J Korean Neurosurg Soc.  2016 Nov;59(6):577-583. 10.3340/jkns.2016.59.6.577.

Parasellar Extension Grades and Surgical Extent in Endoscopic Endonasal Transsphenoidal Surgery for Pituitary Adenomas : A Single Surgeon's Consecutive Series with the Aspects of Reliability and Clinical Validity

• Lee SH
• Park JS
• Lee S
• Kim SW
• Hong YK

• KMID: 2417339
• DOI: http://doi.org/10.3340/jkns.2016.59.6.577

Abstract

OBJECTIVE
The inter-rater reliability of the modified Knosp's classification was measured before the analysis. The clinical validity of the parasellar extension grading system was evaluated by investigating the extents of resection and complication rates among the grades in the endoscopic endonasal transsphenoidal surgery (EETS) for pituitary adenomas.
METHODS
From November 2008 to August 2015, of the 286 patients who underwent EETS by the senior author, 208 were pituitary adenoma cases (146 non-functioning pituitary adenomas, 10 adrenocorticotropic hormone-secreting adenomas, 31 growth hormone-secreting adenomas, 17 prolactin-secreting adenomas, and 4 thyroid-stimulating hormone-secreting adenomas; 23 microadenomas, 174 macroadenomas, and 11 giant adenomas). Two neurosurgeons and a neuroradiologist independently measured the degree of parasellar extension on the preoperative sellar MRI according to the modified Knosp's classification. Inter-rater reliability was statistically assessed by measuring the intraclass correlation coefficient. The extents of resection were evaluated by comparison of the pre- and post-operative MR images; the neurovascular complications were assessed by reviewing the patients' medical records. The extent of resection was measured in each parasellar extension grade; thereafter, their statistical differences were calculated.
RESULTS
The intraclass correlation coefficient value of reliability across the three raters amounted to 0.862. The gross total removal (GTR) rates achieved in each grade were 70.0, 69.8, 62.9, 21.4, 37.5, and 4.3% in Grades 0, 1, 2, 3A, 3B, and 4, respectively. A significant difference in the extent of resection was observed only between Grades 2 and 3A. In addition, significantly higher complication rates were observed in the groups above Grade 3A.
CONCLUSION
Although the modified Knosp's classification system appears to be complex, its inter-rater reliability proves to be excellent. Regarding the clinical validity of the parasellar extension grading system, Grades 3A, 3B, and 4 have a negative predictive value for the GTR rate, with higher complication rates.

Keyword

Cavernous sinus; Complications; Endoscopy; Pituitary neoplasms; Reliability; Transsphenoidal surgery

MeSH Terms

Adenoma
Cavernous Sinus
Classification
Endoscopy
Humans
Magnetic Resonance Imaging
Medical Records
Neurosurgeons
Pituitary Neoplasms*

Figure

• 

  Fig. 1 According to the article of Micko et al.21), SHL redraws illustration of the modified Knosp's classification. A : Grade 0 : the adenoma does not encroach on the CS space. Thus, the tangent of the medial aspects of the intracavernous and supracavernous ICAs is not passed. B : Grade 1 : the medial tangent is passed, but the extension does not go beyond a line drawn between the cross-sectional centers of the intracavernous and supracavernous ICAs (the intercarotid line). C : Grade 2 : the tumor extends beyond the intercarotid line, but does not pass the tangent on the lateral aspects of the intracavernous and supracavernous ICAs. D : Grade 3A : the tumor extends lateral to the lateral tangent of the intracavernous and supracavernous ICAs into the superior CS compartment. E : Grade 3B : the tumor extends lateral to the lateral tangent of the intracavernous and supracavernous ICAs into the inferior CS compartment. F : Grade 4 : there is total encasement of the intracavernous carotid artery. CS : cavernous sinus, ICA : internal carotid artery.

• 

  Fig. 2 An illustrative case emphasizing routine inspection of the T2 weighted image, as well as the gadolinium-enhanced T1 image on a preoperative magnetic resonance image scan. A : T2 weighted image. Cavernous ICA does not seem to be encased by the pituitary mass. In grading, two raters confirmed these cases as Grades 1 and 2, respectively. B : T1 weighted image with gadolinium enhancement. Right cavernous ICA seems to be encased by the pituitary mass. One rater confirmed this case as Grade 4. ICA : internal carotid artery.

• 

  Fig. 3 Inclusion and exclusion flow chart. 208 cases are included in this study.

• 

  Fig. 4 Schematic chart representing the distribution of the extent of resection in each grade. Gross total removal rate shows an inverse proportional relationship with the grade increase. GTR : gross total removal, STR : subtotal tumor removal, PR : partial removal.

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