Endoscopic endonasal resection of ACTH secreting pituitary microadenoma; how I do it
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Transsphenoidal selective adenectomy is considered the treatment of choice in patients with Cushing’s disease given the possibility for high remission and low complication rates. The endoscopic endonasal surgical nuances for Cushing’s disease are not well illustrated in the neurosurgical technique and video collections.
We describe the technical nuances of microadenoma resection for two cases of Cushing’s disease, one in which the adenoma is visualized on imaging and one in which the pre-operative MRI is negative.
Transsphenoidal endoscopic selective adenectomy is a safe and effective surgery for patients with Cushing’s disease regardless of preoperative MRI findings.
KeywordsPituitary Microadenoma ACTH secreting Endoscopic Endonasal Surgical technique
1) Endonasal exposure should achieve complete hemostasis before exploration of the pituitary fossa.
2) Removal of a half of right-sided middle turbinate is helpful.
3) Bimanual binostril technique is essential to optimize the maneuverability of instruments and allow for microsurgical dissection.
4) The medial wall of the cavernous sinuses needs to be explored extra and intra-durally.
5) Dural opening should spare the pituitary capsule.
6) Cuts into the tumor pseudo-capsule start superior and medial to the tumor and are continued circumferentially.
7) If no tumor is identified at the surface, the horizontal cuts are made on the side of MR abnormality or the side of abnormal IPSS findings.
8) Patients should not receive steroids pre-operatively.
9) Immediate (24–48 h) hypocortisolemia is a good indicator of remission.
10) Long-term follow-up (clinical exam, basal cortisol level, and UFC) is necessary even with apparent remission after a successful surgical treatment.
Compliance with ethical standards
No funding was received for this research.
Conflict of interest
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.
Informed consent was obtained from all individual participants included in the study.
Patient 1: A 34-year-old female patient presented with clinical features typical for Cushing’s disease. Medical work-up revealed an elevated cortisol level (28 μg/dl) from a central source. MRI of the sella revealed a small hypointense microadenoma along the inferior and left surface of the pituitary gland (Fig. 2). An endoscopic resection of the micro adenoma was decided. Pathology specimen was confirmed to be an ACTH secreting adenoma and immediate post-operative MRI confirmed complete resection. (MP4 97970 kb)
Patient 2: A 64-year-old female patient presented with high blood pressure and multiple episodes of nausea and vomiting. Medical work-up revealed an elevated ACTH from a central source. MRI of the brain did not reveal a pituitary lesion (Fig. 3). Subsequent IPSS revealed a right-sided pituitary source of ACTH secretion with a very obvious gradient shifted to the right. A transsphenoidal endoscopic exploration on the right side of the pituitary gland was performed and adenoma identified. Pathology specimen was confirmed to be an ACTH secreting adenoma. (MP4 90288 kb)