Predicting extent of resection in transsphenoidal surgery for pituitary adenoma
- 226 Downloads
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.
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.
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).
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.
KeywordsPituitary surgery Pituitary score Outcome prediction Knosp score Pituitary adenoma Transsphenoidal surgery
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.
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 was obtained from all individual participants included in the study.
- 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
- 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
- 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.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.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
- 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.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
- 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
- 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
- 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
- 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