Endoscopic endonasal surgery for giant pituitary adenomas: advantages and limitations

Clinical article

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Object

Giant pituitary adenomas (> 4 cm in maximum diameter) represent a significant surgical challenge. Endoscopic endonasal surgery (EES) has recently been introduced as a treatment option for these tumors. The authors present the results of EES for giant adenomas and analyze the advantages and limitations of this technique.

Methods

The authors retrospectively reviewed the medical files and imaging studies of 54 patients with giant pituitary adenomas who underwent EES and studied the factors affecting surgical outcome.

Results

Preoperative visual impairment was present in 45 patients (83%) and partial or complete pituitary deficiency in 28 cases (52%), and 7 patients (13%) presented with apoplexy. Near-total resection (> 90%) was achieved in 36 patients (66.7%). Vision was improved or normalized in 36 cases (80%) and worsened in 2 cases due to apoplexy of residual tumor. Significant factors that limited the degree of resection were a multilobular configuration of the adenoma (p = 0.002) and extension to the middle fossa (p = 0.045). Cavernous sinus invasion, tumor size, and intraventricular or posterior fossa extension did not influence the surgical outcome. Complications included apoplexy of residual adenoma (3.7%), permanent diabetes insipidus (9.6%), new pituitary insufficiency (16.7%), and CSF leak (16.7%, which was reduced to 7.4% in recent years). Fourteen patients underwent radiation therapy after EES for residual mass or, in a later stage, for recurrence, and 10 with functional pituitary adenomas received medical treatment. During a mean follow-up of 37.9 months (range 1–114 months), 7 patients were reoperated on for tumor recurrence. Three patients were lost to follow-up.

Conclusions

Endoscopic endonasal surgery provides effective initial management of giant pituitary adenomas with favorable results compared with traditional microscopic transsphenoidal and transcranial approaches.

Abbreviations used in this paper:EES = endoscopic endonasal surgery; GH = growth hormone; GTR = gross-total resection.

Article Information

Address correspondence to: Paul A. Gardner, M.D., Department of Neurosurgery, UPMC Presbyterian, 200 Lothrop Street, Suite B400, Pittsburgh, Pennsylvania 15213. email: gardpa@upmc.edu.

Please include this information when citing this paper: published online January 4, 2013; DOI: 10.3171/2012.11.JNS121190.

© AANS, except where prohibited by US copyright law.

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Figures

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    Preoperative (A and B) and immediate postoperative (C and D) T1-weighted MR images obtained in a patient who underwent GTR of a rounded giant pituitary adenoma with cavernous sinus invasion. A and B: Coronal and sagittal images after contrast administration show a giant (45 mm), rounded, heterogeneous adenoma that invaded the right cavernous sinus (arrow), extended into the sphenoid sinus, eroded the upper clivus, and elevated the floor of the third ventricle. C and D: Coronal and sagittal images obtained after contrast administration demonstrate complete resection of the tumor. The invaded cavernous sinus has been evacuated (C, arrow). The surgical defect was reconstructed with a vascularized nasoseptal flap (D, arrowheads) that was held in place with a Foley catheter balloon (D, arrow).

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    Preoperative (A) and postoperative (B and C) coronal T1-weighted MR images with contrast enhancement obtained in a patient who underwent near-total resection of a multilobular giant adenoma with extension to the temporal lobe. A: Image showing a giant adenoma (47 mm) with a lobular extension into the sylvian fissure, invasion of the right cavernous sinus, and expansion of the lateral wall of the cavernous sinus (arrowheads). The pituitary stalk (arrow) is compressed and the normal pituitary gland is displaced to the left, toward the medial wall of the left cavernous sinus, which is intact. B: Immediate postoperative image demonstrates evacuation of the right cavernous sinus with residual tumor at the lateral wall of the sinus and in the sylvian fissure (arrowheads). The pituitary stalk and normal gland are better visualized. C: Image obtained 1 year after EES. The residual tumor has collapsed and minimized (arrowheads) without any adjuvant treatment. The pituitary stalk and normal gland (arrow) have descended into a more midline position.

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    Bar graph showing resection rates after EES according to the shape of the giant pituitary adenoma. The degree of GTR was gradually reduced as the tumor shape became more irregular. The GTR rate was 47% in rounded giant adenomas, 33% in dumbbell adenomas, and only 6% in multilobular tumors. Accordingly, partial resection increases in more demanding tumor shapes.

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    Preoperative (left) and postoperative (right) sagittal T1-weighted MR images after contrast administration obtained in a patient who underwent near-total resection of a lobular adenoma with narrow communication between the tumor components. Left: Image showing a giant adenoma with the upper lobular part almost separated from the main mass of the adenoma. Right: Image obtained 3 years after EES illustrating a small residual tumor in front of the intact pituitary stalk that represents a remnant of the upper tumor lobe that descended to this location. The residual tumor remained stable in size over the years, so no attempt was made to remove it.

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    Preoperative (A and B) and postoperative (C and D) coronal and sagittal T1-weighted MR images after contrast administration, obtained in a patient who underwent near-total resection of a giant adenoma with intraventricular extension and a growth pattern that creates the corridor to the ventricular system. A and B: Images showing a lobular giant adenoma with extension into the third and right lateral ventricle (with obstruction and disfiguration of the lateral ventricle) and the prepontine cistern. The tumor's growth pattern forms a prefixed optic chiasm (arrow) that allows tumor resection without manipulation of the optic apparatus. C and D: Images obtained 24 months after EES demonstrate near-total resection of the tumor. Residual tumor is visualized at the anterior wall of the third ventricle, while the optic chiasm (arrows) is completely decompressed and the lateral ventricles have returned to a more normal shape.

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    Preoperative (left) and postoperative (right) coronal T1-weighted MR images after contrast administration, obtained in a patient who underwent GTR of a rounded, giant pituitary adenoma that eroded the entire clivus and extended to the posterior fossa. Left: Image demonstrating a giant (54 mm) adenoma (prolactinoma) that occupied the sphenoid sinus, eroded the clivus, and contacted the pons. Right: Image obtained 7 months after EES showing GTR of the tumor. The pons is decompressed and the pituitary stalk is well visualized, although the pituitary gland is difficult to distinguish from the enhancing vascularized nasoseptal flap (arrowheads).

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