Practice patterns in the management of recurrent and residual non-functioning pituitary adenomas: Results from a Canada-wide survey

Abstract

Background There is no consensus regarding the management and postoperative follow-up of non-functioning pituitary adenomas (NFAs) in the setting of recurrent or residual disease. Subsequent treatment options include continued follow-up, re-resection or radiotherapy. To address this gap and better understand current practice patterns, we surveyed neurosurgeons and radiation oncologists in Canada. Methods Neurosurgeons and radiation oncologists (ROs) across Canada were invited to complete a standardized online questionnaire. Summary statistics were computed, and Fisher's Exact tests were performed to assess significance. Qualitative analyses were performed through open and axial coding. Results Thirty-three participants completed the questionnaires, with neurosurgeons representing a majority of respondents ( n = 20 vs n = 13). When treating giant (>3 cm) tumors, 90.9% of neurosurgeons in practice for less than 10 years reported using an endoscopic approach, as compared to only 66.7% of neurosurgeons in practice for 10 years of more. Additionally, neurosurgeons who were newer to practice had a greater tendency to advocate for stereotactic radiosurgery (SRS) or re-resection (54.5% and 36.4%, respectively), as compared to older surgeons who showed a higher propensity (22.2%) to advocate for observation. The presence of cavernous sinus extension appeared to encourage ROs to offer radiotherapy sooner (61.4%), as compared to 40% of neurosurgeons. Conclusions Our results identified both variations and commonalities in practice amongst Canadian neurosurgeons. Approaches deviated in the setting of residual tumor based on years of practice. This work provides a critical foundation for future studies aiming to define evidence-based best practices in the management of NFAs.

Primary Endoscopic Endonasal Management of Giant Pituitary Adenomas: Outcome and Pitfalls from a Large Prospective Multicenter Experience

“…Tumoral resection, although technically challenging, constitutes the mainstay for treatment and is usually performed in tertiary centers with large volumes of skull base referrals and SRS or SRT facilities. Since complete resection can be achieved in only a minority of patients, and NTR and STR are reported in less than 50% in most series, a multimodality approach is usually considered, with fractionated stereotactic radiosurgery or stereotactic radiotherapy as adjuvant treatment in most cases of both secreting and non-secreting GPAs [ 22 , 23 , 24 , 25 ]. Even though the transcranial routes via pterional, subfrontal, or fronto-orbitozygomatic approaches represent still a valid alternative to remove the parasellar tumoral component, they provide only limited exposure of the intrasellar region.…”

Prediction of the Recurrence of Non-Functioning Pituitary Adenomas Using Preoperative Supra-Intra Sellar Volume and Tumor-Carotid Distance

“…NFPAs are benign intracranial tumors arising from adenohypophyseal cells. Patients usually visit the clinic much later than the time of disease onset, with symptoms caused by the compressed tissue surrounding the macroadenoma ( 1 , 5 ). Therefore, the treatment and prognostic factors for NFPAs should be taken seriously.…”

“…However, some subtypes of NFPAs, such as silent ACTH adenoma, Pit-1-positive adenomas or plurihormonal adenomas, have a high risk of recurrence but can only be affirmed by postoperative pathological tests. The monoclonal antibody Ki-67 is often used as a tool to aid in recurrence prediction, but its accuracy is still controversial ( 1 ). Currently, there are few reliable indices for the prediction of the recurrence of NFPAs ( 8 ).…”

“…Nonfunctioning pituitary adenomas (NFPAs), accounting for 15% -54% of all types of pituitary adenomas (PAs) (1), are characterized by a lack of hormonal oversecretion except for the high level of prolactin, as well as subclinical or silent hormone dysfunction caused by the "pituitary stalk effect" (2). Over 60% of NFPAs are macroadenomas (diameter over 10 mm), and 57% are invasive (3).…”

Pituitary Tumours

“…Small and asymptomatic recurrences need to be followed up for tumour growth and clinical factors. Elderly with severe systemic diseases is managed conservatively [75][76][77][78][79][80][81][82][83][84][85][86].…”