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Transfenoidal resection of pituitary microadenomas: A consecutive series of 100 patients
S90
Tumours of the CNS - Craniopharyngiomas and Pituitary Tumours
of radioisotope was successful in 300 patients (385 times). Most patients had one operation and some had 2-5 injection at intervals of 72-90 days. Results: 270 patients were followed up for 6 months to 8 years. (average 4 years). Tumors disappeared in 158 patients (58.51%), dramatically decreased in 70 patients (25.92%), decreased less than 50% in 25 patients (9.26%), increased in 12 patients (4.45%) and death occurred in 5 patients (1.85%) (3 were due to deterioration of tumors and 2 unknown reasons.) These results suggest that CT-Guided stereotactic intratumor irradiation is an effective method of treatment and that a calculated dose to the cystic wall in the range of 20,000 to 30,000 rads is safe to the surrounding brain tissue and effective in the control of tumor.
I0-11-1551
Gamma knife surgery plus intracystic isotope injection for the treatment of craniopharyngioma
Li Pan, Liqun Yang, Binjiang Wang, Enmin Wang, Jiazhong Dai 1 , Nan Zhang. Departmentof Neurosurgery, HuashanHospitalShanghaiMedicalUniversity, Shanghai200233, PR China, 1 Departmentof Radiology, Huashan Hospital ShanghaiMedicalUniversity, Shanghai200233, PR China Purpose: To determine the efficacy of gamma knife surgery for the treatment of craniopharyngioma. Materials and Methods: Sixteen patients (7 female, 9 male) with craniopharyngioma were treated with gamma knife radiosurgery between November 1993 and December 1994. Thirteen out of sixteen patients were pathologically verified. Previous surgical treatments were subtotal or partial removal of the tumors in 6 and stereotactic biopsy with cyst drainage using Ommaya reservoir in 7. The mean diameter of the tumors was 32.0 mm and the mean volume 12688 mm 3 (include cystic component). The solid part of tumors was treated with mean maximum dose of 32 Gy and marginal dose of 16 Gy. After gamma knife surgery, 7 patients with the cystic component of craniopharyngioma were treated by intracystic colloidal 32 P injection. Results: All lesions well responded to this treatment with mean follow-up period of 31 months. A marked reduction of tumor size was found in 10 cases. No deterioration of the visual path was found. Conclusion: Gamma knife is an effective method for smaller, residual or recurrent solid craniopharyngioma, whereas combined radioactive 32p injection and gamma knife surgery is the treatment of choice, for the cystic component of craniopharyngiomas.
I0-11-1561
Transfenoidal resection of pituitary microadenomas: A consecutive series of 100 patients
T. van Havenbergh, R. BOUillon, M. Bex, M. Jorissen, C. Plets.
u.z.
Gasthuisberg, Leuven, Belgium Introduction: Transsenoidal approach to small intrasellar adenomas of the pituitary gland causing endocrine dysfunction is a well described and widely spread technique. The purpose of this study was an analysis of the results and complications of a series performed in our department. Methods: In a retrospective study of 100 consecutive patients operated in our department through a transnasal route from january '86 to december '95 we analysed pre- and postoperative endocrine data, radiological and peroperative findings and complications. Minimal follow-up was 1 year, mean follow-up 4.4 year. Results: In our series 83 patients (83%) had Cushing disease, 12 (12%) had acromegaly, 6 (6%) had prolactinoma. Seventy-one patients (86%) with Cushing syndrome were cured after first operation, 7 (8%) needed a second operation. Adrenalectomy was performed in 4 patients (4%). When performed preoperatively, positive venous sampling correlated with peroperative findings in 78% of the cases. Eleven (92%) of the acromegalic patients and all patients with prolactinoma were cured after surgery. Postoperative complications were CSF fistula in 4 cases (4%), meningitis in 3 patients (3%) and perforation of the nasal septum leading to complaints in 8 cases (8%). Conclusions: Transsenoidal resection of pituitary microadenomas in Cushing disease, acromegaly and some selected cases of prolactinoma is a safe treatment with a high rate of success. The transnasal route has proved to be easy and safe without cosmetical restraints.
I0-11-1571 microsurgery Cushing's disease. Results of transsphenoidal in 124 patients over a 24-year period G.T. Tindall, N.M. Oyesiku, L. Blevins. Emory University, Atlanta, Ga, USA Transsphenoidal adenomectomy is the preferred treatment for Cushing's disease. We analyzed a group of 124 patients with presumed Cushing's disease who were treated by transsphenoidal microsurgical adenomectomy between 1972 and 1995. Of these, 24 patients had macroadenomas, 92 had microade-
Tuesday, 8 July 1997
nomas, 4 had corticotroph hyperplasia, 2 had Nelson's syndrome and 2 had bronchial carcinoid tumors. Mean follow-up was 60 months (range 3-164 months). Chart review and current clinical and biochemical data were analyzed to determine remission and recurrence rates and predictors of outcome. Remission was achieved in 15 of 22 (68%) patients with macroadenomas and in 72 of 79 (91%) patients with microadenomas. Recurrent disease occurred in 5 of 15 (33%) patients with macroadenomas, with a mean time to recurrence of 16.2 months. Conversely, 7 of 72 (9.7%) patients with rnicroadenomas experienced a recurrence, albeit with a longer mean time to recurrence of 54 months. This difference in disease-free survival between macroadenomas and microadenomas was statistically significant (p < 0.0005). Cavernous sinus invasion (odds ratio 35,95% CI2.6-475, (p < 0.008) and tumor diameter >2.0 em were the only predictors of residual disease following initial surgery in patients with macroadenomas. Patients who had recurrent or residual disease following initial transsphenoidal adenomectomy were treated by varying combinations of repeat surgery, radiation, medical therapy or adrenalectomy. Repeat transsphenoidal adenomectomy was uniformly unsuccessful in curing residual or recurrent disease in patients with macroadenomas. On the contrary, 4 of 9 (44%) patients with microadenomas with residual or recurrent disease were cured follOWing repeat surgery. Transsphenoidal surgery offers a worthwhile cure rate without the necessity of life-long endocrine therapy. Postoperative endocrine assessment must be rigorous so that early further management can be planned in patients in whom cure is not achieved.
10-11-1581 Treatment of pituitary-dependent Cushing's disease: Long-term outcome M. Scanarini, L. Tosatto, L. Alessio. Dept. of Neurosurgery, Padova University,
Padova, Italy During the past 20 years, 115 patients with pituitary-dependent Cushing's disease underwent transsphenoidal exploration. Survival analysis was employed to characterize the long-term outcome. The estimated cumulative percent of patients remaining in remission after successful pituitary surgery (n 80) was 93.7 after 2 years, 80.6 after 5 yrs. and 74.1 after 10 yrs. These results indicate that the relapse after cure did not decrease over time. Surgical failures were significantly associated with lack of adenoma at microsurgical exploration of the pituitary gland, clinical severity of the disease and presence of major depression. Other risk factors involved age, pre-treatment urinary cortisol and both urinary cortisol and ACTH 1-2 months after treatment. The results are consistent with the published literature. External pituitary irradiation in patients not cured by surgery yielded long-term benefits particularly in younger patients. Our data indicate the need for more therapeutic and preventive efforts in Cushing's disease.
=
I0-11-1591 New evaluation of the usefulness of intraoperative growth hormone measurement in acromegaly
Abe Takumi, Dieter K. l.udecke. Department of Neurosurgery, Pituitary
SurgeryUnit, University HospitalEppendorf, Hamburg, Germany Since 1983, we use intraoperative growth hormone (GH) measurement with improvement of surgical results in acromegaly. We update our results in 86 primary operated patients including 64 pretreated with octreotide (Sandostatin'") from 1992 to 1994. A modified IRMA-Kit is used for intraoperative GH measurement. Intraoperative GH-IRMA was judged by plasma GH at 20 and 60 min after tumor removal. GH of 4.5 fLg /L and less at 60 min is defined as sufficient decline. The half-life of tumor GH is taken into consideration as well. In cases of inadequate GH decline, further operation was considered during continued anesthesia. All patients were followed-up for at least 2 years. Intraoperative GH-IRMA was performed in 78 patients (14 micro-, 54 resectable macro-, and 10 non-resectable macroadenomas). Sufficient GH decline was determined in 48 and proved long-term in 47 patients (98%). From 30 patients with inadequate GH decline, further operation was performed in 18, not in 12 patients: an endocrinological remission was achieved in 11 and 5 patients, respectively. Thus, in 13 of 14 patients with microadenomas (93%) and in 51 of 54 patients with resectable macroadenomas (94%), a remission was achieved without major complications. In 10 non-resectable macroadenomas, no remission was achieved but in 5 tumor mass could be further reduced. In conclusion, with intraoperative GH-IRMA, we can judge the completeness of tumor removal with high accuracy, and determine cases where further operation may improve the results.
Tumours of the CNS - Craniopharyngiomas and Pituitary Tumours
of radioisotope was successful in 300 patients (385 times). Most patients had one operation and some had 2-5 injection at intervals of 72-90 days. Results: 270 patients were followed up for 6 months to 8 years. (average 4 years). Tumors disappeared in 158 patients (58.51%), dramatically decreased in 70 patients (25.92%), decreased less than 50% in 25 patients (9.26%), increased in 12 patients (4.45%) and death occurred in 5 patients (1.85%) (3 were due to deterioration of tumors and 2 unknown reasons.) These results suggest that CT-Guided stereotactic intratumor irradiation is an effective method of treatment and that a calculated dose to the cystic wall in the range of 20,000 to 30,000 rads is safe to the surrounding brain tissue and effective in the control of tumor.
I0-11-1551
Gamma knife surgery plus intracystic isotope injection for the treatment of craniopharyngioma
Li Pan, Liqun Yang, Binjiang Wang, Enmin Wang, Jiazhong Dai 1 , Nan Zhang. Departmentof Neurosurgery, HuashanHospitalShanghaiMedicalUniversity, Shanghai200233, PR China, 1 Departmentof Radiology, Huashan Hospital ShanghaiMedicalUniversity, Shanghai200233, PR China Purpose: To determine the efficacy of gamma knife surgery for the treatment of craniopharyngioma. Materials and Methods: Sixteen patients (7 female, 9 male) with craniopharyngioma were treated with gamma knife radiosurgery between November 1993 and December 1994. Thirteen out of sixteen patients were pathologically verified. Previous surgical treatments were subtotal or partial removal of the tumors in 6 and stereotactic biopsy with cyst drainage using Ommaya reservoir in 7. The mean diameter of the tumors was 32.0 mm and the mean volume 12688 mm 3 (include cystic component). The solid part of tumors was treated with mean maximum dose of 32 Gy and marginal dose of 16 Gy. After gamma knife surgery, 7 patients with the cystic component of craniopharyngioma were treated by intracystic colloidal 32 P injection. Results: All lesions well responded to this treatment with mean follow-up period of 31 months. A marked reduction of tumor size was found in 10 cases. No deterioration of the visual path was found. Conclusion: Gamma knife is an effective method for smaller, residual or recurrent solid craniopharyngioma, whereas combined radioactive 32p injection and gamma knife surgery is the treatment of choice, for the cystic component of craniopharyngiomas.
I0-11-1561
Transfenoidal resection of pituitary microadenomas: A consecutive series of 100 patients
T. van Havenbergh, R. BOUillon, M. Bex, M. Jorissen, C. Plets.
u.z.
Gasthuisberg, Leuven, Belgium Introduction: Transsenoidal approach to small intrasellar adenomas of the pituitary gland causing endocrine dysfunction is a well described and widely spread technique. The purpose of this study was an analysis of the results and complications of a series performed in our department. Methods: In a retrospective study of 100 consecutive patients operated in our department through a transnasal route from january '86 to december '95 we analysed pre- and postoperative endocrine data, radiological and peroperative findings and complications. Minimal follow-up was 1 year, mean follow-up 4.4 year. Results: In our series 83 patients (83%) had Cushing disease, 12 (12%) had acromegaly, 6 (6%) had prolactinoma. Seventy-one patients (86%) with Cushing syndrome were cured after first operation, 7 (8%) needed a second operation. Adrenalectomy was performed in 4 patients (4%). When performed preoperatively, positive venous sampling correlated with peroperative findings in 78% of the cases. Eleven (92%) of the acromegalic patients and all patients with prolactinoma were cured after surgery. Postoperative complications were CSF fistula in 4 cases (4%), meningitis in 3 patients (3%) and perforation of the nasal septum leading to complaints in 8 cases (8%). Conclusions: Transsenoidal resection of pituitary microadenomas in Cushing disease, acromegaly and some selected cases of prolactinoma is a safe treatment with a high rate of success. The transnasal route has proved to be easy and safe without cosmetical restraints.
I0-11-1571 microsurgery Cushing's disease. Results of transsphenoidal in 124 patients over a 24-year period G.T. Tindall, N.M. Oyesiku, L. Blevins. Emory University, Atlanta, Ga, USA Transsphenoidal adenomectomy is the preferred treatment for Cushing's disease. We analyzed a group of 124 patients with presumed Cushing's disease who were treated by transsphenoidal microsurgical adenomectomy between 1972 and 1995. Of these, 24 patients had macroadenomas, 92 had microade-
Tuesday, 8 July 1997
nomas, 4 had corticotroph hyperplasia, 2 had Nelson's syndrome and 2 had bronchial carcinoid tumors. Mean follow-up was 60 months (range 3-164 months). Chart review and current clinical and biochemical data were analyzed to determine remission and recurrence rates and predictors of outcome. Remission was achieved in 15 of 22 (68%) patients with macroadenomas and in 72 of 79 (91%) patients with microadenomas. Recurrent disease occurred in 5 of 15 (33%) patients with macroadenomas, with a mean time to recurrence of 16.2 months. Conversely, 7 of 72 (9.7%) patients with rnicroadenomas experienced a recurrence, albeit with a longer mean time to recurrence of 54 months. This difference in disease-free survival between macroadenomas and microadenomas was statistically significant (p < 0.0005). Cavernous sinus invasion (odds ratio 35,95% CI2.6-475, (p < 0.008) and tumor diameter >2.0 em were the only predictors of residual disease following initial surgery in patients with macroadenomas. Patients who had recurrent or residual disease following initial transsphenoidal adenomectomy were treated by varying combinations of repeat surgery, radiation, medical therapy or adrenalectomy. Repeat transsphenoidal adenomectomy was uniformly unsuccessful in curing residual or recurrent disease in patients with macroadenomas. On the contrary, 4 of 9 (44%) patients with microadenomas with residual or recurrent disease were cured follOWing repeat surgery. Transsphenoidal surgery offers a worthwhile cure rate without the necessity of life-long endocrine therapy. Postoperative endocrine assessment must be rigorous so that early further management can be planned in patients in whom cure is not achieved.
10-11-1581 Treatment of pituitary-dependent Cushing's disease: Long-term outcome M. Scanarini, L. Tosatto, L. Alessio. Dept. of Neurosurgery, Padova University,
Padova, Italy During the past 20 years, 115 patients with pituitary-dependent Cushing's disease underwent transsphenoidal exploration. Survival analysis was employed to characterize the long-term outcome. The estimated cumulative percent of patients remaining in remission after successful pituitary surgery (n 80) was 93.7 after 2 years, 80.6 after 5 yrs. and 74.1 after 10 yrs. These results indicate that the relapse after cure did not decrease over time. Surgical failures were significantly associated with lack of adenoma at microsurgical exploration of the pituitary gland, clinical severity of the disease and presence of major depression. Other risk factors involved age, pre-treatment urinary cortisol and both urinary cortisol and ACTH 1-2 months after treatment. The results are consistent with the published literature. External pituitary irradiation in patients not cured by surgery yielded long-term benefits particularly in younger patients. Our data indicate the need for more therapeutic and preventive efforts in Cushing's disease.
=
I0-11-1591 New evaluation of the usefulness of intraoperative growth hormone measurement in acromegaly
Abe Takumi, Dieter K. l.udecke. Department of Neurosurgery, Pituitary
SurgeryUnit, University HospitalEppendorf, Hamburg, Germany Since 1983, we use intraoperative growth hormone (GH) measurement with improvement of surgical results in acromegaly. We update our results in 86 primary operated patients including 64 pretreated with octreotide (Sandostatin'") from 1992 to 1994. A modified IRMA-Kit is used for intraoperative GH measurement. Intraoperative GH-IRMA was judged by plasma GH at 20 and 60 min after tumor removal. GH of 4.5 fLg /L and less at 60 min is defined as sufficient decline. The half-life of tumor GH is taken into consideration as well. In cases of inadequate GH decline, further operation was considered during continued anesthesia. All patients were followed-up for at least 2 years. Intraoperative GH-IRMA was performed in 78 patients (14 micro-, 54 resectable macro-, and 10 non-resectable macroadenomas). Sufficient GH decline was determined in 48 and proved long-term in 47 patients (98%). From 30 patients with inadequate GH decline, further operation was performed in 18, not in 12 patients: an endocrinological remission was achieved in 11 and 5 patients, respectively. Thus, in 13 of 14 patients with microadenomas (93%) and in 51 of 54 patients with resectable macroadenomas (94%), a remission was achieved without major complications. In 10 non-resectable macroadenomas, no remission was achieved but in 5 tumor mass could be further reduced. In conclusion, with intraoperative GH-IRMA, we can judge the completeness of tumor removal with high accuracy, and determine cases where further operation may improve the results.