Dumbbell-shaped pituitary adenomas: prognostic factors for prediction of tumor nondescent of the supradiaphragmal component from a multicenter series

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  • 1 Department of Neurosurgery, Medical University of Vienna;
  • | 2 Department of Biomedical Imaging and Image-guided Therapy, Division of Neuroradiology and Musculoskeletal Radiology, Medical University of Vienna, Austria; and
  • | 3 Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
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OBJECTIVE

Dumbbell-shaped pituitary adenomas (DSPAs) are a subgroup of macroadenomas with suprasellar extension that are characterized by a smaller diameter at the level of the diaphragma sellae opening compared with the supradiaphragmal tumor component (SDTC). Hence, DSPAs may be particularly prone to a nondescending suprasellar tumor component and risk for residual tumor or postoperative bleeding.

METHODS

A multicenter retrospective cohort analysis of 99 patients with DSPA operated on via direct endoscopic endonasal transsphenoidal approach between 2011 and 2020 was conducted. Patient recruitment was performed at two tertiary care centers (Medical University of Vienna and University of Southern California) with expertise in endoscopic skull base surgery. DSPA was defined as having a smaller diameter at the level of the diaphragma sellae compared with the SDTC.

RESULTS

On preoperative MRI, all DSPAs were macroadenomas (maximum diameter range 17–71 mm, volume range 2–88 cm3). Tumor descent was found in 73 (74%) of 99 patients (group A), and nondescent in 26 (26%) of 99 patients (group B) intraoperatively. DSPAs in group A had a significantly smaller diameter (30 vs 42 mm, p < 0.001) and significantly smaller volume (10 vs 22 cm3, p < 0.001) than those in group B. The ratio of the minimum area at the level of the diaphragmal opening in comparison with the maximum area of the suprasellar tumor component ("neck-to-dome area") was significantly lower in group A than in group B (1.7 vs 2.7, p < 0.001). Receiver operating characteristic curve analysis revealed an area under the curve of 0.75 (95% CI 0.63–0.87). At a cutoff ratio of 1.9, the sensitivity and specificity for a nondescending suprasellar tumor component were 77% and 34%, respectively.

CONCLUSIONS

In the present study, the neck-to-dome area ratio was of prognostic value for prediction of intraoperative tumor nondescent in DSPAs operated on via a direct endonasal endoscopic approach. Pituitary adenoma SDTC nondescent carried the inherent risk of hemorrhagic transformation in all cases.

ABBREVIATIONS

AComA = anterior communicating artery; DSPA = dumbbell-shaped pituitary adenoma; GTR = gross-total resection; IDTC = infradiaphragmal tumor component; ROC = receiver operating characteristic; SDTC = supradiaphragmal tumor component.

Schematics of transseptal interforniceal resection of a superiorly recessed colloid cyst. ©Mark Souweidane, published with permission. See the article by Tosi et al. (pp 813–819).

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  • 1

    Liu JK, Das K, Weiss MH, Laws ER Jr, Couldwell WT. The history and evolution of transsphenoidal surgery. J Neurosurg. 2001;95(6):10831096.

  • 2

    Cappabianca P, Cavallo LM, de Divitiis E. Endoscopic endonasal transsphenoidal surgery. Neurosurgery. 2004;55(4):933941.

  • 3

    Doglietto F, Prevedello DM, Jane JA Jr, Han J, Laws ER Jr. Brief history of endoscopic transsphenoidal surgery—from Philipp Bozzini to the First World Congress of Endoscopic Skull Base Surgery. Neurosurg Focus. 2005;19(6):E3.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 4

    Kanter AS, Dumont AS, Asthagiri AR, Oskouian RJ, Jane JA Jr, Laws ER Jr. The transsphenoidal approach. A historical perspective. Neurosurg Focus. 2005;18(4):e6.

  • 5

    Solari D, Cavallo LM, Cappabianca P. Surgical approach to pituitary tumors. Handb Clin Neurol. 2014;124:291301.

  • 6

    Zada G, Du R, Laws ER Jr. Defining the "edge of the envelope": patient selection in treating complex sellar-based neoplasms via transsphenoidal versus open craniotomy. J Neurosurg. 2011;114(2):286300.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Saito K, Kuwayama A, Yamamoto N, Sugita K. The transsphenoidal removal of nonfunctioning pituitary adenomas with suprasellar extensions: the open sella method and intentionally staged operation. Neurosurgery. 1995;36(4):668676.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Matsuyama J, Kawase T, Yoshida K, Hasegawa M, Hirose Y, Nagahisa S, et al. Management of large and giant pituitary adenomas with suprasellar extensions. Asian J Neurosurg. 2010;5(1):4853.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Ko HC, Lee SH, Shin HS, Koh JS. Predicting arachnoid membrane descent in the chiasmatic cistern in the treatment of pituitary macroadenoma. J Korean Neurosurg Soc. 2021;64(1):110119.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Rutkowski MJ, Chang KE, Cardinal T, Du R, Tafreshi AR, Donoho DA, et al. Development and clinical validation of a grading system for pituitary adenoma consistency. J Neurosurg. 2021;134(6):18001807.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 11

    Alleyne CH Jr, Barrow DL, Oyesiku NM. Combined transsphenoidal and pterional craniotomy approach to giant pituitary tumors. Surg Neurol. 2002;57(6):380390.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Micko A, Agam MS, Brunswick A, Strickland BA, Rutkowski MJ, Carmichael JD, et al. Treatment strategies for giant pituitary adenomas in the era of endoscopic transsphenoidal surgery: a multicenter series. J Neurosurg. Published online August 13, 2021; doi: 10.3171/2021.1.JNS203982

    • Search Google Scholar
    • Export Citation
  • 13

    Micko A, Hosmann A, Marik W, Bartsch S, Weber M, Knosp E, Wolfsberger S. Optimizing MR imaging for intraoperative image guidance in sellar pathologies. Pituitary. 2020;23(3):266272.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Micko A, Hosmann A, Wurzer A, Maschke S, Marik W, Knosp E, Wolfsberger S. An advanced protocol for intraoperative visualization of sinunasal structures: experiences from pituitary surgery. J Neurosurg. 2020;133(1):240248.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 15

    Hardy J, Vezina JL. Transsphenoidal Neurosurgery of Intracranial Neoplasm. Vol 15. Raven Press;1976.

  • 16

    Micko A, Oberndorfer J, Weninger WJ, Vila G, Höftberger R, Wolfsberger S, Knosp E. Challenging Knosp high-grade pituitary adenomas. J Neurosurg. 2019;132(6):17391746.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Micko AS, Wöhrer A, Wolfsberger S, Knosp E. Invasion of the cavernous sinus space in pituitary adenomas: endoscopic verification and its correlation with an MRI-based classification. J Neurosurg. 2015;122(4):803811.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Woodworth GF, Patel KS, Shin B, Burkhardt JK, Tsiouris AJ, McCoul ED, et al. Surgical outcomes using a medial-to-lateral endonasal endoscopic approach to pituitary adenomas invading the cavernous sinus. J Neurosurg. 2014;120(5):10861094.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Ammirati M, Wei L, Ciric I. Short-term outcome of endoscopic versus microscopic pituitary adenoma surgery: a systematic review and meta-analysis. J Neurol Neurosurg Psychiatry. 2013;84(8):843849.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Cappabianca P, Cavallo LM, Colao A, de Divitiis E. Surgical complications associated with the endoscopic endonasal transsphenoidal approach for pituitary adenomas. J Neurosurg. 2002;97(2):293298.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Micko ASG, Wöhrer A, Höftberger R, Vila G, Marosi C, Knosp E, Wolfsberger S. MGMT and MSH6 immunoexpression for functioning pituitary macroadenomas. Pituitary. 2017;20(6):643653.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Ramakrishnan VR, Suh JD, Lee JY, O’Malley BW Jr, Grady MS, Palmer JN. Sphenoid sinus anatomy and suprasellar extension of pituitary tumors. J Neurosurg. 2013;119(3):669674.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    Zada G, Lin N, Laws ER Jr. Patterns of extrasellar extension in growth hormone-secreting and nonfunctional pituitary macroadenomas. Neurosurg Focus. 2010;29(4):E4.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Renn WH, Rhoton AL Jr. Microsurgical anatomy of the sellar region. J Neurosurg. 1975;43(3):288298.

  • 25

    Busch W. Morphology of sella turcica and its relation to the pituitary gland. Article in German. Virchows Arch Pathol Anat Physiol Klin Med. 1951;320(5):437458.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 26

    Rhoton AL Jr. The sellar region. Neurosurgery. 2002;51(4)(suppl):S335S374.

  • 27

    Campero A, Martins C, Yasuda A, Rhoton AL Jr. Microsurgical anatomy of the diaphragma sellae and its role in directing the pattern of growth of pituitary adenomas. Neurosurgery. 2008;62(3):717723.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28

    Nomura M, Tachibana O, Yamashima T, Yamashita J, Suzuki M. MRI evaluation of the diaphragmal opening: using MRI parallel to the transsphenoidal surgical approach. J Clin Neurosci. 2002;9(2):175177.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 29

    Tsutsumi S, Ono H, Yasumoto Y, Ishii H. The diaphragma sellae, diaphragm opening, and subdiaphragmatic cistern: an anatomical study using magnetic resonance imaging. Surg Radiol Anat. 2019;41(5):529534.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30

    Ferreri AJ, Garrido SA, Markarian MG, Yañez A. Relationship between the development of diaphragma sellae and the morphology of the sella turcica and its content. Surg Radiol Anat. 1992;14(3):233239.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31

    Di Maio S, Cavallo LM, Esposito F, Stagno V, Corriero OV, Cappabianca P. Extended endoscopic endonasal approach for selected pituitary adenomas: early experience. J Neurosurg. 2011;114(2):345353.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32

    Semple PL, Jane JA, Lopes MB, Laws ER. Pituitary apoplexy: correlation between magnetic resonance imaging and histopathological results. J Neurosurg. 2008;108(5):909915.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 33

    Sinha S, Sharma BS. Giant pituitary adenomas—an enigma revisited. Microsurgical treatment strategies and outcome in a series of 250 patients. Br J Neurosurg. 2010;24(1):3139.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 34

    Mortini P, Barzaghi R, Losa M, Boari N, Giovanelli M. Surgical treatment of giant pituitary adenomas: strategies and results in a series of 95 consecutive patients. Neurosurgery. 2007;60(6):9931004.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 35

    Leung GK, Law HY, Hung KN, Fan YW, Lui WM. Combined simultaneous transcranial and transsphenoidal resection of large-to-giant pituitary adenomas. Acta Neurochir (Wien). 2011;153(7):14011408.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 36

    Solari D, D’Avella E, Bove I, Cappabianca P, Cavallo LM. Extended endonasal approaches for pituitary adenomas. J Neurosurg Sci. 2021;65(2):160168.

  • 37

    Cappabianca P, Cavallo LM, Esposito F, De Divitiis O, Messina A, De Divitiis E. Extended endoscopic endonasal approach to the midline skull base: the evolving role of transsphenoidal surgery. Adv Tech Stand Neurosurg. 2008;33:151199.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 38

    Zhao B, Wei YK, Li GL, Li YN, Yao Y, Kang J, et al. Extended transsphenoidal approach for pituitary adenomas invading the anterior cranial base, cavernous sinus, and clivus: a single-center experience with 126 consecutive cases. J Neurosurg. 2010;112(1):108117.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 39

    Laufer I, Anand VK, Schwartz TH. Endoscopic, endonasal extended transsphenoidal, transplanum transtuberculum approach for resection of suprasellar lesions. J Neurosurg. 2007;106(3):400406.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation

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