Abstract
Endoscopy in combination with extended approaches allow for resection of large pituitary adenomas via a transsphenoidal route. The objective of the current study was to determine a volumetric threshold for lesions with high perioperative morbidity and high rate of subtotal resection following endonasal endoscopic surgery. Thus, we analyzed a prospectively collected database of 71 patients who underwent endoscopic transsphenoidal approaches for macroadenomas (diameter >1 cm). Extend of resection (EOR) was calculated based on volumetric analysis of pre-and post-operative contrast-enhanced MRI. Average EOR was 97.8% and a gross total resection (GTR) was achieved in 76.1% of all patients. GTR was accomplished in 92.0% versus 38.1% of adenomas either without or with CS invasion, respectively. Likewise, GTR was accomplished in 90.2% versus 40.0% of lesions less than or greater then 10 cm3 respectively. However, even if only subtotal resection was achieved, 90.3% of tumor volume was removed. At 17 months follow-up, visual field defects improved in 80.8% of patients. Complications included permanent diabetes insipidus (5 patients), panhypopituitarism (4 patients), injury to the ophthalmic artery (1 patient) and CSF leak (1 patient). On multivariate logistic regression, two factors negatively predicted GTR: invasion of the CS and volume greater than 10 cm3. A 10 cm3 threshold was a stronger predictor of EOR and complication risk than diameter-based measurements. A volume greater than 10 cm3 and CS invasion may help to identify pituitary lesions associated with a higher likelihood of subtotal resection and post-operative morbidity.
Similar content being viewed by others
References
Jefferson G (1940) Extrasellar extensions of pituitary adenomas: (Section of Neurology). Proc R Soc Med 33(7):433–458
Heimbach SB (1959) Follow-up studies on 105 cases of verified chromophobe and acidophile pituitary adenomata after treatment by transfrontal operation and x-ray irradiation. Acta Neurochir (Wien) 7(2):101–155
Bakay L (1950) The results of 300 pituitary adenoma operations (Prof. Herbert Olivecrona’s series). J Neurosurg 7(3):240–255. doi:10.3171/jns.1950.7.3.0240
Elkington SG, McKissock W (1967) Pituitary adenoma: results of combined surgical and radiotherapeutic treatment of 260 patients. Br Med J 1(5535):263–266
Symon L, Jakubowski J (1979) Transcranial management of pituitary tumours with suprasellar extension. J Neurol Neurosurg Psychiatry 42(2):123–133
Pia HW, Grote E, Hildebrandt G (1985) Giant pituitary adenomas. Neurosurg Rev 8(3–4):207–220
Dolenc VV (1997) Transcranial epidural approach to pituitary tumors extending beyond the sella. Neurosurgery 41(3):542–550; discussion 551–542
Grote E (1982) Characteristics of giant pituitary adenomas. Acta Neurochir (Wien) 60(3–4):141–153
Mortini P, Barzaghi R, Losa M, Boari N, Giovanelli M (2007) Surgical treatment of giant pituitary adenomas: strategies and results in a series of 95 consecutive patients. Neurosurgery 60(6):993–1002; discussion 1003–1004. doi:10.1227/01.NEU.0000255459.14764.BA
Guidetti B, Fraioli B, Cantore GP (1987) Results of surgical management of 319 pituitary adenomas. Acta Neurochir (Wien) 85(3–4):117–124
Guiot G, Thibaut B (1959) Excision of pituitary adenomas by trans-sphenoidal route. Neurochirurgia (Stuttg) 1(2):133–150. doi:10.1055/s-0028-1095527
Hardy J (1969) Transphenoidal microsurgery of the normal and pathological pituitary. Clin Neurosurg 16:185–217
Hardy J (1971) Transsphenoidal hypophysectomy. J Neurosurg 34(4):582–594. doi:10.3171/jns.1971.34.4.0582
Garibi J, Pomposo I, Villar G, Gaztambide S (2002) Giant pituitary adenomas: clinical characteristics and surgical results. Br J Neurosurg 16(2):133–139
Mohr G, Hardy J, Comtois R, Beauregard H (1990) Surgical management of giant pituitary adenomas. Can J Neurol Sci 17(1):62–66
Zhang X, Fei Z, Zhang J, Fu L, Z, Liu W, Chen Y (1999) Management of nonfunctioning pituitary adenomas with suprasellar extensions by transsphenoidal microsurgery. Surg Neurol 52(4):380–385
de Paiva Neto MA, Vandergrift A, Fatemi N, Gorgulho AA, Desalles AA, Cohan P, Wang C, Swerdloff R, Kelly DF (2010) Endonasal transsphenoidal surgery and multimodality treatment for giant pituitary adenomas. Clin Endocrinol (Oxf) 72(4):512–519. doi:10.1111/j.1365-2265.2009.03665.x
Ciric IS, Cozzens JW (1980) Craniopharyngiomas: transsphenoidal method of approach–for the virtuoso only? Clin Neurosurg 27:169–187
Guiot J, Rougerie J, Fourestier M, Fournier A, Comoy C, Vulmiere J, Groux R (1963) Intracranial endoscopic explorations. Presse Med 71:1225–1228
Cappabianca P, Alfieri A, de Divitiis E (1998) Endoscopic endonasal transsphenoidal approach to the sella: towards functional endoscopic pituitary surgery (FEPS). Minim Invasive Neurosurg 41(2):66–73. doi:10.1055/s-2008-1052019
Carrau RL, Jho HD, Ko Y (1996) Transnasal-transsphenoidal endoscopic surgery of the pituitary gland. Laryngoscope 106(7):914–918
Cooke RS, Jones RA (1994) Experience with the direct transnasal transsphenoidal approach to the pituitary fossa. Br J Neurosurg 8(2):193–196
Frank G, Sciarretta V, Mazzatenta D, Farneti G, Modugno GC, Pasquini E (2005) Transsphenoidal endoscopic approach in the treatment of Rathke’s cleft cyst. Neurosurgery 56(1):124–128; discussion 129
Gamea A, Fathi M, el-Guindy A (1994) The use of the rigid endoscope in trans-sphenoidal pituitary surgery. J Laryngol Otol 108(1):19–22
Heilman CB, Shucart WA, Rebeiz EE (1997) Endoscopic sphenoidotomy approach to the sella. Neurosurgery 41(3):602–607
Jankowski R, Auque J, Simon C, Marchal JC, Hepner H, Wayoff M (1992) Endoscopic pituitary tumor surgery. Laryngoscope 102(2):198–202. doi:10.1288/00005537-199202000-00016
Jho HD, Carrau RL (1997) Endoscopic endonasal transsphenoidal surgery: experience with 50 patients. J Neurosurg 87(1):44–51. doi:10.3171/jns.1997.87.1.0044
Jho HD, Ha HG (2004) Endoscopic endonasal skull base surgery: part 1—the midline anterior fossa skull base. Minim Invasive Neurosurg 47(1):1–8. doi:10.1055/s-2003-812538
Rodziewicz GS, Kelley RT, Kellman RM, Smith MV (1996) Transnasal endoscopic surgery of the pituitary gland: technical note. Neurosurgery 39(1):189–192; discussion 192–183
Shikani AH, Kelly JH (1993) Endoscopic debulking of a pituitary tumor. Am J Otolaryngol 14(4):254–256
Wurster CF, Smith DE (1994) The endoscopic approach to the pituitary gland. Arch Otolaryngol Head Neck Surg 120(6):674
Weiss MH (1987) The transnasal transsphenoidal approach. In: Apuzzo MLJ (ed) Surgery of the third ventricle. Williams & Wilkins, Baltimore, pp 476–494
Griffith HB, Veerapen R (1987) A direct transnasal approach to the sphenoid sinus. Technical note. J Neurosurg 66(1):140–142. doi:10.3171/jns.1987.66.1.0140
Kitano M, Taneda M (2001) Extended transsphenoidal approach with submucosal posterior ethmoidectomy for parasellar tumors. Technical note. J Neurosurg 94(6):999–1004. doi:10.3171/jns.2001.94.6.0999
Kitano M, Taneda M, Shimono T, Nakao Y (2008) Extended transsphenoidal approach for surgical management of pituitary adenomas invading the cavernous sinus. J Neurosurg 108(1):26–36. doi:10.3171/JNS/2008/108/01/0026
Couldwell WT, Weiss MH, Rabb C, Liu JK, Apfelbaum RI, Fukushima T (2004) 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(3):539–547; discussion 547–550
Kaptain GJ, Vincent DA, Sheehan JP, Laws ER Jr (2001) Transsphenoidal approaches for the extracapsular resection of midline suprasellar and anterior cranial base lesions. Neurosurgery 49(1):94–100; discussion 100–101
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(5):832–841. doi:10.3171/jns.2005.102.5.0832
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(5):436–445; discussion 445–436. doi:10.1016/j.surneu.2003.08.036
Laufer I, Anand VK, Schwartz TH (2007) Endoscopic, endonasal extended transsphenoidal, transplanum transtuberculum approach for resection of suprasellar lesions. J Neurosurg 106(3):400–406. doi:10.3171/jns.2007.106.3.400
Cappabianca P, Frank G, Pasquini E, De Diviitis E, Calbucci F (2003) Extended endoscopic endonasal transsphenoidal approaches to the suprasellar region, planum sphenoidla and clivus. Endoscopic endonasal transsphenoidal surgery. Springer/Wien, New York
Cavallo LM, Messina A, Cappabianca P, Esposito F, de Divitiis E, Gardner P, Tschabitscher M (2005) Endoscopic endonasal surgery of the midline skull base: anatomical study and clinical considerations. Neurosurg Focus 19(1):E2
de Divitiis E, Cappabianca P, Cavallo LM (2002) Endoscopic transsphenoidal approach: adaptability of the procedure to different sellar lesions. Neurosurgery 51(3):699–705; discussion 705–697
Kassam A, Snyderman CH, Mintz A, Gardner P, Carrau RL (2005) Expanded endonasal approach: the rostrocaudal axis. Part I. Crista galli to the sella turcica. Neurosurg Focus 19(1):E3
Kassam A, Snyderman CH, Mintz A, Gardner P, Carrau RL (2005) Expanded endonasal approach: the rostrocaudal axis. Part II. Posterior clinoids to the foramen magnum. Neurosurg Focus 19(1):E4
Schwartz TH, Anand VK (2007) The endoscopic endonasal transsphenoidal approach to the suprasellar cistern. Clin Neurosurg 54:226–235
Frank G, Pasquini E (2006) Endoscopic endonasal cavernous sinus surgery, with special reference to pituitary adenomas. Front Horm Res 34:64–82. doi:10.1159/000091573
Alahmadi H, Vachhrajani S, Cusimano MD (2010) The natural history of brain contusion: an analysis of radiological and clinical progression. J Neurosurg 112(5):1139–1145. doi:10.3171/2009.5.JNS081369
Kothari RU, Brott T, Broderick JP, Barsan WG, Sauerbeck LR, Zuccarello M, Khoury J (1996) The ABCs of measuring intracerebral hemorrhage volumes. Stroke 27(8):1304–1305
Wapnir IL, Wartenberg DE, Greco RS (1996) Three dimensional staging of breast cancer. Breast Cancer Res Treat 41(1):15–19
Cottier JP, Destrieux C, Brunereau L, Bertrand P, Moreau L, Jan M, Herbreteau D (2000) Cavernous sinus invasion by pituitary adenoma: MR imaging. Radiology 215(2):463–469
Knosp E, Steiner E, Kitz K, Matula C (1993) Pituitary adenomas with invasion of the cavernous sinus space: a magnetic resonance imaging classification compared with surgical findings. Neurosurgery 33(4):610–617; discussion 617–618
Giustina A, Chanson P, Bronstein MD, Klibanski A, Lamberts S, Casanueva FF, Trainer P, Ghigo E, Ho K, Melmed S (2010) A consensus on criteria for cure of acromegaly. J Clin Endocrinol Metab 95(7):3141–3148. doi:10.1210/jc.2009-2670
Losa M, Mortini P, Barzaghi R, Gioia L, Giovanelli M (2002) Surgical treatment of prolactin-secreting pituitary adenomas: early results and long-term outcome. J Clin Endocrinol Metab 87(7):3180–3186
Biller BM, Grossman AB, Stewart PM, Melmed S, Bertagna X, Bertherat J, Buchfelder M, Colao A, Hermus AR, Hofland LJ, Klibanski A, Lacroix A, Lindsay JR, Newell-Price J, Nieman LK, Petersenn S, Sonino N, Stalla GK, Swearingen B, Vance ML, Wass JA, Boscaro M (2008) Treatment of adrenocorticotropin-dependent Cushing’s syndrome: a consensus statement. J Clin Endocrinol Metab 93(7):2454–2462. doi:10.1210/jc.2007-2734
Schwartz TH, Fraser JF, Brown S, Tabaee A, Kacker A, Anand VK (2008) Endoscopic cranial base surgery: classification of operative approaches. Neurosurgery 62(5):991–1002; discussion 1002–1005. doi:10.1227/01.neu.0000325861.06832.06
Placantonakis DG, Tabaee A, Anand VK, Hiltzik D, Schwartz TH (2007) Safety of low-dose intrathecal fluorescein in endoscopic cranial base surgery. Neurosurgery 61(3 Suppl):161–165; discussion 165–166. doi:10.1227/01.neu.0000289729.20083.dc
Symon L, Jakubowski J, Kendall B (1979) Surgical treatment of giant pituitary adenomas. J Neurol Neurosurg Psychiatry 42(11):973–982
Zada G, Du R, Laws ER (2010) Defining the “edge of the envelope”: patient selection in treating complex sellar-based neoplasms via transsphenoidal versus open craniotomy. J Neurosurg 114(2):286–300. doi:10.3171/2010.8.JNS10520
Hardy J, Vezina JL (1976) Transsphenoidal neurosurgery of intracranial neoplasm. Adv Neurol 15:261–273
Wilson CB (1984) A decade of pituitary microsurgery. The Herbert Olivecrona lecture. J Neurosurg 61(5):814–833. doi:10.3171/jns.1984.61.5.0814
Honegger J, Ernemann U, Psaras T, Will B (2007) Objective criteria for successful transsphenoidal removal of suprasellar nonfunctioning pituitary adenomas. A prospective study. Acta Neurochir (Wien) 149(1):21–29; discussion 29. doi:10.1007/s00701-006-1044-6
Jain AK, Gupta AK, Pathak A, Bhansali A, Bapuraj JR (2008) Endonasal transsphenoidal pituitary surgery: is tumor volume a key factor in determining outcome? Am J Otolaryngol 29(1):48–50. doi:10.1016/j.amjoto.2007.01.006
Esposito F, Dusick JR, Fatemi N, Kelly DF (2007) Graded repair of cranial base defects and cerebrospinal fluid leaks in transsphenoidal surgery. Neurosurgery 60(4 Suppl 2):295–303; discussion 303–294. doi:10.1227/01.NEU.0000255354.64077.66
Leng LZ, Brown S, Anand VK, Schwartz TH (2008) “Gasket-seal” watertight closure in minimal-access endoscopic cranial base surgery. Neurosurgery 62(5 Suppl 2):ONSE342–ONSE343; discussion ONSE343. doi:10.1227/01.neu.0000326017.84315.1f
Henderson WR (1939) The pituitary adenomata. A follow-up study of the surgical results in 338 cases (Dr. Harvey Cushing`s series). Br J Surg 26:811–921
Hadad G, Bassagasteguy L, Carrau RL, Mataza JC, Kassam A, Snyderman CH, Mintz A (2006) A novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap. Laryngoscope 116(10):1882–1886. doi:10.1097/01.mlg.0000234933.37779.e4
Vezina JL, Maltais R (1973) The sella turcica in acromegaly. Radiological study. Neurochirurgie 19(2 Suppl 2):35–56
Dehdashti AR, de Tribolet N (2008) Frontobasal interhemispheric trans-lamina terminalis approach for suprasellar lesions. Neurosurgery 62(6 Suppl 3):1233–1239. doi:10.1227/01.neu.0000333789.90972.8f
Acknowledgments
We greatly appreciate Dr. Paul Christos assistance with the statistical analysis.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Hofstetter, C.P., Nanaszko, M.J., Mubita, L.L. et al. Volumetric classification of pituitary macroadenomas predicts outcome and morbidity following endoscopic endonasal transsphenoidal surgery. Pituitary 15, 450–463 (2012). https://doi.org/10.1007/s11102-011-0350-z
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11102-011-0350-z