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Background Tumor consistency recently emerged as a key factor in surgical planning for pituitary adenomas, but its impact on postoperative endocrine function is still unclear. Our study aimed to evaluate the impact of tumor consistency on the development of postoperative pituitary deficiencies. Methods Single-center, retrospective analysis of consecutive pituitary surgeries performed between January 2017 and January 2021 at Policlinico Umberto I in Rome. All patients underwent radiological and biochemical evaluations at baseline, and hormone assessments 3 and 6 months after pituitary surgery. Postoperative MRI studies were used to determine resection rates following surgery. Data on tumor consistency, macroscopic appearance, neurosurgical approach, and intraoperative complications were collected. Results Fifty patients [24 women, mean age 57 ± 13 years, median tumor volume 4800 mm 3 [95% CI 620–8828], were included. Greater tumor volume (χ 2  = 14.621, p  = 0.006) and male sex (χ 2  = 12.178, p  < 0.001) were associated with worse preoperative endocrine function. All patients underwent transsphenoidal adenomectomy. Fibrous consistency was observed in 10% of patients and was associated with a Ki-67 greater than 3% (χ 2  = 8.154, p  = 0.04), greater risk of developing postoperative hormone deficiencies (χ 2  = 4.485, p  = 0.05, OR = 8.571; 95% CI: 0.876–83.908), and lower resection rates (χ2 = 8.148, p  = 0.004; OR 1.385, 95% CI; 1.040–1.844). Similarly, worse resection rates were observed in tumors with suprasellar extension (χ2 = 5.048, p  = 0.02; OR = 6.000, 95% CI; 1.129–31.880) and CSI (χ2 = 4.000, p  = 0.04; OR = 3.857, 95% CI; 0.997–14.916). Conclusions Tumor consistency might provide useful information about postoperative pituitary function, likely due to its impact on surgical procedures. Further prospective studies with larger cohorts are needed to confirm our preliminary findings.

Purpose Preservation of endocrine function in pediatric patients with craniopharyngioma is crucial. However, few reports of endoscopic endonasal surgery (EES) for pediatric craniopharyngiomas with intending endocrine function preservation exist. This study aimed to identify the outcomes of EES with intending preservation of pituitary stalk in pediatric patients with craniopharyngioma. Methods Data from 22 pediatric patients with craniopharyngioma who underwent 35 EESs between 2011 and 2022 were retrospectively assessed. The tumor location (infradiaphragmatic [ID] or supradiaphragmatic [SD]) and endocrine functions were evaluated. The patients were divided into two groups: those with preoperatively preserved some endocrine function (Group P) and already completely lost endocrine function (Group ACL). Morphological preservation of the pituitary stalk (MPPS) and postoperative endocrine functional outcomes were analyzed only in the cases of Group P. Tumor recurrence was evaluated in all patients. Results In the 35 EESs, the tumors were ID in 17 cases and SD in 18. Twenty-five cases were included in Group P and 10 in Group ACL. In Group P, MPPS was achieved in 18 (72%) cases, and postoperative preservation of some endocrine function was achieved in 14 (77.8%) of the MPPS cases. ID tumor ( P  < 0.001) and intraoperative MPPS ( P  < 0.001) were associated with postoperative preservation of some endocrine function. Intraoperative MPPS ( P  = 0.044) was a significantly associated risk factor for tumor recurrence. Conclusions In EES for pediatric craniopharyngiomas, postoperative preservation of some endocrine function is achievable in ID tumors with MPPS. Therefore, preservation of endocrine function should be attempted in cases of ID tumors. However, clinicians should be aware that MPPS increases the risk of tumor recurrence.

Cushing's disease (CD) is a rare cause of hypercortisolemia presenting a major diagnostic and therapeutic challenge. Data on pituitary function in long-term follow-up after CD treatment in childhood is limited. Long-term assessment of patients of the Children's Memorial Health Institute (CMHI) after CD treatment in childhood. Retrospective analysis of 29 CD patients, mean age at the time of diagnosis 13.46 yrs. The long-term follow-up (FU) was done by: 1) obtaining the data from a patient's questionnaire (75% of adult patients); 2) using the data from the last clinic visit for patients who did not respond to the questionnaire and for current CMHI patients. The average long-term FU from transsphenoidal pituitary surgery (TSS) was 10.23 yrs. At the latest FU: 18 patients (62%) had long-term disease remission after TSS1, 2 patients (6.9%) after TSS2, 1 patient (3.4%) after the post-TSS radiotherapy (XRT) cycle and 3 patients (10.3%) after bilateral adrenalectomy (BA). One patient (3.4%) died after TSS2 due to postoperative complications, 1 patient (3.4%) had persistent disease at latest FU, in 1 patient (3.4%) the long-term FU was not possible to perform. CD recurrence occurred in 4 out of 28 patients (14%) at an average time 3.6 yrs. from definitive treatment. One patient (3.4%) after BA was operated because of Nelson's syndrome. Two patients (6.9%) were suspected of relapse at latest assessment. At the time of the last evaluation, 17 patients (63%) were on levothyroxine therapy since definitive treatment, 16 patients (59%) were on hydrocortisone treatment, 10 patients (37%) were taking sex hormones replacement, 4 patients (15%)-antidiuretic hormone. Relatively large number of patients after CD treatment in childhood have hormonal pituitary deficits as well as mood and cognitive disorders. CD recurrence can occur even after a long time post effective treatment.

Purpose Postoperative pituitary dysfunction, a critical problem in the treatment of craniopharyngiomas, can occur even when the pituitary stalk is preserved. We hypothesized that compromise of the primary superior hypophyseal artery (pSHA) might be related to this occurrence. Methods We performed a retrospective review of 131 patients with craniopharyngioma who underwent surgery from April 2009 to September 2021. The inclusion criteria were initial surgery, endoscopic transsphenoidal surgery, preoperative normal pituitary function or pituitary dysfunction in one axis, and morphological preservation of the pituitary stalk. The branches of the pSHA consist mainly of the chiasmatic branches (Cb), infundibular branches (Ib), and descending branches (Db). We analyzed the association between postoperative pituitary function and preservation of these branches. Results Twenty patients met the criteria. Preoperative anterior pituitary function was normal in 18 patients, and there was isolated growth hormone deficiency in two patients. No patient had preoperative diabetes insipidus (DI). Anterior pituitary function was unchanged postoperatively in eight patients. Of these eight patients, bilateral preservation of pSHA Ib was confirmed in seven patients. Bilateral preservation of pSHA Ib was the only factor associated with preserved anterior pituitary function ( p  < 0.01). Fifteen patients were free of permanent DI, and the preservation of any given pSHA branch produced no significant difference in the postoperative occurrence of permanent DI. Conclusions Our study shows that bilateral preservation of pSHA Ib provides favorable postoperative anterior pituitary function in craniopharyngioma surgery; however, such preservation may have little effect on the postoperative occurrence of DI.

The precise understanding of hypothalamic injury (HI) patterns and their relationship with different craniopharyngioma (CP) classifications remains poorly addressed. Here, four HI patterns after CP resection based on endoscopic observation were introduced. A total of 131 CP cases treated with endoscopic endonasal approach (EEA) were reviewed retrospectively and divided into four HI patterns: no‐HI, mild‐HI, unilateral‐HI and bilateral‐HI, according to intraoperative findings. The outcomes were evaluated and compared between groups in terms of weight gain, endocrine status, electrolyte disturbance and neuropsychological function before and after surgery. A systematic correlation was found between CP origin and subsequent HI patterns. The majority of intrasellar and suprasellar stalk origins lead to a no‐HI pattern, the central‐type CP mainly develops a mild or bilateral HI pattern, and the majority of tumors with hypothalamic stalk origins result in unilateral HI and sometimes bilateral HI patterns. The proportion of tumors with a maximum diameter >3 cm in the no‐HI group was higher than that in the mild‐HI group, BMI and quality of life in the no‐HI group showed better results than those in the other groups. The incidence of new‐onset diabetes insipidus in the bilateral‐HI group was significantly higher than that in the other groups. Memory difficulty was observed mainly in the unilateral‐HI and bilateral‐HI groups. However, the outcomes of electrolyte disturbance, sleep, and cognitive disorder in the unilateral‐HI group were significantly better than those in the bilateral‐HI group. This study suggests the possibility of using pre‐ and intraoperative observation of CP origin to predict four HI patterns and even subsequent outcomes after tumor removal. This study provided possibility to use the pre‐ and intraoperative observation of craniopharyngiomas origin to predict the four hypothalamic injury patterns and subsequent outcomes after tumor removal.

Abstract BACKGROUND Compressive optic neuropathy is the most common indication for transsphenoidal surgery for pituitary adenomas. Optical coherence tomography (OCT) is a useful visual assessment tool for predicting postoperative visual field recovery. OBJECTIVE To analyze visual parameters and their association based on long-term follow-up. METHODS Only pituitary adenoma patients with abnormal visual field defects were selected. A total of 188 eyes from 113 patients assessed by visual field index (VFI) and 262 eyes from 155 patients assessed by mean deviation (MD) were enrolled in this study. Postoperative VFI, MD, and retinal nerve fiber layer (RNFL) thickness were evaluated and followed up. After classifying the patients into normal (>5%) and thin (<5%) RNFL groups, we investigated whether preoperative RNFL could predict visual field outcomes. We also observed how RNFL changes after surgery on a long-term basis. RESULTS Both preoperative VFI and MD had a linear proportional relationship with preoperative RNFL thickness. Sustained improvement of the visual field was observed after surgery in both groups, and the degree of improvement over time in each group was similar. RNFL thickness continued to decrease until 36 mo after surgery (80.2 ± 13.3 μm to 66.6 ± 11.9 μm) while visual field continued to improve (VFI, 61.8 ± 24.5 to 84.3 ± 15.4; MD, −12.9 ± 7.3 dB to −6.3 ± 5.9 dB). CONCLUSION Patients with thin preoperative RNFL may experience visual recovery similar to those with normal preoperative RNFL; however, the probability of normalized visual fields was not comparable. RNFL thickness showed a strong correlation with preoperative visual field defect. Long-term follow-up observation revealed a discrepancy between anatomic and functional recovery. Graphical Abstract Graphical Abstract

Background To date, there are no validated intraoperative tools to predict postoperative visual function following endoscopic endonasal surgery (EES). Assessment of post-surgical vision during surgery can help in postoperative planning and disposition and inform surgical decisions in real-time. The objective of this study was to evaluate the capability of intraoperative endoscopic indocyanine green (ICG) angiography to measure optic chiasm perfusion and determine its relationship with postoperative visual function. Methods A retrospective review was performed on patients undergoing EES for sellar and suprasellar lesions. ICG was injected prior to surgical closure at a time when the optic chiasm and anterior circulation were visible. Luminescence of the superior hypophyseal artery (SHA) branches enveloping the optic chiasm was registered 10 seconds after ICG penetration into the anterior cerebral arteries (ACAs). Pre and post-operative visual acuity and field exams were used to assess visual function. Patients with and without new deficits were compared to examine statistical association with intraoperative ICG findings. Results Twenty patients were included (mean age 49 years, 55% female). Eighteen patients displayed stable or improved vision after resection and demonstrated luminescence of all chiasmatic branches within 10 s of ACA fluorescence. Two patients experienced new postoperative visual deficits. Upon review, their ICG administrations showed no fluorescence of the SHA branches enveloping the chiasm. A lack of chiasm fluorescence within ten seconds of ACA fluorescence was associated with new postoperative vision deficits ( p  = 0.005). Conclusions This study shows that the lack of ICG fluorescence of SHA branches at the chiasm correlates with ischemic changes and new post-operative bitemporal hemianopsia. Lack of chiasm fluorescence after 10 seconds of observation reflects compromised chiasm perfusion and likely new post-surgical visual deficits.

Abstract Background We do not fully understand how hypercortisolism causes central hypothyroidism or what factors influence recovery of the hypothalamic-pituitary-thyroid axis. We evaluated thyroid function during and after cure of Cushing syndrome (CS). Methods We performed a retrospective cohort study of adult patients with CS seen from 2005 to 2018 (cohort 1, c1, n = 68) or 1985 to 1994 (cohort 2, c2, n = 55) at a clinical research center. Urine (UFC) and diurnal serum cortisol (F: ~8 am and ~midnight [pm]), morning 3,5,3′-triiodothyronine (T3), free thyroxine (FT4), and thyrotropin (TSH) (c1) or hourly TSH from 1500 to 1900 h (day) and 2400 to 04000 h (night) (c2), were measured before and after curative surgery. Results While hypercortisolemic, 53% of c1 had central hypothyroidism (low/low normal FT4 + unelevated TSH). Of those followed long term, 31% and 44% had initially subnormal FT4 and T3, respectively, which normalized 6 to 12 months after cure. Hypogonadism was more frequent in hypothyroid (69%) compared to euthyroid (13%) patients. Duration of symptoms, morning and midnight F, adrenocorticotropin, and UFC were inversely related to TSH, FT4, and/or T3 levels (r = –0.24 to –0.52, P < .001 to 0.02). In c2, the nocturnal surge of TSH (mIU/L) was subnormal before (day 1.00 ± 0.04 vs night 1.08 ± 0.05, P = .3) and normal at a mean of 8 months after cure (day 1.30 ± 0.14 vs night 2.17 ± 0.27, P = .01). UFC greater than or equal to 1000 μg/day was an independent adverse prognostic marker of time to thyroid hormone recovery. Conclusions Abnormal thyroid function, likely mediated by subnormal nocturnal TSH, is prevalent in Cushing syndrome and is reversible after cure.

Background Transsphenoidal surgery is the preferred first-line therapy for most pituitary adenoma(PA), and the conventional strategy of treatment is intracapsular resection(IR). The protocol of extracapsular resection(ER), which considers the pseudocapsule as the PA boundary for surgical removal, has also been introduced gradually. In this study, the clinical efficacies and complications were explored and compared between these two procedures. Methods A systematic literature review was performed in the PubMed, EMBASE, Web of Science and Cochrane databases. Articles comparing between IR and ER were included. Results There were 7 studies containing 1768 cases in accordance with the inclusion criteria. Although the meta-analysis showed no significant difference in complete resection, a sensitivity analysis revealed that ER was more conducive to total PA resection than IR. Moreover, we found a significant difference in favor of ER regarding biochemical remission. Furthermore, there was no significant difference in the incidence rate of certain complications, such as hormone deficiency, diabetes insipidus, intraoperative cerebrospinal fluid(CSF) and postoperative CSF leakage. However, a sensitivity analysis suggested that IR decreased the risk of intraoperative CSF leakage. Conclusions This meta-analysis unveiled that ER contributed to biochemical remission. To some extent, our results also showed that ER played a positive role in complete resection, but that IR reduced the incidence of intraoperative CSF leakage. However, the available evidence needs to be further authenticated using well-designed prospective, multicenter, randomized controlled clinical trials.

The microsurgical pseudocapsule can be found in the transition zone between an adenoma and the surrounding normal pituitary tissue. We investigated the precise histology of the pseudocapsule. Furthermore, we evaluated the remission rate, the changes in pituitary function, and the recurrence rate after intensive resection of the pseudocapsule. In 616 patients with pituitary adenomas (Hardy Types I-III) over a period of 14 years, we introduced intensive resection of the microsurgical pseudocapsule to achieve complete tumor removal. A combined pituitary function test and radiological study were performed on the patients before surgery, 1 year after surgery, and at subsequent 1.5-year intervals 2 to 13 years postoperatively. Microsurgical pseudocapsules were identified in 343 (55.7%) of 616 patients, and the distinct microsurgical pseudocapsules were observed in 180 (52.5%) of these patients. In the remaining 163 patients, the microsurgical pseudocapsules were incompletely developed. Tumor cluster infiltration was present in the pseudocapsule in 71 (43.6%) of these patients. Aggressive resection of the microsurgical pseudocapsule was more often required in larger tumors than in smaller ones. The presence of a pseudocapsule was slightly more frequent in prolactin-secreting tumors (70.9%) than in growth hormone-secreting (55.0%) and adrenocorticotropic hormone-secreting (40.0%) tumors. In the 243 patients of the total resection group who underwent combined pituitary function tests more than 2 times after surgery, the surgical remission rate was 99.1% in clinically nonfunctional tumors, 88% in growth hormone-secreting, 70.6% in prolactin-secreting, and 100% in adrenocorticotropic hormone-secreting tumors. The surgical remission rate was 86.2% in the presence of a pseudocapsule and 94.3% in the absence of a pseudocapsule. Preoperative hypopituitarism improved in 140 patients (57.6%), persisted in 47 patients (19.3%), and was aggravated in 33 patients (13.6%). There was no statistical difference in improvement or deterioration of pituitary function according to the existence or absence of the pseudocapsule. The tumor recurrence rate was 0.8% in the total resection group and was 42.1% in the subtotal resection group. We have shown that tumor tissue is frequently present within the pseudocapsule, suggesting that any tumor remnant in the pseudocapsule could be a source of recurrence and an obstacle to achieving complete remission. These results indicate that intensive resection of the pseudocapsule could result in a higher remission rate without deteriorating pituitary function.