Endoscopic Endonasal Resection of Nonfunctional Pituitary Adenomas: Comprehensive Clinical Outcomes and the Radiographic Findings Associated with Gross Total Resection

Introduction: Modern endoscopic skull base surgery (ESBS) techniques have improved our ability to effectively and safely resect pituitary tumors. However, an improved comprehensive understanding of the clinical outcomes after non-functional pituitary adenoma (NFA) resection with ESBS is needed.

Objective: This work describes the clinical outcomes of NFA patients treated with ESBS, and the radiographic factors associated with GTR.

Methods: A total of 258 consecutive cases of primary and recurrent NFAs resected via EEA at the University of Pittsburgh Medical Center, and with at least two years of follow-up MRI, were included. Logistic regression was employed to ascertain the radiographic characteristics predictive of achieving GTR.

Results: Mean age at surgery was 57 years (SD = 15), and patients were predominantly male (63%) with primary tumors (83%). Mean follow-up was 4.4 years, (SD = 2.64), with 32% of patients having >5 years of follow-up. Patients most commonly presented with subjective visual field loss (59%) and objective field (62%) and acuity (54%) deficits, and dysfunction of thyroid (37%), gonadal (75%), and adrenal (45%) axes. Visual improvement occurred in the vast majority of such cases and, less commonly, endocrinologic recovery was observed ([Fig. 1A]). Otolaryngological morbidity (olfactory change, chronic sinusitis, mucocele formation) was the most common, while additional endocrinological deficits were uncommon. Visual deterioration was rare ([Fig. 1B]).

Preoperative MRI characteristics of Knosp classification = 3–4 and posterior/lateral cavernous sinus invasion were associated with lower rates of GTR ([Table 1]).

Conclusion: Most NFA patients experience visual recovery following ESBS and, less frequently, can experience recovery of endocrinological function. By the same token, otolaryngological morbidity is the highest from resection by ESBS. GTR is significantly less likely in the setting of more expansive tumors characterized by Knosp classification 3–4 or posterior and lateral cavernous sinus invasion.

Table 1 Logistic regression for radiographic factors associated with achieving GTR

Radiographic feature		OR (95%)	p
Dimension (mm)	Craniocaudad Transverse Anteroposterior	1.00 (0.959–1.050) 0.94 (0.883–0.999) 0.97 (0.919–1.034)	0.891 0.047 0.391
Knosp classification	0 1 2 3A/3B 4	– 0.43 (0.063–1.807) 0.42 (0.064–1.667) 0.18 (0.027–0.702) 0.03 (0.003–0.175)	0.306 0.281 0.030 <0.001
Cavernous sinus invasion	None Superior Inferior Posterior Lateral	– 1.30 (0.645–2.593) 0.79 (0.416–1.515) 0.30 (0.149–0.584) 0.21 (0.071–0.564)	0.462 0.466 <0.001 0.0026

Fig. 1 Neurologic, Endocrinological, Ophthalmological and Otolaryngological Presentations of NFA and Outcomes Following Endoscopic Skull Base Surgery. (A) Amongst patients with available data, the most common deficits were defects in the thyroid (37%), gonadal (75%), and adrenal (45%) axes. 59% of pateints with available data had subjective visual loss, while objective acuity (Snellen) and visual fields (Humphrey or Goldmann) were lost in 54% and 62% of presenting patients, respectively. Patients presented with diplopia due CN III, IV, VI palsies or oculomotor palsies not otherwise specified in 3.7%, 0.84%, 3.3%, 2.5% of cases, respectively. Following surgery the visual status of patients presenting with deficits dramatically improved (83%, 78%, 80% experienced improved subjective vision, objective acuity, and objective field, respectively). Patients with diplopia due to palsies of CN III, IV, VI, or oculomotor palsy NOS improved in 68% of cases. (B) Otolaryngological complications from EEA were the most common occurrences (37% experiencing change of olfaction, 20% with new mucocele formation, 11% developing chronic sinusitis), while those with pre-operatively intact thyroid, gonadal, and adrenal axes developed permanent loss of function in 14 %, 13%, 10% of cases secondary to surgery. Ophthalmologic comlications were much less common (2% experienced subjective visual loss, 0% objective visual field worsening, 9% objective visual acuity worsening) and new oculomotor palsies were exceedingly rare.

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Artikel online veröffentlicht:
15. Februar 2022