Giant invasive pituitary adenomas: surgical approach selection paradigm and its influence on the outcome—case series

Abstract

Objective Pointing out our surgical strategy and experience in selection of surgical approaches in giant pituitary adenomas patients and its relation to surgical and clinical outcome. Methods 31 patients with giant pituitary adenomas (maximum diameter ≥ 4 cm). We analyzed the preoperative clinical presentation, radiological criteria of the tumor, endocrinological profile, approach selected, extent of resection, clinical outcomes and complications. Results 16 males (51.6%) and 15 females (48.4%). All the patients had a visual complaint (13 had mild impairment (41.9%), 18 had significant visual loss (58.1%). 20 were nonfunctioning (64.6%), 5 prolactin secreting (16%) and 6 growth hormone secreting (19.4%). Surgical approaches included: standard endoscopic endonasal approach in 7, extended approach in 4, transcranial (extended pterional approach) in 3. Staged endoscopic surgery in 5. Extended pterional approach followed endoscopic approach in 12. Gross total resection in 18 (58%) subtotal resection in 8 patients (25.8%) and partial resection in 5 patients (16.2%). The most common complications was tumor recurrence in 8, CSF leakage in 3, Permanent diabetes insipidus in 2, postoperative hydrocephalus in 1, transient 6th CN palsy in 3, and unfortunately only one patient died. 8 had complete Visual recovery, 9 were improved partially, and 11 remain unchanged. Only 3 showed further deterioration of vision. Conclusions Giant invasive pituitary adenoma is still one of the challenging issues in decision making for selection of the appropriate management strategy. Advancement of the endoscopic surgical techniques made the transsphenoidal approach is the primary choice for management of giant pituitary adenoma. However, the door is still opened for transcranial approach as staged the procedure after endoscopic approach or sole approach for some selected cases.