Extended endoscopic endonasal approach for selected pituitary adenomas: early experience

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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Endoscopic endonasal transsphenoidal approach to large and giant pituitary adenomas: institutional experience and predictors of extent of resection

Journal of Neurosurgery ◽

10.3171/2014.3.jns131679 ◽

2014 ◽

Vol 121 (1) ◽

pp. 75-83 ◽

Cited By ~ 78

Author(s):

Kyle Juraschka ◽

Osaama H. Khan ◽

Bruno L. Godoy ◽

Eric Monsalves ◽

Alexandra Kilian ◽

...

Keyword(s):

Pituitary Adenomas ◽

Transsphenoidal Surgery ◽

Sphenoid Sinus ◽

Tumor Volume ◽

Extent Of Resection ◽

Tumor Diameter ◽

Endoscopic Endonasal ◽

Posterior Extension ◽

Endoscopic Endonasal Transsphenoidal Surgery ◽

Giant Pituitary Adenomas

Object While the use of endoscopic approaches has become increasingly accepted in the resection of pituitary adenomas, limited evidence exists regarding the success of this technique for patients with large and giant pituitary adenomas. This study reviews the outcomes of a large cohort of patients with large and giant pituitary adenomas who underwent endoscopic endonasal transsphenoidal surgery at the authors' institution and focuses on identifying factors that can predict extent of resection and hence aid in developing guidelines and indications for the use of endoscopic endonasal transsphenoidal surgery versus open craniotomy approaches to large and giant pituitary adenomas. Methods The authors reviewed 487 patients who underwent endoscopic endonasal transsphenoidal resection of sellar masses. From this group, 73 consecutive patients with large and giant pituitary adenomas (defined as maximum diameter ≥ 3 cm and tumor volume ≥ 10 cm3) who underwent endoscopic endonasal transsphenoidal surgery between January 1, 2006, and June 6, 2012, were included in the study. Clinical presentation, radiological studies, laboratory investigations, tumor pathology data, clinical outcomes, extent of resection measured by volumetric analysis, and complications were analyzed. Results The mean preoperative tumor diameter in this series was 4.1 cm and the volume was 18 cm3. The average resection rate was 82.9%, corresponding with a mean residual volume of 3 cm3. Gross-total resection was achieved in 16 patients (24%), near-total in 11 (17%), subtotal in 24 (36%), and partial in 15 (23%). Seventy-three percent of patients experienced improvement in visual acuity, while 24% were unchanged. Visual fields were improved in 61.8% and unchanged in 5.5%. Overall, 27 patients (37%) experienced a total of 32 complications. The most common complications were sinusitis (14%) and CSF leak (10%). Six patients underwent subsequent radiation therapy because of aggressive tumor histopathology. No deaths occurred in this cohort of patients. Statistically significant predictors of extent of resection included highest Knosp grade (p = 0.001), preoperative tumor volume (p = 0.025), preoperative maximum tumor diameter (p = 0.002), hemorrhagic component (p = 0.027), posterior extension (p = 0.001), and sphenoid sinus invasion (p = 0.005). Conclusions Endoscopic endonasal transsphenoidal surgery is an effective treatment method for patients with large and giant pituitary adenomas, which results in high (> 80%) rates of resection and improvement in visual function. It is not associated with high rates of major complications and is safe when performed by experienced surgeons. The preoperative Knosp grade, tumor volume, tumor diameter, hemorrhagic components on MRI, posterior extension, and sphenoid sinus invasion may allow a prediction of extent of resection and in these patients a staged operation may be required to maximize extent of resection.

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Endoscopic endonasal transsphenoidal surgery for growth hormone–secreting pituitary adenomas

Neurosurgical FOCUS ◽

10.3171/2010.7.focus10173 ◽

2010 ◽

Vol 29 (4) ◽

pp. E6 ◽

Cited By ~ 62

Author(s):

Christoph P. Hofstetter ◽

Raaid H. Mannaa ◽

Lynn Mubita ◽

Vijay K. Anand ◽

John W. Kennedy ◽

...

Keyword(s):

Growth Hormone ◽

Pituitary Adenomas ◽

Transsphenoidal Surgery ◽

Tumor Resection ◽

Serum Levels ◽

Extent Of Resection ◽

Maximum Diameter ◽

Oral Glucose ◽

Endoscopic Endonasal ◽

Endoscopic Endonasal Transsphenoidal Surgery

Object The aim of this study was to determine the preoperative predictors of the extent of resection and endocrinological remission following endonasal endoscopic removal of growth hormone (GH)-secreting pituitary adenomas. Methods The authors analyzed a prospectively collected database of 24 consecutive acromegalic patients who underwent endoscopic endonasal transsphenoidal surgery. The extent of resection was evaluated on postoperative contrast-enhanced MR imaging. Endocrinological remission was defined as normal insulin-like growth factor I (IGFI) serum levels and either a nadir GH level of < 0.4 ng/ml after an oral glucose load or a basal GH serum level < 1 ng/ml. Results The majority of acromegalic patients (83%) had macroadenomas > 1 cm in maximum diameter. Gross-total resection was achieved in 17 (71%) of 24 patients. Notably, endoscopic transsphenoidal surgery allowed complete resection of all lesions without cavernous sinus invasion, regardless of the suprasellar extent. Biochemical remission was achieved in 11 (46%) of 24 patients. A smaller tumor volume and a postoperative reduction in GH serum levels were associated with a higher rate of biochemical cure (p < 0.05). During a 23-month follow-up period 5 patients (21%) underwent Gamma Knife treatment of any residual disease to further reduce excess GH production. Twenty patients (83%) reported significant relief of their symptoms, while 3 (13%) considered their symptoms stable. Two patients (8%) with large macroadenomas experienced postoperative panhypopituitarism, and 2 patients (8%) suffered from CSF leaks, which were treated with lumbar CSF diversion. Conclusions A purely endoscopic endonasal transsphenoidal adenoma resection leads to a high rate of gross-total tumor resection and endocrinological remission in acromegalic patients, even those harboring macroadenomas with wide suprasellar extension. Extended approaches and angled endoscopes are useful tools for increasing the extent of resection.

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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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Endoscopic Endonasal Approach for Pituitary Adenomas: A Series of 560 Patients

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0032-1314045 ◽

2012 ◽

Vol 73 (S 02) ◽

Author(s):

A. Paluzzi ◽

P. Gardner ◽

J. Fernandez-Miranda ◽

M. Koutourousiou ◽

M. Tormenti ◽

...

Keyword(s):

Pituitary Adenomas ◽

Endoscopic Endonasal Approach ◽

Endonasal Approach ◽

Endoscopic Endonasal

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Endoscopic endonasal approach to pituitary adenomas: Impact on adenohypophyseal function. Study of 231 cases

Neurocirugía ◽

10.1016/j.neucir.2021.07.004 ◽

2021 ◽

Author(s):

Marta Araujo-Castro ◽

Franklin Mariño-Sánchez ◽

Alfredo García Fernández ◽

Alberto Acitores Cancela ◽

Víctor Rodríguez Berrocal

Keyword(s):

Pituitary Adenomas ◽

Endoscopic Endonasal Approach ◽

Endonasal Approach ◽

Endoscopic Endonasal ◽

Function Study

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Extended endoscopic endonasal approach for selected pituitary adenomas: early experience

Yearbook of Endocrinology ◽

10.1016/j.yend.2011.06.071 ◽

2011 ◽

Vol 2011 ◽

pp. 323-324

Author(s):

W.H. Ludlam

Keyword(s):

Pituitary Adenomas ◽

Early Experience ◽

Endoscopic Endonasal Approach ◽

Endonasal Approach ◽

Endoscopic Endonasal

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Endoscopic transsphenoidal approach in the diagnosis and treatment of chiasmosellar germinomas

Head and neck tumors (HNT) ◽

10.17650/2222-1468-2020-10-1-29-37 ◽

2020 ◽

Vol 10 (1) ◽

pp. 29-37

Author(s):

M. A. Kutin ◽

D. V. Fomichev ◽

A. N. Shkarubo ◽

I. V. Chernov ◽

O. I. Sharipov ◽

...

Keyword(s):

Professional Associations ◽

Subsequent Treatment ◽

Transsphenoidal Approach ◽

Endoscopic Endonasal Approach ◽

Endonasal Approach ◽

Total Removal ◽

Endoscopic Endonasal ◽

Study Objective ◽

Female Ratio ◽

Histological Verification

Introduction. According to the recommendations of Russian and international professional associations, treatment of germinomas can be initiated without histological verification of the diagnosis, since it can be based on biochemical tumor markers. However, patients with brain germinomas usually have normal levels of these markers; therefore, histological verification is required. Stereotactic biopsy and transcranial biopsy are sometimes associated with a risk of damage to crucial anatomical structures. Currently, both biopsy and total removal of sellar and parasellar tumors can be performed via endoscopic endonasal approach. The study objective is to demonstrate the possibility of using endoscopic transsphenoidal approach for biopsy and total removal of chiasmosellar germinomas. Materials and methods. Thirteen patients with primary chiasmosellar germinomas underwent endoscopic endonasal interventions in N. N. Burdenko National Medical Research Center for Neurosurgery between 2010 and 2017. The “Germinoma-2008” protocol was used in the subsequent treatment of these patients. The male to female ratio was 2.25 : 1; mean age was 21.1 years (6–38 years).Results. The surgery volume varied between biopsy (n = 4) and partial (n = 5) or complete (n = 4) tumor removal. The diagnosis was histologically verified in all patients. None of the patients developed liquorrhea and / or meningitis in the postoperative period, which suggests that the surgery was effective and safe. Conclusion. The endoscopic endonasal approach for histological verification of the diagnosis and removal of chiasmosellar germinomas is safe and effective.

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Endoscopic endonasal approach for pituitary adenomas: a series of 555 patients

Pituitary ◽

10.1007/s11102-013-0502-4 ◽

2013 ◽

Vol 17 (4) ◽

pp. 307-319 ◽

Cited By ~ 85

Author(s):

Alessandro Paluzzi ◽

Juan C. Fernandez-Miranda ◽

S. Tonya Stefko ◽

Sue Challinor ◽

Carl H. Snyderman ◽

...

Keyword(s):

Pituitary Adenomas ◽

Endoscopic Endonasal Approach ◽

Endonasal Approach ◽

Endoscopic Endonasal

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Extended Endoscopic Endonasal Resection of a Suprasellar and Third Ventricular Retrochiasmatic Craniopharyngioma with a Narrow Pituitary Gland–Optic Chiasm Interval: Techniques to Optimize Resection

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0038-1625946 ◽

2018 ◽

Vol 79 (S 03) ◽

pp. S252-S253

Author(s):

Tyler Kenning ◽

Carlos Pinheiro-Neto

Keyword(s):

Pituitary Gland ◽

Third Ventricle ◽

Mass Effect ◽

Optic Chiasm ◽

Endoscopic Endonasal Approach ◽

Endonasal Approach ◽

Posterior Aspect ◽

Endoscopic Endonasal ◽

The Third ◽

Extended Endoscopic Approach

AbstractThe extended endoscopic endonasal approach can be utilized to surgically treat pathology within the suprasellar space. This relies on a sufficient corridor and interval between the superior aspect of the pituitary gland and the optic chiasm. Tumors located in the retrochiasmatic space and within the third ventricle, however, may not have a widened interval through which to work. With mass effect on the superior and posterior aspect of the optic chiasm, the corridor between the chiasm and the pituitary gland might even be further narrowed. This may negate the possibility of utilizing the endoscopic endonasal approach for the management of pathology in this location. We present a case of a retrochiasmatic craniopharyngioma with a narrow resection corridor that was treated with the extended endoscopic approach and we review techniques to potentially overcome this limitation.The link to the video can be found at: https://youtu.be/ogRZj-aBqeQ.

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