Extended transsphenoidal approach for pituitary adenomas invading the cavernous sinus using multiple complementary techniques

Object The standard transsphenoidal approach has been successfully used to resect most pituitary adenomas. However, as a result of the limited exposure provided by this procedure, complete surgical removal of pituitary adenomas with parasellar or retrosellar extension remains problematic. By additional bone removal of the cranial base, the extended transsphenoidal approach provides better exposure to the parasellar and clival region compared with the standard approach. The authors describe their surgical experience with the extended transsphenoidal approach to remove pituitary adenomas invading the anterior cranial base, cavernous sinus (CS), and clivus. Methods Retrospective analysis was performed in 126 patients with pituitary adenomas that were surgically treated via the extended transsphenoidal approach between September 1999 and March 2008. There were 55 male and 71 female patients with a mean age of 43.4 years (range 12–75 years). There were 82 cases of macroadenoma and 44 cases of giant adenoma. Results Gross-total resection was achieved in 78 patients (61.9%), subtotal resection in 43 (34.1%), and partial resection in 5 (4%). Postoperative complications included transient cerebrospinal rhinorrhea (7 cases), incomplete cranial nerve palsy (5), panhypopituitarism (5), internal carotid artery injury (2), monocular blindness (2), permanent diabetes insipidus (1), and perforation of the nasal septum (2). No intraoperative or postoperative death was observed. Conclusions The extended transsphenoidal approach provides excellent exposure to pituitary adenomas invading the anterior cranial base, CS, and clivus. This approach enhances the degree of tumor resection and keeps postoperative complications relatively low. However, radical resection of tumors that are firm, highly invasive to the CS, or invading multidirectionally remains a big challenge. This procedure not only allows better visualization of the tumor and the neurovascular structures but also provides significant working space under the microscope, which facilitates intraoperative manipulation. Preoperative imaging studies and new techniques such as the neuronavigation system and the endoscope improve the efficacy and safety of tumor resection.

Download Full-text

Extended transsphenoidal approach for surgical management of pituitary adenomas invading the cavernous sinus

Journal of Neurosurgery ◽

10.3171/jns/2008/108/01/0026 ◽

2008 ◽

Vol 108 (1) ◽

pp. 26-36 ◽

Cited By ~ 57

Author(s):

Masahiko Kitano ◽

Mamoru Taneda ◽

Taro Shimono ◽

Yuzo Nakao

Keyword(s):

Cavernous Sinus ◽

Pituitary Adenomas ◽

Cranial Nerves ◽

University Hospital ◽

Transsphenoidal Approach ◽

Inferior Wall ◽

Tumor Removal ◽

Low Profile ◽

Extended Transsphenoidal Approach ◽

Petrous Portion

Object The authors devised an extended transsphenoidal approach involving a submucosal posterior ethmoidectomy that allows for adequate exposure of the cavernous sinus. To evaluate the adequacy of this approach for removal of adenomas invading the cavernous sinus, the authors retrospectively analyzed the surgical outcomes obtained in treated patients. Methods During a 9-year period, 36 patients with pituitary adenomas extending into the cavernous sinus underwent tumor removal at Kinki University Hospital. In the authors' technique of extended transsphenoidal surgery, the inferior wall of the affected cavernous sinus was entirely exposed, not only to permit safe removal of the tumor but also to secure the petrous portion of the internal carotid artery (ICA). For prevention of intraoperative injury to the cranial nerves, a low-profile pressure sensor was attached on the eyelid to detect eye movements in response to electrical stimulation of the cranial nerves. Results Total or subtotal tumor removal was achieved in 72% of 36 patients. In eight (67%) of 12 patients with growth hormone–secreting adenomas, hormonal remission was achieved postoperatively. Postoperative transient double vision was observed in 27% of the patients, but no serious complications, such as permanent cranial nerve palsy or ICA injury, occurred. Conclusions These reasonable surgical results obtained in the present series of patients suggest that the extended transsphenoidal approach is safe and effective for removal of adenomas within the cavernous sinus. These preliminary results may lead to a reevaluation of the role of surgery as the therapeutic strategy for invasive pituitary adenomas.

Download Full-text

Extended Endoscopic Endonasal Transsphenoidal Approach to Resect the Pituitary Adenomas Invading the Cavernous Sinus

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0032-1314056 ◽

2012 ◽

Vol 73 (S 02) ◽

Author(s):

Q. Wang ◽

X.-J. Lu ◽

W.-Y. Ji ◽

B. Li

Keyword(s):

Cavernous Sinus ◽

Pituitary Adenomas ◽

Transsphenoidal Approach ◽

Endoscopic Endonasal

Download Full-text

Microscopic endonasal transsphenoidal pituitary adenomectomy in the pediatric population

Journal of Neurosurgery Pediatrics ◽

10.3171/2011.2.peds10278 ◽

2011 ◽

Vol 7 (5) ◽

pp. 501-509 ◽

Cited By ~ 21

Author(s):

Phiroz E. Tarapore ◽

Michael E. Sughrue ◽

Lewis Blevins ◽

Kurtis I. Auguste ◽

Nalin Gupta ◽

...

Keyword(s):

Adjuvant Therapy ◽

Cavernous Sinus ◽

Medical Therapy ◽

Pituitary Adenomas ◽

Pediatric Population ◽

Case Series ◽

Endocrine Function ◽

Transsphenoidal Approach ◽

Cavernous Sinus Invasion ◽

Suprasellar Extension

Object Pituitary adenomas are uncommon in childhood. Although medical treatment can be effective in treating prolactinomas and some growth hormone (GH)–secreting tumors, resection is indicated when visual function is affected or the side effects of medical therapy are intolerable. The authors of this report describe their 10-year experience in managing pituitary adenomas via the microscopic endonasal transsphenoidal approach in a pediatric population. Methods They performed a retrospective review of a surgical case series based at a single institution and consisting of 34 consecutive pediatric patients with endocrine-active (32 patients) and endocrine-inactive (2 patients) adenomas. These patients were surgically treated via an endonasal transsphenoidal approach between 1999 and 2008. Patient charts were reviewed, and clinical data were compiled and analyzed using the chi-square and Kaplan-Meier tests. Results The patient cohort consisted of 20 girls and 14 boys, with ages ranging from 9 to 18 years and a median age of 16 years. Thirty-two patients (94%) underwent surgery for endocrine-active tumors, including 10 (29%) with Cushing disease, 21 (62%) with prolactinomas, and 1 (3%) with GH-secreting tumors. Two patients with nonsecreting adenomas underwent surgery for apoplexy. The mean tumor volume was 5.4 cm3, and 13 patients (38%) had suprasellar extension and 7 (21%) had cavernous sinus invasion. Gross-total resection was achieved in 26 patients (76%), although it was significantly less likely to be achieved in the setting of cavernous sinus invasion (p < 0.001) but was unaffected by suprasellar extension. Residual tumor was treated with radiation therapy in 6 patients (18%). The average duration of hospital stay was 1.6 days. The median follow-up time was 18 months. After surgery, 19 patients (56%) had normal hormone function without adjuvant therapy, 8 (24%) had normal function with adjuvant therapy, and 5 (15%) had persistently elevated hormone levels. Patients with a macroprolactinoma were significantly more likely to require postoperative adjuvant therapy than were those with a microprolactinoma (p < 0.03). Conclusions Endonasal transsphenoidal resection is a safe, well-tolerated, and potentially curative treatment option for pituitary adenomas in children. Despite the technical challenges associated with this approach in the pediatric population, these tumors can be effectively managed with minimal morbidity. Endocrine function is usually preserved, and the majority of patients will not require lifelong medical therapy.

Download Full-text

Evaluation of Pure Endoscopic Endonasal Approach in Management of Giant Pituitary Adenoma

QJM ◽

10.1093/qjmed/hcab108.008 ◽

2021 ◽

Vol 114 (Supplement_1) ◽

Author(s):

Mina M Gerges ◽

Hatem Sabry ◽

Hasan Jalalod din ◽

Mohamed Ashraf Ghobashy ◽

Theodore H Schwartz

Keyword(s):

Radiation Therapy ◽

Pituitary Adenoma ◽

Cavernous Sinus ◽

Transsphenoidal Approach ◽

Csf Leak ◽

Tumor Diameter ◽

Giant Pituitary Adenoma ◽

Postoperative Hematoma ◽

Extended Transsphenoidal Approach

Abstract Background Giant pituitary adenoma represents one of the challenging tumor for neurosurgeons. Many microsurgical approaches in the past were used for its management. Recently and with evolution of the endoscopic equipment and instruments, extended endoscopic transsphenoidal approach become one of the preferable approaches for its surgical excision. Methods We prospectively document the clinical , surgical and follow up data for all patients presented with giant pituitary adenoma to Ain-Shams university hospital and Weill Cornell Medical College, Presbyterian hospital and were surgically treated with extended transsphenoidal approach from 2015 till 2019. Results Our group study formed of 44 patients with mean age 53.03 (range 14.7-82.4) and a male predominance (59%). The main presentation was visual problems in 75% followed by partial hypopituitarism in 31.81% while headache was in 13.64%. Only 4 patients had functioning adenoma (3 prolactinoma and 1 acromegaly). Average tumor volume was 26.95 ± 17.25 cm3, while the mean maximum tumor diameter was 4.73 cm (range 4.0-8.0 cm). Radiographic invasion was found in 97.73% to suprasellar cistern, 61.36% to the cavernous sinus and in 34% to the sphenoid sinus. GTR was achieved in 45.45% with Knosp score is the only significant predictor factor for resection rate (p = 0.04). Visual improvement achieved in 75.76%. 50% (2 patient) of the patients with functioning adenoma were cured. Complications included CSF leak in 3 patients, permanent DI in 4 patients and postoperative hematoma in 2 patients. Recurrence and progression rates without upfront radiation therapy were 5.00 % and 31.81% respectively after mean follow up period 57.90 months. Conclusions Extended endoscopic approaches for achieving maximum resection with minimal morbidity for giant pituitary adenoma are very effective. Lateral tumor extension with cavernous sinus invasion represents the limiting point in achieving gross total resection. Upfront radiation therapy for patients with residual adenoma can be avoided but regular follow up should be warranted.

Download Full-text

Extended transsphenoidal approach with submucosal posterior ethmoidectomy for parasellar tumors

Journal of Neurosurgery ◽

10.3171/jns.2001.94.6.0999 ◽

2001 ◽

Vol 94 (6) ◽

pp. 999-1004 ◽

Cited By ~ 96

Author(s):

Masahiko Kitano ◽

Mamoru Taneda

Keyword(s):

Cavernous Sinus ◽

Lateral Wall ◽

Arterial Injury ◽

Transsphenoidal Approach ◽

Content Type ◽

Superior Turbinate ◽

Extended Transsphenoidal Approach ◽

Suprasellar Region ◽

Surgical Methods ◽

Tuberculum Sellae

✓ The authors have developed an extended transsphenoidal approach with submucosal posterior ethmoidectomy for resection of tumors located in the cavernous sinus or the suprasellar region that are difficult to remove via the conventional transsphenoidal approach. Surgery was performed using this approach in 14 patients with large pituitary adenomas, three patients with craniopharyngiomas, and one patient with a meningioma of the tuberculum sellae. The submucosal dissection of the nasal septum used in the conventional transsphenoidal approach was extended to the superior lateral wall of the nasal cavity to expose the bony surface of the superior turbinate lying under the nasal mucosa. Submucosal posterior ethmoidectomy widened the area visualized through the conventional transsphenoidal approach both superiorly and laterally. This provided a safer and less invasive access to lesions in the cavernous sinus or the suprasellar region through the sphenoid sinus. Using this approach the authors encountered no postoperative complications, such as olfactory disturbance, cranial nerve palsy, or arterial injury. In this article the authors present the surgical methods used in this approach.

Download Full-text

Endoscopic endonasal transsphenoidal approach for pituitary adenomas invading the cavernous sinus

Journal of Neurosurgery ◽

10.3171/2009.4.jns09182 ◽

2010 ◽

Vol 112 (1) ◽

pp. 99-107 ◽

Cited By ~ 77

Author(s):

Savas Ceylan ◽

Kenan Koc ◽

Ihsan Anik

Keyword(s):

Growth Hormone ◽

Cavernous Sinus ◽

Pituitary Adenomas ◽

Transsphenoidal Surgery ◽

Adrenocorticotropic Hormone ◽

Multidisciplinary Treatment ◽

Transsphenoidal Approach ◽

Endoscopic Transsphenoidal Surgery ◽

Endoscopic Endonasal ◽

Sinus Wall

Object In this report, the authors describe their experience with surgical access to the cavernous sinus via a fully transnasal endoscopic approach in 20 cases. Clinical and endocrinological follow-up are discussed. Methods The authors used an endoscopic transsphenoidal approach in 192 patients with pituitary adenomas between September 1997 and January 2008, adding a cavernous sinus approach in 20 patients with invasive tumors during the last 5 years of this period. Parasellar extension of the tumor was measured according to the Knosp Scale. Radical tumor removal was achieved in 13 (65%) of 20 patients, and subtotal removal in 7 (35%). The authors used recently defined cavernous sinus approaches in the first 14 cases, including the paraseptal approach in 6, middle turbinectomy in 7, and contralateral middle turbinectomy in 1 case. Combined approaches rather than defined standard cavernous sinus approaches were used in 4 cases and an extended approach in 2. Results The tumors included nonsecretory adenomas in 5 cases (25%), growth hormone–secreting adenomas in 7 (35%), prolactin-secreting adenomas in 4 (20%), and adrenocorticotropic hormone–secreting adenomas in 4 cases (20%). Normal growth hormone and insulin-like growth factor 1 levels were achieved in 4 patients (57%) with growth hormone adenomas, and remission criteria were obtained in 3 patients with prolactinomas and 3 patients with adrenocorticotropic hormone–secreting adenomas. Conclusions Compared with transcranial and microscopic transsphenoidal surgery, endoscopic transsphenoidal surgery offers a wide exposure for cavernous sinus medial wall adenomas that enables removal of the adenoma from the medial cavernous sinus wall. Because of the necessity for multidisciplinary treatment to achieve satisfactory results, Gamma Knife surgery and medical therapy should be supplementary treatment options after endoscopic transsphenoidal surgery.

Download Full-text

Imaging and Demographic Characteristics Associated with Invasion of the Medial Wall of the Cavernous Sinus in Patients with Invasive Pituitary Adenomas

10.1055/s-0039-1679600 ◽

2019 ◽

Author(s):

Ezequiel Goldschmidt ◽

Salomon Cohen-Cohen ◽

Federico Angriman ◽

Carl Snyderman ◽

Eric Wang ◽

...

Keyword(s):

Cavernous Sinus ◽

Pituitary Adenomas ◽

Demographic Characteristics ◽

Medial Wall

Download Full-text

Endoscopic Endonasal Transethmoidal-Transsphenoidal Approach to a Cavernous Sinus Chondrosarcoma

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0041-1726018 ◽

2021 ◽

Author(s):

Gianluca Agresta ◽

Alberto Campione ◽

Fabio Pozzi ◽

Pierlorenzo Veiceschi ◽

Martina Venturini ◽

...

Keyword(s):

Skull Base ◽

Cavernous Sinus ◽

Conformal Radiotherapy ◽

Residual Tumor ◽

Complete Recovery ◽

Tumor Location ◽

Transsphenoidal Approach ◽

Low Grade ◽

Endoscopic Endonasal ◽

Skull Base Reconstruction

Abstract Objective We illustrate a cavernous sinus chondrosarcoma treated with an endoscopic endonasal transethmoidal-transsphenoidal approach. Design Case report of a 15-year-old girl with diplopia and esotropia due to complete abducens palsy. Preoperative images showed a right cavernous sinus lesion with multiple enhanced septa and intralesional calcified spots (Fig. 1). Considering tumor location and the lateral dislocation of the carotid artery, an endoscopic endonasal approach was performed to relieve symptoms and to optimize the target geometry for adjuvant conformal radiotherapy. Setting The study was conducted at University of Insubria, Department of Neurosurgery, Varese, Italy. Participants Skull base team was participated in the study. Main Outcome Measures A transethmoidal-transsphenoidal approach was performed by using a four-hand technique. We used a route lateral to medial turbinate to access ethmoid and the sphenoid sinus. During the sphenoid phase, we exposed the medial wall of the cavernous sinus (Fig. 2) and the lesion was then removed using curette. Skull base reconstruction was performed with fibrin glue and nasoseptal flap. Results No complications occurred after surgery, and the patient experienced a complete recovery of symptoms. A postoperative magnetic resonance imaging showed a small residual tumor inside the cavernous sinus (Fig. 1). After percutaneous proton-bean therapy, patient experienced only temporary low-grade toxicity with local control within 2 years after treatment completion. Conclusion Endoscopic endonasal extended approach is a safe and well-tolerated procedure that is indicated in selected cases (intracavernous tumors, soft tumors not infiltrating the vessels and/or the nerves). A tailored approach according to tumor extension is crucial for the best access to the compartments involved.The link to the video can be found at: https://youtu.be/TsqXjqpuOws.

Download Full-text