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Abstract
Objective:Pituitary adenomas invading the cavernous sinus represent a therapeutic challenge. Those tumors have been traditionally treated with incomplete surgical removal, observation and/ or adjunctive medical therapy, and radiotherapy. In relatively recent years, some authors have suggested a main direct surgical approach to cavernous sinus (CS) with the aim of complete removal of the adenoma, either by a modified trans-sphenoidal route, using or not an endoscopy-assisted approach, or by a transcranial direct approach. The latter has the advantage of allowing direct exposure of the lesion with a view of the surgical field unhindered by important neurovascular structures.Materials and Methods:We report a technical modification of the classical epidural approach for CS adenoma removal. This was used in 14 patients. Surgical technique included a fronto-orbito-zygomatic craniotomy with extradural anterior clinoidectomy, and intradural approach to the Hakuba’s triangle for intracavernous dissection. The tumors were removed under direct vision.Results:Total macroscopical removal was achieved in all but one case. This patient required postoperative radiation therapy as well as adjuvant dopaminergic regime for achieving control of preoperatively increased hormonal values. No other case required radiotherapy. Hormonal and/ or clinical control was also achieved in all the remaining cases. Out of the remaining 13 cases, all appeared to be tumor free at an average postoperative observation at 78 months (34 to 90 months). Significant surgical sequels were detected in only 1 case (persistent 3rd nerve palsy and moderate hemiparesis).Conclusions:This experience, though limited, would suggest that the transcranial limited CS exposure through the Hakuba’s triangle may allow adequate removal of intracavernous pituitary adenomas with very good long-term results and acceptable complication rate.
Highlights
Surgical management of pituitary adenomas is, as a rule, performed using the trans - sphenoidal route
Pituitary adenomas invading the cavernous sinus (CS) represent a challenge for neurosurgeons
On the basis of this consideration, some authors have described their experiences with direct approaches to CS, either from below or transcranially, and have recommended these approaches
Summary
Surgical management of pituitary adenomas is, as a rule, performed using the trans - sphenoidal route. 3% to 7% of pituitary adenomas grow laterally out of the sellar boundaries,[10,26,32,34] and a significant proportion of these tumors invade the cavernous sinus (CS) and represent a management dilemma and difficult-to-treat lesions. Dissection of CS has been introduced mostly by Dolenc[11,12] in the technical armamentarium of modern neurosurgery, and attempts by several authors[2,13,24,33,40,41] to radically remove pituitary adenomas invading the CS have been successful basically the technique described originally by Dolenc. The majority of pituitary surgeons still prefer to accomplish incomplete transsphenoidal removal of an invasive adenoma and to use in some cases postoperative radiotherapy (or better still, radiosurgery[21,29]) for obtaining control of residual tumor
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