Diagnostic value of Knosp grade and modified Knosp grade for cavernous sinus invasion in pituitary adenomas: a systematic review and meta‐analysis

Pituitary (2021)Cite this article

Abstract

Objective

This study aimed to examine the reliability of existing Knosp grade (KG) and modified KG for cavernous sinus invasion (CSI).

Methods

A thorough search of literature from 1993 to 2020 in six databases was performed. Studies that reported the intraoperative confirmation of CSI using KG and/or modified KG were included. The pooled estimates were calculated by meta-analysis with a bivariate mixed-effect model and the assessment of heterogeneity with I2 statistic.

Results

The final search yielded 12 eligible studies, which enrolled 3006 patients assessed with KG and 1315 patients assessed with modified KG. The results of the area under the receiver operating characteristic curve showed the good discriminative abilities of grades 2–4 (0.90), 3–4 (0.86) and 3B–4 (0.91) in predicting CSI. Grade 3A showed a remarkably lower CSI rate (44% versus 81%) and incomplete resection rate (26% versus 52%) than grade 3B. Grades 0 and 1 showed a low CSI rate. CSI and incomplete resection rates in grade 2 (30% and 21%, respectively) were close to those in grade 3A.

Conclusions

Modifying the KG improved its prognostic role in CSI and gross total resection. However, these grading systems cannot be used as the group standard for invasive and non-invasive pituitary adenomas (PAs) because of the weak reliability of the scale’s middle grades (grades 2 and 3A). Authors of future PA studies should consider reporting KG as high (grades 3B and 4), medium (grades 2 and 3A) and low (grades 0 and 1) to optimise the application of the scale.

This is a preview of subscription content, access via your institution.

Access options

Buy single article

Instant access to the full article PDF.

US$ 39.95

Tax calculation will be finalised during checkout.

Fig. 1
Fig. 2
Fig. 3

References

  1. 1.

    Micko A, Oberndorfer J, Weninger WJ, Vila G, Hoftberger R, Wolfsberger S et al (2019) Challenging Knosp high-grade pituitary adenomas. J Neurosurg 31:1–8. https://doi.org/10.3171/2019.3.JNS19367

    Article  Google Scholar 

  2. 2.

    Raverot G, Burman P, McCormack A, Heaney A, Petersenn S, Popovic V et al (2018) European Society of Endocrinology Clinical Practice Guidelines for the management of aggressive pituitary tumours and carcinomas. Eur J Endocrinol 178(1):G1–Gg24. https://doi.org/10.1530/eje-17-0796

    CAS  Article  PubMed  Google Scholar 

  3. 3.

    Zoli M, Milanese L, Bonfatti R, Sturiale C, Pasquini E, Frank G et al (2016) Cavernous sinus invasion by pituitary adenomas: role of endoscopic endonasal surgery. J Neurosurg Sci 60(4):485–494

    PubMed  Google Scholar 

  4. 4.

    Melmed S (2020) Pituitary-Tumor Endocrinopathies. N Engl J Med 382(10):937–950. https://doi.org/10.1056/NEJMra1810772

    CAS  Article  PubMed  Google Scholar 

  5. 5.

    Knosp E, Steiner E, Kitz K, Matula C (1993) Pituitary adenomas with invasion of the cavernous sinus space: a magnetic resonance imaging classification compared with surgical findings. Neurosurgery 33(4):610–617. https://doi.org/10.1227/00006123-199310000-00008

  6. 6.

    Lamback EB, Guterres A, Barbosa MA, Lima CHA, Silva DA, Camacho A et al (2020) Cyclin A in nonfunctioning pituitary adenomas. Endocrine 70(2):380–387. https://doi.org/10.1007/s12020-020-02402-5

    CAS  Article  PubMed  Google Scholar 

  7. 7.

    Kosugi K, Tamura R, Mase T, Tamura H, Jinzaki M, Yoshida K et al (2019) Relationship between pneumatization of lateral recess in the sphenoid sinus and removal of cavernous sinus invasion in pituitary adenomas by endoscopic endonasal surgery. Surg Neurol Int 10:222. https://doi.org/10.25259/sni_169_2019

    Article  PubMed  PubMed Central  Google Scholar 

  8. 8.

    Mooney MA, Hardesty DA, Sheehy JP, Bird R, Chapple K, White WL et al (2017) Interrater and intrarater reliability of the Knosp scale for pituitary adenoma grading. J Neurosurg 126(5):1714–1719. https://doi.org/10.3171/2016.3.Jns153044

    Article  PubMed  Google Scholar 

  9. 9.

    Liu X, Ma L, Wang Z, Ye J, Liu X, Jiang G et al (2019) Expression and clinical significance of doublecortin (DCX) in pituitary adenoma. Bull Cancer 106(12):1080–1085. https://doi.org/10.1016/j.bulcan.2019.05.009

    Article  PubMed  Google Scholar 

  10. 10.

    Li W, Zhang Y, Zhang M, Huang G, Zhang Q (2014) Wnt4 is overexpressed in human pituitary adenomas and is associated with tumor invasion. J Clin Neurosci 21(1):137–141. https://doi.org/10.1016/j.jocn.2013.04.034

    CAS  Article  PubMed  Google Scholar 

  11. 11.

    Dallapiazza R, Bond AE, Grober Y, Louis RG, Payne SC, Oldfield EH et al (2014) Retrospective analysis of a concurrent series of microscopic versus endoscopic transsphenoidal surgeries for Knosp Grades 0–2 nonfunctioning pituitary macroadenomas at a single institution. J Neurosurg 121(3):511–517. https://doi.org/10.3171/2014.6.Jns131321

    Article  PubMed  Google Scholar 

  12. 12.

    Micko AS, Wöhrer A, Wolfsberger S, Knosp E (2015) Invasion of the cavernous sinus space in pituitary adenomas: endoscopic verification and its correlation with an MRI-based classification. J Neurosurg 122(4):803–811. https://doi.org/10.3171/2014.12.Jns141083

    Article  PubMed  Google Scholar 

  13. 13.

    Yamada S, Fukuhara N, Horiguchi K, Yamaguchi-Okada M, Nishioka H, Takeshita A et al (2014) Clinicopathological characteristics and therapeutic outcomes in thyrotropin-secreting pituitary adenomas: a single-center study of 90 cases. J Neurosurg 121(6):1462–1473. https://doi.org/10.3171/2014.7.Jns1471

    Article  PubMed  Google Scholar 

  14. 14.

    Whiting PF, Rutjes AW, Westwood ME, Mallett S, Deeks JJ, Reitsma JB et al (2011) QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies. Ann Intern Med 155(8):529–536. https://doi.org/10.7326/0003-4819-155-8-201110180-00009

    Article  PubMed  Google Scholar 

  15. 15.

    Reitsma JB, Glas AS, Rutjes AW, Scholten RJ, Bossuyt PM, Zwinderman AH (2005) Bivariate analysis of sensitivity and specificity produces informative summary measures in diagnostic reviews. J Clin Epidemiol 58(10):982–990. https://doi.org/10.1016/j.jclinepi.2005.02.022

    Article  Google Scholar 

  16. 16.

    Vieira JO Jr, Cukiert A, Liberman B (2006) Evaluation of magnetic resonance imaging criteria for cavernous sinus invasion in patients with pituitary adenomas: logistic regression analysis and correlation with surgical findings. Surg Neurol 65(2):130–135. https://doi.org/10.1016/j.surneu.2005.05.021

    Article  PubMed  Google Scholar 

  17. 17.

    Cao L, Wang S, Ma M, Zhong Q, H C (2012) Value of MRI characteristics of medial wall of cavernous sinus in preoperative assessment of invasive pituitary adenomas. Chin J Neurosurg 28(4):350–354. https://doi.org/10.3760/cma.j.issn.1001-2346.2012.04.009

    Article  Google Scholar 

  18. 18.

    Nishioka H, Fukuhara N, Horiguchi K, Yamada S (2014) Aggressive transsphenoidal resection of tumors invading the cavernous sinus in patients with acromegaly: predictive factors, strategies, and outcomes. J Neurosurg 121(3):505–510. https://doi.org/10.3171/2014.3.Jns132214

    Article  PubMed  Google Scholar 

  19. 19.

    Paluzzi A, Fernandez-Miranda JC, Tonya Stefko S, Challinor S, Snyderman CH, Gardner PA (2014) Endoscopic endonasal approach for pituitary adenomas: a series of 555 patients. Pituitary 17(4):307–319. https://doi.org/10.1007/s11102-013-0502-4

    Article  PubMed  Google Scholar 

  20. 20.

    Jiang C, Yan X, Wang C, Kang D, Lin Y, Zhangya L (2016) A study of preoperative MRI evaluation for cavernous sinus invasion by pituitary macroadenoma. J Fujian Med Univ 50(1):38–42

    Google Scholar 

  21. 21.

    Lang M, Silva D, Dai L, Kshettry VR, Woodard TD, Sindwani R et al (2018) Superiority of constructive interference in steady-state MRI sequencing over T1-weighted MRI sequencing for evaluating cavernous sinus invasion by pituitary macroadenomas. J Neurosurg 1:1–8. https://doi.org/10.3171/2017.9.Jns171699

    Article  Google Scholar 

  22. 22.

    Buchy M, Lapras V, Rabilloud M (2019) Predicting early post-operative remission in pituitary adenomas: evaluation of the modified knosp classification. Pituitary 22(5):467–475. https://doi.org/10.1007/s11102-019-00976-6

    CAS  Article  PubMed  Google Scholar 

  23. 23.

    Xueyou X, Zhiren W (2019) Performance of Knosp grade for cavernous sinus invasion of Cushing’s disease. Natl Med J China 99(5):388–390. https://doi.org/10.3760/cma.j.issn.0376-2491.2019.05.014

    Article  Google Scholar 

  24. 24.

    Xinyu W, Xiaochuan H, Yue B, Yibao W (2019) The significance of Knosp classification and cavernous sinus division in endoscopic transnasal surgery for invasive pituitary adenomas. Chin J Contemp Neurol Neurosurg 19(3):170–176. https://doi.org/10.3969/j.issn.1672-6731.2019.03.006

    Article  Google Scholar 

  25. 25.

    Dhandapani S, Singh H, Negm HM, Cohen S, Anand VK, Schwartz TH (2016) Cavernous sinus invasion in pituitary adenomas: systematic review and pooled data meta-analysis of radiologic criteria and comparison of endoscopic and microscopic surgery. World Neurosurg 96:36–46. https://doi.org/10.1016/j.wneu.2016.08.088

    Article  PubMed  Google Scholar 

Download references

Author information

Affiliations

  1. Department of Neurosurgery, Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, Fujian, China

    Yi Fang, Zhijie Pei, Hongjie Chen, Liangfeng Wei, Jun Li, Heng Zhang & Shousen Wang

  2. Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China

    Renzhi Wang & Ming Feng

  3. Department of Neurosurgery, Fuzhou 900th Hospital, Fuzong Clinical Medical College of Fujian Medical University, No. 156, Xi’erhuanbei Road, Fuzhou, Fujian, China

    Shousen Wang

Authors
  1. Yi Fang
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Zhijie Pei
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Hongjie Chen
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Renzhi Wang
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Ming Feng
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Liangfeng Wei
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Jun Li
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Heng Zhang
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Shousen Wang
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Shousen Wang.

Ethics declarations

Conflict of interest

The authors declare that they have no conflicts of interest.

Ethical Approval

This is a meta-analysis based on observational studies.

Informed Consent

Informed consent from patients and ethical approval for this type of study are not required.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Fang, Y., Pei, Z., Chen, H. et al. Diagnostic value of Knosp grade and modified Knosp grade for cavernous sinus invasion in pituitary adenomas: a systematic review and meta‐analysis. Pituitary (2021). https://doi.org/10.1007/s11102-020-01122-3

Download citation

Keywords

  • Meta‐analysis
  • Knosp grading
  • Pituitary adenoma
  • Cavernous sinus
  • Invasion
  • Pituitary surgery