Predictive model of resection in endoscopic endonasal approach for pituitary adenomas based on anatomical limits / Modelo predictivo de resección en abordaje endoscópico endonasal de adenomas hipofisarios basado en límites anatómicos

Introduction The aim of this project is to study several anatomical-radiological features of pituitary adenomas obtained from preoperative radiological images and to analyze their relationship with the extent of resection achieved through the endoscopic endonasal approach. The second objective was to create a prediction model of the extent of resection. Material and methods We retrospectively evaluated 105 patients. Tumor volume, Knosp grade, suprasellar-diaphragm coefficient and invasion of the posterior compartment have been analyzed. The extent of resection was assessed by analyzing the postoperative magnetic resonance. We created the predictive scale using statistically independent variables. Results When each of the variables has been studied individually, a statistically significant value of all of them is appreciated to obtain a complete resection. However, only the Knosp grade and the suprasellar-diaphragm coefficient had a statistically significant value as independent variables. The sum of the Odds Ratio obtained from the Knosp scale, and the suprasellar-diaphragm coefficient gives the probability of complete resection. A new set of cases was employed to validate the scale. Conclusions The cavernous sinus invasion and the newly designed suprasellar diaphragm coefficient are directly related to the extent of resection in pituitary adenoma surgery performed by a transellar endoscopic approach. Moreover, based on both radiologic factors, a predictive scale may predict the probability of complete resection in a series of patients (AU)

Introducción El objetivo principal de este proyecto es estudiar diversas variables anatomo-radiológicas de los adenomas hipofisarios obtenidas a partir de imágenes radiológicas preoperatorias y analizar su relación con el grado de resección logrado mediante el abordaje endoscopio endonasal. El segundo objetivo ha sido crear un modelo de predicción del grado de resección tumoral. Material y métodos Se ha evaluado retrospectivamente a 105 pacientes, analizando el volumen tumoral, el grado de Knosp, el coeficiente supraselar-diafragma y la invasión del compartimento posterior. El grado de resección se ha evaluado mediante el análisis de la resonancia magnética postoperatoria. Se ha creado la escala predictiva empleando variables estadísticamente independientes. Resultados Al estudiar cada una de las variables de forma individual, se aprecia un valor estadísticamente significativo en cada una de ellas para obtener una resección completa. Sin embargo, tan solo el grado de Knosp y el coeficiente supraselar-diafragma tuvieron un valor estadísticamente significativo como variables independientes. Empleando la suma de la odds ratio obtenida de la escala Knosp y el coeficiente supraselar-diafragma, se ha obtenido la probabilidad de resección completa. Se ha empleado un nuevo conjunto de casos para validar la escala. Conclusiones La invasión del seno cavernoso y el coeficiente supraselar-diafragma son variables que están directamente relacionadas con el grado de resección en la cirugía de adenoma hipofisario realizada mediante un abordaje endoscópico transellar. Además, basándose en ambos factores radiológicos, se ha creado una escala predictiva que permite predecir la probabilidad de resección completa en una serie de pacientes (AU)

Predictive model of resection in endoscopic endonasal approach for pituitary adenomas based on anatomical limits.

INTRODUCTION: The aim of this project is to study several anatomical-radiological features of pituitary adenomas obtained from preoperative radiological images and to analyze their relationship with the extent of resection achieved through the endoscopic endonasal approach. The second objective was to create a prediction model of the extent of resection. MATERIAL AND METHODS: We retrospectively evaluated 105 patients. Tumor volume, Knosp grade, suprasellar-diaphragm coefficient and invasion of the posterior compartment have been analyzed. The extent of resection was assessed by analyzing the postoperative magnetic resonance. We created the predictive scale using statistically independent variables. RESULTS: When each of the variables has been studied individually, a statistically significant value of all of them is appreciated to obtain a complete resection. However, only the Knosp grade and the suprasellar-diaphragm coefficient had a statistically significant value as independent variables. The sum of the Odds Ratio obtained from the Knosp scale, and the suprasellar-diaphragm coefficient gives the probability of complete resection. A new set of cases was employed to validate the scale. CONCLUSIONS: The cavernous sinus invasion and the newly designed suprasellar diaphragm coefficient are directly related to the extent of resection in pituitary adenoma surgery performed by a transellar endoscopic approach. Moreover, based on both radiologic factors, a predictive scale may predict the probability of complete resection in a series of patients.

Treatment and outcome in 12 cases of olfactory neuroblastoma at Mexico´s National Cancer Institute: A retrospective clinical analysis and literature review.

INTRODUCTION: Olfactory neuroblastoma (ONB) is a malignant neoplasm that arises from the upper nasal vault. OBJECTIVE: We present a retrospective case series and clinical analysis of 12 ONB cases. MATERIALS AND METHODS: Patients with ONB treated at Mexico´s National Cancer Institute between 2011 and 2018. RESULTS: The Kadish proportion of B, C, and D stage was 16%, 58%, or 25%, respectively. Hyams Grade 1, 2, or 3 was 25%, 50%, and 25%, respectively. The most common surgical approach was the craniofacial in 5 cases (42%), followed by the transfacial in 4 cases (33%), and the endonasal endoscopic approach in 3 cases (25%). Gross total resection was achieved in 8 patients (67%). Five patients (42%) underwent a second operation due to recurrent/progressive disease. The surgical complication rate was 8.3%. Progression-free survival was 41 months and the mean overall survival was 63.6 months. CONCLUSIONS: Surgical resection followed by radiotherapy, and chemotherapy for metastatic and recurrent disease provides the best outcome in terms of survival and recurrence. To the best of our knowledge, this is the first series of cases reported in Mexico.

ANTECEDENTES: El neuroblastoma olfatorio es una neoplasia maligna que se origina en la bóveda nasal superior. OBJETIVO: Presentar una serie de casos y un análisis clínico retrospectivo. MÉTODO: Pacientes con neuroblastoma olfatorio tratados en el Instituto Nacional de Cancerología, de México, entre 2011 y 2018. RESULTADOS: La proporción de Kadish en las etapas B, C y D fue del 16, el 58 y el 25%, respectivamente. Los grados 1, 2 y 3 de Hyams fueron el 25, el 50 y el 25%, respectivamente. El abordaje quirúrgico más frecuente fue el craneofacial, en cinco casos (42%), seguido del transfacial en cuatro (33%) y del abordaje endoscópico endonasal en tres (25%). La resección total macroscópica se logró en ocho pacientes (67%). Cinco pacientes (42%) se sometieron a una segunda operación debido a enfermedad recurrente o progresiva. La tasa de complicaciones quirúrgicas fue del 8,3%. La sobrevida libre de progresión fue de 41 meses y la supervivencia media global fue de 63,6 meses. CONCLUSIONES: La resección quirúrgica seguida de radioterapia y quimioterapia para la enfermedad metastásica y recurrente proporciona el mejor resultado en términos de supervivencia y recurrencia. Hasta donde sabemos, esta es la primera serie de casos reportados en México.

Abordaje endoscópico al cavum de Meckel: resección endoscópica endonasal de schwannoma del nervio trigémino / Endoscopic approach to the Meckel's cave: endonasal endoscopic resection of a trigeminal schwannoma

RESUMEN El cavum de Meckel (CM) es un divertículo localizado en la fosa media adyacente al seno cavernoso. Las neoplasias de esta región son extremadamente raras y representan un desafío para el cirujano debido a las estructuras neurovasculares que se encuentran en la región. Para los tumores ubicados en esta área se han descrito diversos abordajes quirúrgicos, los cuales no logran una adecuada exposición a la porción anteromedial del CM. En la última década, se ha postulado el abordaje endoscópico endonasal extendido (AEE) como una alternativa quirúrgica para el manejo de lesiones ubicadas en esta región. Se presenta el caso de un paciente portador de un schwannoma del nervio trigémino situado en el CM derecho tratado mediante AEE.

ABSTRACT The Meckel's cave (CM) is a diverticulum located in the middle fossa adjacent to the cavernous sinus. The neoplasms of this region are extremely rare and represent a challenge for the surgeon due to the neurovascular structures that occupy and surround the parasellar region. For tumors located in this area, several surgical approaches have been described, all of which do not achieve an adequate exposure to the anteromedial portion of CM. In the last decade, the extended endonasal endoscopic approach (EEA) has been postulated as an alternative for the surgical management of tumors located in this region. We present the case of a patient with a trigeminal schwannoma located in the right CM treated by EEA.

Endoscopic Endonasal Odontoidectomy: Nuances of Neurosurgical Technique / Odontoidectomia endoscópica endonasal: nuances da técnica cirúrgica

Odontoidectomy is the treatment of choice for some diseases that cause irreducible ventral compression of the brainstem. In this study, we present our series emphasizing the technical nuances of endoscopic endonasal odontoidectomy

Odontoidectomia é o tratamento de escolha para algumas doenças que cursam com compressão irredutível do tronco encefálico. Neste trabalho, apresentamos nossa série enfatizando as nuances da técnica cirúrgica da odontoidectomia por via endonasal endoscópica.

Endoscopic and Microsurgical Approaches to the Cavernous Sinus ­ Anatomical Review

Cavernous sinus surgery has always represented a surgical challenge due to the great importance of the surrounding anatomical structures and to the high morbidity associated to it. Although the anatomy of this region has been extensively described, controversy remains related to the best treatment and approaches for different kinds of lesions. In this article, a literature review was performed on the surgical anatomy and approaches to the cavernous sinus.

A cirurgia da região do seio cavernoso sempre representou um desafio devido à grande importância das estruturas anatômicas e às altas taxas de morbidade associadas. Embora a anatomia da região tenha sido extensivamente descrita, permanece controverso o melhor tratamento e o acesso para diferentes tipos de lesão que acometem a região. Neste artigo foi realizada uma revisão de literatura focando a anatomia cirúrgica e os acessos à região do seio cavernoso.

Surgical outcomes of the endoscopic endonasal transsphenoidal approach for large and giant pituitary adenomas: institutional experience with special attention to approach-related complications / Resultados cirúrgicos do acesso endonasal endoscópico transesfenoidal para adenomas hipofisários grandes e gigantes: experiência institucional com ênfase às complicações relacionadas ao acesso cirúrgico

ABSTRACT Objective In this study, we investigate our institutional experience of patients who underwent endoscopic endonasal transsphenoidal approach for treatment of large and giant pituitary adenomas emphasizing the surgical results and approach-related complications. Method The authors reviewed 28 consecutive patients who underwent surgery between March, 2010 and March, 2014. Results The mean preoperative tumor diameter was 4.6 cm. Gross-total resection was achieved in 14.3%, near-total in 10.7%, subtotal in 39.3%, and partial in 35.7%. Nine patients experienced improvement in visual acuity, while one patient worsened. The most common complications were transient diabetes insipidus (53%), new pituitary deficit (35.7%), endonasal adhesions (21.4%), and cerebrospinal fluid leak (17.8%). Surgical mortality was 7.1%. Conclusions Endoscopic endonasal transsphenoidal surgery is a valuable treatment option for large or giant pituitary adenomas, which results in high rates of surgical decompression of cerebrovascular structures.

RESUMO Objetivo Neste manuscrito investigamos a experiência institucional com o acesso endonasal endoscópico transesfenoidal no tratamento de adenomas hipofisários grandes e gigantes com ênfase às complicações relacionadas ao acesso cirúrgico. Método Foram incluídos neste estudo 28 pacientes consecutivos submetidos à cirurgia entre Março de 2010 e Março de 2014. Resultados O diâmetro médio pré-operatório dos tumores era 4,6 cm. Uma ressecção total foi obtida em 14,3%; quase total, em 10,7%; subtotal, em 39,3% e parcial, em 35,7%. Nove pacientes evoluíram com melhora na acuidade visual, enquanto um paciente apresentou piora da função visual. As complicações mais comuns foram diabetes insipidus transitório (53%), novo défice hipofisário (35,7%), sinéquias endonasais (21,4%) e fistula liquórica (17,8%). A mortalidade cirúrgica foi 7,1%. Conclusões A cirurgia por via endonasal endoscópica transesfenoidal é uma opção terapêutica extremamente útil para adenomas hipofisários grandes e gigantes, a resultar numa significativa descompressão das estruturas cerebrovasculares.

Endoscopic combined “transseptal/transnasal” approach for pituitary adenoma: reconstruction of skull base using pedicled nasoseptal flap in 91 consecutive cases / O acesso endoscópico transeptal/transnasal em cirurgias de resseção de adenoma de hipófise: reconstrução da base do crânio combinado com a criação do flap naso-septal pediculado em 91 pacientes consecutivos

Objective The purpose of this study was to describe the endoscopic combined “transseptal/transnasal” approach with a pedicled nasoseptal flap for pituitary adenoma and skull base reconstruction, especially with respect to cerebrospinal fluid (CSF) fistula.Method Ninety-one consecutive patients with pituitary adenomas were retrospectively reviewed. All patients underwent the endoscopic combined “transseptal/transnasal” approach by the single team including the otorhinolaryngologists and neurosurgeons. Postoperative complications related to the flap were analyzed.Results Intra- and postoperative CSF fistulae were observed in 36 (40%) and 4 (4.4%) patients, respectively. Among the 4 patients, lumbar drainage and bed rest healed the CSF fistula in 3 patients and reoperation for revision was necessary in one patient. Other flap-related complications included nasal bleeding in 3 patients (3.3%).Conclusion The endoscopic combined “transseptal/transnasal” approach is most suitable for a two-surgeon technique and a pedicled nasoseptal flap is a reliable technique for preventing postoperative CSF fistula in pituitary surgery.

Objetivo O objetivo deste estudo foi descrever o acesso endoscópico transeptal/transnasal combinado com a criação do flap naso-septal pediculado para reconstrução da base do crânio em cirurgias de resseção de adenoma de hipófise, especialmente nos casos que ocorrem fístula líquido cefalorraquidiano (FLC).Método Noventa e um pacientes consecutivos portadores de adenoma de hipófise foram retrospectivamente revisados. Complicações pós-operatórias relacionadas ao flap foram analisadas.Resultados Fístulas líquido cefalorraquidiano intra e pós-operatórias foram observadas em 36 (40%) e 4 (4,4%) dos pacientes, respectivamente. Entre os 4 pacientes, drenagem lombar e repouso absoluto foram suficientes para o fechamento da fístula e intervenção cirúrgica foi necessária em apenas um paciente. Outra complicação relacionada ao flap foi o sangramento em 3 (3,3%) dos pacientes.Conclusão O acesso endoscópico transeptal/transnasal combinado é melhor aplicado quando realizado por dois cirurgiões e o flap naso-septal é uma técnica eficaz para prevenção de fístula pós-operatória em cirurgias de hipófise.

[Three-dimensional endoscopic endonasal study of skull base anatomy]. / Estudio endoscópico endonasal 3D de la anatomía de la base de cráneo.

INTRODUCTION: Training in dissection of the paranasal sinuses and the skull base is essential for anatomical understanding and correct surgical techniques. Three-dimensional (3D) visualisation of endoscopic skull base anatomy increases spatial orientation and allows depth perception. OBJECTIVE: To show endoscopic skull base anatomy based on the 3D technique. METHODS: We performed endoscopic dissection in cadaveric specimens fixed with formalin and with the Thiel technique, both prepared using intravascular injection of coloured material. Endonasal approaches were performed with conventional 2D endoscopes. Then we applied the 3D anaglyph technique to illustrate the pictures in 3D. RESULTS: The most important anatomical structures and landmarks of the sellar region under endonasal endoscopic vision are illustrated in 3D images. CONCLUSION: The skull base consists of complex bony and neurovascular structures. Experience with cadaver dissection is essential to understand complex anatomy and develop surgical skills. A 3D view constitutes a useful tool for understanding skull base anatomy.