Surgical Treatment of Cavernous Sinus Lesion in Patients with Nonfunctioning Pituitary Adenomas via the Endoscopic Endonasal Approach

Abstract

The main purpose of this article is to assess the effectiveness and safety of surgery via the endoscopic endonasal approach (EEA) for cavernous sinus (CS) lesion in patients with nonfunctioning pituitary adenomas (NFPA). Retrospective study. Keio University Hospital. Thirty patients who underwent CS surgery via the EEA between 2009 and 2017 for Knosp grade 4 NFPA with pre- and postoperative magnetic resonance imaging available for volumetric analysis. Clinical presentation, extent of resection, and surgical complications. Gross total and near total resection of CS tumors was achieved in 12/30 (40%) cases of Knosp grade 4 NFPA. The average resection rate of CS lesions in these 30 patients was 73.5%; 77.3% in primary cases and 70.1% in recurrent cases that did not vary significantly. Preoperative visual disturbance and oculomotor nerve palsy improved in 12/19 (63.1%) and ⅗ (60%) cases, respectively. Complications associated with CS via the EEA were postoperative cerebrospinal leakage (1/30, 3.3%), meningitis (1/30, 3.3%), and transient cranial nerve palsy (2/30, 6.7%). These complications except a case of mild transient abducens nerve palsy occurred in recurrent cases with subdural lesions. Although the optimal management of CS lesions in NFPA is controversial, debulking via the EEA is an effective and safe option that improves neurological symptoms and enables effective adjuvant radiotherapy. Recurrent cases with subdural invasion are technically challenging, even using the EEA, and special care is required to avoid complications.

Outcomes and Complications of Aggressive Resection Strategy for Pituitary Adenomas in Knosp Grade 4 With Transsphenoidal Endoscopy

“…In this study, an aggressive resection strategy was adopted, not only for tumors in the medial CS, but also for tumors in the lateral CS. This approach differs from the previous surgical resection strategies of Woodworth et al (18) and Toda et al (19). Their surgical concept included using an aggressive strategy for tumors in the medial CS and a conservative strategy for tumors in the lateral CS.…”

Gamma Knife Radiosurgery as a Primary Treatment for Nonfunctioning Pituitary Adenoma Invading the Cavernous Sinus

“…The most widely used classification of CS invasion in pituitary adenoma (PA) was proposed by Knosp in 1993 and revised in 2015 [8, 9]. The rate of gross total resection (GTR) is negatively correlated with the grade of CS invasion and the residual tumor is usually treated with adjuvant stereotactic radiosurgery (SRS) such as gamma knife radiosurgery (GKRS) [10-12]. Although SRS has been used mainly as a second-line treatment for residual or recurrent NFPA after initial surgery [4, 13-15], SRS also showed favorable tumor control rate as a primary treatment in the minority of NFPA patients with comorbidities or who preferred a nonsurgical treatment option [16-19].…”

Surgical treatment of aggressive pituitary adenomas and pituitary carcinomas

“…Invasion of the cavernous sinus restricts very much the chance to resect a tumor completely. Usually, the parasellar tumor portions are traced along the preexisting communications which the adenoma has created [16,17]. The extent of parasellar tumor growth and cavernous sinus involvement is appreciated from preoperative MRI by using Knosp scale [18] or its updated modification [19] which predicts the likelihood of invasion.…”

“…This has prognostic significance for the chance to totally resect a pituitary tumor and consequently also to achieve endocrine remission in hormonally active pituitary adenomas. However, debulking is, of course, possible, even if no aggressive techniques are applied and the tumor is only traced along the perforations which it has created during its expansion [16,17,21]. For minor involvement and even invasion of the medial wall of the cavernous sinus, deliberate resection of the medial wall has been proposed [22].…”