Maximizing the extent of tumor resection during transsphenoidal surgery for pituitary macroadenomas: can endoscopy replace intraoperative magnetic resonance imaging?

Clinical article

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Object

Endoscopic approaches to pituitary tumors have become an effective alternative to traditional microscopic transsphenoidal approaches. Despite a proven potential to decrease unexpected residual tumor, intraoperative MR (iMR) imaging is infrequently used even in the few operating environments in which such technology is available. Its use is prohibitive because of its cost, increased complexity, and longer operative times. The authors assessed the potential of intrasellar endoscopy to replace the need for iMR imaging without sacrificing the maximum extent of resection.

Methods

In this retrospective study, 27 consecutive patients underwent fully endoscopic resection of pituitary macroadenomas. Intrasellar endoscopy was used to determine the presence of residual tumor within the sella turcica and tumor cavity. Intraoperative MR imaging was used to identify rates of unexpected residual tumor and the need for further tumor resection.

Results

Intraoperative estimates of the extent of tumor resection were correct in 23 patients (85%). Of 4 patients with unacceptable tumor residuals, 3 underwent further tumor resection. After iMR imaging, the rate of successful completion of the planned extent of resection increased to 26 patients (96%). Rates of both endocrinopathy reversal and postoperative complications were consistent with previously published results for microscopic and endoscopic resection techniques.

Conclusions

The findings in this study provided quantitative evidence that intrasellar endoscopy has significant promise for maximizing the extent of tumor resection and is a useful adjunct to surgical approaches to pituitary tumors, particularly when iMR imaging is unavailable. A larger prospective study on the extent of resection following endoscopic transsphenoidal surgery would strengthen these findings.

Abbreviations used in this paper: FOV = field of view; GTR = gross-total resection; iMR = intraoperative MR; STR = subtotal resection.

Article Information

Address correspondence to: Philip V. Theodosopoulos, M.D., c/o Editorial Office, University of Cincinnati, Department of Neurosurgery, P.O. Box 0515, Cincinnati, Ohio, 45267-0515. email: editor@mayfieldclinic.com.

Please include this information when citing this paper: published online October 16, 2009; DOI: 10.3171/2009.6.JNS08916.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Drawing depicting the floor plan of a twin operating room (OR) design. Endoscopic transsphenoidal procedures were performed in the conventional OR. After tumor resection the patient was transported through a sterile corridor to the MR imaging-OR (MR-OR) for intraoperative imaging studies. The Hitachi AIRIS II 0.3-T magnet generates magnetic fringe fields that define work zones: Zone I, MR imaging–compatible instruments and equipment only; Zone II, conventional instruments; Zone IIIa, surgical microscope and computer workstations; Zone IIIb, pacemaker safe. Field strength is indicated in milliteslas. Printed with permission from Mayfield Clinic. From Bohinski RJ, Warnick RE, Gaskill-Shipley MF, et al: Neurosurgery 49:1133–1143, 2001.

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    Intrasellar photograph taken with a 30° endoscope angled superolaterally to view the diaphragma sella (a), the left cavernous sinus wall (b), and a small tumor remnant (c). Printed with permission from Mayfield Clinic. From Theodosopoulos PV: Pituitary Tumor Management. CNS University Tumor Webinar. July 16, 2009.

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    Representative example of a correct prediction of GTR by MR imaging. Preoperative MR images (A and B) used to predict the extent of resection. Intraoperative MR images showing GTR with only stalk and capsular residual enhancement without (C and E) and with (D and F) contrast medium. Printed with permission from Mayfield Clinic. From Theodosopoulos PV: Pituitary Tumor Management. CNS University Tumor Webinar. July 16, 2009.

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    Representative example of a correct prediction of STR with MR imaging. Preoperative images (A and B) used to predict the extent of resection. Intraoperative MR images without (C and E) and with (D and F) contrast medium revealing optimal STR with residual tumor within the left cavernous sinus. Printed with permission from Mayfield Clinic. From Theodosopoulos PV: Pituitary Tumor Management. CNS University Tumor Webinar. July 16, 2009.

  • View in gallery

    Representative example of an incorrect prediction of STR by MR imaging. Preoperative images (A and B) used to predict the extent of resection. Intraoperative MR images without (C and E) and with (D and F) contrast showing residual suprasellar tumor. Postoperative MR images with contrast (G and H) obtained after further resection, revealing GTR. Printed with permission from Mayfield Clinic. From Theodosopoulos PV: Pituitary Tumor Management. CNS University Tumor Webinar. July 16, 2009.

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