Intraoperative Scoring System to Predict Postoperative Remission in Endoscopic Endonasal Transsphenoidal Surgery for Growth HormoneeSecreting Pituitary Adenomas Shigetoshi Yano 1 , Naoki Shinojima 1 , Junji Kawashima 2 , Tatsuya Kondo 2 , Takuichiro Hide 1 - OBJECTIVE: To determine the predictive factors for endocrinological remission of patients with growth hor- mone (GH)-secreting pituitary adenomas. - METHODS: In 47 patients with GH-secreting pituitary adenomas who underwent endoscopic endonasal trans- sphenoidal surgery with intraoperative GH measurements from 2002 to 2011, the relationship between the intra- operative GH levels and postoperative remission was analyzed, and 2 items that predicted remission (GH half-life obtained 30 minutes or less after removal and a minimum surgical GH level less than 2.5 ng/mL) were determined. In addition, 2 surgical observations (endoscopic confirmation of no tumor remnants and pathologic confirmation of the absence of tumor remnants in the bordering tissue) were also considered. Positive items resulted in one point, and scores ranged from 0 to 4. For 27 patients who underwent surgery from 2012 onwards, this scoring system was applied by 3 independent operators, and the remission rates and predictive values were estimated. - RESULTS: Twenty-six of the 47 (55.3%) patients achieved remission. The remission rates were significantly different for different scores. In the 27 patients treated from 2012 onward, repeat residual tumor examinations were per- formed if the GH score did not reach 2 at the end of the removal. Nine patients had final scores of 3 or 4. All of these patients achieved remission. In 16 patients with final scores of 2 or less, only 2 with Knosp grades of 0 and 1 achieved remission. - CONCLUSIONS: Our scoring system, which incorporated GH measurements and surgical observations, predicted postoperative remission. Complete tumor removal was critical to achieve intraoperative scores over 3. INTRODUCTION G rowth hormone (GH)-secreting pituitary adenomas can lead to clinical acromegaly, which is the excessive secretion of GH that causes musculoskeletal deformities, cardiovascular disease, diabetes mellitus, and malignancies. Un- treated acromegaly results in significant morbidity and is associ- ated with a 2- to 3-fold increase in mortality. 2,18,22 Normalization of the GH levels improves symptoms of acromegaly and reduces mortality rates to those observed in the general population. 7 Therefore, the appropriate treatment of acromegaly is crucial. A somatostatin analog is recommended as the first line of treatment for large and invasive adenomas that are unlikely to be removed successfully by surgery. However, for moderate and noninvasive adenomas, transsphenoidal resection of pituitary adenomas remains the primary therapy. 4 Endoscopic endonasal transsphenoidal surgery (ETSS) increas- ingly has been used to treat patients with pituitary adenomas. Endoscopic techniques are preferable to conventional techniques because of the clear visualization and magnification offered by endoscopy. Better surgical results have been reported for patients with acromegaly treated with endoscopy compared with micro- surgery, especially in patients with adenomas that extend into the cavernous sinus. 5 Intraoperative GH measurements 1,19 and Key words - Acromegaly - Endoscopic endonasal surgery - Growth hormone - Intraoperative measurement - Remission Abbreviations and Acronyms 75-g OGTT : 75-g oral glucose tolerance test ETSS: Endoscopic endonasal transsphenoidal surgery GH: Growth hormone IGF-1: Insulin-like growth factor-1 MRI: Magnetic resonance imaging From the Departments of 1 Neurosurgery and 2 Metabolic Medicine, Faculty of Life Sciences, Kumamoto University Graduate School, Kumamoto, Japan To whom correspondence should be addressed: Shigetoshi Yano, M.D., Ph.D. [E-mail: yanos@kumamoto-u.ac.jp] Citation: World Neurosurg. (2017) 105:375-385. http://dx.doi.org/10.1016/j.wneu.2017.05.162 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2017 Published by Elsevier Inc. WORLD NEUROSURGERY 105: 375-385, SEPTEMBER 2017 www.WORLDNEUROSURGERY.org 375 Original Article