Elsevier

Surgical Neurology

Volume 57, Issue 6, June 2002, Pages 380-390
Surgical Neurology

Neoplasm
Combined transsphenoidal and pterional craniotomy approach to giant pituitary tumors

https://doi.org/10.1016/S0090-3019(02)00705-XGet rights and content

Abstract

OBJECTIVE

We describe a combined simultaneous approach to giant pituitary tumors and present a review of 10 patients undergoing this procedure with emphasis on patient selection, surgical technique, and results.

METHODS

A retrospective review was performed of patients who had undergone a combined, simultaneous transsphenoidal and pterional craniotomy approach to a giant pituitary adenoma. Visual findings, endocrine presentation, and tumor type were compiled. Tumor stage and grade (Hardy classification) were based on MRI and intraoperative findings.

RESULTS

Gross total resection of tumor was achieved in 4 of 10 patients, near total (>90%) in 2 of 10, and subtotal (80–90%) in 4. At the time of follow-up (average, 29.7 months; range, 17–44 months), stereotactic radiosurgery had been performed in 2 patients. Of the 9 patients who presented with visual field loss, all had improvement at 1-month follow-up. At 6 months follow-up, resolution was complete in 5 patients and partial in 4. No patient had worsening of vision. Hypopituitarism persisted in all 5 patients who presented with it preoperatively.

CONCLUSION

The combined, simultaneous transsphenoidal and pterional approach described is indicated for a small subset of patients with giant (>3 cm) clinically nonfunctional pituitary tumors who meet the criteria of tumor configuration outlined where the surgeon cannot achieve complete resection by a single approach. We propose adding a new Hardy’s scheme subtype, Stage B-a, to describe giant pituitary tumors with a dumbbell configuration. Combining both craniotomy and transsphenoidal approaches may achieve the goal of tumor resection with less need for multiple sequential operations.

Section snippets

Indications and advantages of the combined procedure

The transsphenoidal approach is successfully employed for lesions confined to the sella, and for larger lesions with significant extrasellar extension and a favorable configuration, which is usually the result of progressive enlargement of the tumor with gradual stretching of an intact diaphragma sellae above. However, if the diaphragma sellae is significantly compromised around the pituitary stalk, a tumor can extend through this hiatus and expand into the suprasellar region. The resulting

Technique

The combined simultaneous approach requires two operating fields with two microscopes and two operating teams (surgeon and scrub nurse). The patient is placed supine on the operating room table and general anesthesia is induced. The patient’s head is placed in the Mayfield™ head holder and pins. The head holder may be oriented in an anteroposterior or transverse direction far enough posteriorly so that it would not preclude an intraoperative lateral skull film if this should be needed. The head

Endonasal transsphenoidal approach

Loupe magnification and headlight illumination are used during the initial exposure. The septum is displaced to the patient’s right nostril and the superior aspect of the naris elevated with a Senn™ retractor. Using a cutting electrocautery, a vertical incision is made in the mucosa over the posterior border of the cartilaginous septum. The septum is separated from the mucosa and the mucoperichondrial plane is developed with a Freer™ dissector. Once the anterior wall of the sphenoid sinus is

Pterional craniotomy

The frontotemporal approach to the suprasellar region is performed simultaneously with the transsphenoidal approach. A curvilinear incision is made from the zygomatic arch to the midline and the flap is reflected anteriorly. One or two burr holes are placed above the zygomatic arch and at the orbitofrontal angle, respectively, and connected to create a frontotemporal craniotomy. The lateral aspect of the lesser sphenoid wing is drilled away until flush with the frontal fossa. Dural tack-up

Results: demographics and clinical presentation

A retrospective chart review was performed of patients who had undergone a combined, simultaneous transsphenoidal and pterional craniotomy approach to a giant pituitary adenoma at our institution. Although we performed some procedures between 1983 and 1989, there was insufficient data to include them in this review format. Ten patients underwent this procedure from 1989 to 1997, 6 of them between 1993 to 1997. There were 5 men and 5 women with an average age of 52.2 years at the time of

Results: histology

Histology was performed using hematoxylin-eosin, immunohistochemistry, and electron microscopy. All tumors were confirmed to be pituitary adenomas. Nonsecreting PRL+ve and FSH-+ve adenomas were each diagnosed in 2 patients. There were 4 nonpositive adenomas, and 1 ACTH +ve adenoma. Immunohistochemistry was inconclusive in another.

Results: clinical

The average follow-up of the 10 patients was 31 months (range 17 to 44 months). Three out-of -state patients with complete tumor resections did not return to clinic for follow-up at Emory after 17, 20, and 17 months postoperatively; however, telephone follow-up with the referring physicians indicated the patients were well without recurrence of tumor. Follow-up MRI studies were performed from 6 to 12 months after surgery. Gross total resection was achieved in 4 of 10 patients, near total (>90%)

Results: complications

The potential complications from the combined approach are the same encountered in either the transsphenoidal approach or the pterional approach alone. The complications encountered in this series are summarized in Table 2; nearly all were transient and resolved completely. A new-onset third-nerve palsy occurred in 3 patients. The palsy had resolved completely at 4-month follow-up in 1 patient and at 12 months in the other 2 patients. A mild postoperative hemiparesis resulted in 3 patients;

Results: discussion

The combined, simultaneous and pterional approach described is not indicated for the vast majority of patients with large pituitary tumors. However, there is a small subset of patients in whom the potential risks and benefits of the combined procedure must be carefully weighed for each patient who meets the general criteria outlined. These criteria in our experience include: 1) endocrine type: clinically non functioning adenomas; 2) tumor size configuration: giant tumors (>3 cm) with large

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