Combined simultaneous transsphenoidal and transcranial regimen improves surgical outcomes in complex giant pituitary adenomas: A longitudinal retrospective cohort study.

BACKGROUND: Surgical treatment of complex giant pituitary adenomas (GPAs) presents significant challenges. The efficacy and safety of combining transsphenoidal and transcranial approaches for these tumors remain controversial. In this largest cohort of patients with complex GPAs, we compared the surgical outcomes between those undergoing a combined regimen and a non-combined regimen. We also examined the differences in risks of complications, costs, and logistics between the two groups, which might offer valuable information for the appropriate management of these patients. MATERIALS AND METHODS: This was a multicenter retrospective cohort study conducted at 13 neurosurgical centers. Consecutive patients who received a combined or non-combined regimen for complex GPAs were enrolled. The primary outcome was gross total resection, while secondary outcomes included complications, surgical duration, and relapse. A propensity score-based weighting method was used to account for differences between the groups. RESULTS: Out of 647 patients (298 [46.1%] women, mean age: 48.5 ± 14.0 years) with complex GPAs, 91 were in the combined group and 556 were in the non-combined group. Compared with the non-combined regimen, the combined regimen was associated with a higher probability of gross total resection (50.5% vs. 40.6%, odds ratio [OR]: 2.18, 95% confidence interval [CI]: 1.30-3.63, P = 0.003). The proportion of patients with life-threatening complications was lower in the combined group than in the non-combined group (4.4% vs. 11.2%, OR: 0.25, 95% CI: 0.08-0.78, P = 0.017). No marked differences were found between the groups in terms of other surgical or endocrine-related complications. However, the combined regimen exhibited a longer average surgery duration of 1.3 h (P < 0.001) and higher surgical costs of 22,000 CNY (approximate 3,000 USD, P = 0.022) compared with the non-combined approach. CONCLUSIONS: The combined regimen offered increased rates of total resection and decreased incidence of life-threatening complications, which might be recommended as the first-line choice for these patients.

Presurgical Medical Treatment in Prolactinomas: Surgical Implications and Pathological Characteristics from 290 Cases.

OBJECTIVE: To review experience regarding the treatment of prolactinomas by endoscopic endonasal surgery (EES) focusing on the association between presurgical dopamine agonist (DA) treatment and perioperative outcomes, surgical morbidities, endocrine outcomes and pathological characteristics. METHODS: A single-center series of 290 cases were analyzed retrospectively and clinical data were collected. Intratumoural collagen content was assessed by Masson's trichrome staining. RESULTS: Tenacious tumor consistency (27.8% vs 9.8%, p < 0.001) was more common in DA pretreated patients compared to patients who prefer initial surgery. Moreover, DA pretreated macroadenomas presented more intraoperative blood loss (200 [100-400] ml vs 175 [100-300] ml, p = 0.014), longer surgical duration (177±95 mins vs 154±57 mins, p = 0.043) and more surgical morbidities (19.4% vs 8.9%, p = 0.034). Additionally, DA pretreated macroadenomas presented higher collagen volume fraction (CVF) than that of the initial surgery group (23.6 ± 2.2% vs 13.2 ± 2.1%, p = 0.001). Correlation analysis revealed a close correlation between CVF and the cumulative dose of bromocriptine (BRC) in macroadenomas (r = 0.438, p < 0.001). Regarding to endocrine outcomes, DA pretreated microadenomas showed lower proportion of initial remission compared to microadenomas who prefer initial surgery (86.7% vs 100%, p = 0.047). CONCLUSIONS: This study described increased surgical difficulty and inferior endocrine outcomes which associated with tumor fibrosis secondary to presurgical BRC treatment in prolactinomas. Neurosurgeons should be noticed that presurgical BRC treatment may render subsequent surgery more challenging.

How I do it? Endoscopic endonasal transpterygoid repair of sphenoid lateral recess cerebrospinal fluid leak after previous unsuccessful transcranial surgery.

BACKGROUND: Direct access to the sphenoid lateral recess offers the best chance of sealing spontaneous cerebrospinal fluid (CSF) rhinorrhea caused by lateral sphenoid encephaloceles of the Sternberg canal defect. METHOD: We present a case of spontaneous left-sided sphenoid lateral recess CSF leak after previous unsuccessful transcranial surgery managed with an endoscopic endonasal transpterygoid approach (EETA). An anatomical-based step-by-step illustration of the EETA was presented in the surgical video. CONCLUSION: This case demonstrates the value of endoscopic endonasal transpterygoid corridor in the exposure and manipulation of the sphenoid lateral recess.

Digital image analysis allows objective stratification of patients with silent PIT1-lineage pituitary neuroendocrine tumors.

Studies describing the clinical presentation and prognosis of patients with silent PIT1 (pituitary specific transcription factor)-lineage pituitary neuroendocrine tumors (PitNETs) are rare. We identified patients with positive PIT1 tumor staining but without evidence of hormone hypersecretion at a tertiary center. Clusters were obtained according to cell morphology and immunostaining from each patient's digitally segmented whole slide image. We compared the clinical presentations, radiological features, and prognoses of the different clusters. We identified 146 patients (68 male, 42.9 ± 14.1 years old) with silent PIT1-lineage PitNETs. Morphology clustering suggested that tumors with large nuclei and apparent eccentricity were associated with a higher proportion of aggressiveness and a higher hazard of recurrence [hazard ratio (HR): 2.64, (95% CI, 1.06-6.55), p = 0.037]. Immunohistochemical clustering suggested that tumors with thyroid stimulating hormone (TSH) staining or all negative PIT1-lineage hormones were associated with a higher proportion of aggressiveness and a higher risk of recurrence [HR: 12.4, (95% CI, 1.60-93.5), p = 0.015]. We obtained three-tier risk profiles by combining morphological and immunohistochemical clustering. Patients with the high-risk profile presented the highest recurrence rate compared with those in the medium-risk and low-risk profiles [HR: 3.54, (95% CI, 1.40-8.93), p = 0.002]. In conclusion, digital image analysis based on cell morphology and immunohistochemical staining allows objective stratification of patients with silent PIT1-lineage tumors. Typical morphological characteristics of high-risk tumors are large tumor nuclei and high eccentricity, and typical immunostaining characteristics are TSH staining or negative staining for all PIT1-lineage hormones.

Surgical strategy of pituitary and cavernous sinus exploration in MRI-Negative Cushing's disease after unsuccessful surgery.

MRI-Negative Cushing's disease continues to be a challenging disease despite better imaging and techniques. The situation can be more complicated in the setting of prior surgery or failed surgery. Often, a narrow surgical corridor is encountered with robust cavernous or intercavernous sinuses. Controlling venous oozing properly is critical to achieving better outcomes. In this video, the authors present a case of MRI-Negative Cushing's disease after previous unsuccessful surgery. The pituitary tumor was detected on the left side of the gland, close to the cavernous sinus. Margin-plus resection is important if it can be achieved. Biochemical remission was achieved after surgery. The video can be found here: https://stream.cadmore.media/r10.3171/2023.4.FOCVID2312.

The recovery time of hypothalamic-pituitary-adrenal axis after curative surgery in Cushing's disease and its related factor.

PURPOSE: Patients with Cushing's disease (CD) experienced transient central adrenal insufficiency (CAI) after successful surgery. However, the reported recovery time of hypothalamic-pituitary-adrenal (HPA) axis varied and the related factors which could affect recovery time of HPA axis had not been extensively studied. This study aimed to analyze the duration of CAI and explore the factors affecting HPA axis recovery in post-operative CD patients with biochemical remission. METHODS: Medical records of diagnosis with CD in Huashan Hospital were reviewed between 2014 and 2020. 140 patients with biochemical remission and regular follow-up after surgery were enrolled in this retrospective cohort study according to the criteria. Demographic details, clinical and biochemical information at baseline and each follow-up (within 2 years) were collected and analyzed. RESULTS: Overall, 103 patients (73.6%) recovered from transient CAI within 2 years follow-up and the median recovery time was 12 months [95% confidence intervals (CI): 10-14]. The age was younger and midnight ACTH at baseline was significantly lower, while the TT3 and FT3 levels were significantly higher in patients with recovered HPA compared to patients with persistent CAI at 2-year follow-up (p < 0.05). In persistent CAI group, more patients underwent partial hypophysectomy. TT3 at diagnosis was an independent related factor of the recovery of HPA axis, even after adjusting for gender, age, duration, surgical history, maximum tumor diameter, surgical strategy, and postoperative nadir serum cortisol level (p = 0.04, OR: 6.03, 95% CI: 1.085, 22.508). Among patients with unrecovered HPA axis at 2-year follow-up, 23 CAI patients (62%) were accompanied by multiple pituitary axis dysfunction besides HPA axis, including hypothyroidism, hypogonadism, or central diabetes insipidus. CONCLUSION: HPA axis recovered in 73.6% of CD patients within 2 years after successful surgery, and the median recovery time was 12 months. TT3 level at diagnosis was an independent related factor of postoperative recovery of HPA axis in CD patients. Moreover, patients coexisted with other hypopituitarism at 2-year follow-up had a high probability of unrecovered HPA axis.

Machine learning prediction of venous thromboembolism after surgeries of major sellar region tumors.

PURPOSE: To describe and predict the risk of venous thromboembolism (VTE) after surgical resection of major sellar region tumors. METHOD: Patients with sellar region tumors were identified from a database. The outcome was VTE, including deep vein thrombosis (DVT) and pulmonary embolism (PE) within 60 days after surgery. We trained regression and machine learning models to predict the outcome using baseline characteristics, surgical findings and postoperative laboratory tests. RESULTS: Among 3818 patients included, 124 patients developed VTE after surgery. The total 60-day VTE incidence was 3.2 %, with incidence peak within ten days after the surgery. The risk increased in patients >65 years old (OR 2.96, p < 0.001), in patients with chordoma (OR 3.40, p = 0.006) or craniopharyngioma (OR 1.86, p = 0.036), in patients underwent craniotomy approach (OR 2.78, p = 0.017), in patients with high volume CSF leakage (OR 4.24, p < 0.001), and in patients with longer surgical duration (OR 1.78, p = 0.029). The linear discriminant analysis algorithm had the highest AUC (0.869, 95%CI, 0.840-0.898) in predicting the outcome. The specificity, accuracy, and sensitivity of the best model were 61.8 %, 93.6 %, and 92.8 %, respectively. Risk stratification using our best model suggested that 1.3 % and 24.5 % of the patient developed VTE in the low-risk group and in the high-risk group, respectively. We developed an online decision-support tool available on https://deepvep.shinyapps.io/VTEpred/. CONCLUSION: The overall incidence of VTE after surgical resection of major sellar region tumors was clinically significant, especially in older patients with chordoma or craniopharyngioma.

Self-reported symptoms in patients with acromegaly: a 6-month follow-up in a single neurosurgical center.

Acromegaly is characterized by hypersecretion of growth hormone (GH) and insulin-like growth factor 1 (IGF-1), accompanied by a compromise in the perception of wellness. The Patient-Assessed Acromegaly Symptom Questionnaire (PASQ) is relevant to assessing signs and symptoms but is mainly used to evaluate the efficacy of a pharmacological intervention. To explore the perioperative variation in symptom severity, the divergence between subgroups stratified according to clinical outcomes or treatment modalities, and the interaction between symptom scores and clinical indices, we prospectively recruited 106 patients with acromegaly from 2016 to 2018. Oral glucose tolerance and GH tests were performed, and PASQ was administered before treatment and 6 months postoperatively. Patients were divided into active (n = 49) and remission (n = 57) groups according to postoperative GH and IGF-1 levels. PASQ scores and GH and IGF-1 levels decreased significantly postoperatively in both groups. A significantly higher preoperative headache score and greater extent of decrease in arthralgia were seen in the active and remission groups, respectively. No significant variation in PASQ scores was found between patients receiving surgery alone and those receiving preoperative somatostatin analogs. Preoperative fasting GH (GH0) levels were positively correlated with preoperative excessive perspiration. Further regression analyses validated the variation in GH0 as a noteworthy determinant of the extent of change in soft-tissue swelling, excessive perspiration, fatigue, and total PASQ scores. Patient-reported symptoms were substantially alleviated after surgery, independent of endocrine remission or use of preoperative somatostatin. A GH level decrease was a notable coefficient for PASQ scores.

Combined pre-retrochiasmatic resection of third ventricle craniopharyngioma by endoscopic endonasal approach.

BACKGROUNDS: Third ventricle craniopharyngioma (TVC) refers to the tumor originating from the tuberoinfundibular, and completely located in the third ventricle; unlike most TVCs, the retrochiasmatic-infundibulum corridor is too narrow to expose the tumor with anterior extension via an endoscopic endonasal approach. METHODS: Retrospective analysis of two TVCs via an endoscopic endonasal combined pre-retrochiasmatic approach. CONCLUSIONS: The tumor inside the third ventricle can be satisfactorily exposed through a combined pre-retrochiasmatic approach and be completely removed with the lowest injury of the hypothalamus and optic nerve.

Single-cell transcriptome reveals cellular hierarchies and guides p-EMT-targeted trial in skull base chordoma.

Skull base chordoma (SBC) is a bone cancer with a high recurrence rate, high radioresistance rate, and poorly understood mechanism. Here, we profiled the transcriptomes of 90,691 single cells, revealed the SBC cellular hierarchies, and explored novel treatment targets. We identified a cluster of stem-like SBC cells that tended to be distributed in the inferior part of the tumor. Combining radiated UM-Chor1 RNA-seq data and in vitro validation, we further found that this stem-like cell cluster is marked by cathepsin L (CTSL), a gene involved in the packaging of telomere ends, and may be responsible for radioresistance. Moreover, signatures related to partial epithelial-mesenchymal transition (p-EMT) were found to be significant in malignant cells and were related to the invasion and poor prognosis of SBC. Furthermore, YL-13027, a p-EMT inhibitor that acts through the TGF-ß signaling pathway, demonstrated remarkable potency in inhibiting the invasiveness of SBC in preclinical models and was subsequently applied in a phase I clinical trial that enrolled three SBC patients. Encouragingly, YL-13027 attenuated the growth of SBC and achieved stable disease with no serious adverse events, underscoring the clinical potential for the precision treatment of SBC with this therapy. In summary, we conducted the first single-cell RNA sequencing of SBC and identified several targets that could be translated to the treatment of SBC.

Recommendation to improve the WHO classification of posterior pituitary tumors as a unique entity: evidence from a large case series.

Introduction: Most studies reporting posterior pituitary tumors (PPTs) are small case series or single cases. Methods: Patients with a histological diagnosis of PPT from January 2010 to December 2021 in a tertiary center were identified. We reported clinical symptoms, endocrine assessments, radiological and pathological features, and surgical outcomes of PPTs. Results: A total of 51 patients (23 males, 51.3 ± 10.3 years old) with PPT were included in this study. Major symptoms were visual defects, headache, and hypopituitarism, while diabetes insipidus was uncommon (9.8%). The typical radiological feature was homogeneous enhancement (84.3%) of a regular-shaped mass on T1 contrast imaging without cystic change, calcification, or cavernous sinus invasion. We achieved gross total resection in 38/51 patients (74.5%). Pathologically, all tumors showed thyroid transcription factor 1 immunoreactivity. Among 29 patients with suprasellar PPTs, postoperative hemorrhage due to tumor residue was encountered in 2/15 cases in the transcranial group and 0/14 in the endoscopy group. Patients with spindle cell oncocytoma (SCO) were more likely to be surgically treated (25% vs 0%, P = 0.018), harbor a higher Ki-67 index (16.7% vs 0% > 5% P = 0.050), and present a lower 2-year recurrence-free survival rate (67.5% vs 90.9%) compared with patients with pituicytoma or granular cell tumor. Conclusion: PPTs should be considered in the differential diagnosis of patients with sellar and suprasellar masses with a regular lesion with homogeneous enhancement. SCOs had high proliferation activity and risk of recurrence.

How I do it? Resection of residual petrous apex chordoma with combined endoscopic endonasal and contralateral transmaxillary approaches.

BACKGROUND: The petrous apex is one of the most challenging areas of the skull base to access. METHOD: We present a case of residual petrous apex chordoma posterolateral to the paraclival segment of the internal carotid artery (ICA) resected with combined endoscopic endonasal and contralateral transmaxillary (CTM) approaches, without lateralization of the ICA. CONCLUSION: This case demonstrates the value of the CTM corridor in resecting petrous apex lesions that are posterolateral to the paraclival segment of the ICA.

The hypothalamic-pituitary-gonad axis in male Cushing's disease before and after curative surgery.

OBJECTIVE: Gonadal and sexual disturbances are commonly encountered in patients with Cushing's disease. Nevertheless, the prevalence of hypogonadism in male Cushing's disease, the risk factors as well as the recovery time have been scarcely reported. Therefore, we aimed to explore the prevalence of hypogonadism at baseline and its determinants. In addition, the recovery time of hypogonadism and risk factors for unrecovered gonadal axis in male Cushing's disease with biochemical remission were investigated. METHODS: We reviewed medical records of males with Cushing's disease managed between 2010 and 2020. Fifty-two male patients were enrolled according to the criteria. Each case attained biochemical remission after transsphenoidal surgery. Demographic details, clinical features, 24-hour UFC, hormonal profile [serum PRL, FSH, LH, TT, ACTH, cortisol, TT4/FT4, TT3/ FT3, TSH and IGF-1] were measured at baseline and during follow-up. The maximal tumor diameter on MRI was recorded at diagnosis. RESULTS: Hypogonadotropic hypogonadism was observed in thirty-nine patients (75%) at diagnosis. Total testosterone was negatively correlated with ACTH and 24-hour UFC. Midnight serum ACTH level at diagnosis was significantly associated with hypogonadism after adjusting for confounding factors. Thirty-two (80%) patients achieved eugonadism within 12 months after the surgery, of which twenty-eight (87.5%) achieved eugonadism within 3 months. Seven patients were persistently hypogonadal during the follow-up (≥1 year), mainly due to the hypopituitarism as a complication of the therapies such as surgery. CONCLUSION: Hypogonadotropic hypogonadism is frequent in male Cushing's disease, but it is reversible in most cases within one-year follow-up after remission.

Transcription Factor ASCL1 Acts as a Novel Potential Therapeutic Target for the Treatment of the Cushing's Disease.

BACKGROUND: The pathogenesis of Cushing's disease (CD) is still not adequately understood despite the identification of somatic driver mutations in USP8, BRAF, and USP48. In this multiomics study, we combined RNA sequencing (RNA-seq) with Sanger sequencing to depict transcriptional dysregulation under different gene mutation backgrounds. Furthermore, we evaluated the potential of achaete-scute complex homolog 1 (ASCL1), a pioneer transcription factor, as a novel therapeutic target for treatment of CD and its possible downstream pathway. METHODS: RNA-seq was adopted to investigate the gene expression profile of CD, and Sanger sequencing was adopted to detect gene mutations. Bioinformatics analysis was used to depict transcriptional dysregulation under different gene mutation backgrounds. The function of ASCL1 in hormone secretion, cell proliferation, and apoptosis were studied in vitro. The effectiveness of an ASCL1 inhibitor was evaluated in primary CD cells, and the clinical relevance of ASCL1 was examined in 68 patients with CD. RNA-seq in AtT-20 cells on Ascl1 knockdown combined with published chromatin immunoprecipitation sequencing data and dual luciferase assays were used to explore downstream pathways. RESULTS: ASCL1 was exclusively overexpressed in USP8-mutant and wild-type tumors. Ascl1 promoted adrenocorticotrophin hormone overproduction and tumorigenesis and directly regulated Pomc in AtT-20 cells. An ASCL1 inhibitor presented promising efficacy in both AtT-20 and primary CD cells. ASCL1 overexpression was associated with a larger tumor volume and higher adrenocorticotrophin secretion in patients with CD. CONCLUSION: Our findings help to clarify the pathogenesis of CD and suggest that ASCL1 is a potential therapeutic target the treatment of CD. SUMMARY: The pathogenesis of Cushing's disease (CD) is still not adequately understood despite the identification of somatic driver mutations in USP8, BRAF, and USP48. Moreover, few effective medical therapies are currently available for the treatment of CD. Here, using a multiomics approach, we first report the aberrant overexpression of the transcription factor gene ASCL1 in USP8-mutant and wild-type tumors of CD. Ascl1 promoted adrenocorticotrophin hormone overproduction and tumorigenesis and directly regulated Pomc in mouse AtT-20 cells. Notably, an ASCL1 inhibitor presented promising efficacy in both AtT-20 and primary CD cells. Importantly, ASCL1 overexpression was associated with a larger tumor volume and higher adrenocorticotrophin secretion in patients with CD. Thus, our findings improve understanding of CD pathogenesis and suggest that ASCL1 is a potential therapeutic target the treatment of CD.

Risk factors of epistaxis after endoscopic endonasal skull base surgeries.

BACKGROUND: Epistaxis after endoscopic endonasal skull base surgeries does not typically occur as an accidental circumstance but often results from multiple factors. We aimed to assess the possible risk factors associated with postoperative epistaxis. METHODS: Patients who underwent endoscopic endonasal skull base surgery at Huashan hospital from August 2018 to November 2019 were enrolled in the study. Postoperative epistaxis was defined as severe, persistent, or recurrent arterial nosebleed, which required therapeutic intervention. Patients were divided into the epistaxis and no epistaxis groups. The incidence, clinical characteristics, management, and intraoperative findings were recorded. RESULTS: A total of 762 patients were included in the study. 20 (2.6%) patients experienced postoperative epistaxis, which happened in a delayed fashion between 6 and 30 postoperative days. Multivariate logistic regression analysis showed that arterial hypertension (OR=3.394, 95%CI: 1.094-10.531, P = 0.034) and preoperative systolic blood pressure (SBP) (OR=1.035, 95%CI: 1.002-1.068) were identified as predictors for postoperative epistaxis. The bleeding sites were identified at the left posterior septal artery (PSA) in 10 (62.5%) cases, the right PSA in 4 (25%) cases, the left palatovaginal artery in 1 (6.25%) case, and the right inferior turbinate branch of the posterior lateral nasal artery in 1 (6.25%) case, respectively. Direct bipolar cauterization was used to stop the bleeding. After definitive treatment, no patients had recurrent epistaxis. CONCLUSIONS: Arterial hypertension and preoperative SBP were associated with postoperative epistaxis after endoscopic endonasal skull base surgery, and the left PSA contributed to the dominant site of bleeding during surgical re-exploration.

Collagen sponge is as effective as autologous fat for grade 1 intraoperative cerebral spinal fluid leakage repair during transsphenoidal surgery.

OBJECTIVE: To compare the efficacy of collagen sponge graft versus autologous fat graft in repairing grade 1 intraoperative CSF leakage and identify potential risk factors for failure repairing. METHODS: We retrospectively recruited patients with grade 1 intraoperative CSF leakage repaired either with a collagen sponge (Group A), with autologous fat graft (Group B), or with only bipolar coagulation and gel foam packing (Group C). Patients with previous radiotherapy, repaired with additional materials, received postoperative lumbar drainage or without sufficient follow-up data were excluded. The primary outcome was the incidence of postoperative CSF leakage. We used propensity score matching to adjust for confounding when comparing Group A and Group B. RESULTS: 459 patients (277 female and 182 male) were recruited. Among them, 296 patients were in Group A, 146 patients were in Group B, and the other 17 patients were in Group C. After propensity score matching, 146 and 146 patients were included in group A and group B, respectively. No difference was observed for the primary outcome in the matched cohort (p = 0.654) with three patients in Group A (1.0% and 2.1% before and after matching, respectively) and two patients in Group B (1.4% and 1.4% before and after matching, respectively) developed postoperative CSF leakage, respectively. Patients repaired only with gel foam and/or bipolar coagulation (OR 770.5, p < 0.001) and older age (OR 1.16, p < 0.001) were associated with a higher likelihood of postoperative CSF leakage. CONCLUSIONS: Collagen sponge is as effective as an autologous fat graft for grade 1 intraoperative CSF leakage repair during transsphenoidal surgery. Repair with gel foam and/or bipolar coagulation and older age are associated with a higher likelihood of postoperative CSF leakage.

Impact of Pituitary Stalk Preservation on Tumor Recurrence/Progression and Surgically Induced Endocrinopathy After Endoscopic Endonasal Resection of Suprasellar Craniopharyngiomas.

Objective: To investigate the factors associated with recurrence/progression after endoscopic endonasal resection of suprasellar craniopharyngiomas. Special attention was paid to assess the impact of pituitary stalk preservation on tumor recurrence/progression and endocrinological outcomes. Methods: We retrospectively recruited 73 patients with suprasellar craniopharyngiomas undergone endoscopic endonasal approach (EEA) surgery from September 2014 to May 2019 and assessed their clinical characteristics, surgical outcomes, and recurrence/progression. Stalk preservation or sacrifice was determined by reviewing operative records, videos, and post-operative magnetic resonance imaging. Results: Gross total resection (GTR) was achieved in 51 cases (69.9%). Tumor recurrence was seen in 5 cases (9.8%) and progression was seen in 8 cases (36.4%), respectively. GTR (OR = 0.248 CI 0.081-0.759; p = 0.015) was the only independent factor influencing recurrence/progression. Kaplan-Meier survival analysis showed that the mean recurrence/progression-free survival were 53 (95% CI 48-59) and 39 (95% CI 28-50) months, respectively, in patients with and without GTR (p = 0.011). Pituitary stalk preservation was more common in cases with peripheral type tumors (83% vs. 30%, p < 0.01). Preserving the pituitary stalk does not appear to decrease the percentage of GTR (75.5% vs. 55.0%, p = 0.089), or increase the rate of tumor recurrence (12.5% vs. 0%, p = 0.508) or progression (46.2% vs. 22.2%, p = 0.486). However, surgically induced hypothyroidism (60.5% vs. 100%, p = 0.041) and diabetes insipidus (35.1% vs. 81.8%, p = 0.017) were significantly lower in patients with stalk preservation. For patients who had hypopituitarism before EEA, there was no difference between those with and without stalk preservation regarding post-operative hypopituitarism (p > 0.05). Conclusion: GTR is the only independent predictor of recurrence/progression after EEA surgery for suprasellar craniopharyngiomas. Preserving the pituitary stalk does not appear to increase the risk of non-GTR and tumor recurrence/progression and might help reduce the risk of surgically induced hypothyroidism and diabetes insipidus. We recommend preserving the pituitary stalk in peripheral type suprasellar craniopharyngiomas with normal pituitary function, especially in cases without hypothyroidism or diabetes insipidus. On the other hand, stalk sacrifice could be considered in central type tumors with severe pre-operative endocrinopathy.

Comparative effectiveness of endoscopic versus microscopic transsphenoidal surgery for patients with growth hormone secreting pituitary adenoma: An emulated trial.

INTRODUCTION: Previous studies failed to show the benefit of endoscopic surgery over microscopic surgery in terms of early endocrine remission. This study was to investigate whether early endocrine outcomes in patients with GH-secreting pituitary adenoma underwent endoscopic transsphenoidal surgery would be better than those operated by microscopic surgery. METHODS: An acromegaly database collected from 2010 to 2019 in a single institution was used to emulate a randomized trial. Adult patients operated by a transsphenoidal approach using either endoscope or microscope were included. The primary outcome was endocrine remission based on insulin-like growth factor-1 (IGF-1) at six-month follow-up after surgery. We used inverse probability weighting to construct a pseudo population from which the treatment effect was estimated. RESULTS: In the original cohort, 1118 patients underwent transsphenoidal surgery (424 with an endoscopic approach and 694 with a microscopic approach). Patients treated with endoscopic surgery were more likely to be previously surgical treated and to have an invasive tumor than patients who underwent microscopic surgery. In the pseudo population, the proportion of endocrine remission was 54.9% in the endoscopic group and 42.0% in the microscopic group (odds ratio, 1.68; 95% CI, 1.27-2.23). This finding was consistent and robust across several sensitivity analyses. CONCLUSIONS: Among patients with growth hormone secreting pituitary adenoma who underwent transsphenoidal surgery, endoscopic surgery was associated with higher early endocrine remission than microscopic surgery.