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Combined high-field intraoperative magnetic resonance imaging and endoscopy increase extent of resection and progression-free survival for pituitary adenomas

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Abstract

Purpose

The clinical benefit of combined intraoperative magnetic resonance imaging (iMRI) and endoscopy for transsphenoidal pituitary adenoma resection has not been completely characterized. This study assessed the impact of microscopy, endoscopy, and/or iMRI on progression-free survival, extent of resection status (gross-, near-, and sub-total resection), and operative complications.

Methods

Retrospective analyses were performed on 446 transsphenoidal pituitary adenoma surgeries at a single institution between 1998 and 2012. Multivariate analyses were used to control for baseline characteristics, differences during extent of resection status, and progression-free survival analysis.

Results

Additional surgery was performed after iMRI in 56/156 cases (35.9 %), which led to increased extent of resection status in 15/156 cases (9.6 %). Multivariate ordinal logistic regression revealed no increase in extent of resection status following iMRI or endoscopy alone; however, combining these modalities increased extent of resection status (odds ratio 2.05, 95 % CI 1.21–3.46) compared to conventional transsphenoidal microsurgery. Multivariate Cox regression revealed that reduced extent of resection status shortened progression-free survival for near- versus gross-total resection [hazard ratio (HR) 2.87, 95 % CI 1.24–6.65] and sub- versus near-total resection (HR 2.10; 95 % CI 1.00–4.40). Complication comparisons between microscopy, endoscopy, and iMRI revealed increased perioperative deaths for endoscopy versus microscopy (4/209 and 0/237, respectively), but this difference was non-significant considering multiple post hoc comparisons (Fisher exact, p = 0.24).

Conclusions

Combined use of endoscopy and iMRI increased pituitary adenoma extent of resection status compared to conventional transsphenoidal microsurgery, and increased extent of resection status was associated with longer progression-free survival. Treatment modality combination did not significantly impact complication rate.

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Acknowledgments

We would like to thank Feng Gao, PhD and J. Phillip Miller, PhD from the Department of Biostatistics at Washington University in St. Louis for his advice regarding the statistical methods performed in this study. Furthermore, we would like to thank Bridget McCullough & Stan Goddard our MRI technologists, and Kathy Draege our neurosurgical operating room charge nurse and our entire operating room staff. These individuals enable the safe completion of these surgical procedures in the complex iMRI environment

Conflict of interest

Michael Chicoine and John Evans received funding from IMRIS Inc. for an unrestricted educational grant that has helped support the iMRI database and outcomes analysis. The authors have no personal financial or institutional interest in any of the drugs, materials, or devices described in this article. Peter Sylvester received grant support from the Clinical and Translational Science Award (CTSA) program of the National Center for Advancing Translational Sciences (NCATS) of the National Institutes of Health (NIH) under Award Numbers UL1 TR000448 and TL1 TR000449.

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Authors and Affiliations

  1. Department of Neurosurgery, Washington University School of Medicine, 660 S Euclid Ave, Campus Box 8057, St. Louis, MO, USA

    Peter T. Sylvester, John A. Evans, Gregory J. Zipfel, Julie Silverstein, Keith M. Rich, Albert H. Kim, Ralph G. Dacey & Michael R. Chicoine

  2. Department of Otolaryngology, Head and Neck Surgery, Washington University School of Medicine, St. Louis, MO, USA

    Richard A. Chole, Ravindra Uppaluri, Bruce H. Haughey & Anne E. Getz

  3. Department of Internal Medicine/Endocrinology, Metabolism, and Lipid Research, Washington University School of Medicine, St. Louis, MO, USA

    Julie Silverstein

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  1. Peter T. Sylvester
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Correspondence to Michael R. Chicoine.

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Sylvester, P.T., Evans, J.A., Zipfel, G.J. et al. Combined high-field intraoperative magnetic resonance imaging and endoscopy increase extent of resection and progression-free survival for pituitary adenomas. Pituitary 18, 72–85 (2015). https://doi.org/10.1007/s11102-014-0560-2

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