Endoscopic Endonasal Approach to Giant Pituitary Adenomas: Surgical Outcomes and Review of the Literature

Rahimli, Tural; Hidayetov, Tural; Yusifli, Zerife; Memmedzade, Hidayet; Rajabov, Tural; Aghayev, Kamran

doi:10.1016/j.wneu.2021.01.019

Cited by 13 publications

(11 citation statements)

References 32 publications

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“…We show here that surgery is able to control tumor volume in most patients, as supported by prior studies (5,6,8,11,23). In this study, a radical resection, including complete or subtotal resections, was obtained in 60% of patients, which may appear as a modest result compared to the higher rate observed for patients with smaller pituitary adenomas (20,22,(39)(40)(41)(42), but comparable to previous series (3,8,10,11,23,34,(43)(44)(45). However, in the particular context of large invasions on surrounding structures and extension, the objective is rather the largest possible debulking than complete resection, due to the uttermost importance of limiting morbidity and complications.…”

Section: Discussionsupporting

confidence: 89%

“…This may explain why the 10% rate of overall complications after endoscopic endonasal approach for giant pituitary adenomas resection is higher than the 3.5% rate we previously reported for non-giant pituitary adenomas (22). Nevertheless, this 10% rate compares favorably with the results described in previous studies (4,8,10,11,23,34,43,45).…”

Section: Discussionsupporting

confidence: 88%

“…During transcranial approach, the neurosurgeon has to alternate different steps of tumor resection in narrow working windows while preserving all perforating arteries. Some perforating arteries ( 43 , 50 ) could also be encased by the tumor, which explains the difficulty to preserve all arterial feeders during surgical dissection and the increased risk of postoperative ischemia ( 3 , 43 , 50 – 52 ). Finally, some trans-diaphragmatic extensions are not well encapsulated and small perforating arteries may run along the pseudo-capsule ( 24 , 50 , 53 , 54 ).…”

Section: Discussionmentioning

confidence: 99%

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Outcome of giant pituitary tumors requiring surgery

et al. 2022

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ObjectiveThe management of giant pituitary tumors is complex, with few publications and recommendations. Consequently, patient’s care mainly relies on clinical experience. We report here a first large series of patients with giant pituitary tumors managed by a multidisciplinary expert team, focusing on treatments and outcome.MethodsA retrospective cohort study was conducted. Giant pituitary tumors were defined by a main diameter > 40mm. Macroprolactinomas sensitive to dopamine agonists were excluded. All patients were operated by a single neurosurgical team. After surgery, multimodal management was proposed, including hormone replacement, radiotherapy and anti-tumor medical therapies. Outcome was modeled using Kaplan-Meyer representation. A logistic regression model was built to identify the risk factors associated with surgical complications.Results63 consecutive patients presented a giant adenoma, most often with visual defects. Patients were operated once, twice or three times in 59%, 40% and 1% of cases respectively, mainly through endoscopic endonasal approach. Giant adenomas included gonadotroph, corticotroph, somatotroph, lactotroph and mixed GH-PRL subtypes in 67%, 14%, 11%, 6% and 2% of patients respectively. Vision improved in 89% of patients with prior visual defects. Severe surgical complications occurred in 11% of patients, mainly for tumors > 50 mm requiring microscopic transcranial approach. Additional radiotherapy was needed for 29% of patients, 3 to 56 months after first surgery. For 6% of patients, Temozolomide treatment was required, 19 to 66 months after first surgery.ConclusionsGiant pituitary tumors require multimodal management, with a central role of surgery. Most often, tumor control can be achieved by expert multidisciplinary teams.

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Section: Discussionsupporting

confidence: 89%

Section: Discussionsupporting

confidence: 88%

Section: Discussionmentioning

confidence: 99%

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Outcome of giant pituitary tumors requiring surgery

et al. 2022

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“…In contrast to new-onset pituitary dysfunction, existing preoperatively impaired pituitary function can be relieved by surgery [47]. However, in most cases, pituitary recovery is partial and requires continued hormone replacement therapy after surgery [48]. A complete postoperative endocrine laboratory assessment is usually performed at 6 and 12 weeks postoperatively [49].…”

Section: Discussionmentioning

confidence: 99%

The effect of endoscopic transsphenoidal somatotroph tumors resection on pituitary hormones: systematic review and meta-analysis

Nie

Fang

Wong

et al. 2022

Preprint

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Purpose： Currently, endoscopic transsphenoidal surgery is the main treatment for pituitary neuroendocrine tumors (PitNets). Excision of the tumor may have positive or negative effects on pituitary endocrine function and the pituitary function of somatotroph tumors is a point of particular concern after the operation. This study aimed to conduct a meta-analysis on the effect of endoscopic transsphenoidal somatotroph tumor resection on pituitary function. Methods： A systematic literature search was conducted for articles that included the evaluation of pituitary target gland before and after endoscopic transsphenoidal pituitary adenoma resection and published between 1992 and 2022 in PubMed, Cochrane, and Ovid MEDLINE. Results： 68 studies that included biochemical remission rates in 4524 somatotroph tumors were concluded. According to the 2000 consensus, the biochemical remission rate after transsphenoidal endoscopic surgery was 66.4% (95%CI,0.622-0.703; P = 0.000), the biochemical remission rate was 56.2% according to the 2010 consensus (95%CI,0.503-0.620; P = 0.041), and with the rate of biochemical remission ranging from 30.0% to 91.7% with investigator's definition. After endoscopic resection, adrenal axis dysfunction was slightly higher than that before surgery, but the difference was not statistically significant. Hypothyroidism was 0.712 times higher risk than that before surgery（OR=0.712; 95%CI, 0.527-0.961; P=0.027). Hypogonadism was 0.541 times higher risk than that before surgery (OR=0.541; 95%CI,0.393-0.746; P = 0.000). Hyperprolactinemia was 0.131 times higher risk than that before surgery (OR=0.131; 95%CI,0.022-0.783; P = 0.026). The incidence of pituitary insufficiency was 1.344 times risk before surgery after endoscopic resection of somatotroph tumors, but the difference was not statistically significant. Conclusions： Although the biochemical response rate of patients with transsphenoidal endoscopic growth hormone tumor resection will be increased as endoscopic surgery matures, some patients still require postoperative treatment, including gamma-ray therapy or drug take-in. Long-term follow-up and drug replacement therapy are required for newly diagnosed pituitary dysfunction, while the existing preoperative hypophysis can be ameliorated to some extent.

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“…In supergiant adenomas, where the size of the tumor is exceptional, both a combine approach versus a solely transcranial or endoscopic approach have been reported. [ 2 , 3 , 5 ]…”

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confidence: 99%

Endoscopic resection of supergiant pituitary adenoma

Penner¹,

Perna²,

Baldassarre³

et al. 2021

Surgical Neurology International

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Background: Giant pituitary adenomas are a rare finding and the literature is inconclusive regarding the most appropriate approach. In supergiant adenomas, where the size of the tumor is exceptional, both a combine approach versus a solely transcranial or endoscopic approach have been reported.[2,3,5] Case Description: In this video, an entirely endoscopic resection of a supergiant pituitary adenoma is demonstrated. The exceptional size (4.5 × 5.8 × 5.4 cm) of the tumor and the peculiarity of the anatomical relations are documented in the video. The anterior cerebral arteries, both the A1 and A2 tracts, as well as the anterior communicating arteries are shown to be posteriorly dislocated and encased by the tumor which is pealed from the arteries themselves. Furthermore, the optic nerves are decompressed and cleaned from any residual tumor. The procedure is highly technically challenging since the furthermost part of the adenoma is also the one attached to the great intracranial arteries. A 45 optic and angle instruments were used for the major part of the surgery. Considering the high risk of postoperative CSF leak, a multilayer closure with nasoseptal flap was chosen. The postoperative MRI showed a gross total resection of the lesion in the absence of any complications and no new neurological nor endocrinological deficit appeared. Conclusion: Expanded endoscopic endonasal approach could represent a valuable way to face giant adenoma, providing a direct corridor toward the lesion and safe control of both the chiasmatic vasculature and the anterior communicating artery complex. Multilayer reconstruction is mandatory to avoid postoperative CSF leak.[1,4]

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Endoscopic Endonasal Approach to Giant Pituitary Adenomas: Surgical Outcomes and Review of the Literature

Cited by 13 publications

References 32 publications

Outcome of giant pituitary tumors requiring surgery

Outcome of giant pituitary tumors requiring surgery

The effect of endoscopic transsphenoidal somatotroph tumors resection on pituitary hormones: systematic review and meta-analysis

Endoscopic resection of supergiant pituitary adenoma

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