Abstract
Background
Pituicytoma is an extremely rare low-grade glial tumor that is closely related to the neurohypophysis axis. Most studies of pituicytomas include only several cases. To better ...understand this disease, we reviewed a series of cases of pituicytomas. The diagnosis and treatment of pituicytoma must be further elucidated.
Methods
Eleven patients with pituicytoma admitted to Beijing Tiantan Hospital from 2012 to 2019 were selected. The clinical features, including radiological and histological examination, surgical records and prognosis were reviewed. Sixty-eight other previously published cases of pituicytoma also were used to analyze the predictive factors for the results. The Cox regression model was used for univariate and multivariate analyses.
Results
Our patients included 5 males (45.5%) and 6 females (54.5%), with a mean age of 49.3 years. The tumor was located in the suprasellar region in 5 patients (45.5%), intrasellar region in 4 patients (36.4%), and intrasellar-suprasellar region in 2 patients (18.2%). All patients were misdiagnosed with other common tumors in the sellar region before the operation. During the operation, gross total resection (GTR) of the tumor was achieved in 6 patients (54.5%), and subtotal resection (STR) was achieved in 5 patients (45.5%). The mean progression-free survival (PFS) time was 29.82 months. Tumor progression after surgical resection occurred in 4 patients (36.4%). Among them, 60.0% of the patients (cases 4, 5, 7) with STR experienced progression, while 16.7% of the patients (case 2) with GTR experienced progression. Combined with the 68 cases in the literature, GTR was an independent risk factor for PFS time (
P
< 0.05).
Conclusions
Pituicytomas are more common in middle-aged people and the sellar region. The clinical manifestations of pituicytomas are different, but no diagnostic clinical features have been identified other than an abnormally abundant blood supply. Currently, GTR is the best approach for the treatment of pituicytomas. More patients and longer follow-up periods were needed to further elucidate the biological features of pituicytomas.
The widespread use of the endoscope in transsphenoidal pituitary surgery has recently contributed to the extension of the approach beyond the tuberculum sellae and planum sphenoidale for the ...management of lesions located in the suprasellar area, either with an endoscope-assisted or purely endoscopic technique. Based on our previous experience with more than 450 standard endoscopic transsphenoidal operations, we have retrospectively evaluated the effectiveness of the extended endoscopic endonasal transsphenoidal approach in the management of lesions mainly located in the suprasellar area.
Between January 2004 and December 2005, 20 consecutive patients underwent extended endoscopic endonasal transsphenoidal surgery for a total of 21 procedures. The series consisted of seven pituitary adenomas, seven craniopharyngiomas, three suprasellar Rathke's cleft cysts, two tuberculum sellae meningiomas, and one pilocytic astrocytoma of the chiasm.
Tumor removal, as assessed by postoperative magnetic resonance imaging, revealed complete removal of the lesion in four out of seven pituitary adenomas, five out of seven craniopharyngiomas, three out of three Rathke's cleft cysts, and two out of two tuberculum sellae meningiomas. One patient (5%) with craniopharyngioma had a postoperative cerebrospinal fluid leak that required reoperation. The same patient experienced a sphenoid mycosis, which was treated with medical therapy. Some specific conditions associated with the anatomy of the surgical route, as well as to the morphology of the lesion, have resulted to condition the feasibility of the approach.
Small and medium sized suprasellar lesions located in the midline, with or without a limited parasellar extension and without involvement of vascular structures, seem amenable to be resected through such extended endoscopic transsphenoidal approach. Improvements in closure techniques and the use of new materials and surgical glues seem to significantly reduce the postoperative cerebrospinal fluid leak rate and meningitis.
Object
Despite their benign histological appearance, craniopharyngiomas can be considered a challenge for the neurosurgeon and a possible source of poor prognosis for the patient. With the widespread ...use of the endoscope in endonasal surgery, this route has been proposed over the past decade as an alternative technique for the removal of craniopharyngiomas.
Methods
The authors retrospectively analyzed data from a series of 103 patients who underwent the endoscopic endonasal approach at two institutions (Division of Neurosurgery of the Università degli Studi di Napoli Federico II, Naples, Italy, and Division of Neurosurgery of the Bellaria Hospital, Bologna, Italy), between January 1997 and December 2012, for the removal of infra- and/or supradiaphragmatic craniopharyngiomas. Twenty-nine patients (28.2%) had previously been surgically treated.
Results
The authors achieved overall gross-total removal in 68.9% of the cases: 78.9% in purely infradiaphragmatic lesions and 66.3% in lesions involving the supradiaphragmatic space. Among lesions previously treated surgically, the gross-total removal rate was 62.1%. The overall improvement rate in visual disturbances was 74.7%, whereas worsening occurred in 2.5%. No new postoperative defect was noted. Worsening of the anterior pituitary function was reported in 46.2% of patients overall, and there were 38 new cases (48.1% of 79) of postoperative diabetes insipidus. The most common complication was postoperative CSF leakage; the overall rate was 14.6%, and it diminished to 4% in the last 25 procedures, thanks to improvement in reconstruction techniques. The mortality rate was 1.9%, with a mean follow-up duration of 48 months (range 3–246 months).
Conclusions
The endoscopic endonasal approach has become a valid surgical technique for the management of craniopharyngiomas. It provides an excellent corridor to infra- and supradiaphragmatic midline craniopharyngiomas, including the management of lesions extending into the third ventricle chamber. Even though indications for this approach are rigorously lesion based, the data in this study confirm its effectiveness in a large patient series.
Objective
The management of intradural bleeding during extended endoscopic endonasal surgery is challenging. This technical note describes the use of a biological haemostatic agent which could be ...useful when other established strategies and materials are not effective.
Materials and methods
From January 2004 to January 2008, 65 consecutive patients underwent extended endoscopic endonasal interventions. Of these, 29 procedures required the application of a thrombin–gelatin haemostatic matrix. We reviewed the patients’ operative records to determine the source, type of bleeding and haemostatic strategy.
Results
We analysed bleedings from the venous sinuses, arteries, tumour bed and internal carotid artery and observed complete haemostasis immediately after application of FloSeal®. The matrix was useful for both oozing and focal haemorrhage and effective even for high-flow bleeding. Only bleeding from an internal carotid artery tear required a second application.
Conclusion
The thrombin–gelatin matrix could represent a valuable tool when other haemostatic strategies are ineffective or suboptimal. It is safe and biocompatible when compared with haemostatic agents currently in use.
Cushing's disease is a state of chronic and excessive cortisol levels caused by a pituitary adenoma
CD is a complex entity and often entails difficulties in its diagnosis and management. For that ...reason, there are still controversial points to that respect. The aim of this consensus paper of the skull base section of the EANS is to review the main aspects of the disease a neurosurgeon has to know and also to offer updated recommendations on the controversial aspects of its management.
PUBMED database was used to search the most pertinent articles published on the last 5 years related with the management of CD. A summary of literature evidence was proposed for discussion within the EANS skull base section and other international experts.
This article represents the consensual opinion of the task force regarding optimal management and surgical strategy in CD
After discussion in the group several recommendations and suggestions were elaborated. Patients should be treated by an experienced multidisciplinary team. Accurate clinical, biochemical and radiological diagnosis is mandatory. The goal of treatment is the complete adenoma resection to achieve permanent remission. If this is not possible, the treatment aims to achieving eucortisolism. Radiation therapy is recommended to patients with CD when surgical options have been exhausted. All patients in remission should be tested all life-long.
•Modalities of management of Cushing disease and recommendations based on the literature and expert's opinion.
Indocyanine green (ICG) angiography has become an established technology in many surgical fields, as well as in neurosurgery with the first application of microscope-integrated indocyanine ...angiography, which dates to 2003.1 More recently we observed the integration of ICG into endoscopic visualization (e-ICG), which resulted in different applications during the endoscopic endonasal approach ranging from evaluation of intranasal flap perfusion to differentiation of pituitary neuroendocrine tumors from normal gland or even as a predictive factor of postoperative visual function after expanded approaches.2-8
A 49-year-old woman was admitted to our hospital after a 1-year history of amenorrhea and radiologic finding of an intrasellar lesion. The clinical picture was compatible with a nonfunctioning pituitary neuroendocrine tumor, and the mass was completely removed by means of an endoscopic endonasal approach with intraoperative use of e-ICG (Video 1). A 25 mg intravenous bolus of ICG was injected immediately after completion of the sphenoid phase of the approach. ICG was visualized with a dedicated ICG-integrated endoscope coupled to an IMAGE1 S camera system set on Chroma enhancement mode. Near-infrared excitation of fluorescence (780–820 nm) was obtained using a D-light P Cold Light Fountain.
At follow-up, the patient experienced resolution of her symptoms, without residues or relapses on control magnetic resonance. This case sheds light on some possible applications and advantages of e-ICG, including visualization of internal carotid arteries before the sellar opening, individuation of the pituitary gland, its distinction from the adenomatous tissue, and the possible evaluation of its degree of compression.
Tuberculum sellae meningioma (TSM) represents a complex skull base tumor. The primary goals of surgical treatment are represented by maximal safe resection and visual recovery; therefore, appropriate ...patient selection is critical to optimize results. In the last 2 decades, the endoscopic endonasal approach (EEA) has appeared as a successful and viable strategy for the management of these tumors. The authors identified preoperative factors associated with extent of resection and visual outcome after EEA for TSM.
In this retrospective cohort study, the authors analyzed patients who underwent extended endoscopic endonasal surgery for TSM between January 2005 and April 2022 at the Division of Neurosurgery, Università degli Studi di Napoli Federico II, Naples, Italy. Tumor size, vessel encasement, and optic canal involvement were classified according to University of California, San Francisco, score. Visual acuity and visual fields were analyzed according to the visual impairment score (VIS), defined as a four-level classification: grade 1 (VIS 0-25), grade 2 (VIS 26-50), grade 3 (VIS 51-75), and grade 4 (VIS 76-100). Ophthalmological functions were tested preoperatively and during the early postoperative period (within 6 months after surgery) and late postoperative period.
A total of 48 patients were enrolled. Forty-one (85.4%) patients experienced blurred vision or visual field defect as a presenting sign. Gross-total resection was achieved in 40 (83.3%), near-total resection in 2 (4.2%), and subtotal resection in 6 (12.5%). Visual defect improved in 82.9% (34/41) of cases, 12.2% (5/41) had no significant changes, and 2.4% (1/41) had worsened visual defect. The mean change in VIS was 42% (95% CI 58.77-31.23). Visual outcome was poorer when preoperative VIS (VIS-pre) was greater than 25 (p = 0.02). Six postoperative CSF leaks occurred (12.5%), and 1 patient (2.1%) required revision surgery.
The EEA is a safe and effective approach for TSM removal, with the advantage of preserving optic apparatus vascularization, and can promote gross-total resection and visual improvement. The authors have defined four categories based on VIS that relate to postoperative outcome: the lower the VIS-pre, the higher the rate of postoperative VIS improvement. This finding may be useful for predicting a patient's visual outcome at the preoperative stage.
Purpose
Pituitary adenomas are among the most frequent intracranial tumors. They may exhibit clinically aggressive behavior, with recurrent disease and resistance to multimodal therapy. The ki-67 ...labeling index represents a proliferative marker which correlates with pituitary adenoma aggressiveness. Aim of our study was to assess the accuracy of machine learning analysis of texture-derived parameters from pituitary adenomas preoperative MRI for the prediction of ki-67 proliferation index class.
Methods
A total of 89 patients who underwent an endoscopic endonasal procedure for pituitary adenoma removal with available ki-67 labeling index were included. From T2w MR images, 1128 quantitative imaging features were extracted. To select the most informative features, different supervised feature selection methods were employed. Subsequently, a
k
-nearest neighbors (
k
-NN) classifier was employed to predict macroadenoma high or low proliferation index. Algorithm validation was performed with a train-test approach.
Results
Of the 12 subsets derived from feature selection, the best performing one was constituted by the 4 highest correlating parameters at Pearson’s test. These all showed very good (ICC ≥ 0.85) inter-observer reproducibility. The overall accuracy of the
k
-NN in the test group was of 91.67% (33/36) of correctly classified patients.
Conclusions
Machine learning analysis of texture-derived parameters from preoperative T2 MRI has proven to be effective for the prediction of pituitary macroadenomas ki-67 proliferation index class. This might aid the surgical strategy making a more accurate preoperative lesion classification and allow for a more focused and cost-effective follow-up and long-term management.
