Early postoperative MRI and detection of residual adenoma after transsphenoidal pituitary surgery

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OBJECTIVE

Current practice guidelines recommend delayed (≥ 3 months after operation) postoperative MRI after transsphenoidal surgery for pituitary adenomas, although this practice defers obtaining important information, such as the presence of a residual adenoma, that might influence patient management during the perioperative period. In this study, the authors compared detection of residual adenomas by means of early postoperative (EPO) MRI (< 48 hours postsurgery) with both surgeon intraoperative assessment and late postoperative (LPO) MRI at 3 months.

METHODS

Adult patients who underwent microscopic transsphenoidal surgery for pituitary adenomas with MRI preoperatively, < 48 hours after the operation, 3 months postoperatively, and yearly for 4 years were included. The presence or absence of residual tumor was assessed intraoperatively by a single surgeon and postoperatively by 2 neuroradiologists blinded to the intraoperative assessment and other postoperative imaging studies. The presence of residual tumor was confirmed by reresection, tumor growth on imaging, or hormonal evidence. Interreader reliability was calculated at each imaging time point. Specificity, sensitivity, positive predictive value, and negative predictive value for EPO and LPO imaging and intraoperative assessment were determined.

RESULTS

In total, 102 consecutive patients who underwent microscopic transsphenoidal resection of a pituitary adenoma were included. Eighteen patients (18%) had confirmed residual tumors (12 confirmed by tumor growth, 5 by surgery, and 1 by biochemical evidence of persistent disease). Interreader reliability for detecting residual tumor on EPO MRI was almost perfect (κ = 0.88) and significantly higher than that for LPO MRI (κ = 0.69, p = 0.03). EPO MRI was highly specific for residual tumor (98%), a finding similar to that for intraoperative assessment (99%, p = 0.60) and significantly higher than that for LPO MRI (81%, p < 0.001). Notably, EPO MRI was significantly more sensitive for residual tumor (100%) than both intraoperative assessment (78%, p = 0.04) and LPO MRI (78%, p = 0.04). EPO MRI had a 100% negative predictive value and was used to find 4 residual tumors that were not identified intraoperatively. Residual tumors found on EPO MRI allowed for reresection during the same hospitalization for 3 patients.

CONCLUSIONS

EPO MRI after transsphenoidal pituitary surgery can be reliably interpreted and has greater sensitivity for detecting residual tumor than intraoperative assessment and LPO MRI. This result challenges current guidelines stating that delayed postoperative imaging is preferable to early imaging. Pituitary surgeons should consider performing EPO MRI either in addition to or instead of delayed imaging.

ABBREVIATIONS EPO = early postoperative (< 48 hours postsurgery); iMRI = intraoperative MRI; LPO = late postoperative (3 months postsurgery).
Article Information

Contributor Notes

Correspondence Lea M. Alhilali: c/o Neuroscience Publications, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ. neuropub@barrowneuro.org.INCLUDE WHEN CITING Published online February 7, 2020; DOI: 10.3171/2019.11.JNS191845.Disclosures Dr. Little has ownership interest in Kogent and Spiway. Dr. Yuen has received research grants to Barrow Neurological Institute from Pfizer, Novartis, Millendo, Ionis, Corcept, and Crinetics and has served on advisory boards for Novo Nordisk and Corcept.
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References
  • 1

    Antunes XVentura NCamilo GBWildemberg LEGuasti APereira PJM: Predictors of surgical outcome and early criteria of remission in acromegaly. Endocrine 60:4154222018

    • Search Google Scholar
    • Export Citation
  • 2

    Berkmann SSchlaffer SBuchfelder M: Tumor shrinkage after transsphenoidal surgery for nonfunctioning pituitary adenoma. J Neurosurg 119:144714522013

    • Search Google Scholar
    • Export Citation
  • 3

    Bladowska JBednarek-Tupikowska GSokolska VBadowski RMoroń KBonicki W: MRI image characteristics of materials implanted at sellar region after transsphenoidal resection of pituitary tumours. Pol J Radiol 75:46542010

    • Search Google Scholar
    • Export Citation
  • 4

    Blevins LS JrSanai NKunwar SDevin JK: An approach to the management of patients with residual Cushing’s disease. J Neurooncol 94:3133192009

    • Search Google Scholar
    • Export Citation
  • 5

    Buchfelder M: Treatment of pituitary tumors: surgery. Endocrine 28:67752005

  • 6

    Buchfelder MSchlaffer S: Imaging of pituitary pathology. Handb Clin Neurol 124:1511662014

  • 7

    Buchfelder MSchlaffer S: Surgical treatment of pituitary tumours. Best Pract Res Clin Endocrinol Metab 23:6776922009

  • 8

    Buchfelder MSchlaffer SM: Intraoperative magnetic resonance imaging during surgery for pituitary adenomas: pros and cons. Endocrine 42:4834952012

    • Search Google Scholar
    • Export Citation
  • 9

    Chowdhury INSinaii NOldfield EHPatronas NNieman LK: A change in pituitary magnetic resonance imaging protocol detects ACTH-secreting tumours in patients with previously negative results. Clin Endocrinol (Oxf) 72:5025062010

    • Search Google Scholar
    • Export Citation
  • 10

    Dort JCSutherland GR: Intraoperative magnetic resonance imaging for skull base surgery. Laryngoscope 111:157015752001

  • 11

    Giustina AChanson PBronstein MDKlibanski ALamberts SCasanueva FF: A consensus on criteria for cure of acromegaly. J Clin Endocrinol Metab 95:314131482010

    • Search Google Scholar
    • Export Citation
  • 12

    Hawass NE: Comparing the sensitivities and specificities of two diagnostic procedures performed on the same group of patients. Br J Radiol 70:3603661997

    • Search Google Scholar
    • Export Citation
  • 13

    Hwang KKwon TPark JJoo JDHan JHOh CW: Growth pattern and prognostic factors of untreated nonfunctioning pituitary adenomas. J Korean Neurosurg Soc 62:2562622019

    • Search Google Scholar
    • Export Citation
  • 14

    Karamouzis ICaputo MMele CNuzzo AZavattaro MCar P: Transsphenoidal surgery for pituitary adenomas: early results from a single center. Hormones (Athens) 17:5515562018

    • Search Google Scholar
    • Export Citation
  • 15

    Kiliç TEkinci GSeker AElmaci IErzen CPamir MN: Determining optimal MRI follow-up after transsphenoidal surgery for pituitary adenoma: scan at 24 hours postsurgery provides reliable information. Acta Neurochir (Wien) 143:110311262001

    • Search Google Scholar
    • Export Citation
  • 16

    Klopfenstein JDSpetzler RFKim LJFeiz-Erfan IHan PPZabramski JM: Comparison of routine and selective use of intraoperative angiography during aneurysm surgery: a prospective assessment. J Neurosurg 100:2302352004

    • Search Google Scholar
    • Export Citation
  • 17

    Kremer PForsting MHamer JSartor K: MR imaging of residual tumor tissue after transsphenoidal surgery of hormone-inactive pituitary macroadenomas: a prospective study. Acta Neurochir Suppl 65:27301996

    • Search Google Scholar
    • Export Citation
  • 18

    Kremer PForsting MRanaei GWüster CHamer JSartor K: Magnetic resonance imaging after transsphenoidal surgery of clinically non-functional pituitary macroadenomas and its impact on detecting residual adenoma. Acta Neurochir (Wien) 144:4334432002

    • Search Google Scholar
    • Export Citation
  • 19

    Little ASChicoine MRKelly DFSarris CEMooney MAWhite WL: Evaluation of surgical resection goal and its relationship to extent of resection and patient outcomes in a multicenter prospective study of patients with surgically treated nonfunctioning pituitary adenomas: a case series. Oper Neurosurg (Hagerstown) 18:26332020

    • Search Google Scholar
    • Export Citation
  • 20

    Little ASKelly DFWhite WLGardner PAFernandez-Miranda JCChicoine MR: Results of a prospective multicenter controlled study comparing surgical outcomes of microscopic versus fully endoscopic transsphenoidal surgery for nonfunctioning pituitary adenomas: the Transsphenoidal Extent of Resection (TRANSSPHER) Study. J Neurosurg [epub ahead of print March 22 2019; DOI: 10.3171/2018.11.JNS181238]

    • Search Google Scholar
    • Export Citation
  • 21

    Mansouri ASymons SSchwartz MChen JPirouzmand F: Quantitative volumetric analysis post transsphenoidal pituitary adenoma surgery. Can J Neurol Sci 39:6006042012

    • Search Google Scholar
    • Export Citation
  • 22

    McHugh ML: Interrater reliability: the kappa statistic. Biochem Med (Zagreb) 22:2762822012

  • 23

    Micko ASWöhrer AWolfsberger SKnosp E: Invasion of the cavernous sinus space in pituitary adenomas: endoscopic verification and its correlation with an MRI-based classification. J Neurosurg 122:8038112015

    • Search Google Scholar
    • Export Citation
  • 24

    Minniti GOsti MFNiyazi M: Target delineation and optimal radiosurgical dose for pituitary tumors. Radiat Oncol 11:1352016

  • 25

    Mooney MAHardesty DASheehy JPBird RChapple KWhite WL: Interrater and intrarater reliability of the Knosp scale for pituitary adenoma grading. J Neurosurg 126:171417192017

    • Search Google Scholar
    • Export Citation
  • 26

    Netuka DMasopust VBelšán TKramář FBeneš V: One year experience with 3.0 T intraoperative MRI in pituitary surgery. Acta Neurochir Suppl 109:1571592011

    • Search Google Scholar
    • Export Citation
  • 27

    Newcombe RG: Two-sided confidence intervals for the single proportion: comparison of seven methods. Stat Med 17:8578721998

  • 28

    Orringer DLau DKhatri SZamora-Berridi GJZhang KWu C: Extent of resection in patients with glioblastoma: limiting factors, perception of resectability, and effect on survival. J Neurosurg 117:8518592012

    • Search Google Scholar
    • Export Citation
  • 29

    Patel KSKazam JTsiouris AJAnand VKSchwartz TH: Utility of early postoperative high-resolution volumetric magnetic resonance imaging after transsphenoidal pituitary tumor surgery. World Neurosurg 82:7777802014

    • Search Google Scholar
    • Export Citation
  • 30

    Patel KSYao YWang RCarter BSChen CC: Intraoperative magnetic resonance imaging assessment of non-functioning pituitary adenomas during transsphenoidal surgery. Pituitary 19:2222312016

    • Search Google Scholar
    • Export Citation
  • 31

    Rajaraman VSchulder M: Postoperative MRI appearance after transsphenoidal pituitary tumor resection. Surg Neurol 52:5925991999

  • 32

    Roelfsema FBiermasz NRPereira AM: Clinical factors involved in the recurrence of pituitary adenomas after surgical remission: a structured review and meta-analysis. Pituitary 15:71832012

    • Search Google Scholar
    • Export Citation
  • 33

    Schwartz THStieg PEAnand VK: Endoscopic transsphenoidal pituitary surgery with intraoperative magnetic resonance imaging. Neurosurgery 58 (1 Suppl):ONS44ONS512006

    • Search Google Scholar
    • Export Citation
  • 34

    Stofko DLNickles TSun HDehdashti AR: The value of immediate postoperative MR imaging following endoscopic endonasal pituitary surgery. Acta Neurochir (Wien) 156:1331402014

    • Search Google Scholar
    • Export Citation
  • 35

    Tanaka YHongo KTada TSakai KKakizawa YKobayashi S: Growth pattern and rate in residual nonfunctioning pituitary adenomas: correlations among tumor volume doubling time, patient age, and MIB-1 index. J Neurosurg 98:3593652003

    • Search Google Scholar
    • Export Citation
  • 36

    Tompkins CPAltman SHEilat E: The precarious pricing system for hospital services. Health Aff (Millwood) 25:45562006

  • 37

    Washington CWDerdeyn CPChicoine MRCross DTDacey RGMoran CJ: Comparing routine versus selective use of intraoperative cerebral angiography in aneurysm surgery: a prospective study. J Neurointerv Surg 8:75802016

    • Search Google Scholar
    • Export Citation
  • 38

    Yoon PHKim DIJeon PLee SILee SKKim SH: Pituitary adenomas: early postoperative MR imaging after transsphenoidal resection. AJNR Am J Neuroradiol 22:109711042001

    • Search Google Scholar
    • Export Citation
  • 39

    Ziu MDunn IFHess CFleseriu MBodach METumialan LM: Congress of Neurological surgeons systematic review and evidence-based guideline on posttreatment follow-up evaluation of patients with nonfunctioning pituitary adenomas. Neurosurgery 79:E541E5432016

    • Search Google Scholar
    • Export Citation
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