These observations have been endorsed by groups in other countries. A high workload, i. Finally, evaluation of efficacy must be based on outcome data [ 34 , 35 ].
Assuming that expertise or excellence comes from the workload of a well-trained surgeon, and considering that most centers serve a fixed number of inhabitants, the solution proposed by several publications would be to have a limited number of surgeons devoted to pituitary tumors at each center, with a backup for emergency cases.
A single neurosurgeon situation, however, has several drawbacks. For example, the center will remain uncovered when the surgeon is absent, the training of new fellows would be difficult, and performing clinical research and communicating results could be impeded. For such reasons, one alternative could be to concentrate several neurosurgeons two to four at a given center that covers the transsphenoidal surgery needs of a whole region that ideally has 2. Such a center would receive patients who were generated locally but also referred from endocrine units located at other hospitals in the region, i.
The regionalized center can receive patients already diagnosed, perform the intervention, and return the patient for follow up at the hospital or physician of origin. This process may be facilitated by implementation of electronic clinical registries working within a network. As the number of patients with pituitary diseases is not large, such an organization should be satisfactory in cost-benefit terms for health administrators, even considering the travel costs of the patient to the reference center.
A PTCOE requires that the neurosurgery group works closely with an endocrinologist on an endocrine unit or a division that has a special emphasis on pituitary diseases. Only a combination of expert neurosurgeons working in liaison with expert neuroendocrinologists can provide the excellence of care needed to meet the definition of a PTCOE. This team will use advanced techniques of diagnoses and treatment, produce scientific reports, and present their results to scientific bodies and administrative authorities.
The mission of the endocrine component of the PTCOE includes suspecting pituitary disease, establishing the diagnosis, determining the optional treatment plan with neurosurgeons regarding surgical intervention, providing support for peri-operative care, and providing long term follow up management. Also document and manage any endocrine deficiencies across radiation procedures. Defining expertise for an endocrinologist appears to be easier than for a neurosurgeon considering that the requiring workloadhas not be determined.
It is evident, however, that an endocrinologist wishing to participate in a PTCOE needs to have received basic training in internal medicine and endocrinology though the residency stage, and then to perform postgraduate training for at least 12 months as part of a group of experts in pituitary disorders that has international stature.
Pituitary Adenoma, An Issue of Neurosurgery Clinics of North America
The expert endocrinologist must have a through knowledge of the laboratory techiques for hormone analysis because diagnosis is based on the accurancy of such techiques. Analytical methods are complex and a true knowledge of reagents, calibrators and degree of standarization is mandatory. An adequate understanding of modern genetic techiques is also relevant for diagnosis.
To substantiate excellence, the endocrinologist should present results at scientific meetings and contribute to the advance of pituitary science. This can be supported by regular publications of peer-reviewed research articles, reviews, chapters in monographs or textbooks, participation in scientific or consensus meetings, as well as by regular participation in multi- center trials of novel pituitary-directed treatments strategies Fig.
The leading team composed by the endocrinology and by neurosurgery teams, and the main supportly units of other specialities. The close relationship of expert pituitary surgeons and pituitary endocrinologists requires the additional support of several specialties to provide a high-level standard of care. For imaging analysis, a group of well-trained neuroradiologists is ordinarily available in most centers and in all academic units.
However in certain circumstances, familiarity with specific protocols to locate often small microadenomas in for example Cushing disease is of importance in a full PTCOE. For diagnosis, reports from the neuropathologist should include tumor immunocytochemistry to make full diagnosis and comments if the tumor exhibits unusually high proliferative potential as this may have bearing on subsequent management. There may be the need for close surgical collaboration between neurosurgery and otolaryngology in the execution of endonasal and other skull-base approaches.
Neuro-ophthalmologists are required for the diagnosis and, in some cases, for follow-up. The contribution of such specialties is mandatory to provide a given PTCOE its necessary support [ 9 , 39 — 47 ]. At a minimum, high field magnetic resonance imaging MRI with at least 1. In addition, around the clock availability of thin-collimation computerized tomography is required for those who have contraindications to MRI.
Orientation of the sections and labelling of the images should be standardized to enable reliable follow-up studies. The centre should have access to digital substraction angiograpy, and to expert selective bilateral venous sampling of the inferior petrosal sinus. Tumor Pathology is an essential aspect of the diagnosis, management and follow-up of patients with pituitary and related disorders. The pathologic diagnosis guides the optimal therapeutic strategy, and helps to determine the response to treatment and the prognosis for the patient.
Radiation therapy is required to treat some pituitary tumors that are completely or partially resistant to medical treatment, or for surgical remnants from such tumors, patients who refuse or cannot undergosurgery,aggressive pituitary tumors or in pituitary cancers. In all of these cases, LINAC radiotherapy, stereotactic radiotherapy or radio-surgery, all of which are computer-assisted techniques performed by radiotherapists expert in the treatment of intracranial tumors, are necessary at a high level PTCOE [ 48 — 57 ].
Single fraction stererotactic radiosurgery single dose or fractionated stereotactic treatmentneed to be accessible from the center of excellence, to be utilized depending on patient and tumor related factors. Radiation neuroncologists treating patients with pituitary adenomas must have an in-depth knowledge of the tolerance of the optic system, cranial nerves of the cavernous sinus, temporal lobes and the normal pituitary gland.
They should also understand the temporal relationship between the delivery of radiation and the interval for development of such complications as hypopituitarism. Radiation oncologists should work in close cooperation with the neuroendocrinologists and neurosurgeons. This should also allow selected radiotherapists to gain enough experience in the treatment of pituitary tumors. In some national Health Systems, radiation neurooncology units are not located in every high level hospital but at specific centers. In such situations close relationship between radiotherapists and neuroendocrinologists must be guaranteed.
All of these different specialties working in a team with neurosurgeons and expert neuroendocrinologists form the core of a PTCOE. The internal architecture of the unit and facilities should allow intense collaborative and interdisciplinary functioning. A bidirectional flux the patients would guarantee the best care for patients suffering of pituitary pathologies Fig.
The Unit of Excellence benefits of working in collaboration with external endocrine units that may be located in other centers or hospitals.
After surgery patients return to their original units. This allows for a networking method of patient care. In the last few decades, a considerable body of evidence supports the concept that patients with pituitary tumors would receive the best care from units of excellence composed of expert neurosurgeons performing pituitary surgery by transsphenoidal and other approaches, plus experienced neuroendocrinologists devoted to these types of tumors.
These experts, working in liaison with supporting units, would form a center of excellence for pituitary tumors PTCOE.tapecubac.ml
Management of Pituitary Tumors, An Issue of Neurosurgery Clinics, Volume 23-4
Such a center would be the optimal organization for patients, the most cost-effective for health administrators, and a more suitable structure to allow for derivation and presentation of results, and advancement of pituitary science. BenShlomo cshs. Bonert cshs. Carmichael med. Gemelli, Rome, Italy, laurademarinis yahoo. Durand, Buenos Aires, Argentina, smalleagil gmail. USA, adam. Mamelak cshs.
Stewart leeds. Strasburger charite.
The other authors Michael Buchfelder, Edward R. This article does not contain any studies with human participants or animals performed by any of the authors. Change history. Misa Pfeifer is affiliated with Medical Faculty, University of Ljubljana, Slovenia and the correct email address to contact is misa. Bruno , Michael Buchfelder , John D.
Casanueva , Richard N. Tritos , Stylianos Tsagarakis , A. National Center for Biotechnology Information , U.
Pituitary Surgery | Hull University Teaching Hospitals NHS Trust
Published online Sep 7. Felipe F. Casanueva , 1 Ariel L. Laws , 5 Jay S. Ariel L. Edward R. Jay S. Author information Copyright and License information Disclaimer. Casanueva, Email: se.
- Die Reformdiskussion in der Bundesrepublik Deutschland: Einführung direktdemokratischer Instrumente auf Bundesebene? (German Edition).
- Join Kobo & start eReading today.
- Journal of Neurological Surgery Part B: Skull Base.
- Management of Pituitary Tumors, An Issue of Neurosurgery Clinics - E-Book.
- Youmans and Winn Neurological Surgery, 4-Volume Set, 7th Edition.
Related Management of Pituitary Tumors, An Issue of Neurosurgery Clinics - E-Book (The Clinics: Surgery)
Copyright 2019 - All Right Reserved