Defining the “edge of the envelope”: patient selection in treating complex sellar-based neoplasms via transsphenoidal versus open craniotomy

Clinical article

Gabriel Zada M.D., Rose Du M.D., Ph.D., and Edward R. Laws Jr. M.D.
View More View Less
  • Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
Restricted access

Purchase Now

USD  $45.00

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $505.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00
Print or Print + Online

Object

Endonasal approaches have become the gold standard intervention for many anterior and middle skull base tumors. The authors aimed to define some of the existing limitations of these approaches by reviewing their experience with complex sellar region tumors that were initially considered for both transsphenoidal and open skull base approaches and were thus deemed tumors at “the edge of the envelope.”

Methods

Between April 2008 and April 2010, 250 transsphenoidal operations were performed at Brigham and Women's Hospital. All cases were retrospectively reviewed to identify patients with complex sellar region tumors that were initially considered for, or soon thereafter required, an open craniotomy as the definitive treatment. The anatomical tumor characteristics that posed limitations to performing safe and effective endonasal skull base operations were reviewed.

Results

Thirteen cases exemplifying some of the existing limitations to achieving optimal surgical outcomes via transsphenoidal-based approaches are presented. The following 8 factors are separately discussed that repeatedly limited the extent of resection, increased the risk of the operation, and contributed to perioperative complications: significant suprasellar extension, lateral extension, retrosellar extension, brain invasion with edema, firm tumor consistency, involvement or vasospasm of the arteries of the circle of Willis, and encasement of the optic apparatus or invasion of the optic foramina.

Conclusions

Although the ability to approach and resect complex tumors using endonasal skull base techniques has evolved dramatically in recent years, several inherent tumor characteristics mandate extensive preoperative consideration. In selected cases these characteristics may lend support to selecting an open craniotomy as the initial operation.

Abbreviations used in this paper: ACA = anterior cerebral artery; DI = diabetes insipidus; EBRT = external-beam radiation therapy; FSH = follicle-stimulating hormone; GTR = gross-total resection; ICA = internal carotid artery; PBRT = proton-beam radiation therapy; PCA = posterior cerebral artery; PCoA = posterior communicating artery; SAH = subarachnoid hemorrhage; STR = subtotal resection; VP = ventriculoperitoneal.

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $505.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00

Contributor Notes

Address correspondence to: Gabriel Zada, M.D., Department of Neurosurgery, Brigham and Women's Hospital, 15 Francis Street, PBB3, Boston, Massachusetts 02115. email: gzada@usc.edu.

Please include this information when citing this paper: published online September 3, 2010; DOI: 10.3171/2010.8.JNS10520.

  • 1

    Alleyne CH Jr, , Barrow DL, & Oyesiku NM: Combined transsphenoidal and pterional craniotomy approach to giant pituitary tumors. Surg Neurol 57:380390, 2002

    • Search Google Scholar
    • Export Citation
  • 2

    Almefty K, , Pravdenkova S, , Colli BO, , Al-Mefty O, & Gokden M: Chordoma and chondrosarcoma: similar, but quite different, skull base tumors. Cancer 110:24572467, 2007

    • Search Google Scholar
    • Export Citation
  • 3

    al-Mefty O, & Borba LA: Skull base chordomas: a management challenge. J Neurosurg 86:182189, 1997

  • 4

    Bahuleyan B, , Raghuram L, , Rajshekhar V, & Chacko AG: To assess the ability of MRI to predict consistency of pituitary macroadenomas. Br J Neurosurg 20:324326, 2006

    • Search Google Scholar
    • Export Citation
  • 5

    Barrow DL, & Tindall GT: Loss of vision after transsphenoidal surgery. Neurosurgery 27:6068, 1990

  • 6

    Black PM, , Zervas NT, & Candia G: Management of large pituitary adenomas by transsphenoidal surgery. Surg Neurol 29:443447, 1988

  • 7

    Camp PE, , Paxton HD, , Buchan GC, & Gahbauer H: Vasospasm after trans-sphenoidal hypophysectomy. Neurosurgery 7:382386, 1980

  • 8

    Cappabianca P, , Alfieri A, & de Divitiis E: Endoscopic endonasal transsphenoidal approach to the sella: towards functional endoscopic pituitary surgery (FEPS). Minim Invasive Neurosurg 41:6673, 1998

    • Search Google Scholar
    • Export Citation
  • 9

    Cappabianca P, , Cavallo LM, , de Divitiis O, , Solari D, , Esposito F, & Colao A: Endoscopic pituitary surgery. Pituitary 11:385390, 2008

  • 10

    Cappabianca P, , Kelly DF, & Laws ER Jr: Endoscopic transnasal versus open transcranial cranial base surgery: the need for a serene assessment. Neurosurgery 63:Suppl 2 240243, 2008

    • Search Google Scholar
    • Export Citation
  • 11

    Carpeggiani P, , Crisi G, & Trevisan C: MRI of intracranial meningiomas: correlations with histology and physical consistency. Neuroradiology 35:532536, 1993

    • Search Google Scholar
    • Export Citation
  • 12

    Carrabba G, , Dehdashti AR, & Gentili F: Surgery for clival lesions: open resection versus the expanded endoscopic endonasal approach. Neurosurg Focus 25:6 E7, 2008

    • Search Google Scholar
    • Export Citation
  • 13

    Cavallo LM, , Prevedello DM, , Solari D, , Gardner PA, , Esposito F, & Snyderman CH, : Extended endoscopic endonasal transsphenoidal approach for residual or recurrent craniopharyngiomas. Clinical article. J Neurosurg 111:578589, 2009

    • Search Google Scholar
    • Export Citation
  • 14

    Chen TC, , Zee CS, , Miller CA, , Weiss MH, , Tang G, & Chin L, : Magnetic resonance imaging and pathological correlates of meningiomas. Neurosurgery 31:10151022, 1992

    • Search Google Scholar
    • Export Citation
  • 15

    Couldwell WT, , Kan P, , Liu JK, & Apfelbaum RI: Decompression of cavernous sinus meningioma for preservation and improvement of cranial nerve function. Technical note. J Neurosurg 105:148152, 2006

    • Search Google Scholar
    • Export Citation
  • 16

    Couldwell WT, , Weiss MH, , Rabb C, , Liu JK, , Apfelbaum RI, & Fukushima T: Variations on the standard transsphenoidal approach to the sellar region, with emphasis on the extended approaches and parasellar approaches: surgical experience in 105 cases. Neurosurgery 55:539550, 2004

    • Search Google Scholar
    • Export Citation
  • 17

    Cusimano MD, , Sekhar LN, , Sen CN, , Pomonis S, , Wright DC, & Biglan AW, : The results of surgery for benign tumors of the cavernous sinus. Neurosurgery 37:110, 1995

    • Search Google Scholar
    • Export Citation
  • 18

    D'Ambrosio AL, , Syed ON, , Grobelny BT, , Freda PU, , Wardlaw S, & Bruce JN: Simultaneous above and below approach to giant pituitary adenomas: surgical strategies and long-term followup. Pituitary 12:217225, 2009

    • Search Google Scholar
    • Export Citation
  • 19

    de Divitiis E, , Esposito F, , Cappabianca P, , Cavallo LM, & de Divitiis O: Tuberculum sellae meningiomas: high route or low route? A series of 51 consecutive cases. Neurosurgery 62:556563, 2008

    • Search Google Scholar
    • Export Citation
  • 20

    de Paiva Neto MA, , Vandergrift A, , Fatemi N, , Gorgulho AA, , Desalles AA, & Cohan P, : Endonasal transsphenoidal surgery and multimodality treatment for giant pituitary adenomas. Clin Endocrinol (Oxf) 72:512519, 2010

    • Search Google Scholar
    • Export Citation
  • 21

    Decker RE, & Chalif DJ: Progressive coma after the transsphenoidal decompression of a pituitary adenoma with marked suprasellar extension: report of two cases. Neurosurgery 28:154158, 1991

    • Search Google Scholar
    • Export Citation
  • 22

    Dehdashti AR, , Ganna A, , Witterick I, & Gentili F: Expanded endoscopic endonasal approach for anterior cranial base and suprasellar lesions: indications and limitations. Neurosurgery 64:677689, 2009

    • Search Google Scholar
    • Export Citation
  • 23

    Fahlbusch R, & Schott W: Pterional surgery of meningiomas of the tuberculum sellae and planum sphenoidale: surgical results with special consideration of ophthalmological and endocrinological outcomes. J Neurosurg 96:235243, 2002

    • Search Google Scholar
    • Export Citation
  • 24

    Gay E, , Sekhar LN, , Rubinstein E, , Wright DC, , Sen C, & Janecka IP, : Chordomas and chondrosarcomas of the cranial base: results and follow-up of 60 patients. Neurosurgery 36:887897, 1995

    • Search Google Scholar
    • Export Citation
  • 25

    Goel A, , Nadkarni T, , Muzumdar D, , Desai K, , Phalke U, & Sharma P: Giant pituitary tumors: a study based on surgical treatment of 118 cases. Surg Neurol 61:436446, 2004

    • Search Google Scholar
    • Export Citation
  • 26

    Goel A, , Shah A, , Jhawar SS, & Goel NK: Fluid-fluid level in pituitary tumors: analysis of management of 106 cases. Clinical article. J Neurosurg 112:13411346, 2010

    • Search Google Scholar
    • Export Citation
  • 27

    Greenfield JP, , Leng LZ, , Chaudhry U, , Brown S, , Anand VK, & Souweidane MM, : Combined simultaneous endoscopic transsphenoidal and endoscopic transventricular resection of a giant pituitary macroadenoma. Minim Invasive Neurosurg 51:306309, 2008

    • Search Google Scholar
    • Export Citation
  • 28

    Hardy J: Transsphenoidal hypophysectomy. J Neurosurg 34:582594, 1971

  • 29

    Hug EB, , Loredo LN, , Slater JD, , DeVries A, , Grove RI, & Schaefer RA, : Proton radiation therapy for chordomas and chondrosarcomas of the skull base. J Neurosurg 91:432439, 1999

    • Search Google Scholar
    • Export Citation
  • 30

    Iuchi T, , Saeki N, , Tanaka M, , Sunami K, & Yamaura A: MRI prediction of fibrous pituitary adenomas. Acta Neurochir (Wien) 140:779786, 1998

    • Search Google Scholar
    • Export Citation
  • 31

    Kaptain GJ, , Vincent DA, , Sheehan JP, & Laws ER Jr: Transsphenoidal approaches for the extracapsular resection of midline suprasellar and anterior cranial base lesions. Neurosurgery 49:94101, 2001

    • Search Google Scholar
    • Export Citation
  • 32

    Kashimura H, , Inoue T, , Ogasawara K, , Arai H, , Otawara Y, & Kanbara Y, : Prediction of meningioma consistency using fractional anisotropy value measured by magnetic resonance imaging. J Neurosurg 107:784787, 2007

    • Search Google Scholar
    • Export Citation
  • 33

    Kasliwal MK, , Srivastava R, , Sinha S, , Kale SS, & Sharma BS: Vasospasm after transsphenoidal pituitary surgery: a case report and review of the literature. Neurol India 56:8183, 2008

    • Search Google Scholar
    • Export Citation
  • 34

    Kassam AB, , Gardner P, , Snyderman C, , Mintz A, & Carrau R: Expanded endonasal approach: fully endoscopic, completely transnasal approach to the middle third of the clivus, petrous bone, middle cranial fossa, and infratemporal fossa. Neurosurg Focus 19:1 E6, 2005

    • Search Google Scholar
    • Export Citation
  • 35

    Kassam AB, , Prevedello DM, , Thomas A, , Gardner P, , Mintz A, & Snyderman C, : Endoscopic endonasal pituitary transposition for a transdorsum sellae approach to the interpeduncular cistern. Neurosurgery 62:Suppl 1 5774, 2008

    • Search Google Scholar
    • Export Citation
  • 36

    King WA, , Rodts GE, , Becker DP, & McBride DQ: Microsurgical management of giant pituitary tumors. Skull Base Surg 6:1726, 1996

  • 37

    Konovalov A, Some problems of cranipharyngiomas treatment. Broggi G: Craniopharyngioma Berlin, Springer, 1995. 8896

  • 38

    Kuo JS, , Chen JC, , Yu C, , Zelman V, , Giannotta SL, & Petrovich Z, : Gamma knife radiosurgery for benign cavernous sinus tumors: quantitative analysis of treatment outcomes. Neurosurgery 54:13851394, 2004

    • Search Google Scholar
    • Export Citation
  • 39

    Lanzino G, , Dumont AS, , Lopes MB, & Laws ER Jr: Skull base chordomas: overview of disease, management options, and outcome. Neurosurg Focus 10:3 E12, 2001

    • Search Google Scholar
    • Export Citation
  • 40

    Larson JJ, , van Loveren HR, , Balko MG, & Tew JM Jr: Evidence of meningioma infiltration into cranial nerves: clinical implications for cavernous sinus meningiomas. J Neurosurg 83:596599, 1995

    • Search Google Scholar
    • Export Citation
  • 41

    Laws ER Jr: Transsphenoidal surgery for tumors of the clivus. Otolaryngol Head Neck Surg 92:100101, 1984

  • 42

    Laws ER Jr, , Fode NC, & Redmond MJ: Transsphenoidal surgery following unsuccessful prior therapy. An assessment of benefits and risks in 158 patients. J Neurosurg 63:823829, 1985

    • Search Google Scholar
    • Export Citation
  • 43

    Liu JK, , Das K, , Weiss MH, , Laws ER Jr, & Couldwell WT: The history and evolution of transsphenoidal surgery. J Neurosurg 95:10831096, 2001

    • Search Google Scholar
    • Export Citation
  • 44

    Manduca A, , Oliphant TE, , Dresner MA, , Mahowald JL, , Kruse SA, & Amromin E, : Magnetic resonance elastography: non-invasive mapping of tissue elasticity. Med Image Anal 5:237254, 2001

    • Search Google Scholar
    • Export Citation
  • 45

    Mathiesen T, & Kihlström L: Visual outcome of tuberculum sellae meningiomas after extradural optic nerve decompression. Neurosurgery 59:570576, 2006

    • Search Google Scholar
    • Export Citation
  • 46

    Mawk JR: Vasospasm after pituitary surgery. J Neurosurg 58:972, 1983

  • 47

    Nishioka H, , Ito H, & Haraoka J: Cerebral vasospasm following transsphenoidal removal of a pituitary adenoma. Br J Neurosurg 15:4447, 2001

    • Search Google Scholar
    • Export Citation
  • 48

    Ojha BK, , Husain M, , Rastogi M, , Chandra A, , Chugh A, & Husain N: Combined trans-sphenoidal and simultaneous transventricular-endoscopic decompression of a giant pituitary adenoma: case report. Acta Neurochir (Wien) 151:843847, 2009

    • Search Google Scholar
    • Export Citation
  • 49

    O'Sullivan MG, , van Loveren HR, & Tew JM Jr: The surgical resectability of meningiomas of the cavernous sinus. Neurosurgery 40:238247, 1997

    • Search Google Scholar
    • Export Citation
  • 50

    Puget S, , Garnett M, , Wray A, , Grill J, , Habrand JL, & Bodaert N, : Pediatric craniopharyngiomas: classification and treatment according to the degree of hypothalamic involvement. J Neurosurg 106:1 Suppl 312, 2007

    • Search Google Scholar
    • Export Citation
  • 51

    Reisch R, & Perneczky A: Ten-year experience with the supraorbital subfrontal approach through an eyebrow skin incision. Neurosurgery 57:4 Suppl 242255, 2005

    • Search Google Scholar
    • Export Citation
  • 52

    Saito K, , Kuwayama A, , Yamamoto N, & Sugita K: The transsphenoidal removal of nonfunctioning pituitary adenomas with suprasellar extensions: the open sella method and intentionally staged operation. Neurosurgery 36:668676, 1995

    • Search Google Scholar
    • Export Citation
  • 53

    Schwartz TH, , Fraser JF, , Brown S, , Tabaee A, , Kacker A, & Anand VK: Endoscopic cranial base surgery: classification of operative approaches. Neurosurgery 62:9911005, 2008

    • Search Google Scholar
    • Export Citation
  • 54

    Sekhar LN, , Patel S, , Cusimano M, , Wright DC, , Sen CN, & Bank WO: Surgical treatment of meningiomas involving the cavernous sinus: evolving ideas based on a ten year experience. Acta Neurochir Suppl 65:5862, 1996

    • Search Google Scholar
    • Export Citation
  • 55

    Sen C, & Hague K: Meningiomas involving the cavernous sinus: histological factors affecting the degree of resection. J Neurosurg 87:535543, 1997

    • Search Google Scholar
    • Export Citation
  • 56

    Sheehan JP, , Kondziolka D, , Flickinger J, & Lunsford LD: Radiosurgery for residual or recurrent nonfunctioning pituitary adenoma. J Neurosurg 97:5 Suppl 408414, 2002

    • Search Google Scholar
    • Export Citation
  • 57

    Sindou M, , Wydh E, , Jouanneau E, , Nebbal M, & Lieutaud T: Long-term follow-up of meningiomas of the cavernous sinus after surgical treatment alone. J Neurosurg 107:937944, 2007

    • Search Google Scholar
    • Export Citation
  • 58

    Stippler M, , Gardner PA, , Snyderman CH, , Carrau RL, , Prevedello DM, & Kassam AB: Endoscopic endonasal approach for clival chordomas. Neurosurgery 64:268278, 2009

    • Search Google Scholar
    • Export Citation
  • 59

    Suzuki Y, , Sugimoto T, , Shibuya M, , Sugita K, & Patel SJ: Meningiomas: correlation between MRI characteristics and operative findings including consistency. Acta Neurochir (Wien) 129:3946, 1994

    • Search Google Scholar
    • Export Citation
  • 60

    Tikkakoski T: Magnetic resonance elastography of brain tumors. Acta Radiol 48:249, 2007

  • 61

    Xu L, , Lin Y, , Han JC, , Xi ZN, , Shen H, & Gao PY: Magnetic resonance elastography of brain tumors: preliminary results. Acta Radiol 48:327330, 2007

    • Search Google Scholar
    • Export Citation
  • 62

    Yamaguchi N, , Kawase T, , Sagoh M, , Ohira T, , Shiga H, & Toya S: Prediction of consistency of meningiomas with preoperative magnetic resonance imaging. Surg Neurol 48:579583, 1997

    • Search Google Scholar
    • Export Citation
  • 63

    Youssef AS, , Agazzi S, & van Loveren HR: Transcranial surgery for pituitary adenomas. Neurosurgery 57:1 Suppl 168175, 2005

  • 64

    Zada G, , Day JD, & Giannotta SL: The extradural temporopolar approach: a review of indications and operative technique. Neurosurg Focus 25:6 E3, 2008

    • Search Google Scholar
    • Export Citation
  • 65

    Zada G, , Kelly DF, , Cohan P, , Wang C, & Swerdloff R: Endonasal transsphenoidal approach for pituitary adenomas and other sellar lesions: an assessment of efficacy, safety, and patient impressions. J Neurosurg 98:350358, 2003

    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 574 213 23
Full Text Views 292 52 9
PDF Downloads 177 26 2
EPUB Downloads 0 0 0