Matteo Zoli

The endoscopic endonasal approach for the management of craniopharyngiomas: a series of 103 patients

OBJECTnDespite their benign histological appearance, craniopharyngiomas can be considered a challenge for the neurosurgeon and a possible source of poor prognosis for the patient. With the widespread use of the endoscope in endonasal surgery, this route has been proposed over the past decade as an alternative technique for the removal of craniopharyngiomas.nnnMETHODSnThe authors retrospectively analyzed data from a series of 103 patients who underwent the endoscopic endonasal approach at two institutions (Division of Neurosurgery of the Università degli Studi di Napoli Federico II, Naples, Italy, and Division of Neurosurgery of the Bellaria Hospital, Bologna, Italy), between January 1997 and December 2012, for the removal of infra- and/or supradiaphragmatic craniopharyngiomas. Twenty-nine patients (28.2%) had previously been surgically treated.nnnRESULTSnThe authors achieved overall gross-total removal in 68.9% of the cases: 78.9% in purely infradiaphragmatic lesions and 66.3% in lesions involving the supradiaphragmatic space. Among lesions previously treated surgically, the gross-total removal rate was 62.1%. The overall improvement rate in visual disturbances was 74.7%, whereas worsening occurred in 2.5%. No new postoperative defect was noted. Worsening of the anterior pituitary function was reported in 46.2% of patients overall, and there were 38 new cases (48.1% of 79) of postoperative diabetes insipidus. The most common complication was postoperative CSF leakage; the overall rate was 14.6%, and it diminished to 4% in the last 25 procedures, thanks to improvement in reconstruction techniques. The mortality rate was 1.9%, with a mean follow-up duration of 48 months (range 3-246 months).nnnCONCLUSIONSnThe endoscopic endonasal approach has become a valid surgical technique for the management of craniopharyngiomas. It provides an excellent corridor to infra- and supradiaphragmatic midline craniopharyngiomas, including the management of lesions extending into the third ventricle chamber. Even though indications for this approach are rigorously lesion based, the data in this study confirm its effectiveness in a large patient series.

Endoscopic endonasal odontoidectomy: clinical series.

Study Design. This study evaluates a series of consecutive endoscopic endonasal odontoidectomies performed since 2008 in our center. Objective. The aim of the study was to analyze the outcome and the surgical technique to enlighten advantages and limitations of this procedure. Summary of Background Data. Odontoidectomy represents the treatment of choice in selected cases of basilar invagination. Transoral-transpharyngeal odontoidectomy is the “gold standard” and more experienced technique. Recently, the endoscopic endonasal approach has been proposed as an alternative route. Methods. All patients underwent a pre- and postoperative evaluation of neurological status using physical neurological examination, assessment of American Spinal Injury Association impairment scale score, and neurophysiological investigations. Pre- and postoperative neuroradiological examinations consisted of magnetic resonance imaging, computed tomography, and radiography in flexion and extension. Surgical complications, time of orotracheal extubation and of resumption of oral feeding after surgery were considered, basing on medical records. Results. The series is composed of 5 cases. All cases presented a progressive tetraparesis despite a posterior occipitocervical arthrodesis. Two patients presented with irreducible atlantoaxial subluxation in Down syndrome, whereas the others presented with an atlanto-occipital malformation with platybasia and basilar invagination. No complications were observed. In all except one case, orotracheal intubation was removed immediately at the end of surgery. Oral feeding was resumed 1 day after surgery in all but one case that initially required an orogastric tube. At follow-up (mean: 34.2 mo; range: 3–57 mo), neurological symptoms have been shown to improve in 2 cases and stabilization, arresting the neurological worsening, in 3 cases. Conclusion. Endoscopic endonasal odontoidectomy resulted in a safe, effective, and well-tolerated procedure. From our experience, we conclude that the different approaches for odontoidectomy should be considered to be complementary rather than alternative: the endonasal endoscopic can be advantageous in selected cases presenting some anatomical conditions related (micrognathia and macroglossia) to the oral cavity and to high position of the odontoid. Level of Evidence: 4

Cabergoline reduces cell viability in non functioning pituitary adenomas by inhibiting vascular endothelial growth factor secretion

Dopamine (DA) therapy of non-functioning pituitary adenomas (NFA) can result in tumor stabilization and shrinkage. However, the mechanism of action is still unknown. Previous evidence showed that DA can inhibit pituitary vascular endothelial growth factor expression (VEGF), that may be involved in pituitary tumor growth. The aim of our study was to clarify whether VEGF secretion modulation might mediate the effects of DA agonists on cell proliferation in human NFA. We assessed DA receptor subtype 2 (DR2) expression in 20 NFA primary cultures, where we also investigated the effects of a selective DR2 agonist, cabergoline (Cab), on VEGF secretion and on cell viability. All NFA samples expressed α-subunit and DR2 was expressed in 11 samples. In DR2 expressing tumors, Cab significantly reduced cell viability (−25%; Pxa0<xa00.05) and VEGF secretion (−20%; Pxa0<xa00.05). These effects were counteracted by treatment with the DA antagonist sulpiride. Cab antiproliferative effects were blocked by VEGF. Our data demonstrate that Cab, via DR2, inhibits cell viability also by reducing VEGF secretion in a selected group of NFA, supporting that DA agonists can be useful in the medical therapy of DR2 expressing NFA.

Mitotane reduces human and mouse ACTH-secreting pituitary cell viability and function

Medical therapy for Cushings disease (CD) is currently based on agents mainly targeting adrenocortical function. Lately, pituitary-directed drugs have been developed, with limited efficacy. Mitotane, a potent adrenolytic drug, has been recently investigated for the treatment of CD, but the direct pituitary effects have not been clarified so far. The aim of our study was to investigate whether mitotane may affect corticotroph function and cell survival in the mouse pituitary cell line AtT20/D16v-F2 and in the primary cultures of human ACTH-secreting pituitary adenomas, as an in vitro model of pituitary corticotrophs. We found that in the AtT20/D16v-F2 cell line and in primary cultures, mitotane reduces cell viability by inducing caspase-mediated apoptosis and reduces ACTH secretion. In the AtT20/D16v-F2 cell line, mitotane reduces Pomc expression and blocks the stimulatory effects of corticotropin-releasing hormone on cell viability, ACTH secretion, and Pomc expression. These effects were apparent at mitotane doses greater than those usually necessary for reducing cortisol secretion in Cushings syndrome, but still in the therapeutic window for adrenocortical carcinoma treatment. In conclusion, our results demonstrate that mitotane affects cell viability and function of human and mouse ACTH-secreting pituitary adenoma cells. These data indicate that mitotane could have direct pituitary effects on corticotroph cells.

Endoscopic endonasal approach for craniovertebral junction pathology: a review of the literature.

OBJECTnThe transoral approach is the gold standard for ventral decompression of the brainstem caused by craniovertebral junction (CVJ) pathology. This approach is often associated with significant morbidity, related to swallowing and respiratory complications. The endoscopic endonasal approach was introduced to reduce the rate of these complications. However, the exact role of this approach in the treatment of CVJ pathology is not well defined.nnnMETHODSnA comprehensive literature search was performed to identify series of patients with pathology of the CVJ treated via the endoscopie endonasal approach. Data on patient characteristics, indications for treatment, complications, and outcome were obtained and analyzed.nnnRESULTSnTwelve studies involving 72 patients were included. The most common indications for treatment were rheumatoid pannus (38.9%) and basilar invagination (29.2%). Cerebrospinal fluid leak was found in 18% of cases intraoperatively and 4.2% of cases postoperatively. One case of meningitis complicated by sepsis and death represents the procedure-related mortality of 1.4%. Of the patients without preoperative swallowing impairment, 95% returned to oral feeding on the 3rd postoperative day. Ninety-three percent of patients experienced improvement in neurological symptoms after the procedure.nnnCONCLUSIONSnThe endonasal endoscopie approach is effective for the treatment of neural compression caused by CVJ pathology. It offers advantages such as lower rates of postoperative dysphagia and respiratory complications when compared with the more traditional transoral approach. However, these 2 approaches should be seen as complementary rather than alternatives. Patient-related factors as well as the surgeons expertise must be considered when making treatment decisions.

Endoscopic Endonasal Odontoidectomy

Odontoidectomy is the treatment of choice for irreducible ventral cervical-medullary compression. The endonasal endoscopic approach is an innovative approach for odontoidectomy. The aim of this article is to identify in which conditions this approach is indicated, discussing variants of the technique for selected cases of craniovertebral malformation with platybasia. We believe that the technical difficulties of this approach are balanced by the advantages for patients. Some conditions related to the patient and to the anatomy of the craniovertebral junction may favor adoption of the endoscopic endonasal approach, which should be considered complementary and not alternative to standard approaches.

L’incidentaloma ipofisario: approccio diagnostico e follow-up

RiassuntoIl riscontro incidentale di un processo espansivo a livello della sella turcica durante indagini neuroradiologiche (risonanza magnetica o tomografia computerizzata) richieste per motivi non correlati al sospetto di malattie ipotalamo-ipofisarie (traumi, vertigine, epilessia, ecc.) è evenienza alquanto frequente nella pratica clinica quotidiana, potendosi verificare in circa il 10% della popolazione. Non v’è dubbio che gli adenomi ipofisari clinicamente non-funzionanti ne siano la causa più frequente; tuttavia, occorre ricordare che anche lesioni sellari più rare (cisti della tasca di Rathke, craniofaringioma, metastasi, ecc.) possono talora mostrarsi con le modalità dell’incidentaloma ipofisario. Nel caso in cui il processo espansivo ha dimensioni inferiori al centimetro, esso è indicato con il termine di “microincidentaloma”; viceversa, nel caso di lesioni superiori al centimetro si utilizza il termine di “macroincidentaloma”. La storia naturale dell’incidentaloma ipofisario è poco nota e cid condiziona le reali difficoltà nel delineare principi generali d’inquadramento iniziale e di successivo follow-up. In questo scenario, le recenti linee guida proposte dall’Endocrine Society costituiscono indubbiamente un aiuto rilevante nella gestione clinica dei pazienti che giungono all’attenzione dei clinici per il riscontro incidentale di una massa sellare, pur persistendo aree d’incertezza che solamente studi prospettici su ampie coorti potranno chiarire.

Cesare Cavina (1888–1935): a father of transsphenoidal surgery

Among the fathers of transsphenoidal surgery, a relevant role should be reserved for Cesare Cavina (1888–1935). He had the merit to develop and popularize in Italy this approach for pituitary tumors, performing 47 transsphenoidal hypophysectomies out of his personal series of 66 patients between 1927 and 1935. He contributed to this surgery by introducing radiological control of the surgical trajectory to reduce the risk of complications and increase the safety of this approach. We think that both his short lifespan (he died when he was 47xa0years old) and the language of his papers (Italian and not English) are two important factors that have contributed to forgetting his role in the history of transsphenoidal surgery. We think that Prof. Cesare Cavina is definitively one of the fathers of transsphenoidal surgery and that it is important to preserve his memory.