Sauradeep Sarkar

Endocrinological outcomes following endoscopic and microscopic transsphenoidal surgery in 113 patients with acromegaly

BACKGROUND To describe outcomes and complications in patients undergoing transsphenoidal surgery for acromegaly using the 2010 consensus criteria for biochemical remission. METHODS Retrospective review of 113 treatment naïve patients who underwent transsphenoidal surgery with the endoscopic (n=66) and the endonasal microscopic technique (n=47). Cure was defined if the age and sex-adjusted IGF-1 level was normal and either the basal GH was <1 ng/ml or the nadir GH was <0.4 ng/ml following oral glucose suppression at last follow-up. RESULTS The mean age at presentation was 38.1 ± 7.1 years and 86% of tumors were macroadenomas. Adenoma sizes averaged 21.1 ± 9.7 mm, but 56% of all tumors were ≥ 2 cm in size and 43.4% were invasive. Remission rates between endoscopic and microscopic transsphenoidal surgery did not differ significantly overall (28.8% versus 36.2%). On univariate analysis, a preoperative GH level <40 ng/ml, adenoma size <20mm and non-invasiveness were predictors of remission at follow-up. Although there were no statistically significant differences in remission rates between the endoscopic and microsurgical groups, surgically induced hypopituitarism was less frequent with the former. CONCLUSIONS We report our surgical experience with predominantly large, invasive GH adenomas using the 2010 criteria for cure. Patients with smaller, non-invasive tumors with lower preoperative GH levels are most likely to achieve remission. Outcomes with either the microscopic or endoscopic approach do not differ significantly, although the rate of surgically induced hypopituitarism may be higher with the former. Transsphenoidal surgery remains the first line of treatment for patients with acromegaly, but invasive adenomas will frequently require adjuvant therapy.

Clinical and radiological outcomes in 153 patients undergoing oblique corpectomy for cervical spondylotic myelopathy

Abstract Objective. To document the clinical and radiological outcomes in a large series of patients undergoing the oblique cervical corpectomy (OCC) for spondylotic myelopathy. Materials and methods. We retrospectively analyzed our series of 153 patients undergoing OCC for cervical spondylotic myelopathy (CSM) over the last 10 years. A mean clinical follow-up of 3 years was obtained in 125 patients (81.7%), while 117 patients (76.5%) were followed up radiologically. Neurological function was measured by the Nurick grade and the modified Japanese Orthopedic Association score (JOA). Plain radiographs and magnetic resonance images (MRI) were reviewed. Results. Ninety-two percent were men with a mean age of 51 years and a mean duration of symptoms of 18 months. Sixty-one had a single level corpectomy, 66 had a 2-level, 24 had a 3-level, and two had a 4-level OCC. There was statistically significant improvement (p < 0.05) in both the Nurick grade and the JOA score at mean follow-up of 34.6 ± 25.4 months. Permanent Horners syndrome was seen in nine patients (5.9%), postoperative C5 radiculopathy in five patients (3.3%), dural tear with CSF leak in one patient (0.7%), and vertebral artery injury in one patient (0.7%). Of the 117 patients who were followed up radiologically, five patients (4.3%) developed an asymptomatic kyphosis of the cervical spine while 22 patients (25.6%) with preoperative lordotic spines had a straightening of the whole spine curvature. Conclusions. The OCC is a safe procedure with good outcomes and a low morbidity for treating cervical cord compression due to CSM. This procedure avoids graft-related complications associated with the central corpectomy, but is technically demanding.

An analysis of granulation patterns, MIB-1 proliferation indices and p53 expression in 101 patients with acromegaly

BackgroundDespite the wide spectrum of adenoma behavior in patients with acromegaly, the ability of most pathological markers to predict clinical and radiological behavior remains controversial. The authors sought to comprehensively examine clinical and radiological correlates of growth hormone (GH)-secreting pituitary adenomas with regard to several commonly used immunocytochemical techniques in patients undergoing transsphenoidal surgery for acromegaly.MethodWe performed a retrospective review of histopathological findings in 101 surgically resected GH adenomas. Tumors were assessed radiologically for different patterns of extension. Each tumor specimen was subject to immunocytochemical analysis, including assessments of granulation patterns, MIB-1 labeling indices, prolactin cosecretion, p53 expression and mitotic activity. Endocrinological outcome was assessed in 93 patients, with remission defined by the 2010 consensus criteria.ResultsMost tumors were macroadenomas and almost half were invasive. When compared to densely granulated tumors, sparsely granulated adenomas were associated with a younger age at presentation, higher preoperative IGF-1 levels, elevated MIB-1 index and pure GH immunostaining, but did not differ significantly in terms of extrasellar invasion or outcome. Increased mitotic activity and p53 expression were also associated with higher proliferation indices and a younger age at presentation. Mixed GH/prolactin tumors demonstrated significantly higher remission rates, independent of variations in extrasellar growth. MIB-1 indices did not correlate with the preoperative GH/IGF-1 levels, adenoma size or Knosp grade.ConclusionThe pathobiology of acromegaly is complex, and the clinicoradiological significance of subtyping on the basis of the markers employed in this study is debatable. Further investigation of newer molecular markers is warranted.

Radiation-induced opticochiasmatic glioblastoma multiforme following conventional radiotherapy for Cushing's disease

Abstract We report the rare occurrence of an opticochiasmatic glioblastoma multiforme 6 years following conventional radiotherapy for Cushings disease. This article highlights the risks of collateral damage to the optic apparatus when irradiating the sellar region.

Clinicopathological correlates of extrasellar growth patterns in pituitary adenomas

We reviewed clinical, imaging and histopathology details of 297 patients who underwent surgery for pituitary adenomas, with an equal distribution of functional and non-functioning tumors, to examine clinicopathological correlates of extrasellar growth. Knosp grades of 3 and 4 on MRI defined cavernous sinus invasion, Hardy grades of C and D defined significant suprasellar/subfrontal extension, and intraoperative evidence of tumor eroding through the clivus or sellar floor defined infrasellar invasion. Disease status at follow-up was known in 246 patients overall, including 35 patients who were evaluated for progression of residual disease on serial imaging. On univariate analysis, we found several statistically significant associations (p < 0.05) including adenoma size with age, sex and tumor protein p53 reactivity; cavernous sinus invasion with size, non-functional status, increased mitotic activity, an elevated MIB-1 proliferation index and p53 reactivity; suprasellar/subfrontal extension with p53 reactivity; and infrasellar invasion with age and tumor size. When adjusting for confounders with logistic regression, several significant associations were evident including adenoma size with male sex and p53 reactivity; cavernous sinus invasion with size and elevated MIB-1 proliferation index; suprasellar/subfrontal extension with p53 reactivity; and infrasellar invasion with adenoma size alone. Patients with early progression of postoperative residual tumor were younger with a non-significant trend towards higher MIB-1 proliferation indices. Individual patterns of extrasellar growth in pituitary adenomas are associated with unique clinical and immunohistochemical profiles. Younger patients with elevated MIB-1 values are probably at high risk for early recurrence of non-functioning tumors. Definitions of atypia must be standardized before more robust assumptions about tumor biology can be established.

A randomized controlled trial to determine the role of intraoperative lumbar cerebrospinal fluid drainage in patients undergoing endoscopic transsphenoidal surgery for pituitary adenomas

Background: Intraoperative cerebrospinal fluid (CSF) leaks are a frequent cause of morbidity in patients undergoing transsphenoidal surgery. This prospective study was performed to examine the impact of intraoperative lumbar subarachnoid drainage (LSAD) on the incidence of this complication and on the extent of resection in patients undergoing endoscopic transsphenoidal surgery for pituitary adenomas. Materials and Methods: This prospective study was conducted in a single large academic medical center. All patients with pituitary adenomas who had not undergone prior transsphenoidal surgery were eligible for inclusion in the study. Patients were randomly assigned to undergo transsphenoidal surgery with intraoperative lumbar drain insertion (LSAD group) or no lumbar drain insertion (no LSAD group). An otolaryngologist independently determined the occurrence of an intraoperative CSF leak. Extent of tumor resection was determined by volumetric analysis of postoperative magnetic resonance images in patients with nonfunctional tumors or functional adenomas with a large suprasellar component. Results: Sixty patients were eligible for inclusion, of which 30 were assigned to the LSAD group and 30 to the no LSAD group. There were no statistically significant differences in patient demographics, tumor pathology, or radiology between the two groups. The LSAD catheter was successfully inserted in all patients in the LSAD group. Intraoperative CSF drainage significantly reduced the incidence of CSF leak from 46.7% in the no LSAD group to 3.3% in the LSAD group (P < 0.001). However, there were no statistically significant differences in the incidence of postoperative CSF rhinorrhea between the two groups. There were no major catheter-related complications. There was no statistically significant difference in the extent of resection between the two groups. Conclusions: Controlled intraoperative CSF drainage significantly reduces the incidence of intraoperative CSF leakage in patients undergoing endoscopic transsphenoidal surgery for pituitary adenomas.