Pituitary adenoma in the elderly: surgical outcomes and treatment trends in the United States

Eric J. ChalifDepartment of Neurological Surgery, University of California, San Francisco, California

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Ramin A. MorshedDepartment of Neurological Surgery, University of California, San Francisco, California

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Jacob S. YoungDepartment of Neurological Surgery, University of California, San Francisco, California

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Alexander F. HaddadDepartment of Neurological Surgery, University of California, San Francisco, California

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Saket JainDepartment of Neurological Surgery, University of California, San Francisco, California

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Manish K. AghiDepartment of Neurological Surgery, University of California, San Francisco, California

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OBJECTIVE

Decision-making in how to manage pituitary adenomas (PAs) in the elderly (age ≥ 65 years) can be challenging given the benign nature of these tumors and concerns about surgical morbidity in these patients. In this study involving a large multicenter national registry, the authors examined treatment trends and surgical outcomes in elderly compared to nonelderly patients.

METHODS

The National Cancer Data Base (NCDB) was queried for adults aged ≥ 18 years with PA diagnosed by MRI (in observed cases) or pathology (in surgical cases) from 2004 to 2016. Univariate and multivariate logistic regressions were used to evaluate the prognostic impact of age and other covariates on 30- and 90-day postsurgical mortality (30M/90M), prolonged (≥ 5 days) length of inpatient hospital stay (LOS), and extent of resection.

RESULTS

A total of 96,399 cases met the study inclusion criteria, 27% of which were microadenomas and 73% of which were macroadenomas. Among these cases were 25,464 elderly patients with PA. Fifty-three percent of these elderly patients were treated with surgery, 1.9% underwent upfront radiotherapy, and 44.9% were observed without treatment. Factors associated with surgical treatment compared to observation included younger age, higher income, private insurance, higher Charlson-Deyo comorbidity (CD) score, larger tumor size, and receiving treatment at an academic hospital (each p ≤ 0.01). Elderly patients undergoing surgery had increased rates of 30M (1.4% vs 0.6%), 90M (2.8% vs 0.9%), prolonged LOS (26.1% vs 23.0%), and subtotal resection (27.2% vs 24.5%; each p ≤ 0.01) compared to those in nonelderly PA patients. On multivariate analysis, age, tumor size, and CD score were independently associated with worse postsurgical mortality. High-volume facilities (HVFs) had significantly better outcomes than low-volume facilities: 30M (0.9% vs 1.8%, p < 0.001), 90M (2.0% vs 3.5%, p < 0.001), and prolonged LOS (21.8% vs 30.3%, p < 0.001). A systematic literature review composed of 22 studies demonstrated an elderly PA patient mortality rate of 0.7%, which is dramatically lower than real-world NCDB outcomes and speaks to substantial selection bias in the previously published literature.

CONCLUSIONS

The study findings confirm that elderly patients with PA are at higher risk for postoperative mortality than younger patients. Surgical risk in this age group may have been previously underreported in the literature. Resection at HVFs better reflects these historical rates, which has important implications in elderly patients for whom surgery is being considered.

ABBREVIATIONS

30M = 30-day mortality; 90M = 90-day mortality; CD = Charlson-Deyo comorbidity; CoC = Commission on Cancer; EES = endoscopic endonasal surgery; GTR = gross-total resection; HVF = high-volume facility; LOS = length of inpatient hospital stay; LVF = low-volume facility; NCDB = National Cancer Data Base; OS = overall survival; PA = pituitary adenoma; STR = subtotal resection.

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Figure from Kim et al. (pp 1601–1609).

  • 1

    Ostrom QT, Cioffi G, Gittleman H, et al. CBTRUS Statistical Report: Primary Brain and Other Central Nervous System Tumors Diagnosed in the United States in 2012-2016. Neuro Oncol. 2019;21(suppl 5):v1v100.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Ezzat S, Asa SL, Couldwell WT, et al. The prevalence of pituitary adenomas: a systematic review. Cancer. 2004;101(3):613619.

  • 3

    Freda PU, Bruce JN. Surgery: risks of pituitary surgery in the elderly. Nat Rev Endocrinol. 2010;6(11):606608.

  • 4

    Puchner MJA, Knappe UJ, Lüdecke DK. Pituitary surgery in elderly patients with acromegaly. Neurosurgery. 1995;36(4):677684.

  • 5

    Locatelli M, Bertani G, Carrabba G, et al. The trans-sphenoidal resection of pituitary adenomas in elderly patients and surgical risk. Pituitary. 2013;16(2):146151.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Gondim JA, Almeida JP, de Albuquerque LAF, Gomes E, Schops M, Mota JI. Endoscopic endonasal transsphenoidal surgery in elderly patients with pituitary adenomas. J Neurosurg. 2015;123(1):3138.

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

    Tuleasca C, Ducos Y, Leroy HA, et al. Transsphenoidal resection for pituitary adenoma in elderly versus younger patients: a systematic review and meta-analysis. Acta Neurochir (Wien). 2020;162(6):12971308.

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

    Pereira MP, Oh T, Joshi RS, et al. Clinical characteristics and outcomes in elderly patients undergoing transsphenoidal surgery for nonfunctioning pituitary adenoma. Neurosurg Focus. 2020;49(4):E19.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Rolston JD, Han SJ, Aghi MK. Nationwide shift from microscopic to endoscopic transsphenoidal pituitary surgery. Pituitary. 2016;19(3):248250.

  • 10

    Lee CC, Kano H, Yang HC, et al. Initial Gamma Knife radiosurgery for nonfunctioning pituitary adenomas. J Neurosurg. 2014;120(3):647654.

  • 11

    Zhang L, Chen W, Ding C, et al. Gamma Knife radiosurgery as the initial treatment for elderly patients with nonfunctioning pituitary adenomas. J Neurooncol. 2021;152(2):257264.

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

    Bilimoria KY, Stewart AK, Winchester DP, Ko CY. The National Cancer Data Base: a powerful initiative to improve cancer care in the United States. Ann Surg Oncol. 2008;15(3):683690.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Verma V, Ahern CA, Berlind CG, et al. Facility volume and postoperative outcomes for malignant pleural mesothelioma: a National Cancer Data Base analysis. Lung Cancer. 2018;120:713.

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

    Haque W, Verma V, Butler EB, Teh BS. Definitive chemoradiation at high volume facilities is associated with improved survival in glioblastoma. J Neurooncol. 2017;135(1):173181.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Verma V, Allen PK, Simone CB II, Gay HA, Lin SH. Association of treatment at high-volume facilities with survival in patients receiving chemoradiotherapy for nasopharyngeal cancer. JAMA Otolaryngol Head Neck Surg. 2018;144(1):8689.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Robenshtok E, Benbassat CA, Hirsch D, et al. Clinical course and outcome of nonfunctioning pituitary adenomas in the elderly compared with younger age groups. Endocr Pract. 2014;20(2):159164.

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

    Liu J, Li C, Xiao Q, et al. Comparison of pituitary adenomas in elderly and younger adults: Clinical characteristics, surgical outcomes, and prognosis. J Am Geriatr Soc. 2015;63(9):19241930.

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

    Marenco HA, Zymberg ST, Santos R de P, Ramalho CO. Surgical treatment of non-functioning pituitary macroadenomas by the endoscopic endonasal approach in the elderly. Arq Neuropsiquiatr. 2015;73(9):764769.

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

    Zhan R, Ma Z, Wang D, Li X. Pure endoscopic endonasal transsphenoidal approach for nonfunctioning pituitary adenomas in the elderly: surgical outcomes and complications in 158 patients. World Neurosurg. 2015;84(6):15721578.

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

    Zhao Y, Lian W, Xing B, et al. The clinical characteristics and microsurgical therapy of pituitary adenomas in elderly patients: a retrospective study of 130 cases. J Clin Neurosci. 2017;46:1316.

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

    Azab MA, O’Hagan M, Abou-Al-Shaar H, Karsy M, Guan J, Couldwell WT. Safety and outcome of transsphenoidal pituitary adenoma resection in elderly patients. World Neurosurg. 2019;122:e1252e1258.

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

    Memel Z, Chesney K, Pangal DJ, Bonney PA, Carmichael JD, Zada G. Outcomes following transsphenoidal pituitary surgery in the elderly: a retrospective single-center review. Oper Neurosurg (Hagerstown). 2019;16(3):302309.

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

    Wilson PJ, Omay SB, Kacker A, Anand VK, Schwartz TH. Endonasal endoscopic pituitary surgery in the elderly. J Neurosurg. 2018;128(2):429436.

  • 24

    Spina A, Losa M, Mortini P. Pituitary adenomas in elderly patients: clinical and surgical outcome analysis in a large series. Endocrine. 2019;65(3):637645.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 25

    Tardivo V, Penner F, Garbossa D, et al. Surgical management of pituitary adenomas: does age matter?. Pituitary. 2020;23(2):92102.

  • 26

    Pospiech J, Stolke D, Pospiech FR. Surgical treatment of pituitary adenomas in elderly patients. Acta Neurochir Suppl (Wien). 1996;65(65):3536.

    • Search Google Scholar
    • Export Citation
  • 27

    Villar-Taibo R, Díaz-Ortega C, Sifontes-Dubon M, et al. Pituitary surgery in elderly patients: a safe and effective procedure. Endocrine. 2021;72(3):814822.

  • 28

    Thakur JD, Corlin A, Mallari RJ, et al. Pituitary adenomas in older adults (≥ 65 years): 90-day outcomes and readmissions: a 10-year endoscopic endonasal surgical experience. Pituitary. 2021;24(1):1426.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29

    Kurosaki M, Lüdecke DK, Flitsch J, Saeger W. Surgical treatment of clinically nonsecreting pituitary adenomas in elderly patients. Neurosurgery. 2000;47(4):843849.

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

    Del Monte P, Foppiani L, Ruelle A, et al. Clinically non-functioning pituitary macroadenomas in the elderly. Aging Clin Exp Res. 2007;19(1):3440.

  • 31

    Hong J, Ding X, Lu Y. Clinical analysis of 103 elderly patients with pituitary adenomas: transsphenoidal surgery and follow-up. J Clin Neurosci. 2008;15(10):10911095.

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

    Sheehan JM, Douds GL, Hill K, Farace E. Transsphenoidal surgery for pituitary adenoma in elderly patients. Acta Neurochir (Wien). 2008;150(6):571574.

  • 33

    Rogne SG, Konglund A, Meling TR, et al. Intracranial tumor surgery in patients >70 years of age: is clinical practice worthwhile or futile?. Acta Neurol Scand. 2009;120(5):288294.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 34

    Pereira EAC, Plaha P, Chari A, et al. Transsphenoidal pituitary surgery in the elderly is safe and effective. Br J Neurosurg. 2014;28(5):616621.

  • 35

    Grossman R, Mukherjee D, Chaichana KL, et al. Complications and death among elderly patients undergoing pituitary tumour surgery. Clin Endocrinol (Oxf). 2010;73(3):361368.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 36

    Goshtasbi K, Lehrich BM, Abouzari M, et al. Endoscopic versus nonendoscopic surgery for resection of pituitary adenomas: a national database study. J Neurosurg. 2020;134(3):816824.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 37

    Sivakumar W, Chamoun R, Nguyen V, Couldwell WT. Incidental pituitary adenomas. Neurosurg Focus. 2011;31(6):E18.

  • 38

    Zhu P, Du XL, Zhu JJ, Esquenazi Y. Improved survival of glioblastoma patients treated at academic and high-volume facilities: a hospital-based study from the National Cancer Database. J Neurosurg. 2019;132(2):491502.

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

    Zhu P, Du XL, Blanco AI, et al. Impact of facility type and volume in low-grade glioma outcomes. J Neurosurg. 2020;133(5):13131323.

  • 40

    Chalif EJ, Couldwell WT, Aghi MK. Effect of facility volume on giant pituitary adenoma neurosurgical outcomes. J Neurosurg. Published online January 14, 2022. doi: 10.3171/2021.11.JNS211936

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 41

    Li A, Liu W, Cao P, Zheng Y, Bu Z, Zhou T. Endoscopic versus microscopic transsphenoidal surgery in the treatment of pituitary adenoma: a systematic review and meta-analysis. World Neurosurg. 2017;101:236246.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 42

    Castro DG, Cecílio SA, Canteras MM. Radiosurgery for pituitary adenomas: evaluation of its efficacy and safety. Radiat Oncol. 2010;5(1):109.

  • 43

    Hasegawa T, Shintai K, Kato T, Iizuka H. Stereotactic Radiosurgery as the Initial Treatment for Patients with Nonfunctioning Pituitary Adenomas. World Neurosurg. 2015;83(6):11731179.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 44

    Park KJ, Kano H, Parry PV, et al. Long-term outcomes after gamma knife stereotactic radiosurgery for nonfunctional pituitary adenomas. Neurosurgery. 2011;69(6):11881199.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 45

    Yu J, Li Y, Quan T, et al. Initial Gamma Knife radiosurgery for nonfunctioning pituitary adenomas: results from a 26-year experience. Endocrine. 2020;68(2):399410.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 46

    Brown DA, Himes BT, Kerezoudis P, et al. Insurance correlates with improved access to care and outcome among glioblastoma patients. Neuro Oncol. 2018;20(10):13741382.

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