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Acta Neurochirurgica

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01-06-2021 | Pituitary Adenoma | Original Article - Brain Tumors

Utility of intraoperative ultrasonography for resection of pituitary adenomas: a comparative retrospective study

Authors: Mohammed Alshareef, Stephen Lowe, Yeonhee Park, Bruce Frankel

Published in: Acta Neurochirurgica | Issue 6/2021

Abstract

Background

The evolution of pituitary surgery has made it a safe and effective form of treatment; however, risks of inadequate tumor resection, cerebrospinal fluid (CSF) leak, pituitary dysfunction, and vascular injury still exist. The use of intraoperative ultrasonography (IOUS) in pituitary surgery has been well described. Recent advancements in ultrasound technology have allowed for expanded utility as described here.

Methods

A retrospective review was performed between January 2016 and December 2019. One hundred thirty-eight patients (mean age 53.7 years, 47% females) were identified undergoing transsphenoidal surgery for pituitary tumors. Thirty-four patients had IOUS performed using a side-firing ultrasound probe, while 104 did not. Data was analyzed for preoperative (demographics, clinical, and radiographic features), perioperative (blood loss, operative time), and postoperative (complications, length of stay, hormone remission, and extent of resection) outcomes.

Results

There were no significant differences in patient age, gender, tumor volume, Knosp grade, and hormone-secreting status between the two groups. Patients treated using IOUS had significantly higher rates of gross total resection (79% vs. 44%, p = 0.0008), shorter operative times (74 vs. 146 min, p < 0.0001), lower blood loss (119 vs. 284 cc, p < 0.0001), and hospital stays (2.9 vs. 4.2 days, p = 0.001). Overall complication rates were lower in the IOUS group compared to standard pituitary surgery but did not reach significance.

Conclusions

Recent improvements in ultrasound technology have allowed for miniaturization of probes capable of delivering high-resolution images. The use of IOUS in transsphenoidal pituitary surgery may significantly increase rates of gross total resection, while decreasing blood loss, hospital LOS, and operative time.

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Amar AP, Couldwell WT, Chen JC, Weiss MH (2002) Predictive value of serum prolactin levels measured immediately after transsphenoidal surgery. J Neurosurg 97:307–314. https://doi.org/10.3171/jns.2002.97.2.0307CrossRefPubMed

Arita K, Kurisu K, Tominaga A, Kawamoto H, Iida K, Mizoue T, Pant B, Uozumi T (1998) Trans-sellar color Doppler ultrasonography during transsphenoidal surgery. Neurosurgery 42:81–85 discussion 86CrossRef

Babey M, Sahli R, Vajtai I, Andres RH, Seiler RW (2011) Pituitary surgery for small prolactinomas as an alternative to treatment with dopamine agonists. Pituitary 14:222–230. https://doi.org/10.1007/s11102-010-0283-yCrossRefPubMed

Bao X, Deng K, Liu X, Feng M, Chen CC, Lian W, Xing B, Yao Y, Wang R (2016) Extended transsphenoidal approach for pituitary adenomas invading the cavernous sinus using multiple complementary techniques. Pituitary 19:1–10. https://doi.org/10.1007/s11102-015-0675-0CrossRefPubMed

Bellut D, Hlavica M, Muroi C, Woernle CM, Schmid C, Bernays RL (2012) Impact of intraoperative MRI-guided transsphenoidal surgery on endocrine function and hormone substitution therapy in patients with pituitary adenoma. Swiss Med Wkly 142:w13699. https://doi.org/10.4414/smw.2012.13699CrossRefPubMed

Berkmann S, Schlaffer S, Nimsky C, Fahlbusch R, Buchfelder M (2014) Intraoperative high-field MRI for transsphenoidal reoperations of nonfunctioning pituitary adenoma. J Neurosurg 121:1166–1175. https://doi.org/10.3171/2014.6.JNS131994CrossRefPubMed

Cook DM, Ezzat S, Katznelson L, Kleinberg DL, Laws ER Jr, Nippoldt TB, Swearingen B, Vance ML, Force AAGT (2004) AACE medical guidelines for clinical practice for the diagnosis and treatment of acromegaly. Endocr Pract 10:213–225. https://doi.org/10.4158/EP.10.3.213CrossRefPubMed

Dallapiazza RF, Grober Y, Starke RM, Laws ER Jr, Jane JA Jr (2015) Long-term results of endonasal endoscopic transsphenoidal resection of nonfunctioning pituitary macroadenomas. Neurosurgery 76:42–52; discussion 52-43. https://doi.org/10.1227/NEU.0000000000000563CrossRefPubMed

Davis DH, Laws ER Jr, Ilstrup DM, Speed JK, Caruso M, Shaw EG, Abboud CF, Scheithauer BW, Root LM, Schleck C (1993) Results of surgical treatment for growth hormone-secreting pituitary adenomas. J Neurosurg 79:70–75. https://doi.org/10.3171/jns.1993.79.1.0070CrossRefPubMed

10.

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.2016.08.088CrossRefPubMed

11.

Doppman JL, Ram Z, Shawker TH, Oldfield EH (1994) Intraoperative US of the pituitary gland. Work in progress. Radiology 192:111–115. https://doi.org/10.1148/radiology.192.1.8208921CrossRefPubMed

12.

Esposito F, Dusick JR, Cohan P, Moftakhar P, McArthur D, Wang C, Swerdloff RS, Kelly DF (2006) Clinical review: early morning cortisol levels as a predictor of remission after transsphenoidal surgery for Cushing’s disease. J Clin Endocrinol Metab 91:7–13. https://doi.org/10.1210/jc.2005-1204CrossRefPubMed

13.

Esquenazi Y, Essayed WI, Singh H, Mauer E, Ahmed M, Christos PJ, Schwartz TH (2017) Endoscopic endonasal versus microscopic transsphenoidal surgery for recurrent and/or residual pituitary adenomas. World Neurosurg 101:186–195. https://doi.org/10.1016/j.wneu.2017.01.110CrossRefPubMed

14.

Fomekong E, Duprez T, Docquier MA, Ntsambi G, Maiter D, Raftopoulos C (2014) Intraoperative 3T MRI for pituitary macroadenoma resection: initial experience in 73 consecutive patients. Clin Neurol Neurosurg 126:143–149. https://doi.org/10.1016/j.clineuro.2014.09.001CrossRefPubMed

15.

Furtado SV, Thakar S, Hegde AS (2012) The use of image guidance in avoiding vascular injury during trans-sphenoidal access and decompression of recurrent pituitary adenomas. J Craniomaxillofac Surg 40:680–684. https://doi.org/10.1016/j.jcms.2011.12.002CrossRefPubMed

16.

Gerlach R, de Rochemont RM, Gasser T, Marquardt G, Imoehl L, Seifert V (2011) Implementation of the ultra low field intraoperative MRI PoleStar N20 during resection control of pituitary adenomas. Acta Neurochir Suppl 109:73–79. https://doi.org/10.1007/978-3-211-99651-5_12CrossRefPubMed

17.

Jane JA Jr, Starke RM, Elzoghby MA, Reames DL, Payne SC, Thorner MO, Marshall JC, Laws ER Jr, Vance ML (2011) Endoscopic transsphenoidal surgery for acromegaly: remission using modern criteria, complications, and predictors of outcome. J Clin Endocrinol Metab 96:2732–2740. https://doi.org/10.1210/jc.2011-0554CrossRefPubMed

18.

Kanter AS, Dumont AS, Asthagiri AR, Oskouian RJ, Jane JA Jr, Laws ER Jr (2005) The transsphenoidal approach. A historical perspective. Neurosurg Focus 18:e6CrossRef

19.

Knappe UJ, Engelbach M, Konz K, Lakomek HJ, Saeger W, Schonmayr R, Mann WA (2011) Ultrasound-assisted microsurgery for Cushing’s disease. Exp Clin Endocrinol Diabetes 119:191–200. https://doi.org/10.1055/s-0029-1241207CrossRefPubMed

20.

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 617-618PubMed

21.

Kuo JS, Barkhoudarian G, Farrell CJ, Bodach ME, Tumialan LM, Oyesiku NM, Litvack Z, Zada G, Patil CG, Aghi MK (2016) Congress of neurological surgeons systematic review and evidence-based guideline on surgical techniques and technologies for the management of patients with nonfunctioning pituitary adenomas. Neurosurgery 79:E536–E538. https://doi.org/10.1227/NEU.0000000000001390CrossRefPubMed

22.

Laws ER Jr, Iuliano SL, Cote DJ, Woodmansee W, Hsu L, Cho CH (2016) A benchmark for preservation of normal pituitary function after endoscopic transsphenoidal surgery for pituitary macroadenomas. World Neurosurg 91:371–375. https://doi.org/10.1016/j.wneu.2016.04.059CrossRefPubMed

23.

Magro E, Graillon T, Lassave J, Castinetti F, Boissonneau S, Tabouret E, Fuentes S, Velly L, Gras R, Dufour H (2016) Complications related to the endoscopic endonasal transsphenoidal approach for nonfunctioning pituitary macroadenomas in 300 consecutive patients. World Neurosurg 89:442–453. https://doi.org/10.1016/j.wneu.2016.02.059CrossRefPubMed

24.

Marcus HJ, Vercauteren T, Ourselin S, Dorward NL (2017) Intraoperative ultrasound in patients undergoing transsphenoidal surgery for pituitary adenoma: systematic review [corrected]. World Neurosurg 106:680–685. https://doi.org/10.1016/j.wneu.2017.07.054CrossRefPubMed

25.

Martin CH, Schwartz R, Jolesz F, Black PM (1999) Transsphenoidal resection of pituitary adenomas in an intraoperative MRI unit. Pituitary 2:155–162CrossRef

26.

McLaughlin N, Eisenberg AA, Cohan P, Chaloner CB, Kelly DF (2013) Value of endoscopy for maximizing tumor removal in endonasal transsphenoidal pituitary adenoma surgery. J Neurosurg 118:613–620. https://doi.org/10.3171/2012.11.JNS112020CrossRefPubMed

27.

Mindermann T, Wilson CB (1994) Age-related and gender-related occurrence of pituitary adenomas. Clin Endocrinol (Oxf) 41:359–364. https://doi.org/10.1111/j.1365-2265.1994.tb02557.xCrossRef

28.

Negm HM, Al-Mahfoudh R, Pai M, Singh H, Cohen S, Dhandapani S, Anand VK, Schwartz TH (2017) Reoperative endoscopic endonasal surgery for residual or recurrent pituitary adenomas. J Neurosurg 127:397–408. https://doi.org/10.3171/2016.8.JNS152709CrossRefPubMed

29.

Nimsky C, von Keller B, Ganslandt O, Fahlbusch R (2006) Intraoperative high-field magnetic resonance imaging in transsphenoidal surgery of hormonally inactive pituitary macroadenomas. Neurosurgery 59:105–114; discussion 105-114. https://doi.org/10.1227/01.NEU.0000219198.38423.1ECrossRefPubMed

30.

Ostrom QT, Gittleman H, Farah P, Ondracek A, Chen Y, Wolinsky Y, Stroup NE, Kruchko C, Barnholtz-Sloan JS (2013) CBTRUS statistical report: primary brain and central nervous system tumors diagnosed in the United States in 2006-2010. Neuro Oncol 15 Suppl 2:ii1-56. https://doi.org/10.1093/neuonc/not151

31.

Penn DL, Burke WT, Laws ER (2017) Management of non-functioning pituitary adenomas: surgery. Pituitary. https://doi.org/10.1007/s11102-017-0854-2

32.

Przybylowski CJ, Dallapiazza RF, Williams BJ, Pomeraniec IJ, Xu Z, Payne SC, Laws ER, Jane JA Jr (2017) Primary versus revision transsphenoidal resection for nonfunctioning pituitary macroadenomas: matched cohort study. J Neurosurg 126:889–896. https://doi.org/10.3171/2016.3.JNS152735CrossRefPubMed

33.

Ram Z, Bruck B, Hadani M (1999) Ultrasound in pituitary tumor surgery. Pituitary 2:133–138CrossRef

34.

Ram Z, Shawker TH, Bradford MH, Doppman JL, Oldfield EH (1995) Intraoperative ultrasound-directed resection of pituitary tumors. J Neurosurg 83:225–230. https://doi.org/10.3171/jns.1995.83.2.0225CrossRefPubMed

35.

Romero A, Lal Gangadharan J, Bander ED, Gobin YP, Anand VK, Schwartz TH (2017) Managing arterial injury in endoscopic skull base surgery: case series and review of the literature. Oper Neurosurg (Hagerstown) 13:138–149. https://doi.org/10.1227/NEU.0000000000001180CrossRef

36.

Solheim O, Selbekk T, Lovstakken L, Tangen GA, Solberg OV, Johansen TF, Cappelen J, Unsgard G (2010) Intrasellar ultrasound in transsphenoidal surgery: a novel technique. Neurosurgery 66:173–185; discussion 185-176. https://doi.org/10.1227/01.NEU.0000360571.11582.4FCrossRefPubMed

37.

Thawani JP, Ramayya AG, Pisapia JM, Abdullah KG, Lee JY, Grady MS (2017) Operative strategies to minimize complications following resection of pituitary macroadenomas. J Neurol Surg B Skull Base 78:184–190. https://doi.org/10.1055/s-0036-1597276CrossRefPubMed

38.

Watson JC, Shawker TH, Nieman LK, DeVroom HL, Doppman JL, Oldfield EH (1998) Localization of pituitary adenomas by using intraoperative ultrasound in patients with Cushing’s disease and no demonstrable pituitary tumor on magnetic resonance imaging. J Neurosurg 89:927–932. https://doi.org/10.3171/jns.1998.89.6.0927CrossRefPubMed

39.

Yamasaki T, Moritake K, Hatta J, Nagai H (1996) Intraoperative monitoring with pulse Doppler ultrasonography in transsphenoidal surgery: technique application. Neurosurgery 38:95–97 discussion 97-98CrossRef

Title: Utility of intraoperative ultrasonography for resection of pituitary adenomas: a comparative retrospective study
Authors: Mohammed Alshareef
Stephen Lowe
Yeonhee Park
Bruce Frankel
Publication date: 01-06-2021
Publisher: Springer Vienna
Keywords: Pituitary Adenoma
Ultrasound
Ultrasound
Published in: Acta Neurochirurgica / Issue 6/2021
Print ISSN: 0001-6268
Electronic ISSN: 0942-0940
DOI: https://doi.org/10.1007/s00701-020-04674-2

At a glance: The STEP trials

Springer Medicine

Utility of intraoperative ultrasonography for resection of pituitary adenomas: a comparative retrospective study

Abstract

Background

Methods

Results

Conclusions

At a glance: The STEP trials

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

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