- Email: [email protected]
A Survey on Pituitary Surgery in Italy
Original Article
A Survey on Pituitary Surgery in Italy Domenico Solari1, Francesco Zenga2, Filippo F. Angileri3, Andrea Barbanera4, Silvia Berlucchi5, Claudio Bernucci6, Carmine Carapella7, Domenico Catapano8, Giuseppe Catapano9, Luigi M. Cavallo1, Corrado D’Arrigo10, Michelangelo de Angelis11, Luca Denaro12, Nicola Desogus13, Paolo Ferroli14, Marco M. Fontanella15, Renato J. Galzio16,17, Cosimo D. Gianfreda18, Maurizio Iacoangeli19, Liverana Lauretti20, Davide Locatelli21, Marco Locatelli22, Davide Luglietto23, Diego Mazzatenta24, Agazio Menniti25, Davide Milani26, Maria Teresa Nasi27, Antonio Romano28, Andrea G. Ruggeri29, Andrea Saladino30, Orazio Santonocito31, Andreas Schwarz32, Miran Skrap33, Roberto Stefini34, Lorenzo Volpin35, Giulio C. Wembagher36, Cesare Zoia17, Gianluigi Zona37, Paolo Cappabianca1
BACKGROUND: Pituitary tumors are a heterogeneous group of lesions that are usually benign. Therefore, a proper understanding of the anatomy, physiology, and pathology is mandatory to achieve favorable outcomes. Accordingly, diagnostic tests and treatment guidelines should be determined and implemented. Thus, we decided to perform a multicenter study among Italian neurosurgical centers performing pituitary surgery to provide an actual depiction from the neurosurgical standpoint.
-
METHODS: On behalf of the SINch (Società Italiana di Neurochirurgia), a survey was undertaken with the participants to explore the activities in the field of pituitary surgery within 41 public institutions.
-
RESULTS: Of the 41 centers, 37 participated in the present study. The total number of neurosurgical procedures
-
Key words - Craniopharyngiomas - Endoscopic endonasal surgery - Multidisciplinary team - Pituitary adenomas - Pituitary/hypothalamus - Pituitary surgery - Transsphenoidal surgery Abbreviations and Acronyms MDT: Multidisciplinary team From the 1Division of Neurosurgery, Università degli Studi di Napoli “Federico II”, Naples; 2 Division of Neurosurgery, Università degli Studi di Torino e Città della Salute e della Scienza, Turin; 3Division of Neurosurgery, Università degli Studi di Messina e Policlinico “G. Martino”, Messina; 4Division of Neurosurgery, AO “SS. Antonio e Biagio e Cesare Arrigo”, Alessandria; 5Division of Neurosurgery, AOU Ospedale Civile di Baggiovara, Modena; 6 Division of Neurosurgery, ASST “Papa Giovanni XXIII”, Bergamo; 7Division of Neurosurgery, IRCCS Istituto Nazionale Tumori “Regina Elena”, Rome; 8Division of Neurosurgery, IRCCS “Casa Sollievo della Sofferenza”, San Giovanni Rotondo; 9Division of Neurosurgery, AO “G. Rummo”, Benevento; 10Division of Neurosurgery, AO “Cannizzaro”, Catania; 11Division of Neurosurgery, IRCCS Neuromed, Pozzilli; 12Division of Neurosurgery, Università degli Studi di Padova, Padua; 13Division of Neurosurgery, AO “G. Brotzu”, Cagliari; 14Division of Neurosurgery (NCH 2), Fondazione IRCCS Istituto Neurologico “Carlo Besta”, Milan; 15 Division of Neurosurgery, Università degli Studi di Brescia e Spedali Civili, Brescia; 16 Division of Neurosurgery, Università degli Studi e Ospedale Civile “S. Salvatore”, L’Aquila; 17 Division of Neurosurgery, Università degli Studi di Pavia e Fondazione IRCCS Policlinico “S. Matteo”, Pavia; 18Division of Neurosurgery, Presidio Ospedaliero “V. Fazzi”, Lecce;
WORLD NEUROSURGERY -: e1-e10, - 2018
performed in 2016 was 1479. Most of the procedures were performed using the transsphenoidal approach (1320 transsphenoidal [1204 endoscopic, 53 microscopic, 53 endoscope-assisted microscopic] vs. 159 transcranial). A multidisciplinary tumor board is convened regularly in 32 of 37 centers, and a research laboratory is present in 18 centers. CONCLUSIONS: Diagnosing pituitary/hypothalamus disorders and treating them is the result of teamwork, composed of several diverse experts. Regarding neurosurgery, our findings have confirmed the central role of the transsphenoidal approach, with preference toward the endoscopic technique. Better outcomes can be expected at centers with a multidisciplinary team and a full, or part of a, residency program, with a greater surgical caseload.
-
Division of Neurosurgery, Università Politecnica delle Marche e Ospedali Riuniti Torrette, Ancona; 20Division of Neurosurgery, Università Cattolica del Sacro Cuore e Policlinico “A. Gemelli”, Rome; 21Division of Neurosurgery, Università degli Studi dell’Insubria, Ospedale di Circolo e Fondazione Macchi, Varese; 22Division of Neurosurgery, Fondazione IRCCS Cà Granda e Ospedale Maggiore e Policlinico, Milan; 23Division of Neurosurgery, AOU Senese “Le Scotte”, Siena; 24Division of Neurosurgery, IRCCS Isituto delle Scienze Neurologiche, Ospedale Bellaria, Bologna; 25Division of Neurosurgery, AO “San Camillo-Forlanini”, Rome; 26 Division of Neurosurgery, Humanitas Research Hospital, Rozzano; 27Division of Neurosurgery, AO “M. Bufalini”, Cesena; 28Division of Neurosurgery, AOU Parma-Reggio Emilia; 29Division of Neurosurgery, Università degli Studi di Roma “La Sapienza”, Rome; 30 Division of Neurosurgery (NCH 1), Fondazione IRCCS Istituto Neurologico “Carlo Besta”, Milan; 31Division of Neurosurgery, Spedali Riuniti di Livorno e USL Toscana Nord-Ovest, Livorno; 32Division of Neurosurgery, Ospedale di Bolzano, Bolzano; 33Division of Neurosurgery, AOU di Udine, Udine; 34Division of Neurosurgery, AO Ospedale Civile di Legnano, Legnano; 35Division of Neurosurgery, Ospedale San Bortolo, Vicenza; 36Division of Neurosurgery, AOU “Careggi”, Firenze; and 37Division of Neurosurgery, Università degli Studi di Genova e Ospedale “San Martino”, Genoa, Italy 19
To whom correspondence should be addressed: Domenico Solari, M.D., Ph.D. [E-mail: [email protected]] Additional contributors listed in the Appendix. Citation: World Neurosurg. (2018). https://doi.org/10.1016/j.wneu.2018.11.186 Journal homepage: www.journals.elsevier.com/world-neurosurgery Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2018 Elsevier Inc. All rights reserved.
www.journals.elsevier.com/world-neurosurgery
e1
ORIGINAL ARTICLE DOMENICO SOLARI ET AL.
A SURVEY ON PITUITARY SURGERY IN ITALY
INTRODUCTION
T
he incidence of hypothalamic/pituitary disorders in Italy has been increasing over the past several years, and it has been reported that 3.9e4.0 of 100,000 new cases are diagnosed annually, with a prevalence of 78e94 of 100,000 people. Pituitary tumors, usually benign, can have unpredictable behavior that can range from indolent, surgically curable disease to rare, highly aggressive cancer.1-3 A proper and thorough understanding of the anatomy and pathophysiology of the hypothalamic/pituitary region is essential for an accurate diagnosis and to define the essential treatment options (i.e., surgery, medical therapy, and radiotherapy, alone or combined).1-9 Different entities should also be considered in the differential diagnosis, which has been well represented in the SATCHMO acronym (sarcoidosis, adenoma/aneurysms, teratomas, craniopharyngiomas/chordomas, hypothalamic gliomas, metastases/ meningiomas, optic gliomas).1-3 Surgery has been the primary treatment chosen for all tumors involving the hypothalamic/pituitary area, except for the prolactinomas10-13 (i.e., acromegaly, Cushing’s disease, thyroid-stimulating hormone-secreting adenomas, resistant prolactinomas, and nonfunctioning pituitary adenomas causing a mass effect). Medical and radiation therapy should be reserved for cases in which surgery is not possible or did not obtain a complete cure.10 Surgical resection has also been recommended as first-line treatment for pituitary apoplexy, parasellar pathologic entities such as craniopharyngioma, chordoma, and Rathke’s cleft cysts, and in rare cases of pituitary cancer. In these latter lesions, a multimodality management strategy is mandatory, as per neurooncology policy. However, when a patient is referred to a primary center showing symptoms of a hypothalamic or pituitary disorder, no consensus has been reached regarding the best management approach, and the chances of a successful outcome have been strongly correlated with the presence of a dedicated team.14-18 The management of each case relies heavily on the decisionmaking process in a multidisciplinary team (MDT), composed of dedicated endocrinologists and experienced pituitary surgeons, assisted by specialists from adjoining branches such as neuropathologists, ear, nose, and throat surgeons, neuroradiologists, radiation oncologists, ophthalmologists, and neurological anesthesiologists. A mutual exchange of expert opinions in such fields can provide the most satisfactory treatment strategy, which should be the most appropriate, in accordance with the scientific community standards. Pituitary apoplexy can be used as an example.19-22 In 2016, the Society for Endocrinology launched a guidance document to provide a paradigm for its management.23 Zoli et al.24 recently reported that endoscopic transsphenoidal surgery, performed by expert neurosurgeons acting within a dedicated pituitary unit, is an effective and safe treatment of this condition. This has confirmed that patients with hypothalamic or pituitary disorders should be referred to dedicated tertiary centers for the most appropriate multidisciplinary management. Thus, it is of utmost importance that reference guidelines should be compiled and implemented by all caregivers. Therefore, a multicenter study was performed to determine the procedures
e2
www.SCIENCEDIRECT.com
used in Italian neurosurgical centers that perform pituitary surgery. The aim of our study was to determine the treatment methods, lines of research, best available treatment options, unmet needs, and requirements to create a national network that could serve as guidance for nontertiary centers in the management of hypothalamic/pituitary disease. METHODS On behalf of SINch (Società Italiana di Neurochirurgia), a survey was conducted to explore the activities in the field of pituitary surgery in 2016, within 41 public institutions well-renowned for having been constantly involved in this field from the clinical and scientific perspectives. Overall, the surgical procedures performed in 2016 for the treatment of hypothalamic/pituitary tumors (i.e., pituitary adenomas, craniopharyngiomas, Rathke’s cleft cysts, chordomas) were investigated. Although chordomas should not be considered among the hypothalamic/pituitary diseases, we included data concerning these lesions in the survey for 2 main reasons. First, in 1971, Hardy25 recognized these tumors were amenable to transsphenoidal surgery according to their growth pattern and inner features. Second, we have noted a certain enthusiasm in considering the transsphenoidal approach as a viable surgical option for treating chordomas, when these lesions are extradural and have a prevalent midline extension.26-35 Data were extracted from the Italian registry of disease according to the International Classification of Diseases, Clinical Modification, 10th edition, codes for diagnosis and DiagnosisRelated Group procedures. The number of procedures performed using a transcranial approach or transsphenoidal approach was then retrieved for each tumor group. The senior surgeons were asked to state whether they had adopted microscopic, endoscopic, or endoscope-assisted techniques. The presence of a dedicated MDT and facilities with a research laboratory on site were recorded. The scientific strength and research activities at each center according to specific parameters, such as the number of relevant studies reported and the number of research grants obtained in the previous 5 years, were evaluated. We also recorded whether the center was a university hospital, whether a neurosurgery residency program was present, and whether dedicated staff had been involved as faculty members at pertinent workshops (>5 in 2016). After data collection and analysis, the respondents met to discuss and establish the present report. We decided to not analyze the data from single institutions but, rather, to present the overall national volumes for each of the variables we considered. It was not the purpose of our study to discuss the strength of the single units and/or to measure the clinical parameters of each procedure (i.e., the extent of resection, visual outcomes, complications). RESULTS Of the 41 centers, 37 were enrolled in the present study; 4 of the invitees did not respond (Table 1). Of the 37 included centers, 15 were university hospitals running a full neurosurgery residency program, 10 were community hospitals providing part of a
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2018.11.186
ORIGINAL ARTICLE DOMENICO SOLARI ET AL.
A SURVEY ON PITUITARY SURGERY IN ITALY
Table 1. Italian Public Institutions Invited to Participate in the Survey on Pituitary Surgery Center
Response
Residency Program
Multidisciplinary Team
Università degli Studi di Messina e Policlinico “G. Martino”
Yes
Full
Yes
AOU Ospedale Civile di Baggiovara e Modena
Yes
Adjunct
Yes
ASST “Papa Giovanni XXIII” e Bergamo
Yes
Adjunct
Yes
IRCCS Istituto Nazionale Tumori “Regina Elena” e Roma
Yes
Adjunct
Yes
Università degli Studi di Verona, Ospedale Maggiore di Borgo Trento e Verona
No
Full
Not available
Università degli Studi di Napoli “Federico II”
Yes
Full
Yes
AO “Cannizzaro” e Catania
Yes
No
Yes
AO “G. Rummo” e Benevento
Yes
Adjunct
Yes
AO “San Camillo-Forlanini” e Rome
Yes
No
Yes
Università degli Studi di Padova
Yes
Full
Yes
IRCCS Neuromed (NCH 1) e Pozzilli
Yes
Adjunct
Yes
Fondazione IRCCS Istituto Neurologico “Carlo Besta” (NCH 1) e Milano
Yes
Adjunct
No
Fondazione IRCCS Istituto Neurologico “Carlo Besta” (NCH 2) e Milan
Yes
Adjunct
Yes
Università degli Studi di Brescia, Spedali Civili
Yes
Full
Yes
Università degli Studi, Ospedale Civile “S. Salvatore” e L’Aquila
Yes
Full
Yes
Presidio Ospedaliero “V. Fazzi” e Lecce
Yes
No
No
Università Politecnica delle Marche, Ospedali Riuniti Torrette e Ancona
Yes
Full
Yes
Humanitas Research Hospital e Rozzano
Yes
Full
Yes
Fondazione IRCCS “Cà Granda,” Ospedale Maggiore, Policlinico e Milan
Yes
Full
Yes
Università degli Studi dell’Insubria, Ospedale di Circolo e Fondazione Macchi e Varese
Yes
Full
Yes
IRCCS Isituto delle Scienze Neurologiche, Ospedale Bellaria e Bologna
Yes
No
Yes
AO “M. Bufalini” e Cesena
Yes
Full
Yes
Università Cattolica del Sacro Cuore, Policlinico “A Gemelli” e Rome
Yes
Full
Yes
AOU Parma-Reggio Emilia
Yes
No
Yes
Università degli Studi di Roma “La Sapienza” e Rome
Yes
Full
Yes
Ospedale di Bolzano
Yes
No
Yes
AOU di Udine
Yes
No
Yes
AO Ospedale Civile di Legnano
Yes
No
No
Università Vita-Salute “San Raffaele” e Milan
No
Full
Not available
Ospedale San Bortolo e Vicenza
Yes
Adjunct
Yes
Università degli Studi di Torino, Città della Salute e della Scienza
Yes
Full
Yes
Fondazione IRCCS Policlinico “S. Matteo” e Pavia
Yes
Full
Yes
Università degli Studi di Genova e Ospedale “San Martino”
Yes
Adjunct
Yes
AO “G. Brotzu” e Cagliari
Yes
Adjunct
Yes
AO “SS. Antonio e Biagio e Cesare Arrigo” e Alessandria
Yes
No
Yes
Università degli Studi di Roma “Tor Vergata”
No
Full
Not available
AOU “Careggi” e Firenze
Yes
Full
No
IRCCS “Casa Sollievo della Sofferenza” San Giovanni Rotondo
Yes
Adjunct
Yes
AOU Senese “Le Scotte” e Siena
Yes
Full
No
Spedali Riuniti di Livorno e USL Toscana Nord-Ovest
Yes
No
Yes
Ospedale di Pisa
No
Adjunct
No
WORLD NEUROSURGERY -: e1-e10, - 2018
www.journals.elsevier.com/world-neurosurgery
e3
ORIGINAL ARTICLE DOMENICO SOLARI ET AL.
A SURVEY ON PITUITARY SURGERY IN ITALY
neurosurgery residency program for adjacent area universities, and 12 were nonteaching hospitals. We recorded a total of 1479 neurosurgical procedures for hypothalamic/pituitary tumors in 2016. Of these, 1203 were for pituitary adenomas, 135 for craniopharyngiomas, 68 for Rathke cleft cysts, and 73 for chordomas. Most of the procedures were performed via the transsphenoidal approach (1320 transsphenoidal vs. 159 transcranial), and most of the centers had adopted the endoscopic endonasal technique (Figure 1). All the centers had a dedicated neuropathologist and neuroradiologist. However, radiotherapy service was not available in 3 centers, and no endocrinology service was available in 2 centers. Accordingly, a multidisciplinary tumor board was convened regularly in 32 of 37 centers (Table 1). The total number of studies reported on this topic from 2012 to 2016 was 474. Of the 37 centers, 15 did not report any study, and 10 institutions had reported <10 studies within the study period. Fourteen centers, all university or teaching hospitals, had obtained 45 grants to support their research projects. A research laboratory was present in 18 centers. Finally, only 16 teams were involved as tutors or faculty members in 5 courses or congresses in 2016 (Figure 2). DISCUSSION The multifaceted aspect of hypothalamic-pituitary disorders implies a variety of treatments that should be considered and properly tailored to each case. Through the years, the understanding of the clinical epiphenomena of these diseases, especially in terms of cellular and molecular biology, has tremendously expanded, along with the possibilities of creating more innovative and refined treatment strategies. However, a consensus has not yet been reached regarding the optimal management in clinical situations, especially at primary centers. Recent reports have established the need for hospitals to be considered a pituitary center of excellence and which primary missions should be completed.17,18 The focus in the clinical environment has been on the core duo of practitioners, the endocrinologist and the pituitary neurosurgeon, which are at the heart of a dedicated MDT. The achievement of optimal results can be compared to a precise clock, in which each part is working simultaneously to achieve a common goal, such as a pituitary team working to determine the most appropriate treatment. A vital component is the presence of an experienced neurosurgeon capable of performing pituitary surgery safely and effectively. Moreover, the neurosurgeon should have knowledge of the hypothalamic-pituitary organ physiology principles and solid training in basic neurosurgery. The association between hospital volume and operative mortality has been largely mediated by surgeon volume for many procedures. That is, patients will have better chances of survival when treated by surgeons who perform that procedure frequently.36,37 This idea can be applied to pituitary surgery, with surgeons usually starting their learning curve treating relatively common nonfunctioning pituitary adenomas, acquiring confidence with the anatomy and technique. Next, they should treat functioning adenomas, for which the goal is to cure and preserve pituitary function, such as surgery for Cushing’s disease and acromegaly. The final challenge is the treatment of
e4
www.SCIENCEDIRECT.com
more complex diseases such as intradural diseases, craniopharyngioma, and/or other parasellar skull base lesions.38-40 Resection of 50 adenomas annually could represent the optimal number to provide neurosurgeons with sufficient surgical experience.18 This could improve the surgeons’ abilities in patient selection and operative techniques with a lower risk of complications. This can lead to better outcomes, even when treating pathologic entities other than adenomas.17,37,41-44 This so-called experienceeoutcome effect allows for the development of a virtuoso circuit. In addition to increasing experience, better outcomes will be achieved. The knowledge gained increases the options for treatment strategies and the indications can be refined; thus, the volume of activity will be expanded.17,18,41 The results of our series have confirmed this trend. The vast majority of Italian centers with a consolidated pituitary unit performed a sufficient number of procedures. In terms of variety, we found that the greater experience with surgery of pituitary adenomas allowed for enrollment of a larger number of patients with complex diseases. Thus, it is advisable to have difficult cases referred to those centers at which high-quality care can be provided (i.e., tertiary care centers with a MDT and larger caseload). In addition, such as occurred in the healthcare system in Emilia-Romagna for neurotrauma and stroke, applying the so-called hub and spoke paradigm to pituitary surgery could be a viable option. For these reasons, it is of utmost importance to define virtuoso strategies and the best available strategies within a national network to provide guidelines for the proper and tailored treatment of patients. Thus, small primary centers could take advantage of discussions within an “expanded” MDT regarding the most suitable strategies and whether it would be possible to treat the patients admitted to that center. The present analysis showed that the vast majority of procedures (in all centers but 2) were performed using a transsphenoidal approach, a statistically significant difference (1320 vs. 159; P < 0.001, Student’s t test). This was in accordance with data reporting the use of a transsphenoidal approach for >95% of the surgical procedures to the sellar area,11-13,45,46 with an increase in the extent of resection and a decrease in the morbidity rates and length of stay.47-51 The number of transcranial procedures overall we recorded reached w10% and was used for almost 8% of adenomas and 38% of craniopharyngiomas. This could have been mostly related to surgeon experience and/or a preference in the treatment of lesions with an eccentric growth pattern, expanding outside the sella. Nevertheless, it might be possible that those procedures were performed transcranially in an attempt to contain the risk of postoperative cerebrospinal fluid leakage related to extended approaches. In such situations, it is not surprising that most of the Italian centers (32 of 37) had adopted the endoscopic endonasal technique (1204 endoscopic, 53 microscopic, and 53 endoscope-assisted microscopic) for the transsphenoidal procedures. This choice also depends on the patient’s attitude. Most patients will be more willing to undergo surgical intervention via an endoscopic endonasal technique after a pituitary tumor has been diagnosed.8 The introduction of the endoscopic technique has confirmed the effectiveness of the transsphenoidal route, providing further advantages in terms of visualization, including a superior
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2018.11.186
ORIGINAL ARTICLE DOMENICO SOLARI ET AL.
Figure 1. Graph showing the caseload of pituitary surgeries in 2016 at 37 Italian centers of the present study (37 of 41 responded to the survey). The colored bars (blue, transcranial approach; red, transsphenoidal endoscopic approach; green, transsphenoidal endoscopic-assisted microscopic
panoramic and close-up view of the relevant anatomy, which is very important at the tumoregland interface, and an enlarged working angle.14,47,48,52-65 It has been proved that this technique results in similar resection rates with less risk of surgical and clinical complications.63,66-70 The endoscopic technique has favored the adoption of an endonasal corridor for treating different pathologic entities of the median and paramedian skull base.71-80 Recent clinical studies81-83 have reported that endoscopic resection provides a safe and compelling alternative to transcranial surgery for craniopharyngiomas. Endoscopic resection provides good results in terms of the extent of removal and visual outcomes, with a limited risk of complications, in particular, the risk of postoperative cerebrospinal fluid leakage.84-95 The use of widespread endoscopic surgery has increased, based on the peer-reviewed data on the topic in the past 10 years. The use of endoscopic surgery also resulted in interdisciplinary cooperation and renewal of the positive interaction between
WORLD NEUROSURGERY -: e1-e10, - 2018
A SURVEY ON PITUITARY SURGERY IN ITALY
approach; violet, transsphenoidal microscopic approach; light blue, total number of procedures per tumor) represent the surgical technique chosen to treat the pathology.
scientific medical innovations and technological industries. Neuronavigation systems, high-definition, 3-dimensional, or 4K endoscopes, robotic devices, and thrombin foam hemostatic agents, are only few of the most representative tools that have been developed to provide safer, more precise, and specialized surgery.55,96-105 Our data have shown that the volume of research and development are greater at university hospitals, where it is easier to build a strong expertise team. These teams also are more often recipients for research funding and promoting contributions to the scientific data, with more reports in the previous 5 years (university centers, 278 studies; community teaching hospitals, 100 reports; and nonteaching hospitals, 96 reports; P ¼ 0.008, Mann-Whitney U test). This significant difference reflects the boost in the contribution added by the younger colleagues; their learning commitment results in a viable and relentless engine for ideas and innovations, which results in further work and better allocation of competencies and effectiveness.
www.journals.elsevier.com/world-neurosurgery
e5
ORIGINAL ARTICLE DOMENICO SOLARI ET AL.
A SURVEY ON PITUITARY SURGERY IN ITALY
Figure 2. Graph showing the research and scientific activity at 37 Italian centers of the present study (37 of 41 responded to the survey). The colored bars represent the overall volume of the activity stratified by
The education of young neurosurgeons in the field of pituitary/ hypothalamus disease treatment stands crucial. University hospitals must train future pituitary surgeons with refined surgical skills but also provide them with the most recent and appropriate information.1,106-109 Therefore, it is essential to teach to younger colleagues the concept of “teamwork” so they can better treat patients with hypothalamic/pituitary disease.17,18,54 Hence, dedicated training—at the least, fellowships—in a specialized tertiary center would definitely shorten the learning curve. The statistical data have shown that the adoption of common strategies is the next step in improving the standard of care and the quality of scientific data.
category of Italian institutions (blue, university center; green, teaching hospital; red, community hospital).
their knowledge, remembering working as a team is equally important as considering the anatomy, pathophysiology, and the natural history of pituitary disease in detail and performing neuroimaging studies. Better outcomes can be expected within high-volume centers with MDTs and running a residency program. Finally, it is worth remembering that surgical techniques or instruments should not be considered a “magic wand.” Although more studies are required to determine the best approach to treating hypothalamic/pituitary diseases, the greatest point from the present survey is to remind all medical professionals to continue to exchange ideas and knowledge to allow the community to continue to look further and beyond, to the next level of a cure.
CONCLUSIONS Although guidelines have not yet been established, a wide variety of techniques and treatments are available. Most Italian centers understand that the best management of hypothalamic/pituitary disorders will result from teamwork and should take advantage of the extraordinary ongoing advancements. In Italy, neurosurgeons who would like to focus their activities in this field should expand
e6
www.SCIENCEDIRECT.com
ACKNOWLEDGMENTS Paolo Cappabianca, Luigi Maria Cavallo, and Domenico Solari, among other authors, would like to once again show their profound appreciation to Professor Enrico de Divitiis for mentoring and teaching as pioneer and leader of transsphenoidal surgery at the School of Naples.
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2018.11.186
ORIGINAL ARTICLE DOMENICO SOLARI ET AL.
REFERENCES 1. Asa SL, Mete O. What’s new in pituitary pathology? Histopathology. 2018;72:133-141. 2. Daly AF, Rixhon M, Adam C, Dempegioti A, Tichomirowa MA, Beckers A. High prevalence of pituitary adenomas: a cross-sectional study in the province of Liege, Belgium. J Clin Endocrinol Metab. 2006;91:4769-4775. 3. Fernandez A, Karavitaki N, Wass JA. Prevalence of pituitary adenomas: a community-based, cross-sectional study in Banbury (Oxfordshire, UK). Clin Endocrinol (Oxf). 2010;72:377-382. 4. Clayton RN. Sporadic pituitary tumours: from epidemiology to use of databases. Baillieres Best Pract Res Clin Endocrinol Metab. 1999;13:451-460. 5. Daly AF, Petrossians P, Beckers A. An overview of the epidemiology and genetics of acromegaly. J Endocrinol Invest. 2005;28(11 suppl international): 67-69. 6. Ezzat S, Asa SL, Couldwell WT, et al. The prevalence of pituitary adenomas: a systematic review. Cancer. 2004;101:613-619. 7. Golden SH, Robinson KA, Saldanha I, Anton B, Ladenson PW. Clinical review: prevalence and incidence of endocrine and metabolic disorders in the United States: a comprehensive review. J Clin Endocrinol Metab. 2009;94:1853-1878.
A SURVEY ON PITUITARY SURGERY IN ITALY
18. Casanueva FF, Barkan AL, Buchfelder M, et al. Criteria for the definition of pituitary tumor centers of excellence (PTCOE): a pituitary society statement. Pituitary. 2017;20:489-498. 19. Semple PL, Webb MK, de Villiers JC, Laws ER Jr. Pituitary apoplexy. Neurosurgery. 2005;56:65-72 [discussion: 72-73]. 20. Semple PL, Jane JA Jr, Laws ER Jr. Clinical relevance of precipitating factors in pituitary apoplexy. Neurosurgery. 2007;61:956-961 [discussion: 961-962]. 21. Semple PL, Jane JA, Lopes MB, Laws ER. Pituitary apoplexy: correlation between magnetic resonance imaging and histopathological results. J Neurosurg. 2008;108:909-915. 22. Capatina C, Inder W, Karavitaki N, Wass JA. Management of endocrine disease: pituitary tumour apoplexy. Eur J Endocrinol. 2015;172: R179-R190. 23. Baldeweg SE, Vanderpump M, Drake W, et al. Society for Endocrinology endocrine emergency guidance: emergency management of pituitary apoplexy in adult patients. Endocr Connect. 2016;5: G12-G15. 24. Zoli M, Milanese L, Faustini-Fustini M, et al. Endoscopic endonasal surgery for pituitary apoplexy: evidence on a 75-case series from a tertiary care center. World Neurosurg. 2017;106: 331-338.
8. Villwock JA, Villwock M, Deshaies E, Goyal P. Significant increases of pituitary tumors and resections from 1993 to 2011. Int Forum Allergy Rhinol. 2014;4:767-770.
25. Hardy J. Transsphenoidal J Neurosurg. 1971;34:582-594.
9. Yildirim AE, Divanlioglu D, Nacar OA, et al. Incidence, hormonal distribution and postoperative follow up of atypical pituitary adenomas. Turk Neurosurg. 2013;23:226-231.
26. Fraser JF, Nyquist GG, Moore N, Anand VK, Schwartz TH. Endoscopic endonasal transclival resection of chordomas: operative technique, clinical outcome, and review of the literature. J Neurosurg. 2010;112:1061-1069.
10. Molitch ME. Diagnosis and treatment of pituitary adenomas: a review. JAMA. 2017;317:516-524. 11. Jane JA Jr, Thapar K, Kaptain GJ, Maartens N, Laws ER Jr. Pituitary surgery: transsphenoidal approach. Neurosurgery. 2002;51:435-442 [discussion: 442-444]. 12. Laws ER, Jane JA Jr. Pituitary tumors—long-term outcomes and expectations. Clin Neurosurg. 2001; 48:306-319. 13. Laws ER, Lanzino G, eds. Transsphenoidal Surgery. Philadelphia: Saunders-Elsevier; 2010. 14. Solari D, Cavallo LM, Cappabianca P. Surgical approach to pituitary tumors. Handbk Clin Neurol. 2014;124:291-301. 15. Laws ER Jr, Thapar K. Pituitary surgery. Endocrinol Metab Clin North Am. 1999;28:119-131. 16. Thapar K, Laws ERJ. Pituitary tumors. In: Kaye Jr AW, Laws ER, eds. Brain Tumors. London: Churchill Livingstone; 2001:804-854. 17. McLaughlin N, Laws ER, Oyesiku NM, Katznelson L, Kelly DF. Pituitary centers of excellence. Neurosurgery. 2012;71:916-924 [discussion: 924-926].
hypophysectomy.
27. Laws E. Clivus chordomas. In: Sekhar LN, Janecka IP, eds. Surgery of Cranial Base Tumors. New York: Raven Press; 1993:679-685. 28. Maira G, Pallini R, Anile C, et al. Surgical treatment of clival chordomas: the transsphenoidal approach revisited. J Neurosurg. 1996; 85:784-792. 29. al-Mefty O, Borba LA. Skull base chordomas: a management challenge. J Neurosurg. 1997;86: 182-189. 30. Frank G, Sciarretta V, Calbucci F, Farneti G, Mazzatenta D, Pasquini E. The endoscopic transnasal transsphenoidal approach for the treatment of cranial base chordomas and chondrosarcomas. Neurosurgery. 2006;59(suppl 1): ONS50-ONS57 [discussion: ONS50-ONS57]. 31. Samii A, Gerganov VM, Herold C, et al. Chordomas of the skull base: surgical management and outcome. J Neurosurg. 2007;107:319-324. 32. Stippler M, Gardner PA, Snyderman CH, Carrau RL, Prevedello DM, Kassam AB. Endoscopic endonasal approach for clival chordomas. Neurosurgery. 2009;64:268-277 [discussion: 277-278].
WORLD NEUROSURGERY -: e1-e10, - 2018
33. Komotar RJ, Starke RM, Raper DM, Anand VK, Schwartz TH. The endoscope-assisted ventral approach compared with open microscopeassisted surgery for clival chordomas. World Neurosurg. 2011;76:318-327 [discussion: 259-362]. 34. Koutourousiou M, Gardner PA, Tormenti MJ, et al. Endoscopic endonasal approach for resection of cranial base chordomas: outcomes and learning curve. Neurosurgery. 2012;71:614-624 [discussion: 624-625]. 35. Chibbaro S, Cornelius JF, Froelich S, et al. Endoscopic endonasal approach in the management of skull base chordomas—clinical experience on a large series, technique, outcome, and pitfalls. Neurosurg Rev. 2014;37:217-224 [discussion: 224-225]. 36. Birkmeyer JD, Stukel TA, Siewers AE, Goodney PP, Wennberg DE, Lucas FL. Surgeon volume and operative mortality in the United States. N Engl J Med. 2003;349:2117-2127. 37. 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. 1997;40: 225-236 [discussion: 236-237]. 38. Liu JK, Das K, Weiss MH, Laws ER Jr, Couldwell WT. The history and evolution of transsphenoidal surgery. J Neurosurg. 2001;95: 1083-1096. 39. Snyderman C, Kassam A, Carrau R, Mintz A, Gardner P, Prevedello DM. Acquisition of surgical skills for endonasal skull base surgery: a training program. Laryngoscope. 2007;117:699-705. 40. Wang YY, Higham C, Kearney T, Davis JR, Trainer P, Gnanalingham KK. Acromegaly surgery in Manchester revisited—the impact of reducing surgeon numbers and the 2010 consensus guidelines for disease remission. Clin Endocrinol (Oxf). 2012;76:399-406. 41. Shahlaie K, McLaughlin N, Kassam AB, Kelly DF. The role of outcomes data for assessing the expertise of a pituitary surgeon. Curr Opin Endocrinol Diabetes Obes. 2010;17:369-376. 42. Dusick JR, Esposito F, Kelly DF, et al. The extended direct endonasal transsphenoidal approach for nonadenomatous suprasellar tumors. J Neurosurg. 2005;102:832-841. 43. Zada G, Kelly DF, Cohan P, Wang C, Swerdloff R. Endonasal transsphenoidal approach for pituitary adenomas and other sellar lesions: an assessment of efficacy, safety, and patient impressions. J Neurosurg. 2003;98:350-358. 44. Zada G, Du R, Laws ER Jr. Defining the "edge of the envelope": patient selection in treating complex sellar-based neoplasms via transsphenoidal versus open craniotomy. J Neurosurg. 2011;114:286-300. 45. Pratheesh R, Rajaratnam S, Prabhu K, Mani SE, Chacko G, Chacko AG. The current role of transcranial surgery in the management of pituitary adenomas. Pituitary. 2013;16:419-434. 46. O’Malley BW Jr, Grady MS, Gabel BC, et al. Comparison of endoscopic and microscopic
www.journals.elsevier.com/world-neurosurgery
e7
ORIGINAL ARTICLE DOMENICO SOLARI ET AL.
removal of pituitary adenomas: single-surgeon experience and the learning curve. Neurosurg Focus. 2008;25:E10. 47. McLaughlin N, Eisenberg AA, Cohan P, Chaloner CB, Kelly DF. Value of endoscopy for maximizing tumor removal in endonasal transsphenoidal pituitary adenoma surgery. J Neurosurg. 2013;118:613-620. 48. Cappabianca P, Cavallo LM, de Divitiis O, Solari D, Esposito F, Colao A. Endoscopic pituitary surgery. Pituitary. 2008;11:385-390. 49. Tabaee A, Anand VK, Barron Y, et al. Endoscopic pituitary surgery: a systematic review and metaanalysis. J Neurosurg. 2009;111:545-554. 50. Cappabianca P, Cavallo LM, de Divitiis O, Esposito F. Pituitary surgery. In: DeGroot LJ, Jameson JL, eds. Endocrinology. 6th ed. Philadelphia, PA: Saunders-Elsevier; 2010:358-376. 51. Kassam AB, Prevedello DM, Carrau RL, et al. Endoscopic endonasal skull base surgery: analysis of complications in the authors’ initial 800 patients. J Neurosurg. 2011;114:1544-1568. 52. Spencer WR, Das K, Nwagu C, et al. Approaches to the sellar and parasellar region: anatomic comparison of the microscope versus endoscope. Laryngoscope. 1999;109:791-794. 53. de Divitiis E. Endoscopic transsphenoidal surgery: stone-in-the-pond effect. Neurosurgery. 2006;59:512-520. 54. Cappabianca P, de Divitiis E. Endoscopy and transsphenoidal surgery. Neurosurgery. 2004;54: 1043-1048 [discussion: 1048-1050]. 55. Cappabianca P, Decq P, Schroeder HW. Future of endoscopy in neurosurgery. Surg Neurol. 2007;67: 496-498. 56. Cappabianca P, Cavallo LM, Esposito F, de Divitiis O, Messina A, de Divitiis E. Extended endoscopic endonasal approach to the midline skull base: the evolving role of transsphenoidal surgery. In: Pickard JD, Akalan N, Di Rocco C, et al., eds. Advances and Technical Standards in Neurosurgery. New York, NY: Springer-Verlag Wien; 2008:152-199. 57. Cappabianca P, Cavallo LM, Solari D, Stagno V, Esposito F, de Angelis M. Endoscopic endonasal surgery for pituitary adenomas. World Neurosurg. 2014;82(suppl):S3-S11. 58. de Notaris M, Prats-Galino A, Ensenat J, et al. Quantitative analysis of progressive removal of nasal structures during endoscopic suprasellar approach. Laryngoscope. 2014;124:2231-2237. 59. Benveniste RJ, King WA, Walsh J, Lee JS, Delman BN, Post KD. Repeated transsphenoidal surgery to treat recurrent or residual pituitary adenoma. J Neurosurg. 2005;102:1004-1012. 60. Rudnik A, Zawadzki T, Galuszka-Ignasiak B, et al. Endoscopic transsphenoidal treatment in recurrent and residual pituitary adenomas—first experience. Minim Invasive Neurosurg. 2006;49: 10-14.
e8
www.SCIENCEDIRECT.com
A SURVEY ON PITUITARY SURGERY IN ITALY
61. Chang EF, Sughrue ME, Zada G, Wilson CB, Blevins LS Jr, Kunwar S. Long term outcome following repeat transsphenoidal surgery for recurrent endocrine-inactive pituitary adenomas. Pituitary. 2010;13:223-229. 62. Cavallo LM, Solari D, Tasiou A, et al. Endoscopic endonasal transsphenoidal removal of recurrent and regrowing pituitary adenomas: experience on a 59-patient series. World Neurosurg. 2013;80: 342-350. 63. Cappabianca P, Cavallo LM, Solari D, de Divitiis O, Chiaramonte C, Esposito F. Size does not matter: the intrigue of giant adenomas: a true surgical challenge. Acta Neurochir (Wien). 2014;156:2217-2220. 64. Gondim JA, Almeida JP, Albuquerque LA, Gomes EF, Schops M. Giant pituitary adenomas: surgical outcomes of 50 cases operated on by the endonasal endoscopic approach. World Neurosurg. 2014;82:e281-e290. 65. Cappabianca P, Cavallo LM, Colao A, de Divitiis E. Surgical complications associated with the endoscopic endonasal transsphenoidal approach for pituitary adenomas. J Neurosurg. 2002;97:293-298.
74. Kassam AB, Gardner P, Snyderman C, Mintz A, Carrau R. Expanded endonasal approach: fully endoscopic, completely transnasal approach to the middle third of the clivus, petrous bone, middle cranial fossa, and infratemporal fossa. Neurosurg Focus. 2005;19:E6. 75. Kassam A, Thomas AJ, Snyderman C, et al. Fully endoscopic expanded endonasal approach treating skull base lesions in pediatric patients. J Neurosurg. 2007;106(suppl):75-86. 76. Prevedello DM, Thomas A, Gardner P, Snyderman CH, Carrau RL, Kassam AB. Endoscopic endonasal resection of a synchronous pituitary adenoma and a tuberculum sellae meningioma: technical case report. Neurosurgery. 2007;60(suppl 2):E401 [discussion: E401]. 77. Gardner PA, Kassam AB, Thomas A, et al. Endoscopic endonasal resection of anterior cranial base meningiomas. Neurosurgery. 2008;63: 36-52 [discussion: 52-54]. 78. Gardner PA, Prevedello DM, Kassam AB, Snyderman CH, Carrau RL, Mintz AH. The evolution of the endonasal approach for craniopharyngiomas. J Neurosurg. 2008;108:1043-1047.
66. Bander ED, Singh H, Ogilvie CB, et al. Endoscopic endonasal versus transcranial approach to tuberculum sellae and planum sphenoidale meningiomas in a similar cohort of patients. J Neurosurg. 2018;128:40-48.
79. Kassam AB, Prevedello DM, Carrau RL, et al. The front door to meckel’s cave: an anteromedial corridor via expanded endoscopic endonasal approach—technical considerations and clinical series. Neurosurgery. 2009;64(suppl):71-82 [discussion: 82-83].
67. Komotar RJ, Starke RM, Raper DM, Anand VK, Schwartz TH. Endoscopic endonasal compared with microscopic transsphenoidal and open transcranial resection of giant pituitary adenomas. Pituitary. 2012;15:150-159.
80. Laufer I, Anand VK, Schwartz TH. Endoscopic, endonasal extended transsphenoidal, transplanum transtuberculum approach for resection of suprasellar lesions. J Neurosurg. 2007;106: 400-406.
68. Koutourousiou M, Gardner PA, FernandezMiranda JC, Paluzzi A, Wang EW, Snyderman CH. Endoscopic endonasal surgery for giant pituitary adenomas: advantages and limitations. J Neurosurg. 2013;118:621-631.
81. Wannemuehler TJ, Rubel KE, Hendricks BK, et al. Outcomes in transcranial microsurgery versus extended endoscopic endonasal approach for primary resection of adult craniopharyngiomas. Neurosurg Focus. 2016;41:E6.
69. Wang S, Li D, Ni M, et al. Clinical predictors of diabetes insipidus after transcranial surgery for pituitary adenoma. World Neurosurg. 2017; 101:1-10.
82. Moussazadeh N, Prabhu V, Bander ED, et al. Endoscopic endonasal versus open transcranial resection of craniopharyngiomas: a casematched single-institution analysis. Neurosurg Focus. 2016;41:E7.
70. de Divitiis E, Cappabianca P, Cavallo LM. Endoscopic transsphenoidal approach: adaptability of the procedure to different sellar lesions. Neurosurgery. 2002;51:699-705 [discussion: 705-707]. 71. de Divitiis E, Cavallo LM, Cappabianca P, Esposito F. Extended endoscopic endonasal transsphenoidal approach for the removal of suprasellar tumors: part 2. Neurosurgery. 2007;60: 46-58 [discussion: 58-59]. 72. Kassam A, Snyderman CH, Mintz A, Gardner P, Carrau RL. Expanded endonasal approach: the rostrocaudal axis. Part II. Posterior clinoids to the foramen magnum. Neurosurg Focus. 2005;19:E4. 73. Kassam A, Snyderman CH, Mintz A, Gardner P, Carrau RL. Expanded endonasal approach: the rostrocaudal axis. Part I. Crista galli to the sella turcica. Neurosurg Focus. 2005;19:E3.
83. Jeswani S, Nuno M, Wu A, et al. Comparative analysis of outcomes following craniotomy and expanded endoscopic endonasal transsphenoidal resection of craniopharyngioma and related tumors: a single-institution study. J Neurosurg. 2016;124:627-638. 84. Barajas MA, Ramirez-Guzman G, RodriguezVazquez C, et al. Multimodal management of craniopharyngiomas: neuroendoscopy, microsurgery, and radiosurgery. J Neurosurg. 2002; 97(suppl):607-609. 85. Frank G, Pasquini E, Doglietto F, et al. The endoscopic extended transsphenoidal approach for craniopharyngiomas. Neurosurgery. 2006; 59(suppl 1):ONS75-ONS83. 86. de Divitiis E, Cappabianca P, Cavallo LM, Esposito F, de Divitiis O, Messina A. Extended endoscopic transsphenoidal approach for
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2018.11.186
ORIGINAL ARTICLE DOMENICO SOLARI ET AL.
extrasellar craniopharyngiomas. Neurosurgery. 2007;61(suppl 2):219-227 [discussion: 228]. 87. Gardner PA, Kassam AB, Snyderman CH, et al. Outcomes following endoscopic, expanded endonasal resection of suprasellar craniopharyngiomas: a case series. J Neurosurg. 2008;109: 6-16. 88. Cavallo LM, Prevedello DM, Solari D, et al. Extended endoscopic endonasal transsphenoidal approach for residual or recurrent craniopharyngiomas. J Neurosurg. 2009;111:578-589. 89. Komotar RJ, Starke RM, Raper DM, Anand VK, Schwartz TH. Endoscopic endonasal compared with microscopic transsphenoidal and open transcranial resection of craniopharyngiomas. World Neurosurg. 2012;77:329-341. 90. Leng LZ, Greenfield JP, Souweidane MM, Anand VK, Schwartz TH. Endoscopic, endonasal resection of craniopharyngiomas: analysis of outcome including extent of resection, cerebrospinal fluid leak, return to preoperative productivity, and body mass index. Neurosurgery. 2012; 70:110-123 [discussion: 123-124]. 91. Prevedello DM, Solari D, Carrau RL, Gardner P, Kassam AB. Endoscopic endonasal approach for craniopharyngiomas. In: Quinones-Hinojosa A, ed. Schmideck & Sweet Operative Neurosurgical Techniques: Indications, Methods, and Results. 6th ed. 1. Philadelphia: Elsevier Saunders; 2012:303-310. 92. Cavallo LM, Solari D, Esposito F, Cappabianca P. The endoscopic endonasal approach for the management of craniopharyngiomas involving the third ventricle. Neurosurg Rev. 2013;36:27-37 [discussion: 38]. 93. Koutourousiou M, Gardner PA, FernandezMiranda JC, Tyler-Kabara EC, Wang EW, Snyderman CH. Endoscopic endonasal surgery for craniopharyngiomas: surgical outcome in 64 patients. J Neurosurg. 2013;119:1194-1207. 94. Cavallo LM, Frank G, Cappabianca P, et al. The endoscopic endonasal approach for the management of craniopharyngiomas: a series of 103 patients. J Neurosurg. 2014;121:100-113.
A SURVEY ON PITUITARY SURGERY IN ITALY
95. Dhandapani S, Singh H, Negm HM, et al. Endonasal endoscopic reoperation for residual or recurrent craniopharyngiomas. J Neurosurg. 2017; 126:418-430. 96. Fraser JF, Allen B, Anand VK, Schwartz TH. Three-dimensional neurostereoendoscopy: subjective and objective comparison to 2D. Minim Invasive Neurosurg. 2009;52:25-31. 97. Kari E, Oyesiku NM, Dadashev V, Wise SK. Comparison of traditional 2-dimensional endoscopic pituitary surgery with new 3-dimensional endoscopic technology: intraoperative and early postoperative factors. Int Forum Allergy Rhinol. 2012;2:2-8. 98. Barkhoudarian G, Del Carmen Becerra Romero A, Laws ER. Evaluation of the 3dimensional endoscope in transsphenoidal surgery. Neurosurgery. 2013;73(1 suppl operative): ons74-ons78 [discussion: ons78-ons79]. 99. O’Malley BW Jr, Weinstein GS. Robotic skull base surgery: preclinical investigations to human clinical application. Arch Otolaryngol Head Neck Surg. 2007;133:1215-1219. 100. O’Malley BW Jr, Weinstein GS. Robotic anterior and midline skull base surgery: preclinical investigations. Int J Radiat Oncol Biol Phys. 2007; 69(suppl):S125-S128. 101. Trevillot V, Garrel R, Dombre E, Poignet P, Sobral R, Crampette L. Robotic endoscopic sinus and skull base surgery: review of the literature and future prospects. Eur Ann Otorhinolaryngol Head Neck Dis. 2013;130:201-207. 102. Ellegala DB, Maartens NF, Laws ER Jr. Use of FloSeal hemostatic sealant in transsphenoidal pituitary surgery: technical note. Neurosurgery. 2002;51:513-515 [discussion: 515-516]. 103. Cavallo LM, Di Somma A, Solari D, de Divitiis O, Bracale UM, Cappabianca P. Preliminary experience with a new multidirectional videoendoscope for neuroendoscopic surgical procedures. PLoS One. 2016;11:e0147524.
WORLD NEUROSURGERY -: e1-e10, - 2018
104. Esposito F, Cappabianca P, Angileri FF, et al. Gelatin-thrombin hemostatic matrix in neurosurgical procedures: hemostasis effectiveness and economic value of clinical and surgical procedure-related benefits [e-pub ahead of print] J Neurosurg Sci. 2016. 105. Esposito F, Angileri FF, Kruse P, et al. Fibrin sealants in dura sealing: a systematic literature review. PLoS One. 2016;11:e0151533. 106. Asa SL, Casar-Borota O, Chanson P, et al. From pituitary adenoma to pituitary neuroendocrine tumor (PitNET): an International Pituitary Pathology Club proposal. Endocr Relat Cancer. 2017; 24:C5-C8. 107. Osamura RY, Lopes MBS, Grossman A, et al. Pituitary adenoma. In: Lloyd RV, Osamura RY, Klöppel G, Rosai J, eds. WHO Classification of Tumours of Endocrine Organs. 10. Lyon, France: IARC; 2017:14-18. 108. Manojlovic-Gacic E, Engstrom BE, CasarBorota O. Histopathological classification of non-functioning pituitary neuroendocrine tumors. Pituitary. 2018;21:119-129. 109. Nishioka H, Inoshita N, Mete O, et al. The complementary role of transcription factors in the accurate diagnosis of clinically nonfunctioning pituitary adenomas. Endocr Pathol. 2015; 26:349-355.
Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Received 2 August 2018; accepted 20 November 2018 Citation: World Neurosurg. (2018). https://doi.org/10.1016/j.wneu.2018.11.186 Journal homepage: www.journals.elsevier.com/worldneurosurgery Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2018 Elsevier Inc. All rights reserved.
www.journals.elsevier.com/world-neurosurgery
e9
ORIGINAL ARTICLE DOMENICO SOLARI ET AL.
A SURVEY ON PITUITARY SURGERY IN ITALY
APPENDIX Additional contributors: F. Ammannati, M.D. (Division of Neurosurgery, AOU "Careggi", Firenze, Italy), M. Cappelletti, M.D. (Division of Neurosurgery, Università degli Studi di Roma "La Sapienza," Rome, Italy), C. Conti, M.D. (Division of Neurosurgery, AO "G. Brotzu," Cagliari, Italy), D. Criminelli Rossi, M.D. (Division of Neurosurgery, Università degli Studi di Genova e Ospedale "San Martino," Genua, Italy), M. G. de Notaris, M.D., Ph.D. (Division of Neurosurgery, AO "G. Rummo," Benevento, Italy), A. Delitala, M.D. (Division of Neurosurgery, AO "San Camillo-Forlanini," Rome, Italy), F. DiMeco, M.D. (Division of Neurosurgery (NCH 1), Fondazione IRCCS Istituto Neurologico "Carlo Besta", Milan, Italy), F. Doglietto, M.D., Ph.D. (Division of Neurosurgery, Università degli Studi di Brescia e Spedali Civili, Brescia, Italy), E. Emanuelli, M.D. (Division of Neurosurgery, Università degli Studi di Padova, Padua, Italy), F. Esposito, M.D., Ph.D. (Division of Neurosurgery, Università degli Studi di Messina e Policlinico “G. Martino,” Messina, Italy), V. Esposito, M.D. (Division of Neurosurgery, IRCCS Neuromed, Pozzilli (IS), Italy), P. Gaetani, M.D. (Division of Neurosurgery, Università degli Studi di Pavia e Fondazione IRCCS Policlinico "S. Matteo," Pavia, Italy), G. Lasio, M.D. (Division of Neurosurgery, Humanitas Research Hospital, Rozzano, Italy), S. Luzzi, M.D. (Division of Neurosurgery, Università degli Studi e Ospedale Civile "S. Salvatore," L’Aquila, Italy and Division of Neurosurgery, Università degli Studi di Pavia e Fondazione IRCCS Policlinico "S. Matteo," Pavia, Italy), A. Melatini, M.D. (Division of Neurosurgery, Presidio Ospedaliero
e10
www.SCIENCEDIRECT.com
"V. Fazzi," Lecce, Italy), V. Monte, M.D. (Division of Neurosurgery, IRCCS "Casa Sollievo della Sofferenza," San Giovanni Rotondo, Italy), D. Nasi, M.D. (Division of Neurosurgery, Università Politecnica delle Marche e Ospedali Riuniti Torrette, Ancona, Italy), G. Oliveri, M.D. (Division of Neurosurgery, AOU Senese "Le Scotte," Siena, Italy), A. Olivi, M.D., Ph.D. (Division of Neurosurgery, Università Cattolica del Sacro Cuore e Policlinico "A. Gemelli," Rome, Italy), G. Pavesi, M.D. (Division of Neurosurgery, AOU Ospedale Civile di Baggiovara, Modena, Italy), F. Penner, M.D. (Division of Neurosurgery, Università degli Studi di Torino e Città della Salute e della Scienza, Turin, Italy), S. Peron, M.D. (Division of Neurosurgery, AO Ospedale Civile di Legnano, Legnano, Italy), F. Pieri, M.D. (Division of Neurosurgery, Spedali Riuniti di Livorno e USL Toscana Nord-Ovest, Livorno, Italy), F. Pozzi, M.D. (Division of Neurosurgery, Università degli Studi dell’Insubria, Ospedale di Circolo e Fondazione Macchi, Varese, Italy), P. Rampini, M.D. (Division of Neurosurgery, Fondazione IRCCS Cà Granda e Ospedale Maggiore e Policlinico, Milan, Italy), M. Sicignano, M.D. (Division of Neurosurgery, ASST "Papa Giovanni XXIII," Bergamo, Italy), S. Telera, M.D. (Division of Neurosurgery, IRCCS Istituto Nazionale Tumori "Regina Elena," Rome, Italy), L. Tosatto, M.D. (Division of Neurosurgery, AO "M. Bufalini," Cesena, Italy), M. Vitali, M.D. (Division of Neurosurgery, AO "SS. Antonio e Biagio e Cesare Arrigo," Alessandria, Italy), M. Zoli, M.D. (Division of Neurosurgery, IRCCS Isituto delle Scienze Neurologiche, Ospedale Bellaria, Bologna, Italy).
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2018.11.186
A Survey on Pituitary Surgery in Italy Domenico Solari1, Francesco Zenga2, Filippo F. Angileri3, Andrea Barbanera4, Silvia Berlucchi5, Claudio Bernucci6, Carmine Carapella7, Domenico Catapano8, Giuseppe Catapano9, Luigi M. Cavallo1, Corrado D’Arrigo10, Michelangelo de Angelis11, Luca Denaro12, Nicola Desogus13, Paolo Ferroli14, Marco M. Fontanella15, Renato J. Galzio16,17, Cosimo D. Gianfreda18, Maurizio Iacoangeli19, Liverana Lauretti20, Davide Locatelli21, Marco Locatelli22, Davide Luglietto23, Diego Mazzatenta24, Agazio Menniti25, Davide Milani26, Maria Teresa Nasi27, Antonio Romano28, Andrea G. Ruggeri29, Andrea Saladino30, Orazio Santonocito31, Andreas Schwarz32, Miran Skrap33, Roberto Stefini34, Lorenzo Volpin35, Giulio C. Wembagher36, Cesare Zoia17, Gianluigi Zona37, Paolo Cappabianca1
BACKGROUND: Pituitary tumors are a heterogeneous group of lesions that are usually benign. Therefore, a proper understanding of the anatomy, physiology, and pathology is mandatory to achieve favorable outcomes. Accordingly, diagnostic tests and treatment guidelines should be determined and implemented. Thus, we decided to perform a multicenter study among Italian neurosurgical centers performing pituitary surgery to provide an actual depiction from the neurosurgical standpoint.
-
METHODS: On behalf of the SINch (Società Italiana di Neurochirurgia), a survey was undertaken with the participants to explore the activities in the field of pituitary surgery within 41 public institutions.
-
RESULTS: Of the 41 centers, 37 participated in the present study. The total number of neurosurgical procedures
-
Key words - Craniopharyngiomas - Endoscopic endonasal surgery - Multidisciplinary team - Pituitary adenomas - Pituitary/hypothalamus - Pituitary surgery - Transsphenoidal surgery Abbreviations and Acronyms MDT: Multidisciplinary team From the 1Division of Neurosurgery, Università degli Studi di Napoli “Federico II”, Naples; 2 Division of Neurosurgery, Università degli Studi di Torino e Città della Salute e della Scienza, Turin; 3Division of Neurosurgery, Università degli Studi di Messina e Policlinico “G. Martino”, Messina; 4Division of Neurosurgery, AO “SS. Antonio e Biagio e Cesare Arrigo”, Alessandria; 5Division of Neurosurgery, AOU Ospedale Civile di Baggiovara, Modena; 6 Division of Neurosurgery, ASST “Papa Giovanni XXIII”, Bergamo; 7Division of Neurosurgery, IRCCS Istituto Nazionale Tumori “Regina Elena”, Rome; 8Division of Neurosurgery, IRCCS “Casa Sollievo della Sofferenza”, San Giovanni Rotondo; 9Division of Neurosurgery, AO “G. Rummo”, Benevento; 10Division of Neurosurgery, AO “Cannizzaro”, Catania; 11Division of Neurosurgery, IRCCS Neuromed, Pozzilli; 12Division of Neurosurgery, Università degli Studi di Padova, Padua; 13Division of Neurosurgery, AO “G. Brotzu”, Cagliari; 14Division of Neurosurgery (NCH 2), Fondazione IRCCS Istituto Neurologico “Carlo Besta”, Milan; 15 Division of Neurosurgery, Università degli Studi di Brescia e Spedali Civili, Brescia; 16 Division of Neurosurgery, Università degli Studi e Ospedale Civile “S. Salvatore”, L’Aquila; 17 Division of Neurosurgery, Università degli Studi di Pavia e Fondazione IRCCS Policlinico “S. Matteo”, Pavia; 18Division of Neurosurgery, Presidio Ospedaliero “V. Fazzi”, Lecce;
WORLD NEUROSURGERY -: e1-e10, - 2018
performed in 2016 was 1479. Most of the procedures were performed using the transsphenoidal approach (1320 transsphenoidal [1204 endoscopic, 53 microscopic, 53 endoscope-assisted microscopic] vs. 159 transcranial). A multidisciplinary tumor board is convened regularly in 32 of 37 centers, and a research laboratory is present in 18 centers. CONCLUSIONS: Diagnosing pituitary/hypothalamus disorders and treating them is the result of teamwork, composed of several diverse experts. Regarding neurosurgery, our findings have confirmed the central role of the transsphenoidal approach, with preference toward the endoscopic technique. Better outcomes can be expected at centers with a multidisciplinary team and a full, or part of a, residency program, with a greater surgical caseload.
-
Division of Neurosurgery, Università Politecnica delle Marche e Ospedali Riuniti Torrette, Ancona; 20Division of Neurosurgery, Università Cattolica del Sacro Cuore e Policlinico “A. Gemelli”, Rome; 21Division of Neurosurgery, Università degli Studi dell’Insubria, Ospedale di Circolo e Fondazione Macchi, Varese; 22Division of Neurosurgery, Fondazione IRCCS Cà Granda e Ospedale Maggiore e Policlinico, Milan; 23Division of Neurosurgery, AOU Senese “Le Scotte”, Siena; 24Division of Neurosurgery, IRCCS Isituto delle Scienze Neurologiche, Ospedale Bellaria, Bologna; 25Division of Neurosurgery, AO “San Camillo-Forlanini”, Rome; 26 Division of Neurosurgery, Humanitas Research Hospital, Rozzano; 27Division of Neurosurgery, AO “M. Bufalini”, Cesena; 28Division of Neurosurgery, AOU Parma-Reggio Emilia; 29Division of Neurosurgery, Università degli Studi di Roma “La Sapienza”, Rome; 30 Division of Neurosurgery (NCH 1), Fondazione IRCCS Istituto Neurologico “Carlo Besta”, Milan; 31Division of Neurosurgery, Spedali Riuniti di Livorno e USL Toscana Nord-Ovest, Livorno; 32Division of Neurosurgery, Ospedale di Bolzano, Bolzano; 33Division of Neurosurgery, AOU di Udine, Udine; 34Division of Neurosurgery, AO Ospedale Civile di Legnano, Legnano; 35Division of Neurosurgery, Ospedale San Bortolo, Vicenza; 36Division of Neurosurgery, AOU “Careggi”, Firenze; and 37Division of Neurosurgery, Università degli Studi di Genova e Ospedale “San Martino”, Genoa, Italy 19
To whom correspondence should be addressed: Domenico Solari, M.D., Ph.D. [E-mail: [email protected]] Additional contributors listed in the Appendix. Citation: World Neurosurg. (2018). https://doi.org/10.1016/j.wneu.2018.11.186 Journal homepage: www.journals.elsevier.com/world-neurosurgery Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2018 Elsevier Inc. All rights reserved.
www.journals.elsevier.com/world-neurosurgery
e1
ORIGINAL ARTICLE DOMENICO SOLARI ET AL.
A SURVEY ON PITUITARY SURGERY IN ITALY
INTRODUCTION
T
he incidence of hypothalamic/pituitary disorders in Italy has been increasing over the past several years, and it has been reported that 3.9e4.0 of 100,000 new cases are diagnosed annually, with a prevalence of 78e94 of 100,000 people. Pituitary tumors, usually benign, can have unpredictable behavior that can range from indolent, surgically curable disease to rare, highly aggressive cancer.1-3 A proper and thorough understanding of the anatomy and pathophysiology of the hypothalamic/pituitary region is essential for an accurate diagnosis and to define the essential treatment options (i.e., surgery, medical therapy, and radiotherapy, alone or combined).1-9 Different entities should also be considered in the differential diagnosis, which has been well represented in the SATCHMO acronym (sarcoidosis, adenoma/aneurysms, teratomas, craniopharyngiomas/chordomas, hypothalamic gliomas, metastases/ meningiomas, optic gliomas).1-3 Surgery has been the primary treatment chosen for all tumors involving the hypothalamic/pituitary area, except for the prolactinomas10-13 (i.e., acromegaly, Cushing’s disease, thyroid-stimulating hormone-secreting adenomas, resistant prolactinomas, and nonfunctioning pituitary adenomas causing a mass effect). Medical and radiation therapy should be reserved for cases in which surgery is not possible or did not obtain a complete cure.10 Surgical resection has also been recommended as first-line treatment for pituitary apoplexy, parasellar pathologic entities such as craniopharyngioma, chordoma, and Rathke’s cleft cysts, and in rare cases of pituitary cancer. In these latter lesions, a multimodality management strategy is mandatory, as per neurooncology policy. However, when a patient is referred to a primary center showing symptoms of a hypothalamic or pituitary disorder, no consensus has been reached regarding the best management approach, and the chances of a successful outcome have been strongly correlated with the presence of a dedicated team.14-18 The management of each case relies heavily on the decisionmaking process in a multidisciplinary team (MDT), composed of dedicated endocrinologists and experienced pituitary surgeons, assisted by specialists from adjoining branches such as neuropathologists, ear, nose, and throat surgeons, neuroradiologists, radiation oncologists, ophthalmologists, and neurological anesthesiologists. A mutual exchange of expert opinions in such fields can provide the most satisfactory treatment strategy, which should be the most appropriate, in accordance with the scientific community standards. Pituitary apoplexy can be used as an example.19-22 In 2016, the Society for Endocrinology launched a guidance document to provide a paradigm for its management.23 Zoli et al.24 recently reported that endoscopic transsphenoidal surgery, performed by expert neurosurgeons acting within a dedicated pituitary unit, is an effective and safe treatment of this condition. This has confirmed that patients with hypothalamic or pituitary disorders should be referred to dedicated tertiary centers for the most appropriate multidisciplinary management. Thus, it is of utmost importance that reference guidelines should be compiled and implemented by all caregivers. Therefore, a multicenter study was performed to determine the procedures
e2
www.SCIENCEDIRECT.com
used in Italian neurosurgical centers that perform pituitary surgery. The aim of our study was to determine the treatment methods, lines of research, best available treatment options, unmet needs, and requirements to create a national network that could serve as guidance for nontertiary centers in the management of hypothalamic/pituitary disease. METHODS On behalf of SINch (Società Italiana di Neurochirurgia), a survey was conducted to explore the activities in the field of pituitary surgery in 2016, within 41 public institutions well-renowned for having been constantly involved in this field from the clinical and scientific perspectives. Overall, the surgical procedures performed in 2016 for the treatment of hypothalamic/pituitary tumors (i.e., pituitary adenomas, craniopharyngiomas, Rathke’s cleft cysts, chordomas) were investigated. Although chordomas should not be considered among the hypothalamic/pituitary diseases, we included data concerning these lesions in the survey for 2 main reasons. First, in 1971, Hardy25 recognized these tumors were amenable to transsphenoidal surgery according to their growth pattern and inner features. Second, we have noted a certain enthusiasm in considering the transsphenoidal approach as a viable surgical option for treating chordomas, when these lesions are extradural and have a prevalent midline extension.26-35 Data were extracted from the Italian registry of disease according to the International Classification of Diseases, Clinical Modification, 10th edition, codes for diagnosis and DiagnosisRelated Group procedures. The number of procedures performed using a transcranial approach or transsphenoidal approach was then retrieved for each tumor group. The senior surgeons were asked to state whether they had adopted microscopic, endoscopic, or endoscope-assisted techniques. The presence of a dedicated MDT and facilities with a research laboratory on site were recorded. The scientific strength and research activities at each center according to specific parameters, such as the number of relevant studies reported and the number of research grants obtained in the previous 5 years, were evaluated. We also recorded whether the center was a university hospital, whether a neurosurgery residency program was present, and whether dedicated staff had been involved as faculty members at pertinent workshops (>5 in 2016). After data collection and analysis, the respondents met to discuss and establish the present report. We decided to not analyze the data from single institutions but, rather, to present the overall national volumes for each of the variables we considered. It was not the purpose of our study to discuss the strength of the single units and/or to measure the clinical parameters of each procedure (i.e., the extent of resection, visual outcomes, complications). RESULTS Of the 41 centers, 37 were enrolled in the present study; 4 of the invitees did not respond (Table 1). Of the 37 included centers, 15 were university hospitals running a full neurosurgery residency program, 10 were community hospitals providing part of a
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2018.11.186
ORIGINAL ARTICLE DOMENICO SOLARI ET AL.
A SURVEY ON PITUITARY SURGERY IN ITALY
Table 1. Italian Public Institutions Invited to Participate in the Survey on Pituitary Surgery Center
Response
Residency Program
Multidisciplinary Team
Università degli Studi di Messina e Policlinico “G. Martino”
Yes
Full
Yes
AOU Ospedale Civile di Baggiovara e Modena
Yes
Adjunct
Yes
ASST “Papa Giovanni XXIII” e Bergamo
Yes
Adjunct
Yes
IRCCS Istituto Nazionale Tumori “Regina Elena” e Roma
Yes
Adjunct
Yes
Università degli Studi di Verona, Ospedale Maggiore di Borgo Trento e Verona
No
Full
Not available
Università degli Studi di Napoli “Federico II”
Yes
Full
Yes
AO “Cannizzaro” e Catania
Yes
No
Yes
AO “G. Rummo” e Benevento
Yes
Adjunct
Yes
AO “San Camillo-Forlanini” e Rome
Yes
No
Yes
Università degli Studi di Padova
Yes
Full
Yes
IRCCS Neuromed (NCH 1) e Pozzilli
Yes
Adjunct
Yes
Fondazione IRCCS Istituto Neurologico “Carlo Besta” (NCH 1) e Milano
Yes
Adjunct
No
Fondazione IRCCS Istituto Neurologico “Carlo Besta” (NCH 2) e Milan
Yes
Adjunct
Yes
Università degli Studi di Brescia, Spedali Civili
Yes
Full
Yes
Università degli Studi, Ospedale Civile “S. Salvatore” e L’Aquila
Yes
Full
Yes
Presidio Ospedaliero “V. Fazzi” e Lecce
Yes
No
No
Università Politecnica delle Marche, Ospedali Riuniti Torrette e Ancona
Yes
Full
Yes
Humanitas Research Hospital e Rozzano
Yes
Full
Yes
Fondazione IRCCS “Cà Granda,” Ospedale Maggiore, Policlinico e Milan
Yes
Full
Yes
Università degli Studi dell’Insubria, Ospedale di Circolo e Fondazione Macchi e Varese
Yes
Full
Yes
IRCCS Isituto delle Scienze Neurologiche, Ospedale Bellaria e Bologna
Yes
No
Yes
AO “M. Bufalini” e Cesena
Yes
Full
Yes
Università Cattolica del Sacro Cuore, Policlinico “A Gemelli” e Rome
Yes
Full
Yes
AOU Parma-Reggio Emilia
Yes
No
Yes
Università degli Studi di Roma “La Sapienza” e Rome
Yes
Full
Yes
Ospedale di Bolzano
Yes
No
Yes
AOU di Udine
Yes
No
Yes
AO Ospedale Civile di Legnano
Yes
No
No
Università Vita-Salute “San Raffaele” e Milan
No
Full
Not available
Ospedale San Bortolo e Vicenza
Yes
Adjunct
Yes
Università degli Studi di Torino, Città della Salute e della Scienza
Yes
Full
Yes
Fondazione IRCCS Policlinico “S. Matteo” e Pavia
Yes
Full
Yes
Università degli Studi di Genova e Ospedale “San Martino”
Yes
Adjunct
Yes
AO “G. Brotzu” e Cagliari
Yes
Adjunct
Yes
AO “SS. Antonio e Biagio e Cesare Arrigo” e Alessandria
Yes
No
Yes
Università degli Studi di Roma “Tor Vergata”
No
Full
Not available
AOU “Careggi” e Firenze
Yes
Full
No
IRCCS “Casa Sollievo della Sofferenza” San Giovanni Rotondo
Yes
Adjunct
Yes
AOU Senese “Le Scotte” e Siena
Yes
Full
No
Spedali Riuniti di Livorno e USL Toscana Nord-Ovest
Yes
No
Yes
Ospedale di Pisa
No
Adjunct
No
WORLD NEUROSURGERY -: e1-e10, - 2018
www.journals.elsevier.com/world-neurosurgery
e3
ORIGINAL ARTICLE DOMENICO SOLARI ET AL.
A SURVEY ON PITUITARY SURGERY IN ITALY
neurosurgery residency program for adjacent area universities, and 12 were nonteaching hospitals. We recorded a total of 1479 neurosurgical procedures for hypothalamic/pituitary tumors in 2016. Of these, 1203 were for pituitary adenomas, 135 for craniopharyngiomas, 68 for Rathke cleft cysts, and 73 for chordomas. Most of the procedures were performed via the transsphenoidal approach (1320 transsphenoidal vs. 159 transcranial), and most of the centers had adopted the endoscopic endonasal technique (Figure 1). All the centers had a dedicated neuropathologist and neuroradiologist. However, radiotherapy service was not available in 3 centers, and no endocrinology service was available in 2 centers. Accordingly, a multidisciplinary tumor board was convened regularly in 32 of 37 centers (Table 1). The total number of studies reported on this topic from 2012 to 2016 was 474. Of the 37 centers, 15 did not report any study, and 10 institutions had reported <10 studies within the study period. Fourteen centers, all university or teaching hospitals, had obtained 45 grants to support their research projects. A research laboratory was present in 18 centers. Finally, only 16 teams were involved as tutors or faculty members in 5 courses or congresses in 2016 (Figure 2). DISCUSSION The multifaceted aspect of hypothalamic-pituitary disorders implies a variety of treatments that should be considered and properly tailored to each case. Through the years, the understanding of the clinical epiphenomena of these diseases, especially in terms of cellular and molecular biology, has tremendously expanded, along with the possibilities of creating more innovative and refined treatment strategies. However, a consensus has not yet been reached regarding the optimal management in clinical situations, especially at primary centers. Recent reports have established the need for hospitals to be considered a pituitary center of excellence and which primary missions should be completed.17,18 The focus in the clinical environment has been on the core duo of practitioners, the endocrinologist and the pituitary neurosurgeon, which are at the heart of a dedicated MDT. The achievement of optimal results can be compared to a precise clock, in which each part is working simultaneously to achieve a common goal, such as a pituitary team working to determine the most appropriate treatment. A vital component is the presence of an experienced neurosurgeon capable of performing pituitary surgery safely and effectively. Moreover, the neurosurgeon should have knowledge of the hypothalamic-pituitary organ physiology principles and solid training in basic neurosurgery. The association between hospital volume and operative mortality has been largely mediated by surgeon volume for many procedures. That is, patients will have better chances of survival when treated by surgeons who perform that procedure frequently.36,37 This idea can be applied to pituitary surgery, with surgeons usually starting their learning curve treating relatively common nonfunctioning pituitary adenomas, acquiring confidence with the anatomy and technique. Next, they should treat functioning adenomas, for which the goal is to cure and preserve pituitary function, such as surgery for Cushing’s disease and acromegaly. The final challenge is the treatment of
e4
www.SCIENCEDIRECT.com
more complex diseases such as intradural diseases, craniopharyngioma, and/or other parasellar skull base lesions.38-40 Resection of 50 adenomas annually could represent the optimal number to provide neurosurgeons with sufficient surgical experience.18 This could improve the surgeons’ abilities in patient selection and operative techniques with a lower risk of complications. This can lead to better outcomes, even when treating pathologic entities other than adenomas.17,37,41-44 This so-called experienceeoutcome effect allows for the development of a virtuoso circuit. In addition to increasing experience, better outcomes will be achieved. The knowledge gained increases the options for treatment strategies and the indications can be refined; thus, the volume of activity will be expanded.17,18,41 The results of our series have confirmed this trend. The vast majority of Italian centers with a consolidated pituitary unit performed a sufficient number of procedures. In terms of variety, we found that the greater experience with surgery of pituitary adenomas allowed for enrollment of a larger number of patients with complex diseases. Thus, it is advisable to have difficult cases referred to those centers at which high-quality care can be provided (i.e., tertiary care centers with a MDT and larger caseload). In addition, such as occurred in the healthcare system in Emilia-Romagna for neurotrauma and stroke, applying the so-called hub and spoke paradigm to pituitary surgery could be a viable option. For these reasons, it is of utmost importance to define virtuoso strategies and the best available strategies within a national network to provide guidelines for the proper and tailored treatment of patients. Thus, small primary centers could take advantage of discussions within an “expanded” MDT regarding the most suitable strategies and whether it would be possible to treat the patients admitted to that center. The present analysis showed that the vast majority of procedures (in all centers but 2) were performed using a transsphenoidal approach, a statistically significant difference (1320 vs. 159; P < 0.001, Student’s t test). This was in accordance with data reporting the use of a transsphenoidal approach for >95% of the surgical procedures to the sellar area,11-13,45,46 with an increase in the extent of resection and a decrease in the morbidity rates and length of stay.47-51 The number of transcranial procedures overall we recorded reached w10% and was used for almost 8% of adenomas and 38% of craniopharyngiomas. This could have been mostly related to surgeon experience and/or a preference in the treatment of lesions with an eccentric growth pattern, expanding outside the sella. Nevertheless, it might be possible that those procedures were performed transcranially in an attempt to contain the risk of postoperative cerebrospinal fluid leakage related to extended approaches. In such situations, it is not surprising that most of the Italian centers (32 of 37) had adopted the endoscopic endonasal technique (1204 endoscopic, 53 microscopic, and 53 endoscope-assisted microscopic) for the transsphenoidal procedures. This choice also depends on the patient’s attitude. Most patients will be more willing to undergo surgical intervention via an endoscopic endonasal technique after a pituitary tumor has been diagnosed.8 The introduction of the endoscopic technique has confirmed the effectiveness of the transsphenoidal route, providing further advantages in terms of visualization, including a superior
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2018.11.186
ORIGINAL ARTICLE DOMENICO SOLARI ET AL.
Figure 1. Graph showing the caseload of pituitary surgeries in 2016 at 37 Italian centers of the present study (37 of 41 responded to the survey). The colored bars (blue, transcranial approach; red, transsphenoidal endoscopic approach; green, transsphenoidal endoscopic-assisted microscopic
panoramic and close-up view of the relevant anatomy, which is very important at the tumoregland interface, and an enlarged working angle.14,47,48,52-65 It has been proved that this technique results in similar resection rates with less risk of surgical and clinical complications.63,66-70 The endoscopic technique has favored the adoption of an endonasal corridor for treating different pathologic entities of the median and paramedian skull base.71-80 Recent clinical studies81-83 have reported that endoscopic resection provides a safe and compelling alternative to transcranial surgery for craniopharyngiomas. Endoscopic resection provides good results in terms of the extent of removal and visual outcomes, with a limited risk of complications, in particular, the risk of postoperative cerebrospinal fluid leakage.84-95 The use of widespread endoscopic surgery has increased, based on the peer-reviewed data on the topic in the past 10 years. The use of endoscopic surgery also resulted in interdisciplinary cooperation and renewal of the positive interaction between
WORLD NEUROSURGERY -: e1-e10, - 2018
A SURVEY ON PITUITARY SURGERY IN ITALY
approach; violet, transsphenoidal microscopic approach; light blue, total number of procedures per tumor) represent the surgical technique chosen to treat the pathology.
scientific medical innovations and technological industries. Neuronavigation systems, high-definition, 3-dimensional, or 4K endoscopes, robotic devices, and thrombin foam hemostatic agents, are only few of the most representative tools that have been developed to provide safer, more precise, and specialized surgery.55,96-105 Our data have shown that the volume of research and development are greater at university hospitals, where it is easier to build a strong expertise team. These teams also are more often recipients for research funding and promoting contributions to the scientific data, with more reports in the previous 5 years (university centers, 278 studies; community teaching hospitals, 100 reports; and nonteaching hospitals, 96 reports; P ¼ 0.008, Mann-Whitney U test). This significant difference reflects the boost in the contribution added by the younger colleagues; their learning commitment results in a viable and relentless engine for ideas and innovations, which results in further work and better allocation of competencies and effectiveness.
www.journals.elsevier.com/world-neurosurgery
e5
ORIGINAL ARTICLE DOMENICO SOLARI ET AL.
A SURVEY ON PITUITARY SURGERY IN ITALY
Figure 2. Graph showing the research and scientific activity at 37 Italian centers of the present study (37 of 41 responded to the survey). The colored bars represent the overall volume of the activity stratified by
The education of young neurosurgeons in the field of pituitary/ hypothalamus disease treatment stands crucial. University hospitals must train future pituitary surgeons with refined surgical skills but also provide them with the most recent and appropriate information.1,106-109 Therefore, it is essential to teach to younger colleagues the concept of “teamwork” so they can better treat patients with hypothalamic/pituitary disease.17,18,54 Hence, dedicated training—at the least, fellowships—in a specialized tertiary center would definitely shorten the learning curve. The statistical data have shown that the adoption of common strategies is the next step in improving the standard of care and the quality of scientific data.
category of Italian institutions (blue, university center; green, teaching hospital; red, community hospital).
their knowledge, remembering working as a team is equally important as considering the anatomy, pathophysiology, and the natural history of pituitary disease in detail and performing neuroimaging studies. Better outcomes can be expected within high-volume centers with MDTs and running a residency program. Finally, it is worth remembering that surgical techniques or instruments should not be considered a “magic wand.” Although more studies are required to determine the best approach to treating hypothalamic/pituitary diseases, the greatest point from the present survey is to remind all medical professionals to continue to exchange ideas and knowledge to allow the community to continue to look further and beyond, to the next level of a cure.
CONCLUSIONS Although guidelines have not yet been established, a wide variety of techniques and treatments are available. Most Italian centers understand that the best management of hypothalamic/pituitary disorders will result from teamwork and should take advantage of the extraordinary ongoing advancements. In Italy, neurosurgeons who would like to focus their activities in this field should expand
e6
www.SCIENCEDIRECT.com
ACKNOWLEDGMENTS Paolo Cappabianca, Luigi Maria Cavallo, and Domenico Solari, among other authors, would like to once again show their profound appreciation to Professor Enrico de Divitiis for mentoring and teaching as pioneer and leader of transsphenoidal surgery at the School of Naples.
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2018.11.186
ORIGINAL ARTICLE DOMENICO SOLARI ET AL.
REFERENCES 1. Asa SL, Mete O. What’s new in pituitary pathology? Histopathology. 2018;72:133-141. 2. Daly AF, Rixhon M, Adam C, Dempegioti A, Tichomirowa MA, Beckers A. High prevalence of pituitary adenomas: a cross-sectional study in the province of Liege, Belgium. J Clin Endocrinol Metab. 2006;91:4769-4775. 3. Fernandez A, Karavitaki N, Wass JA. Prevalence of pituitary adenomas: a community-based, cross-sectional study in Banbury (Oxfordshire, UK). Clin Endocrinol (Oxf). 2010;72:377-382. 4. Clayton RN. Sporadic pituitary tumours: from epidemiology to use of databases. Baillieres Best Pract Res Clin Endocrinol Metab. 1999;13:451-460. 5. Daly AF, Petrossians P, Beckers A. An overview of the epidemiology and genetics of acromegaly. J Endocrinol Invest. 2005;28(11 suppl international): 67-69. 6. Ezzat S, Asa SL, Couldwell WT, et al. The prevalence of pituitary adenomas: a systematic review. Cancer. 2004;101:613-619. 7. Golden SH, Robinson KA, Saldanha I, Anton B, Ladenson PW. Clinical review: prevalence and incidence of endocrine and metabolic disorders in the United States: a comprehensive review. J Clin Endocrinol Metab. 2009;94:1853-1878.
A SURVEY ON PITUITARY SURGERY IN ITALY
18. Casanueva FF, Barkan AL, Buchfelder M, et al. Criteria for the definition of pituitary tumor centers of excellence (PTCOE): a pituitary society statement. Pituitary. 2017;20:489-498. 19. Semple PL, Webb MK, de Villiers JC, Laws ER Jr. Pituitary apoplexy. Neurosurgery. 2005;56:65-72 [discussion: 72-73]. 20. Semple PL, Jane JA Jr, Laws ER Jr. Clinical relevance of precipitating factors in pituitary apoplexy. Neurosurgery. 2007;61:956-961 [discussion: 961-962]. 21. Semple PL, Jane JA, Lopes MB, Laws ER. Pituitary apoplexy: correlation between magnetic resonance imaging and histopathological results. J Neurosurg. 2008;108:909-915. 22. Capatina C, Inder W, Karavitaki N, Wass JA. Management of endocrine disease: pituitary tumour apoplexy. Eur J Endocrinol. 2015;172: R179-R190. 23. Baldeweg SE, Vanderpump M, Drake W, et al. Society for Endocrinology endocrine emergency guidance: emergency management of pituitary apoplexy in adult patients. Endocr Connect. 2016;5: G12-G15. 24. Zoli M, Milanese L, Faustini-Fustini M, et al. Endoscopic endonasal surgery for pituitary apoplexy: evidence on a 75-case series from a tertiary care center. World Neurosurg. 2017;106: 331-338.
8. Villwock JA, Villwock M, Deshaies E, Goyal P. Significant increases of pituitary tumors and resections from 1993 to 2011. Int Forum Allergy Rhinol. 2014;4:767-770.
25. Hardy J. Transsphenoidal J Neurosurg. 1971;34:582-594.
9. Yildirim AE, Divanlioglu D, Nacar OA, et al. Incidence, hormonal distribution and postoperative follow up of atypical pituitary adenomas. Turk Neurosurg. 2013;23:226-231.
26. Fraser JF, Nyquist GG, Moore N, Anand VK, Schwartz TH. Endoscopic endonasal transclival resection of chordomas: operative technique, clinical outcome, and review of the literature. J Neurosurg. 2010;112:1061-1069.
10. Molitch ME. Diagnosis and treatment of pituitary adenomas: a review. JAMA. 2017;317:516-524. 11. Jane JA Jr, Thapar K, Kaptain GJ, Maartens N, Laws ER Jr. Pituitary surgery: transsphenoidal approach. Neurosurgery. 2002;51:435-442 [discussion: 442-444]. 12. Laws ER, Jane JA Jr. Pituitary tumors—long-term outcomes and expectations. Clin Neurosurg. 2001; 48:306-319. 13. Laws ER, Lanzino G, eds. Transsphenoidal Surgery. Philadelphia: Saunders-Elsevier; 2010. 14. Solari D, Cavallo LM, Cappabianca P. Surgical approach to pituitary tumors. Handbk Clin Neurol. 2014;124:291-301. 15. Laws ER Jr, Thapar K. Pituitary surgery. Endocrinol Metab Clin North Am. 1999;28:119-131. 16. Thapar K, Laws ERJ. Pituitary tumors. In: Kaye Jr AW, Laws ER, eds. Brain Tumors. London: Churchill Livingstone; 2001:804-854. 17. McLaughlin N, Laws ER, Oyesiku NM, Katznelson L, Kelly DF. Pituitary centers of excellence. Neurosurgery. 2012;71:916-924 [discussion: 924-926].
hypophysectomy.
27. Laws E. Clivus chordomas. In: Sekhar LN, Janecka IP, eds. Surgery of Cranial Base Tumors. New York: Raven Press; 1993:679-685. 28. Maira G, Pallini R, Anile C, et al. Surgical treatment of clival chordomas: the transsphenoidal approach revisited. J Neurosurg. 1996; 85:784-792. 29. al-Mefty O, Borba LA. Skull base chordomas: a management challenge. J Neurosurg. 1997;86: 182-189. 30. Frank G, Sciarretta V, Calbucci F, Farneti G, Mazzatenta D, Pasquini E. The endoscopic transnasal transsphenoidal approach for the treatment of cranial base chordomas and chondrosarcomas. Neurosurgery. 2006;59(suppl 1): ONS50-ONS57 [discussion: ONS50-ONS57]. 31. Samii A, Gerganov VM, Herold C, et al. Chordomas of the skull base: surgical management and outcome. J Neurosurg. 2007;107:319-324. 32. Stippler M, Gardner PA, Snyderman CH, Carrau RL, Prevedello DM, Kassam AB. Endoscopic endonasal approach for clival chordomas. Neurosurgery. 2009;64:268-277 [discussion: 277-278].
WORLD NEUROSURGERY -: e1-e10, - 2018
33. Komotar RJ, Starke RM, Raper DM, Anand VK, Schwartz TH. The endoscope-assisted ventral approach compared with open microscopeassisted surgery for clival chordomas. World Neurosurg. 2011;76:318-327 [discussion: 259-362]. 34. Koutourousiou M, Gardner PA, Tormenti MJ, et al. Endoscopic endonasal approach for resection of cranial base chordomas: outcomes and learning curve. Neurosurgery. 2012;71:614-624 [discussion: 624-625]. 35. Chibbaro S, Cornelius JF, Froelich S, et al. Endoscopic endonasal approach in the management of skull base chordomas—clinical experience on a large series, technique, outcome, and pitfalls. Neurosurg Rev. 2014;37:217-224 [discussion: 224-225]. 36. Birkmeyer JD, Stukel TA, Siewers AE, Goodney PP, Wennberg DE, Lucas FL. Surgeon volume and operative mortality in the United States. N Engl J Med. 2003;349:2117-2127. 37. 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. 1997;40: 225-236 [discussion: 236-237]. 38. Liu JK, Das K, Weiss MH, Laws ER Jr, Couldwell WT. The history and evolution of transsphenoidal surgery. J Neurosurg. 2001;95: 1083-1096. 39. Snyderman C, Kassam A, Carrau R, Mintz A, Gardner P, Prevedello DM. Acquisition of surgical skills for endonasal skull base surgery: a training program. Laryngoscope. 2007;117:699-705. 40. Wang YY, Higham C, Kearney T, Davis JR, Trainer P, Gnanalingham KK. Acromegaly surgery in Manchester revisited—the impact of reducing surgeon numbers and the 2010 consensus guidelines for disease remission. Clin Endocrinol (Oxf). 2012;76:399-406. 41. Shahlaie K, McLaughlin N, Kassam AB, Kelly DF. The role of outcomes data for assessing the expertise of a pituitary surgeon. Curr Opin Endocrinol Diabetes Obes. 2010;17:369-376. 42. Dusick JR, Esposito F, Kelly DF, et al. The extended direct endonasal transsphenoidal approach for nonadenomatous suprasellar tumors. J Neurosurg. 2005;102:832-841. 43. Zada G, Kelly DF, Cohan P, Wang C, Swerdloff R. Endonasal transsphenoidal approach for pituitary adenomas and other sellar lesions: an assessment of efficacy, safety, and patient impressions. J Neurosurg. 2003;98:350-358. 44. Zada G, Du R, Laws ER Jr. Defining the "edge of the envelope": patient selection in treating complex sellar-based neoplasms via transsphenoidal versus open craniotomy. J Neurosurg. 2011;114:286-300. 45. Pratheesh R, Rajaratnam S, Prabhu K, Mani SE, Chacko G, Chacko AG. The current role of transcranial surgery in the management of pituitary adenomas. Pituitary. 2013;16:419-434. 46. O’Malley BW Jr, Grady MS, Gabel BC, et al. Comparison of endoscopic and microscopic
www.journals.elsevier.com/world-neurosurgery
e7
ORIGINAL ARTICLE DOMENICO SOLARI ET AL.
removal of pituitary adenomas: single-surgeon experience and the learning curve. Neurosurg Focus. 2008;25:E10. 47. McLaughlin N, Eisenberg AA, Cohan P, Chaloner CB, Kelly DF. Value of endoscopy for maximizing tumor removal in endonasal transsphenoidal pituitary adenoma surgery. J Neurosurg. 2013;118:613-620. 48. Cappabianca P, Cavallo LM, de Divitiis O, Solari D, Esposito F, Colao A. Endoscopic pituitary surgery. Pituitary. 2008;11:385-390. 49. Tabaee A, Anand VK, Barron Y, et al. Endoscopic pituitary surgery: a systematic review and metaanalysis. J Neurosurg. 2009;111:545-554. 50. Cappabianca P, Cavallo LM, de Divitiis O, Esposito F. Pituitary surgery. In: DeGroot LJ, Jameson JL, eds. Endocrinology. 6th ed. Philadelphia, PA: Saunders-Elsevier; 2010:358-376. 51. Kassam AB, Prevedello DM, Carrau RL, et al. Endoscopic endonasal skull base surgery: analysis of complications in the authors’ initial 800 patients. J Neurosurg. 2011;114:1544-1568. 52. Spencer WR, Das K, Nwagu C, et al. Approaches to the sellar and parasellar region: anatomic comparison of the microscope versus endoscope. Laryngoscope. 1999;109:791-794. 53. de Divitiis E. Endoscopic transsphenoidal surgery: stone-in-the-pond effect. Neurosurgery. 2006;59:512-520. 54. Cappabianca P, de Divitiis E. Endoscopy and transsphenoidal surgery. Neurosurgery. 2004;54: 1043-1048 [discussion: 1048-1050]. 55. Cappabianca P, Decq P, Schroeder HW. Future of endoscopy in neurosurgery. Surg Neurol. 2007;67: 496-498. 56. Cappabianca P, Cavallo LM, Esposito F, de Divitiis O, Messina A, de Divitiis E. Extended endoscopic endonasal approach to the midline skull base: the evolving role of transsphenoidal surgery. In: Pickard JD, Akalan N, Di Rocco C, et al., eds. Advances and Technical Standards in Neurosurgery. New York, NY: Springer-Verlag Wien; 2008:152-199. 57. Cappabianca P, Cavallo LM, Solari D, Stagno V, Esposito F, de Angelis M. Endoscopic endonasal surgery for pituitary adenomas. World Neurosurg. 2014;82(suppl):S3-S11. 58. de Notaris M, Prats-Galino A, Ensenat J, et al. Quantitative analysis of progressive removal of nasal structures during endoscopic suprasellar approach. Laryngoscope. 2014;124:2231-2237. 59. Benveniste RJ, King WA, Walsh J, Lee JS, Delman BN, Post KD. Repeated transsphenoidal surgery to treat recurrent or residual pituitary adenoma. J Neurosurg. 2005;102:1004-1012. 60. Rudnik A, Zawadzki T, Galuszka-Ignasiak B, et al. Endoscopic transsphenoidal treatment in recurrent and residual pituitary adenomas—first experience. Minim Invasive Neurosurg. 2006;49: 10-14.
e8
www.SCIENCEDIRECT.com
A SURVEY ON PITUITARY SURGERY IN ITALY
61. Chang EF, Sughrue ME, Zada G, Wilson CB, Blevins LS Jr, Kunwar S. Long term outcome following repeat transsphenoidal surgery for recurrent endocrine-inactive pituitary adenomas. Pituitary. 2010;13:223-229. 62. Cavallo LM, Solari D, Tasiou A, et al. Endoscopic endonasal transsphenoidal removal of recurrent and regrowing pituitary adenomas: experience on a 59-patient series. World Neurosurg. 2013;80: 342-350. 63. Cappabianca P, Cavallo LM, Solari D, de Divitiis O, Chiaramonte C, Esposito F. Size does not matter: the intrigue of giant adenomas: a true surgical challenge. Acta Neurochir (Wien). 2014;156:2217-2220. 64. Gondim JA, Almeida JP, Albuquerque LA, Gomes EF, Schops M. Giant pituitary adenomas: surgical outcomes of 50 cases operated on by the endonasal endoscopic approach. World Neurosurg. 2014;82:e281-e290. 65. Cappabianca P, Cavallo LM, Colao A, de Divitiis E. Surgical complications associated with the endoscopic endonasal transsphenoidal approach for pituitary adenomas. J Neurosurg. 2002;97:293-298.
74. Kassam AB, Gardner P, Snyderman C, Mintz A, Carrau R. Expanded endonasal approach: fully endoscopic, completely transnasal approach to the middle third of the clivus, petrous bone, middle cranial fossa, and infratemporal fossa. Neurosurg Focus. 2005;19:E6. 75. Kassam A, Thomas AJ, Snyderman C, et al. Fully endoscopic expanded endonasal approach treating skull base lesions in pediatric patients. J Neurosurg. 2007;106(suppl):75-86. 76. Prevedello DM, Thomas A, Gardner P, Snyderman CH, Carrau RL, Kassam AB. Endoscopic endonasal resection of a synchronous pituitary adenoma and a tuberculum sellae meningioma: technical case report. Neurosurgery. 2007;60(suppl 2):E401 [discussion: E401]. 77. Gardner PA, Kassam AB, Thomas A, et al. Endoscopic endonasal resection of anterior cranial base meningiomas. Neurosurgery. 2008;63: 36-52 [discussion: 52-54]. 78. Gardner PA, Prevedello DM, Kassam AB, Snyderman CH, Carrau RL, Mintz AH. The evolution of the endonasal approach for craniopharyngiomas. J Neurosurg. 2008;108:1043-1047.
66. Bander ED, Singh H, Ogilvie CB, et al. Endoscopic endonasal versus transcranial approach to tuberculum sellae and planum sphenoidale meningiomas in a similar cohort of patients. J Neurosurg. 2018;128:40-48.
79. Kassam AB, Prevedello DM, Carrau RL, et al. The front door to meckel’s cave: an anteromedial corridor via expanded endoscopic endonasal approach—technical considerations and clinical series. Neurosurgery. 2009;64(suppl):71-82 [discussion: 82-83].
67. Komotar RJ, Starke RM, Raper DM, Anand VK, Schwartz TH. Endoscopic endonasal compared with microscopic transsphenoidal and open transcranial resection of giant pituitary adenomas. Pituitary. 2012;15:150-159.
80. Laufer I, Anand VK, Schwartz TH. Endoscopic, endonasal extended transsphenoidal, transplanum transtuberculum approach for resection of suprasellar lesions. J Neurosurg. 2007;106: 400-406.
68. Koutourousiou M, Gardner PA, FernandezMiranda JC, Paluzzi A, Wang EW, Snyderman CH. Endoscopic endonasal surgery for giant pituitary adenomas: advantages and limitations. J Neurosurg. 2013;118:621-631.
81. Wannemuehler TJ, Rubel KE, Hendricks BK, et al. Outcomes in transcranial microsurgery versus extended endoscopic endonasal approach for primary resection of adult craniopharyngiomas. Neurosurg Focus. 2016;41:E6.
69. Wang S, Li D, Ni M, et al. Clinical predictors of diabetes insipidus after transcranial surgery for pituitary adenoma. World Neurosurg. 2017; 101:1-10.
82. Moussazadeh N, Prabhu V, Bander ED, et al. Endoscopic endonasal versus open transcranial resection of craniopharyngiomas: a casematched single-institution analysis. Neurosurg Focus. 2016;41:E7.
70. de Divitiis E, Cappabianca P, Cavallo LM. Endoscopic transsphenoidal approach: adaptability of the procedure to different sellar lesions. Neurosurgery. 2002;51:699-705 [discussion: 705-707]. 71. de Divitiis E, Cavallo LM, Cappabianca P, Esposito F. Extended endoscopic endonasal transsphenoidal approach for the removal of suprasellar tumors: part 2. Neurosurgery. 2007;60: 46-58 [discussion: 58-59]. 72. Kassam A, Snyderman CH, Mintz A, Gardner P, Carrau RL. Expanded endonasal approach: the rostrocaudal axis. Part II. Posterior clinoids to the foramen magnum. Neurosurg Focus. 2005;19:E4. 73. Kassam A, Snyderman CH, Mintz A, Gardner P, Carrau RL. Expanded endonasal approach: the rostrocaudal axis. Part I. Crista galli to the sella turcica. Neurosurg Focus. 2005;19:E3.
83. Jeswani S, Nuno M, Wu A, et al. Comparative analysis of outcomes following craniotomy and expanded endoscopic endonasal transsphenoidal resection of craniopharyngioma and related tumors: a single-institution study. J Neurosurg. 2016;124:627-638. 84. Barajas MA, Ramirez-Guzman G, RodriguezVazquez C, et al. Multimodal management of craniopharyngiomas: neuroendoscopy, microsurgery, and radiosurgery. J Neurosurg. 2002; 97(suppl):607-609. 85. Frank G, Pasquini E, Doglietto F, et al. The endoscopic extended transsphenoidal approach for craniopharyngiomas. Neurosurgery. 2006; 59(suppl 1):ONS75-ONS83. 86. de Divitiis E, Cappabianca P, Cavallo LM, Esposito F, de Divitiis O, Messina A. Extended endoscopic transsphenoidal approach for
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2018.11.186
ORIGINAL ARTICLE DOMENICO SOLARI ET AL.
extrasellar craniopharyngiomas. Neurosurgery. 2007;61(suppl 2):219-227 [discussion: 228]. 87. Gardner PA, Kassam AB, Snyderman CH, et al. Outcomes following endoscopic, expanded endonasal resection of suprasellar craniopharyngiomas: a case series. J Neurosurg. 2008;109: 6-16. 88. Cavallo LM, Prevedello DM, Solari D, et al. Extended endoscopic endonasal transsphenoidal approach for residual or recurrent craniopharyngiomas. J Neurosurg. 2009;111:578-589. 89. Komotar RJ, Starke RM, Raper DM, Anand VK, Schwartz TH. Endoscopic endonasal compared with microscopic transsphenoidal and open transcranial resection of craniopharyngiomas. World Neurosurg. 2012;77:329-341. 90. Leng LZ, Greenfield JP, Souweidane MM, Anand VK, Schwartz TH. Endoscopic, endonasal resection of craniopharyngiomas: analysis of outcome including extent of resection, cerebrospinal fluid leak, return to preoperative productivity, and body mass index. Neurosurgery. 2012; 70:110-123 [discussion: 123-124]. 91. Prevedello DM, Solari D, Carrau RL, Gardner P, Kassam AB. Endoscopic endonasal approach for craniopharyngiomas. In: Quinones-Hinojosa A, ed. Schmideck & Sweet Operative Neurosurgical Techniques: Indications, Methods, and Results. 6th ed. 1. Philadelphia: Elsevier Saunders; 2012:303-310. 92. Cavallo LM, Solari D, Esposito F, Cappabianca P. The endoscopic endonasal approach for the management of craniopharyngiomas involving the third ventricle. Neurosurg Rev. 2013;36:27-37 [discussion: 38]. 93. Koutourousiou M, Gardner PA, FernandezMiranda JC, Tyler-Kabara EC, Wang EW, Snyderman CH. Endoscopic endonasal surgery for craniopharyngiomas: surgical outcome in 64 patients. J Neurosurg. 2013;119:1194-1207. 94. Cavallo LM, Frank G, Cappabianca P, et al. The endoscopic endonasal approach for the management of craniopharyngiomas: a series of 103 patients. J Neurosurg. 2014;121:100-113.
A SURVEY ON PITUITARY SURGERY IN ITALY
95. Dhandapani S, Singh H, Negm HM, et al. Endonasal endoscopic reoperation for residual or recurrent craniopharyngiomas. J Neurosurg. 2017; 126:418-430. 96. Fraser JF, Allen B, Anand VK, Schwartz TH. Three-dimensional neurostereoendoscopy: subjective and objective comparison to 2D. Minim Invasive Neurosurg. 2009;52:25-31. 97. Kari E, Oyesiku NM, Dadashev V, Wise SK. Comparison of traditional 2-dimensional endoscopic pituitary surgery with new 3-dimensional endoscopic technology: intraoperative and early postoperative factors. Int Forum Allergy Rhinol. 2012;2:2-8. 98. Barkhoudarian G, Del Carmen Becerra Romero A, Laws ER. Evaluation of the 3dimensional endoscope in transsphenoidal surgery. Neurosurgery. 2013;73(1 suppl operative): ons74-ons78 [discussion: ons78-ons79]. 99. O’Malley BW Jr, Weinstein GS. Robotic skull base surgery: preclinical investigations to human clinical application. Arch Otolaryngol Head Neck Surg. 2007;133:1215-1219. 100. O’Malley BW Jr, Weinstein GS. Robotic anterior and midline skull base surgery: preclinical investigations. Int J Radiat Oncol Biol Phys. 2007; 69(suppl):S125-S128. 101. Trevillot V, Garrel R, Dombre E, Poignet P, Sobral R, Crampette L. Robotic endoscopic sinus and skull base surgery: review of the literature and future prospects. Eur Ann Otorhinolaryngol Head Neck Dis. 2013;130:201-207. 102. Ellegala DB, Maartens NF, Laws ER Jr. Use of FloSeal hemostatic sealant in transsphenoidal pituitary surgery: technical note. Neurosurgery. 2002;51:513-515 [discussion: 515-516]. 103. Cavallo LM, Di Somma A, Solari D, de Divitiis O, Bracale UM, Cappabianca P. Preliminary experience with a new multidirectional videoendoscope for neuroendoscopic surgical procedures. PLoS One. 2016;11:e0147524.
WORLD NEUROSURGERY -: e1-e10, - 2018
104. Esposito F, Cappabianca P, Angileri FF, et al. Gelatin-thrombin hemostatic matrix in neurosurgical procedures: hemostasis effectiveness and economic value of clinical and surgical procedure-related benefits [e-pub ahead of print] J Neurosurg Sci. 2016. 105. Esposito F, Angileri FF, Kruse P, et al. Fibrin sealants in dura sealing: a systematic literature review. PLoS One. 2016;11:e0151533. 106. Asa SL, Casar-Borota O, Chanson P, et al. From pituitary adenoma to pituitary neuroendocrine tumor (PitNET): an International Pituitary Pathology Club proposal. Endocr Relat Cancer. 2017; 24:C5-C8. 107. Osamura RY, Lopes MBS, Grossman A, et al. Pituitary adenoma. In: Lloyd RV, Osamura RY, Klöppel G, Rosai J, eds. WHO Classification of Tumours of Endocrine Organs. 10. Lyon, France: IARC; 2017:14-18. 108. Manojlovic-Gacic E, Engstrom BE, CasarBorota O. Histopathological classification of non-functioning pituitary neuroendocrine tumors. Pituitary. 2018;21:119-129. 109. Nishioka H, Inoshita N, Mete O, et al. The complementary role of transcription factors in the accurate diagnosis of clinically nonfunctioning pituitary adenomas. Endocr Pathol. 2015; 26:349-355.
Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Received 2 August 2018; accepted 20 November 2018 Citation: World Neurosurg. (2018). https://doi.org/10.1016/j.wneu.2018.11.186 Journal homepage: www.journals.elsevier.com/worldneurosurgery Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2018 Elsevier Inc. All rights reserved.
www.journals.elsevier.com/world-neurosurgery
e9
ORIGINAL ARTICLE DOMENICO SOLARI ET AL.
A SURVEY ON PITUITARY SURGERY IN ITALY
APPENDIX Additional contributors: F. Ammannati, M.D. (Division of Neurosurgery, AOU "Careggi", Firenze, Italy), M. Cappelletti, M.D. (Division of Neurosurgery, Università degli Studi di Roma "La Sapienza," Rome, Italy), C. Conti, M.D. (Division of Neurosurgery, AO "G. Brotzu," Cagliari, Italy), D. Criminelli Rossi, M.D. (Division of Neurosurgery, Università degli Studi di Genova e Ospedale "San Martino," Genua, Italy), M. G. de Notaris, M.D., Ph.D. (Division of Neurosurgery, AO "G. Rummo," Benevento, Italy), A. Delitala, M.D. (Division of Neurosurgery, AO "San Camillo-Forlanini," Rome, Italy), F. DiMeco, M.D. (Division of Neurosurgery (NCH 1), Fondazione IRCCS Istituto Neurologico "Carlo Besta", Milan, Italy), F. Doglietto, M.D., Ph.D. (Division of Neurosurgery, Università degli Studi di Brescia e Spedali Civili, Brescia, Italy), E. Emanuelli, M.D. (Division of Neurosurgery, Università degli Studi di Padova, Padua, Italy), F. Esposito, M.D., Ph.D. (Division of Neurosurgery, Università degli Studi di Messina e Policlinico “G. Martino,” Messina, Italy), V. Esposito, M.D. (Division of Neurosurgery, IRCCS Neuromed, Pozzilli (IS), Italy), P. Gaetani, M.D. (Division of Neurosurgery, Università degli Studi di Pavia e Fondazione IRCCS Policlinico "S. Matteo," Pavia, Italy), G. Lasio, M.D. (Division of Neurosurgery, Humanitas Research Hospital, Rozzano, Italy), S. Luzzi, M.D. (Division of Neurosurgery, Università degli Studi e Ospedale Civile "S. Salvatore," L’Aquila, Italy and Division of Neurosurgery, Università degli Studi di Pavia e Fondazione IRCCS Policlinico "S. Matteo," Pavia, Italy), A. Melatini, M.D. (Division of Neurosurgery, Presidio Ospedaliero
e10
www.SCIENCEDIRECT.com
"V. Fazzi," Lecce, Italy), V. Monte, M.D. (Division of Neurosurgery, IRCCS "Casa Sollievo della Sofferenza," San Giovanni Rotondo, Italy), D. Nasi, M.D. (Division of Neurosurgery, Università Politecnica delle Marche e Ospedali Riuniti Torrette, Ancona, Italy), G. Oliveri, M.D. (Division of Neurosurgery, AOU Senese "Le Scotte," Siena, Italy), A. Olivi, M.D., Ph.D. (Division of Neurosurgery, Università Cattolica del Sacro Cuore e Policlinico "A. Gemelli," Rome, Italy), G. Pavesi, M.D. (Division of Neurosurgery, AOU Ospedale Civile di Baggiovara, Modena, Italy), F. Penner, M.D. (Division of Neurosurgery, Università degli Studi di Torino e Città della Salute e della Scienza, Turin, Italy), S. Peron, M.D. (Division of Neurosurgery, AO Ospedale Civile di Legnano, Legnano, Italy), F. Pieri, M.D. (Division of Neurosurgery, Spedali Riuniti di Livorno e USL Toscana Nord-Ovest, Livorno, Italy), F. Pozzi, M.D. (Division of Neurosurgery, Università degli Studi dell’Insubria, Ospedale di Circolo e Fondazione Macchi, Varese, Italy), P. Rampini, M.D. (Division of Neurosurgery, Fondazione IRCCS Cà Granda e Ospedale Maggiore e Policlinico, Milan, Italy), M. Sicignano, M.D. (Division of Neurosurgery, ASST "Papa Giovanni XXIII," Bergamo, Italy), S. Telera, M.D. (Division of Neurosurgery, IRCCS Istituto Nazionale Tumori "Regina Elena," Rome, Italy), L. Tosatto, M.D. (Division of Neurosurgery, AO "M. Bufalini," Cesena, Italy), M. Vitali, M.D. (Division of Neurosurgery, AO "SS. Antonio e Biagio e Cesare Arrigo," Alessandria, Italy), M. Zoli, M.D. (Division of Neurosurgery, IRCCS Isituto delle Scienze Neurologiche, Ospedale Bellaria, Bologna, Italy).
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2018.11.186