Giant pituitary tumors: a study based on surgical treatment of 118 cases

Intraoperative magnetic resonance imaging-guided transsphenoidal surgery for giant pituitary adenomas

“…The most frequent postoperative complications include transient diabetes insipidus (DI) in 3.7% to 18.8% and CSF leak with meningitis in 7.4% to 14.6% [8,9]. In one study, these complications were not significantly more frequent than in non-giant PAs [8].…”

“…Hardy's classification groups PAs into four types, according to qualitative extensions [11,14]. Other authors define GPAs as tumors ≥30 mm in diameter [1,8], as ≥40 mm in diameter [9,10,19], or as tumors extending more than 40 mm from the midpoint of the jugum sphenoidale or to within 6 mm of the interventricular foramen [7,12,18]. Patients with GPAs compared to patients with non-GPAs [8] more frequently present clinically with visual symptoms and headaches than hormonal disturbances [1,8,9,12,14].…”

“…Between 27.9% and 40% of tumors are excised totally according to several reports [1,8,9], and surgery can improve the primary symptom of the patient, diminished vision, in 65% to 90% [1,9].…”

Size does not matter. The intrigue of giant adenomas: a true surgical challenge

“…The same principles are valid in cases of giant adenomas, where the extended approach has proved to facilitate, in most instances, a wider lesion exposure just after the dural opening over the sellar-suprasellar space, thus avoiding any retraction of neurovascular structures [16][17][18][19]. However, there are conditions that could render more troublesome the transsphenoidal approach, either related to the anatomy of the surgical route or to the inner features of the lesion itself, i.e., the size of the sella, its degree of ossification, the size and the pneumatization of the sphenoid sinus, and/or carotid arteries position and shape [1,6,20,21].On the other hand, transcranial surgery should be preferred when tumors present with extensive intracranial invasion, with asymmetric lateral development, into the anterior cranial fossa or lateral or posterior extension into the middle and posterior cranial fossa, particularly if major vessel involvement is present and/or whether transsphenoidal surgery has been already unsuccessful, and in these regards, several authors have reported surgical strategy and results, properly addressing indications, pros, and cons [22][23][24].When perceiving this controversial scenario, we moved backward through our series and analyzed the decisionmaking process, i.e., surgical approach choice, in those special-featured adenomas (giant, asymmetric, dumb-bell shaped). Although it is not possible to define a unique paradigm of management, we could thread a common line of attitude we have been relying on.…”

“…On the other hand, transcranial surgery should be preferred when tumors present with extensive intracranial invasion, with asymmetric lateral development, into the anterior cranial fossa or lateral or posterior extension into the middle and posterior cranial fossa, particularly if major vessel involvement is present and/or whether transsphenoidal surgery has been already unsuccessful, and in these regards, several authors have reported surgical strategy and results, properly addressing indications, pros, and cons [22][23][24].…”