surgery, who underwent endoscopic endonasal transsphenoidal surgery. METHODS: In this single-center study, clinical, radiological, surgical, and endocrinological data of 49 patients diagnosed with thyrotropin-secreting pituitary adenoma were retrospectively reviewed. RESULTS: Mean tumor size was 21.12 mm (6 microadenomas, 41 macroadenomas, 2 giant adenomas). Cavernous sinus invasion was present in 12 (24.48%) patients. Tumor consistency was firm in 23 (46.93%) patients. Plurihormonal secretion characteristics were present in 9 patients (5 growth hormone + thyrotropin and 4 growth hormone + prolactin + thyrotropin). Mean follow-up duration was 51.73 months. Of the cases with firm tumors, 14 patients had a history of antithyroid drug use; there was no statistically significant correlation between the antithyroid medication and the firmness of the tumor. Gross total resection was achieved in 32 (65.30%) cases, near-total resection was achieved in 14 (28.57%) cases, and subtotal resection was achieved in 3 (6.12%) cases. The analysis showed that the negative effect of >2 cm tumor size and cavernous sinus invasion on resection rate was statistically significant (P < 0.001). Although early remission was achieved in 33 (67.34%) patients, 44 (89.79%) patients were in euthyroid state at >3 months' follow-up. Complications were 4 new-onset pituitary deficiencies, 3 cases of permanent diabetes insipidus, 1 thyrotoxic crisis, and 1 cerebrospinal fluid leak. CONCLUSIONS: Endoscopic endonasal transsphenoidal surgery is the first-line treatment in thyrotropin-secreting pituitary adenoma and should be performed in a tertiary center. Gross total resection is the goal, and early diagnosis is essential for surgical success.