Assessment of the extent of pituitary macroadenomas resection in immediate postoperative MRI

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Paciente de 66 años. Estudio por alteraciones visuales. Se realiza estudio de RM hipofisaria de diagnóstico (a-d) que identifica un macroadenoma invasivo de 32mm de diámetro máximo, con extensión supraselar, compresión del quiasma óptico y afectación de ambos senos cavernosos, grados de Knosp 4 izquierdo y 3 derecho. Se observa el brillo de la neurohipófisis en posición correcta (flecha). Estudio RM postquirúrgico inmediato realizado al tercer día (e-h) que identifica el realce periférico del material hemostático ocupando el mismo espacio de la lesión. Control tardío a los 4 meses tras la cirugía (i-l) que confirma la resección completa del tumor. En las imágenes coronales (j-l) se observan el quiasma, el tallo hipofisario y la glándula en la silla turca, con hiperseñal de la neurohipófisis en la vertiente posterior (i)." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "E. Taberner López, M. Vañó Molina, J. Calatayud Gregori, M. Jornet Sanz, J. Jornet Fayos, A. 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Taberner López, M. Vañó Molina, J. Calatayud Gregori, M. Jornet Sanz, J. Jornet Fayos, A. Pastor del Campo, A. Caño Gómez, E. Mollá Olmos" "autores" => array:8 [ 0 => array:4 [ "nombre" => "E." "apellidos" => "Taberner López" "email" => array:1 [ 0 => "etaberner@hospital-ribera.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "M." "apellidos" => "Vañó Molina" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "J." "apellidos" => "Calatayud Gregori" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "M." "apellidos" => "Jornet Sanz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "J." 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"apellidos" => "Mollá Olmos" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Radiología, Hospital Universitario de la Ribera, Alzira, Valencia, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Instituto Universitario de Matemática Multidisciplinar, Universidad Politécnica de Valencia, Valencia, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Valoración del grado de resección de los macroadenomas hipofisarios en la resonancia magnética posquirúrgica inmediata" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1953 "Ancho" => 2500 "Tamanyo" => 414225 ] ] "descripcion" => array:1 [ "en" => "Early MRI of operated macroadenoma. Changes characteristics of recent surgery. (a) Sagittal T1-weighted SPIR image. On the upper edge, we can see the hypophyseal stalk (arrow), and normal hypophyseal gland remains. (b and c) Sagittal and coronal T1-weighted images after the administration of IV contrast, with hypointense filling of the cavity with Surgicel®, and the hyper-uptake edge, without signs indicative of adenoma. (d) Preoperative study images. (e) Control MRI after 3 months." ] ] ] "textoCompleto" => "IntroductionPostoperative evaluation of hypophyseal adenomas after endoscopic nasal surgery is still an important challenge for both surgeons and radiologists. The magnetic resonance imaging (MRI) is the modality of choice to detect remnant or recurrent tumors, and their possible complications. However, there are no established reproducible criteria to evaluate postoperative studies, in particular to differentiate the implanted material from the residual or recurrent tumor, or to correlate the MRI findings with the patient's clinical status and endocrine function. It is difficult to determine when one hypophyseal macroadenoma has been completely resected after conducting transsphenoidal surgery. Usually, the assessment depends on the neurosurgeon's intraoperative impression; the clinical examination after the surgery; and the postoperative images. In the days following the transsphenoidal–transnasal resection of hypophyseal macroadenomas, inflammatory changes; traces of blood; the access filling material; and the surgical base can interfere during the MRI assessment of the degree of lesion resection.<a class="elsevierStyleCrossRefs" href="#bib0135">1–3</a>In the first immediate MRI control, in addition to diagnosing possible complications and assessing the normal gland,<a class="elsevierStyleCrossRef" href="#bib0150">4</a> we will be able to assess the degree of lesion resection; detect residual tumors at an early stage; and have a basal study that can be used as a reference for subsequent evolutionary controls. This is why any changes in signal intensity of the surgical bed and contrast uptake play such an important role in the interpretation of postoperative images. If signal intensity and contrast uptake are similar to those of the lesion in the preoperative study, such tissue is suspicious of residual tumor. When contrast uptake is linear and peripheral, the chances are that it is consistent with postoperative changes.<a class="elsevierStyleCrossRef" href="#bib0155">5</a> Knowledge about the radiological characteristics of the materials implanted in the sellar region is also very important, since some materials, such as fat, can be identified even years after the surgery, whereas others, such as hemostatic materials, only for a few weeks after the surgery. There is no clear consensus on what is the best time to conduct an MRI study.<a class="elsevierStyleCrossRefs" href="#bib0160">6,7</a>The goal of this study is to confirm whether it is possible to determine the degree of hypophyseal macroadenomas resection using immediate postoperative hypophyseal MRI, within the first week after surgery.Material and methodsPatientsOne retrospective, descriptive study was conducted reviewing the hypophyseal MRI studies of those patients who underwent surgery for hypophyseal macroadenomas whose cases were confirmed through pathological anatomy study, from January 2010 to October 2014. The ethics committee considered that due to the characteristics of the study, it could be conducted without the patients’ informed consent, since it was an observational study and as such, the cases were identified using the medical history registry system. All patients signed the informed consent prior to the MRI. Those patients who had diagnostic pre-operative MRIs, immediate postoperative MRIs and, at least, one control MRI after 4–6 months were included.In all the cases, surgery was performed using the endoscopic transnasal–transsphenoidal approach by the team of neurosurgeons. The description of the surgical technique is beyond the scope of this paper.<a class="elsevierStyleCrossRefs" href="#bib0170">8–10</a>The immediate postoperative MRIs were conducted in the days following the surgery, thought no more than 7 days after surgery.Seventy-three patients were included, 35 women and 38 males, with ages ranging from 21 to 85 years (average age, 53 years). Five of the cases included were functioning macroadenomas, and even though immediate MRIs were conducted, they were considered complete resection because the clinical manifestations receded and the hormone values reached normal levels. The cases without evolutionary controls (on images or analysis) and those with reoperations due to recurrences were excluded.Imaging modalityAll the radiological hypophyseal MRI studies were conducted using the Intera Achieva 1.5 Teslas Philips machine (model ES6600158241; manufacturing date: 2012; upgraded back in 2016; Eindhoven, Holland).The sequence protocol was always the same for all the cases, both before and after the surgery, and it was made up of two parts: one morphological–physiological one and one dynamic one with IV contrast. The first part consists of one sagittal T1-weighted TSE image with fat saturation (SPIR), 500/17ms (RT/ET), with a 180mm field of vision (FOV); a 236×189 matrix and a TSE T2 coronal 4000/120ms (RT/ET); with a 130mm FOV and a 192×152 matrix; both centered on the sella turcica, with 2 and 1.5mm slices, respectively. Prior to the contrast sequences, one coronal T1 TSE Image 600 Image 600/10ms (RT/ET) is added; with a 130mm field of vision (FOV); a 192×153 matrix and a slice thickness of 1.5mm. Afterwards, the dynamic studio consists of coronal T1-weighted TSE sequences with IV contrast; 500/10ms (RT/ET); with a rectangular 180mm FOV and a 256×140 matrix, with 3mm slices. Ten cyclic acquisitions are performed after administration of a 8ml gadolinium bolus at 2.5ml/s, followed by a 20ml physiological saline solution. With the dynamic studio five or six slices of the hypophysis are obtained and in each and every one of these slices, the progressive uptake of the normal hypophyseal gland can be seen, and is compared to the rest of the tissues. Finally, two sequences with IV contrast are obtained (late contrast): one coronal T1 TSE Image 600/10ms (RT/ET), with a 130mm FOV and a 192×153 matrix, with 1.5mm slices, and one T1 SE Image 400 Image 400/15ms (RT/ET), with a 180mm FOV and a 256×192 matrix, with 2mm slices.In order to assess the degree of resection in immediate postoperative studies the preoperative study was taken as reference. In many cases, it could be confirmed that the volume occupied by the macroadenoma was barely modified on the postoperative MRIs, because after its resection it was occupied by filling material; inflammatory changes; or traces of blood.<a class="elsevierStyleCrossRef" href="#bib0185">11</a>In the subsequent evolutionary controls, most inflammatory changes and changes in the postoperative filling material have been solved or reabsorbed, and do not interfere anymore in the interpretation of the images. This is why the immediate postoperative studies were compared to subsequent controls to see if the findings were consistent by measuring the sensitivity, specificity, positive predictive value (PPV); and negative predictive value (NPV) data.Image interpretationThe images were interpreted by two neuroradiologists, one of them was a junior neuroradiologist and the other one had over 10 years of experience. Both had access to the patient's medical history. When in doubt, consensus was reached by the two of them. The following parameters were assessed: (1) the hypophyseal gland and its enhancement pattern; (2) the nodular enhancement (suggestive of residual tumor); or the linear enhancement (suggestive of no tumor); (3) pituitary stalk (deviated, compressed, not visualized); and (4) postoperative filling material and material for sellar floor reconstruction. The findings were compared to the immediate postoperative MRIs and the MRIs with evolutive control. The assessment of residual tumors was conducted qualitatively. The degree of resection was established as 1 (complete); 2 (partial); and 3 (doubtful).Statistical analysisIn the statistical analysis, the sensitivity, specificity, PPV and NPV of the immediate postoperative MRIs were analyzed with respect to the evolutionary controls. Also, using the “R” programming language statistical analysis through generalized linear models, one statistical analysis was conducted to study the relation between the degree of resection in evolutionary controls from months 4 to 6 and the variables of sex; age; size of adenoma in cubic millimeters; Knosp grades (left and right sides); compression of the chiasm; suprasellar spread, degree of resection according to the neurosurgeon; and degree of resection based on the immediate postoperative MRIs.ResultsThe histological confirmation of all the 73 cases reviewed was hypophyseal adenoma. Sixty-eight out of the 73 were non-functioning and out of the remaining five, three were producers of the growth hormone, one a producer of the thyroid stimulating hormone, and the remaining one a producer of corticotropin.In the diagnostic study, the size of the macroadenomas ranged from a maximum diameter of 47mm to a minimum diameter of 11mm (average size: 25mm), with an average volume of 13.89cc (range: 0.4–90cc). Out of the 73 tumors, 58 infiltrated the cavernous sinuses. The degree of cavernous sinus affectation according to the Knosp criteria,<a class="elsevierStyleCrossRef" href="#bib0190">12</a> is shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. There was suprasellar spread in 47 cases, thirty-nine of which caused compression of the optic chiasm (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). In 50 of the 73 cases, adenohypophysis gland remains could be identified, not in the remaining twenty-three.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia>With respect to the occurrence of transoperative complications during the surgical procedure, nine cases were documented. In eight of them, there were cerebrospinal fluid (CSF) fistulas and in the remaining one venous hemorrhage connected to the dural opening. In all patients, the complication was managed intraoperatively, and there were no further incidences.Out of the 73 cases reviewed, the immediate postoperative hypophysis MRI was interpreted as total resection in 38 cases and as residual tumor in 28 cases (22 of which were interpreted as broad partial resection, and 6 as partial resection) (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>). In seven cases, there were doubts between residual tumor or complete resection.<elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia>In the evolutionary controls, it was determined that there was total resection in 41 cases and residual tumor in 32 (26 of which were interpreted as broad partial resection and 6 as partial resection). In four cases the normal hypophyseal gland continued to be unidentified and in one case there were still doubts. Thirty-four out of the 38 cases of complete resection, and 25 out of the 28 cases of residual tumor were interpreted correctly.Out of the seven uncertain cases on the immediate postoperative MRIs, four were confirmed to be total resections and three residual tumors. Strictly speaking, although no mistake was made during their classification, for statistical reasons, these uncertain cases were considered as four false negatives and three false positives (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>Taking all this data into consideration, one descriptive correlation was established between the immediate postoperative MRI and the evolutionary controls with a 0.78 sensitivity and a 0.82 specificity. The PPV and the NPV were both 0.89.As a result of the generalized linear model conducted using the “R” software it was determined that, among the variables studied, the ones associated with the degree of resection in the evolutionary controls are the size of the macroadenoma, and the degree of resection on the immediate postoperative MRI. With these two variables, one generalized linear regression model was applied to know what chances does that the degree of resection in the evolutionary control have of being complete or partial. We will use the letter p to describe the probability of the degree of resection in the evolutionary control being 2 (partial), and 1-p to refer to the probability of being 1 (complete); there are no uncertain cases in the evolutionary control. This will be the model:<elsevierMultimedia ident="eq0005"></elsevierMultimedia>α=exp (−2.790+3.271425×residual tumor on the MRI+1.8363×doubtful MRI+8.019×10−5×macro size), where exp is the exponential function, the residual tumor on the MRI is 1 when the degree of resection on the MRI has been 2, and 0 if it has been otherwise; doubtful MRI is 1 when the degree of resection on the MRI has been 3, and 0 if it has been otherwise; and macro size is the size of the macroadenoma. Thanks to these formulas, from the data available on the degree of resection on the MRI and the size of the macroadenoma, the degree of resection can be predicted in the evolutionary control. As a quality assessment of this model, out of the 73 study cases, this model successfully predicted 63, being p≥0.5 residual tumor, and p<0.5 complete resection.Also, from the signs of the coefficients, the following can be deduced:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">•The bigger the size of the macroadenoma, the higher the chances that resection will be partial in the late evolutionary control.</li><li class="elsevierStyleListItem" id="lsti0010">•The fact that there is uncertainty about residual tumor on the immediate postoperative MRI increases the probability of finding residual tumor/s in the late evolutionary control, whereas the complete resection on the immediate postoperative MRI increases the probability of complete resection in the late evolutionary control.</li></ul>DiscussionAlthough the immediate postoperative MRI (<24–48h) has already been implemented in many imaging protocols for the assessment of residual tumors in central nervous system neoplasms,<a class="elsevierStyleCrossRefs" href="#bib0195">13,5</a> this is not the case with hypophyseal tumors. This kind of tumors shows a very different clinical, radiological and prognostic behavior from other intracranial tumors, since they rarely become malignant. Also, their proximity to critical neurovascular structures frequently leads to the appearance of postoperative complications and deficient symptomatology, especially when there is damage to the hypophyseal stalk.During the last few decades and with the advancement of new technologies, the endoscopic approaches of the cranial base have become more and more popular, improving many of the challenges posed by other technologies; today it is considered the surgical route of choice for the management of conditions of the sellar region, for the resection of most intrasellar lesions, and for the management of lesions with parasellar and suprasellar spread, since it not only provides direct endonasal access, but also panoramic views from within the sphenoid sinuses, the sella turcica and the tumor cavity.This technique causes less damage to the hypothalamus–hypophyseal axis due to its simplicity in the approach and quick access to the sella turcica, takes fewer hours in the operating room and shorter hospital stays for the patient, which are some of the advantages that make it the technique of choice.<a class="elsevierStyleCrossRefs" href="#bib0165">7–9,14,15</a> However, it is a real challenge for neurosurgeons, not only during the approach, but also during intradural time since they encounter a great distortion of the normal anatomy. At our center we have one Neurosurgery Unit that has been conducting this type of surgery for over 10 years.Endoscopic transsphenoidal surgery for the resection of hypophyseal adenomas poses complications that are inherent to the procedure, and medical complications associated with the resection of conditions of the sellar region. The complications of the procedure in our series were minimum, the presence of one intraoperative CSF fistula was documented in approximately 10% of the cases, it was objectified and treated in all patients during the same surgical procedure and blocked with autologous fascia, muscle and fat, and sealed using hemostatic material. Another minor surgical complication was the presence of venous hemorrhages (<1%) that were controlled by plugging. No significant surgical complications were documented in the postoperative period in our study. This very significant fact contrasts with the medical literature. Some series like López-Arbolay et al.’s series<a class="elsevierStyleCrossRef" href="#bib0210">16</a> and other more recent ones like Zhan et al.’s series<a class="elsevierStyleCrossRef" href="#bib0215">17</a> prove that a percentage of their patients had complications during the postoperative period, especially diabetes insipidus.The most common age of presentation for hypophyseal macroadenomas is between 30 and 60 years of age (the average is 46 years old)<a class="elsevierStyleCrossRefs" href="#bib0220">18,19</a> slightly more predominant in women,<a class="elsevierStyleCrossRef" href="#bib0230">20</a> especially in younger years. Most cases are sporadic, and only a minority having to do with family history.<a class="elsevierStyleCrossRef" href="#bib0225">19</a> In our series, the average age was 53 years old, which is close to the average age reported by the medical literature. We did not find any sex-related significant differences, and family associations were not studied.Although there is no clear consensus on what the best time is to conduct the first postoperative MRI, it usually happens after 3 or 6 months and, then, after one year. In the absence of residual adenomas, the annual monitoring is recommended during the first 5 years, and then after 7, 10 and 15 years.<a class="elsevierStyleCrossRef" href="#bib0235">21</a>With our study we wish to give credit to this imaging modality when performed immediately (within the first week), since it has been confirmed that it has high sensitivity (0.78) and specificity (0.82) when it comes to findings residual tumors compared to follow-up MRI controls. This confirms other studies published, such as the study published by Di Maio et al.,<a class="elsevierStyleCrossRef" href="#bib0150">4</a> where they also obtained high sensitivity and specificity ratios, and the studies conducted by Rodríguez et al.<a class="elsevierStyleCrossRef" href="#bib0240">22</a> and Yoon et al.,<a class="elsevierStyleCrossRef" href="#bib0160">6</a> who also think that it is possible to differentiate residual tumors on MRIs within the first week after surgery.The immediate postoperative control is interesting especially in cases of hypophyseal macroadenomas—the ones we based our study on, since most of them (over 90% in our series) are non-functioning from the hormone point of view, which is why the hormone levels cannot be determined to make the assessment of complete resection. This percentage is higher than the averages reported in other series (30–55%).<a class="elsevierStyleCrossRefs" href="#bib0245">23,24</a>Having the information about the residual tumor available during the days following the surgery allows a better assessment of prognosis; provides the patient with information to be able to make future decisions such as early reoperations; radiosurgeries; pharmacotherapies; or other therapeutical options; and, ultimately, decide when to conduct future follow-ups.There are references sources describing the difficulties of interpreting immediate postoperative studies, given the presence of filling or reconstruction materials; inflammatory changes; etc.<a class="elsevierStyleCrossRef" href="#bib0185">11</a> One of the main reasons for this is that the volume of the lesion seems to occupy the same space than in the study prior to the surgery; nevertheless, there is a change in the signal intensity and the contrast uptake, since this space is occupied by filling materials<a class="elsevierStyleCrossRefs" href="#bib0140">2,3,25</a> and postoperative inflammatory changes.Regenerated oxidized cellulose (Oxycel® or Surgicel®); absorbable gelatin sponge (Spongostan® or Gelfoam®); tissue adhesives (Tissucol® or Beriplast®), wax to stop bone bleeding,<a class="elsevierStyleCrossRefs" href="#bib0140">2,11,12</a> etc., are normally used to maintain hemostasis. At our center, Surgicel® is used to achieve the hemostasis of the tumor bed, while the cavity is sealed with Tissucol®. It is very important to know the type of material used during the surgery in order to avoid erroneous interpretation of the imaging studies, since on the MRI, in the T1-weighted sequences, both Surgicel® and Oxycel® are identified as a low signal intensity, regular oval shaped-heterogeneous structure surrounded by one hyperintense edge. This material is mainly identified during the immediate postoperative period, since later (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>) it starts a process of progressive degeneration and it becomes more difficult to identify.<a class="elsevierStyleCrossRef" href="#bib0165">7</a> After the administration of contrast, the central part of the hemostatic material remains hypointense, with peripheral edge enhancement.<a class="elsevierStyleCrossRefs" href="#bib0165">7,12</a> This peripheral enhancement is due to the granulation tissue building up around the implanted material.<a class="elsevierStyleCrossRefs" href="#bib0165">7,12</a> Nevertheless, we should say that one hypointense mass with peripheral enhancement after the administration of contrast can be consistent with necrosis within the tumor, or fibrous granulation tissue.<a class="elsevierStyleCrossRefs" href="#bib0165">7,12,22</a><elsevierMultimedia ident="fig0015"></elsevierMultimedia>Fat tissue is part of the filling material used, and unlike other materials, its identification is easy due to the hyperintensity that it produces on the T1-weighted sequences and because it persists for a long period of time; as a matter of fact, in some series, it has been identified even 3–4 years after surgery.<a class="elsevierStyleCrossRef" href="#bib0235">21</a>The most important thing is to make a comparison with the preoperative study and check whether the residual tumor signal intensity is the same as that of the macroadenoma in the preoperative study, and whether it occupies the same spot where the lesion was, which is usually in the least accessible areas during surgery (cavernous sinuses, suprasellar spaces, etc.) To this end, it is useful to see how it behaves on the T2 and T1-weighted sequences both with and without contrast; though maybe, in most cases in our series, the most useful sequence of all was the T1-weighted sequence with late contrast, both on the coronal and sagittal planes. If the signal intensity and the contrast uptake are similar to that of the lesion in the preoperative study, we say that such tissue is suspicious of residual tumor. When contrast uptake is linear and peripheral, the chances are that it is consistent with postoperative changes.The dynamic study is more useful for the detection of possible adenohypophysis gland remains, and to be able to differentiate them from residual tumors, due to the early uptake that the gland tissue shows.When it comes to diffusion weighted imaging (DWI), some works have already been published correlating the apparent diffusion coefficient (ADC) values with the consistency (soft or hard) of pituitary macroadenomas, which can determine how endoscopic surgery will eventually be conducted. This sequence was not performed in our series.When analyzing the generalized linear mathematical model study carried out with the data gathered, it seems proven that the variables that are better associated with the degree of actual lesion resection are the size of the lesion and the immediate postoperative MRI results. Other studies published have demonstrated that the degree of invasion of cavernous sinuses on preoperative MRIs can also predict the degree of resection, which is usually lower when it affects the lateral and inferolateral compartments, and with a higher Knosp grade.<a class="elsevierStyleCrossRef" href="#bib0260">26</a> In our study, the degree of resection is more associated with the size of the tumor and, consequently, the bigger the macroadenoma, the harder it is to resect completely.The value of the data obtained on the postoperative immediate MRIs is worth mentioning particularly since there is a consistent association with the degree of final resection when compared to evolutionary controls.In our study, we found no association whatsoever between the local spread or invasion of macroadenomas and the prediction of the degree of resection, especially in adenomas invading the cavernous sinus. This may be justified by the small number of patients with Knosp grades 3 and 4, which would be one of the limitations of our study.We have no anatomopathological confirmation of the cases with residual tumors, because not all the cases are reoperated, since this is mainly based on the size and location of these tumors. In our series, most of the 28 cases of residual tumors corresponded to broad resections and therefore, which means that since almost no tumor remained, the patients were not reoperated, and in only six cases resection was partial; among these, one case was reoperated. The remaining patients were followed-up through imaging monitoring, which would be another limitation of our study.Lastly, the control workup of the five cases of functioning adenomas also limits the results of our work – conducted with hormone tests and not with imaging follow-ups.In sum, the immediate postoperative MRI after the transsphenoidal surgery of macroadenomas is useful for the early assessment of the degree of tumor resection, and it is a good predictor of the degree of actual or final resection of such tumors. Thus, this kind of MRI allows us to study what the earliest optimal treatment really is, especially through reoperation or radiosurgery.Authors contribution<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0015">1.Manager of the integrity of the study: MVM and ETL.</li><li class="elsevierStyleListItem" id="lsti0020">2.Study Idea: MVM, ETL and JJF.</li><li class="elsevierStyleListItem" id="lsti0025">3.Study Design: ETL, MVM, JJF and EMO.</li><li class="elsevierStyleListItem" id="lsti0030">4.Data Mining: ETL, MVM, JJF, JCG, MJS, APC, ACG and EMO.</li><li class="elsevierStyleListItem" id="lsti0035">5.Data Analysis and Interpretation: MJS, JCG, JJF, ETL and MVM.</li><li class="elsevierStyleListItem" id="lsti0040">6.Statistical Analysis: MJS and JCG.</li><li class="elsevierStyleListItem" id="lsti0045">7.Reference: MVM, ETL, ACG, APC and JJF.</li><li class="elsevierStyleListItem" id="lsti0050">8.Writing: MVM, ETL and JJF.</li><li class="elsevierStyleListItem" id="lsti0055">9.Critical review of the manuscript with intellectually relevant remarks: ETL, MVM, JJF, JCG, MJS, APC, ACG and EMO.</li><li class="elsevierStyleListItem" id="lsti0060">10.Approval of final version: ETL, MVM, JJF, JCG, MJS, APC, ACG and EMO.</li></ul>Conflict of interestsThe authors declare no conflict of interests." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres976657" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec946430" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres976658" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec946431" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Material and methods" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Patients" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Imaging modality" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Image interpretation" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Statistical analysis" ] ] ] 6 => array:2 [ "identificador" => "sec0035" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0040" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0045" "titulo" => "Authors contribution" ] 9 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflict of interests" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-02-22" "fechaAceptado" => "2017-10-02" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec946430" "palabras" => array:4 [ 0 => "Pituitary neoplasms" 1 => "Adenoma" 2 => "Magnetic resonance imaging" 3 => "Neoplasm residual" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec946431" "palabras" => array:4 [ 0 => "Macroadenoma hipofisario" 1 => "Resonancia magnética hipofisaria" 2 => "Resección quirúrgica" 3 => "Resto tumoral" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "ObjectiveTo evaluate if it is possible to determine the extent of pituitary macroadenomas resection in the immediate postoperative pituitary magnetic resonance imaging (MRI). Material and methodsMRI of patient with pituitary macroadenomas from January 2010 until October 2014 were reviewed. Those patients who had diagnostic MRI, immediate post-surgical MRI and at least one MRI control were included. We evaluate if the findings between the immediate postsurgical MRI and the subsequent MRI were concordant. Cases which did not have evolutionary controls and those who were reoperation for recurrence were excluded. The degree of tumor resection was divided into groups: total resection, partial resection and doubtful. All MRI studies were performed on a 1.5T machine following the same protocol sequences for all cases. One morphological part, a dynamic contrast IV and late contrast part. ResultsOf the 73 cases included, immediate postoperative pituitary MRI was interpreted as total resection in 38 cases and tumoral rest in 28 cases, uncertainty among rest or inflammatory changes in 7 cases. Follow-up MRI identified 41 cases total resection and tumoral rest in 32. Sensitivity and specificity of 0.78 and 0.82 and positive and negative predictive value (PPV and NPV) 0.89 and 0.89 respectively were calculated. ConclusionImmediate post-surgery pituitary MRI is useful for assessing the degree of tumor resection and is a good predictor of the final degree of real resection compared with the following MRI studies. It allows us to decide the most appropriate treatment at an early stage." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "ObjetivoComprobar si es posible determinar el grado de resección de macroadenomas hipofisarios en la resonancia magnética (RM) hipofisaria posquirúrgica inmediata. Material y métodosSe revisaron las RM hipofisarias de pacientes intervenidos desde enero de 2010 hasta octubre de 2014. Se incluyeron aquellos que tenían RM diagnóstica, RM posquirúrgica inmediata y al menos un control posterior. Se comprobó si los hallazgos entre la RM posquirúrgica inmediata y las RM posteriores eran concordantes. Se excluyeron los casos sin controles evolutivos y las reintervenciones por recidivas. El grado de resección tumoral lo dividimos en grupos: resección total, resección parcial y dudoso. Los estudios se realizaron en una máquina de 1.5T siguiendo el mismo protocolo de secuencias: una parte morfológica, otra dinámica con contraste intravenoso y otra con contraste tardío. ResultadosDe 73 casos incluidos, la RM posquirúrgica inmediata se interpretó como resección total en 38 casos y resto tumoral en 28 casos, habiendo dudas en 7 casos. En los controles evolutivos se determinó resección total en 41 casos y resto tumoral en 32. Se obtuvo una sensibilidad para detección de restos tumorales de 0,71, una especificidad de 0,82, un valor predictivo positivo de 0,89 y un valor predictivo negativo de 0,85 en la RM posquirúrgica inmediata respecto a los controles evolutivos. ConclusiónLa RM posquirúrgica inmediata de macroadenomas hipofisarios es útil para valorar el grado de resección tumoral y es un buen predictor del grado de resección real definitivo al comparar con las RM posteriores, permitiendo plantear el tratamiento adecuado de forma precoz." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Taberner López E, Vañó Molina M, Calatayud Gregori J, Jornet Sanz M, Jornet Fayos J, Pastor del Campo A, et al. Valoración del grado de resección de los macroadenomas hipofisarios en la resonancia magnética posquirúrgica inmediata. Radiología. 2018:60;64–72." ] ] "multimedia" => array:7 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2206 "Ancho" => 3123 "Tamanyo" => 533456 ] ] "descripcion" => array:1 [ "en" => "Partial resection. Residual tumor. Fifty-eight-year-old patient. Headache study. Diagnostic hypophyseal MRIs conducted (a–d) that identify the presence of one macroadenoma of 30mm maximum diameter, with suprasellar spread, and damage to the optic chiasm and both Knosp grade 2 cavernous sinuses. The normal hypophyseal gland is not identified. On the immediate postoperative MRI study conducted on day 4 (e–h), the volume occupied by the tumor has hardly changed due to the occupation of the filling material. We can see the peripheral enhancement of the hemostatic material occupying the same space-occupying lesion (asterisk), and a small hypo-uptake region in the right cavernous sinus (f and h) indicative of residual tumor, of the same signal intensity as on the diagnostic MRI (h). The late control 6 months after the surgery (i–l) confirms the partial resection of the tumor, and a small residual tumor (j–l) in the right cavernous sinus." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2433 "Ancho" => 3167 "Tamanyo" => 474277 ] ] "descripcion" => array:1 [ "en" => "Complete resection. Sixty-six-year-old patient. Study due to vision alterations. One diagnostic hypophyseal MRI study is conducted (a–d) that identifies one invasive macroadenoma of 32mm maximum diameter, with suprasellar spread, compression of the optic chiasm and damage to both cavernous sinuses—Knosp grade 4 on the left, and Knosp grade 3 on the right. The shine of the neurohypophysis is observed in the right position (arrow). Immediate postoperative MRI study conducted on day 3 (e–h) that identifies the peripheral enhancement of the hemostatic material that occupies the same space as the lesion. Late control 4 months after surgery (i–l) that confirms the complete resection of tumor. On the coronal images (j–l) we can see the chiasm; the hypophyseal stalk; and the gland that sits in the sella turcica, with hypersignal of the neurohypophysis on the posterior side (i)." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1953 "Ancho" => 2500 "Tamanyo" => 414225 ] ] "descripcion" => array:1 [ "en" => "Early MRI of operated macroadenoma. Changes characteristics of recent surgery. (a) Sagittal T1-weighted SPIR image. On the upper edge, we can see the hypophyseal stalk (arrow), and normal hypophyseal gland remains. (b and c) Sagittal and coronal T1-weighted images after the administration of IV contrast, with hypointense filling of the cavity with Surgicel®, and the hyper-uptake edge, without signs indicative of adenoma. (d) Preoperative study images. (e) Control MRI after 3 months." ] ] 3 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Knosp grade \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Left cavernous sinus \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Right cavernous sinus \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">0: The tumor does not touch the cavernous sinus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">31 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">25 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1: The tumor does not reach the intercarotid line \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2: The tumor extends beyond the intercarotid line, but does not reach the line that is tangent to the carotid lateral sides as it passes through the cavernous sinus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3: The tumor extends beyond the lateral line tangent to the carotid \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4: The tumor totally wraps around the carotid artery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1654428.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Cavernous sinus affectation based on the Knosp criteria." ] ] 4 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "ACTH: adrenocorticotropic hormone; GH: growth hormone; MRI: magnetic resonance imaging; TSH: thyroid stimulating hormone." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " colspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Characteristics</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Men:women \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">38:35 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Average age \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">53 years (range: 21–85) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mean size of macroadenoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">24.86mm (range: 11–47) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mean volume of macroadenoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14 cc (range: 0.4–90) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hormone-secreting macroadenomas \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">GH 3 cases \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">TSH 1 case \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ACTH 1 case \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Infiltration of cavernous sinuses \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">58 cases (79.45%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Suprasellar spread \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">47 cases (64.38%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Compression of chiasm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">39 cases (53.42%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Location of the normal hypophyseal gland on the preoperative MRIs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Unidentified: 24 cases (32.9%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Unidentified: 49 cases (67.12%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Lateral: 17 cases (11 right, 6 left) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Superior: 14 cases \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Posterior: 12 cases \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Inferior: 1 case \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Anterior: 2 cases \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">On sella turcica: 3 cases \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Degree of resection according to the neurosurgery report/immediate MRI report \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Total: 57/38 cases \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Broad partial: 16/28 cases \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Location of residual tumor on the immediate postoperative MRI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Residual tumor: \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Cavernous sinuses: 11 cases (6 right, 5 left) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Suprasellar: 9 cases \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Lateral: 6 cases (5 right, 1 left) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Inferior: 3 cases \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Posterior: 2 cases \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Peripheral: 3 cases \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No residual tumor: 38 cases (52%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1654426.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Summary of the study data (n=73)." ] ] 5 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "TP: true positive; TN: true negative; FP: false positive; FN: false negative." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Residual tumor \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Complete Resection \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Residual tumor \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Complete resection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">34 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Diagnostic uncertainty \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total patients \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">41 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1654427.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Assessment of degree of resection of macroadenomas on immediate postoperative MRIs and in the subsequent controls (TP=25; TN=34; FP=3+4; FN=4+3)." ] ] 6 => array:5 [ "identificador" => "eq0005" "tipo" => "MULTIMEDIAFORMULA" "mostrarFloat" => false "mostrarDisplay" => true "Formula" => array:5 [ "Matematica" => "p0=α1+α1+α2 p1=α11+α1+α2 p2=α21+α1+α2" "Fichero" => "STRIPIN_si1.jpeg" "Tamanyo" => 3199 "Alto" => 33 "Ancho" => 373 ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:26 [ 0 => array:3 [ "identificador" => "bib0135" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Imaging of the pituitary" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "T. 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Valoración del grado de resección de los macroadenomas hipofisarios en la resonancia magnética posquirúrgica inmediata

E. Taberner Lópeza,

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etaberner@hospital-ribera.com

Corresponding author.

, M. Vañó Molinaa, J. Calatayud Gregorib, M. Jornet Sanzb, J. Jornet Fayosa, A. Pastor del Campoa, A. Caño Gómeza, E. Mollá Olmosa

a Servicio de Radiología, Hospital Universitario de la Ribera, Alzira, Valencia, Spain

b Instituto Universitario de Matemática Multidisciplinar, Universidad Politécnica de Valencia, Valencia, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Postoperative evaluation of hypophyseal adenomas after endoscopic nasal surgery is still an important challenge for both surgeons and radiologists&#46; The magnetic resonance imaging &#40;MRI&#41; is the modality of choice to detect remnant or recurrent tumors&#44; and their possible complications&#46; However&#44; there are no established reproducible criteria to evaluate postoperative studies&#44; in particular to differentiate the implanted material from the residual or recurrent tumor&#44; or to correlate the MRI findings with the patient&#39;s clinical status and endocrine function&#46; It is difficult to determine when one hypophyseal macroadenoma has been completely resected after conducting transsphenoidal surgery&#46; Usually&#44; the assessment depends on the neurosurgeon&#39;s intraoperative impression&#59; the clinical examination after the surgery&#59; and the postoperative images&#46; In the days following the transsphenoidal&#8211;transnasal resection of hypophyseal macroadenomas&#44; inflammatory changes&#59; traces of blood&#59; the access filling material&#59; and the surgical base can interfere during the MRI assessment of the degree of lesion resection&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">1&#8211;3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In the first immediate MRI control&#44; in addition to diagnosing possible complications and assessing the normal gland&#44;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">4</span></a> we will be able to assess the degree of lesion resection&#59; detect residual tumors at an early stage&#59; and have a basal study that can be used as a reference for subsequent evolutionary controls&#46; This is why any changes in signal intensity of the surgical bed and contrast uptake play such an important role in the interpretation of postoperative images&#46; If signal intensity and contrast uptake are similar to those of the lesion in the preoperative study&#44; such tissue is suspicious of residual tumor&#46; When contrast uptake is linear and peripheral&#44; the chances are that it is consistent with postoperative changes&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">5</span></a> Knowledge about the radiological characteristics of the materials implanted in the sellar region is also very important&#44; since some materials&#44; such as fat&#44; can be identified even years after the surgery&#44; whereas others&#44; such as hemostatic materials&#44; only for a few weeks after the surgery&#46; There is no clear consensus on what is the best time to conduct an MRI study&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">6&#44;7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The goal of this study is to confirm whether it is possible to determine the degree of hypophyseal macroadenomas resection using immediate postoperative hypophyseal MRI&#44; within the first week after surgery&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Patients</span><p id="par0020" class="elsevierStylePara elsevierViewall">One retrospective&#44; descriptive study was conducted reviewing the hypophyseal MRI studies of those patients who underwent surgery for hypophyseal macroadenomas whose cases were confirmed through pathological anatomy study&#44; from January 2010 to October 2014&#46; The ethics committee considered that due to the characteristics of the study&#44; it could be conducted without the patients&#8217; informed consent&#44; since it was an observational study and as such&#44; the cases were identified using the medical history registry system&#46; All patients signed the informed consent prior to the MRI&#46; Those patients who had diagnostic pre-operative MRIs&#44; immediate postoperative MRIs and&#44; at least&#44; one control MRI after 4&#8211;6 months were included&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">In all the cases&#44; surgery was performed using the endoscopic transnasal&#8211;transsphenoidal approach by the team of neurosurgeons&#46; The description of the surgical technique is beyond the scope of this paper&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">8&#8211;10</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The immediate postoperative MRIs were conducted in the days following the surgery&#44; thought no more than 7 days after surgery&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Seventy-three patients were included&#44; 35 women and 38 males&#44; with ages ranging from 21 to 85 years &#40;average age&#44; 53 years&#41;&#46; Five of the cases included were functioning macroadenomas&#44; and even though immediate MRIs were conducted&#44; they were considered complete resection because the clinical manifestations receded and the hormone values reached normal levels&#46; The cases without evolutionary controls &#40;on images or analysis&#41; and those with reoperations due to recurrences were excluded&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Imaging modality</span><p id="par0040" class="elsevierStylePara elsevierViewall">All the radiological hypophyseal MRI studies were conducted using the Intera Achieva 1&#46;5 Teslas Philips machine &#40;model ES6600158241&#59; manufacturing date&#58; 2012&#59; upgraded back in 2016&#59; Eindhoven&#44; Holland&#41;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The sequence protocol was always the same for all the cases&#44; both before and after the surgery&#44; and it was made up of two parts&#58; one morphological&#8211;physiological one and one dynamic one with IV contrast&#46; The first part consists of one sagittal T1-weighted TSE image with fat saturation &#40;SPIR&#41;&#44; 500&#47;17<span class="elsevierStyleHsp" style=""></span>ms &#40;RT&#47;ET&#41;&#44; with a 180<span class="elsevierStyleHsp" style=""></span>mm field of vision &#40;FOV&#41;&#59; a 236<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>189 matrix and a TSE T2 coronal 4000&#47;120<span class="elsevierStyleHsp" style=""></span>ms &#40;RT&#47;ET&#41;&#59; with a 130<span class="elsevierStyleHsp" style=""></span>mm FOV and a 192<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>152 matrix&#59; both centered on the sella turcica&#44; with 2 and 1&#46;5<span class="elsevierStyleHsp" style=""></span>mm slices&#44; respectively&#46; Prior to the contrast sequences&#44; one coronal T1 TSE Image 600 Image 600&#47;10<span class="elsevierStyleHsp" style=""></span>ms &#40;RT&#47;ET&#41; is added&#59; with a 130<span class="elsevierStyleHsp" style=""></span>mm field of vision &#40;FOV&#41;&#59; a 192<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>153 matrix and a slice thickness of 1&#46;5<span class="elsevierStyleHsp" style=""></span>mm&#46; Afterwards&#44; the dynamic studio consists of coronal T1-weighted TSE sequences with IV contrast&#59; 500&#47;10<span class="elsevierStyleHsp" style=""></span>ms &#40;RT&#47;ET&#41;&#59; with a rectangular 180<span class="elsevierStyleHsp" style=""></span>mm FOV and a 256<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>140 matrix&#44; with 3<span class="elsevierStyleHsp" style=""></span>mm slices&#46; Ten cyclic acquisitions are performed after administration of a 8<span class="elsevierStyleHsp" style=""></span>ml gadolinium bolus at 2&#46;5<span class="elsevierStyleHsp" style=""></span>ml&#47;s&#44; followed by a 20<span class="elsevierStyleHsp" style=""></span>ml physiological saline solution&#46; With the dynamic studio five or six slices of the hypophysis are obtained and in each and every one of these slices&#44; the progressive uptake of the normal hypophyseal gland can be seen&#44; and is compared to the rest of the tissues&#46; Finally&#44; two sequences with IV contrast are obtained &#40;late contrast&#41;&#58; one coronal T1 TSE Image 600&#47;10<span class="elsevierStyleHsp" style=""></span>ms &#40;RT&#47;ET&#41;&#44; with a 130<span class="elsevierStyleHsp" style=""></span>mm FOV and a 192<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>153 matrix&#44; with 1&#46;5<span class="elsevierStyleHsp" style=""></span>mm slices&#44; and one T1 SE Image 400 Image 400&#47;15<span class="elsevierStyleHsp" style=""></span>ms &#40;RT&#47;ET&#41;&#44; with a 180<span class="elsevierStyleHsp" style=""></span>mm FOV and a 256<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>192 matrix&#44; with 2<span class="elsevierStyleHsp" style=""></span>mm slices&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">In order to assess the degree of resection in immediate postoperative studies the preoperative study was taken as reference&#46; In many cases&#44; it could be confirmed that the volume occupied by the macroadenoma was barely modified on the postoperative MRIs&#44; because after its resection it was occupied by filling material&#59; inflammatory changes&#59; or traces of blood&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">11</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">In the subsequent evolutionary controls&#44; most inflammatory changes and changes in the postoperative filling material have been solved or reabsorbed&#44; and do not interfere anymore in the interpretation of the images&#46; This is why the immediate postoperative studies were compared to subsequent controls to see if the findings were consistent by measuring the sensitivity&#44; specificity&#44; positive predictive value &#40;PPV&#41;&#59; and negative predictive value &#40;NPV&#41; data&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Image interpretation</span><p id="par0060" class="elsevierStylePara elsevierViewall">The images were interpreted by two neuroradiologists&#44; one of them was a junior neuroradiologist and the other one had over 10 years of experience&#46; Both had access to the patient&#39;s medical history&#46; When in doubt&#44; consensus was reached by the two of them&#46; The following parameters were assessed&#58; &#40;1&#41; the hypophyseal gland and its enhancement pattern&#59; &#40;2&#41; the nodular enhancement &#40;suggestive of residual tumor&#41;&#59; or the linear enhancement &#40;suggestive of no tumor&#41;&#59; &#40;3&#41; pituitary stalk &#40;deviated&#44; compressed&#44; not visualized&#41;&#59; and &#40;4&#41; postoperative filling material and material for sellar floor reconstruction&#46; The findings were compared to the immediate postoperative MRIs and the MRIs with evolutive control&#46; The assessment of residual tumors was conducted qualitatively&#46; The degree of resection was established as 1 &#40;complete&#41;&#59; 2 &#40;partial&#41;&#59; and 3 &#40;doubtful&#41;&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Statistical analysis</span><p id="par0065" class="elsevierStylePara elsevierViewall">In the statistical analysis&#44; the sensitivity&#44; specificity&#44; PPV and NPV of the immediate postoperative MRIs were analyzed with respect to the evolutionary controls&#46; Also&#44; using the &#8220;R&#8221; programming language statistical analysis through generalized linear models&#44; one statistical analysis was conducted to study the relation between the degree of resection in evolutionary controls from months 4 to 6 and the variables of sex&#59; age&#59; size of adenoma in cubic millimeters&#59; Knosp grades &#40;left and right sides&#41;&#59; compression of the chiasm&#59; suprasellar spread&#44; degree of resection according to the neurosurgeon&#59; and degree of resection based on the immediate postoperative MRIs&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Results</span><p id="par0070" class="elsevierStylePara elsevierViewall">The histological confirmation of all the 73 cases reviewed was hypophyseal adenoma&#46; Sixty-eight out of the 73 were non-functioning and out of the remaining five&#44; three were producers of the growth hormone&#44; one a producer of the thyroid stimulating hormone&#44; and the remaining one a producer of corticotropin&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">In the diagnostic study&#44; the size of the macroadenomas ranged from a maximum diameter of 47<span class="elsevierStyleHsp" style=""></span>mm to a minimum diameter of 11<span class="elsevierStyleHsp" style=""></span>mm &#40;average size&#58; 25<span class="elsevierStyleHsp" style=""></span>mm&#41;&#44; with an average volume of 13&#46;89<span class="elsevierStyleHsp" style=""></span>cc &#40;range&#58; 0&#46;4&#8211;90<span class="elsevierStyleHsp" style=""></span>cc&#41;&#46; Out of the 73 tumors&#44; 58 infiltrated the cavernous sinuses&#46; The degree of cavernous sinus affectation according to the Knosp criteria&#44;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">12</span></a> is shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; There was suprasellar spread in 47 cases&#44; thirty-nine of which caused compression of the optic chiasm &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; In 50 of the 73 cases&#44; adenohypophysis gland remains could be identified&#44; not in the remaining twenty-three&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">With respect to the occurrence of transoperative complications during the surgical procedure&#44; nine cases were documented&#46; In eight of them&#44; there were cerebrospinal fluid &#40;CSF&#41; fistulas and in the remaining one venous hemorrhage connected to the dural opening&#46; In all patients&#44; the complication was managed intraoperatively&#44; and there were no further incidences&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Out of the 73 cases reviewed&#44; the immediate postoperative hypophysis MRI was interpreted as total resection in 38 cases and as residual tumor in 28 cases &#40;22 of which were interpreted as broad partial resection&#44; and 6 as partial resection&#41; &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#41;&#46; In seven cases&#44; there were doubts between residual tumor or complete resection&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">In the evolutionary controls&#44; it was determined that there was total resection in 41 cases and residual tumor in 32 &#40;26 of which were interpreted as broad partial resection and 6 as partial resection&#41;&#46; In four cases the normal hypophyseal gland continued to be unidentified and in one case there were still doubts&#46; Thirty-four out of the 38 cases of complete resection&#44; and 25 out of the 28 cases of residual tumor were interpreted correctly&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Out of the seven uncertain cases on the immediate postoperative MRIs&#44; four were confirmed to be total resections and three residual tumors&#46; Strictly speaking&#44; although no mistake was made during their classification&#44; for statistical reasons&#44; these uncertain cases were considered as four false negatives and three false positives &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">Taking all this data into consideration&#44; one descriptive correlation was established between the immediate postoperative MRI and the evolutionary controls with a 0&#46;78 sensitivity and a 0&#46;82 specificity&#46; The PPV and the NPV were both 0&#46;89&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">As a result of the generalized linear model conducted using the &#8220;R&#8221; software it was determined that&#44; among the variables studied&#44; the ones associated with the degree of resection in the evolutionary controls are the size of the macroadenoma&#44; and the degree of resection on the immediate postoperative MRI&#46; With these two variables&#44; one generalized linear regression model was applied to know what chances does that the degree of resection in the evolutionary control have of being complete or partial&#46; We will use the letter <span class="elsevierStyleItalic">p</span> to describe the probability of the degree of resection in the evolutionary control being 2 &#40;partial&#41;&#44; and 1-<span class="elsevierStyleItalic">p</span> to refer to the probability of being 1 &#40;complete&#41;&#59; there are no uncertain cases in the evolutionary control&#46; This will be the model&#58;<elsevierMultimedia ident="eq0005"></elsevierMultimedia></p><p id="par0110" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">&#945;</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>exp &#40;&#8722;2&#46;790<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>3&#46;271425<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>residual tumor on the MRI<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>1&#46;8363<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>doubtful MRI<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>8&#46;019<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">&#8722;5</span><span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>macro size&#41;&#44; where <span class="elsevierStyleItalic">exp</span> is the exponential function&#44; the residual tumor on the MRI is 1 when the degree of resection on the MRI has been 2&#44; and 0 if it has been otherwise&#59; doubtful MRI is 1 when the degree of resection on the MRI has been 3&#44; and 0 if it has been otherwise&#59; and macro size is the size of the macroadenoma&#46; Thanks to these formulas&#44; from the data available on the degree of resection on the MRI and the size of the macroadenoma&#44; the degree of resection can be predicted in the evolutionary control&#46; As a quality assessment of this model&#44; out of the 73 study cases&#44; this model successfully predicted 63&#44; being <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>0&#46;5 residual tumor&#44; and <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;5 complete resection&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Also&#44; from the signs of the coefficients&#44; the following can be deduced&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0120" class="elsevierStylePara elsevierViewall">The bigger the size of the macroadenoma&#44; the higher the chances that resection will be partial in the late evolutionary control&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0125" class="elsevierStylePara elsevierViewall">The fact that there is uncertainty about residual tumor on the immediate postoperative MRI increases the probability of finding residual tumor&#47;s in the late evolutionary control&#44; whereas the complete resection on the immediate postoperative MRI increases the probability of complete resection in the late evolutionary control&#46;</p></li></ul></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Discussion</span><p id="par0130" class="elsevierStylePara elsevierViewall">Although the immediate postoperative MRI &#40;&#60;24&#8211;48<span class="elsevierStyleHsp" style=""></span>h&#41; has already been implemented in many imaging protocols for the assessment of residual tumors in central nervous system neoplasms&#44;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">13&#44;5</span></a> this is not the case with hypophyseal tumors&#46; This kind of tumors shows a very different clinical&#44; radiological and prognostic behavior from other intracranial tumors&#44; since they rarely become malignant&#46; Also&#44; their proximity to critical neurovascular structures frequently leads to the appearance of postoperative complications and deficient symptomatology&#44; especially when there is damage to the hypophyseal stalk&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">During the last few decades and with the advancement of new technologies&#44; the endoscopic approaches of the cranial base have become more and more popular&#44; improving many of the challenges posed by other technologies&#59; today it is considered the surgical route of choice for the management of conditions of the sellar region&#44; for the resection of most intrasellar lesions&#44; and for the management of lesions with parasellar and suprasellar spread&#44; since it not only provides direct endonasal access&#44; but also panoramic views from within the sphenoid sinuses&#44; the sella turcica and the tumor cavity&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">This technique causes less damage to the hypothalamus&#8211;hypophyseal axis due to its simplicity in the approach and quick access to the sella turcica&#44; takes fewer hours in the operating room and shorter hospital stays for the patient&#44; which are some of the advantages that make it the technique of choice&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">7&#8211;9&#44;14&#44;15</span></a> However&#44; it is a real challenge for neurosurgeons&#44; not only during the approach&#44; but also during intradural time since they encounter a great distortion of the normal anatomy&#46; At our center we have one Neurosurgery Unit that has been conducting this type of surgery for over 10 years&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Endoscopic transsphenoidal surgery for the resection of hypophyseal adenomas poses complications that are inherent to the procedure&#44; and medical complications associated with the resection of conditions of the sellar region&#46; The complications of the procedure in our series were minimum&#44; the presence of one intraoperative CSF fistula was documented in approximately 10&#37; of the cases&#44; it was objectified and treated in all patients during the same surgical procedure and blocked with autologous fascia&#44; muscle and fat&#44; and sealed using hemostatic material&#46; Another minor surgical complication was the presence of venous hemorrhages &#40;&#60;1&#37;&#41; that were controlled by plugging&#46; No significant surgical complications were documented in the postoperative period in our study&#46; This very significant fact contrasts with the medical literature&#46; Some series like L&#243;pez-Arbolay et al&#46;&#8217;s series<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">16</span></a> and other more recent ones like Zhan et al&#46;&#8217;s series<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">17</span></a> prove that a percentage of their patients had complications during the postoperative period&#44; especially diabetes insipidus&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">The most common age of presentation for hypophyseal macroadenomas is between 30 and 60 years of age &#40;the average is 46 years old&#41;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">18&#44;19</span></a> slightly more predominant in women&#44;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">20</span></a> especially in younger years&#46; Most cases are sporadic&#44; and only a minority having to do with family history&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">19</span></a> In our series&#44; the average age was 53 years old&#44; which is close to the average age reported by the medical literature&#46; We did not find any sex-related significant differences&#44; and family associations were not studied&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Although there is no clear consensus on what the best time is to conduct the first postoperative MRI&#44; it usually happens after 3 or 6 months and&#44; then&#44; after one year&#46; In the absence of residual adenomas&#44; the annual monitoring is recommended during the first 5 years&#44; and then after 7&#44; 10 and 15 years&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">21</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">With our study we wish to give credit to this imaging modality when performed immediately &#40;within the first week&#41;&#44; since it has been confirmed that it has high sensitivity &#40;0&#46;78&#41; and specificity &#40;0&#46;82&#41; when it comes to findings residual tumors compared to follow-up MRI controls&#46; This confirms other studies published&#44; such as the study published by Di Maio et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">4</span></a> where they also obtained high sensitivity and specificity ratios&#44; and the studies conducted by Rodr&#237;guez et al&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">22</span></a> and Yoon et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">6</span></a> who also think that it is possible to differentiate residual tumors on MRIs within the first week after surgery&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">The immediate postoperative control is interesting especially in cases of hypophyseal macroadenomas&#8212;the ones we based our study on&#44; since most of them &#40;over 90&#37; in our series&#41; are non-functioning from the hormone point of view&#44; which is why the hormone levels cannot be determined to make the assessment of complete resection&#46; This percentage is higher than the averages reported in other series &#40;30&#8211;55&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">23&#44;24</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">Having the information about the residual tumor available during the days following the surgery allows a better assessment of prognosis&#59; provides the patient with information to be able to make future decisions such as early reoperations&#59; radiosurgeries&#59; pharmacotherapies&#59; or other therapeutical options&#59; and&#44; ultimately&#44; decide when to conduct future follow-ups&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">There are references sources describing the difficulties of interpreting immediate postoperative studies&#44; given the presence of filling or reconstruction materials&#59; inflammatory changes&#59; etc&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">11</span></a> One of the main reasons for this is that the volume of the lesion seems to occupy the same space than in the study prior to the surgery&#59; nevertheless&#44; there is a change in the signal intensity and the contrast uptake&#44; since this space is occupied by filling materials<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">2&#44;3&#44;25</span></a> and postoperative inflammatory changes&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Regenerated oxidized cellulose &#40;Oxycel<span class="elsevierStyleSup">&#174;</span> or Surgicel<span class="elsevierStyleSup">&#174;</span>&#41;&#59; absorbable gelatin sponge &#40;Spongostan<span class="elsevierStyleSup">&#174;</span> or Gelfoam<span class="elsevierStyleSup">&#174;</span>&#41;&#59; tissue adhesives &#40;Tissucol<span class="elsevierStyleSup">&#174;</span> or Beriplast<span class="elsevierStyleSup">&#174;</span>&#41;&#44; wax to stop bone bleeding&#44;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">2&#44;11&#44;12</span></a> etc&#46;&#44; are normally used to maintain hemostasis&#46; At our center&#44; Surgicel<span class="elsevierStyleSup">&#174;</span> is used to achieve the hemostasis of the tumor bed&#44; while the cavity is sealed with Tissucol<span class="elsevierStyleSup">&#174;</span>&#46; It is very important to know the type of material used during the surgery in order to avoid erroneous interpretation of the imaging studies&#44; since on the MRI&#44; in the T1-weighted sequences&#44; both Surgicel<span class="elsevierStyleSup">&#174;</span> and Oxycel<span class="elsevierStyleSup">&#174;</span> are identified as a low signal intensity&#44; regular oval shaped-heterogeneous structure surrounded by one hyperintense edge&#46; This material is mainly identified during the immediate postoperative period&#44; since later &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41; it starts a process of progressive degeneration and it becomes more difficult to identify&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">7</span></a> After the administration of contrast&#44; the central part of the hemostatic material remains hypointense&#44; with peripheral edge enhancement&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">7&#44;12</span></a> This peripheral enhancement is due to the granulation tissue building up around the implanted material&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">7&#44;12</span></a> Nevertheless&#44; we should say that one hypointense mass with peripheral enhancement after the administration of contrast can be consistent with necrosis within the tumor&#44; or fibrous granulation tissue&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">7&#44;12&#44;22</span></a></p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0185" class="elsevierStylePara elsevierViewall">Fat tissue is part of the filling material used&#44; and unlike other materials&#44; its identification is easy due to the hyperintensity that it produces on the T1-weighted sequences and because it persists for a long period of time&#59; as a matter of fact&#44; in some series&#44; it has been identified even 3&#8211;4 years after surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">21</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">The most important thing is to make a comparison with the preoperative study and check whether the residual tumor signal intensity is the same as that of the macroadenoma in the preoperative study&#44; and whether it occupies the same spot where the lesion was&#44; which is usually in the least accessible areas during surgery &#40;cavernous sinuses&#44; suprasellar spaces&#44; etc&#46;&#41; To this end&#44; it is useful to see how it behaves on the T2 and T1-weighted sequences both with and without contrast&#59; though maybe&#44; in most cases in our series&#44; the most useful sequence of all was the T1-weighted sequence with late contrast&#44; both on the coronal and sagittal planes&#46; If the signal intensity and the contrast uptake are similar to that of the lesion in the preoperative study&#44; we say that such tissue is suspicious of residual tumor&#46; When contrast uptake is linear and peripheral&#44; the chances are that it is consistent with postoperative changes&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">The dynamic study is more useful for the detection of possible adenohypophysis gland remains&#44; and to be able to differentiate them from residual tumors&#44; due to the early uptake that the gland tissue shows&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">When it comes to diffusion weighted imaging &#40;DWI&#41;&#44; some works have already been published correlating the apparent diffusion coefficient &#40;ADC&#41; values with the consistency &#40;soft or hard&#41; of pituitary macroadenomas&#44; which can determine how endoscopic surgery will eventually be conducted&#46; This sequence was not performed in our series&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">When analyzing the generalized linear mathematical model study carried out with the data gathered&#44; it seems proven that the variables that are better associated with the degree of actual lesion resection are the size of the lesion and the immediate postoperative MRI results&#46; Other studies published have demonstrated that the degree of invasion of cavernous sinuses on preoperative MRIs can also predict the degree of resection&#44; which is usually lower when it affects the lateral and inferolateral compartments&#44; and with a higher Knosp grade&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">26</span></a> In our study&#44; the degree of resection is more associated with the size of the tumor and&#44; consequently&#44; the bigger the macroadenoma&#44; the harder it is to resect completely&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">The value of the data obtained on the postoperative immediate MRIs is worth mentioning particularly since there is a consistent association with the degree of final resection when compared to evolutionary controls&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">In our study&#44; we found no association whatsoever between the local spread or invasion of macroadenomas and the prediction of the degree of resection&#44; especially in adenomas invading the cavernous sinus&#46; This may be justified by the small number of patients with Knosp grades 3 and 4&#44; which would be one of the limitations of our study&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">We have no anatomopathological confirmation of the cases with residual tumors&#44; because not all the cases are reoperated&#44; since this is mainly based on the size and location of these tumors&#46; In our series&#44; most of the 28 cases of residual tumors corresponded to broad resections and therefore&#44; which means that since almost no tumor remained&#44; the patients were not reoperated&#44; and in only six cases resection was partial&#59; among these&#44; one case was reoperated&#46; The remaining patients were followed-up through imaging monitoring&#44; which would be another limitation of our study&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">Lastly&#44; the control workup of the five cases of functioning adenomas also limits the results of our work &#8211; conducted with hormone tests and not with imaging follow-ups&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">In sum&#44; the immediate postoperative MRI after the transsphenoidal surgery of macroadenomas is useful for the early assessment of the degree of tumor resection&#44; and it is a good predictor of the degree of actual or final resection of such tumors&#46; Thus&#44; this kind of MRI allows us to study what the earliest optimal treatment really is&#44; especially through reoperation or radiosurgery&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Authors contribution</span><p id="par0235" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">1&#46;</span><p id="par0240" class="elsevierStylePara elsevierViewall">Manager of the integrity of the study&#58; MVM and ETL&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">2&#46;</span><p id="par0245" class="elsevierStylePara elsevierViewall">Study Idea&#58; MVM&#44; ETL and JJF&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">3&#46;</span><p id="par0250" class="elsevierStylePara elsevierViewall">Study Design&#58; ETL&#44; MVM&#44; JJF and EMO&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">4&#46;</span><p id="par0255" class="elsevierStylePara elsevierViewall">Data Mining&#58; ETL&#44; MVM&#44; JJF&#44; JCG&#44; MJS&#44; APC&#44; ACG and EMO&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">5&#46;</span><p id="par0260" class="elsevierStylePara elsevierViewall">Data Analysis and Interpretation&#58; MJS&#44; JCG&#44; JJF&#44; ETL and MVM&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">6&#46;</span><p id="par0265" class="elsevierStylePara elsevierViewall">Statistical Analysis&#58; MJS and JCG&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">7&#46;</span><p id="par0270" class="elsevierStylePara elsevierViewall">Reference&#58; MVM&#44; ETL&#44; ACG&#44; APC and JJF&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">8&#46;</span><p id="par0275" class="elsevierStylePara elsevierViewall">Writing&#58; MVM&#44; ETL and JJF&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">9&#46;</span><p id="par0280" class="elsevierStylePara elsevierViewall">Critical review of the manuscript with intellectually relevant remarks&#58; ETL&#44; MVM&#44; JJF&#44; JCG&#44; MJS&#44; APC&#44; ACG and EMO&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">10&#46;</span><p id="par0285" class="elsevierStylePara elsevierViewall">Approval of final version&#58; ETL&#44; MVM&#44; JJF&#44; JCG&#44; MJS&#44; APC&#44; ACG and EMO&#46;</p></li></ul></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflict of interests</span><p id="par0290" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interests&#46;</p></span></span>"
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      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To evaluate if it is possible to determine the extent of pituitary macroadenomas resection in the immediate postoperative pituitary magnetic resonance imaging &#40;MRI&#41;&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">MRI of patient with pituitary macroadenomas from January 2010 until October 2014 were reviewed&#46; Those patients who had diagnostic MRI&#44; immediate post-surgical MRI and at least one MRI control were included&#46; We evaluate if the findings between the immediate postsurgical MRI and the subsequent MRI were concordant&#46; Cases which did not have evolutionary controls and those who were reoperation for recurrence were excluded&#46; The degree of tumor resection was divided into groups&#58; total resection&#44; partial resection and doubtful&#46; All MRI studies were performed on a 1&#46;5<span class="elsevierStyleHsp" style=""></span>T machine following the same protocol sequences for all cases&#46; One morphological part&#44; a dynamic contrast IV and late contrast part&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Of the 73 cases included&#44; immediate postoperative pituitary MRI was interpreted as total resection in 38 cases and tumoral rest in 28 cases&#44; uncertainty among rest or inflammatory changes in 7 cases&#46; Follow-up MRI identified 41 cases total resection and tumoral rest in 32&#46; Sensitivity and specificity of 0&#46;78 and 0&#46;82 and positive and negative predictive value &#40;PPV and NPV&#41; 0&#46;89 and 0&#46;89 respectively were calculated&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Immediate post-surgery pituitary MRI is useful for assessing the degree of tumor resection and is a good predictor of the final degree of real resection compared with the following MRI studies&#46; It allows us to decide the most appropriate treatment at an early stage&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objective"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Material and methods"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusion"
          ]
        ]
      ]
      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Comprobar si es posible determinar el grado de resecci&#243;n de macroadenomas hipofisarios en la resonancia magn&#233;tica &#40;RM&#41; hipofisaria posquir&#250;rgica inmediata&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se revisaron las RM hipofisarias de pacientes intervenidos desde enero de 2010 hasta octubre de 2014&#46; Se incluyeron aquellos que ten&#237;an RM diagn&#243;stica&#44; RM posquir&#250;rgica inmediata y al menos un control posterior&#46; Se comprob&#243; si los hallazgos entre la RM posquir&#250;rgica inmediata y las RM posteriores eran concordantes&#46; Se excluyeron los casos sin controles evolutivos y las reintervenciones por recidivas&#46; El grado de resecci&#243;n tumoral lo dividimos en grupos&#58; resecci&#243;n total&#44; resecci&#243;n parcial y dudoso&#46; Los estudios se realizaron en una m&#225;quina de 1&#46;5<span class="elsevierStyleHsp" style=""></span>T siguiendo el mismo protocolo de secuencias&#58; una parte morfol&#243;gica&#44; otra din&#225;mica con contraste intravenoso y otra con contraste tard&#237;o&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">De 73 casos incluidos&#44; la RM posquir&#250;rgica inmediata se interpret&#243; como resecci&#243;n total en 38 casos y resto tumoral en 28 casos&#44; habiendo dudas en 7 casos&#46; En los controles evolutivos se determin&#243; resecci&#243;n total en 41 casos y resto tumoral en 32&#46; Se obtuvo una sensibilidad para detecci&#243;n de restos tumorales de 0&#44;71&#44; una especificidad de 0&#44;82&#44; un valor predictivo positivo de 0&#44;89 y un valor predictivo negativo de 0&#44;85 en la RM posquir&#250;rgica inmediata respecto a los controles evolutivos&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusi&#243;n</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La RM posquir&#250;rgica inmediata de macroadenomas hipofisarios es &#250;til para valorar el grado de resecci&#243;n tumoral y es un buen predictor del grado de resecci&#243;n real definitivo al comparar con las RM posteriores&#44; permitiendo plantear el tratamiento adecuado de forma precoz&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Objetivo"
          ]
          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Material y m&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusi&#243;n"
          ]
        ]
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Taberner L&#243;pez E&#44; Va&#241;&#243; Molina M&#44; Calatayud Gregori J&#44; Jornet Sanz M&#44; Jornet Fayos J&#44; Pastor del Campo A&#44; et al&#46; Valoraci&#243;n del grado de resecci&#243;n de los macroadenomas hipofisarios en la resonancia magn&#233;tica posquir&#250;rgica inmediata&#46; Radiolog&#237;a&#46; 2018&#58;60&#59;64&#8211;72&#46;</p>"
      ]
    ]
    "multimedia" => array:7 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Partial resection&#46; Residual tumor&#46; Fifty-eight-year-old patient&#46; Headache study&#46; Diagnostic hypophyseal MRIs conducted &#40;a&#8211;d&#41; that identify the presence of one macroadenoma of 30<span class="elsevierStyleHsp" style=""></span>mm maximum diameter&#44; with suprasellar spread&#44; and damage to the optic chiasm and both Knosp grade 2 cavernous sinuses&#46; The normal hypophyseal gland is not identified&#46; On the immediate postoperative MRI study conducted on day 4 &#40;e&#8211;h&#41;&#44; the volume occupied by the tumor has hardly changed due to the occupation of the filling material&#46; We can see the peripheral enhancement of the hemostatic material occupying the same space-occupying lesion &#40;asterisk&#41;&#44; and a small hypo-uptake region in the right cavernous sinus &#40;f and h&#41; indicative of residual tumor&#44; of the same signal intensity as on the diagnostic MRI &#40;h&#41;&#46; The late control 6 months after the surgery &#40;i&#8211;l&#41; confirms the partial resection of the tumor&#44; and a small residual tumor &#40;j&#8211;l&#41; in the right cavernous sinus&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Complete resection&#46; Sixty-six-year-old patient&#46; Study due to vision alterations&#46; One diagnostic hypophyseal MRI study is conducted &#40;a&#8211;d&#41; that identifies one invasive macroadenoma of 32<span class="elsevierStyleHsp" style=""></span>mm maximum diameter&#44; with suprasellar spread&#44; compression of the optic chiasm and damage to both cavernous sinuses&#8212;Knosp grade 4 on the left&#44; and Knosp grade 3 on the right&#46; The shine of the neurohypophysis is observed in the right position &#40;arrow&#41;&#46; Immediate postoperative MRI study conducted on day 3 &#40;e&#8211;h&#41; that identifies the peripheral enhancement of the hemostatic material that occupies the same space as the lesion&#46; Late control 4 months after surgery &#40;i&#8211;l&#41; that confirms the complete resection of tumor&#46; On the coronal images &#40;j&#8211;l&#41; we can see the chiasm&#59; the hypophyseal stalk&#59; and the gland that sits in the sella turcica&#44; with hypersignal of the neurohypophysis on the posterior side &#40;i&#41;&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
            "Alto" => 1953
            "Ancho" => 2500
            "Tamanyo" => 414225
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Early MRI of operated macroadenoma&#46; Changes characteristics of recent surgery&#46; &#40;a&#41; Sagittal T1-weighted SPIR image&#46; On the upper edge&#44; we can see the hypophyseal stalk &#40;arrow&#41;&#44; and normal hypophyseal gland remains&#46; &#40;b and c&#41; Sagittal and coronal T1-weighted images after the administration of IV contrast&#44; with hypointense filling of the cavity with Surgicel<span class="elsevierStyleSup">&#174;</span>&#44; and the hyper-uptake edge&#44; without signs indicative of adenoma&#46; &#40;d&#41; Preoperative study images&#46; &#40;e&#41; Control MRI after 3 months&#46;</p>"
        ]
      ]
      3 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at1"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Knosp grade&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Left cavernous sinus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Right cavernous sinus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">0&#58; The tumor does not touch the cavernous sinus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1&#58; The tumor does not reach the intercarotid line&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2&#58; The tumor extends beyond the intercarotid line&#44; but does not reach the line that is tangent to the carotid lateral sides as it passes through the cavernous sinus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3&#58; The tumor extends beyond the lateral line tangent to the carotid&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4&#58; The tumor totally wraps around the carotid artery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab1654428.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Cavernous sinus affectation based on the Knosp criteria&#46;</p>"
        ]
      ]
      4 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at2"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">ACTH&#58; adrenocorticotropic hormone&#59; GH&#58; growth hormone&#59; MRI&#58; magnetic resonance imaging&#59; TSH&#58; thyroid stimulating hormone&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " colspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Characteristics</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Men&#58;women&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">38&#58;35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Average age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">53 years &#40;range&#58; 21&#8211;85&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mean size of macroadenoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24&#46;86<span class="elsevierStyleHsp" style=""></span>mm &#40;range&#58; 11&#8211;47&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mean volume of macroadenoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">14 cc &#40;range&#58; 0&#46;4&#8211;90&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hormone-secreting macroadenomas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">GH 3 cases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">TSH 1 case&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ACTH 1 case&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Infiltration of cavernous sinuses&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">58 cases &#40;79&#46;45&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Suprasellar spread&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">47 cases &#40;64&#46;38&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Compression of chiasm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">39 cases &#40;53&#46;42&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Location of the normal hypophyseal gland on the preoperative MRIs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Unidentified&#58; 24 cases &#40;32&#46;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Unidentified&#58; 49 cases &#40;67&#46;12&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Lateral&#58; 17 cases &#40;11 right&#44; 6 left&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Superior&#58; 14 cases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Posterior&#58; 12 cases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Inferior&#58; 1 case&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Anterior&#58; 2 cases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">On sella turcica&#58; 3 cases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Degree of resection according to the neurosurgery report&#47;immediate MRI report&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Total&#58; 57&#47;38 cases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Broad partial&#58; 16&#47;28 cases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Location of residual tumor on the immediate postoperative MRI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Residual tumor&#58;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cavernous sinuses&#58; 11 cases &#40;6 right&#44; 5 left&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Suprasellar&#58; 9 cases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Lateral&#58; 6 cases &#40;5 right&#44; 1 left&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Inferior&#58; 3 cases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Peripheral&#58; 3 cases&nbsp;\t\t\t\t\t\t\n
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Article information

ISSN: 21735107
Original language: English

DOI:10.1016/j.rxeng.2017.10.006

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