Jose M. Pascual
Liangxue Zhou and Chao You
Paolo Cappabianca, Luigi M. Cavallo, Felice Esposito and Enrico De Divitiis
Paul A. Gardner, Daniel M. Prevedello, Amin B. Kassam, Carl H. Snyderman, Ricardo L. Carrau and Arlan H. Mintz
✓Craniopharyngiomas have always been an extremely challenging type of tumor to treat. The transsphenoidal route has been used for resection of these lesions since its introduction. The authors present a historical review of the literature from the introduction of the endonasal route for resection of craniopharyngiomas until the present. Abandoned early due to technological limitations, this approach has been expanded both in its application and in its anatomical boundaries with subsequent progressive improvements in outcomes. This expansion has coincided with advances in visualization devices, imaging guidance techniques, and anatomical understanding. The progression from the use of headlights, to microscopy, to endoscopy and fluoroscopy, and finally to modern intraoperative magnetic resonance–guided techniques, combined with collaboration between otolaryngologists and neurosurgeons, has provided the framework for the development of current techniques for the resection of sellar and suprasellar craniopharyngiomas.
Amin B. Kassam, Paul A. Gardner, Carl H. Snyderman, Ricardo L. Carrau, Arlan H. Mintz and Daniel M. Prevedello
Craniopharyngiomas are notoriously difficult to treat. Surgeons must weigh the risks of aggressive resection against the long-term challenges of recurrence. Because of their parasellar location, often extending well beyond the sella, these tumors challenge vision and pituitary and hypothalamic function. New techniques are needed to improve outcomes in patients with these tumors while decreasing treatment morbidity. An endoscopic expanded endonasal approach (EEA) is one such technique that warrants understanding and evaluation. The authors explain the techniques and approach used for the endoscopic endonasal resection of suprasellar craniopharyngiomas and introduce a tumor classification scheme.
The techniques and approach used for the endoscopic, endonasal resection of suprasellar craniopharyngiomas is explained, including the introduction of a tumor classification scheme. This scheme is helpful for understanding both the appropriate expanded approach as well as relevant involved anatomy.
The classification scheme divides tumors according to their suprasellar extension: Type I is preinfundibular; Type II is transinfundibular (extending into the stalk); Type III is retroinfundibular, extending behind the gland and stalk, and has 2 subdivisions (IIIa, extending into the third ventricle; and IIIb, extending into the interpeduncular cistern); and Type IV is isolated to the third ventricle and/or optic recess and is not accessible via an endonasal approach.
The endoscopic EEA requires a thorough understanding of both sinus and skull base anatomy. Moreover, in its application for craniopharyngiomas, an understanding of tumor growth and extension with respect to the optic chiasm and infundibulum is critical to safely approach the lesion via an endonasal route.
Luigi M. Cavallo, Daniel M. Prevedello, Domenico Solari, Paul A. Gardner, Felice Esposito, Carl H. Snyderman, Ricardo L. Carrau, Amin B. Kassam and Paolo Cappabianca
The management of recurrent or residual craniopharyngiomas remains controversial. Although possible, revision surgery is more challenging than primary surgery, and more often results in incomplete resection and an increased risk of death and complications. The extended (also called expanded) endoscopic endonasal transsphenoidal approach through the planum sphenoidale has been proposed over the past decade as an alternative surgical route for removal of various suprasellar tumors including craniopharyngiomas. In this study, the authors describe the feasibility and advantages of this technique in recurrent or symptomatic residual craniopharyngiomas.
Between January 2004 and June 2008, 22 patients underwent surgery via the extended endoscopic transsphenoidal approach for the treatment of recurrent or residual symptomatic craniopharyngiomas at either the University of Pittsburgh or the Universita degli Studi di Napoli. The lesions included 12 purely suprasellar craniopharyngiomas, 9 with both intra- and suprasellar extensions, and 1 arising from a remnant in the Meckel cave. To better evaluate the features of the extended endonasal approach for recurrent or residual craniopharyngiomas, each patient was assigned to 1 of 3 subgroups depending on the original surgical treatment: transcranial pterional route (13 patients), transphenoidal approach (3 patients; 2 microsurgically and 1 with the standard endoscopic technique), or extended endonasal endoscopic approach (6 patients).
Total removal was achieved in 9 patients (40.9%), and in 8 patients (36.4%) near-total removal (defined as > 95% removal) was possible. Subtotal removal (> 70%) was attained in 4 patients (18.2%), and tumor removal was partial (< 50%) in only 1 case (4.5%). There were no deaths or major complications, including behavior changes. Postoperative CSF leaks developed in 2 patients in the transcranial subgroup, and 1 in the transsphenoidal subgroup (overall rate 13.6%), requiring early successful endoscopic revision surgery for the cranial base defect.
Most of the advantages of the endoscopic endonasal technique were noted during tumor dissection from the inferior aspect of the chiasm, the infundibulum, the third ventricle, and/or the retro- and parasellar areas. These benefits were best appreciated in patients who had originally undergone transcranial surgery, since in such cases the authors' endoscopic endonasal approach was a virgin route. However, the extended endoscopic endonasal technique can also be safely used in patients who originally underwent transsphenoidal surgery. The endoscopic endonasal technique should be considered as a therapeutic option in selected cases of recurrent or symptomatic residual craniopharyngiomas.
Hilal A. Kanaan, Paul A. Gardner, Gabrielle Yeaney, Daniel M. Prevedello, Edward A. Monaco III, Geoffrey Murdoch, Ian F. Pollack and Amin B. Kassam
Olfactory schwannomas are rare tumors of the anterior skull base that are possibly derived from ectopic Schwann cells, perivascular neural tissue, or sensory nerves of the meninges. The authors report the case of a 14-year-old boy with an olfactory schwannoma that extended inferiorly through the cranial base and superiorly into the frontal lobe. Because of the growth characteristics of the tumor and the significant overlying frontal lobe edema, the lesion was approached via an endonasal endoscopic route, as a strategy to minimize brain retraction. This tumor was characterized radiographically as contrast-enhancing with cystic areas and erosion into bone. The tumor showed immunoreactivity for S100 protein and leukocyte antigen 7 (CD57) but not epithelial membrane antigen, supporting the diagnosis of olfactory schwannoma. A gross-total resection was achieved. This approach represents a novel application of endoscopic endonasal surgery to the pediatric neurosurgical context, as well as a favorable outcome in an extremely unusual tumor type, that should be applicable to other appropriately selected pediatric brain tumors.
Andrew S. Little, Paul A. Gardner, Juan C. Fernandez-Miranda, Michael R. Chicoine, Garni Barkhoudarian, Daniel M. Prevedello, Kevin C. J. Yuen, Daniel F. Kelly and for the TRANSSPHER Study Group
Recovery from preexisting hypopituitarism after transsphenoidal surgery for pituitary adenoma is an important outcome to investigate. Furthermore, pituitary function has not been thoroughly evaluated after fully endoscopic surgery, and benchmark outcomes have not been clearly established. Here, the authors characterize pituitary gland outcomes with a focus on gland recovery following endoscopic transsphenoidal removal of clinically nonfunctioning adenomas.
This multicenter prospective study was conducted at 6 US pituitary centers among adult patients with nonfunctioning pituitary macroadenomas who had undergone endoscopic endonasal pituitary surgery. Pituitary gland function was evaluated 6 months after surgery.
The 177 enrolled patients underwent fully endoscopic transsphenoidal surgery; 169 (95.5%) of them were available for follow-up. Ninety-five (56.2%) of the 169 patients had had a preoperative deficiency in at least one hormone axis, and 20/95 (21.1%) experienced recovery in at least one axis at the 6-month follow-up. Patients with adrenal insufficiency were more likely to recover (10/34 [29.4%]) than were those with hypothyroidism (8/72 [11.1%]) or male hypogonadism (5/50 [10.0%]). At the 6-month follow-up, 14/145 (9.7%) patients had developed at least one new deficiency. The study did not identify any predictors of gland recovery (p ≥ 0.20). Permanent diabetes insipidus was observed in 4/166 (2.4%) patients. Predictors of new gland dysfunction included a larger tumor size (p = 0.009) and Knosp grade 3 and 4 (p = 0.051).
Fully endoscopic pituitary surgery resulted in improvement of pituitary gland function in a substantial minority of patients. The deficiency from which patients were most likely to recover was adrenal insufficiency. Overall rates of postoperative permanent diabetes insipidus were low. This study provides multicenter benchmark neuroendocrine clinical outcome data for the endoscopic technique.
Andrew S. Little, Daniel F. Kelly, William L. White, Paul A. Gardner, Juan C. Fernandez-Miranda, Michael R. Chicoine, Garni Barkhoudarian, James P. Chandler, Daniel M. Prevedello, Brandon D. Liebelt, John Sfondouris, Marc R. Mayberg and for the TRANSSPHER Study Group
Many surgeons have adopted fully endoscopic over microscopic transsphenoidal surgery for nonfunctioning pituitary tumors, although no high-quality evidence demonstrates superior patient outcomes with endoscopic surgery. The goal of this analysis was to compare these techniques in a prospective multicenter controlled study.
Extent of tumor resection was compared after endoscopic or microscopic transsphenoidal surgery in adults with nonfunctioning adenomas. The primary end point was gross-total tumor resection determined by postoperative MRI. Secondary end points included volumetric extent of tumor resection, pituitary hormone outcomes, and standard quality measures.
Seven pituitary centers and 15 surgeons participated in the study. Of the 530 patients screened, 260 were enrolled (82 who underwent microscopic procedures, 177 who underwent endoscopic procedures, and 1 who cancelled surgery) between February 2015 and June 2017. Surgeons who used the microscopic technique were more experienced than the surgeons who used the endoscopic technique in terms of years in practice and number of transsphenoidal surgeries performed (p < 0.001). Gross-total resection was achieved in 80.0% (60/75) of microscopic surgery patients and 83.7% (139/166) of endoscopic surgery patients (p = 0.47, OR 0.8, 95% CI 0.4–1.6). Volumetric extent of resection, length of stay, surgery-related deaths, and unplanned readmission rates were similar between groups (p > 0.2). New hormone deficiency was present at 6 months in 28.4% (19/67) of the microscopic surgery patients and 9.7% (14/145) of the endoscopic surgery patients (p < 0.001, OR 3.7, 95% CI 1.7–7.7). Microscopic surgery cases were significantly shorter in duration than endoscopic surgery cases (p < 0.001).
Experienced surgeons who performed microscopic surgery and less experienced surgeons who performed endoscopic surgery achieved similar extents of tumor resection and quality outcomes in patients with nonfunctioning pituitary adenomas. The endoscopic technique may be associated with lower rates of postoperative pituitary gland dysfunction. This study generally supports the transition to endoscopic pituitary surgery when the procedure is performed by proficient surgeons, although both techniques yield overall acceptable surgical outcomes.
■ CLASSIFICATION OF EVIDENCE Type of question: therapeutic; study design: prospective cohort trial; evidence: class III.
Clinical trial registration no.: NCT02357498 (clinicaltrials.gov)