Intraoperative high-field MRI for transsphenoidal reoperations of nonfunctioning pituitary adenoma

Clinical article

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  • 1 Department of Neurosurgery, University Hospital Erlangen, Erlangen;
  • 2 Department of Neurosurgery, University of Marburg, Marburg; and
  • 3 International Neuroscience Institute, Hannover, Germany
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Object

The loss of anatomical landmarks, frequently invasive tumor growth, and tissue changes make transsphenoidal reoperation of nonfunctioning pituitary adenomas (NFAs) challenging. The use of intraoperative MRI (iMRI) may lead to improved results. The goal of this retrospective study was to evaluate the impact of iMRI on transsphenoidal reoperations for NFA.

Methods

Between September 2002 and July 2012, 109 patients underwent reoperations in which 111 transsphenoidal procedures were performed and are represented in this study. A 1.5-T Magnetom Sonata Maestro Class scanner (Siemens) was used for iMRI. Follow-up iMRI scans were acquired if gross-total resection (GTR) was suspected or if no further removal seemed possible.

Results

Surgery was performed for tumor persistence and regrowth in 26 (23%) and 85 (77%) patients, respectively. On the initial iMRI scans, GTR was confirmed in 19 (17%) patients. Remnants were located as follows: 65 in the cavernous sinus (71%), 35 in the suprasellar space (38%), 9 in the retrosellar space (10%). Additional resection was possible in 62 (67%) patients, resulting in a significant volume reduction and increased GTR rate (49%). The GTR rates of invasive tumors on initial iMRI and postoperative MRI (poMRI) were 7% and 25%, respectively. Additional remnant resection was possible in 64% of the patients. Noninvasive tumors were shown to be totally resected on the initial iMRI in 31% of cases. After additional resection for 69% of the procedures, the GTR rate on poMRI was 75%. Transcranial surgery to resect tumor remnants was indicated in 5 (5%), and radiotherapy was performed in 29 (27%) patients. After GTR, no recurrence was detected during a mean follow-up of 2.2 ± 2.1 years.

Conclusions

The use of iMRI in transsphenoidal reoperations for NFA leads to significantly higher GTR rates. It thus prevents additional operations and reduces the number of tumor remnants. The complication rates do not exceed the incidences reported in the literature for primary transsphenoidal surgery. If complete tumor resection is not possible, iMRI guidance can facilitate tumor volume reduction.

Abbreviations used in this paper:DI = diabetes insipidus; FSH = follicle-stimulating hormone; GKS = Gamma Knife surgery; GTR = gross-total resection; iMRI = intraoperative MRI; LH = luteinizing hormone; NFA = nonfunctioning pituitary adenoma; poMRI = postoperative MRI; VA = visual acuity; VF = visual field.

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Contributor Notes

Address correspondence to: Sven Berkmann, M.D., Department of Neurosurgery, University Hospital Erlangen, Schwabachanlage 6, 91054 Erlangen, Germany. email: sven.berkmann@ksa.ch.

Please include this information when citing this paper: published online August 15, 2014; DOI: 10.3171/2014.6.JNS131994.

  • 1

    Abosch A, , Tyrrell JB, , Lamborn KR, , Hannegan LT, , Applebury CB, & Wilson CB: Transsphenoidal microsurgery for growth hormone-secreting pituitary adenomas: initial outcome and longterm results. J Clin Endocrinol Metab 83:34113418, 1998

    • Search Google Scholar
    • Export Citation
  • 2

    Ahn JY, , Jung JY, , Kim J, , Lee KS, & Kim SH: How to overcome the limitations to determine the resection margin of pituitary tumours with low-field intra-operative MRI during transsphenoidal surgery: usefulness of Gadolinium-soaked cotton pledgets. Acta Neurochir (Wien) 150:763771, 2008

    • Search Google Scholar
    • Export Citation
  • 3

    Albayrak B, , Samdani AF, & Black PM: Intra-operative magnetic resonance imaging in neurosurgery. Acta Neurochir (Wien) 146:543557, 2004

  • 4

    Barker FG II, , Klibanski A, & Swearingen B: Transsphenoidal surgery for pituitary tumors in the United States, 1996-2000: mortality, morbidity, and the effects of hospital and surgeon volume. J Clin Endocrinol Metab 88:47094719, 2003

    • Search Google Scholar
    • Export Citation
  • 5

    Baumann F, , Schmid C, & Bernays RL: Intraoperative magnetic resonance imaging-guided transsphenoidal surgery for giant pituitary adenomas. Neurosurg Rev 33:8390, 2010

    • Search Google Scholar
    • Export Citation
  • 6

    Benveniste RJ, , King WA, , Walsh J, , Lee JS, , Delman BN, & Post KD: Repeated transsphenoidal surgery to treat recurrent or residual pituitary adenoma. J Neurosurg 102:10041012, 2005

    • Search Google Scholar
    • Export Citation
  • 7

    Berg C, , Meinel T, , Lahner H, , Mann K, & Petersenn S: Recovery of pituitary function in the late-postoperative phase after pituitary surgery: results of dynamic testing in patients with pituitary disease by insulin tolerance test 3 and 12 months after surgery. Eur J Endocrinol 162:853859, 2010

    • Search Google Scholar
    • Export Citation
  • 8

    Berkmann S, , Fandino J, , Müller B, , Kothbauer KF, , Henzen C, & Landolt H: Pituitary surgery: experience from a large network in Central Switzerland. Swiss Med Wkly 142:w13680, 2012

    • Search Google Scholar
    • Export Citation
  • 9

    Berkmann S, , Fandino J, , Müller B, , Remonda L, & Landolt H: Intraoperative MRI and endocrinological outcome of transsphenoidal surgery for non-functioning pituitary adenoma. Acta Neurochir (Wien) 154:639647, 2012

    • Search Google Scholar
    • Export Citation
  • 10

    Berkmann S, , Fandino J, , Zosso S, , Killer HE, , Remonda L, & Landolt H: Intraoperative magnetic resonance imaging and early prognosis for vision after transsphenoidal surgery for sellar lesions. Clinical article. J Neurosurg 115:518527, 2011

    • Search Google Scholar
    • Export Citation
  • 11

    Berkmann S, , Schlaffer S, & Buchfelder M: Tumor shrinkage after transsphenoidal surgery for nonfunctioning pituitary adenoma. Clinical article. J Neurosurg 119:14471452, 2013

    • Search Google Scholar
    • Export Citation
  • 12

    Black PM, , Zervas NT, & Candia GL: Incidence and management of complications of transsphenoidal operation for pituitary adenomas. Neurosurgery 20:920924, 1987

    • Search Google Scholar
    • Export Citation
  • 13

    Boelaert K, & Gittoes NJ: Radiotherapy for non-functioning pituitary adenomas. Eur J Endocrinol 144:569575, 2001

  • 14

    Bohinski RJ, , Warnick RE, , Gaskill-Shipley MF, , Zuccarello M, , van Loveren HR, & Kormos DW, : Intraoperative magnetic resonance imaging to determine the extent of resection of pituitary macroadenomas during transsphenoidal microsurgery. Neurosurgery 49:11331144, 2001

    • Search Google Scholar
    • Export Citation
  • 15

    Bradley KJ, , Wass JA, & Turner HE: Non-functioning pituitary adenomas with positive immunoreactivity for ACTH behave more aggressively than ACTH immunonegative tumours but do not recur more frequently. Clin Endocrinol (Oxf) 58:5964, 2003

    • Search Google Scholar
    • Export Citation
  • 16

    Brochier S, , Galland F, , Kujas M, , Parker F, , Gaillard S, & Raftopoulos C, : Factors predicting relapse of nonfunctioning pituitary macroadenomas after neurosurgery: a study of 142 patients. Eur J Endocrinol 163:193200, 2010

    • Search Google Scholar
    • Export Citation
  • 17

    Buchfelder M, & Schlaffer SM: Intraoperative magnetic resonance imaging during surgery for pituitary adenomas: pros and cons. Endocrine 42:483495, 2012

    • Search Google Scholar
    • Export Citation
  • 18

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

    • Search Google Scholar
    • Export Citation
  • 19

    Chen Y, , Li ZF, , Zhang FX, , Li JX, , Cai L, & Zhuge QC, : Gamma knife surgery for patients with volumetric classification of nonfunctioning pituitary adenomas: a systematic review and meta-analysis. Eur J Endocrinol 169:487495, 2013

    • Search Google Scholar
    • Export Citation
  • 20

    Cho HY, , Cho SW, , Kim SW, , Shin CS, , Park KS, & Kim SY: Silent corticotroph adenomas have unique recurrence characteristics compared with other nonfunctioning pituitary adenomas. Clin Endocrinol (Oxf) 72:648653, 2010

    • Search Google Scholar
    • Export Citation
  • 21

    Ciric I, , Ragin A, , Baumgartner C, & Pierce D: Complications of transsphenoidal surgery: results of a national survey, review of the literature, and personal experience. Neurosurgery 40:225237, 1997

    • Search Google Scholar
    • Export Citation
  • 22

    Coburger J, , König R, , Seitz K, , Bäzner U, , Wirtz CR, & Hlavac M: Determining the utility of intraoperative magnetic resonance imaging for transsphenoidal surgery: a retrospective study. Clinical article. J Neurosurg 120:346356, 2014

    • Search Google Scholar
    • Export Citation
  • 23

    Colao A, , Cerbone G, , Cappabianca P, , Ferone D, , Alfieri A, & Di Salle F, : Effect of surgery and radiotherapy on visual and endocrine function in nonfunctioning pituitary adenomas. J Endocrinol Invest 21:284290, 1998

    • Search Google Scholar
    • Export Citation
  • 24

    Comtois R, , Beauregard H, , Somma M, , Serri O, , Aris-Jilwan N, & Hardy J: The clinical and endocrine outcome to transsphenoidal microsurgery of nonsecreting pituitary adenomas. Cancer 68:860866, 1991

    • Search Google Scholar
    • Export Citation
  • 25

    Darakchiev BJ, , Tew JM Jr, , Bohinski RJ, & Warnick RE: Adaptation of a standard low-field (0.3-T) system to the operating room: focus on pituitary adenomas. Neurosurg Clin N Am 16:155164, 2005

    • Search Google Scholar
    • Export Citation
  • 26

    de Lara D, , Ditzel Filho LF, , Prevedello DM, , Otto BA, & Carrau RL: Application of image guidance in pituitary surgery. Surg Neurol Int 3:Suppl 2 S73S78, 2012

    • Search Google Scholar
    • Export Citation
  • 27

    De Witte O, , Makiese O, , Wikler D, , Levivier M, , Vandensteene A, & Pandin P, : [Transsphenoidal approach with low field MRI for pituitary adenoma]. Neurochirurgie 51:577583, 2005. (Fr)

    • Search Google Scholar
    • Export Citation
  • 28

    Fahlbusch R, , Ganslandt O, , Buchfelder M, , Schott W, & Nimsky C: Intraoperative magnetic resonance imaging during transsphenoidal surgery. J Neurosurg 95:381390, 2001

    • Search Google Scholar
    • Export Citation
  • 29

    Fahlbusch R, , Keller B, , Ganslandt O, , Kreutzer J, & Nimsky C: Transsphenoidal surgery in acromegaly investigated by intraoperative high-field magnetic resonance imaging. Eur J Endocrinol 153:239248, 2005

    • Search Google Scholar
    • Export Citation
  • 30

    Fatemi N, , Dusick JR, , Mattozo C, , McArthur DL, , Cohan P, & Boscardin J, : Pituitary hormonal loss and recovery after transsphenoidal adenoma removal. Neurosurgery 63:709719, 2008

    • Search Google Scholar
    • Export Citation
  • 31

    Gerlach R, , du Mesnil de Rochemont R, , Gasser T, , Marquardt G, , Reusch J, & Imoehl L, : 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 63:272285, 2008

    • Search Google Scholar
    • Export Citation
  • 32

    Hardy J, & Wigser SM: Trans-sphenoidal surgery of pituitary fossa tumors with televised radiofluoroscopic control. J Neurosurg 23:612619, 1965

    • Search Google Scholar
    • Export Citation
  • 33

    Jane JA Jr, , Thapar K, , Alden TD, & Laws ER Jr: Fluoroscopic frameless stereotaxy for transsphenoidal surgery. Neurosurgery 48:13021308, 2001

    • Search Google Scholar
    • Export Citation
  • 34

    Jones J, & Ruge J: Intraoperative magnetic resonance imaging in pituitary macroadenoma surgery: an assessment of visual outcome. Neurosurg Focus 23:5 E12, 2007

    • Search Google Scholar
    • Export Citation
  • 35

    Knosp E, , Steiner E, , Kitz K, & Matula C: Pituitary adenomas with invasion of the cavernous sinus space: a magnetic resonance imaging classification compared with surgical findings. Neurosurgery 33:610618, 1993

    • Search Google Scholar
    • Export Citation
  • 36

    Kopp C, , Theodorou M, , Poullos N, , Jacob V, , Astner ST, & Molls M, : Tumor shrinkage assessed by volumetric MRI in long-term follow-up after fractionated stereotactic radiotherapy of nonfunctioning pituitary adenoma. Int J Radiat Oncol Biol Phys 82:12621267, 2012

    • Search Google Scholar
    • Export Citation
  • 37

    Landolt AM, Surgical management of recurrent pituitary tumors. Schmidek HH: Operative Neurosurgical Techniques ed 4 Philadelphia, WB Saunders, 2000. 455466

    • Search Google Scholar
    • Export Citation
  • 38

    Laws ER Jr, , Fode NC, & Redmond MJ: Transsphenoidal surgery following unsuccessful prior therapy. An assessment of benefits and risks in 158 patients. J Neurosurg 63:823829, 1985

    • Search Google Scholar
    • Export Citation
  • 39

    Laws ER Jr, , Trautmann JC, & Hollenhorst RW Jr: Transsphenoidal decompression of the optic nerve and chiasm. Visual results in 62 patients. J Neurosurg 46:717722, 1977

    • Search Google Scholar
    • Export Citation
  • 40

    Lewin JS, , Nour SG, , Meyers ML, , Metzger AK, , Maciunas RJ, & Wendt M, : Intraoperative MRI with a rotating, tiltable surgical table: a time use study and clinical results in 122 patients. AJR Am J Roentgenol 189:10961103, 2007

    • Search Google Scholar
    • Export Citation
  • 41

    Littley MD, , Shalet SM, , Beardwell CG, , Ahmed SR, , Applegate G, & Sutton ML: Hypopituitarism following external radiotherapy for pituitary tumours in adults. Q J Med 70:145160, 1989

    • Search Google Scholar
    • Export Citation
  • 42

    Losa M, , Franzin A, , Mangili F, , Terreni MR, , Barzaghi R, & Veglia F, : Proliferation index of nonfunctioning pituitary adenomas: correlations with clinical characteristics and longterm follow-up results. Neurosurgery 47:13131319, 2000

    • Search Google Scholar
    • Export Citation
  • 43

    Losa M, , Valle M, , Mortini P, , Franzin A, , da Passano CF, & Cenzato M, : Gamma knife surgery for treatment of residual nonfunctioning pituitary adenomas after surgical debulking. J Neurosurg 100:438444, 2004

    • Search Google Scholar
    • Export Citation
  • 44

    Lundin P, & Pedersen F: Volume of pituitary macroadenomas: assessment by MRI. J Comput Assist Tomogr 16:519528, 1992

  • 45

    Martin CH, , Schwartz R, , Jolesz F, & Black PM: Transsphenoidal resection of pituitary adenomas in an intraoperative MRI unit. Pituitary 2:155162, 1999

    • Search Google Scholar
    • Export Citation
  • 46

    McPherson CM, , Bohinski RJ, , Dagnew E, , Warnick RE, & Tew JM: Tumor resection in a shared-resource magnetic resonance operating room: experience at the University of Cincinnati. Acta Neurochir Suppl 85:3944, 2003

    • Search Google Scholar
    • Export Citation
  • 47

    Murad MH, , Fernández-Balsells MM, , Barwise A, , Gallegos-Orozco JF, , Paul A, & Lane MA, : Outcomes of surgical treatment for nonfunctioning pituitary adenomas: a systematic review and meta-analysis. Clin Endocrinol (Oxf) 73:777791, 2010

    • Search Google Scholar
    • Export Citation
  • 48

    Netuka D, , Masopust V, , Belšán T, , Kramář F, & Beneš V: One year experience with 3.0 T intraoperative MRI in pituitary surgery. Acta Neurochir Suppl 109:157159, 2011

    • Search Google Scholar
    • Export Citation
  • 49

    Nimsky C, , Ganslandt O, & Fahlbusch R: Comparing 0.2 tesla with 1.5 tesla intraoperative magnetic resonance imaging analysis of setup, workflow, and efficiency. Acad Radiol 12:10651079, 2005

    • Search Google Scholar
    • Export Citation
  • 50

    Nimsky C, , Ganslandt O, & Fahlbusch R: Functional neuronavigation and intraoperative MRI. Adv Tech Stand Neurosurg 29:229263, 2004

  • 51

    Nimsky C, , Ganslandt O, , Hofmann B, & Fahlbusch R: Limited benefit of intraoperative low-field magnetic resonance imaging in craniopharyngioma surgery. Neurosurgery 53:7281, 2003

    • Search Google Scholar
    • Export Citation
  • 52

    Nimsky C, , Ganslandt O, , von Keller B, & Fahlbusch R: Intraoperative high-field MRI: anatomical and functional imaging. Acta Neurochir Suppl 98:8795, 2006

    • Search Google Scholar
    • Export Citation
  • 53

    Nimsky C, , Ganslandt O, , Von Keller B, , Romstöck J, & Fahlbusch R: Intraoperative high-field-strength MR imaging: implementation and experience in 200 patients. Radiology 233:6778, 2004

    • Search Google Scholar
    • Export Citation
  • 54

    Nimsky C, , von Keller B, , Ganslandt O, & Fahlbusch R: Intraoperative high-field magnetic resonance imaging in transsphenoidal surgery of hormonally inactive pituitary macroadenomas. Neurosurgery 59:105114, 2006

    • Search Google Scholar
    • Export Citation
  • 55

    Noh TW, , Jeong HJ, , Lee MK, , Kim TS, , Kim SH, & Lee EJ: Predicting recurrence of nonfunctioning pituitary adenomas. J Clin Endocrinol Metab 94:44064413, 2009

    • Search Google Scholar
    • Export Citation
  • 56

    Nomikos P, , Ladar C, , Fahlbusch R, & Buchfelder M: Impact of primary surgery on pituitary function in patients with nonfunctioning pituitary adenomas — a study on 721 patients. Acta Neurochir (Wien) 146:2735, 2004

    • Search Google Scholar
    • Export Citation
  • 57

    Pamir MN, , Peker S, , Ozek MM, & Dinçer A: Intraoperative MR imaging: preliminary results with 3 tesla MR system. Acta Neurochir Suppl 98:97100, 2006

    • Search Google Scholar
    • Export Citation
  • 58

    Pandin P, & Dewitte O: Open low-field intraoperative MRI for transsphenoidal pituitary surgery. Anesth Analg 105:886, 2007. (Letter)

  • 59

    Pergolizzi RS Jr, , Nabavi A, , Schwartz RB, , Hsu L, , Wong TZ, & Martin C, : Intra-operative MR guidance during transsphenoidal pituitary resection: preliminary results. J Magn Reson Imaging 13:136141, 2001

    • Search Google Scholar
    • Export Citation
  • 60

    Pollock BE, & Carpenter PC: Stereotactic radiosurgery as an alternative to fractionated radiotherapy for patients with recurrent or residual nonfunctioning pituitary adenomas. Neurosurgery 53:10861094, 2003

    • Search Google Scholar
    • Export Citation
  • 61

    Ramírez C, , Cheng S, , Vargas G, , Asa SL, , Ezzat S, & González B, : Expression of Ki-67, PTTG1, FGFR4, and SSTR 2, 3, and 5 in nonfunctioning pituitary adenomas: a high throughput TMA, immunohistochemical study. J Clin Endocrinol Metab 97:17451751, 2012

    • Search Google Scholar
    • Export Citation
  • 62

    Roelfsema F, , Biermasz NR, & Pereira AM: Clinical factors involved in the recurrence of pituitary adenomas after surgical remission: a structured review and meta-analysis. Pituitary 15:7183, 2012

    • Search Google Scholar
    • Export Citation
  • 63

    Sandeman D, & Moufid A: Interactive image-guided pituitary surgery. An experience of 101 procedures. Neurochirurgie 44:331338, 1998

  • 64

    Sasaki R, , Murakami M, , Okamoto Y, , Kono K, , Yoden E, & Nakajima T, : The efficacy of conventional radiation therapy in the management of pituitary adenoma. Int J Radiat Oncol Biol Phys 47:13371345, 2000

    • Search Google Scholar
    • Export Citation
  • 65

    Schulder M, , Jacobs A, & Carmel PW: Intraoperative MRI and adjuvant radiosurgery. Stereotact Funct Neurosurg 76:151158, 2001

  • 66

    Schwartz TH, , Stieg PE, & Anand VK: Endoscopic transsphenoidal pituitary surgery with intraoperative magnetic resonance imaging. Neurosurgery 58:1 Suppl ONS44ONS51, 2006

    • Search Google Scholar
    • Export Citation
  • 67

    Sheehan JP, , Kondziolka D, , Flickinger J, & Lunsford LD: Radiosurgery for residual or recurrent nonfunctioning pituitary adenoma. Clinical article. J Neurosurg 97:5 Suppl 408414, 2002

    • Search Google Scholar
    • Export Citation
  • 68

    Sheehan JP, , Starke RM, , Mathieu D, , Young B, , Sneed PK, & Chiang VL, : Gamma Knife radiosurgery for the management of nonfunctioning pituitary adenomas: a multicenter study. Clinical article. J Neurosurg 119:446456, 2013

    • Search Google Scholar
    • Export Citation
  • 69

    Shou XF, , Li SQ, , Wang YF, , Zhao Y, , Jia PF, & Zhou LF: Treatment of pituitary adenomas with a transsphenoidal approach. Neurosurgery 56:249256, 2005

    • Search Google Scholar
    • Export Citation
  • 70

    Starke RM, , Williams BJ, , Jane JA Jr, & Sheehan JP: Gamma Knife surgery for patients with nonfunctioning pituitary macroadenomas: predictors of tumor control, neurological deficits, and hypopituitarism. Clinical article. J Neurosurg 117:129135, 2012

    • Search Google Scholar
    • Export Citation
  • 71

    Steinmeier R, , Fahlbusch R, , Ganslandt O, , Nimsky C, , Buchfelder M, & Kaus M, : Intraoperative magnetic resonance imaging with the magnetom open scanner: concepts, neurosurgical indications, and procedures: a preliminary report. Neurosurgery 43:739748, 1998

    • Search Google Scholar
    • Export Citation
  • 72

    Thapar K, & Laws ER Jr, Transsphenoidal surgery for recurrent pituitary tumors. Kaye AH, & Black PM: Operative Neurosurgery London, Churchill Livingstone, 1999. 685707

    • Search Google Scholar
    • Export Citation
  • 73

    Theodosopoulos PV, , Leach J, , Kerr RG, , Zimmer LA, , Denny AM, & Guthikonda B, : Maximizing the extent of tumor resection during transsphenoidal surgery for pituitary macroadenomas: can endoscopy replace intraoperative magnetic resonance imaging? Clinical article. J Neurosurg 112:736743, 2010

    • Search Google Scholar
    • Export Citation
  • 74

    Thomale UW, , Stover JF, & Unterberg AW: The use of neuronavigation in transnasal transsphenoidal pituitary surgery. Zentralbl Neurochir 66:126132, 2005

    • Search Google Scholar
    • Export Citation
  • 75

    Verma J, , McCutcheon IE, , Waguespack SG, & Mahajan A: Feasibility and outcome of re-irradiation in the treatment of multiply recurrent pituitary adenomas. Pituitary [epub ahead of print], 2013

    • Search Google Scholar
    • Export Citation
  • 76

    Webb SM, , Rigla M, , Wägner A, , Oliver B, & Bartumeus F: Recovery of hypopituitarism after neurosurgical treatment of pituitary adenomas. J Clin Endocrinol Metab 84:36963700, 1999

    • Search Google Scholar
    • Export Citation
  • 77

    Wu JS, , Shou XF, , Yao CJ, , Wang YF, , Zhuang DX, & Mao Y, : Transsphenoidal pituitary macroadenomas resection guided by PoleStar N20 low-field intraoperative magnetic resonance imaging: comparison with early postoperative high-field magnetic resonance imaging. Neurosurgery 65:6371, 2009

    • Search Google Scholar
    • Export Citation
  • 78

    Zierhut D, , Flentje M, , Adolph J, , Erdmann J, , Raue F, & Wannenmacher M: External radiotherapy of pituitary adenomas. Int J Radiat Oncol Biol Phys 33:307314, 1995

    • Search Google Scholar
    • Export Citation

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