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

2014 ◽  
Vol 121 (1) ◽  
pp. 75-83 ◽  
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.

Extended endoscopic endonasal approach for selected pituitary adenomas: early experience

2011 ◽  
Vol 114 (2) ◽  
pp. 345-353 ◽  
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.

Endoscopic endonasal transsphenoidal surgery for growth hormone–secreting pituitary adenomas

2010 ◽  
Vol 29 (4) ◽  
pp. E6 ◽  
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.

scholarly journals Surgical outcomes of the endoscopic endonasal transsphenoidal approach for large and giant pituitary adenomas: institutional experience with special attention to approach-related complications

2016 ◽  
Vol 74 (5) ◽  
pp. 388-395 ◽  
Author(s):  
Edson Rocha Constantino ◽  
Rafael Leal ◽  
Christian Cândido Ferreira ◽  
Marcus André Acioly ◽  
José Alberto Landeiro
Keyword(s):  
Pituitary Adenomas ◽  
Cerebrospinal Fluid Leak ◽  
Transsphenoidal Approach ◽  
Tumor Diameter ◽  
Endoscopic Endonasal ◽  
Valuable Treatment ◽  
Institutional Experience ◽  
Endoscopic Endonasal Transsphenoidal Surgery ◽  
Giant Pituitary Adenomas ◽  
Fluid Leak

ABSTRACT Objective In this study, we investigate our institutional experience of patients who underwent endoscopic endonasal transsphenoidal approach for treatment of large and giant pituitary adenomas emphasizing the surgical results and approach-related complications. Method The authors reviewed 28 consecutive patients who underwent surgery between March, 2010 and March, 2014. Results The mean preoperative tumor diameter was 4.6 cm. Gross-total resection was achieved in 14.3%, near-total in 10.7%, subtotal in 39.3%, and partial in 35.7%. Nine patients experienced improvement in visual acuity, while one patient worsened. The most common complications were transient diabetes insipidus (53%), new pituitary deficit (35.7%), endonasal adhesions (21.4%), and cerebrospinal fluid leak (17.8%). Surgical mortality was 7.1%. Conclusions Endoscopic endonasal transsphenoidal surgery is a valuable treatment option for large or giant pituitary adenomas, which results in high rates of surgical decompression of cerebrovascular structures.

scholarly journals Impact of tumor characteristics and pre- and postoperative hormone levels on hormonal remission following endoscopic transsphenoidal surgery in patients with acromegaly

2020 ◽  
Vol 48 (6) ◽  
pp. E10 ◽  
Author(s):  
Tyler Cardinal ◽  
Martin J. Rutkowski ◽  
Alexander Micko ◽  
Mark Shiroishi ◽  
Chia-Shang Jason Liu ◽  
...  
Keyword(s):  
Pituitary Adenoma ◽  
Medical Therapy ◽  
Pituitary Adenomas ◽  
Transsphenoidal Surgery ◽  
Cranial Nerves ◽  
Elevated Serum ◽  
Tumor Control ◽  
Tumor Diameter ◽  
Endoscopic Endonasal ◽  
Csf Leakage

OBJECTIVEAcromegaly is a disease of acral enlargement and elevated serum levels of insulin-like growth factor–1 (IGF-1) and growth hormone (GH), usually caused by a pituitary adenoma. A lack of consensus on factors that reliably predict outcomes in acromegalic patients following endoscopic endonasal transsphenoidal surgery (EETS) warrants additional investigation.METHODSThe authors identified 52 patients with acromegaly who underwent an endoscopic endonasal approach (EEA) for resection of a GH-secreting pituitary adenoma. Preoperative and postoperative tumor and endocrinological characteristics such as tumor size, invasiveness, and GH/IGF-1 levels were evaluated as potential indicators of postoperative hormonal remission. Endocrinological remission was defined as postoperative IGF-1 levels at or below the age- and sex-normalized values.RESULTSThe 52 patients had a mean age of 50.7 ± 13.4 years and a mean follow-up duration of 24.4 ± 19.1 months. Ten patients (19%) had microadenomas and 42 (81%) had macroadenomas. Five patients (9.6%) had giant adenomas. Forty-four tumors (85%) had extrasellar extension, with 40 (77%) exhibiting infrasellar invasion, 18 (35%) extending above the sella, and 7 (13%) invading the cavernous sinuses. Thirty-six patients (69%) underwent gross-total resection (GTR; mean maximal tumor diameter 1.47 cm), and 16 (31%) underwent subtotal resection (STR; mean maximal tumor diameter 2.74 cm). Invasive tumors were significantly larger, and Knosp scores were negatively correlated with GTR. Thirty-eight patients (73%) achieved hormonal remission after EEA resection alone, which increased to 87% with adjunctive medical therapy. Ninety percent of patients with microadenomas and 86% of patients with macroadenomas achieved hormonal remission. Preoperative IGF-1 and postoperative day 1 (POD1) GH levels were inversely correlated with hormonal remission. Postoperative CSF leakage occurred in 2 patients (4%), and none experienced vision loss, death, or injury to internal carotid arteries or cranial nerves.CONCLUSIONSEndoscopic transsphenoidal resection of GH-secreting pituitary adenomas is a safe and highly effective treatment for achieving hormonal remission and tumor control in up to 87% of patients with acromegaly when combined with postoperative medical therapy. Patients with lower preoperative IGF-1 and POD1 GH levels, with less invasive pituitary adenomas, and who undergo GTR are more likely to achieve postoperative biochemical remission.

scholarly journals Risk factors for postoperative intracranial infections in patients with pituitary adenoma after endoscopic endonasal transsphenoidal surgery: pneumocephalus deserves further study

2019 ◽  
Vol 47 (2) ◽  
pp. E5 ◽  
Author(s):  
Kang Guo ◽  
Lijun Heng ◽  
Haihong Zhang ◽  
Lei Ma ◽  
Hui Zhang ◽  
...  
Keyword(s):  
Risk Factors ◽  
Pituitary Adenoma ◽  
Pituitary Adenomas ◽  
Transsphenoidal Surgery ◽  
Bubble Diameter ◽  
Csf Leak ◽  
Endoscopic Endonasal ◽  
Cns Infections ◽  
Endoscopic Endonasal Transsphenoidal Surgery ◽  
Intracranial Infections

OBJECTIVEThe authors sought to identify the relevance between pneumocephalus and postoperative intracranial infections, as well as bacteriological characteristics and risk factors for intracranial infections, in patients with pituitary adenomas after endoscopic endonasal transsphenoidal surgery.METHODSIn total, data from 251 consecutive patients with pituitary adenomas who underwent pure endoscopic endonasal transsphenoidal surgeries from 2014 to 2018 were reviewed for preoperative comorbidities, intraoperative techniques, and postoperative care.RESULTSThis retrospective study found 18 cases of postoperative pneumocephalus (7.17%), 9 CNS infections (3.59%), and 12 CSF leaks (4.78%). Of the patients with pneumocephalus, 5 (27.8%) had CNS infections. In patients with CNS infections, the culture results were positive in 7 cases and negative in 2 cases. The statistical analysis suggested that pneumocephalus (maximum bubble diameter of ≥ 1 cm), diaphragmatic defects (intraoperative CSF leak, Kelly grade ≥ 1), and a postoperative CSF leak are risk factors for postoperative CNS infections.CONCLUSIONSIn pituitary adenoma patients who underwent pure endoscopic endonasal transsphenoidal surgeries, intraoperative saddle reconstruction has a crucial role for patients with postoperative intracranial infections. Additionally, postoperative pneumocephalus plays an important role in predicting intracranial infections that must not be neglected. Therefore, neurosurgeons should pay close attention to the discovery of postoperative intracranial pneumocephalus because this factor is as important as a postoperative CSF leak. Pneumocephalus (maximum bubble diameter of ≥ 1 cm), diaphragmatic defects (an intraoperative CSF leak, Kelly grade ≥ 1), and a postoperative CSF leak were risk factors predictive of postoperative intracranial infections. In addition, it is essential that operative procedures be carefully performed to avoid diaphragmatic defects, to reduce exposure to the external environment, and to decrease patients’ suffering.

Endoscopic Endonasal Transsphenoidal Surgery for Pituitary Adenomas

2015 ◽  
Vol 26 (1) ◽  
pp. 201-205 ◽  
Author(s):  
Ercan Pinar ◽  
Nurullah Yuceer ◽  
Abdulkadir Imre ◽  
Gonul Guvenc ◽  
Onur Gundogan
Keyword(s):  
Pituitary Adenomas ◽  
Transsphenoidal Surgery ◽  
Endoscopic Endonasal ◽  
Endoscopic Endonasal Transsphenoidal Surgery

scholarly journals Primary Endoscopic Endonasal Management of Giant Pituitary Adenomas: Outcome and Pitfalls from a Large Prospective Multicenter Experience

Cancers ◽  
2021 ◽  
Vol 13 (14) ◽  
pp. 3603
Author(s):  
Salvatore Chibbaro ◽  
Francesco Signorelli ◽  
Davide Milani ◽  
Helene Cebula ◽  
Antonino Scibilia ◽  
...  
Keyword(s):  
Pituitary Adenomas ◽  
Anterior Pituitary ◽  
Extent Of Resection ◽  
Incomplete Resection ◽  
Pituitary Insufficiency ◽  
Recurrence Rates ◽  
Endoscopic Endonasal ◽  
Multi Stage ◽  
Clinical And Radiological Outcome ◽  
Giant Pituitary Adenomas

Purpose: To evaluate factors influencing clinical and radiological outcome of extended endoscopic endonasal transtuberculum/transplanum approach (EEA-TTP) for giant pituitary adenomas (GPAs). Methods: We recruited prospectively all consecutive GPAs patients undergoing EEA-TTP between 2015 and 2019 in 5 neurosurgical centers. Preoperative clinical and radiologic features, visual and hormonal outcomes, extent of resection (EoR), complications and recurrence rates were recorded and analyzed. Results: Of 1169 patients treated for pituitary adenoma, 96 (8.2%) had GPAs. Seventy-eight (81.2%) patients had visual impairment, 12 (12.5%) had headaches, 3 (3.1%) had drowsiness due to hydrocephalus, and 53 (55.2%) had anterior pituitary insufficiency. EoR was gross or near-total in 46 (47.9%) and subtotal in 50 (52.1%) patients. Incomplete resection was associated with lateral suprasellar, intraventricular and/or cavernous sinus extension and with firm/fibrous consistence. At the last follow-up, all but one patient (77, 98.7%) with visual deficits improved. Headache improved in 8 (88.9%) and anterior pituitary function recovered in 27 (50.9%) patients. Recurrence rate was 16.7%, with 32 months mean recurrence-free survival. Conclusions: EEA-TTP is a valid option for GPAs and seems to provide better outcomes, lower rate of complications and higher EoR compared to one- or multi-stage microscopic, non-extended endoscopic transsphenoidal, and transcranial resections.

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