Fronto - temporal approach in sellar and parasellar tumors

Abstract Introduction: The fronto-temporal approach represent the shortest distance to the ipsilateral optic nerve and carotid artery, and allow the direct verification of the optical nerves, the carotid arteries, the pituitary stalk, the tumor and its relationship with the suprasellar structures. Objective: The purpose of this study is to advocate an available cranial base technique for removing these tumors and to delineate the technique’s advantages that aid in achieving an improved extent of tumor resection and enhancing the patients’ overall outcome. Materials and methods: We present a retrospective study of a single surgeon experience on 355 consecutive cases with sellar and parasellar tumors admitted and operated by transcranial approaches in our department between January 2000 and December 2012. Results: Tumors in the sellar region represent 11, 8% of all tumors operated in our department. The most common type of tumor was pituitary adenomas, 165 of cases, followed by sellar and parasellar meningiomas, 128 of cases. Craniopharyngioma represent 12% of cases encountered in this region. All our cases underwent surgery by transcranial approach, unilateral frontotemporal in 252 of cases (71%). In pituitary adenomas total and near total resection was achieved in 100% of patients operated by transcranial approaches. For resection of craniopharyngiomas we have frequently chosen the extended fronto-temporal approach. The most common surgical related complications were: postoperative hematomas 9 of cases; wound infections, 6 of cases and CSF leakage, 12 of cases; transient visual alteration in 12 cases, transient third cranial nerve palsy in 6 of cases, transient motor deficit in 7 cases, hydrocephalus, 6 cases; transient diabetes insipidus in the large majority of pituitary adenomas and craniopharingiomas. Only 4 cases of pituitary adenomas and 6 of craniopharingiomas recurred after subtotal resection, requiring re-intervention. The mortality rate in our study was 2%. Conclusions: Our experience demonstrated that the management of the large suprasellar tumors via fronto-temporal approach remains the main route for these tumors with significant extrasellar extension, fibrous tumors, cases with unrelated pathology that might complicate a transsphenoidal approach and recurrent tumors after previous transsphenoidal surgery. In our opinion there is no need for larger osteotomies or extensive drilling of cranial base. “Instead of bone, remove the tumor; it's easier even for the patient”.

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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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Transcranial versus Endoscopic Transsphenoidal Approaches in Management of Recurrent Giant Pituitary Adenomas

Open Access Macedonian Journal of Medical Sciences ◽

10.3889/oamjms.2020.4213 ◽

2020 ◽

Vol 8 (B) ◽

pp. 273-280

Author(s):

Mohamed Ismail ◽

Omar Abdel Aleem Abdel Moneim Ragab ◽

Mohamed M. Salama ◽

Basim M. Ayoub ◽

Wael Elmahdy

Keyword(s):

Clinical Outcome ◽

Pituitary Adenomas ◽

Tumor Resection ◽

Transsphenoidal Approach ◽

Subtotal Resection ◽

Visual Improvement ◽

Group A ◽

Transcranial Approach ◽

Giant Pituitary Adenomas ◽

Group B

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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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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Outcomes and Complications of Aggressive Resection Strategy for Pituitary Adenomas in Knosp Grade 4 With Transsphenoidal Endoscopy

Frontiers in Oncology ◽

10.3389/fonc.2021.693063 ◽

2021 ◽

Vol 11 ◽

Author(s):

Taohui Ouyang ◽

Na Zhang ◽

Shenhao Xie ◽

Bin Tang ◽

Junjun Li ◽

...

Keyword(s):

Endoscopic Surgery ◽

Pituitary Adenomas ◽

Internal Carotid ◽

Surgical Complication ◽

Tumor Resection ◽

Incomplete Resection ◽

Csf Leakage ◽

Transsphenoidal Endoscopic Surgery ◽

Aggressive Tumor ◽

Surgery Outcomes

Surgery for pituitary adenomas (PAs) with cavernous sinus (CS) invasion in Knosp grade 4 is a great challenge and whether to adopt a conservative or aggressive surgical strategy is controversial. The aim of this study is to provide the outcomes and complications of an aggressive resection strategy for Knosp grade 4 PAs with transsphenoidal endoscopic surgery. Outcomes and complications were retrospectively analyzed in 102 patients with Knosp grade 4 PAs. Among them, primary PAs were seen in 60 patients and recurrent PAs were seen in 42 cases. Gross total resection (GTR) of the entire tumor was achieved in 72 cases (70.6%), subtotal tumor resection (STR) in 18 cases (17.6%), and partial tumor resection (PTR) in 12 cases (11.8%). Additionally, GTR of the tumor within the CS was achieved in 82 patients (80.4%), STR in 17 patients (16.7%), and PTR in 3 patients (2.9%). Statistical analyses showed that both recurrent tumors and firm consistency tumors were adverse factors for complete resection (P<0.05). Patients with GTR of the entire tumor were more likely to have favorable endocrine and visual outcomes than those with incomplete resection (P<0.05). Overall, the most common surgical complication was new cranial nerve palsy (n=7, 6.8%). The incidence of internal carotid artery (ICA) injury and postoperative cerebrospinal fluid (CSF) leakage was 2.0% (n=2) and 5.9% (n=6), respectively. Six patients (5.9%) experienced tumor recurrence postoperatively. For experienced neuroendoscopists, an aggressive tumor resection strategy via transsphenoidal endoscopic surgery may be an effective and safe option for Knosp grade 4 PAs.

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Pseudocapsule-Based Resection for Pituitary Adenomas via the Endoscopic Endonasal Approach

Frontiers in Oncology ◽

10.3389/fonc.2021.812468 ◽

2022 ◽

Vol 11 ◽

Author(s):

Yuefei Zhou ◽

Jialiang Wei ◽

Feng Feng ◽

Jianguo Wang ◽

Pengfei Jia ◽

...

Keyword(s):

Pituitary Adenomas ◽

Tumor Resection ◽

Csf Leak ◽

Safe Procedure ◽

Endoscopic Endonasal Approach ◽

Endonasal Approach ◽

Endoscopic Endonasal ◽

Csf Leakage ◽

Extracapsular Resection

IntroductionThe endoscopic endonasal approach (EEA) is a safe and effective treatment for pituitary adenomas (PAs). Since extracapsular resection (ER) of PAs improves tumor resection and endocrine remission rates, the interface between the pseudocapsule and gland draws increasing attention. However, it is difficult to precisely dissect the tumor along the exact boundary, and complete removal of the tumor increases the risks of normal tissue damage and cerebrospinal fluid (CSF) leakage. In this study, we investigated the extracapsular resection as well as the pseudocapsule histology to evaluate the effectiveness and safety of pseudocapsule-related surgical interventions.MethodsFrom December 2017 to December 2019, 189 patients of PAs via EEA in our single center were analyzed retrospectively. The images, operative details, and clinical follow-up of patients were collected. Sixty-four patients underwent pseudocapsule-based ER, and 125 patients also underwent traditional intracapsular resection (IR) with or without intensive excision for FPAs. The clinical characteristics, tumor resection, endocrinological outcomes, and postoperative morbidities of the two groups were compared. Informed consent for publication of our article was obtained from each patient. Histological examination of pseudocapsule was performed using hematoxylin and eosin and reticulin staining.ResultsThe gross total recession was 62 (96.9%) in the ER group and 107 (85.6%) cases in the IR group, whereas the endocrine remission rate was 29/31 (93.5%) and 40/53 (75.5%) cases, respectively. Anterior pituitary functions were not aggravated postoperatively in any patient, but transient diabetes insipidus (DI) occurred more in the IR group (64.0%) than in ER (48.4%). Pseudocapsule specimens were obtained in 93 patients, and clusters of small cell aggregation were detected in 11 pseudocapsule specimens (11.8%) whereas other patients showed no remarkable developed pseudocapsule. Intraoperative CSF leak occurred more in the ER group (28.1%) than in the IR group (13.6%), but no difference was seen between two groups postoperatively. No case of intracranial hematoma or pituitary crisis occurred in both groups. After a mean follow-up of 22.8 months, tumor recurrence was observed in 4 (2.1%) cases.ConclusionPseudocapsule-based extracapsular resection of PAs via EEA is an effective and safe procedure to achieve complete resection with high and sustained endocrine remission and without deteriorating pituitary function.

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Evaluation of Surgical Resection Goal and Its Relationship to Extent of Resection and Patient Outcomes in a Multicenter Prospective Study of Patients With Surgically Treated, Nonfunctioning Pituitary Adenomas: A Case Series

Operative Neurosurgery ◽

10.1093/ons/opz085 ◽

2019 ◽

Vol 18 (1) ◽

pp. 26-33

Author(s):

Andrew S Little ◽

Michael R Chicoine ◽

Daniel F Kelly ◽

Christina E Sarris ◽

Michael A Mooney ◽

...

Keyword(s):

Patient Outcomes ◽

Predictive Value ◽

Pituitary Adenomas ◽

Tumor Resection ◽

Case Series ◽

Residual Tumor ◽

Pituitary Surgery ◽

Extent Of Resection ◽

Subtotal Resection ◽

Nonfunctioning Pituitary Adenomas

Abstract BACKGROUND The influence of the surgeon's preoperative goal regarding the extent of tumor resection on patient outcomes has not been carefully studied among patients with nonfunctioning pituitary adenomas. OBJECTIVE To analyze the relationship between surgical tumor removal goal and patient outcomes in a prospective multicenter study. METHODS Centrally adjudicated extent of tumor resection (gross total resection [GTR] and subtotal resection [STR]) data were analyzed using standard univariate and multivariable analyses. RESULTS GTR was accomplished in 148 of 171 (86.5%) patients with planned GTR and 32 of 50 (64.0%) patients with planned STR (P = .001). Sensitivity, specificity, positive predictive value, and negative predictive value of GTR goal were 82.2, 43.9, 86.5, and 36.0%, respectively. Knosp grade 0-2, first surgery, and being an experienced surgeon were associated with surgeons choosing GTR as the goal (P < .01). There was no association between surgical goal and presence of pituitary deficiency at 6 mo (P = .31). Tumor Knosp grade (P = .004) and size (P = .001) were stronger predictors of GTR than was surgical goal (P = .014). The most common site of residual tumor was the cavernous sinus (29 of 41 patients; 70.1%). CONCLUSION This is the first pituitary surgery study to examine surgical goal regarding extent of tumor resection and associated patient outcomes. Surgical goal is a poor predictor of actual tumor resection. A more aggressive surgical goal does not correlate with pituitary gland dysfunction. A better understanding of the ability of surgeons to meet their expectations and of the factors associated with surgical result should improve prognostication and preoperative counseling.

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Comparison of outcomes between a less experienced surgeon using a fully endoscopic technique and a very experienced surgeon using a microscopic transsphenoidal technique for pituitary adenoma

Journal of Neurosurgery ◽

10.3171/2015.4.jns15102 ◽

2016 ◽

Vol 124 (3) ◽

pp. 596-604 ◽

Cited By ~ 31

Author(s):

Hasan A. Zaidi ◽

Al-Wala Awad ◽

Michael A. Bohl ◽

Kristina Chapple ◽

Laura Knecht ◽

...

Keyword(s):

Pituitary Adenoma ◽

Endoscopic Surgery ◽

Pituitary Adenomas ◽

Transsphenoidal Surgery ◽

Tumor Resection ◽

Endoscopic Technique ◽

Endoscopic Transsphenoidal Surgery ◽

Experienced Surgeon ◽

Surgery Technique ◽

Surgeon Experience

OBJECT The comparative efficacy of microscopic and fully endoscopic transsphenoidal surgery for pituitary adenomas has not been well studied despite the adoption of fully endoscopic surgery by many pituitary centers. The influence of surgeon experience has also not been examined in this setting. The authors therefore compared the extent of tumor resection (EOR) and the endocrine outcomes of 1 very experienced surgeon performing a microscopic transsphenoidal surgery technique with those of a less experienced surgeon using a fully endoscopic transsphenoidal surgery technique for resection of nonfunctioning pituitary adenomas in a concurrent series of patients. METHODS Post hoc analysis was conducted of a cohort of adult patients prospectively enrolled in a pituitary adenoma quality-of-life study between October 2011 and June 2014. Patients were followed up for 6 months after surgery. Patients were treated either by a less experienced surgeon (100 independent cases) who practices fully endoscopic surgery exclusively or by a very experienced surgeon (1800 independent cases) who practices microscopic surgery exclusively. Patient demographic characteristics, tumor characteristics, hypopituitarism, complications, and length of hospital stay were analyzed. Tumor volumes and EOR were determined by formal volumetric analysis involving manual segmentation of MR images performed before surgery and within 6 months after surgery. Logistic regression analysis was used to determine predictors of EOR. RESULTS Fifty-five patients underwent fully endoscopic transsphenoidal surgery, and 80 patients underwent fully microscopic transsphenoidal surgery. The baseline characteristics of the 2 treatment groups were well matched. EOR was similar between the endoscopic and microscopic groups, respectively, as estimated by gross-total resection rate (78.2% vs 81.3%, p = 0.67), percentage of tumor resected (99.2% vs 98.7%, p = 0.42), and volume of residual tumor (0.12 cm3 vs 0.20 cm3, p = 0.41). Multivariate modeling suggested that preoperative tumor volume was the most important predictor of EOR (p = 0.001). No difference was found in the development of anterior gland dysfunction (p > 0.14), but there was a higher incidence of permanent posterior gland dysfunction in the microscopic group (p = 0.04). Combined rates of major complications and unplanned readmissions were lower in the endoscopic group (p = 0.02), but individual complications were not significantly different. CONCLUSIONS A less experienced surgeon using a fully endoscopic technique was able to achieve outcomes similar to those of a very experienced surgeon using a microscopic technique in a cohort of patients with nonfunctioning tumors smaller than 60 cm3. The study raises the provocative notion that certain advantages afforded by the fully endoscopic technique may impact the learning curve in pituitary surgery for nonfunctioning adenomas.

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

Journal of Neurosurgical Sciences ◽

10.23736/s0390-5616.16.03889-3 ◽

2020 ◽

Vol 64 (1) ◽

Cited By ~ 1

Author(s):

Thomas Graillon ◽

Frédéric Castinetti ◽

Stéphane Fuentes ◽

Regis Gras ◽

Thierry Brue ◽

...

Keyword(s):

Pituitary Adenomas ◽

Transcranial Approach ◽

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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Venous Thromboembolism Anticoagulation Prophylaxis Timing in Patients Undergoing Craniotomy for Tumor

Neurosurgery Open ◽

10.1093/neuopn/okaa018 ◽

2021 ◽

Vol 2 (1) ◽

Author(s):

Hanna Algattas ◽

Spencer E Talentino ◽

Bradley Eichar ◽

Abraham A Williams ◽

Joseph M Murphy ◽

...

Keyword(s):

Venous Thromboembolism ◽

Clinical Judgment ◽

Tumor Resection ◽

The Elderly ◽

Extent Of Resection ◽

Subtotal Resection ◽

Hemorrhagic Complication ◽

Increased Risk ◽

Hemorrhagic Complications ◽

Prophylactic Anticoagulation

ABSTRACT BACKGROUND Prophylactic anticoagulation helps prevent postoperative venous thromboembolism (VTE) and time to initiation postcraniotomy has relied on clinical judgment and practice patterns. OBJECTIVE To compare risks of postoperative VTE and hemorrhage among patients undergoing tumor resection with initiation of prophylactic anticoagulation on postoperative day 1 (POD1) vs POD2. METHODS Adult patients undergoing craniotomy for tumor between 2008 and 2018 were retrospectively reviewed. Outcomes were recorded from the Electronic medical record (EMR) including deep vein thrombosis (DVT), pulmonary embolism (PE), and hemorrhage. RESULTS Of a total of 1168 patients undergoing craniotomy, 225 initiated anticoagulation on POD1 and 389 initiated on POD2. Of the 171 glioblastoma (GBM) cases, 64 initiated on POD1 and 107 on POD2. There were 9 DVTs (1.5%), 1 PE (0.20%), overall VTE rate of 1.6%, and 7 hemorrhagic complications (1.10%), 4 being clinically significant. The GBM cohort contained 4 DVTs (2.3%) and 3 hemorrhagic complications (1.80%). There was no increased risk of VTE or hemorrhage with anticoagulation initiated on POD2 compared to POD1 in either cohort. Multivariate analysis in both cohorts did not reveal a significant association between DVT, PE, or hemorrhagic complications with age, body mass index, GBM pathology, or extent of resection. Interestingly, glioma patients older than 70 with subtotal resection had a higher likelihood of suffering intracranial hemorrhage when anticoagulation was started on POD1 (odds ratio 12.98). CONCLUSION Risk of VTE or hemorrhagic complication did not significantly differ with prophylactic anticoagulation started on POD1 vs POD2. Early anticoagulation may certainly be considered in high risk cases; however, 1 group where risk may outweigh benefit is the elderly glioma population receiving a subtotal resection.

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