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Surgical complications in 226 pituitary tumors according to tumor consistency (*p < 0.05; **p < 0.01)
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Background
Most pituitary adenomas (PAs) are considered to have a soft tumor consistency. However, there is a non-negligible percentage (5–13%) of tumors presenting or exhibiting a fibrous consistency that would entail a more difficult and complicated surgical excision with higher surgical morbidity and mortality rates.
Purpose
To analyze the clin...
Similar publications
Introduction: Transsphenoidal surgery with an operative microscope was a standard procedure for pituitary adenomas resection in our institution. Still, since the end of 2020, we have shifted the protocol to endoscopic transsphenoidal approach. This paper presented our learning curve in pituitary surgery using endoscopy instruments.
Method: Patients...
Citations
... The histological features evaluated were pituitary hormone immunostaining and proliferation index based on Ki67 immunoexpression as described in our previous study [8]. Tumor consistency was classified into two groups: "soft", which includes easily aspirated tumors with conventional 8-10 french suction tip, and "fibrous", which implies that the tumor had to be fragmented previously with ring curettes and occasionally needs extracapsular dissection for its complete removal [1]. ...
Purpose
To identify differences in the presentation and surgical outcomes between very large (30–39 mm) and giant (≥ 40 mm) (LARGE group) pituitary adenomas (PAs) compared to the smaller group (< 30 mm) (non-LARGE group).
Methods
Eighty patients with very large (n = 44) or giant (n = 36) PAs and 226 patients in the non-LARGE group who underwent tumor resection by pituitary surgery between 2008 and 2023 were studied. Hormonal, radiological, ophthalmological, and pathological data, and surgical outcomes were evaluated.
Results
Preoperatively, patients of the LARGE group presented more frequently with visual impairment (82.5% vs. 22.1%, P < 0.001) and with pituitary apoplexy (15.0% vs. 2.7%, P < 0.001) than the non-LARGE group. Moreover, the LARGE group were more commonly associated with preoperative panhypopituitarism (28.8% vs. 6.2%, P < 0.001). This group presented cavernous sinus invasion more frequently (71.3% vs. 23.9%, P < 0.001). The non-LARGE group achieved surgical cure more often than the LARGE group (79.7% vs. 50.0%, P < 0.001), and the rate of major complications was higher in the latest (8.8% vs. 1.3%, P < 0.004).
Conclusions
PAs ≥ 30 mm are most frequently accompanied by hormonal dysfunction, cavernous sinus invasion, and visual impairment. All this implies lower resection rates and higher postoperative complications than the smaller adenomas, posing a real surgical challenge.
... While most pituitary adenomas can be easily extracted using this neurosurgical approach, 10-15% of these tumors are composed of fibrotic tissue, which are technically more demanding with regard to resection and require different neurosurgical techniques, as well as augmented resection equipment [5][6][7]. Therefore, pre-surgical knowledge of tumor consistency is crucial and will facilitate neurosurgical planning, which is key to improve postoperative clinical outcomes [2,[8][9][10]. However, modalities with which to assess pituitary adenoma consistency non-invasively prior to surgery are currently lacking [5,11]. ...
... Pituitary adenomas with a fibrous component account for approximately 10-15% of sellar lesions [5][6][7]. These tumors are associated with lower total resection rates and higher risks of recurrence after surgery, which is accompanied by an unsatisfactory clinical outcome [2,[8][9][10]. Thus, a priori information about lesion texture may facilitate preoperative planning with the chance to improve post-surgical outcomes. ...
Purpose
Pre-surgical information about tumor consistency could facilitate neurosurgical planning. This study used multi-dynamic-multi-echo (MDME)-based relaxometry for the quantitative determination of pituitary tumor consistency, with the aim of predicting lesion resectability.
Methods
Seventy-two patients with suspected pituitary adenomas, who underwent preoperative 3 T MRI between January 2020 and January 2022, were included in this prospective study. Lesion-specific T1-/T2-relaxation times (T1R/T2R) and proton density (PD) metrics were determined. During surgery, data about tumor resectability were collected. A Receiver Operating Characteristic (ROC) curve analysis was performed to investigate the diagnostic performance (sensitivity/specificity) for discriminating between easy- and hard-to-remove by aspiration (eRAsp and hRAsp) lesions. A Mann-Whitney-U-test was done for group comparison.
Results
A total of 65 participants (mean age, 54 years ± 15, 33 women) were enrolled in the quantitative analysis. Twenty-four lesions were classified as hRAsp, while 41 lesions were assessed as eRAsp. There were significant differences in T1R (hRAsp: 1221.0 ms ± 211.9; eRAsp: 1500.2 ms ± 496.4; p = 0.003) and T2R (hRAsp: 88.8 ms ± 14.5; eRAsp: 137.2 ms ± 166.6; p = 0.03) between both groups. The ROC analysis revealed an area under the curve of 0.72 (95% CI: 0.60–0.85) at p = 0.003 for T1R (cutoff value: 1248 ms; sensitivity/specificity: 78%/58%) and 0.66 (95% CI: 0.53–0.79) at p = 0.03 for T2R (cutoff value: 110 ms; sensitivity/specificity: 39%/96%).
Conclusion
MDME-based relaxometry enables a non-invasive, pre-surgical characterization of lesion consistency and, therefore, provides a modality with which to predict tumor resectability.
... Most PAs are soft in consistency, facilitating complete excision [3,7,24]. However, up to 13% of pituitary tumors have a fibrous consistency associated with lower resection rates and greater morbimortality [2,11,24,26]. ...
... None demonstrated sufficient accuracy and reliability in clinical use." A fibrous PA consistency can, independent of other variables, significantly impact on the surgery and the patient's outcomes and prognosis [2,11]. Preoperatively identifying these challenging fibrous adenomas could facilitate centralization of these high-complexity tumors to referral centers. ...
... Fibrous PAs are associated with lower resection rates, higher complication rates, requirement for more subsequent treatments, and longer surgical time [2,11]. Most authors differentiate easily aspirated tumors (soft) from those that require prior fragmentation (fibrous) [3,5,7,24,25]. ...
Purpose
Pituitary adenomas (PAs) usually have a soft consistency, facilitating gross total resection. However, 5–13% of PAs with fibrous consistency are challenging to remove entirely and are accompanied by greater morbimortality. This study aims to identify the clinical and radiological characteristics that correlate with PA fibrous consistency preoperatively. A simple scoring system has been proposed to predict incidence of fibrous PAs.
Materials and methods
Consecutive interventions (226) were analyzed, all performed through an endoscopic endonasal transsphenoidal approach. Univariable and multivariable logistic regression analysis was performed. Hosmer–Lemeshow test and receiver operating characteristic (ROC) curves were assessed to evaluate the model. A point scoring system (PiTCon) was derived based on the multivariable regression model. Our study aimed to identify the clinical and radiological characteristics that correlate with fibrous tumor consistency preoperatively.
Results
The best diagnostic accuracy for predicting PA consistency consisted of five predictive factors: age, compressive symptoms, panhypopituitarism, craniocaudal extension of the PA in mm, and prior surgery. The multivariable model achieved good discrimination with an area under the curve (AUC) of the ROC curve being 0.82 and the 95% CI 0.76 to 0.88. Internal validation yielded an optimism-adjusted C-statistic of 0.80 (95% CI 0.74 to 0.86). A point scoring system (PiTCon score) was designed using the best predictive model.
Conclusions
PA consistency can be estimated preoperatively regarding clinical and radiological characteristics. We propose a point-based scoring system (PiTCon score) that can better guide neurosurgeons in clinical decision-making and surgical risk assessment and help establish and describe patient prognosis.
... Knowledge of the preoperative tumor consistency allows the neurosurgeon to plan the best surgical strategy in order to avoid multiple surgeries and reduce the possibility of tumor residue [12][13][14]. ...
... Recently, a study showed that tumor consistency and the Knosp grade play a greater role as predictors of the extent of tumor resection [11]. Predicting the preoperative PA consistency would be important for planning the surgical approach, reducing the chances of complications in the surgical procedure, such as cerebrospinal fluid fistula or injury of major cerebral vessels [14,39]. This would also allow referring more complex cases to neurosurgeons with greater experience in surgeries of the sella turcica region, reducing the risk of incomplete resection, which in turn minimizes the possibility of recurrence [12,13]. ...
Purpose
To prospectively evaluate the usefulness of T1-weighted imaging (T1WI) and diffusion-weighted imaging (DWI) sequences in predicting the consistency of macroadenomas. In addition, to determine their values as prognostic factors of surgical outcomes.
Methods
Patients with pituitary macroadenoma and surgical indication were included. All patients underwent pre-surgical magnetic resonance imaging (MRI) that included the sequences T1WI before and after contrast administration and DWI with the apparent diffusion coefficient (ADC) map. Post-surgical MRI was performed at least 3 months after surgery. The consistency of the macroadenomas was evaluated at surgery, and they were grouped into soft and intermediate/hard adenomas. Mean ADC values, signal on T1WI and the ratio of tumor ADC values to pons (ADCR) were compared with tumor consistency and grade of surgical resection.
Results
A total of 80 patients were included. A softened consistency was found at surgery in 53 patients and hardened in 27 patients. The median ADC in the soft consistency group was 0.532 × 10–3 mm²/sec (0.306 – 1.096 × 10–3 mm²/sec), and in the intermediate/hard consistency group was 0.509 × 10–3 mm²/sec (0.308 − 0.818 × 10–3 mm²/sec). There was no significant difference between the median values of ADC, ADCR and signal on T1W between the soft and hard tumor groups, or between patients with and without tumor residue.
Conclusion
Our results did not show usefulness of the DWI and T1WI for assessing the consistency of pituitary macroadenomas, nor as a predictor of the degree of surgical resection.
... Moreover, the true prevalence of hard-consistency PAs is unknown with reports ranging from 5-13%[8]. This is important for pre-operatory planning since more adverse events are associated with hard-consistency tumors [9]. Therefore the present study aims to evaluate the overall prevalence of pituitary tumors with hard consistency and the utility of radiological ndings in predicting tumor stiffness. ...
OBJECTIVE
Transsphenoidal resection of pituitary adenomas can be challenging in patients with tumors with a hard consistency. We performed a systematic review and meta-analysis of the literature to identify the true incidence and the performance of radiological findings in identifying pituitary adenomas with a hard consistency.
METHODS
A literature search was conducted and included studies that compared intraoperative pituitary tumor consistency and pre-operative magnetic resonance imaging (MRI). Using random-effects meta-analysis and univariate analysis, we evaluate the prevalence of hard pituitary tumors.
RESULTS
Of studies the 916 studies, 888 studies were excluded. Finally, 28 studies harboring 1116 patients with pituitary tumors were included. Of them, hard-consistency tumors were intraoperatively adjudicated in 219 patients (weighted incidence of 16,82%,95% CI, 12.35–22.48%; I2 = 65,1%). Seventeen (60%) reported a relation between radiological findings and intraoperative tumor consistency in at least one MRI sequence, with a weighted proportion of 15%, 95% CI, 10,31% − 22,70%). Apparent diffusion correlation(ADC), and T2-weighted sequences were associated with tumor consistency in 31% and 53% of the studies, respectively. Nonetheless, conflicting signal intensities across the studies precluded conventional MRI sequences from accurately predicting pituitary tumor consistency.
CONCLUSION
The weighted incidence of pituitary tumors adjudicated as having a hard consistency was 16% in the present sample of studies.
... To our knowledge, despite current evidence linking tumor consistency to the surgical outcomes for pituitary adenomas [14], its impact on postoperative endocrine function is still largely unexplored, with few published series recently suggesting an association with higher rates of postoperative hypopituitarism [55][56][57]. In accordance with current Literature, 10% of tumors in our cohort presented as fibrous during the intraoperative assessment. ...
Background
Tumor consistency recently emerged as a key factor in surgical planning for pituitary adenomas, but its impact on postoperative endocrine function is still unclear. Our study aimed to evaluate the impact of tumor consistency on the development of postoperative pituitary deficiencies.
Methods
Single-center, retrospective analysis of consecutive pituitary surgeries performed between January 2017 and January 2021 at Policlinico Umberto I in Rome. All patients underwent radiological and biochemical evaluations at baseline, and hormone assessments 3 and 6 months after pituitary surgery. Postoperative MRI studies were used to determine resection rates following surgery. Data on tumor consistency, macroscopic appearance, neurosurgical approach, and intraoperative complications were collected.
Results
Fifty patients [24 women, mean age 57 ± 13 years, median tumor volume 4800 mm³ [95% CI 620–8828], were included. Greater tumor volume (χ² = 14.621, p = 0.006) and male sex (χ² = 12.178, p < 0.001) were associated with worse preoperative endocrine function. All patients underwent transsphenoidal adenomectomy. Fibrous consistency was observed in 10% of patients and was associated with a Ki-67 greater than 3% (χ² = 8.154, p = 0.04), greater risk of developing postoperative hormone deficiencies (χ² = 4.485, p = 0.05, OR = 8.571; 95% CI: 0.876–83.908), and lower resection rates (χ2 = 8.148, p = 0.004; OR 1.385, 95% CI; 1.040–1.844). Similarly, worse resection rates were observed in tumors with suprasellar extension (χ2 = 5.048, p = 0.02; OR = 6.000, 95% CI; 1.129–31.880) and CSI (χ2 = 4.000, p = 0.04; OR = 3.857, 95% CI; 0.997–14.916).
Conclusions
Tumor consistency might provide useful information about postoperative pituitary function, likely due to its impact on surgical procedures. Further prospective studies with larger cohorts are needed to confirm our preliminary findings.
Purpose
To identify differences in the presentation and surgical outcomes between very large (30–39 mm) and giant (≥40mm) (LARGE group) pituitary adenomas (PAs) compared to the smaller group (< 30mm) (non-LARGE group).
Methods
Eighty patients with very large (n = 44) or giant (n = 36) PAs and 226 patients in the non-LARGE group who underwent tumor resection by pituitary surgery between 2008 and 2023 were studied. Hormonal, radiological, ophthalmological, and pathological data and surgical outcomes were evaluated.
Results
Preoperatively, patients of the LARGE group presented more frequently with visual impairment (82.5% vs. 22.1%, P < 0.001) and with apoplexy (15.0% vs. 2.7%, P < 0.001) than the non-LARGE group. Moreover, the LARGE group is more commonly associated with preoperative panhypopituitarism (28.8% vs. 6.2%, P < 0.001). This group presented cavernous sinus invasion more frequently (71.3% vs. 23.9%, P < 0.001). The non-LARGE group achieved surgical cure more often than the LARGE group (79.7% vs. 50.0%, P < 0.001), and the rate of major complications was higher in the latest (8.8% vs. 1.3%, P < 0.004).
Conclusions
PAs ≥30 mm are most frequently accompanied by hormonal dysfunction, cavernous sinus invasion, and visual impairment. All this implies lower resection rates and higher postoperative complications than small adenomas, posing a real surgical challenge.
