Transcranial approach in giant pituitary adenomas: results and outcome in a modern series.

BACKGROUND: Today, transcranial (TC) approach indications are particularly rare in pituitary adenomas (PA), representing 1.1% of all PA surgeries in our experience. In these rare and selected cases, the complications, advantages, and disadvantages of TC approach were also analyzed. METHODS: Nineteen cases of giant PA (≥40 mm) operated via TC approach alone or combined with transsphenoidal (TS) approach between 2000 and 2016 were selected. RESULTS: The most frequently observed symptom was visual disturbance. Most PA (79%) were non-secreting. Only one tumor was aggressive. Maximal diameter average was 51.5 mm. Tumor removal was total, subtotal and partial in respectively 21%, 68.5%, and 10.5% of cases. Mean follow-up was 57 months. No recurrence was observed after total tumor removal. Visual improvement was observed in 53% of patients. Visual impairment rate was 21% after TC approach. New cases of panhypopituitarism were reported in 26.5% of patients in the TC approach. Total (including definitive and transient) postoperative diabetes insipidus occurred in 42% of patients in the TC approach. Ischemic and hemorrhagic complications were observed in 16% and 10.5% of patients, respectively, in the TC approach. Preoperative neurocognitive disturbance was identified in 31.5% of patients and only 16.5% of them showed postoperative improvement. Neurocognitive examination showed impaired results in 7.5% of patients with normal preoperative examination. CONCLUSIONS: TC approach remains a requirement in giant and invasive PAs non-accessible via TS approach. However, the high morbidity associated with TC approach, including ischemic complications and visual impairment, has to be balanced with patient preoperative symptoms, and benign features of the tumor.

Association of Autofluorescence-Based Detection of the Parathyroid Glands During Total Thyroidectomy With Postoperative Hypocalcemia Risk: Results of the PARAFLUO Multicenter Randomized Clinical Trial.

Importance: Because inadvertent damage of parathyroid glands can lead to postoperative hypocalcemia, their identification and preservation, which can be challenging, are pivotal during total thyroidectomy. Objective: To determine if intraoperative imaging systems using near-infrared autofluorescence (NIRAF) light to identify parathyroid glands could improve parathyroid preservation and reduce postoperative hypocalcemia. Design, Setting, and Participants: This randomized clinical trial was conducted from September 2016 to October 2018, with a 6-month follow-up at 3 referral hospitals in France. Adult patients who met eligibility criteria and underwent total thyroidectomy were randomized. The exclusion criteria were preexisting parathyroid diseases. Interventions: Use of intraoperative NIRAF imaging system during total thyroidectomy. Main Outcomes and Measures: The primary outcome was the rate of postoperative hypocalcemia (a corrected calcium <8.0 mg/dL [to convert to mmol/L, multiply by 0.25] at postoperative day 1 or 2). The main secondary outcomes were the rates of parathyroid gland autotransplantation and inadvertent parathyroid gland resection. Results: A total of 245 of 529 eligible patients underwent randomization. Overall, 241 patients were analyzed for the primary outcome (mean [SD] age, 53.6 [13.6] years; 191 women [79.3%]): 121 who underwent NIRAF-assisted thyroidectomy and 120 who underwent conventional thyroidectomy (control group). The temporary postoperative hypocalcemia rate was 9.1% (11 of 121 patients) in the NIRAF group and 21.7% (26 of 120 patients) in the control group (between-group difference, 12.6% [95% CI, 5.0%-20.1%]; P = .007). There was no significant difference in permanent hypocalcemia rates (0% in the NIRAF group and 1.6% [2 of 120 patients] in the control group). Multivariate analyses accounting for center and surgeon heterogeneity and adjusting for confounders, found that use of NIRAF reduced the risk of hypocalcemia with an odds ratio of 0.35 (95% CI, 0.15-0.83; P = .02). Analysis of secondary outcomes showed that fewer patients experienced parathyroid autotransplantation in the NIRAF group than in the control group: respectively, 4 patients (3.3% [95% CI, 0.1%-6.6%) vs 16 patients (13.3% [95% CI, 7.3%-19.4%]; P = .009). The number of inadvertently resected parathyroid glands was significantly lower in the NIRAF group than in the control group: 3 patients (2.5% [95% CI, 0.0%-5.2%]) vs 14 patients (11.7% [95% CI, 5.9%-17.4%], respectively; P = .006). Conclusions and Relevance: The use of NIRAF for the identification of the parathyroid glands may help improve the early postoperative hypocalcemia rate significantly and increase parathyroid preservation after total thyroidectomy. Trial Registration: ClinicalTrials.gov Identifier: NCT02892253.

Ophthalmoplegic complications in transsphenoidal pituitary surgery.

OBJECTIVE: Ophthalmoplegia is a rare complication of transsphenoidal surgery, only noted in a few studies. The purpose of this study was to analyze the complications of cranial nerve III, IV, or VI palsy after transsphenoidal surgery for pituitary adenoma and understand its physiopathology and outcome. METHODS: The authors retrospectively analyzed 24 cases of postoperative ophthalmoplegia selected from the 1694 patients operated via a transsphenoidal route in their department. RESULTS: Two patients were operated on via microscopy and 22 via endoscopy. Patients operated on endoscopically had a greater risk of presenting with an extraocular nerve deficit postoperatively (p = 0.0115). It was found that an extension into or an invasion of the cavernous sinus (Knosp grade 3 or 4 on MRI, 18/24 patients) was correlated with a higher risk of postoperative ophthalmoplegia (p < 0.0001). The deficit was apparent immediately after surgery in 2 patients. For these 2 patients, the mechanisms of ophthalmoplegia were compression or intraoperative nerve lesion. The other 22 patients became symptomatic in the 12-72 hours following the surgery. The mechanisms implied in these cases were intrasellar compressive hematoma (4/22 cases), intracavernous hemorrhagic suffusion, or incomplete resection of the intracavernous portion of the tumor. All patients who did not present with oculomotor palsy immediately after surgery completely recovered their deficits in the 3 months that followed, while the other 2 experienced permanent damage. CONCLUSIONS: Extraocular nerve dysfunction after transsphenoidal pituitary surgery is a rare complication that occurs more frequently in the case of the invasion or an important extension into the cavernous sinus. In this series, it also appears to be significantly more frequent in patients operated on via an endoscopic approach. Most patients have deficits that appear with a delay of 12-72 hours postoperatively and they are most likely to completely recover.

Complications Related to the Endoscopic Endonasal Transsphenoidal Approach for Nonfunctioning Pituitary Macroadenomas in 300 Consecutive Patients.

OBJECTIVE: To analyze complications of endoscopic transsphenoidal surgery (ETS) for nonfunctioning pituitary macroadenomas (NFPAs). METHODS: A retrospective study of 300 NFPAs was performed. Complications and factors that could influence these complications were analyzed. RESULTS: Visual and pituitary functions worsened in 2.4% and 13.7% of cases, respectively. Postoperative diabetes insipidus was permanent in 6.2% of cases. Postoperative meningitis occurred in 3.3% of patients. Meningitis was strongly associated with intraoperative cerebrospinal fluid (CSF) leaks (P = 0.01), postoperative CSF leaks (P = 0.0001), and operation times longer than 1 hour (P = 0.023). Detection of Staphylococcus aureus and preoperative treatment with mupirocin in the nostrils did not impact the occurrence of meningitis. Two patients with meningitis died (unique causes of death). Postoperative CSF leaks occurred in 2.7% of cases and were associated with intraoperative CSF leaks (P = 0.007) and permanent diabetes insipidus (P = 0.028). The rate of CSF leak decreased from 4% to 0.8% (P = 0.048) after we moved from a soft to hard reconstruction of the sella. The rate of postoperative epistaxis decreased from 6.7% to 1.25% after we stopped using monopolar coagulation (P = 0.013). CONCLUSIONS: ETS permits a wide view, allowing good conditions for a satisfactory resection in the majority of NFPAs. Some pitfalls of endoscopy can lead to complications that improve with modification of the operative technique (i.e., CSF leak and postoperative epistaxis). This study confirms an acceptable rate of complications associated with ETS.

[Kinetic values of lymphoscintigraphy of sentinel ganglion in cutaneous cervicofacial melanomas]. / Valeurs cinetiques de la lymphoscintigraphie du ganglion sentinelle dans les melanomes malins cutanes cervico-faciaux.

OBJECTIVE: The aim of this study was to evaluate the lymphoscintigraphy appearance time (LAT) of the sentinel lymph node (SLN) in head and neck cutaneous melanoma and to determine whether a correlation exists between LAT and SLN status (negativity or positivity). DESIGN/SETTING: In vivo study. MATERIALS AND METHODS: A retrospective cohort of 33 patients with Breslow index >or= 1.5 mm, Clark index >or= 4 mm, and ulceration > 1 mm underwent a lymphoscintigraphy and SLN biopsy for a cutaneous head and neck melanoma. MAIN OUTCOME MEASURES: LAT was noted and correlated to SLN status, Breslow and Clark indices, ulceration, and recurrence. RESULTS: Sixty SLNs were identified; 58 were removed, and 17 were positive. In 31% (n = 18), the LAT was < 10 minutes; in 59% (n = 34), the LAT was > 10 minutes and < 30 minutes; and in 10% (n = 6), the LAT was > 30 minutes. SLN was significantly positive (p = .02) when the LAT was less than 10 minutes and the negative predictive value was 100% for LAT > 30 minutes. A recurrence was significantly observed (p = .02) for LAT < 10 minutes. CONCLUSION: LAT > 30 minutes is associated with negative SLN in head and neck melanoma; however, a prospective study on a more important cohort is needed for a better evaluation of this new variable.