Recovery of Cranial Nerve Deficits in Patients Presenting with Pituitary Apoplexy: A Case Series.

Background Pituitary apoplexy (PA) is a rare complication of pituitary tumors that can present with a myriad of symptoms, including sudden onset cranial nerve deficits. After patient stabilization and hormone replacement, surgical decompression is often recommended. The timing of surgical decompression remains controversial. In this case series, we describe our institutional experience pertaining to the cranial nerve recovery in patients who underwent endoscopic endonasal transsphenoidal (EETS) surgery for PA while evaluating outcome based on tumor stage using the suprasellar infrasellar parasellar anterior posterior (SIPAP) classification. Design Present study is a single-institution retrospective cohort. Methods A retrospective review of all EETS cases for pituitary tumor resection between November 2009 and August 2018. Queries of the hospital database were completed by trained personnel to identify cases of PA treated using the EETS approach. Baseline characteristics, tumor type, endocrine data, and SIPAP classification based on preoperative magnetic resonance imaging (MRI) and operation characteristics were extracted from medical records. Postoperative results were extracted for the duration of the follow-up period available for each patient. Results Fifteen cases of PA were identified. Patient follow-up period was a mean of 30 months. The cranial nerve deficits present at admission were visual deficit (33%); unilateral third nerve palsy (47%) and unilateral sixth nerve palsy (27%). No fourth nerve palsies were observed. Following EETS, 60% of patients with preoperative visual deficit had normal visual fields. For those with third and sixth nerve palsies preoperatively, 43 and 75%, respectively, had return to normal function postoperatively. SIPAP tumor characteristics were not related to postoperative cranial nerve recovery. Conclusion In this series of surgically treated patients with pituitary apoplexy, all cranial nerve deficits normalized or improved following surgery. The tumor SIPAP classification was not associated with patient outcome. Though in a small series, the presented results suggest surgical treatment is beneficial for these patients.

Clinical Outcomes of Endoscopic Endonasal Odontoidectomy: A Single-Center Experience.

BACKGROUND: Odontoidectomy for basilar invagination and craniovertebral junction pathology traditionally has been performed using a transoral route. However, the endoscopic endonasal approach to the anterior craniovertebral junction may offer safer and more effective access when compared with transoral approaches. The objective of this study is to review the surgical outcomes and complications associated with endoscopic endonasal odontoidectomy. METHODS: This study is a retrospective chart review of all adult patients who underwent an endoscopic endonasal odontoidectomy at a single tertiary care center between January 2011 and May 2019. RESULTS: Seventeen patients who underwent endoscopic endonasal odontoidectomy were included. The median age at admission was 67 years (range: 33-84 years) and 65% of the patients were female. One patient (1/17, 6%) had vertebral artery injury, which had to be coiled with no neurologic deficits, and 4 patients (4/17, 24%) had intraoperative CSF leaks with no postoperative leak. Fourteen (14/17, 82%) patients were extubated by postoperative day 1. Three patients (3/17, 18%) developed postoperative sinus infections and required antibiotics. Eight patients (8/17, 47%) developed transient postoperative dysphagia. One patient (1/17, 6%) had postoperative epistaxis and 1 patient (1/17, 6%) had postoperative lower cranial nerve symptoms. The median length of hospital stay was 13 days (range: 2-44 days). CONCLUSIONS: Although the transoral approach has been the traditional route for anterior decompression of the craniovertebral junction, endoscopic endonasal odontoidectomy is a feasible and well-tolerated procedure associated with satisfactory patient outcomes and low morbidity.

Planum-Clival Angle Classification: A Novel Preoperative Evaluation for Sellar/Parasellar Surgery.

Objective Endonasal approaches are increasingly used to treat sellar pathologies, leading to increased interest in achieving maximal safe resection. We propose a tool-the planum-clival angle (PCA)-and explore its surgical implications for sellar pathology resections. Design Retrospective analysis. Participants Consecutive patients with pituitary lesions between 2003 and 2013. Outcome Measures The PCA and suprasellar extension ratios; head position and extent of surgical resection. Results We enrolled 89 patients (ages 21-88 years). There were 15 type A patients (17%), 13 with suprasellar extension (89%) and ratios between 0.12 and 0.70. There were 61 type B patients (70%), 49 with suprasellar extension (81%) and ratios from 0.09 to 0.66. Finally, there were 13 type C patients (13%), 10 with suprasellar extension (73%) and ratios from 0.21 to 0.76. Type B was treated with a sphenoidectomy and neutral head positioning, type A with 10 to 20 degrees of flexion and an additional posterior ethmoidectomy with or without posterior planum resection, and type C with 10 to 20 degrees of extension and an additional superior clival resection. Conclusions Sellar anatomy and PCA influence the growth patterns of sellar lesions. Thus PCA should allow for better surgical planning and thereby improve surgical efficacy.

Interstitial brachytherapy in the management of persistent head and neck disease after definitive external beam radiation therapy.

PURPOSE: Persistent disease after definitive external beam radiation therapy for head and neck (H&N) malignancies negatively impacts survival. In this series, the effectiveness of low-dose-rate brachytherapy in the management of persistent H&N disease is explored. METHODS: All patients who received brachytherapy for persistent H&N disease between 1987 and 2002 were identified. Tumor and treatment characteristics and toxicities were recorded. Progression-free survival and overall survival estimates were generated. The influence of prognostic factors was determined. RESULTS: Twelve patients were analyzable. Brachytherapy was given curatively (n=4) in patients not amenable to surgery or in combination with surgical dissection to avoid carotid resection (n=8). Seven patients had disease progression with a median time to progression of 11 months (95% confidence interval: 0-22.9). The only negative prognostic factor was time to re-treatment (brachytherapy >4 months) after definitive treatment (p=0.003). Overall survival at 1 and 5 years was 50% and 21%, respectively. Toxicity was limited to one major complication (fistula) and five minor toxicities: low-grade radionecrosis (n=2), cellulitis (n=1), and wound dehiscence (n=2). CONCLUSION: In patients with persistent disease, brachytherapy is an appealing re-treatment alternative. When combined with neck dissection, brachytherapy yields less morbidity than the surgical alternative of carotid resection.

Brachytherapy in the retreatment of patients with new primary head and neck cancer.

OBJECTIVE: Re-treatment for cure of the Head and Neck (H&N) region is therapeutically challenging. In this review we explore the long-term results of Ir(192) low-dose-rate (LDR) brachytherapy in the select subgroup of patients treated for a new H&N malignancy. METHODS & MATERIAL: Thirteen patients received brachytherapy between 1987-2004 for a new primary H&N cancer, six of whom had been retreated previously. Brachytherapy was given as a monotherapy in eight patients and delivered adjuvantly in five patients. Three of the thirteen patients had advanced disease at the time of diagnosis. MAIN OUTCOME MEASURES: In addition to the known prognostic factors of stage and site, intent of brachytherapy and prior re-treatment status were assessed for their influence on local control (LC) and overall survival (OS). RESULTS: Local control differed by disease stage of the new primary tumor. With a median follow-up of 50 months, mean progression-free survival was 50.2 months [95%CI = 30.1-70.4] and the 2-year rate of LC was 58%. Adjuvant brachytherapy following surgery resulted in poor LC and OS due to advanced disease at diagnosis. Prior retreatment did not appear to affect LC or OS. OS at 2 and 5 years was 69% and 38%, respectively. There were no cases of grade III toxicity. CONCLUSIONS: LDR Brachytherapy for a new primary H&N cancer is a well-tolerated retreatment alternative that results in good local control. Our results suggest that the best chance for long-term survival remains in the routine follow-up and early diagnosis of the new H&N malignancy.

Interstitial low-dose-rate brachytherapy in the treatment of recurrent head and neck malignancies.

BACKGROUND: Recurrent head and neck malignancies are therapeutically challenging. Brachytherapy is a retreatment alternative to external-beam radiation therapy (EBRT). METHODS: Patients receiving brachytherapy during 1987-2004 for recurrent head and neck cancer were identified. Tumor and treatment characteristics and toxicities were recorded. Progression-free survival (PFS) and overall survival (OS) estimates were generated. The influence of prognostic factors was determined. RESULTS: Eighty-two patients were analyzable. Analysis was limited to patients who had brachytherapy for a first recurrence (n = 45). Brachytherapy (> or = 55 Gy) was a monotherapy in 22 of 45 patients. As part of their salvage brachytherapy treatments, 14 patients also underwent surgery; 3 patients also underwent EBRT; and 6 patients underwent surgery, EBRT, and brachytherapy. Retreatment morbidity included acute toxicity (n = 7) and late toxicity (n = 18). Median PFS was 15 months, and locoregional control rates at 1 and 2 years were 50% and 37%, respectively. Time to progression differed by site of the primary tumor (p = .10). Median OS was 16 months, and OS at 2 and 5 years was 33% and 11%, respectively. CONCLUSIONS: Brachytherapy for recurrent head and neck cancer has an acceptable toxicity profile and is viable alternative to EBRT. Further optimization of the best sites and doses for neck brachytherapy is required.