Nonfunctioning pituitary adenomas are benign, slow-growing tumors. After gross-total resection (GTR) or subtotal resection (STR), tumors can recur or progress and may ultimately require additional ...intervention. A greater understanding of long-term recurrence and progression rates following complete or partial resection and the need for further intervention will help clinicians provide meaningful counsel for their patients and assist data-driven decision-making.
The authors retrospectively analyzed their institutional database for patients undergoing endoscopic endonasal surgery (EES) for nonfunctioning pituitary macroadenomas (2003-2014). Only patients with follow-up of at least 5 years after surgery were included. Tumor volumes were measured on pre- and postoperative MRI. Tumor recurrence was defined as the presence of a 0.1-cm3 tumor volume after GTR, and tumor progression was defined as a 25.0% increase in residual tumor after STR.
A total of 190 patients were included, with a mean age of 63.8 ± 13.2 years; 79 (41.6%) were female. The mean follow-up was 75.0 ± 18.0 months. GTR was achieved in 127 (66.8%) patients. In multivariate analysis, age (p = 0.04), preoperative tumor volume (p = 0.03), Knosp score (p < 0.001), and Ki-67 (p = 0.03) were significant predictors of STR. In patients with GTR, the probability of recurrence at 5 and 10 years was 3.9% and 4.7%, and the probability of requiring treatment for recurrence was 0.79% and 1.6%, respectively. In 63 patients who underwent STR, 6 (9.5%) received early postoperative radiation and did not experience progression, while the remaining 57 (90.5%) were observed. Of these, the probability of disease progression at 5 and 10 years was 21% and 24.5%, respectively, and the probability of requiring additional treatment for progression was 17.5% and 21%. Predictors of recurrence or progression in the entire group were Knosp score (p < 0.001) and elevated Ki-67 (p = 0.03). Significant predictors of progression after STR in those who did not receive early radiotherapy were cavernous sinus location (p < 0.05) and tumor size > 1.0 cm3 (p = 0.005).
Following GTR for nonfunctioning pituitary adenomas, the 10-year chance of recurrence is low and the need for treatment even lower. After STR, although upfront radiation therapy may prevent progression, even without radiotherapy, the need for intervention at 10 years is only approximately 20% and a period of observation may be warranted to prevent unnecessary prophylactic radiation therapy. Tumor volume > 1 cm3, Knosp score ≥ 3, and Ki-67 ≥ 3% may be useful metrics to prompt closer follow-up or justify early prophylactic radiation therapy.
Background
Endonasal endoscopic transsphenoidal surgery (EETS) for pituitary adenoma has become a mainstay of treatment over the last two decades and it is generally accepted that once this learning ...curve is achieved, a plateau is reached with little incremental improvement.
Objective
The objective of this study was to assess the slope of the learning curve over a long period of time for a variety of outcomes measures.
Methods
We examined outcomes and complications in a consecutive series of 600 EETS for pituitary adenoma grouped into quartiles based on date of surgery.
Results
GTR significantly increased across quartiles from 55 to 79% in the last quartile (
p
< 0.005). The rate of intraoperative CSF leak significantly decreased from 60% in the first quartile to 33% in the last quartile and the rate of lumbar drain placement from 28% in the first quartile to 6% in the last quartile (
p
< 0.005). Hormonal remission for secreting adenomas increased from 68% in the first quartile to 90% in the last quartile (
p
< 0.05). The rate of post-operative CSF leak trended lower (3% in first quartile to 0.7% in last two quartiles). The greatest improvement in outcome occurred between the first and second quartiles (19.9%), but persistent improvement occurred between the second and third (6.7%) and third and fourth quartiles (8.0%).
Conclusion
Although the slope of the learning curve is steeper earlier in a surgeon’s experience, the slope does not plateau and continues to increase even over more than a decade.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Background
Skull base reconstruction after extended endoscopic endonasal approaches (EEAs) can be challenging. In addition to the nasoseptal flap, which has been adopted by most centers, autologous ...fascia lata is also often utilized. Harvesting of fascia lata requires a separate thigh incision, may prolong recovery, and results in a visible scar. In principal, the use of non-autologous materials would be preferable to avoid a second incision and maintain the minimally invasive nature of the approach, assuming the CSF leak rate is not compromised.
Objective
To assess the efficacy of acellular dermal matrix (ADM) as a non-autologous alternative to autologous fascia lata graft for watertight closure of the cranial base following EEAs.
Methods
A retrospective chart review of extended EEAs performed before and after the transition from fascia lata to ADM was performed. Cases were frequency matched for approach, pathology, BMI, use of lumbar drainage, and tumor volume. Power analysis was performed to estimate the sample size needed to demonstrate non-inferiority.
Results
ADM was used for watertight closure of the cranial base in 19 consecutive extended endoscopic endonasal approaches (16 gasket-seals and 3 buttons) with 1 postoperative CSF leak at the last follow-up (median 5.3, range 1.0–12.6 months). All patients had high-flow intraoperative leaks. The cohort included 8 meningiomas, 8 craniopharyngiomas, 2 chordomas, and 1 pituicytoma ranging in size from 0.2 to 37.2cm
3
(median 5.5, IQR 2.8–13.3 cm
3
). In 19 historical controls who received fascia lata, there were 2 postoperative CSF leaks.
Conclusions
Preliminary results suggest that ADM provides a non-inferior non-autologous alternative to fascia lata for watertight gasket-seal and button closures following extended EEAs, potentially reducing or eliminating the need to harvest autologous tissue.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Background
Respiratory epithelial adenomatoid hamartoma (REAH) is a recently classified histopathologic diagnosis often identified incidentally following endoscopic sinus surgery (ESS) for presumed ...chronic rhinosinusitis. Limited data exist defining preoperative imaging features and surgical outcomes. The purpose of this study is to examine characteristic imaging findings of REAH and postoperative olfactory and recurrence outcomes.
Methods
A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta‐Analysis (PRISMA) guidelines on articles published from 1995 to present. PubMed, EMBASE, and Ovid MEDLINE databases were queried for studies pertinent to imaging findings of REAH and surgical outcomes. Quality of articles was assessed using the Methodological Index for Non‐Randomized Studies (MINORS).
Results
A total of 294 articles were identified, with 15 meeting inclusion criteria. Seven articles assessed both imaging findings and surgical outcomes. Three articles focused exclusively on imaging, whereas 5 examined surgical outcomes. Olfactory cleft (OC) widening greater than 10 mm on computed tomography (CT) was characteristic of REAH. A total of 441 patients with REAH were included; 221 patients (50.1%) had concurrent nasal polyposis, whereas 154 patients (34.9%) had isolated REAH. Surgical intervention ranged from simple excision to complete ESS. Sixty‐five percent (65%) of patients reported improved olfaction; 4.1% of patients recurred with follow‐up ranging from 4 months to 5 years.
Conclusion
A widened OC may suggest the presence of REAH. This disease process has been identified in patients with nasal polyposis or encountered as an isolated lesion. Targeted surgery may result in improved olfaction and a low likelihood of recurrence, though long‐term prospective studies are necessary.
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Patients with refractory chronic rhinosinusitis, by definition, have persistent, poorly controlled symptoms and objective inflammatory findings despite prior medical and surgical therapy. These ...patients represent a diagnostic and treatment challenge given the complexity of the underlying disease factors and the limitations in available management options. This article presents a practical framework for clinical evaluation and treatment. Germane to discussion are emerging concepts in refractory chronic rhinosinusitis that will likely have important implications in the near future.
Purpose:
To evaluate the improvement in epiphora and need for surgical revision in patients with acquired nasolacrimal duct obstruction following balloon-assisted, middle meatal endoscopic ...dacryocystorhinostomy with chitosan-based dressing versus bioresorbable polyurethane packing versus no packing.
Patients and Methods:
This was a retrospective study of consecutive adult patients seen from 2015 to 2018 with follow-up evaluation of epiphora at least 3 months after balloon-assisted, middle meatal endoscopic dacryocystorhinostomy. Patients with a history of prior punctoplasty, septoplasty, sinus surgery, or dacryocystorhinostomy of any kind were excluded. Those meeting criteria were stratified by postoperative hemostatic intervention: no packing, bioresorbable packing, and chitosan-based dressing (groups 1, 2, and 3, respectively). Procedural outcomes were graded as successes or failures based on subjective report and anatomical findings at most recent visit within an 18-month postoperative window. Instances of recommendation for revision surgery were also recorded.
Results:
Forty-three cases (36 patients) met the abovementioned criteria. Groups 1, 2, and 3 comprised 12, 17, and 14 cases each, respectively. Average patient age was 55.3 years old, and average duration of follow-up was 6.7 months. Significant variation in outcomes was detected across the 3 groups (P = .0495), particularly between groups 1 and 3 (P = .033). Use of chitosan-based dressing trended toward reduced rates of recommendation for surgical revision (P = .203, P = .113).
Conclusions:
Use of chitosan-based dressing after endoscopic dacryocystorhinostomy was associated with improved subjective and anatomical outcomes. It may also contribute to less frequent need for revision surgery. Further study in a larger prospective trial is recommended.
Refractory Chronic Rhinosinusitis Tabaee, Abtin; McCoul, Edward D
Otolaryngologic clinics of North America,
02/2017, Volume:
50, Issue:
1
Journal Article
Objectives/Hypothesis: Direct connection between the sinonasal and intracranial cavities and passage of multiple instruments and graft materials through a contaminated field occur routinely during ...endoscopic pituitary and skull base surgery. Despite the theoretical risk of intracranial contamination with sinonasal flora, the incidence of central nervous system (CNS) infection following such procedures is not well documented, and the ideal antibiotic regimen has yet to be determined.
Study Design: Prospective case series of 24 to 48 hours of single‐agent perioperative antibiotics in patients undergoing endoscopic skull base surgery.
Methods: Prospective database of procedures performed between January 2004 and May 2006 was reviewed for antibiotic use and infectious complications.
Results: The diagnoses of the 90 patients in this series included pituitary tumor (62%), craniopharyngioma (9%), encephalocele (9%), and meningioma (8%). Fifty‐eight (64%) patients experienced intraoperative cerebrospinal fluid (CSF) leak. A variety of autologous, synthetic grafts, hemostatic agents, and tissue sealants were placed through the sinonasal cavity for reconstruction. All patients received 24 to 48 hours of a single antibiotic based on patient sensitivity: cefazolin (87%), vancomycin (10%), or clindamycin (3%). Additional antibiotics were subsequently required during the hospital stay in eight (9%) patients for a variety of indications. There were no cases of intracranial infections or meningitis in patients with or without intraoperative CSF leak.
Conclusions: Despite direct contamination of the intracranial cavity during endoscopic, endonasal skull base surgery, the risk of CNS infections is low. Limited use of a single perioperative antibiotic may be sufficient prophylaxis.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Non-contrast CT scan of the paranasal sinuses demonstrated post-endoscopic sinus surgery changes and a 1.6x1.5x2.1cm soft tissue lesion located on the left lateral nasal wall anterior to the ...maxillary antrostomy site (Fig. 1). ...the most accepted current classification is that R. seeberi is a eukaryotic pathogen in the Mesomycetozoea class 3.The mature phenotype of the organism includes a thick walled spherical structure termed sporangia containing smaller spherical structures termed sporangiospores. Patients with rhinosporidiosis involving the sinonasal cavities may present with non-specific symptoms including unilateral nasal bleeding, nasal obstruction, rhinorrhea, foreign body sensation, and postnasal drip.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
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