Prognosis of pituitary adenomas in the early 1970s and today—Is there a benefit of modern surgical techniques and treatment modalities?

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Highlights

  • We analysed patients surgically treated on pituitary adenomas with long term follow up as far as 38 years.

  • Prognosis of pituitary adenoma patients could be improved by introduction of modern surgical approaches.

  • The perioperative morbidity and mortality rate have been reduced since the 1970s.

  • The recurrence rate has been reduced clearly in the last decades.

  • Our results confirm necessity of lifelong follow-up after successfully treated pituitary adenomas.

Abstract

Objective

Neurosurgical techniques for the treatment of sellar pathologies have been evolving continuously over the last decades. Additionally to the innovation of approaches and surgical techniques, this progress yielded to the application of modern intraoperative surgical tools as well as peri- and intraoperative imaging. Until now, no long-term analysis of the impact of new therapy concepts on the patient’s outcome exists. Aim of this study was to analyse the impact of new operative approaches on perioperative mortality and morbidity as well as the long-term outcome after pituitary surgery.

Patients and methods

Three groups of patients were compared in this retrospective analysis of surgically treated pituitary adenomas between the years of 1963 and 2014. Group A contains 93 patients, treated between 1963–1980 with a mean follow-up of 12.1 years (±14.3 years), group B comprises 89 patients treated between 1990 and 2000 with a mean follow-up of 10.1 years (±8.1 years) and group C consists of 95 patients treated between 2011–2014 with a mean follow-up of 3.4 years (±1.9 years).

Results

The surgical treatment was performed significantly earlier today on smaller tumors with less preoperative complaints (p < 0.01). Panhypopituitarism was detected only in 9.5% of the cases in group C compared to 50.8% in group A (p < 0.01). Also, the incidence of revision surgery (5.6 vs. 2% vs 0%), postoperative hemorrhage (10.8% vs. 3.4% vs. 1%) and diabetes insipidus (34.4% vs. 11.2% vs. 5.2%) was decreased (p < 0.01). Moreover, a significant postoperative improvement of ophthalmological complaints was detected (p < 0.001).

The long-term follow-up showed 40% of the entire recurrence rate occurring after the ninth postoperative year. The progression-free survival time increased significantly from group A to group B (p < 0.05).

Conclusions

The results demonstrate a benefit of the recent developments of pituitary surgery in the short-term results as well as in the long-term outcome. The prognosis of pituitary adenoma patients could be improved by the introduction of new surgical approaches and techniques in the last decades. Also the perioperative morbidity and mortality rate has been reduced clearly since the 1970s. Furthermore our results emphasise the necessity of lifelong follow-up of all patients with successfully treated pituitary adenomas.

Introduction

The development of new diagnostic modalities, surgical techniques and treatment strategies has changed the concept of pituitary adenoma therapy over the last 30 years remarkably. The computer tomographic (CT) scanning introduced by Hounsfield in 1973 [2], [24], [25], [26] and the magnetic resonance (MR) imaging in 1978 as described in detail by Doyle et al. in 1981 [17] represent the ‘gold standard’ methods for the diagnosis and follow up of intracranial tumors, in general. The use of the operating microscope has become a standard technique in most intracranial procedures since the 1960s [33], [56]. The microsurgical transsphenoidal approach was investigated and established over almost a century of research [32]. It used to represent the “gold standard” for surgical treatment of sellar lesions in the neurosurgical field [1], [11], [19], [23], [34]. However, further developments of endoscopic techniques and its applications in neurosurgery influenced also transnasal approaches [8], [20], [39], [40], [45], [50], [51], [52], [53], [57]. Continuous efforts to improve surgical techniques are still being made [3], [4], [5], [6], [7], [12], [30], [31]. Many publications on endonasal endoscopic surgery stress the less invasive nature of this technique, [35], [36], [38], [42], [43] providing a wider field of view. Additionally, angled telescopes allow inspection of retrocarotid, intracavernous and suprasellar space [42].

Although the mortality and morbidity rate in patients with gliomas [9], [44], meningiomas [37] and in those with brain abscesses [49] has been reduced in the last decades due to modern neurosurgical interventions, evidence of better prognosis for patients with pituitary adenomas is still lacking.

To evaluate the influence of the new modern diagnostic tools as well as new modern surgical techniques and approaches on the prognosis of patients with pituitary adenomas, the authors analysed patients who had surgical therapy for pituitary adenomas at their clinic in the years between 1963 and 2014 retrospectively.

Section snippets

Patient population

We performed a retrospective analysis on selected 277 patients [133 women and 144 men] operated at the department of Neurosurgery, at Saarland University between 1963 and 2014. The average age of the overall patient population was 51.2 years [SD ± 13.9 years].

Three groups of patients were selected according to the time interval, in which they were treated: we selected a first group of patients (group A) who was treated in the time period from 1963 until 1980. This collective was surgically treated

Overall results

A total of 93 patients met the inclusion criteria in group A (treated between 1963 and 1980), a total of 88 patients were included in group B (those treated between 1990 and 2000) and a total of 95 patients were included in group C (those treated between 2011 and 2014). In the first group, 52% (49/93) were of male and 48% (44/93) were of female gender. In the second group, 61% (54/88) were male and 39% (34/88) were female. In the third group, 42% (40/95) were male and 58% (55/95) were female.

Discussion

Although there have been notable technical advances in the surgical methods, including the development of new approaches to the sellar region and also in diagnostic modalities, including CT and MR imaging for diagnosis, as well as new intraoperative imaging tools and neuronavigation [10], [12], [14], [18], [23], [27], [29], [41], [46], [47], [55] in the last decades, the exact consequences of these new modalities on the prognosis and the recurrence free survival time in pituitary patients were

Conclusion

In conclusion, our study demonstrates that the prognosis of pituitary adenoma patients was improved by the introduction of new surgical approaches and techniques over the last decades. Clearly the perioperative morbidity and mortality rate has been reduced since the 1970s. In addition, even in initially successfully operated patients with pituitary adenomas a lifelong follow up period is necessary for the ultimate success of neurosurgical therapy.

Financial disclosure

J Oertel acts as consultant to Karl Storz Company. Besides this, the authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers' bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations,

Acknowledgement

We thank Prof. Dr. Jörg Rahnenführer, Faculty of Statistics of the University of Dortmund, Germany, for the partial support of our statistical analysis.

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