Impact of intraoperative MRI-guided transsphenoidal surgery on endocrine function and hormone substitution therapy in patients with pituitary adenoma
BACKGROUND: Pituitary adenomas are rare with an incidence of 0.4–8.2 per 105 inhabitants. Symptoms range from headaches to pituitary insufficiency or excessive output of hormones with associated disease. Except for prolactinomas, surgery is recommended as the first line and most effective treatment for the majority of these tumours. One of the refinements of surgical therapy introduced was intraoperative magnetic resonance imaging (iMRI).
OBJECTIVE: The aim of this study was to analyse the postoperative pituitary function and the general outcome of patients treated for non-functioning and GH-producing pituitary adenomas with a transsphenoidal iMRI-assisted approach using the PoleStar™ N20 imager.
METHODS: A total of 148 consecutive iMRI-guided surgeries for GH-producing and non-functioning pituitary adenomas were retrospectively analysed. Patients' clinical data, endocrinological parameters, clinical examinations and pre-/post- and intraoperative imaging studies were evaluated.
RESULTS: A total of 101 patients could be classified as being in remission at follow-up; 26 (17.6%) of them due to iMRI allowing additional tumour removal. A total of 44 patients (29.7%) had more complete tumour removal because remnants were detected by iMRI.
The mean hormone levels of patients did not differ significantly between pre- and postoperative examinations. There were 62 patients with preoperative, and 43 patients with postoperative pituitary insufficiency, thus, due to surgery there were 19 (12.8%) patients with improved pituitary function.
CONCLUSIONS: The results show this method to be a safe and effective treatment option increasing remission rate and keeping complication rate low. Postoperative pituitary function was preserved or improved – possibly due to more exact iMRI-assisted tumour removal.
- Kreutzer J, Fahlbusch R. Diagnosis and treatment of pituitary tumors. Curr Opin Neurol. 2004;17:693–703.
- Monson J. The epidemiology of endocrine tumours. Endocr Relat Cancer. 2000;7:29–36.
- Wöhrer A, Waldhör T, Heinzl H, Hackl M, Feichtinger J, Gruber-Mösenbacher U, et al. The Austrian Brain Tumour Registry: a cooperative way to establish a population-based brain tumour registry. J Neurooncol. 2009;95:401–11.
- Comtois R, Beauregard H, Somma M, Serri O, Aris-Jilwan N, Hardy J. The clinical and endocrine outcome to trans-sphenoidal microsurgery of nonsecreting pituitary adenomas. Cancer. 1991;68:860–6.
- Gondim J, Schops M, de Almeida J, de Albuquerque L, Gomes E, Ferraz T, et al. Endoscopic endonasal transsphenoidal surgery: surgical results of 228 pituitary adenomas treated in a pituitary center. Pituitary. 2010;13:68–77.
- Jaffe C. Clinically non-functioning pituitary adenoma. Pituitary. 2006;9:317–21.
- Losa M, Mortini P, Barzaghi R, Franzin A, Giovanelli M. Endocrine inactive and gonadotroph adenomas: diagnosis and management. J Neurooncol. 2001;54:167–77.
- Bengtsson BA, Eden S, Ernest I, Oden A, Sjogren B. Epidemiology and long-term survival in acromegaly. A study of 166 cases diagnosed between 1955 and 1984. Acta Med Scand. 1988;223:327–35.
- Nabarro JD. Acromegaly. Clin Endocrinol. (Oxf) 1987;26:481–512.
- Wright AD, Hill DM, Lowy C, Fraser TR. Mortality in acromegaly. Q J Med. 1970;39:1–16.
- Schloffer H. Erfolgreiche Operation eines Hypophysentumors auf nasalem Wege. Wein Klein Wochenschr. 1907;20:621–4.
- Alexander J, Biller B, Bikkal H, Zervas N, Arnold A, Klibanski A. Clinically nonfunctioning pituitary tumors are monoclonal in origin. J Clin Invest. 1990;86:336–40.
- Saunders S, Vora J. Endocrine evaluation of pituitary tumours. Br J Neurosurg. 2008;22:602–8.
- Nomikos P, Ladar C, Fahlbusch R, Buchfelder M. Impact of primary surgery on pituitary function in patients with non-functioning pituitary adenomas – a study on 721 patients. Acta Neurochir. (Wien) 2004;146:27–35.
- Cappabianca P, Alfieri A, Colao A, Ferone D, Lombardi G, de Divitiis E. Endoscopic endonasal transsphenoidal approach: an additional reason in support of surgery in the management of pituitary lesions. Skull Base Surg. 1999;9:109–17.
- Ezzat S, Serri O, Chik CL, Johnson MD, Beauregard H, Marcovitz S, Nyomba BL, Ramirez JR, Ur E. Canadian consensus guidelines for the diagnosis and management of acromegaly. Clin Invest Med. 2006;29:29–39.
- Melmed S, Casanueva FF, Cavagnini F, Chanson P, Frohman L, Grossman A, et al. Guidelines for acromegaly management. J Clin Endocrinol Metab. 2002;87:4054–8.
- Melmed S, Colao A, Barkan A, Molitch M, Grossman AB, Kleinberg D, et al. Guidelines for acromegaly management: an update. J Clin Endocrinol Metab. 2009;94:1509–17.
- Jane JJ, Laws EJ. The management of non-functioning pituitary adenomas. Neurol India. 2003;51:461–5.
- Laws E, Jane JJ. Neurosurgical approach to treating pituitary adenomas. Growth Horm IGF Res. 2005;15(Suppl A):S36–41.
- Nimsky C, von Keller B, Ganslandt O, Fahlbusch R. Intraoperative high-field magnetic resonance imaging in transsphenoidal surgery of hormonally inactive pituitary macroadenomas. Neurosurgery. 2006;59:105–14; discussion 105–14.
- Cushing H. III. Partial hypophysectomy for acromegaly: with remarks on the function of the hypophysis. Ann Surg. 1909;50:1002–17.
- Hardy J. The transsphenoidal surgical approach to the pituitary. Hosp Pract. 1979;14:81–9.
- Baumann F, Schmid C, Bernays RL. Intraoperative magnetic resonance imaging-guided transsphenoidal surgery for giant pituitary adenomas. Neurosurg Rev. 2010;33:83–90.
- Bellut D, Hlavica M, Schmid C, Bernays RL. Intraoperative magnetic resonance imaging-assisted transsphenoidal pituitary surgery in patients with acromegaly. Neurosurg Focus. 2010;29:E9.
- Bohinski RJ, Warnick RE, Gaskill-Shipley MF, Zuccarello M, van Loveren HR, Kormos DW, et al. Intraoperative magnetic resonance imaging to determine the extent of resection of pituitary macroadenomas during transsphenoidal microsurgery. Neurosurgery. 2001;49:1133–43; discussion 1143–34.
- Fahlbusch R, Ganslandt O, Buchfelder M, Schott W, Nimsky C. Intraoperative magnetic resonance imaging during transsphenoidal surgery. J Neurosurg. 2001;95:381–90.
- Gerlach R, du Mesnil de Rochemont R, Gasser T, Marquardt G, Reusch J, Imoehl L, et al. Feasibility of Polestar N20, an ultra-low-field intraoperative magnetic resonance imaging system in resection control of pituitary macroadenomas: lessons learned from the first 40 cases. Neurosurgery. 2008;63:272–84; discussion 284–75.
- Martin CH, Schwartz R, Jolesz F, Black PM. Transsphenoidal resection of pituitary adenomas in an intraoperative MRI unit. Pituitary. 1999;2:155–62.
- Nimsky C, Ganslandt O, Von Keller B, Romstöck J, Fahlbusch R. Intraoperative high-field-strength MR imaging: implementation and experience in 200 patients. Radiology. 2004;233:67–78.
- Schwartz TH, Stieg PE, Anand VK. Endoscopic transsphenoidal pituitary surgery with intraoperative magnetic resonance imaging. Neurosurgery 58:ONS44-51; discussion ONS44-51, 2006.
- Theodosopoulos PV, Leach J, Kerr RG, Zimmer LA, Denny AM, Guthikonda B, et al. Maximizing the extent of tumor resection during transsphenoidal surgery for pituitary macroadenomas: can endoscopy replace intraoperative magnetic resonance imaging? J Neurosurg. 2010;112:736–43.
- Wu JS, Shou XF, Yao CJ, Wang YF, Zhuang DX, Mao Y, Li SQ, Zhou LF. Transsphenoidal pituitary macroadenomas resection guided by PoleStar N20 low-field intraoperative magnetic resonance imaging: comparison with early postoperative high-field magnetic resonance imaging. Neurosurgery. 2009;65:63–70; discussion 70–61.
- Beauregard C, Truong U, Hardy J, Serri O. Long-term outcome and mortality after transsphenoidal adenomectomy for acromegaly. Clin Endocrinol. (Oxf) 2003;58:86–91.
- Laws ER, Vance ML, Thapar K. Pituitary surgery for the management of acromegaly. Horm Res. 2000;53(Suppl 3):71–5.
- Nomikos P, Buchfelder M, Fahlbusch R. The outcome of surgery in 668 patients with acromegaly using current criteria of biochemical “cure”. Eur J Endocrinol. 2005;152:379–87.
- Cappabianca P, Cavallo LM, Colao A, Del Basso De Caro M, Esposito F, Cirillo S, et al. Endoscopic endonasal transsphenoidal approach: outcome analysis of 100 consecutive procedures. Minim Invasive Neurosurg. 2002;45:193–200.
- Dehdashti AR, Ganna A, Karabatsou K, Gentili F. Pure endoscopic endonasal approach for pituitary adenomas: early surgical results in 200 patients and comparison with previous microsurgical series. Neurosurgery. 62:1006-1015.
- Frank G, Pasquini E, Farneti G, Mazzatenta D, Sciarretta V, Grasso V, et al. The endoscopic versus the traditional approach in pituitary surgery. Neuroendocrinology. 2006;83:240–8.
- Jho HD. Endoscopic transsphenoidal surgery. J Neurooncol. 2001;54:187–95.
- Santos AR, Fonseca Neto RM, Veiga JC, Viana Jr J, Scaliassi NM, Lancellotti CL, et al. Endoscopic endonasal transsphenoidal approach for pituitary adenomas: technical aspects and report of casuistic. Arq Neuropsiquiatr. 2010;68:608–12.
- Kristof RA, Schramm J, Redel L, Neuloh G, Wichers M, Klingmüller D. Endocrinological outcome following first time transsphenoidal surgery for GH-, ACTH-, and ORL-secreting pituitary adenomas. Acta Neurochir. 2002;11:555–61.
- Basso A. Commentary to giant pituitary tumors: a study based on surgical treatment of 118 cases. Surgical Neurology. 2004;61:445.
- Goel A, Nadkarni T, Muzumdar D, Desai K, Phalke U, Sharma P. Giant pituitary tumors: a study based on surgical treatment of 118 cases. Surg Neurol. 2004;61:436–45; discussion 445–36.
- Losa M, Mortini P, Barzaghi R, Ribotto P, Terreni MR, Marzoli SB, et al. Early results of surgery in patients with nonfunctioning pituitary adenoma and analysis of the risk of tumor recurrence. J Neurosurg. 2008;108:525–32.