Imaging of Resected Nonfunctioning Pituitary Adenomas: The Cost of Surveillance

Abstract

Objectives To determine the cost of annual magnetic resonance imaging (MRI) surveillance after resection of nonfunctioning pituitary adenomas (NFPAs) and its effectiveness in reducing visual compromise due to tumor recurrence.

Design Retrospective case series.

Setting Vanderbilt University Medical Center (2003–2011).

Participants A total of 120 patients underwent primary transsphenoidal resection and surveillance of NFPAs between 2003 and 2011.

Main Outcome Measures Time from initial surgery to most recent imaging or progression. Surveillance MRI costs according to Centers for Medicare and Medicaid database and visual field deficits.

Results Patients received 382 surveillance scans at a total cost of $218,477.30. The median follow-up was 47 months (interquartile range [IQR]: 26–76), and the median interval between scans was 357 days (IQR: 225–434). Overall, 50 scans (13%) revealed tumor growth. The cost per scan revealing growth was $4,369.55. The cost to identify 19 patients (16%) with clinically significant growth was $11,498.80 per patient. A total of 5 of 19 patients (26%) experienced new visual deficits prior to intervention. Patients with visual decline tended to have longer scan intervals than those with preserved vision (mean: 239 versus 794 days; p = 0.0584). No patient with annual surveillance imaging experienced visual decline.

Conclusions Annual MRI scans are a sensitive and cost-conscious method to identify NFPA recurrence prior to visual decline.

Keywords

pituitary adenoma - follow-up - management - cost - MRI

• References

• 1 Chen Y, Wang CD, Su ZP , et al. Natural history of postoperative nonfunctioning pituitary adenomas: a systematic review and meta-analysis. Neuroendocrinology 2012; 96 (4) 333-342
• 2 Wass JA, Reddy R, Karavitaki N. The postoperative monitoring of nonfunctioning pituitary adenomas. Nat Rev Endocrinol 2011; 7 (7) 431-434
• 3 Roelfsema F, Biermasz NR, Pereira AM. Clinical factors involved in the recurrence of pituitary adenomas after surgical remission: a structured review and meta-analysis. Pituitary 2012; 15 (1) 71-83
• 4 Chang EF, Zada G, Kim S , et al. Long-term recurrence and mortality after surgery and adjuvant radiotherapy for nonfunctional pituitary adenomas. J Neurosurg 2008; 108 (4) 736-745
• 5 Brada M, Rajan B, Traish D , et al. The long-term efficacy of conservative surgery and radiotherapy in the control of pituitary adenomas. Clin Endocrinol (Oxf) 1993; 38 (6) 571-578
• 6 Raappana A, Pirilä T, Ebeling T, Salmela P, Sintonen H, Koivukangas J. Long-term health-related quality of life of surgically treated pituitary adenoma patients: a descriptive study. ISRN Endocrinol 2012; 2012: 675310
• 7 Trouillas J, Roy P, Sturm N , et al; members of HYPOPRONOS. A new prognostic clinicopathological classification of pituitary adenomas: a multicentric case-control study of 410 patients with 8 years post-operative follow-up. Acta Neuropathol 2013; 126 (1) 123-135
• 8 Ruggeri RM, Trimarchi F, Curtò L. Morphometric characteristics, cell proliferation parameters and apoptosis indices do not correlate with tendency to relapse in non-functioning pituitary macroadenomas. Endocrine 2013; 43 (2) 464-466
• 9 Ruggeri RM, Costa G, Simone A , et al. Cell proliferation parameters and apoptosis indices in pituitary macroadenomas. J Endocrinol Invest 2012; 35 (5) 473-478
• 10 Nishioka H, Inoshita N, Sano T, Fukuhara N, Yamada S. Correlation between histological subtypes and MRI findings in clinically nonfunctioning pituitary adenomas. Endocr Pathol 2012; 23 (3) 151-156
• 11 Honegger J, Prettin C, Feuerhake F, Petrick M, Schulte-Mönting J, Reincke M. Expression of Ki-67 antigen in nonfunctioning pituitary adenomas: correlation with growth velocity and invasiveness. J Neurosurg 2003; 99 (4) 674-679
• 12 Kontogeorgos G. Predictive markers of pituitary adenoma behavior. Neuroendocrinology 2006; 83 (3–4) 179-188
• 13 Connor SE, Wilson F, Hogarth K. Magnetic resonance imaging criteria to predict complete excision of parasellar pituitary macroadenoma on postoperative imaging. J Neurol Surg B Skull Base 2014; 75 (1) 41-46
• 14 Reddy R, Cudlip S, Byrne JV, Karavitaki N, Wass JA. Can we ever stop imaging in surgically treated and radiotherapy-naive patients with non-functioning pituitary adenoma?. Eur J Endocrinol 2011; 165 (5) 739-744
• 15 Greenman Y, Stern N. How should a nonfunctioning pituitary macroadenoma be monitored after debulking surgery?. Clin Endocrinol (Oxf) 2009; 70 (6) 829-832
• 16 Famini P, Maya MM, Melmed S. Pituitary magnetic resonance imaging for sellar and parasellar masses: ten-year experience in 2598 patients. J Clin Endocrinol Metab 2011; 96 (6) 1633-1641
• 17 Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009; 42 (2) 377-381
• 18 Microsoft. Microsoft Excel. Redmond, WA: Microsoft Corporation; 2011
• 19 JMP Pro, v.11. Cary, NC: SAS Institute Inc.; 1989. –2007
• 20 Physician Fee Schedule Search. Available from: http://www.cms.gov/apps/physician-fee-schedule/
• 21 Frick KD, Gower EW, Kempen JH, Wolff JL. Economic impact of visual impairment and blindness in the United States. Arch Ophthalmol 2007; 125 (4) 544-550
• 22 Köberlein J, Beifus K, Schaffert C, Finger RP. The economic burden of visual impairment and blindness: a systematic review. BMJ Open 2013; 3 (11) e003471
• 23 Dekkers OM, Pereira AM, Roelfsema F , et al. Observation alone after transsphenoidal surgery for nonfunctioning pituitary macroadenoma. J Clin Endocrinol Metab 2006; 91 (5) 1796-1801
• 24 Chang EF, Sughrue ME, Zada G, Wilson CB, Blevins Jr LS, Kunwar S. Long term outcome following repeat transsphenoidal surgery for recurrent endocrine-inactive pituitary adenomas. Pituitary 2010; 13 (3) 223-229
• 25 Nielsen EH, Lindholm J, Laurberg P , et al. Nonfunctioning pituitary adenoma: incidence, causes of death and quality of life in relation to pituitary function. Pituitary 2007; 10 (1) 67-73
• 26 Dekkers OM, van der Klaauw AA, Pereira AM , et al. Quality of life is decreased after treatment for nonfunctioning pituitary macroadenoma. J Clin Endocrinol Metab 2006; 91 (9) 3364-3369
• 27 Grosse SD. Assessing cost-effectiveness in healthcare: history of the $50,000 per QALY threshold. Expert Rev Pharmacoecon Outcomes Res 2008; 8 (2) 165-178
• 28 Bodhinayake I, Ottenhausen M, Mooney MA , et al. Results and risk factors for recurrence following endoscopic endonasal transsphenoidal surgery for pituitary adenoma. Clin Neurol Neurosurg 2014; 119: 75-79
• 29 Bokhari AR, Davies MA, Diamond T. Endoscopic transsphenoidal pituitary surgery: a single surgeon experience and the learning curve. Br J Neurosurg 2013; 27 (1) 44-49
• 30 Shahlaie K, McLaughlin N, Kassam AB, Kelly DF. The role of outcomes data for assessing the expertise of a pituitary surgeon. Curr Opin Endocrinol Diabetes Obes 2010; 17 (4) 369-376
• 31 McVay MA, Friedman KE, Applegate KL, Portenier DD. Patient predictors of follow-up care attendance in Roux-en-Y gastric bypass patients. Surg Obes Relat Dis 2013; 9 (6) 956-962
• 32 Heckman BD, Holroyd KA, O'Donnell FJ , et al. Race differences in adherence to headache treatment appointments in persons with headache disorders. J Natl Med Assoc 2008; 100 (2) 247-255
• 33 McClure RJ, Newell SJ, Edwards S. Patient characteristics affecting attendance at general outpatient clinics. Arch Dis Child 1996; 74 (2) 121-125
• 34 Clark AM, King-Shier KM, Thompson DR , et al. A qualitative systematic review of influences on attendance at cardiac rehabilitation programs after referral. Am Heart J 2012; 164 (6) 835-45.e2