Advertisement

Journal of Neuro-Oncology

, Volume 87, Issue 3, pp 317–325 | Cite as

Safety and efficacy of the direct endonasal transsphenoidal approach for challenging sellar tumors

  • Nader SanaiEmail author
  • Alfredo Quiñones-Hinojosa
  • Jared Narvid
  • Sandeep Kunwar
Clinical Study - patient Studies

Abstract

Introduction The direct endonasal approach to pituitary microadenomas is relatively atraumatic, rapid, and carries a lower complication rate than the sublabial approach. Large macroadenomas (3–4 cm) can still be addressed with this simple, unmodified direct endonasal approach. We present our experience with this unique and challenging patient population. Methods About 64 consecutive patients with large (3–4 cm) pituitary adenomas and craniopharyngiomas were treated by the senior author (SK) using the direct endonasal approach from May 2001 to July 2004. The hospital course, endocrinological function, radiographic imaging, and outpatient follow-up were retrospectively reviewed for each patient. Results The mean volume of these lesions was 31.5 cm3 (range, 10.3–168 cm3). Tumor pathologies included 2 craniopharyngiomas, 16 functional, and 46 nonfunctional pituitary adenomas. Suprasellar extension of tumor was evident in all patients and 10 had cavernous sinus invasion. Gross total resection was achieved in 30 patients, near-gross total in 6 patients, and subtotal resection in 26 patients. Eight patients (12.5%) demonstrated postoperative complications, with diabetes insipidus for less than 1 year (n = 4) being the most common. There was no incidence of CSF leak, new panhypopituitarism, or worsened vision. Five patients (7.8%) had tumor residual requiring radiation therapy. Additionally, after a mean clinical follow-up of 24.5 months, 4 patients (6.3%) demonstrated recurrent disease. Conclusions Direct endonasal transsphenoidal surgery enables safe and effective resection of large sellar masses while maintaining a favorable morbidity profile.

Keywords

Pituitary adenoma Transsphenoidal Endonasal Endoscopic Extended 

References

  1. 1.
    Wilson CB (1997) Surgical management of pituitary tumors. J Clin Endocrinol Metab 82:2381–2385PubMedCrossRefGoogle Scholar
  2. 2.
    Ebersold MJ, Quast LM, Laws ER Jr, Scheithauer B, Randall RV (1986) Long-term results in transsphenoidal removal of nonfunctioning pituitary adenomas. J Neurosurg 64:713–719PubMedGoogle Scholar
  3. 3.
    Honegger J, Fahlbusch R, Buchfelder M, Huk WJ, Thierauf P (1993) The role of transsphenoidal microsurgery in the management of sellar and parasellar meningioma. Surg Neurol 39:18–24PubMedCrossRefGoogle Scholar
  4. 4.
    Jane JA Jr, Thapar K, Kaptain GJ, Maartens N, Laws ER Jr (2002) Pituitary surgery: transsphenoidal approach. Neurosurgery 51:435–442; discussion 442–434PubMedCrossRefGoogle Scholar
  5. 5.
    Griffith HB, Veerapen R (1987) A direct transnasal approach to the sphenoid sinus. Technical note. J Neurosurg 66:140–142PubMedGoogle Scholar
  6. 6.
    Zada G, Kelly DF, Cohan P, Wang C, Swerdloff R (2003) Endonasal transsphenoidal approach for pituitary adenomas and other sellar lesions: an assessment of efficacy, safety, and patient impressions. J Neurosurg 98:350–358PubMedGoogle Scholar
  7. 7.
    Liu JK, Das K, Weiss MH, Laws ER Jr, Couldwell WT (2001) The history and evolution of transsphenoidal surgery. J Neurosurg 95:1083–1096PubMedGoogle Scholar
  8. 8.
    Spencer WR, Levine JM, Couldwell WT, Brown-Wagner M, Moscatello A (2000) Approaches to the sellar and parasellar region: a retrospective comparison of the endonasal-transsphenoidal and sublabial-transsphenoidal approaches. Otolaryngol Head Neck Surg 122:367–369PubMedCrossRefGoogle Scholar
  9. 9.
    Sheehan MT, Atkinson JL, Kasperbauer JL, Erickson BJ, Nippoldt TB (1999) Preliminary comparison of the endoscopic transnasal vs the sublabial transseptal approach for clinically nonfunctioning pituitary macroadenomas. Mayo Clin Proc 74:661–670PubMedGoogle Scholar
  10. 10.
    Das K, Spencer W, Nwagwu CI, Schaeffer S, Wenk E, Weiss MH, Couldwell WT (2001) Approaches to the sellar and parasellar region: anatomic comparison of endonasal-transsphenoidal, sublabial-transsphenoidal, and transethmoidal approaches. Neurol Res 23:51–54PubMedCrossRefGoogle Scholar
  11. 11.
    Fahlbusch R, Schott W (2002) Pterional surgery of meningiomas of the tuberculum sellae and planum sphenoidale: surgical results with special consideration of ophthalmological and endocrinological outcomes. J Neurosurg 96:235–243PubMedCrossRefGoogle Scholar
  12. 12.
    Goel A, Nadkarni T, Muzumdar D, Desai K, Phalke U, Sharma P (2004) Giant pituitary tumors: a study based on surgical treatment of 118 cases. Surg Neurol 61:436–445; discussion 445–436PubMedCrossRefGoogle Scholar
  13. 13.
    Alleyne CH Jr, Barrow DL, Oyesiku NM (2002) Combined transsphenoidal and pterional craniotomy approach to giant pituitary tumors. Surg Neurol 57:380–390; discussion 390PubMedCrossRefGoogle Scholar
  14. 14.
    Weiss MH (1987) Transnasal transsphenoidal approach. In: Apuzzo MLJ (ed) Surgery of the third ventricle. Williams & Wilkens, Baltimore, pp 476–494Google Scholar
  15. 15.
    Agrawal A, Cincu R, Goel A (2007) Current concepts and controversies in the management of non-functioning giant pituitary macroadenomas. Clin Neurol Neurosurg 109(8):645–650PubMedCrossRefGoogle Scholar
  16. 16.
    Dusick JR, Esposito F, Kelly DF, Cohan P, DeSalles A, Becker DP, Martin NA (2005) The extended direct endonasal transsphenoidal approach for nonadenomatous suprasellar tumors. J Neurosurg 102:832–841PubMedGoogle Scholar
  17. 17.
    Nimsky C, von Keller B, Ganslandt O, Fahlbusch R (2006) Intraoperative high-field magnetic resonance imaging in transsphenoidal surgery of hormonally inactive pituitary macroadenomas. Neurosurgery 59:105–114; discussion 105–114PubMedCrossRefGoogle Scholar
  18. 18.
    Schwartz TH, Stieg PE, Anand VK (2006) Endoscopic transsphenoidal pituitary surgery with intraoperative magnetic resonance imaging. Neurosurgery 58:S44–S51; discussion ONS44–S51CrossRefGoogle Scholar
  19. 19.
    Dusick JR, Esposito F, Malkasian D, Kelly DF (2007) Avoidance of carotid artery injuries in transsphenoidal surgery with the Doppler probe and micro-hook blades. Neurosurgery 60:322–328; discussion 328–329PubMedCrossRefGoogle Scholar
  20. 20.
    Ram Z, Bruck B, Hadani M (1999) Ultrasound in pituitary tumor surgery. Pituitary 2:133–138PubMedCrossRefGoogle Scholar
  21. 21.
    Yamasaki T, Moritake K, Nagai H, Kimura Y (2002) Integration of ultrasonography and endoscopy into transsphenoidal surgery with a “picture-in-picture” viewing system–technical note. Neurol Med Chir (Tokyo) 42:275–277; discussion 278CrossRefGoogle Scholar
  22. 22.
    Wilson CB (1979) Neurosurgical management of large and invasive pituitary tumors. In: Tindall GT, Collins, WF (ed) Clinical managment of pituitary disorders. Raven Press, New York, pp 335–342Google Scholar
  23. 23.
    Barrow DL, Tindall GT (1990) Loss of vision after transsphenoidal surgery. Neurosurgery 27:60–68PubMedCrossRefGoogle Scholar
  24. 24.
    Cohen AR, Cooper PR, Kupersmith MJ, Flamm ES, Ransohoff J (1985) Visual recovery after transsphenoidal removal of pituitary adenomas. Neurosurgery 17:446–452PubMedCrossRefGoogle Scholar
  25. 25.
    Marazuela M, Astigarraga B, Vicente A, Estrada J, Cuerda C, Garcia-Uria J, Lucas T (1994) Recovery of visual and endocrine function following transsphenoidal surgery of large nonfunctioning pituitary adenomas. J Endocrinol Invest 17:703–707PubMedGoogle Scholar
  26. 26.
    Zhang X, Li A, Yi S, Zhang Z, Fei Z, Zhang J, Fu L, Liu W, Chen Y (1998) Transsphenoidal microsurgical removal of large pituitary adenomas. Chin Med J (Engl) 111:963–967Google Scholar
  27. 27.
    Kim J, Cheong J, Yi H, Bak K, Kim C, Lee S (2002) Usefulness of silicone plate for sellar floor reconstruction. Minim Invasive Neurosurg 45:124–127PubMedCrossRefGoogle Scholar
  28. 28.
    Kitano M, Taneda M (2004) Subdural patch graft technique for watertight closure of large dural defects in extended transsphenoidal surgery. Neurosurgery 54:653–660; discussion 660–651PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC. 2007

Authors and Affiliations

  • Nader Sanai
    • 1
    Email author
  • Alfredo Quiñones-Hinojosa
    • 2
  • Jared Narvid
    • 1
  • Sandeep Kunwar
    • 1
  1. 1.Department of Neurological SurgeryUniversity of California at San FranciscoSan FranciscoUSA
  2. 2.Department of Neurological SurgeryThe Johns Hopkins Hospital, Brain Tumor Surgery Program & Pituitary CenterBaltimoreUSA

Personalised recommendations