1Department of Neurosurgery, Weill Cornell Medical College, New York.
Departments of2Neurosurgery.
J Neurosurg. 2020 Jul 3;134(6):1824-1835. doi: 10.3171/2020.4.JNS20178. Print 2021 Jun 1.
The utility and safety of intraoperative MRI (iMRI) for resection of pituitary adenomas is not clearly established in the context of advances in endoscopic approaches. The goal in this study was to evaluate the safety and efficacy of iMRI for pituitary adenoma resection, with endoscopic transsphenoidal (ETS) versus microscopic transsphenoidal (MTS) approaches.
Radiographic and clinical outcomes of all pituitary adenomas resected using iMRI between 2008 and 2017 at a single institution were retrospectively evaluated.
Of 212 tumors treated, 131 (62%) underwent further resection based on iMRI findings, resulting in a significant increase in gross-total resection on postoperative MRI compared with iMRI (p = 0.0001) in both ETS and MTS groups. iMRI increased rates of gross-total resection for cavernous sinus invasion Knosp grades 1 and 2, but not in Knosp ≥ 3 across treatment groups (p < 0.0001). The extent of resection on postoperative MRI was significantly correlated with increased progression-free survival (p < 0.0001). Initial hormone remission off medical therapy was achieved in 64%, with a significantly higher rate of remission in tumors resected via the ETS approach (81%) compared with the MTS approach (55%) (p = 0.02). The rate of persistent new hormone deficit was low at 8%, including a 2.8% rate of permanent diabetes insipidus, and 45% of patients had improvement in preoperative hormone deficit following surgery. Serious postoperative complications including CSF leaks requiring reoperation were rare at 1%, with no postoperative infections.
These results suggest that iMRI is a safe and effective method of increasing the extent of resection for pituitary adenomas while preserving hormone function. When paired with the endoscope, iMRI may offer the ability to tailor more aggressive removal of tumors while optimizing pituitary function, resulting in high rates of secretory hormone remission. Secretory tumors and adenomas with Knosp grade < 3 cavernous sinus invasion may benefit most from the use of iMRI.
在神经内镜技术进步的背景下，术中磁共振成像（iMRI）在垂体腺瘤切除中的应用的实用性和安全性尚不清楚。本研究旨在评估 iMRI 在垂体腺瘤切除中的安全性和有效性，比较内镜经蝶窦（ETS）与显微镜经蝶窦（MTS）两种入路。
回顾性分析了 2008 年至 2017 年期间在一家单中心使用 iMRI 切除的所有垂体腺瘤的影像学和临床结果。
212 例肿瘤中，131 例（62%）根据 iMRI 结果进一步切除，与 iMRI 相比，ETS 和 MTS 两组的术后 MRI 全切除率均显著增加（p = 0.0001）。iMRI 增加了海绵窦侵袭 Knosp 1 级和 2 级的全切率，但在各治疗组的 Knosp ≥ 3 级中并无此作用（p < 0.0001）。术后 MRI 的切除程度与无进展生存时间显著相关（p < 0.0001）。初始激素治疗缓解率为 64%，ETS 组（81%）明显高于 MTS 组（55%）（p = 0.02）。新发激素缺乏的持续率较低，为 8%，其中永久性尿崩症的发生率为 2.8%，术后 45%的患者术前激素缺乏得到改善。严重的术后并发症，包括需要再次手术的脑脊液漏，发生率较低，为 1%，且无术后感染。
这些结果表明，iMRI 是一种安全有效的方法，可以增加垂体腺瘤的切除范围，同时保留激素功能。当与内镜结合使用时，iMRI 可能能够更积极地切除肿瘤，同时优化垂体功能，从而实现高比例的分泌激素缓解。分泌性肿瘤和 Knosp 分级 < 3 的海绵窦侵袭性肿瘤可能最受益于 iMRI 的应用。
