Endonasal transsphenoidal pituitary surgery: is tumor volume a key factor in determining outcome?

doi:10.1016/j.amjoto.2007.01.006

American Journal of Otolaryngology

Volume 29, Issue 1, January–February 2008, Pages 48-50

https://doi.org/10.1016/j.amjoto.2007.01.006 Get rights and content

Abstract

Purpose

This study was conducted to evaluate the role of tumor volume in excision of pituitary adenomas.

Materials and methods

A total of 20 patients with pituitary adenoma underwent surgical excision of the tumor by endonasal transsphenoidal approach.

Results

A preoperative tumor volume of more than 5 mL is associated with a 90.90% probability of residual tumor (P < .05, statistically significant).

Conclusion

Tumor volume as a predicting factor for the surgical outcome is an evolving concept. Other factors determining the efficacy of tumor removal are parasellar and suprasellar extension.

Introduction

The development of pituitary surgery is largely credited to the pioneering work of Harvey Cushing in the early 1900s [1]. He had extensive experience with both transcranial and transsphenoidal approaches to the pituitary gland [2], [3]. In 1907, Schloffer [4] was the first to perform transsphenoidal pituitary tumor resection. In the 1960s, Jules Hardy [5] introduced intraoperative fluoroscopy and microscopy for transseptal-transsphenoidal pituitary surgery. The improved exposure afforded by these technologies allowed for complete removal of larger pituitary tumors, obviating the need for a complex transcranial operation in most patients. As a result, the transseptal-transsphenoidal approach became the procedure of choice for the surgical management of most pituitary tumors.

Transcranial techniques were reserved for resection of large tumors with extensive parasellar and suprasellar invasion. In recent years, developments in the field of endoscopic surgery has prompted surgeons to attempt endoscope-assisted surgery of the pituitary gland [6], [7], [8]. Nowadays, the endonasal endoscopic removal of the pituitary tumors is the recommended procedure, which also obviates the need for septal incisions. In the present study, we have attempted to identify factors that may affect the complete resection of tumor after the endonasal endoscopic removal of the pituitary tumors.

Section snippets

Materials and methods

This prospective study was conducted in the Department of Otorhinolaryngology in collaboration with the Neurosurgery Department, Post-Graduate Institute of Medical Education and Research, Chandigarh, India. A total of 20 patients with suspected radiologic diagnosis of pituitary tumor were included in this study. All patients underwent preoperative and postoperative endocrinal, visual function evaluation, magnetic resonance imaging (MRI) and computed tomographic scanning. All cases were

Results

There were 11 female and 9 male patients, whose age ranged from 18 to 58 years (mean, 35.85 ± 9.46 years). Eleven (55%) patients had functioning pituitary tumor, among which there were 5 (25%) somatotropinomas, 3 (15%) prolactinomas, and 3 (15%) corticotropinomas (Cushing's disease, 2; Nelson syndrome, 1). Of these tumors, there were 3 microadenomas and 17 macroadenomas (85%) (including 1 giant adenoma; largest diameter was more than 4 cm).

Tumor volume (π × length × breadth × height) ranged

Discussion

Pituitary adenomas are seen in adults with a peak incidence in the fourth to sixth decades [9], [10]. Nonfunctioning pituitary adenomas constituted 40% of cases in most of the reported series. A variety of transcranial and extracranial approaches have been mentioned [11]. Open rhinoplasty approach could not gain popularity due to limitations in access and problem of an external scar [12]. Transpalatal, transethmoidal, and transantral-transethmoidal approaches carry a high risk of damage to

Conclusion

These days, the concept of tumor volume is becoming more popular. Tumor volume is a 3-dimensional assessment of tumors. Parasellar and suprasellar extensions are the other determinants for residual tumor. Favorable factors for total removal are tumor volume of less than 5 mL with no parasellar or suprasellar extension.

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Cited by (22)

Effect of Intraoperative Lumbar Drainage on Gross Total Resection and Cerebrospinal Fluid Leak Rates in Endoscopic Transsphenoidal Surgery of Pituitary Macroadenomas
2020, World Neurosurgery
Citation Excerpt :
The overall rate of GTR in our LD group (92.4%) was similar to the classical results of endoscopic transsphenoidal surgery of pituitary macroadenomas in the literature (~90%).18,19 However, besides the tumor volume, which is a well-established predicting factor for tumor GTR,20 suprasellar and parasellar extension of tumors also affect the possibility of GTR.2 Comparing the subgroups of advanced Wilson grades (80.4% vs. 55.1%) and invasive Knosp grades (70.4% vs. 41.2%) with previous studies, an improved GTR was shown in our LD group with greater control of suprasellar and parasellar extension.2
We sought to assess whether controlled, intraoperative lumbar drainage (LD) of cerebrospinal fluid (CSF) could facilitate resection of pituitary macroadenomas and reduce the rate of CSF leak.
A retrospective cohort study from a prospective database was conducted on 189 patients with pituitary macroadenoma who received endoscopic transsphenoidal surgery between 2013 and 2017. Patients were classified into 2 groups: 119 patients received an intraoperative LD (LD group) and 70 patients underwent routine endoscopic surgery without LD (control group). In the LD group, lumbar catheters were placed preoperatively and CSF was drained intermittently during tumor resection. The rates of gross total resection (GTR) and CSF leaks were assessed both intraoperatively and postoperatively.
Intraoperative LD was associated with a higher rate of GTR (92.4% in the LD group vs. 78.6% in the control group, P = 0.006), especially in macroadenomas with suprasellar extension (90.3% vs. 75.0%, P = 0.012). Both intraoperative and postoperative CSF leak rates were significantly decreased in the LD group (intraoperative: 10.1% vs. 31.4%, P < 0.001; postoperative: 3.4% vs. 11.4%, P = 0.035). In functioning adenomas, a better remission rate of excess-hormone secretion was observed in the LD group compared with the controls (89.1% vs. 60.6%, P = 0.001). Patients in the LD group also had an enhanced recovery with a shorter postoperative length of stay (7 days vs. 5 days, P = 0.020).
Intraoperative LD may assist surgeons during endoscopic transsphenoidal resection of pituitary macroadenomas by achieving a higher rate of GTR and a lower rate of perioperative CSF leaks. Validation in prospective randomized controlled studies is needed.
History, Current Situation, and Future Development of Endoscopic Neurosurgery in China
2018, World Neurosurgery
Citation Excerpt :
Cases with >200 patients were included in the comparison. The results showed that the gross total resection rate of pituitary adenoma in Chinese large-scale departments of neurosurgery was 63.9%–91.6%, the recurrence rate was 15.2%–38.7%, and the complication rate was 11.4%–35.2%21,22,30-37; these results are close to the international level (gross total rate 56%–79%, recurrence rate 8.5%–42%, complication rate 9.5%–36.1%, with complications mainly consisting of cerebrospinal fluid leak, diabetes insipidus, anterior lobe insufficiency, and epistaxis).38-47 Currently, there are several large-scale neurosurgery centers (Beijing Tiantan Hospital, Shanghai Huashan Hospital, Peking Union Medical College Hospital, 301 Hospital, and West China Hospital) that perform >200 cases of endoscopic transnasal pituitary adenoma resection each year.
During the past few decades, Chinese endoscopic neurosurgery has rapidly developed in synchrony with the rest of the world. The aim of this article is to review the development of Chinese endoscopic neurosurgery, including its birth, growth, current situation, and prospects.
The history of Chinese endoscopic neurosurgery development can be divided into 3 stages: cognition and initial stage (1964–1995), exploration and maturity stage (1995–2006), and rapid development and promotion stage (2006–present).
In the first stage, we mainly began to become aware of endoscopic neurosurgery from the translation and review of literature. In the mid to late 1990s, Chinese neurosurgery pioneers began using neuroendoscopic techniques. In the following decade, many leading neurosurgeons made persistent efforts to push the development of Chinese endoscopic neurosurgery forward, focusing on advocating for and promoting and popularizing neuroendoscopic technology. In the rapid development and promotion stage, many representative national and regional neurosurgical centers became skilled and efficient in the application of neuroendoscopic technology and became new advocates of the technology. The number of cases, level of technology, and treatment effectiveness are gradually nearing international standards. However, future development requires promotion of balanced development to decrease regional disparities, further strengthen international exchanges, follow the latest developments, and constantly innovate for continuous improvement.
Following the dramatic efforts of several pioneers, development of Chinese endoscopic neurosurgery has been considerable, and it has become an important component of neurosurgery worldwide.
Utility and safety of the flexible-Fiber CO<inf>2</inf> laser in endoscopic endonasal transsphenoidal surgery
2011, World Neurosurgery
Citation Excerpt :
In our series, the case cohort was small (n = 16); all of the tumors were macroadenomas, with an average size being 22.7 mm. This average size is larger than those reported by other groups (15, 27). Further, our study included tumors other than pituitary adenomas as well.
This study sought to report on the utility and safety of the flexible-fiber CO₂ laser in endoscopic endonasal transsphenoidal surgery.
A retrospective chart review identified 16 patients who underwent laser-assisted transsphenoidal surgery. All tumor pathology types were considered. Results were assessed based on hormone status, tumor size, pathology, complications, and resection rates.
Sixteen pituitary lesions (pituitary adenomas, 12; Rathke cleft cyst, 2; pituitary cyst and craniopharyngioma, 1 each) with an average size of 22.7 mm were identified by radiographic and pathologic criteria. All patients underwent flexible-fiber CO₂ laser-assisted endoscopic endonasal transsphenoidal surgery. Of the adenomas, 8 were nonsecreting and 4 were secreting (3 prolactinomas and 1 ACTH secreting). Gross total resection was achieved in 7 of 16 patients (43.75%) with hormone remission in all patients (100%) after a mean follow-up of 19.3 months. Postoperative complications occurred in 3 patients (18.75%): 2 patients developed transient diabetes insipidus (DI) and 1 developed a CSF leak requiring surgical repair. Five patients (31.25%) underwent postoperative radiation to the residual lesions.
We found that CO₂-laser-assisted endoscopic endonasal transsphenoidal surgery for sellar tumors is a minimally invasive approach using a tool that is quick and effective at cutting and coagulation. The surgery has a low rate of complication, and no laser-related complications were encountered. The laser fiber allows the surgeon to safely cut and coagulate without the line-of-sight problems encountered with conventional CO₂ lasers. Further studies are recommended to further define its role in endoscopic endonasal sellar surgery.
Endoscopic Transsphenoidal Surgery of Pituitary Adenomas: Preliminary Results of the Neurosurgery Service of Hospital Cristo Redentor
2021, Brazilian Neurosurgery
India's march towards development of treatment for pituitary tumors
2020, Neurology India
Endoscopic Transnasal Trans-Sphenoidal Approach for Pituitary Adenomas: A Comparison to the Microscopic Approach Cohort by Propensity Score Analysis
2020, Clinical Neurosurgery

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Original contributionEndonasal transsphenoidal pituitary surgery: is tumor volume a key factor in determining outcome?

Abstract

Purpose

Materials and methods

Results

Conclusion

Introduction

Section snippets

Materials and methods

Results

Discussion

Conclusion

Trans-sphenoidal approach to the pituitary gland

Surgical experiences with pituitary disorders

JAMA

Disorders of the pituitary gland. Retrospective and prophetic

JAMA

Zur Frage Der Operationen an der Hypophyse. Beitr Klin Chir 50:767–817, 1906, as quoted by Spencer WR, Levine J, Couldwell W, Brown-Wegener, Moscatello A: approaches to sellar and parasellar region

Otolaryngol Head Neck Surg

Transphenoidal microsurgery of the normal and pathological pituitary

Clin Neurosurg

Functional endoscopic sinus surgery. Theory and diagnostic evaluation

Arch Otolaryngol

The use of the rigid endoscope in transsphenoidal pituitary surgery

J Laryngol Otol

Endoscopic transseptal transsphenoidal surgery for pituitary tumors

Neurosurgery

Endoscopic endonasal transsphenoidal approach to the sella: towards functional endoscopic pituitary surgery (FEPS)

Minim Invasive Neurosurg

The endocrine system

Endoscopic endonasal pituitary surgery: evolution of surgical technique and equipment in 150 operations

Minim Invasive Neurosurg

Transsphenoidal approach in surgical treatment of pituitary adenomas: general principles and indications in non functioning adenomas

Excerpta Med Int Congr Ser

Original contribution
Endonasal transsphenoidal pituitary surgery: is tumor volume a key factor in determining outcome?