Abstract
Simple SummaryGiant pituitary adenomas are highly invasive tumors whose treatment is challenging. Surgery is their management mainstay. However, there is no consensus about the type of approach. Open transcranial, microscopic, and endoscopic trans-sphenoidal approaches have all been employed, alone or in combination. Extended endoscopic endonasal techniques may represent a versatile and safe one-stage approach. Our research aimed at evaluating prospectively their applicability, effectiveness, and safety in a multicenter series, to acquire further evidence toward its use in the treatment of those challenging lesions. Ninety-six patients were recruited and followed-up for 52.4 months on average. Most of them (81.2%) presented with visual deficits and >50% had various degrees of adenohypophysis insufficiency. Resection of at least 75% of initial volume was achieved in all cases, with 98.7% visual improvement, >50% endocrine deficit recovery and a permanent complication rate of 4.2%, indicating extended endoscopic endonasal approaches as a valuable treatment option.Purpose: To evaluate factors influencing clinical and radiological outcome of extended endoscopic endonasal transtuberculum/transplanum approach (EEA-TTP) for giant pituitary adenomas (GPAs). Methods: We recruited prospectively all consecutive GPAs patients undergoing EEA-TTP between 2015 and 2019 in 5 neurosurgical centers. Preoperative clinical and radiologic features, visual and hormonal outcomes, extent of resection (EoR), complications and recurrence rates were recorded and analyzed. Results: Of 1169 patients treated for pituitary adenoma, 96 (8.2%) had GPAs. Seventy-eight (81.2%) patients had visual impairment, 12 (12.5%) had headaches, 3 (3.1%) had drowsiness due to hydrocephalus, and 53 (55.2%) had anterior pituitary insufficiency. EoR was gross or near-total in 46 (47.9%) and subtotal in 50 (52.1%) patients. Incomplete resection was associated with lateral suprasellar, intraventricular and/or cavernous sinus extension and with firm/fibrous consistence. At the last follow-up, all but one patient (77, 98.7%) with visual deficits improved. Headache improved in 8 (88.9%) and anterior pituitary function recovered in 27 (50.9%) patients. Recurrence rate was 16.7%, with 32 months mean recurrence-free survival. Conclusions: EEA-TTP is a valid option for GPAs and seems to provide better outcomes, lower rate of complications and higher EoR compared to one- or multi-stage microscopic, non-extended endoscopic transsphenoidal, and transcranial resections.
Highlights
Pituitary adenomas (PAs) are benign, slow growing tumors that may cause compression and/or encasement of surrounding neural structures, such as optic nerve, chiasm, pituitary stalk, and hypothalamus, and/or vascular structures, such as carotid artery, anterior cerebral artery, anterior communicating artery complex, and cavernous sinus (CS).Clinically, they may present with either signs and symptoms secondary to mass effect, or with clinical syndromes related to abnormal hormonal secretion [1,2]
A multimodal strategy should be tailored on a case-bycase basis
Long-term disease control often needs adjuvant treatment, the initial course of action consists in an aggressive maximal resection, which should be pursued, with the aim of relieving mass effect in order to improve visual and endocrinologic function
Summary
Pituitary adenomas (PAs) are benign, slow growing tumors that may cause compression and/or encasement of surrounding neural structures, such as optic nerve, chiasm, pituitary stalk, and hypothalamus, and/or vascular structures, such as carotid artery, anterior cerebral artery, anterior communicating artery complex, and cavernous sinus (CS).Clinically, they may present with either signs and symptoms secondary to mass effect (headache, visual dysfunction), or with clinical syndromes related to abnormal hormonal secretion [1,2]. By using minimally invasive endoscopic tools and enlarging the trans-sphenoidal corridor, it is possible to visualize structures beyond the sella, appreciate tumor margins including suprasellar extension and achieve satisfactory quality of resection with acceptable complication rate [7]. In this prospective multicenter study, we enrolled consecutively patients harboring GPAs treated via extended endoscopic endonasal approach transtuberculum/transplanum (EEA-TTP). This study focuses on surgical pitfalls and analyzes the advantages and disadvantages of EEA-TTP as well as the implications of multimodality management for these extremely challenging lesions
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