title: Combined high-field intraoperative magnetic resonance imaging and endoscopy increase extent of resection and progression-free survival for pituitary adenomas.
abstract: OBJECTIVE
  The clinical benefit of combined intraoperative magnetic resonance imaging (iMRI) and endoscopy for transsphenoidal pituitary adenoma resection has not been completely characterized. This study assessed the impact of microscopy, endoscopy, and/or iMRI on progression-free survival, extent of resection status (gross-, near-, and sub-total resection), and operative complications.
  
  
  METHODS
  Retrospective analyses were performed on 446 transsphenoidal pituitary adenoma surgeries at a single institution between 1998 and 2012. Multivariate analyses were used to control for baseline characteristics, differences during extent of resection status, and progression-free survival analysis.
  
  
  RESULTS
  Additional surgery was performed after iMRI in 56/156 cases (35.9%), which led to increased extent of resection status in 15/156 cases (9.6%). Multivariate ordinal logistic regression revealed no increase in extent of resection status following iMRI or endoscopy alone; however, combining these modalities increased extent of resection status (odds ratio 2.05, 95% CI 1.21-3.46) compared to conventional transsphenoidal microsurgery. Multivariate Cox regression revealed that reduced extent of resection status shortened progression-free survival for near- versus gross-total resection [hazard ratio (HR) 2.87, 95% CI 1.24-6.65] and sub- versus near-total resection (HR 2.10; 95% CI 1.00-4.40). Complication comparisons between microscopy, endoscopy, and iMRI revealed increased perioperative deaths for endoscopy versus microscopy (4/209 and 0/237, respectively), but this difference was non-significant considering multiple post hoc comparisons (Fisher exact, p = 0.24).
  
  
  CONCLUSIONS
  Combined use of endoscopy and iMRI increased pituitary adenoma extent of resection status compared to conventional transsphenoidal microsurgery, and increased extent of resection status was associated with longer progression-free survival. Treatment modality combination did not significantly impact complication rate.
authors.affiliation: Department of Neurosurgery, Washington University School of Medicine, 660 S Euclid Ave, Campus Box 8057, St. Louis, MO, USA.
authors.forename: Peter T
authors.initials: PT
authors.lastname: Sylvester
authors.forename: John A
authors.initials: JA
authors.lastname: Evans
authors.forename: Gregory J
authors.initials: GJ
authors.lastname: Zipfel
authors.forename: Richard A
authors.initials: RA
authors.lastname: Chole
authors.forename: Ravindra
authors.initials: R
authors.lastname: Uppaluri
authors.forename: Bruce H
authors.initials: BH
authors.lastname: Haughey
authors.forename: Anne E
authors.initials: AE
authors.lastname: Getz
authors.forename: Julie
authors.initials: J
authors.lastname: Silverstein
authors.forename: Keith M
authors.initials: KM
authors.lastname: Rich
authors.forename: Albert H
authors.initials: AH
authors.lastname: Kim
authors.forename: Ralph G
authors.initials: RG
authors.lastname: Dacey
authors.forename: Michael R
authors.initials: MR
authors.lastname: Chicoine
mesh_terms: D000328:Adult; D000368:Aged; D018572:Disease-Free Survival; D004724:Endoscopy / Q000379:methods*; D005260:Female; D006801:Humans; D008279:Magnetic Resonance Imaging / Q000379:methods*; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D010911:Pituitary Neoplasms / Q000401:mortality* / Q000601:surgery*; D012189:Retrospective Studies; D055815:Young Adult