Transcranial approach in giant pituitary adenomas: results and outcome in a modern series

AIM: The aim of this study was to compare the transcranial and the endoscopic transsphenoidal approaches for patients with recurrent giant pituitary adenomas as regards the extent of tumor resection and the clinical outcome. METHODS: The study included 21 patients with recurrent giant pituitary adenomas divided into two groups; Group A included nine patients operated on by transcranial approaches and Group B included 12 patients operated on by the endoscopic transsphenoidal approach. Both groups were compared as regards the extent of tumor resection and the post-operative clinical outcome, particularly the visual and endocrinological outcomes, in addition to morbidity and mortality. RESULTS: There was a higher incidence of total and near-total resection in Group B (41.7%) and a higher incidence of subtotal resection in Group A (55.6%). The incidence of visual improvement was higher in Group B (55.6%) than in Group A (28.6%). Post-operative biochemical remission was achieved in 100% of Group B patients and in 50% of Group A patients with functioning adenomas. The incidence of post-operative complications was higher in Group A (77.8%) than in Group B (50%). CONCLUSION: The endoscopic transsphenoidal approach for recurrent giant pituitary adenomas is associated with a higher extent of tumor resection, better rates of visual improvement and endocrinological remission, and lower incidence of complications. The transcranial approach should be reserved for some adenomas with marked lateral or anterior extensions, fibrous tumors, and after the failure of the endoscopic transsphenoidal approach.

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Microsurgical Management of Giant Pituitary Adenomas: A Series of 177 Cases

Skull Base ◽

10.1055/s-2007-983989 ◽

2007 ◽

Vol 17 (S 1) ◽

Author(s):

Sumit Sinha ◽

B. Sharma ◽

A. Mahapatra

Keyword(s):

Pituitary Adenomas ◽

Giant Pituitary Adenomas

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The clinic-hormonal description of patients with giant pituitary adenomas

Endocrine Abstracts ◽

10.1530/endoabs.49.ep965 ◽

2017 ◽

Author(s):

Yulduz Urmanova ◽

Kamola Alimova

Keyword(s):

Pituitary Adenomas ◽

Giant Pituitary Adenomas

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Estimating Risk of Pituitary Apoplexy after Resection of Giant Pituitary Adenomas

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0041-1722993 ◽

2021 ◽

Author(s):

John T. Butterfield ◽

Takako Araki ◽

Daniel Guillaume ◽

Ramachandra Tummala ◽

Emiro Caicedo-Granados ◽

...

Keyword(s):

Pituitary Adenomas ◽

Pituitary Apoplexy ◽

Residual Tumor ◽

Extent Of Resection ◽

Morbidity And Mortality ◽

Surgical Approaches ◽

Subtotal Resection ◽

Advantages And Disadvantages ◽

Cranial Nerve Palsies ◽

Giant Pituitary Adenomas

Abstract Background Pituitary apoplexy after resection of giant pituitary adenomas is a rare but often cited morbidity associated with devastating outcomes. It presents as hemorrhage and/or infarction of residual tumor in the postoperative period. Because of its rarity, its incidence and consequences remain ill defined. Objective The aim of this study is to estimate the rate of postoperative pituitary apoplexy after resection of giant pituitary adenomas and assess the morbidity and mortality associated with apoplexy. Methods A systematic review of literature was performed to examine extent of resection in giant pituitary adenomas based on surgical approach, rate of postoperative apoplexy, morbidities, and mortality. Advantages and disadvantages of each approach were compared. Results Seventeen studies were included in quantitative analysis describing 1,031 cases of resection of giant pituitary adenomas. The overall rate of subtotal resection (<90%) for all surgical approaches combined was 35.6% (95% confidence interval: 28.0–43.1). Postoperative pituitary apoplexy developed in 5.65% (n = 19) of subtotal resections, often within 24 hours and with a mortality of 42.1% (n = 8). Resulting morbidities included visual deficits, altered consciousness, cranial nerve palsies, and convulsions. Conclusion Postoperative pituitary apoplexy is uncommon but is associated with high rates of morbidity and mortality in subtotal resection cases. These findings highlight the importance in achieving a maximal resection in a time sensitive fashion to mitigate the severe consequences of postoperative apoplexy.

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Surgical Management of Giant Pituitary Adenomas

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/s0317167100030055 ◽

1990 ◽

Vol 17 (1) ◽

pp. 62-66 ◽

Cited By ~ 98

Author(s):

Gérard Mohr ◽

Jules Hardy ◽

Ronald Comtois ◽

Hughes Beauregard

Keyword(s):

Pituitary Adenomas ◽

Residual Tumor ◽

Empty Sella ◽

Csf Leak ◽

Visual Field Defects ◽

Pituitary Insufficiency ◽

Empty Sella Syndrome ◽

Type D ◽

Giant Pituitary Adenomas ◽

Type C

ABSTRACT:During the past 25 years, 77 giant pituitary adenomas have been treated surgically, including suprasellar extensions of type C in 66 cases and of type D in 11 cases. Non-secreting adenomas were present in 53 and secreting adenomas in 24 cases. All patients except 3 presented with significant visual field defects; including bitemporal hemianopia, superior quadranopia or unilateral temporal hemianopia, contralateral blindness in 73% of the cases, and one case with sudden bilateral blindness due to acute pituitary apoplexy. A single transsphenoidal procedure was carried out in 74% of the patients while 11 patients (7%) required re-operations for recurrent or residual tumor. Only 3 patients required a subsequent transcranial procedure. Complications included 1 CSF-leak, 1 empty-sella syndrome and 4 fatal post-operative hematomas. We prefer the transsphenoidal route even in very large or giant pituitary adenomas, since it allows rapid and adequate decompression of the optic nerves and chiasm, avoids major pituitary insufficiency in 60% of the cases and is associated with low morbidity-mortality rates.

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Transcranial approaches for pituitary adenomas: current indications and clinical and radiological outcomes

Egyptian Journal of Neurosurgery ◽

10.1186/s41984-021-00117-x ◽

2021 ◽

Vol 36 (1) ◽

Author(s):

Mohamed M. Salama ◽

Mohamed Reda Rady

Keyword(s):

Pituitary Adenomas ◽

Third Ventricle ◽

Tumor Resection ◽

Subtotal Resection ◽

Combined Approach ◽

Total Resection ◽

Third Nerve Palsy ◽

Clinical And Radiological Outcome ◽

Transcranial Approach ◽

Anterior Fossa

Abstract Background The indications of transcranial approaches for pituitary adenomas have declined in the last decades with the widespread performance of endoscopic transsphenoidal approaches. The aim of the study was to review the current indications of transcranial approaches for pituitary adenomas and to evaluate the clinical and radiological outcome following these approaches. Patients and methods This study included 16 patients with fresh, residual, or recurrent pituitary adenomas operated upon by transcranial approaches alone or in combination with transsphenoidal approaches. The indication to perform a transcranial approach was reviewed for each patient. Postoperative clinical outcome and the extent of tumor resection were assessed. Results The indications of transcranial approaches were significant parasellar and/or anterior fossa extensions in 6 patients, failed previous transsphenoidal surgery in 3 patients, giant adenoma extending into the third ventricle in 3 patients, dumbbell-shaped adenoma in 2 patients, and doubtful diagnosis in 2 patients. Two patients with invasive giant adenomas were operated upon by a combined approach. There was a single mortality. Permanent complications included visual loss in one patient, third nerve palsy in one patient, hypopituitarism in two patients, and permanent diabetes insipidus in two patients. Gross total resection was achieved in one patient, subtotal resection in seven patients, and partial resection in eight patients. Conclusion Transcranial approaches are still needed for some complex pituitary adenomas particularly giant tumors with significant lateral, anterior, or superior extensions, tumors with fibrous consistency particularly after failure of transsphenoidal approach, and dumbbell-shaped tumors with severe constriction at the diaphragm.

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NCOG-31. GIANT PITUITARY ADENOMA (GPA) SCORE: A NOVEL SCORING SYSTEM TO PREDICT POSTOPERATIVE OUTCOMES OF GIANT PITUITARY ADENOMAS

Neuro-Oncology ◽

10.1093/neuonc/noab196.621 ◽

2021 ◽

Vol 23 (Supplement_6) ◽

pp. vi158-vi158

Author(s):

Syed Ather Enam ◽

Fauzan Alam Hashmi ◽

Sanam Mir Ghazi ◽

Ahsan Ali Khan ◽

Muhammad Bilal Tariq ◽

...

Keyword(s):

Pituitary Adenoma ◽

Linear Regression ◽

Pituitary Adenomas ◽

Scoring System ◽

Tumor Resection ◽

Maximum Diameter ◽

Giant Pituitary Adenoma ◽

Giant Pituitary Adenomas ◽

The Mean ◽

Suprasellar Extension

Abstract BACKGROUND Giant pituitary adenomas (GPA) are uncommon and highly variable in morphology and extension. There is no scoring system that considers all the dimensions of adenoma invasion. We developed a new Giant Pituitary Adenoma score and report our surgical experience and evaluate outcomes after resection of these tumors in accordance with the preoperative score. METHODS We developed a novel scoring system for classifying giant pituitary adenomas, and 11-year data of GPA surgery at our center was collected retrospectively, based on this scoring system. GPA Score considered tumor’s parasellar extension, encasement of cavernous internal carotid artery (ICA), suprasellar extension > 2 cm, suprasellar extension > 4cm and retrosellar extension. Maximum possible score was 9. The scoring system was applied to 53 patients of GPA who underwent surgical resection between January 1, 2006, and December 2017. The Lundin-Pederson (ABC/2) method was used to calculate the tumor volume both pre- and post-resection and linear regression was used to assess the relationship between extent of tumor resection and GPA score. RESULTS The median age of the study population was 42.08 ± 16.49 years. The mean maximum diameter of the pituitary adenomas was 5.0 cm (range 4.0 cm-8.5cm) while the mean volume of the adenomas was 27.3 cm3 (range 10 cm3-149 cm3). There were 3 cases of score 2, 5 cases of score 3, 13 cases of score 4, 20 cases of score 5, 9 cases of score 6 and 3 cases of score 7. The range of tumor volumes of tumors for scores from 2-7 was 17.3 cm3 to 65.8 cm3 and GPA score was correlated with the percent residual tumor using linear regression that was statistically significant (p= 0.001). CONCLUSION GPA Score is a reliable scoring system to predict the extent and subsequent difficulty in tumor resection in GPA.

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