Pituitary Adenomas with Invasion of the Cavernous Sinus Space

Abstract

We present 25 pituitary adenomas that were confirmed surgically to have invaded the cavernous sinus space. The surgical results are compared with the preoperative magnetic resonance imaging findings. For comparable radiological criteria, we classified parasellar growth into five grades. This proposed classification is based on coronal sections of unenhanced and gadolinium diethylene-triamine-pentaacetic acid enhanced magnetic resonance imaging scans, with the readily detectable internal carotid artery serving as the radiological landmark. The anatomical, radiological, and surgical conditions of each grade are considered. Grades 0, 1, 2, and 3 are distinguished from each other by a medial tangent, the intercarotid line--through the cross-sectional centers--and a lateral tangent on the intra- and supracavernous internal carotid arteries. Grade 0 represents the normal condition, and Grade 4 corresponds to the total encasement of the intracavernous carotid artery. According to this classification, surgically proven invasion of the cavernous sinus space was present in all Grade 4 and Grade 3 cases and in all but one of the Grade 2 cases; no invasion was present in Grade 0 and Grade 1 cases. Therefore, the critical area where invasion of the cavernous sinus space becomes very likely and can be proven surgically is located between the intercarotid line and the lateral tangent, which is represented by our Grade 2. We also measured tumor growth rates, using the monoclonal antibody KI-67, which shows a statistically higher proliferation rate (P < 0.001) in adenomas with surgically observed invasion into the cavernous sinus space, as compared with noninvasive adenomas.

Surgical outcomes using a medial-to-lateral endonasal endoscopic approach to pituitary adenomas invading the cavernous sinus

“…All pre- and post-operative images were retrospectively reviewed by an independent neuroradiologist (AJT), who calculated the volume of the tumor, degree of CS invasion [based on the Knosp-Steiner (KS) criteria], and extent of both total surgical resection and resection within each CS. The KS grading system includes 5 categories (Figure 1) 28 : (0) no invasion with all of the lesion medial to the cavernous carotid artery (CCA), (1) invasion extending to but not past, the medial aspect of the CCA, (2) invasion extending to but not past, the lateral aspect of the CCA, (3) invasion past the lateral aspect of the CCA but not completely filling the CS, and (4) completely filling the CS both medial and lateral to the CCA. Only those cases with intraoperative confirmation of CS invasion were included in the study, regardless of the pre-operative KS grade.…”

Low Aryl Hydrocarbon Receptor-Interacting Protein Expression Is a Better Marker of Invasiveness in Somatotropinomas than Ki-67 and p53

“…Tumors were classified as invasive or noninvasive according to radiological criteria using Hardy’s modified criteria and Knosp-Steiner criteria [17] and according to surgical observation of invasion. All tumors were evaluated by preoperative MRI, and all images were analyzed by the same radiologist (E.L.G.…”

“…There is no consensus about the best radiological classification of tumor invasiveness. Several classifications have been proposed, such as Knosp-Steiner, SIPAP, and Hardy [17,18,19]. However, the most widely used criterion is the classification of Hardy modified by Bates [2,19].…”

Transsphenoidal Microsurgery for Newly Diagnosed Acromegaly: A Personal View after More than 1,000 Operations

“…As shown in figure 5, an additional grading of the adenomas according to Hardy et al [1], adapted from Knosp et al [10], including 3 grades of macroadenomas according to the extension of MRI and surgical respectability, was introduced by us [11]: enclosed (grade 2), resectable invasive (grade 3), and nonresectable, grossly invasive adenomas (grade 4). For the changes of the adenomas, under medication, the largest changing diameter of at least 2 mm was used in comparable 3-mm slices of the MRI [11].…”