Quality of care evaluation in non-functioning pituitary adenoma with chiasm compression: visual outcomes and timing of intervention clinical recommendations based on a systematic literature review and cohort study

Abstract

Purpose Surgery in patients with non-functioning pituitary macroadenomas (NFMA) is effective in ameliorating visual function. The urgency for decompression, and preferred timing of surgery related to the preoperative severity of dysfunction is unknown. Methods Systematic review for evidence to provide clinical guidance for timing of surgical decompression of the optic chiasm, and a cohort study of 30 NFMA patients, in whom mean deviation (MD), and severity of visual dysfunction was assessed. Results Systematic review 44 studies were included with a total of 4789 patients. Postoperatively, visual field defects improved in 87.0% of patients, stabilized in 12.8% and worsened in 1.0%. Specific protocols regarding timing of surgery were not reported. Only seven studies (16.7%) reported on either the duration of visual symptoms, or diagnostic, or treatment delay. Cohort study 30 NFMA patients (50% female, 60 eyes, mean age 58.5 ± 14.8 years), had a median MD of − 5.3 decibel (IQR − 3.1 to − 10.1). MD was strongly correlated with clinical severity (r = − 0.94, P < 0.0001), and were used for severity of defects cut-off values: (1) normal > − 2 dB, (2) mild − 2 dB to − 4 dB, (3) moderate − 4 to − 8 dB, (4) severe − 8 to − 17 dB, (5) very severe < − 17 dB. Conclusion Surgical decompression is highly effective in improving visual function. Uniform, quantitative grading of visual dysfunction was lacking. MD is a promising quantitative outcome measure. We provide recommendations for the evaluation of timing of surgery, considering severity of visual impairment, which will need further validation based on expert clinical practice.

Non-functioning pituitary macroadenomas: factors affecting postoperative recurrence, and pre- and post-surgical endocrine and visual function

“…8 Cranio-caudal dimension of the NPFA, which determines the degree of compromise of the visual apparatus, clearly correlated with visual field defects in our series as also shown in a recent systematic review which examined 44 studies with a total of 4789 patients. 29 Neither age nor tumour volume had any correlation with endocrine dysfunction (such as hypogonadism, hypothyroidism or adrenal insufficiency) or headaches as shown by previous studies. 13,30 Functional recovery in at least one of the endocrine deficits after transsphenoidal surgery in 24% of patients in our cohort is comparable with the studies by Little et al 11 and Najmaldin et al 13 However, other authors reported higher rates of hormonal recovery, 12,31,32 probably because of the tumour characteristics in the individual cases these series.…”

“…[14][15][16][17][18][19][20][21][22][23][24][25][26][27] Tumour size was also found to influence postoperative visual recovery in previous studies. 28,29 However, there is discrepancy in the reported effects of age and tumour volume on preoperative headache, endocrine symptoms, and the recovery/ improvement of these postoperatively. 11,13,[30][31][32] Therefore, we share the experience in managing NFPAs in our regional referral centre in the United Kingdom (UK) outlining the pre-and postsurgical outcomes.…”

Chiasmal herniation following treatment of pituitary macroadenoma

“…The HFA perimetry, initially developed for glaucoma patients, allows a more exact outcome and comparison [40,41]. Recent studies show that this scale can also be used to investigate VFs in patients with pituitary adenomas [33]. Reason to use the MD instead of the VFI was because MD scores have been measured during the whole follow-up period of the patients in this study, where the VFI has been introduced in 2011.…”

“…The MD score depicts the VFs compared to a healthy control group. A recent literature study showed that this score can be used to assess the VF for patients with pituitary adenomas [33]. Unreliable measurements, based on loss of fixation, falls positive and falls negative measurements, were excluded, as reviewed by two independent observers (M.T., I.C.N).…”

Surgical Outcome of Endoscopic Transsphenoidal Surgery for Giant Pituitary Adenoma

“…Non-secreting tumors usually do not present until they are sufficiently large enough to cause neurological deficits by mass effect. They also can be classified according to size for microadenoma less than one centimeter, macroadenoma more than 1cm and giant adenoma more than 4cm [4][5] . Giant pituitary adenomas are defined as tumors larger than 4 cm that usually extend within 6 mm of the foramen of Monro.…”