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Pituitary Aug 2020Surgery in patients with non-functioning pituitary macroadenomas (NFMA) is effective in ameliorating visual function. The urgency for decompression, and preferred timing...
Quality of care evaluation in non-functioning pituitary adenoma with chiasm compression: visual outcomes and timing of intervention clinical recommendations based on a systematic literature review and cohort study.
PURPOSE
Surgery in patients with non-functioning pituitary macroadenomas (NFMA) is effective in ameliorating visual function. The urgency for decompression, and preferred timing of surgery related to the preoperative severity of dysfunction is unknown.
METHODS
Systematic review for evidence to provide clinical guidance for timing of surgical decompression of the optic chiasm, and a cohort study of 30 NFMA patients, in whom mean deviation (MD), and severity of visual dysfunction was assessed.
RESULTS
Systematic review 44 studies were included with a total of 4789 patients. Postoperatively, visual field defects improved in 87.0% of patients, stabilized in 12.8% and worsened in 1.0%. Specific protocols regarding timing of surgery were not reported. Only seven studies (16.7%) reported on either the duration of visual symptoms, or diagnostic, or treatment delay. Cohort study 30 NFMA patients (50% female, 60 eyes, mean age 58.5 ± 14.8 years), had a median MD of - 5.3 decibel (IQR - 3.1 to - 10.1). MD was strongly correlated with clinical severity (r = - 0.94, P < 0.0001), and were used for severity of defects cut-off values: (1) normal > - 2 dB, (2) mild - 2 dB to - 4 dB, (3) moderate - 4 to - 8 dB, (4) severe - 8 to - 17 dB, (5) very severe < - 17 dB.
CONCLUSION
Surgical decompression is highly effective in improving visual function. Uniform, quantitative grading of visual dysfunction was lacking. MD is a promising quantitative outcome measure. We provide recommendations for the evaluation of timing of surgery, considering severity of visual impairment, which will need further validation based on expert clinical practice.
Topics: Adenoma; Cohort Studies; Decompression, Surgical; Female; Hemianopsia; Humans; Male; Middle Aged; Optic Chiasm; Pituitary Neoplasms; Quality of Health Care; Recovery of Function; Severity of Illness Index; Time Factors; Treatment Outcome; Tumor Burden; Vision Disorders; Visual Acuity; Visual Field Tests
PubMed: 32419072
DOI: 10.1007/s11102-020-01044-0 -
Acta Neurochirurgica Jun 2020Pituitary adenomas (PA) are common intracranial tumors. In the context of the aging of the population, the question is whether postsurgical outcomes are comparable to... (Meta-Analysis)
Meta-Analysis
INTRODUCTION
Pituitary adenomas (PA) are common intracranial tumors. In the context of the aging of the population, the question is whether postsurgical outcomes are comparable to the younger ones. The primary objective of the present study was to review published resection and recurrence rates after transsphenoidal resection. The secondary aim was to evaluate visual improvement and complication rates.
METHODS
The authors searched PubMed and Medline databases, of published English series, with no time frame limit, evaluating outcomes of transsphenoidal resection in populations aged more or less than 65, 70, and 80 years. We performed a systematic review and meta-analysis.
RESULTS
Median overall resection rates for younger population was 70.7% (range 54-76.8) and for elderly one was 65.7% (range 16.6-78.2) (two-sample t test, p = 0.35). The only statistically significant difference for gross total resection rates (GTR) favored patients aged less than 80 (p = 0.01). There was no statistically significant difference among recurrence rates. There was a statistically significant difference for visual improvement favoring patients aged more than 80 (p = 0.03). For the age groups of less versus more than 70, there was a statistically significant difference for overall complication rate favoring younger groups (p < 0.05).
CONCLUSION
Present data shows GTR rates favoring younger patients. Recurrence rates remain similar over the mean follow-up period. Moreover, visual improvement favors patients aged more than 80. Overall complication rates favor patients younger than 70, which might be also related to additional comorbidities, frequently present in seniors. Transsphenoidal surgery is safe and effective even for older patients.
Topics: Adenoma; Adult; Age Factors; Aged; Aged, 80 and over; Female; Humans; Male; Middle Aged; Neurosurgical Procedures; Pituitary Neoplasms; Postoperative Complications
PubMed: 32221730
DOI: 10.1007/s00701-020-04300-1 -
Neuro-oncology Mar 2020This systematic review reports on outcomes and toxicities following stereotactic radiosurgery (SRS) for non-functioning pituitary adenomas (NFAs) and presents consensus... (Meta-Analysis)
Meta-Analysis
BACKGROUND
This systematic review reports on outcomes and toxicities following stereotactic radiosurgery (SRS) for non-functioning pituitary adenomas (NFAs) and presents consensus opinions regarding appropriate patient management.
METHODS
Using the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, a systematic review was performed from articles of ≥10 patients with NFAs published prior to May 2018 from the Medline database using the key words "radiosurgery" and "pituitary" and/or "adenoma." Weighted random effects models were used to calculate pooled outcome estimates.
RESULTS
Of the 678 abstracts reviewed, 35 full-text articles were included describing the outcomes of 2671 patients treated between 1971 and 2017 with either single fraction SRS or hypofractionated stereotactic radiotherapy (HSRT). All studies were retrospective (level IV evidence). SRS was used in 27 studies (median dose: 15 Gy, range: 5-35 Gy) and HSRT in 8 studies (median total dose: 21 Gy, range: 12-25 Gy, delivered in 3-5 fractions). The 5-year random effects local control estimate after SRS was 94% (95% CI: 93.0-96.0%) and 97.0% (95% CI: 93.0-98.0%) after HSRT. The 10-year local control random effects estimate after SRS was 83.0% (95% CI: 77.0-88.0%). Post-SRS hypopituitarism was the most common treatment-related toxicity observed, with a random effects estimate of 21.0% (95% CI: 15.0-27.0%), whereas visual dysfunction or other cranial nerve injuries were uncommon (range: 0-7%).
CONCLUSIONS
SRS is an effective and safe treatment for patients with NFAs. Encouraging short-term data support HSRT for select patients, and mature outcomes are needed before definitive recommendations can be made. Clinical practice opinions were developed on behalf of the International Stereotactic Radiosurgery Society (ISRS).
Topics: Adenoma; Disease Management; Humans; Pituitary Neoplasms; Radiation Dose Hypofractionation; Radiosurgery; Societies, Medical; Treatment Outcome
PubMed: 31790121
DOI: 10.1093/neuonc/noz225 -
The Journal of Clinical Endocrinology... Mar 2020The improved remission and complication rates of current transsphenoidal surgery warrant reappraisal of the position of surgery as a viable alternative to dopamine... (Meta-Analysis)
Meta-Analysis
CONTEXT
The improved remission and complication rates of current transsphenoidal surgery warrant reappraisal of the position of surgery as a viable alternative to dopamine agonists in the treatment algorithm of prolactinomas.
OBJECTIVE
To compare clinical outcomes after dopamine agonist withdrawal and transsphenoidal surgery in prolactinoma patients.
METHODS
Eight databases were searched up to July 13, 2018. Primary outcome was disease remission after drug withdrawal or surgery. Secondary outcomes were biochemical control and side effects during dopamine agonist treatment and postoperative complications. Fixed- or random-effects meta-analysis was performed to estimate pooled proportions. Robustness of results was assessed by sensitivity analyses.
RESULTS
A total of 1469 articles were screened: 55 (10 low risk of bias) on medical treatment (n = 3564 patients) and 25 (12 low risk of bias) on transsphenoidal surgery (n = 1836 patients). Long-term disease remission after dopamine agonist withdrawal was 34% (95% confidence interval [CI], 26-46) and 67% (95% CI, 60-74) after surgery. Subgroup analysis of microprolactinomas showed 36% (95% CI, 21-52) disease remission after dopamine agonist withdrawal, and 83% (95% CI, 76-90) after surgery. Biochemical control was achieved in 81% (95% CI, 75-87) of patients during dopamine agonists with side effects in 26% (95% CI, 13-41). Transsphenoidal surgery resulted in 0% mortality, 2% (95% CI, 0-5) permanent diabetes insipidus, and 3% (95% CI, 2-5) cerebrospinal fluid leakage. Multiple sensitivity analyses yielded similar results.
CONCLUSIONS
In the majority of prolactinoma patients, disease remission can be achieved through surgery, with low risks of long-term surgical complications, and disease remission is less often achieved with dopamine agonists.
Topics: Critical Pathways; Dopamine Agonists; Female; Humans; Hypophysectomy; Microsurgery; Pituitary Gland; Pituitary Neoplasms; Practice Guidelines as Topic; Prolactin; Prolactinoma; Remission Induction; Retrospective Studies; Treatment Outcome
PubMed: 31665485
DOI: 10.1210/clinem/dgz144 -
World Neurosurgery Dec 2019To systematically review and analyze clinical, diagnostic, and management trends in sellar and parasellar brown tumors reported in existing literature.
OBJECTIVE
To systematically review and analyze clinical, diagnostic, and management trends in sellar and parasellar brown tumors reported in existing literature.
METHODS
In this systematic review, PubMed, Ovid MEDLINE, Scopus, and Google Scholar databases were searched for reported cases of sellar/parasellar brown tumors. Relevant titles and abstracts were screened in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol. Articles meeting inclusion criteria were subjected to data extraction, summarization, and analysis. A rare case of parasellar brown tumor was also presented.
RESULTS
Eight reports (including the current report) were eligible for inclusion. Mean patient age was 42.75 years. Reported symptoms included visual disturbances (n = 6), headache (n = 5), fatigue (n = 3), nausea/vomiting (n = 2), chest pain (n = 1), neck pain (n = 1), and dysphagia (n = 1). In cases where computed tomography findings were provided (n = 6), lesions were noted to be expansile and lytic. Lesions were hyperintense on T2-weighted magnetic resonance imaging (66.7%) and demonstrated contrast enhancement (83.3%). Histology unanimously showed multinucleated giant cells in a fibrovascular connective tissue stroma. Dramatic symptom resolution was noted in all patients who underwent resection of the sellar/parasellar brown tumor (n = 4; 50%).
CONCLUSIONS
Sellar/parasellar brown tumors are a rare, tertiary manifestation of hyperparathyroidism and can be elusive to diagnose. Diagnosis requires a high index of clinical suspicion in addition to comprehensive biochemical testing, imaging, and histopathologic analysis. Surgical extirpation is favored in cases where the lesion is causing compressive symptoms, or if it is unresponsive to management of hyperparathyroidism.
Topics: Adolescent; Adult; Female; Humans; Hyperparathyroidism; Male; Middle Aged; Pituitary Neoplasms; Young Adult
PubMed: 31470158
DOI: 10.1016/j.wneu.2019.08.126 -
Journal of Neuro-oncology Feb 2019Differentiation of normal pituitary from abnormal tumor tissue remains a surgical challenge despite improvements in optical visualization technology for pituitary...
INTRODUCTION
Differentiation of normal pituitary from abnormal tumor tissue remains a surgical challenge despite improvements in optical visualization technology for pituitary adenoma (PA) surgery. During neurosurgical procedures for other tumor types, 5-aminolevulinic acid (5-ALA) has become a focus of investigation based on its high specificity in differentiating tumor tissue. However, the role of 5-ALA and other optical fluorescent agents in PA surgery remains less clear.
OBJECTIVE
To perform a systematic review on the use of various optical fluorescent agents in PA surgery.
METHOD
Using PRISMA guidelines, a systematic literature review to identify reports describing 5-ALA and other optical agents for fluorescence-guided surgery for PA was performed. Eleven research studies met inclusion criteria and were reviewed.
RESULTS
In two studies, 5-ALA was not shown to be effective in aiding PA resection using standard neurosurgical endoscopic/microscopic approaches. 5-ALA photodynamic therapy was evaluated in two in-vitro models with inconsistent results. Intraoperative use of indocyanine green (ICG) concluded with varying results, but showed a tendency towards improved differentiation of functional PA. OTL38 showed potential for intraoperative identification of nonfunctioning PA, particularly in tumors with high folate receptor expression. One study reported clinically useful fluorescence following sodium fluorescein administration.
CONCLUSION
We conclude that selected optical fluorescent agents, including ICG and folate receptors, are most likely to hold promise for clinical use in differentiating PA from normal tissue.
Topics: Adenoma; Aminolevulinic Acid; Fluorescent Dyes; Humans; Optical Imaging; Pituitary Neoplasms; Surgery, Computer-Assisted
PubMed: 30523607
DOI: 10.1007/s11060-018-03062-2 -
Clinical Interventions in Aging 2018Whether conservative treatment or surgical management is the most appropriate treatment for pituitary apoplexy (PA) is controversial. In general, if severe symptoms of...
Conservative treatment cures an elderly pituitary apoplexy patient with oculomotor paralysis and optic nerve compression: a case report and systematic review of the literature.
BACKGROUND
Whether conservative treatment or surgical management is the most appropriate treatment for pituitary apoplexy (PA) is controversial. In general, if severe symptoms of compression occur, such as oculomotor nerve palsy, neurosurgery is performed to relieve the compression of anatomical structures near the PA.
CASE DESCRIPTION
We describe the case of a 79-year-old man who was found to have an intrasellar pituitary incidentaloma. The tumor was discovered accidentally, during an investigation into the cause of his dizziness. Two months later, he suddenly developed headaches, left ophthalmoplegia, decreased vision, severe blepharoptosis and diplopia. He was diagnosed with PA and hypocortisolemia based on magnetic resonance imaging (MRI) and blood tests, respectively. His symptoms of oculomotor palsy and optic nerve compression were serious, but his ophthalmological deficits were nonprogressive and his hormone levels improved through conservative treatment (hydrocortisone supplementation). Due to this older patient's poor physical condition and serious coronary heart disease, after multidisciplinary consultation and according to his family's wishes, we continued the conservative treatment and watched closely for any changes in the patient's condition. After 6 months of conservative treatment, the patient's symptoms of oculomotor nerve paralysis, pupil and vision defects completely disappeared, and no new complications occurred. Repeated MRI tests showed that the PA lesion gradually improved. The patient's hypocortisolemia was completely relieved through oral supplementation with low-dose hydrocortisone.
CONCLUSION
In older PA patients who have surgical contraindications, even with symptoms of compression, such as oculomotor nerve palsy, according to the international guidelines, if conservative treatment is effective and the condition is not progressing, it is possible to monitor patients' condition closely and continue conservative treatment, which may yield good results.
Topics: Aged; Conservative Treatment; Humans; Hydrocortisone; Incidental Findings; Male; Nerve Compression Syndromes; Ophthalmoplegia; Optic Nerve; Pituitary Apoplexy; Pituitary Neoplasms; Vision Disorders
PubMed: 30349217
DOI: 10.2147/CIA.S181109 -
Pituitary Oct 2018Systematic review and meta-analysis comparing endoscopic and microscopic transsphenoidal surgery for Cushing's disease regarding surgical outcomes (remission,... (Meta-Analysis)
Meta-Analysis
PURPOSE
Systematic review and meta-analysis comparing endoscopic and microscopic transsphenoidal surgery for Cushing's disease regarding surgical outcomes (remission, recurrence, and mortality) and complication rates. To stratify the results by tumor size.
METHODS
Nine electronic databases were searched in February 2017 to identify potentially relevant articles. Cohort studies assessing surgical outcomes or complication rates after endoscopic or microscopic transsphenoidal surgery for Cushing's disease were eligible. Pooled proportions were reported including 95% confidence intervals.
RESULTS
We included 97 articles with 6695 patients in total (5711 microscopically and 984 endoscopically operated). Overall, remission was achieved in 5177 patients (80%), with no clear difference between both techniques. Recurrence was around 10% and short term mortality < 0.5% for both techniques. Cerebrospinal fluid leak occurred more often in endoscopic surgery (12.9 vs. 4.0%), whereas transient diabetes insipidus occurred less often (11.3 vs. 21.7%). For microadenomas, results were comparable between both techniques. For macroadenomas, the percentage of patients in remission was higher after endoscopic surgery (76.3 vs. 59.9%), and the percentage recurrence lower after endoscopic surgery (1.5 vs. 17.0%).
CONCLUSIONS
Endoscopic surgery for patients with Cushing's disease reaches comparable results for microadenomas, and probably better results for macroadenomas than microscopic surgery. This is present despite the presumed learning curve of the newer endoscopic technique, although confounding cannot be excluded. Based on this study, endoscopic surgery may thus be considered the current standard of care. Microscopic surgery can be used based on neurosurgeon's preference. Endocrinologists and neurosurgeons in pituitary centers performing the microscopic technique should at least consider referring Cushing's disease patients with a macroadenoma.
Topics: Cerebrospinal Fluid Leak; Confidence Intervals; Neoplasm Recurrence, Local; Neurosurgical Procedures; Pituitary ACTH Hypersecretion; Pituitary Neoplasms
PubMed: 29767319
DOI: 10.1007/s11102-018-0893-3 -
Journal of Cellular and Molecular... Mar 2018Both microscopic and endoscopic transsphenoidal surgery are effective approaches for nonfunctioning pituitary adenomas. The issue on the comparison of their efficacy and... (Meta-Analysis)
Meta-Analysis
Both microscopic and endoscopic transsphenoidal surgery are effective approaches for nonfunctioning pituitary adenomas. The issue on the comparison of their efficacy and safety remains inconsistent. A thorough search of the literatures (PubMed, EMBASE, MEDLINE) were performed up to March 2017. Studies reporting outcomes of microscopic or endoscopic transsphenoidal surgery on nonfunctioning pituitary adenomas were included. A meta-analysis was performed focusing on the early stage and long term outcomes. The final search yielded 19 eligible studies enrolling 3847 patients, 389 of them underwent microscopic approach and 3458 of them with endoscopic approach. As to the early stage outcomes, the rate of gross tumor resection was significantly higher in the endoscopic group than that in microscopic group (73% versus 60%, P < 0.001). Meanwhile, endoscopic approach showed priority over microscopy on postoperative hypopituitarism (63% versus 65%, P < 0.001) and CSF leakage (3% versus 7%, P < 0.001). For the long term outcomes, the rate of visual improvement was significant higher in the endoscopic group than that in microscopic group (77% versus 50%, P < 0.001). However, there was no significant difference between the groups regarding the rate of permanent diabetic insipidus and meningitis. The endoscopic approach may be associated with higher rate of gross tumor movement and lower risk of postoperatively complications for treating nonfunctioning pituitary adenoma, when compared with microscopic approach. However, the confidence was shorted due to limited high quality evidence (largely randomized and controlled studies).
Topics: Adenoma; Diabetes Insipidus; Endoscopy; Female; Humans; Hypopituitarism; Male; Meningitis; Middle Aged; Pituitary Neoplasms; Postoperative Complications; Sphenoid Bone; Treatment Outcome; Visual Acuity
PubMed: 29314715
DOI: 10.1111/jcmm.13445 -
Neuro-oncology Feb 2018Epilepsy is the most common symptom in patients with supratentorial low-grade gliomas (LGGs), which adversely affects the patient's quality of life. Poor seizure control... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Epilepsy is the most common symptom in patients with supratentorial low-grade gliomas (LGGs), which adversely affects the patient's quality of life. Poor seizure control with anti-epileptic therapy is an indication for surgery in these patients. Recent studies have sought to identify predictors of postoperative seizure control after surgical resection of LGG; gross total resection was shown to be a significant predictor in this respect. However, the prognostic value of other factors is not clear.
METHODS
We performed a systematic review and meta-analysis of 23 studies with a combined study population of 2641 patients with LGG, in order to identify potential factors associated with favorable postoperative seizure control. Data were extracted on age and sex of patient, tumor location, tumor histology, type of seizure, seizure duration, extent of resection, and imaging characteristics.
RESULTS
Patients ≥45 years of age achieved better postoperative seizure control (risk ratio [RR], 0.89; 95% CI, 0.81-0.99). Focal seizures were associated with poor seizure control (RR, 1.32; 95% CI, 1.18-1.49) compared with generalized seizures (RR, 0.77; 95% CI, 0.68-0.87). Prolonged history of seizures (≥1 y) had a negative impact on postoperative seizure control (RR, 1.22; 95% CI, 1.10-1.34). Gross total resection was superior to subtotal resection with respect to postoperative seizure control (RR, 0.68; 95% CI, 0.63-0.73).
CONCLUSIONS
This systematic review and meta-analysis identified predictors of postoperative seizure control in patients undergoing surgical resection of LGGs. Our results provide a reference for clinical treatment of LGG-related epilepsy.
Topics: Adult; Brain Neoplasms; Glioma; Humans; Neoplasm Grading; Neurosurgical Procedures; Postoperative Complications; Quality of Life; Seizures; Treatment Outcome
PubMed: 29016869
DOI: 10.1093/neuonc/nox130