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

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.

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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.

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Endoscopic Endonasal Management of Nonfunctioning Pituitary Adenomas with Cavernous Sinus Invasion: Our Experience

Otolaryngology ◽

10.1177/0194599813495815a48 ◽

2013 ◽

Vol 149 (2_suppl) ◽

pp. P48-P48

Author(s):

Fabio Ferreli ◽

Mario Turri-Zanoni ◽

Stefania Gallo ◽

Maurizio Bignami ◽

Giustino Tomei ◽

...

Keyword(s):

Cavernous Sinus ◽

Pituitary Adenomas ◽

Endoscopic Endonasal ◽

Cavernous Sinus Invasion ◽

Nonfunctioning Pituitary Adenomas

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Endoscopic Endonasal Transsphenoidal Approach Through the Bilateral Nostrils for Pituitary Adenomas

Neurologia medico-chirurgica ◽

10.2176/nmc.49.1 ◽

2009 ◽

Vol 49 (1) ◽

pp. 1-7 ◽

Cited By ~ 51

Author(s):

Shigetoshi YANO ◽

Takayuki KAWANO ◽

Mareina KUDO ◽

Keishi MAKINO ◽

Hideo NAKAMURA ◽

...

Keyword(s):

Pituitary Adenomas ◽

Transsphenoidal Approach ◽

Endoscopic Endonasal

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Endoscopic Endonasal Ethmoid-Pterygoid Transsphenoidal Approach to the Cavernous Sinus

Midline Skull Base Surgery ◽

10.1007/978-3-319-21533-4_3 ◽

2016 ◽

pp. 35-48

Author(s):

Giorgio Frank ◽

Ernesto Pasquini

Keyword(s):

Cavernous Sinus ◽

Transsphenoidal Approach ◽

Endoscopic Endonasal

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Extended transsphenoidal approach for pituitary adenomas invading the anterior cranial base, cavernous sinus, and clivus: a single-center experience with 126 consecutive cases

Journal of Neurosurgery ◽

10.3171/2009.3.jns0929 ◽

2010 ◽

Vol 112 (1) ◽

pp. 108-117 ◽

Cited By ~ 49

Author(s):

Bing Zhao ◽

Yu-Kui Wei ◽

Gui-Lin Li ◽

Yong-Ning Li ◽

Yong Yao ◽

...

Keyword(s):

Postoperative Complications ◽

Cavernous Sinus ◽

Pituitary Adenomas ◽

Tumor Resection ◽

Cranial Base ◽

Transsphenoidal Approach ◽

Preoperative Imaging ◽

Surgical Removal ◽

Extended Transsphenoidal Approach ◽

Anterior Cranial Base

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.

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Letter to the Editor: Endoscopic endonasal transsphenoidal approach to pituitary adenomas

Journal of Neurosurgery ◽

10.3171/2014.8.jns141716 ◽

2015 ◽

Vol 122 (2) ◽

pp. 473-474 ◽

Cited By ~ 7

Author(s):

Paolo Cappabianca ◽

Luigi Maria Cavallo ◽

Domenico Solari ◽

Felice Esposito

Keyword(s):

Pituitary Adenomas ◽

Transsphenoidal Approach ◽

Endoscopic Endonasal ◽

Letter To The Editor

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Extended endoscopic endonasal approach for selected pituitary adenomas: early experience

Journal of Neurosurgery ◽

10.3171/2010.9.jns10262 ◽

2011 ◽

Vol 114 (2) ◽

pp. 345-353 ◽

Cited By ~ 44

Author(s):

Salvatore Di Maio ◽

Luigi M. Cavallo ◽

Felice Esposito ◽

Vita Stagno ◽

Olga Valeria Corriero ◽

...

Keyword(s):

Pituitary Adenomas ◽

Transsphenoidal Surgery ◽

Extent Of Resection ◽

Transsphenoidal Approach ◽

Endoscopic Endonasal Approach ◽

Endonasal Approach ◽

Endoscopic Endonasal ◽

Csf Leakage ◽

Endoscopic Endonasal Transsphenoidal Surgery ◽

Extended Endoscopic Approach

Object Whereas most pituitary adenomas are removable via the transsphenoidal approach, certain cases, such as dumbbell-shaped or suprasellar adenomas and recurrent and/or fibrous tumors, remain difficult to treat. The authors present their experience with the extended endoscopic endonasal approach to the suprasellar area in managing this subset of tumors, which are classically treated through a transcranial route. Methods From June 1997 to December 2008, 615 patients underwent endoscopic endonasal transsphenoidal surgery for pituitary adenomas in the Department of Neurosurgery of the Università degli Studi di Napoli Federico II. Of this group, 20 patients with pituitary adenomas needed an extended endoscopic endonasal transtuberculum/transplanum approach for tumor removal. Two surgical corridors were used during the transsphenoidal approach: 1) the conventional endosellar extraarachnoidal corridor and 2) a suprasellar transarachnoidal corridor. Results The extent of resection was gross total in 12 (60%) of the 20 patients, near total in 4 (20%), subtotal in 3 (15%), and partial in 1 (5%). Postoperative CSF leakage occurred in 1 patient. One patient experienced worsening of temporal hemianopsia. Conclusions The authors' initial results with the extended endoscopic approach to the suprasellar area for selected pituitary adenomas are promising and may justify a widening of the current classical indications for transsphenoidal surgery.

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