Hipofiz makroadenomlarında cerrahi tedavi etkinliğini öngörmede manyetik rezonans görüntüleme bulgularının değerlendirilmesi
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Dosyalar
Tarih
2023
Yazarlar
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Yayıncı
Selçuk Üniversitesi, Tıp Fakültesi
Erişim Hakkı
info:eu-repo/semantics/openAccess
Özet
Amaç: Hipofiz tümörleri tüm yaş gruplarında en sık görülen intrakranial tümörlerdendir. Hipofiz tümörlerinin büyük kısmını adenomlar oluşturur. Hipofiz adenomları aşırı hormon üretimi, çevre dokulara bası ya da invazyon yaparak klinik bulgulara neden olabilir. Cerrahi tedavi tümörün kitle etkisini ortadan kaldırmayı, fonksiyonel hipofiz adenomlarında aşırı hormon üretimini ortadan kaldırmayı, hem hipofiz fonksiyonunu hem de komşu sinir yapıları korumayı ve gelecekteki nüks riskini ortadan kaldırmayı veya azaltmayı amaçlar. Cerrahi tedavide farklı yöntemler mevcut olsa da transnazal transsfenoidal yaklaşım minimal invaziv olması nedeniyle altın standart haline gelmiştir. Manyetik rezonans görüntüleme (MRG), sellar bölgeyi değerlendirmek için en iyi teknik olarak kabul edilir. Adenomun boyut ve çevre yapılara invazyon gibi özellikleri MRG ile değerlendirilebilir. Hipofiz makroadenomlarının MRG'de tespit edilen çevre yapılara invazyonu cerrahi rezeksiyon sonrası sonuçlarla ilişkilidir. Çalışmamızda hipofiz makroadenomlarında tedavi öncesi elde olunan dinamik kontrastlı hipofiz MRG bulguları retrospektif olarak incelenip cerrahi tedavi başarısını etkileyebilecek faktörlerin ayrıntılı değerlendirilmesi amaçlanmıştır. Belirlenen parametrelerin operasyon sonrası rezidü tümör kalması ile ilişkisini ortaya koymayı ve etkinliğini tespit etmeyi amaçladık. Gereç ve Yöntem: Çalışmamızda, hastanemizde sellar kitle nedeniyle Ocak 2016 ile Haziran 2022 tarihleri arasında opere edilen 178 hasta retrospektif olarak incelendi. Kriterlere uyan 130 hasta çalışmaya dahil edildi. Çalışmaya dahil edilen hastaların operasyondan en fazla 1 ay önce ve operasyondan sonra 1. gün ile ilk 6 aydaki dinamik kontrastlı hipofiz MRG incelemeleri değerlendirildi. Preoperatif MRG incelemesinde adenomun üç planda boyutu ölçüldü. Üç plandaki çapları üzerinden elipsoid hacim denklemi ile tümör hacimleri hesaplandı. Tümörün her iki taraf kavernöz sinüs (CS) invazyonu modifiye Knosp skorlama sistemine göre kontrastlı koronal plan T1A görüntülerde değerlendirildi. Adenomun her iki tarafta intrakavernöz internal karotis arter (İCA) ile teması var ise açı cinsinden ölçüldü. Rezidü varlığı için operasyondan sonra 1. gün ve ilk 6 ayda elde olunan MRG incelemesi olmak üzere iki adet dinamik kontrastlı hipofiz MRG birlikte değerlendirildi. Adenomun maksimum çapı, adenomun hacmi, adenomun İCA ile temas açısı parametrelerinin operasyon sonrası rezidü olan ve rezidü olmayan gruplar arasında anlamlı farklılık gösterip göstermediği Student t testi ile karşılaştırıldı. Knosp skorunun rezidü olan ve rezidü olmayan gruplar arasında anlamlı farklılık gösterip göstermediği Ki-Kare testi ile karşılaştırıldı. Rezidü tümörü saptamada bağımsız prediktörleri belirlemek için çok değişkenli lojistik regresyon analizi yapıldı. Bulgular: Çalışmaya dahil edilen 130 adenomun patolojik incelemesinde en sık görülen alt tipi %26,9 (n=35) ile somatotrop adenomlar iken en az görülen alt tipi %0,8 (n=1) ile tirotrop adenomlardı. 130 hastadan 66'sında (%50,8) operasyon sonrası MRG incelemelerinde rezidü tespit edilmezken 64'ünde (%49,2) rezidü tümör saptanmıştır. Çalışmamızda Knosp skoru, tümörün en büyük çapı, ortalama tümör hacmi ve İCA sarma açısı için rezidü olan ve olmayan grupta yapılan karşılaştırmada istatistiksel olarak anlamlı farklılık bulundu (p<0,001). Çok değişkenli regresyon analizi sonucunda İCA sarma açısı ve Knosp skorunun rezidü tümör varlığını saptamada bağımsız prediktörler olduğu saptandı (p<0.001). Rezidü tümör varlığını saptamada tümör boyutu, hacmi, Knosp skoru, İCA sarma açısı ve regresyon modeli iyi tanısal performans göstermiştir. Regresyon modelinin (İCA sarma açısı + Knosp skoru) eğri altında kalan alanı 0,976 (0,955-0,996) olup en yüksek bulunmuştur. Rezidü varlığı açısından Knosp skoru için eşik değer ≥3 alındığında sensitivite %81,25, spesifisite %98,48 bulunmuştur. Rezidü varlığı açısından İCA sarma açısı için eşik değer ≥142,50 derece alındığında sensitivite %90,62, spesifisite %92,42 bulunmuştur. Sonuç: Çalışmamızda hipofiz makroadenomlarında transsfenoidal cerrahi tedavi başarısını öngörmede en başarılı iki parametrenin adenomun Knosp skoru ve İCA sarma açısı olduğunu tespit ettik ve bunlara ait tanısal doğruluğu yüksek eşik değerler belirledik. Dinamik kontrastlı hipofiz MRG incelemesinde pratik ve objektif olarak değerlendirilebilen bu parametrelerin kombine olarak kullanılması cerrahi tedavinin zorluğu, operasyon sonrası ek tedavi ihtiyacı gibi önemli bilgileri sağlayabilir.
Objective: Pituitary tumors are among the most common intracranial tumors in all age groups. Adenomas constitute the majority of pituitary tumors. Pituitary adenomas may cause clinical findings by increased hormone production, compression or invasion of surrounding tissues. Surgical treatment aims to eliminate the mass effect of the tumor, to eliminate excessive hormone production in functional pituitary adenomas, to preserve both pituitary function and adjacent nerve structures, and to eliminate or reduce the risk of future recurrence. Although there are different methods in surgical treatment, the transnasal transsphenoidal approach has become the gold standard due to its minimal invasiveness. Magnetic resonance imaging (MRI) is considered the best technique for evaluating the sellar region. Features of the adenoma, such as size and invasion of surrounding structures, can be evaluated with MRI. Invasion of pituitary macroadenomas to surrounding structures detected on MRI is associated with outcomes after surgical resection. In our study, we aimed to retrospectively examine the dynamic contrast enhanced pituitary MRI findings obtained before treatment in pituitary macroadenomas and to evaluate in detail the factors that may affect the success of surgical treatment. We aimed to reveal the relationship between the determined parameters and the presence of post-operative residual tumor and to determine its effectiveness. Material and Method: In our study, 178 patients who were operated between January 2016 and June 2022 due to a sellar mass in our hospital were retrospectively analyzed. 130 patients who met the criteria were included in the study. Dynamic contrast-enhanced pituitary MRI examinations of the patients included in the study were evaluated at most one month before the operation and on the first day and the first six months after the operation. In the preoperative MRI examination, the size of the adenoma was measured in three plans. Tumor volumes were calculated by the ellipsoid volume equation. Tumor's cavernous sinus (CS) invasion was evaluated according to the modified Knosp scoring system. The contact of adenoma with intracavernous internal carotid artery (ICA) was measured in terms of angle. The presence of residu tumor was evaluated with postoperative MRI investigations. The maximum diameter, volume and contact angle of the adenoma with ICA were compared with the Student T test whether it shows significant differences between the residual and non-residual groups. It was compared with the Ki-square test whether the Knosp score showed a significant difference between the groups. Multivariable logistics regression analysis was performed to determine independent predictors in residual tumor detection. Tumor size, volume, Knosp score, ICA contact angle and regression model showed good diagnostic performance in detecting residual tumor. Results: In the pathological examination of 130 adenomas included in the study, the most common subtype was somatotropic adenomas with 26.9% (n=35) while the least common subtype was thyrotropic adenomas with 0.8% (n=1). Postoperative residual tumor was not detected in 66 (50.8%) of 130 patients, while residual tumor was detected in 64 (49.2%) patients. A statistically significant difference was found in the comparison between the groups with and without residue tumor for Knosp score, the largest tumor diameter, mean tumor volume and ICA contact angle (p<0.001). As a result of multivariate regression analysis, ICA contact angle and Knosp score were found to be independent predictors of residual tumor presence (p<0.001). Tumor size, volume, Knosp score, ICA contact angle and regression model showed good diagnostic performance in detecting residual tumor. The area under the curve of the regression model (ICA contact angle + Knosp score) was found to be 0.976 (0.955-0.996), the highest. When the threshold value for the Knosp score was ≥3 in terms of the presence of residue, the sensitivity was 81.25% and the specificity was 98.48%. When the threshold value for the ICA contact angle was taken as ≥142.50 degrees for the presence of residue, the sensitivity was 90.62% and the specificity was 92.42%. Conclusion: In our study, we determined that the two most successful parameters in predicting the success of transsphenoidal surgical treatment in pituitary macroadenomas were the adenoma Knosp score and ICA contact angle, and we determined threshold values with high diagnostic accuracy. The combined use of these parameters, which can be evaluated practically and objectively in dynamic contrast-enhanced pituitary MRI examination, can provide important information such as the difficulty of surgical treatment and the need for additional treatment after the operation.
Objective: Pituitary tumors are among the most common intracranial tumors in all age groups. Adenomas constitute the majority of pituitary tumors. Pituitary adenomas may cause clinical findings by increased hormone production, compression or invasion of surrounding tissues. Surgical treatment aims to eliminate the mass effect of the tumor, to eliminate excessive hormone production in functional pituitary adenomas, to preserve both pituitary function and adjacent nerve structures, and to eliminate or reduce the risk of future recurrence. Although there are different methods in surgical treatment, the transnasal transsphenoidal approach has become the gold standard due to its minimal invasiveness. Magnetic resonance imaging (MRI) is considered the best technique for evaluating the sellar region. Features of the adenoma, such as size and invasion of surrounding structures, can be evaluated with MRI. Invasion of pituitary macroadenomas to surrounding structures detected on MRI is associated with outcomes after surgical resection. In our study, we aimed to retrospectively examine the dynamic contrast enhanced pituitary MRI findings obtained before treatment in pituitary macroadenomas and to evaluate in detail the factors that may affect the success of surgical treatment. We aimed to reveal the relationship between the determined parameters and the presence of post-operative residual tumor and to determine its effectiveness. Material and Method: In our study, 178 patients who were operated between January 2016 and June 2022 due to a sellar mass in our hospital were retrospectively analyzed. 130 patients who met the criteria were included in the study. Dynamic contrast-enhanced pituitary MRI examinations of the patients included in the study were evaluated at most one month before the operation and on the first day and the first six months after the operation. In the preoperative MRI examination, the size of the adenoma was measured in three plans. Tumor volumes were calculated by the ellipsoid volume equation. Tumor's cavernous sinus (CS) invasion was evaluated according to the modified Knosp scoring system. The contact of adenoma with intracavernous internal carotid artery (ICA) was measured in terms of angle. The presence of residu tumor was evaluated with postoperative MRI investigations. The maximum diameter, volume and contact angle of the adenoma with ICA were compared with the Student T test whether it shows significant differences between the residual and non-residual groups. It was compared with the Ki-square test whether the Knosp score showed a significant difference between the groups. Multivariable logistics regression analysis was performed to determine independent predictors in residual tumor detection. Tumor size, volume, Knosp score, ICA contact angle and regression model showed good diagnostic performance in detecting residual tumor. Results: In the pathological examination of 130 adenomas included in the study, the most common subtype was somatotropic adenomas with 26.9% (n=35) while the least common subtype was thyrotropic adenomas with 0.8% (n=1). Postoperative residual tumor was not detected in 66 (50.8%) of 130 patients, while residual tumor was detected in 64 (49.2%) patients. A statistically significant difference was found in the comparison between the groups with and without residue tumor for Knosp score, the largest tumor diameter, mean tumor volume and ICA contact angle (p<0.001). As a result of multivariate regression analysis, ICA contact angle and Knosp score were found to be independent predictors of residual tumor presence (p<0.001). Tumor size, volume, Knosp score, ICA contact angle and regression model showed good diagnostic performance in detecting residual tumor. The area under the curve of the regression model (ICA contact angle + Knosp score) was found to be 0.976 (0.955-0.996), the highest. When the threshold value for the Knosp score was ≥3 in terms of the presence of residue, the sensitivity was 81.25% and the specificity was 98.48%. When the threshold value for the ICA contact angle was taken as ≥142.50 degrees for the presence of residue, the sensitivity was 90.62% and the specificity was 92.42%. Conclusion: In our study, we determined that the two most successful parameters in predicting the success of transsphenoidal surgical treatment in pituitary macroadenomas were the adenoma Knosp score and ICA contact angle, and we determined threshold values with high diagnostic accuracy. The combined use of these parameters, which can be evaluated practically and objectively in dynamic contrast-enhanced pituitary MRI examination, can provide important information such as the difficulty of surgical treatment and the need for additional treatment after the operation.
Açıklama
Anahtar Kelimeler
Hipofiz Bezi, Adenom, MRG, Transsfenoidal Cerrahi, Pituitary Gland, Adenoma, MRI, Transsphenoidal Surgery
Kaynak
WoS Q Değeri
Scopus Q Değeri
Cilt
Sayı
Künye
Cansız, M. S. (2023). Hipofiz makroadenomlarında cerrahi tedavi etkinliğini öngörmede manyetik rezonans görüntüleme bulgularının değerlendirilmesi. (Uzmanlık Tezi). Selçuk Üniversitesi, Tıp Fakültesi, Konya.
