Management Of Giant Pituitary Adenomas Research Articles

Endoscopic endonasal surgical management of giant pituitary adenomas with extension into ventricle system

Objective: to estimate the results of endoscopic endonasal surgical management of giant pituitary adenomas (GPAs) with extension into ventricular system (VS), to study the peculiarities of surgical techniques. Materials and methods. 49 adult patients with GPAs with extension into VS were included in the study. The depth of research 2016-2021. This is a consecutive sampling of 1339 pituitary adenomas. GPAs with extension into VS made up 3.66% (49/1339) among all treated pituitary adenomas, and 43.4% among 113 GPAs. Distribution by gender – 18 (36.7%) women and 31 (63.3%) men. Average age was 54.1±11.3 years. Results. The largest consecutive series of GPAs with extension into VS that underwent endoscopic endonasal surgery was analyzed. Gross total resection was achieved in 32.7% (16/49), subtotal – 42.9% (21/49), partial – 12.2% (6/49), contraindications for tumor removal were issued in 12.2% (6/49) cases, these patients underwent extended biopsy and ventriculoperitoneal shunting in 4 patients. In 67.4% (33/49) was admitted visual function improvement. In 12.2% (6/49) vision remained at preoperative level, with no visual impairment. In 20.4% (10/49) of cases, vision deteriorated immediately after surgery. Upon re-examination at 6‒8 weeks in this group, vision returned to baseline in 60% (6/10) of patients. An immunohistochemical study found that 89.8% of the tumors were hormonally inactive. There was allocated a separate group of null cell pituitary adenomas, which accounted for 18.9% of cases. ACTH, LH-FSH, GH, TTH, prolactin secreting PAs were detected in 30.6%, 24.5%, 16.3%, 8.2% and 2.0% respectively. Hypopituitarism was diagnosed in 30.6% (15/49) of patients. Diabetes insipidus was detected for the first time in the postoperative period in 12.2% (6/49) of patients. 14.3% (7/49) of the cases of postoperative cerebrospinal fluid leak were diagnosed. Meningitis developed in 8.1% (4/49). The mortality rate was 6.1% (3/49). Conclusions. An analysis of complications in the early postoperative period found that the incidence of complications in GPAs with extension into VS was statistically significantly higher when compared to the cohort of patients who underwent endoscopic endonasal surgery for pituitary adenomas removal, indicating the complexity of this pathology. Despite the significant increase in the complexity of endoscopic interventions and still considerable threats of postoperative cerebrospinal fluid leak in the opening of the VS, we can already consider endonasal operations in the vast majority of GPAs as the method of choice. A new classification approach to the study group of GPAs was proposed. It allows us to separate the relatively low-risk and high-risk groups of high-flow intraoperative cerebrospinal fluid leak, which is directly correlated with the risks of postoperative complications and mortality in our study. In addition, we emphasize a special, although the smallest group of GPAs with extension into the third ventricle (type 3). Such cases require special attention and the decision to have ventriculoperitoneal shunting before or immediately after the removal of the tumor.

Surgical management of giant pituitary adenomas: institutional experience and clinical outcomes of 94 patients

BackgroundGiant (with a diameter of at least 40 mm and a volume of at least 10 cm3) pituitary adenomas (GPAs) are intricate tumors that pose considerable difficulty for surgical removal. While endoscopic transsphenoidal surgery (ETS) is a commonly employed technique for these destructive tumors, its effectiveness may be restricted in cases where invasion into multiple compartments is present, leading to limited resection.MethodsA retrospective review was conducted on the clinical records of 94 patients diagnosed with GPAs who had undergone surgical resection from 2014 to 2022. An analysis was conducted on the outcomes of the surgical and clinical procedures.ResultsIn this group, the average size of the tumor before surgery was 44.6 ± 5.6 mm (range, 40–73 mm), and the volume was 25. 5± 16.6 cm3 (range, 10–20.67 cm3). Of the total number of patients, 72 (76.6%) underwent a single ETS, 12 (12.8%) opted for transcranial surgery (TCS), and 10 (10.6%) chose a combined method. Gross total resection (GTR) was successfully performed in 49 (68.1%), 3 (25.0%), and 8 (80.0%) patients who underwent each surgical approach. Seventy-four (78.7%) patients had improved vision, 20 (21.3%) were unchanged, and none had deterioration. Twenty-two patients (23.4%) experienced a total of 43 complications, which comprised hormonal insufficiency (11/94, 11.7%), diabetic insipidus (6/88, 6.8%), electrolyte disorders (7/94, 7.4%), cerebrospinal fluid leakage (5/94, 5.3%), meningitis (8/94, 8.5%), and hydrocephalus (6/94, 6.4%). The GTR, subtotal resection (STR), and partial resection (PTR) rates were 63.8% (60/94), 21.3% (20/94), and 14.9% (14/94), respectively. Throughout the follow-up duration, 18.1% (17/94) of patients required reoperation and/or adjuvant radiation treatment as a result of tumor regrowth or inadequate biochemical remission of functioning GPAs.ConclusionETS remains the optimal surgical option for most GPAs and generally offers safe and efficient tumor resection. However, a combined approach with TCS remains a requirement in cases that are not suitable for treatment with a single ETS. To achieve optimal tumor removal and minimize the occurrence of surgical complications, a flexible combination of ETS and TCS is recommended based on the characteristics of the tumor.

Surgical Strategies in the Treatment of Giant Pituitary Adenomas.

The management of giant pituitary adenomas (GPAs) is challenging due to associated endocrinopathies and the close proximity of these tumors to critical structures, such as the optic nerves, structures of the cavernous sinus, and hypothalamus. The objective of this review article was to summarize the current management strategies for giant pituitary adenomas, including the role of open and endoscopic surgical approaches and the role of medical and radiation therapy in conjunction with surgery. We conducted a retrospective review of GPAs operated at our institute between January 2010 and March 2023. Surgical approaches, extent of resection, and associated complications were documented. Furthermore, we conducted a thorough literature review to identify relevant studies published in the past decade, which were incorporated along with insights gained from our institutional case series of GPAs to analyze and integrate both the existing knowledge base and our institution's firsthand experience in the management of GPAs. A total of 46 giant pituitary adenomas (GPAs) were operated on, using various surgical approaches. Transsphenoidal approach was used in 25 cases and a staged approach using transsphenoidal and pterional was used in 15 cases. Other approaches included transcortical-transventricular, transcallosal, pterional/orbitozygomatic, and subfrontal approaches. Complications and technical nuances were reported. The management of giant pituitary adenomas remains complex, often involving several modalities-open or endoscopic resection, radiosurgery, and medical management of both the tumor and associated endocrinopathies. Surgical resections are often challenging procedures that require careful consideration of several factors, including patient characteristics, tumor location, and size, and the experience and skill of the surgical team.

Outcomes and surgical nuances in management of giant pituitary adenomas: a review of 108 cases in the endoscopic era.

Giant (maximum diameter ≥ 4 cm) pituitary macroadenomas are complex tumors that require resection for decompression of optic nerves, relief of mass effect, and symptom improvement. Given the lack of surgical accessibility, the lateral extent of the lesions, and the invasion of the cavernous sinus, management presents a significant challenge. Transsphenoidal, transcranial, and combined approaches have been viable options for resection. The authors present their findings from a large series of patients to characterize giant pituitary adenomas, document outcomes, and outline surgical nuances in resection of these tumors. The authors reviewed 887 consecutive patients who underwent resection of pituitary adenomas at a single institution. From this group, 108 patients with giant pituitary adenomas who underwent resection between January 1, 2002, and December 31, 2020, were identified for inclusion in the study. The patient demographics, clinical presentation, tumor imaging characteristics, surgical approaches, and postoperative outcomes were analyzed using descriptive statistics. The mean preoperative tumor diameter in this cohort was 4.6 ± 0.8 cm, with a mean volume of 25.9 ± 19.2 cm3. Ninety-seven patients underwent transsphenoidal approaches only, 3 underwent transcranial resection, and 8 patients underwent a combined approach. Gross-total resection was achieved in 42 patients. Tumor stability without a need for additional therapy was achieved in 77 patients, with 26 patients undergoing subsequent adjuvant radiotherapy. Among 100 patients with sufficient follow-up, 14 underwent adjuvant therapy-repeat operation and/or adjuvant radiation therapy-because of recurrence or tumor progression. Six patients with recurrence were observed without additional treatment. Overall, the morbidity associated with removal of these lesions was 11.1%; the most common morbidities were cerebrospinal fluid leak (5 patients, 4.6%) and hydrocephalus (4 patients, 3.7%). One death due to postoperative pituitary apoplexy of the residual tumor and malignant cerebral edema occurred in this cohort. Giant pituitary tumors still represent a surgical challenge, with significant morbidity. Gross-total resection occurs in a minority of patients. Surgical goals for removal of giant pituitary tumors should include attempts at removal of most tumor tissue to minimize the risk of residual tumor apoplexy by tailoring the approach along the major axis of the tumor. Experience with both transsphenoidal and multiple transcranial techniques is necessary for minimizing complications and improving outcomes.

Primary Endoscopic Endonasal Management of Giant Pituitary Adenomas: Outcome and Pitfalls from a Large Prospective Multicenter Experience.

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.

Outcomes and Surgical Nuances in Management of Giant Pituitary Adenomas

Makarenko, Serge MD, BS; Alzahrani, Ibrahim; Karsy, Michael MD, PhD, MS; Couldwell, William T MD, PhD; Deopujari, Chandrashekhar MD Author Information

Endoscopic Endonasal Approach as the Primary Surgical Management of Giant Pituitary Adenomas

Endoscopic Endonasal Approach as the Primary Surgical Management of Giant Pituitary Adenomas

Endoscopic endonasal transsphenoidal surgery for giant pituitary adenomas: a report of 69 cases

Objective To present our experience with the surgical management of giant pituitary adenomas through endoscopic endonasal transsphenoidal approach. Methods A retrospective data analysis of all patients who underwent endoscopic endonasal transsphenoidal surgery in Nanfang Hospital between January 2007 and June 2013 was performed. Patients who presented with pituitary adenomas larger than 4 cm were included in the study. Analysis of factors related to the choice of the operative approach, extent of resection, follow-up outcome, and complications were evaluated. Results Sixty-nine patients (18%) with giant adenomas matched our inclusion criteria. This included 51 (74%) patients with nonfunctional tumors, 11 (16%) prolactinomas, and 7 (10%) growth hormone-secreting adenomas. Gross total removal of the tumor was achieved in 26 cases (38%), subtotal removal in 23 (33%), and 20 (29%) had partial resection. Postoperative diabetes insipidus occurred in 9 cases (13%), new anterior pituitary insufficiency in 10 (15%), CSF leaks in 2 (3%), and meningitis in 2(3%). There was no dead case. The patients with Knosp score 3-4 adenomas had a higher total resection rate than those with Knosp score 0-2 (P< 0.001). Preoperative headache, visual dysfunction, oculomotor disorders and hypopituitarism were recovered in 20(83%), 59(86%), 9(60%), and 12(36%) cases, respectively. Nine patients with nonfunctional tumors underwent a second transsphenoidal surgery, 10 underwent radiotherapy, and 14 had a follow-up care. Drug therapy was performed in 11 patients with functional tumors, and radiotherapy in 3. Conclusions Endoscopic endonasal surgery might provide safe and effective treatment for patients with giant adenomas. The selection of surgical approach should be established according to the tumor extension and personal experience. In cases in which total resection might be associated with high risk, we advocated the use of partial resection followed by adjuvant drug therapy or radiotherapy. In cases of progressive enlargement of residual lesions, a second endoscopic procedure or radiotherapy might be considered. Key words: Endoscopy; Giant pituitary adenomas; Transsphenoidal surgery

A Giant Pituitary Adenoma: Surgical Excision via a Staged Endoscopic and Open Approach

The operative management of giant pituitary adenomas represents a significant challenge for neurosurgeons. This challenge is amplified by the degree of local tumour infiltration into adjacent structures such as the cavernous sinus. The degree of parasellar tumour extension can be classified according to the Knosp grading system’ while suprasellar extension is qualified in accordance with the Modified Hardys classification system. We report a 59 year male with a Knosp grade 4, Hardys C giant pituitary adenoma in which two-stage near total surgical resection via an expanded endoscopic transphenoidal approach and subsequent bifrontal craniotomy was achieved. Typically, resection rates of less than 50% have been reported following surgery on giant pituitary adenomas. Traditionally multi-modal treatment strategies with adjuvant stereotactic radiotherapy or radio surgery, has been the gold standard in the management of these locally aggressive tumours. This case serves to illustrate that even in the presence of significant suprasellar and parasellar extension, radical resection of giant pituitary adenomas can be achieved.

Endoscopic endonasal surgery for giant pituitary adenomas: advantages and limitations

Giant pituitary adenomas (> 4 cm in maximum diameter) represent a significant surgical challenge. Endoscopic endonasal surgery (EES) has recently been introduced as a treatment option for these tumors. The authors present the results of EES for giant adenomas and analyze the advantages and limitations of this technique. The authors retrospectively reviewed the medical files and imaging studies of 54 patients with giant pituitary adenomas who underwent EES and studied the factors affecting surgical outcome. Preoperative visual impairment was present in 45 patients (83%) and partial or complete pituitary deficiency in 28 cases (52%), and 7 patients (13%) presented with apoplexy. Near-total resection (> 90%) was achieved in 36 patients (66.7%). Vision was improved or normalized in 36 cases (80%) and worsened in 2 cases due to apoplexy of residual tumor. Significant factors that limited the degree of resection were a multilobular configuration of the adenoma (p = 0.002) and extension to the middle fossa (p = 0.045). Cavernous sinus invasion, tumor size, and intraventricular or posterior fossa extension did not influence the surgical outcome. Complications included apoplexy of residual adenoma (3.7%), permanent diabetes insipidus (9.6%), new pituitary insufficiency (16.7%), and CSF leak (16.7%, which was reduced to 7.4% in recent years). Fourteen patients underwent radiation therapy after EES for residual mass or, in a later stage, for recurrence, and 10 with functional pituitary adenomas received medical treatment. During a mean follow-up of 37.9 months (range 1-114 months), 7 patients were reoperated on for tumor recurrence. Three patients were lost to follow-up. Endoscopic endonasal surgery provides effective initial management of giant pituitary adenomas with favorable results compared with traditional microscopic transsphenoidal and transcranial approaches.

Microsurgical Management of Giant Pituitary Adenomas: A Series of 177 Cases

Microsurgical Management of Giant Pituitary Adenomas: A Series of 177 Cases

Microsurgical Management of Giant Pituitary Adenomas: A Series of 177 Cases

Results: Fifty-two and two-tenths percent had nonfunctioning adenomas. Among the functioning adenomas, prolactinomas (25.4%) were most common. A total of 116 trans-sphenoidal and 63 transcranial procedures were performed in 177 patients. The complications and deaths were significantly higher in the transcranial group. There were a total of 21 deaths (11.8%). Vision was improved in 89 patients (50.3%) at the time of discharge.

Therapeutic strategy of giant pituitary adenomas

目的 通过回顾性分析32例巨大垂体腺瘤病例的临床资料,探讨其治疗策略.方法男性17例,女性15例,平均年龄46.7岁,平均病程4.7年.其中垂体生长激素(GH)腺瘤1例,泌乳素(PRL)腺瘤6例,无功能腺瘤25例.采用经口鼻蝶窦入路手术24例,经额下入路手术1例,经蝶窦和经颅分期手术6例,药物治疗1例.结果手术显微镜下肿瘤全部切除20例,次全切除9例,部分切除2例;手术后放疗10例,药物治疗5例.术后死亡1例.随访6个月～4年,影像学检查显示肿瘤全部切除15例,次全切除14例,部分切除2例;肿瘤无复发.结论对巨大垂体腺瘤,应根据患者的临床表现、内分泌学检查和肿瘤的生长方式决定治疗方案;大多数巨大垂体腺瘤可以首选经蝶窦入路手术,并发症较少,死亡率低;对侵袭性生长的肿瘤,应采用手术、放疗和药物综合治疗。

Surgical management of giant pituitary adenomas

Pituitary tumors whose maximum dimension exceeds 4 cm are defined as giant pituitary adenomas. Such giant pituitary tumors are rare and their management is a formidable and controversial problem. Of the 850 pituitary tumors operated upon during the period between 1995 and 2002 in the authors' Institute, there were 118 ‘hormonally inactive’ giant pituitary tumors. The tumors were divided into four grades, depending on the extensions and the nature of their meningeal coverings. The grades reflected an increasing order of invasiveness of adjacent dural and arachnoidal compartments. Giant pituitary tumors, which remained within the confines of sellar dura and under the diaphragma sellae and did not enter into the compartment of cavernous sinus, were classified as Grade I (54 cases); those which transgressed the medial wall of the cavernous sinus were classified as Grade II (38 cases); those which elevated the dura of the superior wall of the cavernous sinus were classified as Grade III (24 cases); and those with supradiaphragmatic–subarachnoid extension were classified as Grade IV (2 cases). Radical surgery by a transsphenoidal route was seen to be suitable in Grade I–III pituitary tumors. It offered a reasonable opportunity for radical tumor resection and recovery of vision. Biopsy of the tumor followed by radiotherapy could be suitable for Grade IV pituitary tumors.

Radiotherapy in the management of giant pituitary adenomas

Background and purpose: The description of giant pituitary adenoma is not clear yet. In this study we tried to identify which adenomas can be defined as giant pituitary adenomas when tumor control and progression free survival (PFS) are taken as end points and we also tried to evaluate prognostic factors other than tumor size. Materials and methods: Between January 1981 and December 1997, 74 patients with pituitary macroadenomas more than 2 cm in size were treated. Of these 30 had tumors of more than 4 cm, while 44 patients were with tumors of 2–4 cm. Two patients received primary radiotherapy, while 72 were treated postoperatively. In the postoperative group, 52 patients underwent immediate radiotherapy after surgery and 20 were treated with irradiation after regrowth or progression of the tumor after initial surgery. The mean and median tumor doses were 5518 and 5425 cGy, respectively. Results: Overall primary tumor control rate was 84%. The local control rates among patients with tumors more than 4 cm and among patients with tumors 2–4 cm after radiotherapy were 73 and 91%, respectively. PFS was 65% for patients who had a tumor size of more than 4 cm and 87% for the patients with tumor size of 2–4 cm ( P=0.09). Young age (<20) and tumors of unclassified histology were the bad prognostic factors. Six months after radiotherapy normalisation or improvement in hormonal hypersecretion and visual field and acuity deficits were 82 and 63%, respectively. Conclusion: Tumors more than 4 cm in size may be more convenient for the definition of ‘giant pituitary adenoma’ when tumor control and PFS are taken as the end points.

Surgical Management of Giant Pituitary Adenomas

During the past 25 years, 77 giant pituitary adenomas have been treated surgically, including suprasellar extensions of type C in 66 cases and of type D in 11 cases. Non-secreting adenomas were present in 53 and secreting adenomas in 24 cases. All patients except 3 presented with significant visual field defects; including bitemporal hemianopia, superior quadranopia or unilateral temporal hemianopia, contralateral blindness in 73% of the cases, and one case with sudden bilateral blindness due to acute pituitary apoplexy. A single transsphenoidal procedure was carried out in 74% of the patients while 11 patients (7%) required re-operations for recurrent or residual tumor. Only 3 patients required a subsequent transcranial procedure. Complications included 1 CSF-leak, 1 empty-sella syndrome and 4 fatal post-operative hematomas. We prefer the transsphenoidal route even in very large or giant pituitary adenomas, since it allows rapid and adequate decompression of the optic nerves and chiasm, avoids major pituitary insufficiency in 60% of the cases and is associated with low morbidity-mortality rates.