Advertisement

Acta Neurochirurgica

, Volume 160, Issue 11, pp 2255–2262 | Cite as

Predicting extent of resection in transsphenoidal surgery for pituitary adenoma

  • Carlo SerraEmail author
  • Victor E. Staartjes
  • Nicolai Maldaner
  • Giovanni Muscas
  • Kevin Akeret
  • David Holzmann
  • Michael B. Soyka
  • Christoph Schmid
  • Luca Regli
Original Article - Pituitaries
Part of the following topical collections:
  1. Pituitaries

Abstract

Background

The extent of resection (EOR) is a crucial outcome parameter in transsphenoidal pituitary surgery (TSS), and is linked to endocrinological outcome, postoperative morbidity, and mortality. We aimed to build a robust, quantitative, and easily reproducible imaging score able to predict EOR in TSS.

Methods

The ratio (R) between the maximum horizontal adenoma diameter and intercarotid distance at the horizontal C4 segment was used to stratify our patient series in four classes: class I R ≤ 0.75, class II 0.75 < R ≤ 1.25, and class III R ≥ 1.25. Class IV included adenomas which completely encased the internal carotid artery. The resulting score was internally validated for robustness.

Results

One hundred sixteen patients were included in the study, of which 96 (83%) for derivation and 20 (17%) for validation. EOR showed significant differences between grades (grade I, 100%; II, 97.9%; III, 94.2%; IV, 87.2%; all P < 0.05). The same applied to residual volume (RV) (grade I, 0 cm3; II, 0.08 cm3; III, 1.11 cm3; IV, 1.63 cm3; all P < 0.05). Differences in gross total resection (GTR) were statistically significant among classes I, II, and III (P < 0.05). The incidence of residual adenoma in the cavernous sinus increased also constantly from grade I up to grade IV although a significant difference was only found between grades III and II (P = 0.004). The score performed equally well in the validation cohort. Inter-observer agreement was high, with intraclass correlation coefficients > 0.89 for measurement of both the horizontal tumor diameter and the ICD among two independent raters (P < 0.001).

Conclusions

The proposed score is a simple and reproducible tool which reliably predicts surgical outcome including EOR, RV, and GTR of pituitary adenoma patients undergoing TSS.

Keywords

Pituitary surgery Pituitary score Outcome prediction Knosp score Pituitary adenoma Transsphenoidal surgery 

Notes

Acknowledgements

We thank Jorn Fierstra, MD, PhD, and Bas van Niftrik, MD, for their independent measurements used for the assessment of interrater agreement, and Nicola Podda for his graphical work (Fig. 2).

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee (Cantonal Ethics Committee Zürich, KEK St-V-Nr 2015-0142) and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Supplementary material

701_2018_3690_MOESM1_ESM.docx (14 kb)
Supplementary Table 1 Surgical results at 3 months follow up. Values are given separately for both the derivation and validation cohort. IQR, interquartile range; SD, standard deviation; CSS, cavernous sinus space. (DOCX 13 kb)

References

  1. 1.
    Banu MA, Rathman A, Patel KS, Souweidane MM, Anand VK, Greenfield JP, Schwartz TH (2014) Corridor-based endonasal endoscopic surgery for pediatric skull base pathology with detailed radioanatomic measurements. Neurosurgery 10(Suppl 2):273–293; discussion 293.  https://doi.org/10.1227/NEU.0000000000000252 CrossRefPubMedGoogle Scholar
  2. 2.
    Bouthillier A, van Loveren HR, Keller JT (1996) Segments of the internal carotid artery: a new classification. Neurosurgery 38:425–432 discussion 432-433PubMedGoogle Scholar
  3. 3.
    Cebula H, Kurbanov A, Zimmer LA, Poczos P, Leach JL, De Battista JC, Froelich S, Theodosopoulos PV, Keller JT (2014) Endoscopic, endonasal variability in the anatomy of the internal carotid artery. World Neurosurg 82:e759–e764.  https://doi.org/10.1016/j.wneu.2014.09.021 CrossRefPubMedGoogle Scholar
  4. 4.
    Conrad J, Ayyad A, Wüster C, Omran W, Weber MM, Konerding MA, Müller-Forell W, Giese A, Oertel J (2016) Binostril versus mononostril approaches in endoscopic transsphenoidal pituitary surgery: clinical evaluation and cadaver study. J Neurosurg 125:334–345.  https://doi.org/10.3171/2015.6.JNS142637 CrossRefPubMedGoogle Scholar
  5. 5.
    Dallapiazza RF, Grober Y, Starke RM, Laws ER, Jane JA (2015) Long-term results of endonasal endoscopic transsphenoidal resection of nonfunctioning pituitary macroadenomas. Neurosurgery 76:42–52; discussion 52-53.  https://doi.org/10.1227/NEU.0000000000000563 CrossRefPubMedGoogle Scholar
  6. 6.
    Dehdashti AR, Ganna A, Karabatsou K, Gentili F (2008) Pure endoscopic endonasal approach for pituitary adenomas: early surgical results in 200 patients and comparison with previous microsurgical series. Neurosurgery 62:1006–1015; discussion 1015-1017.  https://doi.org/10.1227/01.neu.0000325862.83961.12 CrossRefPubMedGoogle Scholar
  7. 7.
    Dhandapani S, Singh H, Negm HM, Cohen S, Anand VK, Schwartz TH (2016) Cavernous sinus invasion in pituitary adenomas: systematic review and pooled data meta-analysis of radiologic criteria and comparison of endoscopic and microscopic surgery. World Neurosurg 96:36–46.  https://doi.org/10.1016/j.wneu.2016.08.088 CrossRefPubMedGoogle Scholar
  8. 8.
    Elhadi AM, Hardesty DA, Zaidi HA, Kalani MYS, Nakaji P, White WL, Preul MC, Little AS (2015) Evaluation of surgical freedom for microscopic and endoscopic transsphenoidal approaches to the sella. Neurosurgery 11(Suppl 2):69–78; discussion 78-79.  https://doi.org/10.1227/NEU.0000000000000601 CrossRefPubMedGoogle Scholar
  9. 9.
    Hardy J, Vezina JL (1976) Transsphenoidal neurosurgery of intracranial neoplasm. Adv Neurol 15:261–273PubMedGoogle Scholar
  10. 10.
    Hardy J, Wigser SM (1965) Trans-sphenoidal surgery of pituitary fossa tumors with televised radiofluoroscopic control. J Neurosurg 23:612–619.  https://doi.org/10.3171/jns.1965.23.6.0612 CrossRefPubMedGoogle Scholar
  11. 11.
    Hofstetter CP, Nanaszko MJ, Mubita LL, Tsiouris J, Anand VK, Schwartz TH (2012) Volumetric classification of pituitary macroadenomas predicts outcome and morbidity following endoscopic endonasal transsphenoidal surgery. Pituitary 15:450–463.  https://doi.org/10.1007/s11102-011-0350-z CrossRefPubMedGoogle Scholar
  12. 12.
    Juraschka K, Khan OH, Godoy BL, Monsalves E, Kilian A, Krischek B, Ghare A, Vescan A, Gentili F, Zadeh G (2014) Endoscopic endonasal transsphenoidal approach to large and giant pituitary adenomas: institutional experience and predictors of extent of resection. J Neurosurg 121:75–83.  https://doi.org/10.3171/2014.3.JNS131679 CrossRefPubMedGoogle Scholar
  13. 13.
    Kanter AS, Dumont AS, Asthagiri AR, Oskouian RJ, Jane JA, Laws ER (2005) The transsphenoidal approach. A historical perspective. Neurosurg Focus 18:e6CrossRefGoogle Scholar
  14. 14.
    Knosp E, Steiner E, Kitz K, Matula C (1993) Pituitary adenomas with invasion of the cavernous sinus space: a magnetic resonance imaging classification compared with surgical findings. Neurosurgery 33:610–617 discussion 617-618Google Scholar
  15. 15.
    Meij BP, Lopes M-BS, Ellegala DB, Alden TD, Laws ER (2002) The long-term significance of microscopic dural invasion in 354 patients with pituitary adenomas treated with transsphenoidal surgery. J Neurosurg 96:195–208.  https://doi.org/10.3171/jns.2002.96.2.0195 CrossRefPubMedGoogle Scholar
  16. 16.
    Micko ASG, Wöhrer A, Wolfsberger S, Knosp E (2015) Invasion of the cavernous sinus space in pituitary adenomas: endoscopic verification and its correlation with an MRI-based classification. J Neurosurg 122:803–811.  https://doi.org/10.3171/2014.12.JNS141083 CrossRefPubMedGoogle Scholar
  17. 17.
    Mooney MA, Hardesty DA, Sheehy JP, Bird R, Chapple K, White WL, Little AS (2016) Interrater and intrarater reliability of the Knosp scale for pituitary adenoma grading. J Neurosurg 126:1714–1719.  https://doi.org/10.3171/2016.3.JNS153044 CrossRefPubMedGoogle Scholar
  18. 18.
    Negm HM, Al-Mahfoudh R, Pai M, Singh H, Cohen S, Dhandapani S, Anand VK, Schwartz TH (2016) Reoperative endoscopic endonasal surgery for residual or recurrent pituitary adenomas. J Neurosurg:1–12.  https://doi.org/10.3171/2016.8.JNS152709 CrossRefGoogle Scholar
  19. 19.
    Nishioka H, Hara T, Nagata Y, Fukuhara N, Yamaguchi-Okada M, Yamada S (2017) Inherent tumor characteristics that limit effective and safe resection of giant nonfunctioning pituitary adenomas. World Neurosurg.  https://doi.org/10.1016/j.wneu.2017.07.043 CrossRefGoogle Scholar
  20. 20.
    Perondi GE, Isolan GR, de Aguiar PHP, Stefani MA, Falcetta EF (2013) Endoscopic anatomy of sellar region. Pituitary 16:251–259.  https://doi.org/10.1007/s11102-012-0413-9 CrossRefPubMedGoogle Scholar
  21. 21.
    Serra C, Burkhardt J-K, Esposito G, Bozinov O, Pangalu A, Valavanis A, Holzmann D, Schmid C, Regli L (2016) Pituitary surgery and volumetric assessment of extent of resection: a paradigm shift in the use of intraoperative magnetic resonance imaging. Neurosurg Focus 40:E17.  https://doi.org/10.3171/2015.12.FOCUS15564 CrossRefPubMedGoogle Scholar
  22. 22.
    Serra C, Maldaner N, Muscas G, Staartjes V, Pangalu A, Holzmann D, Soyka M, Schmid C, Regli L (2017) The changing sella: internal carotid artery shift during transsphenoidal pituitary surgery. Pituitary:1–7.  https://doi.org/10.1007/s11102-017-0830-x CrossRefGoogle Scholar
  23. 23.
    Sughrue ME, Chang EF, Gabriel RA, Aghi MK, Blevins LS (2011) Excess mortality for patients with residual disease following resection of pituitary adenomas. Pituitary 14:276–283.  https://doi.org/10.1007/s11102-011-0308-1 CrossRefPubMedGoogle Scholar
  24. 24.
    Sylvester PT, Evans JA, Zipfel GJ, Chole RA, Uppaluri R, Haughey BH, Getz AE, Silverstein J, Rich KM, Kim AH, Dacey RG, Chicoine MR (2015) Combined high-field intraoperative magnetic resonance imaging and endoscopy increase extent of resection and progression-free survival for pituitary adenomas. Pituitary 18:72–85.  https://doi.org/10.1007/s11102-014-0560-2 CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Taniguchi M, Hosoda K, Akutsu N, Takahashi Y, Kohmura E (2015) Endoscopic endonasal transsellar approach for laterally extended pituitary adenomas: volumetric analysis of cavernous sinus invasion. Pituitary 18:518–524.  https://doi.org/10.1007/s11102-014-0604-7 CrossRefPubMedGoogle Scholar
  26. 26.
    Woodworth GF, Patel KS, Shin B, Burkhardt J-K, Tsiouris AJ, McCoul ED, Anand VK, Schwartz TH (2014) Surgical outcomes using a medial-to-lateral endonasal endoscopic approach to pituitary adenomas invading the cavernous sinus. J Neurosurg 120:1086–1094.  https://doi.org/10.3171/2014.1.JNS131228 CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer-Verlag GmbH Austria, part of Springer Nature 2018

Authors and Affiliations

  • Carlo Serra
    • 1
    Email author
  • Victor E. Staartjes
    • 1
  • Nicolai Maldaner
    • 1
  • Giovanni Muscas
    • 2
  • Kevin Akeret
    • 1
  • David Holzmann
    • 3
  • Michael B. Soyka
    • 3
  • Christoph Schmid
    • 4
  • Luca Regli
    • 1
  1. 1.Department of Neurosurgery, Clinical Neuroscience Center, University Hospital ZurichUniversity of ZurichZurichSwitzerland
  2. 2.Department of Neurosurgery, Tuscany School of NeurosurgeryUniversity of FirenzeFlorenceItaly
  3. 3.Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital ZurichUniversity of ZurichZurichSwitzerland
  4. 4.Department of Endocrinology and Diabetes, University Hospital ZurichUniversity of ZurichZurichSwitzerland

Personalised recommendations