Endoscopic endonasal transsphenoidal approach for pituitary adenomas invading the cavernous sinus

Clinical article

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Object

In this report, the authors describe their experience with surgical access to the cavernous sinus via a fully transnasal endoscopic approach in 20 cases. Clinical and endocrinological follow-up are discussed.

Methods

The authors used an endoscopic transsphenoidal approach in 192 patients with pituitary adenomas between September 1997 and January 2008, adding a cavernous sinus approach in 20 patients with invasive tumors during the last 5 years of this period. Parasellar extension of the tumor was measured according to the Knosp Scale. Radical tumor removal was achieved in 13 (65%) of 20 patients, and subtotal removal in 7 (35%). The authors used recently defined cavernous sinus approaches in the first 14 cases, including the paraseptal approach in 6, middle turbinectomy in 7, and contralateral middle turbinectomy in 1 case. Combined approaches rather than defined standard cavernous sinus approaches were used in 4 cases and an extended approach in 2.

Results

The tumors included nonsecretory adenomas in 5 cases (25%), growth hormone–secreting adenomas in 7 (35%), prolactin-secreting adenomas in 4 (20%), and adrenocorticotropic hormone–secreting adenomas in 4 cases (20%). Normal growth hormone and insulin-like growth factor 1 levels were achieved in 4 patients (57%) with growth hormone adenomas, and remission criteria were obtained in 3 patients with prolactinomas and 3 patients with adrenocorticotropic hormone–secreting adenomas.

Conclusions

Compared with transcranial and microscopic transsphenoidal surgery, endoscopic transsphenoidal surgery offers a wide exposure for cavernous sinus medial wall adenomas that enables removal of the adenoma from the medial cavernous sinus wall. Because of the necessity for multidisciplinary treatment to achieve satisfactory results, Gamma Knife surgery and medical therapy should be supplementary treatment options after endoscopic transsphenoidal surgery.

Abbreviations used in this paper: ACTH = adrenocorticotropic hormone; CN = cranial nerve; GH = growth hormone; GKS = Gamma Knife surgery; ICA = internal carotid artery.

Article Information

Address correspondence to: Savas Ceylan, M.D., Prof. Dr. Kocaeli University, School of Medicine, Department of Neurosurgery, Eski İstanbul Yolu 10.Km, Izmit, Kocaeli, Turkey. email: ssceylan@yahoo.com.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Case 12. Images obtained in a 25-year-old man with a GH-secreting adenoma. Paraseptal approach. Intraoperative photograph (A), and pre- (B) and postoperative (C) Gd-enhanced, T1-weighted MR images of the adenoma, which descends through the paraclival carotid artery vertical segment in ventral area and is defined as ventral type. Note the angled suction cannula, designed for suctioning in different directions in parasellar areas. PC = paraclival carotis; SF = sellar floor.

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    Case 2. Preoperative (A) and postoperative (B) coronal, Gd-enhanced, T1-weighted MR images obtained in a 42-year-old man with a prolactin-secreting adenoma. The paraseptal approach was used to remove the tumor (Knosp Grade 4) localized to cavernous sinus.

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    Illustrative drawing of the cavernous sinus approach with the resection of the middle turbinate and posterior ethmoid cells. Dotted lines indicate the removal of middle turbinate, posterior ethmoid cells, and opening of the sellar floor. EC = ethmoid cells; M = medial side of cavernous sinus; MT = middle turbinate; NS = nasal septum; PG = pituitary gland; V = ventral side of cavernous sinus.

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    Case 7. Images obtained in a 53-year-old man with a Knosp Grade 4 GH-secreting adenoma. Middle turbinate approach was used. Endoscopic view showing removal of the tumor localized in cavernous sinus using the medial corridor (A), and pre- (B) and postoperative (C) coronal, Gd-enhanced, T1-weighted MR images. HS = horizontal segment of the ICA; MC = medial corridor.

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    Case 3. Images obtained in an 11-year-old girl with a Knosp Grade 4 ACTH-secreting adenoma. The contralateral middle turbinate approach was used. Intraoperative view (A) showing removal of the tumor localized in cavernous sinus using lateral corridor (LC) and intraoperative images of the horizontal (HS), posterior bend (PB), and vertical segment (VS) of the ICA. Preoperative (B) and postoperative (C) coronal, Gd-enhanced, T1-weighted MR images.

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    Case 16. Images obtained in a 54-year-old man with nonsecretory adenoma; the middle turbinate approach was used. The lesion was an intrasuprasellar macroadenoma with parasellar extension into the cavernous sinus. Preoperative (A and B) and postoperative (C and D) coronal and sagittal, Gd-enhanced, T1-weighted MR images.

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    Case 16. A–C: Endoscopic intraoperative views of the extended approach for intrasuprasellar macroadenoma with parasellar extension into the cavernous sinus. C = carotid artery (paraclival segment); OC = optic chiasm; PSt = pituitary stalk; SC = suprasellar cistern, T = tumor.

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    Case 19. Endoscopic image obtained in a 65-year-old woman with a nonsecretory adenoma; a combined approach was used. Lesion grows into the cavernous sinus through fragile points in the cavernous sinus wall (*).

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    Case 10. Endoscopic image obtained in a 53-year-old woman with a GH-secreting adenoma; the paraseptal approach was used. Hemostasis was achieved with clip placement (*) necessitated by intercavernous sinus bleeding (InCS).

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    Case 5. Endoscopic image obtained in a 21-year-old woman with a nonsecretory adenoma in whom the paraseptal approach was used. Segments of the carotid artery and branches in the cavernous sinus can be observed with endoscopy. PB = posterior bend of the ICA.

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