Endoscopic approach for giant pituitary adenoma: clinical outcomes of 205 patients and comparison of two proposed classification systems for preoperative prediction of extent of resection

OBJECTIVE Giant pituitary adenoma is considered a challenging pathology for surgery owing to its complications and low resection rate. In this study, the authors present their experience of using the endoscopic endonasal approach to treat patients with giant pituitary adenoma, and they aimed to develop a classification system for prediction of extent of resection. METHODS The institutional medical records of patients diagnosed with giant pituitary adenoma who underwent endoscopic endonasal transsphenoidal surgery between August 1997 and December 2019 were retrospectively reviewed. Surgical and clinical outcomes were evaluated in detail. The effects of tumor characteristics on extent of resection were analyzed. The findings were used to develop two classification systems that could preoperatively predict extent of resection. Morphological score was based on tumor characteristics, and landmark-based classification was defined according to surgical zones based on neurovascular landmarks. The effects of change in surgical strategy, which aimed to maximize tumor resection and capsule dissection, on rates of resection and complications were evaluated before and after 2017. RESULTS This study included 205 patients, with a mean patient age of 46.95 years and mean preoperative tumor diameter of 46.56 mm. Gross-total resection (GTR) was achieved in 35.12% of patients, near-total resection (NTR) in 39.51%, and subtotal resection (STR) in 25.36%. Extent of resection differed significantly between the grades and zones of the classification systems (p < 0.001 for both). Among patients with grade 3 tumor, 75.75% of patients achieved STR, 21.21% achieved NTR, and 3.03% achieved GTR. Among patients with zone 3 tumor, 65.75% achieved STR, 32.87% achieved NTR, and 1.36% achieved GTR. Both grade 3 and zone 3 indicated limited extent of resection. The mean (range) follow-up duration was 50.16 (9–247) months. Postoperative recovery of at least one hormone axis was seen in 15.24% of patients with pituitary deficiency, and development of new hormonal deficiency was observed in 22.43% of patients. Complications included permanent diabetes insipidus (7.80%), cerebrospinal fluid leakage (3.90%), postoperative apoplexy (3.90%), meningitis (3.41%), and epistaxis (3.41%). The surgical mortality rate was 1.46%. Among 85 patients treated before 2017, 27.05% of patients achieved GTR, 37.64% achieved NTR, and 35.29% achieved STR; among 120 patients treated after 2017, 40.83% achieved GTR, 40.83% achieved NTR, and 18.33% achieved STR. Seven patients in the pre-2017 cohort had postoperative apoplexy versus only 1 patient in the post-2017 cohort. There were no statistically significant differences between the two periods in terms of the incidence rates of other complications. CONCLUSIONS Capsule dissection and GTR are valuable for preventing serious complications and reducing recurrence of giant adenoma. Treatment of giant pituitary adenoma may be better managed with the help of a classification system that provides information about extent of resection that can be achieved with an endoscopic approach.

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Endoscopic endonasal versus transcranial surgery for primary resection of craniopharyngiomas based on a new QST classification system: a comparative series of 315 patients

Journal of Neurosurgery ◽

10.3171/2020.7.jns20257 ◽

2021 ◽

pp. 1-12

Author(s):

Jun Fan ◽

Yi Liu ◽

Jun Pan ◽

Yuping Peng ◽

Junxiang Peng ◽

...

Keyword(s):

Recurrence Rate ◽

Classification System ◽

Growth Patterns ◽

Gross Total Resection ◽

Tumor Type ◽

Tumor Characteristics ◽

Resection Rate ◽

Total Resection ◽

Endoscopic Endonasal ◽

Different Types

OBJECTIVE An assessment of the transcranial approach (TCA) and the endoscopic endonasal approach (EEA) for craniopharyngiomas (CPs) according to tumor types has not been reported. The aim of this study was to evaluate both surgical approaches for different types of CPs. METHODS A retrospective review of primary resected CPs was performed. A QST classification system based on tumor origin was used to classify tumors into 3 types as follows: infrasellar/subdiaphragmatic CPs (Q-CPs), subarachnoidal CPs (S-CPs), and pars tuberalis CPs (T-CPs). Within each tumor type, patients were further arranged into two groups: those treated via the TCA and those treated via the EEA. Patient and tumor characteristics, surgical outcomes, and postoperative complications were obtained. All variables were statistically analyzed between surgical groups for each tumor type. RESULTS A total of 315 patients were included in this series, of whom 87 were identified with Q-CPs (49 treated via TCA and 38 via EEA); 56 with S-CPs (36 treated via TCA and 20 via EEA); and 172 with T-CPs (105 treated via TCA and 67 via EEA). Patient and tumor characteristics were equivalent between both surgical groups in each tumor type. The overall gross-total resection rate (90.5% TCA vs 91.2% EEA, p = 0.85) and recurrence rate (8.9% TCA vs 6.4% EEA, p = 0.35) were similar between surgical groups. The EEA group had a greater chance of visual improvement (61.6% vs 35.8%, p = 0.01) and a decreased risk of visual deterioration (1.6% vs 11.0%, p < 0.001). Of the patients with T-CPs, postoperative hypothalamic status was better in the TCA group than in the EEA group (p = 0.016). Postoperative CSF leaks and nasal complication rates occurred more frequently in the EEA group (12.0% vs 0.5%, and 9.6% vs 0.5%; both p < 0.001). For Q-CPs, EEA was associated with an increased gross-total resection rate (97.4% vs 85.7%, p = 0.017), decreased recurrence rate (2.6% vs 12.2%, p = 0.001), and lower new hypopituitarism rate (28.9% vs 57.1%, p = 0.008). The recurrence-free survival in patients with Q-CPs was also significantly different between surgical groups (log-rank test, p = 0.037). The EEA required longer surgical time for T-CPs (p = 0.01). CONCLUSIONS CPs could be effectively treated by radical surgery with favorable results. Both TCA and EEA have their advantages and limitations when used to manage different types of tumors. Individualized surgical strategies based on tumor growth patterns are mandatory to achieve optimal outcomes.

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Endoscopic Endonasal Transtuberculum Transplanum Approach for Resection of Giant Pituitary Adenoma: The Second Floor Strategy to Avoid Postoperative Pituitary Apoplexy

10.1055/s-0040-1702625 ◽

2020 ◽

Author(s):

Dante L. Pezzutti ◽

Daniel M. Prevedello

Keyword(s):

Pituitary Adenoma ◽

Pituitary Apoplexy ◽

Endoscopic Endonasal ◽

Giant Pituitary Adenoma

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Endoscopic Endonasal Approach to Multilobular Giant Pituitary Adenoma with Cavernous Sinus Invasion and Petroclival Extension

10.1055/s-0041-1725507 ◽

2021 ◽

Author(s):

Tural Rahimli

Keyword(s):

Pituitary Adenoma ◽

Cavernous Sinus ◽

Endoscopic Endonasal Approach ◽

Endonasal Approach ◽

Endoscopic Endonasal ◽

Giant Pituitary Adenoma ◽

Cavernous Sinus Invasion

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Do We Need Intraoperative Magnetic Resonance Imaging in All Endoscopic Endonasal Pituitary Adenoma Surgery Cases? A Retrospective Study

Frontiers in Oncology ◽

10.3389/fonc.2021.733838 ◽

2021 ◽

Vol 11 ◽

Author(s):

Emrah Celtikci ◽

Muammer Melih Sahin ◽

Mustafa Caglar Sahin ◽

Emetullah Cindil ◽

Zuhal Demirtaş ◽

...

Keyword(s):

Magnetic Resonance Imaging ◽

Pituitary Adenoma ◽

Magnetic Resonance ◽

Cavernous Sinus ◽

Residual Tumor ◽

Correct Prediction ◽

Resonance Imaging ◽

Mri Scan ◽

Endoscopic Endonasal ◽

Grade 3

There are previous reports investigating effectiveness of intraoperative magnetic resonance imaging (IO-MRI) in pituitary adenoma surgery but there is no clear data in the literature recommending when there is no need of intraoperative scan. This retrospective analysis was based on determining which patients does not need any IO-MRI scan following endoscopic endonasal pituitary adenoma surgery. Patients with functional or non-functional pituitary adenomas that were operated via endoscopic endonasal approach (EEA) between June 2017 and May 2019 were enrolled. Patients younger than 18 years old, patients who did not underwent IO-MRI procedure or not operated via EEA were excluded from the study. Hence, this study is designed to clarify if IO-MRI is useful in both functional and non-functional pituitary adenomas, functional adenomas did not split into subgroups. A total of 200 patients treated with pituitary adenoma were included. In Knosp Grade 0 – 2 group, primary surgeon’s opinion and IO-MRI findings were compatible in 150 patients (98.6%). In Knosp Grade 3 – 4 correct prediction were performed in 32 (66.6%) patients. When incorrectly predicted Knosp Grade 3 – 4 patients (n = 16) was analyzed, in 13 patients there were still residual tumor in cavernous sinus and in 3 patients there were no residual tumor. Fisher’s exact test showed there is a statistically significant difference of correct prediction between two different Knosp Grade groups (two-tailed P < 0.0001). Eighteen patients had a residual tumor extending to the suprasellar and parasellar regions which second most common site for residual tumor. Our findings demonstrate that there is no need of IO-MRI scan while operating adenomas limited in the sellae and not invading the cavernous sinus. However, we strongly recommend IO-MRI if there is any suprasellar and parasellar extension and/or cavernous sinus invasion.

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Preserve or sacrifice the stalk? Endocrinological outcomes, extent of resection, and recurrence rates following endoscopic endonasal resection of craniopharyngiomas

Journal of Neurosurgery ◽

10.3171/2018.6.jns18901 ◽

2019 ◽

Vol 131 (4) ◽

pp. 1163-1171 ◽

Cited By ~ 4

Author(s):

Edgar G. Ordóñez-Rubiano ◽

Jonathan A. Forbes ◽

Peter F. Morgenstern ◽

Leopold Arko ◽

Georgiana A. Dobri ◽

...

Keyword(s):

Diabetes Insipidus ◽

Extent Of Resection ◽

Endocrine Function ◽

Subtotal Resection ◽

Type I ◽

Pituitary Insufficiency ◽

Recurrence Rates ◽

Total Resection ◽

Endoscopic Endonasal ◽

Operative Notes

OBJECTIVEGross-total resection (GTR) of craniopharyngiomas (CPs) is potentially curative and is often the goal of surgery, but endocrinopathy generally results if the stalk is sacrificed. In some cases, GTR can be attempted while still preserving the stalk; however, stalk manipulation or devascularization may cause endocrinopathy and this strategy risks leaving behind small tumor remnants that can recur.METHODSA retrospective review of a prospective cohort of patients who underwent initial resection of CP using the endoscopic endonasal approach over a period of 12 years at Weill Cornell Medical College, NewYork-Presbyterian Hospital, was performed. Postresection integrity of the stalk was retrospectively assessed using operative notes, videos, and postoperative MRI. Tumors were classified based on location into type I (sellar), type II (sellar-suprasellar), and type III (purely suprasellar). Pre- and postoperative endocrine function, tumor location, body mass index, rate of GTR, radiation therapy, and complications were reviewed.RESULTSA total of 54 patients who had undergone endoscopic endonasal procedures for first-time resection of CP were identified. The stalk was preserved in 33 (61%) and sacrificed in 21 (39%) patients. GTR was achieved in 24 patients (73%) with stalk preservation and 21 patients (100%) with stalk sacrifice (p = 0.007). Stalk-preservation surgery achieved GTR and maintained completely normal pituitary function in only 4 (12%) of 33 patients. Permanent postoperative diabetes insipidus was present in 16 patients (49%) with stalk preservation and in 20 patients (95%) following stalk sacrifice (p = 0.002). In the stalk-preservation group, rates of progression and radiation were higher with intentional subtotal resection or near-total resection compared to GTR (67% vs 0%, p < 0.001, and 100% vs 12.5%, p < 0.001, respectively). However, for the subgroup of patients in whom GTR was achieved, stalk preservation did not lead to significantly higher rates of recurrence (12.5%) compared with those in whom it was sacrificed (5%, p = 0.61), and stalk preservation prevented anterior pituitary insufficiency in 33% and diabetes insipidus in 50%.CONCLUSIONSWhile the decision to preserve the stalk reduces the rate of postoperative endocrinopathy by roughly 50%, nevertheless significant dysfunction of the anterior and posterior pituitary often ensues. The decision to preserve the stalk does not guarantee preserved endocrine function and comes with a higher risk of progression and need for adjuvant therapy. Nevertheless, to reduce postoperative endocrinopathy attempts should be made to preserve the stalk if GTR can be achieved.

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Endoscopic endonasal resection of skull base meningiomas: the significance of a “cortical cuff” and brain edema compared with careful case selection and surgical experience in predicting morbidity and extent of resection

Neurosurgical FOCUS ◽

10.3171/2014.7.focus14321 ◽

2014 ◽

Vol 37 (4) ◽

pp. E7 ◽

Cited By ~ 17

Author(s):

Osaama H. Khan ◽

Vijay K. Anand ◽

Theodore H. Schwartz ◽

Keyword(s):

Skull Base ◽

Brain Edema ◽

Extent Of Resection ◽

Gross Total Resection ◽

Surgical Experience ◽

Total Resection ◽

Endoscopic Endonasal ◽

Case Selection ◽

Skull Base Meningiomas ◽

Group 1

Object This paper describes a consecutive series of skull base meningiomas resected using an endoscopic endonasal approach through various corridors at a single institution over 7 years. The impact of case selection and experience, the presence of a cortical cuff between the tumor and surrounding vessels, and brain edema on morbidity and rates of gross-total resection (GTR) were examined. Methods A retrospective review of a series of 46 skull base meningiomas from a prospective database was conducted. The series of cases were divided by location: olfactory groove (n = 15), tuberculum and planum (n = 20), sellar/cavernous (n = 9) and petroclival (n = 2). Gross-total resection was never intended in the sellar/cavernous tumors, which generally invaded the cavernous sinus. Clinical charts, volumetric imaging, and pathology were reviewed to assess the extent of resection and complications. Cases were divided based on a time point in which surgical technique and case selection improved into Group 1 (surgery prior to June 2008; n = 21) and Group 2 (surgery after June 2008; n = 25) and into those with and without a cortical cuff and with and without brain edema. Results Improved case selection had the greatest impact on extent of resection. For the entire cohort, rates of GTR went from 38% to 76% (p = 0.02), and for cases in which GTR was the intent, the rates went from 63% to 84% (not significant), which was mostly driven by the planum and tuberculum meningiomas, which went from 75% to 91.7 % (nonsignificant difference). The presence of a cortical cuff and brain edema had no impact on outcomes. There were 3 CSF leaks (6.5%) but all were in Group 1. Hence, CSF leak improved from 14.2% to 0% with surgical experience. Lessons learned for optimal case selection are discussed. Conclusions Surgical outcome for endonasal endoscopic resection of skull base meningiomas depends mostly on careful case selection and surgical experience. Imaging criteria such as the presence of a cortical cuff or brain edema are less important.

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Clinical outcomes of an endoscopic transclival and transpetrosal approach for primary skull base malignancies involving the clivus

Journal of Neurosurgery ◽

10.3171/2016.12.jns161920 ◽

2018 ◽

Vol 128 (5) ◽

pp. 1454-1462 ◽

Cited By ~ 10

Author(s):

Yong Hwy Kim ◽

Chiman Jeon ◽

Young-Bem Se ◽

Sang Duk Hong ◽

Ho Jun Seol ◽

...

Keyword(s):

Prognostic Factors ◽

Skull Base ◽

Clinical Outcomes ◽

Univariate Analysis ◽

Extent Of Resection ◽

Subtotal Resection ◽

Endoscopic Endonasal Approach ◽

Endonasal Approach ◽

Endoscopic Endonasal ◽

Tumor Laterality

OBJECTIVEThe endoscopic endonasal approach for treating primary skull base malignancies involving the clivus is a formidable task. The authors hypothesized that tumor involvement of nearby critical anatomical structures creates hurdles to endoscopic gross-total resection (GTR). The aim of this study was to retrospectively review the clinical outcomes of patients who underwent an endoscopic endonasal approach to treat primary malignancies involving the clivus and to analyze prognostic factors for GTR.METHODSBetween January 2009 and November 2015, 42 patients underwent the endoscopic endonasal approach for resection of primary skull base malignancies involving the clivus at 2 independent institutions. Clinical data; tumor locations within the clivus; and anatomical involvement of the cavernous or paraclival internal carotid artery, cisternal trigeminal nerve, hypoglossal canal, and dura mater were investigated to assess the extent of resection. Possible prognostic factors affecting GTR were also analyzed.RESULTSOf the 42 patients, 37 were diagnosed with chordomas and 5 were diagnosed with chondrosarcomas. The mean (± SD) preoperative tumor volume was 25.2 ± 30.5 cm3 (range 0.8–166.7 cm3). GTR was achieved in 28 patients (66.7%) and subtotal resection in 14 patients (33.3%). All tumors were classified as upper (n = 17), middle (n = 17), or lower (n = 8) clival tumors based on clival involvement, and as central (24 [57.1%]) or paramedian (18 [42.9%]) based on laterality of the tumor. Univariate analysis identified the tumor laterality (OR 6.25, 95% CI 1.51–25.86; p = 0.011) as significantly predictive of GTR. In addition, the laterality of the tumor was found to be a statistically significant predictor in multivariate analysis (OR 41.16, 95% CI 1.12–1512.65; p = 0.043).CONCLUSIONSAn endoscopic endonasal approach can provide favorable clinical and surgical outcomes. However, the tumor laterality should be considered as a potential obstacle to total removal.

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The Subtemporal Approach to Retroinfundibular Craniopharyngiomas: A New Look at an Old Approach

Operative Neurosurgery ◽

10.1227/neu.0000000000000972 ◽

2015 ◽

Vol 11 (4) ◽

pp. 495-503 ◽

Cited By ~ 2

Author(s):

Ricky H Wong ◽

Kenneth De Los Reyes ◽

Puya Alikhani ◽

Sananthan Sivakanthan ◽

Jamie van Gompel ◽

...

Keyword(s):

Temporal Lobe ◽

Tumor Volume ◽

Extent Of Resection ◽

Total Resection ◽

Endoscopic Endonasal ◽

Subtemporal Approach ◽

Advantages And Disadvantages ◽

Time To Recurrence ◽

Average Tumor Volume ◽

Neurovascular Structures

Abstract BACKGROUND Retrochiasmatic, retroinfundibular craniopharyngiomas are surgically challenging tumors. Anterolateral, posterolateral, and endoscopic endonasal approaches represent the most commonly used techniques to access these tumors, but all require an extensive exposure time, and each has its own risks and limitations. The subtemporal approach is a well-known neurosurgical approach that is rarely described for craniopharyngiomas. OBJECTIVE To assess the feasibility, advantages, and disadvantages of a subtemporal approach for craniopharyngiomas. METHODS Five patients with retrochiasmatic craniopharyngiomas where the majority of the tumor extended behind the dorsal clival line underwent a subtemporal approach for resection. Extent of resection, degree of temporal lobe injury, visual and endocrine outcomes, and time to recurrence were analyzed. RESULTS Average tumor volume was 6.4 cm3. Near-total resection was achieved in 80% (4/5) and subtotal in 20% (1/5). All patients had stable or improved vision. There was 1 new permanent endocrine deficiency. Minimal temporal lobe edema was observed in 80% (4/5) of patients. Three patients required postoperative radiation. CONCLUSION The subtemporal approach represents a feasible approach for retrochiasmatic, retroinfundibular craniopharyngiomas when gross total resection is not mandatory. It provides rapid access to the tumor and a caudal-to-cranial visualization that promotes minimal manipulation of critical neurovascular structures, particularly the optic apparatus.

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Endoscopic endonasal pituitary adenoma surgery: our surgical experience in 116 patients

International Journal of Otorhinolaryngology and Head and Neck Surgery ◽

10.18203/issn.2454-5929.ijohns20204626 ◽

2020 ◽

Vol 6 (11) ◽

pp. 2029

Author(s):

Krishna Vikas Potdukhe ◽

Kalpesh Patel ◽

Rajesh Vishwakarma

Keyword(s):

Pituitary Adenoma ◽

Visual Outcome ◽

Primary Objective ◽

Partial Resection ◽

High Rate ◽

Endocrine Function ◽

Gross Total Resection ◽

Imaging Data ◽

Total Resection ◽

Endoscopic Endonasal

Background: The primary objective of this study was to evaluate the outcome of excision in terms of gross and partial resection rates compared to the grades of pituitary adenoma (based on Hardy-Vezina classification). We also evaluated the post-operative complications and the effect of resection on visual outcomes and endocrinological remission.Methods: We retrospectively analysed 116 patients who underwent surgical resection of pituitary adenoma via endonasal trans-sphenoidal approach at Civil Hospital (Ahmedabad) between March 2013 and March 2019 and collected pre-operative and post-operative data in terms of imaging, endocrine function and vision. Results: According to the postoperative imaging data and endocrine examination results, gross-total resection (GTR) was achieved in 79.3% (92 patients), and partial (PR) in 20.6% (24 patients) which was significant (p<0.05). Improvement in vision was seen in 62% (40 patients out of 64 patients). Out of 44 patients having endocrine dysfunction, endocrinological remission was achieved in 32 patients with functional adenomas (72.7%). Sinusitis followed by headache was the most common minor complication seen in the study.Conclusions: Endoscopic endonasal transsphenoidal surgery is a valuable treatment option for patients having grade 3 or lower pituitary adenomas, which leads to gross total resection in comparison to patients having grade 4 adenoma. It also results in high rate of surgical decompression and better visual outcome. Partial resection may result in endocrinological response in functional tumors.

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