Skip to main content

Advertisement

SpringerLink
Log in

Extended transsphenoidal approach for pituitary adenomas invading the cavernous sinus using multiple complementary techniques

  • Published:
Pituitary Aims and scope Submit manuscript

Abstract

Purpose

Transsphenoidal surgery is the treatment of choice for most pituitary adenomas (PA), except prolactinomas. Difficulties achieving radical resection with this method are encountered in patients with PAs invading the cavernous sinus (CS), due to the inability of the standard transsphenoidal approach to expose all tumors adequately. This study analyzed methods to resect PAs invading the CS and factors influencing the degree of tumor resection and occurrence of complications.

Methods

Outcomes were retrospectively analyzed in 52 patients with PA invading the CS who underwent surgery via the extended transsphenoidal approach utilizing multiple techniques, including microscopy, endoscopy, neuronavigation, and intraoperative Doppler ultrasonography.

Results

Gross-total resection (GTR) was achieved in 33 patients (63.5 %). GTR rate was significantly higher in patients with Knosp Grade 3 than Knosp Grade 4 (92.3 vs. 53.8 %) and in patients undergoing initial surgery than reoperation (77.1 vs. 35.3 %). One patient (2.9 %) undergoing initial surgery experienced transient cranial nerve palsy, without other postoperative complications. Postoperative complications were significantly higher after reoperation. Firm tumor consistency was significantly more frequent in patients undergoing reoperation than initial surgery (52.9 vs. 8.6 %).

Conclusion

Extended transsphenoidal surgery incorporating multiple complementary techniques was highly effective for PAs invading the CS. Postoperative complications rates were relatively low, especially for patients undergoing initial surgery and those with Knosp Grade 3 tumors. Total resection of PAs invading the CS remains challenging, especially in patients undergoing reoperation or having firm tumors.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Jane JA Jr, Thapar K, Kaptain GJ, Maartens N, Laws ER Jr (2002) Pituitary surgery: transsphenoidal approach. Neurosurgery 51:435–442 (discussion 442-444)

    PubMed  Google Scholar 

  2. Rhoton AL Jr (2003) Operative techniques and instrumentation for neurosurgery. Neurosurgery 53:907–934 (discussion 934)

    Article  PubMed  Google Scholar 

  3. Ciric I, Ragin A, Baumgartner C, Pierce D (1997) Complications of transsphenoidal surgery: results of a national survey, review of the literature, and personal experience. Neurosurgery 40:225–236 (discussion 236-237)

    Article  PubMed  CAS  Google Scholar 

  4. Couldwell WT (2004) Transsphenoidal and transcranial surgery for pituitary adenomas. J Neurooncol 69:237–256

    Article  PubMed  Google Scholar 

  5. Kurosaki M, Kambe A, Ishibashi M, Watanabe T, Horie Y (2014) A case report of sarcoma of the sella caused by postoperative radiotherapy for a prolactin-producing pituitary adenoma. Brain Tumor Pathol 31:187–191

    Article  PubMed  Google Scholar 

  6. Sheehan JP, Niranjan A, Sheehan JM, Jane JA Jr, Laws ER, Kondziolka D, Flickinger J, Landolt AM, Loeffler JS, Lunsford LD (2005) Stereotactic radiosurgery for pituitary adenomas: an intermediate review of its safety, efficacy, and role in the neurosurgical treatment armamentarium. J Neurosurg 102:678–691

    Article  PubMed  Google Scholar 

  7. Hayashi M, Chernov M, Tamura N, Nagai M, Yomo S, Ochiai T, Amano K, Izawa M, Hori T, Muragaki Y, Iseki H, Okada Y, Takakura K (2010) Gamma Knife robotic microradiosurgery of pituitary adenomas invading the cavernous sinus: treatment concept and results in 89 cases. J Neurooncol 98:185–194

    Article  PubMed  Google Scholar 

  8. Hakuba A, Tanaka K, Suzuki T, Nishimura S (1989) A combined orbitozygomatic infratemporal epidural and subdural approach for lesions involving the entire cavernous sinus. J Neurosurg 71:699–704

    Article  PubMed  CAS  Google Scholar 

  9. van Lindert EJ, Grotenhuis JA, Meijer E (1991) Results of follow-up after removal of non-functioning pituitary adenomas by transcranial surgery. Br J Neurosurg 5:129–133

    Article  PubMed  Google Scholar 

  10. Laws ER Jr, Onofrio BM, Pearson BW, McDonald TJ, Dirrenberger RA (1979) Successful management of bilateral carotid-cavernous fistulae with a trans-sphenoidal approach. Neurosurgery 4:162–167

    Article  PubMed  Google Scholar 

  11. Ceylan S, Koc K, Anik I (2010) Endoscopic endonasal transsphenoidal approach for pituitary adenomas invading the cavernous sinus. J Neurosurg 112:99–107

    Article  PubMed  Google Scholar 

  12. 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 55:539–547 (discussion 547-550)

    Article  PubMed  Google Scholar 

  13. Fraioli B, Esposito V, Santoro A, Iannetti G, Giuffre R, Cantore G (1995) Transmaxillosphenoidal approach to tumors invading the medial compartment of the cavernous sinus. J Neurosurg 82:63–69

    Article  PubMed  CAS  Google Scholar 

  14. Frank G, Pasquini E (2006) Endoscopic endonasal cavernous sinus surgery, with special reference to pituitary adenomas. Front Horm Res 34:64–82

    Article  PubMed  Google Scholar 

  15. Hashimoto N, Kikuchi H (1990) Transsphenoidal approach to infrasellar tumors involving the cavernous sinus. J Neurosurg 73:513–517

    Article  PubMed  CAS  Google Scholar 

  16. Kitano M, Taneda M (2001) Extended transsphenoidal approach with submucosal posterior ethmoidectomy for parasellar tumors. J Neurosurg 94:999–1004

    Article  PubMed  CAS  Google Scholar 

  17. Kitano M, Taneda M, Shimono T, Nakao Y (2008) Extended transsphenoidal approach for surgical management of pituitary adenomas invading the cavernous sinus. J Neurosurg 108:26–36

    Article  PubMed  Google Scholar 

  18. Sabit I, Schaefer SD, Couldwell WT (2000) Extradural extranasal combined transmaxillary transsphenoidal approach to the cavernous sinus: a minimally invasive microsurgical model. Laryngoscope 110:286–291

    Article  PubMed  CAS  Google Scholar 

  19. Woodworth GF, Patel KS, Shin B, Burkhardt JK, Tsiouris AJ, McCoul ED, Anand VK, Schwartz TH (2014) Surgical outcomes using a medial-to-lateral endonasal endoscopic approach to pituitary adenomas invading the cavernous sinus. J Neurosurg 120:1086–1094

    Article  PubMed  PubMed Central  Google Scholar 

  20. Zhao B, Wei YK, Li GL, Li YN, Yao Y, Kang J, Ma WB, Yang Y, Wang RZ (2010) Extended transsphenoidal approach for pituitary adenomas invading the anterior cranial base, cavernous sinus, and clivus: a single center experience with 126 consecutive cases. J Neurosurg 112:108–117

    Article  PubMed  Google Scholar 

  21. Li Y, Wang R, Li G (2009) Transsphenoidal approach to pituitary adenoma: surgical technique of the Peking Union Medical College Hospital. Chin Med J (Engl) 122:3086–3090

    Google Scholar 

  22. 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 33:610–617 (discussion 617-618)

    Article  PubMed  CAS  Google Scholar 

  23. Kristof RA, Schramm J, Redel L, Neuloh G, Wichers M, Klingmüller D (2002) Endocrinological outcome following first time transsphenoidal surgery for GH-, ACTH-, and PRL-secreting pituitary adenomas. Acta Neurochir (Wien) 144:555–561

    Article  CAS  Google Scholar 

  24. Kassam AB, Thomas A, Carrau RL, Snyderman CH, Vescan A, Prevedello D, Mintz A, Gardner P (2008) Endoscopic reconstruction of the cranial base using a pedicled nasoseptal flap. Neurosurgery 63:ONS44–ONS52 (discussion ONS52-53)

    PubMed  Google Scholar 

  25. 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 328-329)

    PubMed  Google Scholar 

  26. Gardner PA, Tormenti MJ, Pant H, Fernandez-Miranda JC, Snyderman CH, Horowitz MB (2013) Carotid artery injury during endoscopic endonasal skull base surgery: incidence and outcomes. Neurosurgery 73:ons261–ons269 (discussion ons269-270)

    PubMed  Google Scholar 

  27. Berkmann S, Fandino J, Zosso S, Killer HE, Remonda L, Landolt H (2011) Intraoperative magnetic resonance imaging and early prognosis for vision after transsphenoidal surgery for sellar lesions. J Neurosurg 115:518–527

    Article  PubMed  Google Scholar 

  28. 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 105-114)

    Article  PubMed  Google Scholar 

  29. Schwartz TH, Stieg PE, Anand VK (2006) Endoscopic transsphenoidal pituitary surgery with intraoperative magnetic resonance imaging. Neurosurgery 58:ONS44–ONS51 (discussion ONS44-51)

    PubMed  Google Scholar 

  30. Tabaee A, Anand VK, Fraser JF, Brown SM, Singh A, Schwartz TH (2009) Three-dimensional endoscopic pituitary surgery. Neurosurgery 64:288–293 (discussion 294-295)

    PubMed  Google Scholar 

  31. Zhao Y, Yu S, Wang R, Zhao J (2006) Clinical application of a neuronavigation system in transsphenoidal surgery of pituitary macroadenoma. Neurosurg Rev 29:306–311 (discussion 311-312)

    Article  PubMed  Google Scholar 

  32. Jho HD, Carrau RL (1997) Endoscopic endonasal transsphenoidal surgery: experience with 50 patients. J Neurosurg 87:44–51

    Article  PubMed  CAS  Google Scholar 

  33. Cappabianca P, Cavallo LM, de Divitiis O, Solari D, Esposito F, Colao A (2008) Endoscopic pituitary surgery. Pituitary 11:385–390

    Article  PubMed  Google Scholar 

  34. Jane JA Jr, Han J, Prevedello DM, Jagannathan J, Dumont AS, Laws ER Jr (2005) Perspectives on endoscopic transsphenoidal surgery. Neurosurg Focus 19:E2

    PubMed  Google Scholar 

  35. Doglietto F, Lauretti L, Frank G, Pasquini E, Fernandez E, Tschabitscher M, Maira G (2009) Microscopic and endoscopic extracranial approaches to the cavernous sinus: anatomic study. Neurosurgery 64:413–421 (discussion 421-422)

    PubMed  Google Scholar 

  36. Har-El G (2005) Endoscopic transnasal transsphenoidal pituitary surgery-comparison with the traditional sublabial transseptal approach. Otolaryngol Clin North Am 38:723–735

    Article  PubMed  Google Scholar 

  37. de Divitiis E (2006) Endoscopic transsphenoidal surgery: stone-in-the-pond effect. Neurosurgery 59:512–520 (discussion 512-520)

    Article  PubMed  Google Scholar 

  38. Locatelli D, Canevari FR, Acchiardi I, Castelnuovo P (2010) The endoscopic diving technique in pituitary and cranial base surgery: technical note. Neurosurgery 66:E400–E401 (discussion E401)

    Article  PubMed  Google Scholar 

  39. Ammirati M, Wei L, Ciric I (2013) Short term outcome of endoscopic versus microscopic pituitary adenoma surgery: a systemic review and meta-analysis. J Neurol Neurosurg Psychiatry 84:843–849

    Article  PubMed  PubMed Central  Google Scholar 

  40. Dallapiazza RF, Grober Y, Starke RM, Laws ER Jr, Jane JA Jr (2015) Long-term results of endonasal endoscopic transsphenoidal resection of nonfunctioning pituitary macroadenomas. Neurosurgery 76:42–53

    Article  PubMed  Google Scholar 

  41. Catapano D, Sloffer CA, Frank G, Pasquini E, D’Angelo VA, Lanzino G (2006) Comparison between the microscope and endoscope in the direct endonasal extended transsphenoidal approach: anatomical study. J Neurosurg 104:419–425

    Article  PubMed  Google Scholar 

  42. Al-Mefty O, Pravdenkova S, Gragnaniello C (2010) A technical note on endonasal combined microscopic endoscopic with free head navigation technique of removal of pituitary adenomas. Neurosurg Rev 33:243–248 (discussion 248-249)

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

This work was supported by The Capital Medical Development Research Foundation of China (Grant No. 2011-4001-06) and the Ministry of Science and Technology of China (2014BAI04B03).

Author information

Author notes

    Authors and Affiliations

    1. Department of Neurosurgery, Pituitary Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China

      Xinjie Bao, Kan Deng, Xiaohai Liu, Ming Feng, Wei Lian, Bing Xing, Yong Yao & Renzhi Wang

    2. Division of Neurosurgery, Center for Theoretic and Applied Neuro-Oncology, University of California, San Diego, CA, USA

      Clark C. Chen

    Authors
    1. Xinjie Bao
      View author publications

      You can also search for this author in PubMed Google Scholar

    2. Kan Deng
      View author publications

      You can also search for this author in PubMed Google Scholar

    3. Xiaohai Liu
      View author publications

      You can also search for this author in PubMed Google Scholar

    4. Ming Feng
      View author publications

      You can also search for this author in PubMed Google Scholar

    5. Clark C. Chen
      View author publications

      You can also search for this author in PubMed Google Scholar

    6. Wei Lian
      View author publications

      You can also search for this author in PubMed Google Scholar

    7. Bing Xing
      View author publications

      You can also search for this author in PubMed Google Scholar

    8. Yong Yao
      View author publications

      You can also search for this author in PubMed Google Scholar

    9. Renzhi Wang
      View author publications

      You can also search for this author in PubMed Google Scholar

    Corresponding authors

    Correspondence to Yong Yao or Renzhi Wang.

    Ethics declarations

    Conflict of interest

    We do not have a financial relationship with the organizations that sponsored the research. None of the authors has any potential financial conflicts of interests in relation to this article.

    Additional information

    Xinjie Bao and Kan Deng have contributed equally to this work.

    Rights and permissions

    Reprints and permissions

    About this article

    Check for updates. Verify currency and authenticity via CrossMark

    Cite this article

    Bao, X., Deng, K., Liu, X. et al. Extended transsphenoidal approach for pituitary adenomas invading the cavernous sinus using multiple complementary techniques. Pituitary 19, 1–10 (2016). https://doi.org/10.1007/s11102-015-0675-0

    Download citation

    • Published:

    • Issue Date:

    • DOI: https://doi.org/10.1007/s11102-015-0675-0

    Keywords

    Search

    Navigation