Neurosurg Rev DOI 10.1007/s10143-015-0613-7
ORIGINAL ARTICLE
Endoscopic versus microscopic approach for surgical treatment of acromegaly Hussein Fathalla & Michael D. Cusimano & Antonio Di Ieva & John Lee & Omar Alsharif & Jeannette Goguen & Stanley Zhang & Harley Smyth
Received: 9 June 2014 / Revised: 10 October 2014 / Accepted: 16 November 2014 # Springer-Verlag Berlin Heidelberg 2015
Abstract Transsphenoidal surgery in the setting of acromegaly is quite challenging due to increased soft tissue mass, bony overgrowth, and bleeding. There is a debate on the endoscopic versus microscopic approach for these patients. The purpose of our study is to compare the outcomes for acromegaly after transsphenoidal surgery using both techniques. Retrospective review of 65 acromegalic patients who underwent transsphenoidal surgery in our department. Clinical remission was defined as resolution of typical acromegalic symptoms. Radiological resection was defined by volumetric criteria, and biochemical remission was defined as by the 2010 consensus on the criteria for remission of acromegaly. There was no significant difference in age, preoperative endocrine status, percent of macro adenomas, suprasellar, or infrasellar extension between H. Fathalla (*) : M. D. Cusimano : A. Di Ieva : O. Alsharif : S. Zhang : H. Smyth Division of Neurosurgery, St. Michael’s Hospital, 30 Bond Street, Toronto, ON M5B 1W8, Canada e-mail: [email protected]
both groups. Patients were assigned to both groups based on our existing referral pattern. Endoscopic approach was performed in 42 patients, while the microscopic approach was performed in 23 patients. No significant difference in remission rates was found between both groups (45.2 vs. 34.7 %, p=0.40). The endoscopic group, however, had a significantly higher rate of gross total resections (61 vs. 42 %, p=0.05). There was also a trend towards higher rates of gross total resections when cavernous sinus was present (48 vs. 14.2 %, p=0.09). Postoperative diabetes insipidus occurred more in microscopic patients (34.7 vs. 17 %, p=0.05), otherwise there was no significant difference in rates of complications. The median follow-up period was 56.6 months (range 6–156, mean 66.1). There is no significant difference in the rates of biochemical remission between the endoscopic and microscopic techniques. The endoscope technique, however, seems to be superior in achieving gross total resection especially with tumors invading the cavernous sinus. Keywords Acromegaly . Endoscopic transsphenoid . 2010 consensus for acromegaly . Microscopic transsphenoid
H. Fathalla e-mail: [email protected] H. Fathalla e-mail: [email protected] M. D. Cusimano Faculty of Medicine, Education and Public Health, University of Toronto, Toronto, ON, Canada J. Goguen Division of Endocrinology, Department of Pathology, St. Michael’s Hospital, Toronto, ON M5B 1W8 (JG), Canada J. Lee Department of Otorhinolaryngology and Head and Neck Surgery, St. Michael’s Hospital, Toronto, ON, Canada H. Fathalla Division of Neurosurgery, Cairo University Hospitals, Cairo, Egypt
Introduction Acromegaly is a clinical syndrome of excess growth hormone (GH) that is secondary to GH-secreting pituitary adenoma in nearly all cases. It is a rare condition [13] with significant morbidity and mortality [13, 21, 24]. Transsphenoidal resection of the GH-secreting pituitary adenoma is considered the first-line treatment for acromegaly [13, 15]. The optimal surgical approach continues to be debated and most series that are reported are based on criteria published before the most recent consensus for the diagnosis and remission of acromegaly in 2010 [12]. It is recognized that acromegalic patients usually
Neurosurg Rev
have bony overgrowth and soft tissue hyperplasia making transnasal approaches more challenging [33]. The proponents of the binasal endoscopic approach argue that the panoramic view, binasal surgery, and the ability to access extensions of the tumor anteriorly, posteriorly, superiorly, and laterally are superior with the endoscopic technique [3, 7, 15, 22, 26, 28, 30]. Those in favor of the microscopic approach argue in favor of the stereoscopic 3D view offered by the microscope, its familiarity, and the ability for one surgeon to do the technique [28]. There are a number of series that report the short-term outcomes using the microscopic [2, 9, 16, 20, 23, 28, 31] or endoscopic [4, 10, 13, 25, 28, 29, 32] transsphenoidal approaches. However, these studies are generally limited to a single modality, have limited follow-up or variable definitions of remission, and so are difficult to compare. In 2010, consensuses on the criteria for remission of acromegaly were set [12] and these most recent criteria define remission as normal age and sex adjusted IGF-1 levels and either random GH levels less than 1 μg/l or GH suppression to 2)a Suprasellar extensiona Infrasellar (clivus) extensiona a
Endoscopic
Microscopic
43.2
42.1
21 21 785 20.8 35/42 (83.3 %) 3.62 cm3 25/40 (62.5 %) 18/39 (46 %) 11/39 (28.2 %)
7 16 700 27.4 17/23 (73.9 %) 2.70 cm3 8/23 (34.7 %) 10/19 (52.6 %) 6/19 (31.5 %)
Some patients had missing data
excluded because they failed to show on follow-up and thus were not included. These patients had returned to their countries after surgeries and could not be contacted. The remaining 65 patients with complete data and follow-up were included for the final analysis. Endocrinological criteria of diagnosis and outcome A diagnosis of acromegaly is based on clinical judgment, IGFI concentration above normal age- and sex-adjusted levels and failure to suppress GH levels following the administration of a 75 g oral glucose load [13]. According to the criteria of the 2010 Consensus, remission was defined as normal age- and sex-adjusted IGF-I levels and either a random GH of
ORIGINAL ARTICLE
Endoscopic versus microscopic approach for surgical treatment of acromegaly Hussein Fathalla & Michael D. Cusimano & Antonio Di Ieva & John Lee & Omar Alsharif & Jeannette Goguen & Stanley Zhang & Harley Smyth
Received: 9 June 2014 / Revised: 10 October 2014 / Accepted: 16 November 2014 # Springer-Verlag Berlin Heidelberg 2015
Abstract Transsphenoidal surgery in the setting of acromegaly is quite challenging due to increased soft tissue mass, bony overgrowth, and bleeding. There is a debate on the endoscopic versus microscopic approach for these patients. The purpose of our study is to compare the outcomes for acromegaly after transsphenoidal surgery using both techniques. Retrospective review of 65 acromegalic patients who underwent transsphenoidal surgery in our department. Clinical remission was defined as resolution of typical acromegalic symptoms. Radiological resection was defined by volumetric criteria, and biochemical remission was defined as by the 2010 consensus on the criteria for remission of acromegaly. There was no significant difference in age, preoperative endocrine status, percent of macro adenomas, suprasellar, or infrasellar extension between H. Fathalla (*) : M. D. Cusimano : A. Di Ieva : O. Alsharif : S. Zhang : H. Smyth Division of Neurosurgery, St. Michael’s Hospital, 30 Bond Street, Toronto, ON M5B 1W8, Canada e-mail: [email protected]
both groups. Patients were assigned to both groups based on our existing referral pattern. Endoscopic approach was performed in 42 patients, while the microscopic approach was performed in 23 patients. No significant difference in remission rates was found between both groups (45.2 vs. 34.7 %, p=0.40). The endoscopic group, however, had a significantly higher rate of gross total resections (61 vs. 42 %, p=0.05). There was also a trend towards higher rates of gross total resections when cavernous sinus was present (48 vs. 14.2 %, p=0.09). Postoperative diabetes insipidus occurred more in microscopic patients (34.7 vs. 17 %, p=0.05), otherwise there was no significant difference in rates of complications. The median follow-up period was 56.6 months (range 6–156, mean 66.1). There is no significant difference in the rates of biochemical remission between the endoscopic and microscopic techniques. The endoscope technique, however, seems to be superior in achieving gross total resection especially with tumors invading the cavernous sinus. Keywords Acromegaly . Endoscopic transsphenoid . 2010 consensus for acromegaly . Microscopic transsphenoid
H. Fathalla e-mail: [email protected] H. Fathalla e-mail: [email protected] M. D. Cusimano Faculty of Medicine, Education and Public Health, University of Toronto, Toronto, ON, Canada J. Goguen Division of Endocrinology, Department of Pathology, St. Michael’s Hospital, Toronto, ON M5B 1W8 (JG), Canada J. Lee Department of Otorhinolaryngology and Head and Neck Surgery, St. Michael’s Hospital, Toronto, ON, Canada H. Fathalla Division of Neurosurgery, Cairo University Hospitals, Cairo, Egypt
Introduction Acromegaly is a clinical syndrome of excess growth hormone (GH) that is secondary to GH-secreting pituitary adenoma in nearly all cases. It is a rare condition [13] with significant morbidity and mortality [13, 21, 24]. Transsphenoidal resection of the GH-secreting pituitary adenoma is considered the first-line treatment for acromegaly [13, 15]. The optimal surgical approach continues to be debated and most series that are reported are based on criteria published before the most recent consensus for the diagnosis and remission of acromegaly in 2010 [12]. It is recognized that acromegalic patients usually
Neurosurg Rev
have bony overgrowth and soft tissue hyperplasia making transnasal approaches more challenging [33]. The proponents of the binasal endoscopic approach argue that the panoramic view, binasal surgery, and the ability to access extensions of the tumor anteriorly, posteriorly, superiorly, and laterally are superior with the endoscopic technique [3, 7, 15, 22, 26, 28, 30]. Those in favor of the microscopic approach argue in favor of the stereoscopic 3D view offered by the microscope, its familiarity, and the ability for one surgeon to do the technique [28]. There are a number of series that report the short-term outcomes using the microscopic [2, 9, 16, 20, 23, 28, 31] or endoscopic [4, 10, 13, 25, 28, 29, 32] transsphenoidal approaches. However, these studies are generally limited to a single modality, have limited follow-up or variable definitions of remission, and so are difficult to compare. In 2010, consensuses on the criteria for remission of acromegaly were set [12] and these most recent criteria define remission as normal age and sex adjusted IGF-1 levels and either random GH levels less than 1 μg/l or GH suppression to 2)a Suprasellar extensiona Infrasellar (clivus) extensiona a
Endoscopic
Microscopic
43.2
42.1
21 21 785 20.8 35/42 (83.3 %) 3.62 cm3 25/40 (62.5 %) 18/39 (46 %) 11/39 (28.2 %)
7 16 700 27.4 17/23 (73.9 %) 2.70 cm3 8/23 (34.7 %) 10/19 (52.6 %) 6/19 (31.5 %)
Some patients had missing data
excluded because they failed to show on follow-up and thus were not included. These patients had returned to their countries after surgeries and could not be contacted. The remaining 65 patients with complete data and follow-up were included for the final analysis. Endocrinological criteria of diagnosis and outcome A diagnosis of acromegaly is based on clinical judgment, IGFI concentration above normal age- and sex-adjusted levels and failure to suppress GH levels following the administration of a 75 g oral glucose load [13]. According to the criteria of the 2010 Consensus, remission was defined as normal age- and sex-adjusted IGF-I levels and either a random GH of
