Endoscopic endonasal surgery for giant pituitary adenomas: advantages and limitations

Clinical article

Restricted access

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

Contributor Notes

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.

© Copyright 1944-2019 American Association of Neurological Surgeons

Headings
References
  • 1

    Alleyne CH JrBarrow DLOyesiku NM: Combined transsphenoidal and pterional craniotomy approach to giant pituitary tumors. Surg Neurol 57:3803902002

    • Search Google Scholar
    • Export Citation
  • 2

    Buchfelder MKreutzer J: Transcranial surgery for pituitary adenomas. Pituitary 11:3753842008

  • 3

    Cappabianca PCavallo LMEsposito FDe Divitiis OMessina ADe Divitiis E: Extended endoscopic endonasal approach to the midline skull base: the evolving role of transsphenoidal surgery. Adv Tech Stand Neurosurg 33:1511992008

    • Search Google Scholar
    • Export Citation
  • 4

    Cardoso ERPeterson EW: Pituitary apoplexy: a review. Neurosurgery 14:3633731984

  • 5

    Cavallo LMPrevedello DMSolari DGardner PAEsposito FSnyderman CH: Extended endoscopic endonasal transsphenoidal approach for residual or recurrent craniopharyngiomas. Clinical article. J Neurosurg 111:5785892009

    • Search Google Scholar
    • Export Citation
  • 6

    de Divitiis ECavallo LMEsposito FStella LMessina A: Extended endoscopic transsphenoidal approach for tuberculum sellae meningiomas. Neurosurgery 62:6 Suppl 3119212012008

    • Search Google Scholar
    • Export Citation
  • 7

    de Paiva Neto MAVandergrift AFatemi NGorgulho AADesalles AACohan P: Endonasal transsphenoidal surgery and multimodality treatment for giant pituitary adenomas. Clin Endocrinol (Oxf) 72:5125192010

    • Search Google Scholar
    • Export Citation
  • 8

    Dehdashti ARGanna AWitterick IGentili F: Expanded endoscopic endonasal approach for anterior cranial base and suprasellar lesions: indications and limitations. Neurosurgery 64:6776892009

    • Search Google Scholar
    • Export Citation
  • 9

    Dolenc VV: Transcranial epidural approach to pituitary tumors extending beyond the sella. Neurosurgery 41:5425521997

  • 10

    Dusick JREsposito FKelly DFCohan PDeSalles ABecker DP: The extended direct endonasal transsphenoidal approach for nonadenomatous suprasellar tumors. J Neurosurg 102:8328412005

    • Search Google Scholar
    • Export Citation
  • 11

    Fahlbusch RBuchfelder M: Transsphenoidal surgery of parasellar pituitary adenomas. Acta Neurochir (Wien) 92:93991988

  • 12

    Fahlbusch RMarguth FOptic nerve compression by pituitary adenomas. Samii MJannetta PJ: The Cranial Nerves BerlinSpringer1981. 140147

    • Search Google Scholar
    • Export Citation
  • 13

    Fatemi NDusick JRde Paiva Neto MAKelly DF: The endonasal microscopic approach for pituitary adenomas and other parasellar tumors: a 10-year experience. Neurosurgery 63:4 Suppl 22442562008

    • Search Google Scholar
    • Export Citation
  • 14

    Fatemi NDusick JRMattozo CMcArthur DLCohan PBoscardin J: Pituitary hormonal loss and recovery after transsphenoidal adenoma removal. Neurosurgery 63:7097192008

    • Search Google Scholar
    • Export Citation
  • 15

    Gardner PAKassam ABThomas ASnyderman CHCarrau RLMintz AH: Endoscopic endonasal resection of anterior cranial base meningiomas. Neurosurgery 63:36542008

    • Search Google Scholar
    • Export Citation
  • 16

    Garibi JPomposo IVillar GGaztambide S: Giant pituitary adenomas: clinical characteristics and surgical results. Br J Neurosurg 16:1331392002

    • Search Google Scholar
    • Export Citation
  • 17

    Goel ADeogaonkar MDesai K: Fatal postoperative ‘pituitary apoplexy’: its cause and management. Br J Neurosurg 9:37401995

  • 18

    Goel ANadkarni TMuzumdar DDesai KPhalke USharma P: Giant pituitary tumors: a study based on surgical treatment of 118 cases. Surg Neurol 61:4364462004

    • Search Google Scholar
    • Export Citation
  • 19

    Kassam ASnyderman CHMintz AGardner PCarrau RL: Expanded endonasal approach: the rostrocaudal axis. Part I. Crista galli to the sella turcica. Neurosurg Focus 19:1E32005

    • Search Google Scholar
    • Export Citation
  • 20

    Kassam ASnyderman CHMintz AGardner PCarrau RL: Expanded endonasal approach: the rostrocaudal axis. Part II. Posterior clinoids to the foramen magnum. Neurosurg Focus 19:1E42005

    • Search Google Scholar
    • Export Citation
  • 21

    Kassam ABThomas ACarrau RLSnyderman CHVescan APrevedello D: Endoscopic reconstruction of the cranial base using a pedicled nasoseptal flap. Neurosurgery 63:1 Suppl 1ONS44ONS532008

    • Search Google Scholar
    • Export Citation
  • 22

    Knosp ESteiner EKitz KMatula C: Pituitary adenomas with invasion of the cavernous sinus space: a magnetic resonance imaging classification compared with surgical findings. Neurosurgery 33:6106181993

    • Search Google Scholar
    • Export Citation
  • 23

    Kurwale NSAhmad FSuri AKale SSSharma BSMahapatra AK: Post operative pituitary apoplexy: preoperative considerations toward preventing nightmare. Br J Neurosurg 26:59632012

    • Search Google Scholar
    • Export Citation
  • 24

    Losa MMortini PBarzaghi RRibotto PTerreni MRMarzoli SB: Early results of surgery in patients with nonfunctioning pituitary adenoma and analysis of the risk of tumor recurrence. J Neurosurg 108:5255322008

    • Search Google Scholar
    • Export Citation
  • 25

    Mohr GHardy JComtois RBeauregard H: Surgical management of giant pituitary adenomas. Can J Neurol Sci 17:62661990

  • 27

    Mortini PBarzaghi RLosa MBoari NGiovanelli M: Surgical treatment of giant pituitary adenomas: strategies and results in a series of 95 consecutive patients. Neurosurgery 60:99310042007

    • Search Google Scholar
    • Export Citation
  • 26

    Mortini PGiovanelli M: Transcranial approaches to pituitary tumors. Op Tech Neurosurg 5:2392512002

  • 28

    Nelson AT JrTucker HS JrBecker DP: Residual anterior pituitary function following transsphenoidal resection of pituitary macroadenomas. J Neurosurg 61:5775801984

    • Search Google Scholar
    • Export Citation
  • 29

    Nomikos PLadar CFahlbusch RBuchfelder M: Impact of primary surgery on pituitary function in patients with nonfunctioning pituitary adenomas—a study on 721 patients. Acta Neurochir (Wien) 146:27352004

    • Search Google Scholar
    • Export Citation
  • 30

    Stippler MGardner PASnyderman CHCarrau RLPrevedello DMKassam AB: Endoscopic endonasal approach for clival chordomas. Neurosurgery 64:2682782009

    • Search Google Scholar
    • Export Citation
  • 31

    Symon LJakubowski JKendall B: Surgical treatment of giant pituitary adenomas. J Neurol Neurosurg Psychiatry 42:9739821979

  • 32

    Tindall GTWoodard EJBarrow DLPituitary adenomas: general considerations. Apuzzo ML: Brain Surgery: Complication Avoidance and Management New YorkChurchill Livingstone1993. 269312

    • Search Google Scholar
    • Export Citation
  • 33

    Youssef ASAgazzi Svan Loveren HR: Transcranial surgery for pituitary adenomas. Neurosurgery 57:1 Suppl1681752005

  • 34

    Zanation AMCarrau RLSnyderman CHGermanwala AVGardner PAPrevedello DM: Nasoseptal flap reconstruction of high flow intraoperative cerebral spinal fluid leaks during endoscopic skull base surgery. Am J Rhinol Allergy 23:5185212009

    • Search Google Scholar
    • Export Citation
TrendMD
Cited By
Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 534 524 23
Full Text Views 412 269 8
PDF Downloads 300 182 9
EPUB Downloads 0 0 0
PubMed
Google Scholar