J Neurosurg. 2022 Apr 29;137(6):1687-1698. doi: 10.3171/2022.3.JNS212940. Print 2022 Dec 1.
Decision-making in how to manage pituitary adenomas (PAs) in the elderly (age ≥ 65 years) can be challenging given the benign nature of these tumors and concerns about surgical morbidity in these patients. In this study involving a large multicenter national registry, the authors examined treatment trends and surgical outcomes in elderly compared to nonelderly patients.
The National Cancer Data Base (NCDB) was queried for adults aged ≥ 18 years with PA diagnosed by MRI (in observed cases) or pathology (in surgical cases) from 2004 to 2016. Univariate and multivariate logistic regressions were used to evaluate the prognostic impact of age and other covariates on 30- and 90-day postsurgical mortality (30M/90M), prolonged (≥ 5 days) length of inpatient hospital stay (LOS), and extent of resection.
A total of 96,399 cases met the study inclusion criteria, 27% of which were microadenomas and 73% of which were macroadenomas. Among these cases were 25,464 elderly patients with PA. Fifty-three percent of these elderly patients were treated with surgery, 1.9% underwent upfront radiotherapy, and 44.9% were observed without treatment. Factors associated with surgical treatment compared to observation included younger age, higher income, private insurance, higher Charlson-Deyo comorbidity (CD) score, larger tumor size, and receiving treatment at an academic hospital (each p ≤ 0.01). Elderly patients undergoing surgery had increased rates of 30M (1.4% vs 0.6%), 90M (2.8% vs 0.9%), prolonged LOS (26.1% vs 23.0%), and subtotal resection (27.2% vs 24.5%; each p ≤ 0.01) compared to those in nonelderly PA patients. On multivariate analysis, age, tumor size, and CD score were independently associated with worse postsurgical mortality. High-volume facilities (HVFs) had significantly better outcomes than low-volume facilities: 30M (0.9% vs 1.8%, p < 0.001), 90M (2.0% vs 3.5%, p < 0.001), and prolonged LOS (21.8% vs 30.3%, p < 0.001). A systematic literature review composed of 22 studies demonstrated an elderly PA patient mortality rate of 0.7%, which is dramatically lower than real-world NCDB outcomes and speaks to substantial selection bias in the previously published literature.
The study findings confirm that elderly patients with PA are at higher risk for postoperative mortality than younger patients. Surgical risk in this age group may have been previously underreported in the literature. Resection at HVFs better reflects these historical rates, which has important implications in elderly patients for whom surgery is being considered.
鉴于这些肿瘤的良性性质以及对这些患者手术发病率的担忧，对于 65 岁及以上的老年患者（年龄≥65 岁）如何治疗垂体腺瘤（PA），决策可能具有挑战性。在这项涉及大型多中心国家注册中心的研究中，作者研究了与非老年患者相比，老年患者的治疗趋势和手术结果。
从 2004 年至 2016 年，国家癌症数据库（NCDB）查询了通过 MRI（在观察病例中）或病理（在手术病例中）诊断为 PA 的≥18 岁成年人。使用单变量和多变量逻辑回归评估年龄和其他协变量对 30 天和 90 天手术后死亡率（30M/90M）、延长（≥5 天）住院时间（LOS）和切除程度的预后影响。
共有 96399 例符合研究纳入标准，其中 27%为微腺瘤，73%为大腺瘤。这些病例中有 25464 例老年 PA 患者。其中 53%的老年患者接受了手术治疗，1.9%接受了 upfront 放疗，44.9%未接受治疗。与观察相比，接受手术治疗的因素包括年龄较小、收入较高、私人保险、较高的 Charlson-Deyo 合并症（CD）评分、较大的肿瘤大小和在学术医院接受治疗（均 p≤0.01）。与非老年 PA 患者相比，接受手术治疗的老年患者的 30M（1.4%对 0.6%）、90M（2.8%对 0.9%）、延长 LOS（26.1%对 23.0%）和次全切除术（27.2%对 24.5%；均 p≤0.01）发生率更高。多变量分析显示，年龄、肿瘤大小和 CD 评分与术后死亡率独立相关。高容量设施（HVF）的结果明显优于低容量设施：30M（0.9%对 1.8%，p<0.001）、90M（2.0%对 3.5%，p<0.001）和延长 LOS（21.8%对 30.3%，p<0.001）。一项由 22 项研究组成的系统文献回顾表明，老年 PA 患者的死亡率为 0.7%，远低于真实世界 NCDB 的结果，表明之前发表的文献中存在大量选择偏倚。
研究结果证实，老年 PA 患者的术后死亡率高于年轻患者。该年龄组的手术风险在文献中可能以前报告不足。在 HVF 进行切除更好地反映了这些历史比率，这对考虑手术的老年患者具有重要意义。
