Resection of suprasellar tumors by using a modified transsphenoidal approach

Abstract

Generally accepted contraindications to using a transsphenoidal approach for resection of tumors that arise in or extend into the suprasellar region include a normal-sized sella turcica, normal pituitary function, and adherence of tumor to vital intracranial structures. Thus, the transsphenoidal approach has traditionally been restricted to the removal of tumors involving the pituitary fossa and, occasionally, to suprasellar extensions of such tumors if the sella is enlarged. However, conventional transcranial approaches to the suprasellar region require significant brain retraction and offer limited visualization of contralateral tumor extension and the interface between the tumor and adjacent structures, such as the hypothalamus, third ventricle, optic apparatus, and major arteries. In this paper the authors describe successful removal of suprasellar tumors by using a modified transsphenoidal approach that circumvents some of the traditional contraindications to transsphenoidal surgery, while avoiding some of the disadvantages of transcranial surgery. Four patients harbored tumors (two craniopharyngiomas and two hemangioblastomas) that arose in the suprasellar region and were located either entirely (three patients) or primarily (one patient) within the suprasellar space. All patients had a normal-sized sella turcica. Preoperatively, three of the four patients had significant endocrinological deficits signifying involvement of the hypothalamus, pituitary stalk, or pituitary gland. Two patients exhibited preoperative visual field defects. For tumor excision, a recently described modification of the traditional transsphenoidal approach was used. Using this modification, one removes the posterior portion of the planum sphenoidale, allowing access to the suprasellar region. Total resection of tumor was achieved (including absence of residual tumor on follow-up imaging) in three of the four patients. In the remaining patient, total removal was not possible because of adherence of tumor to the hypothalamus and midbrain. One postoperative cerebrospinal fluid leak occurred. Postoperative endocrinological function was worse than preoperative function in one patient. No other new postoperative endocrinological or neurological deficits were encountered. This study demonstrates the feasibility of using a modified transsphenoidal approach for resection of certain suprasellar, nonpituitary tumors.

Outcomes following endoscopic, expanded endonasal resection of suprasellar craniopharyngiomas: a case series

“…The addition and sole use of the endoscope in the expanded, microscopic approaches described by others 17,20,25 allows improved visualization, which, in turn, allows the further expansion of the previously described approaches.…”

“…21,24,30 Although the transsphenoidal approach is traditionally limited to predominantly sellar lesions with secondary suprasellar extension, 23 the development and application of the "extended approach" have provided greater access to suprasellar lesions. 17,20,25 Despite this modification, outcomes from the transsphenoidal approach for the resection of suprasellar tumors with adherence to critical surrounding structures have led to more frequent recurrences and poorer overall outcomes compared with purely sellar tumors. 17 Some of the limitations of this approach, as previously described, may be secondary to the use of the microscope, 2 distance from the surgical target, the small portal of entry to the surgical field (that is, the nostril), and the need for a speculum.…”

“…HE microscopic, transsphenoidal approach for the resection of certain craniopharyngiomas is well established and generally accepted, 6,[13][14][15]17,[20][21][22][23][24]29,30 and there are several studies comparing this approach with a transcranial approach. 21,24,30 Although the transsphenoidal approach is traditionally limited to predominantly sellar lesions with secondary suprasellar extension, 23 the development and application of the "extended approach" have provided greater access to suprasellar lesions.…”

Craniocaudal Extension as an Indication of Surgical Outcome in Transsphenoidal Surgery for Pituitary Adenomas

“…A second staged transsphenoidal approach can be contemplated if there is descent of the remaining tumor in the sella [18,19]. Modified and extended endoscopic transsphenoidal approach can be also used [20][21][22]. One should never also forget other lines of treatment that can still be used successfully and involves medical and radiotherapeutic approaches [11].…”

“…Most tumors are soft and suckable. However, invasive, vascular and fibrous tumors can limit the surgical removal especially with enlarged size [20,21]. Prognosis should always be correlated to well-defined criteria of invasion such as MRI, growth rate and clinical follow-up.…”