Elsevier

World Neurosurgery

Volume 82, Issues 1–2, July–August 2014, Pages e281-e290
World Neurosurgery

Peer-Review Report
Giant Pituitary Adenomas: Surgical Outcomes of 50 Cases Operated on by the Endonasal Endoscopic Approach

https://doi.org/10.1016/j.wneu.2013.08.028Get rights and content

Objective

To present our experience with the surgical management of giant pituitary adenomas in a series of 50 cases operated on by an endoscopic endonasal approach.

Methods

A retrospective data analysis of all patients who underwent transsphenoidal endonasal endoscopic surgery at the General Hospital of Fortaleza, Brazil, between January 1998 and November 2011 was performed. Patients who presented with pituitary adenomas larger than 4 cm were included in the study. Analysis of factors related to the choice of the operative approach, hormonal and visual status, extent of resection, tumor control rates, clinical outcome, and complications were evaluated.

Results

Fifty cases (10.41%) matched our inclusion criteria. Nonfunctioning tumors were present in 42 patients (84%); among functioning adenomas, five patients (10%) had growth hormone−secreting adenomas, and three patients (6%) had prolactinomas. Total removal of the tumor occurred in 19 cases (38%), near-total removal in 9 cases (18%), and partial removal in 22 cases (44%). Postoperative cerebrospinal fluid leaks occurred in four cases (8%). Postoperative diabetes insipidus was present in 10% and new anterior pituitary insufficiency affecting one axis or more than one axis was observed in 22% and 14%, respectively. The presence of Knosp score ≥3 was associated with subtotal resection. Patients harboring hormonally active adenomas were submitted to adjuvant medical therapy for long-term clinical control. Vision improved in 38 patients (76%), with only one case of visual deterioration reported.

Conclusion

Transsphenoidal endoscopic endonasal surgery may provide effective treatment for patients with giant adenomas when performed by a surgical team that specializes in pituitary surgery. In cases in which total resection by the endoscopic approach may be associated with important complications, we advocate the use of partial resections followed by adjuvant drug therapy or radiotherapy. In cases of progressive enlargement of residual lesions, a second endoscopic debulking of the tumor may be considered for control of the disease.

Introduction

Giant pituitary adenomas are defined as tumors larger than 4 cm in maximum diameter in any direction. They comprise 5%−16% of all pituitary adenomas in surgical series 1, 16, 29, 42, 43. This type of tumor grows slowly and, in some cases, becomes demarcated from normal pituitary tissue by a pseudocapsule (6).

The large dimension of those tumors and their proximity to important neurovascular structures in the skull base justify, partially, the low rates of gross total resection, which less than 50% in some previous studies 7, 29, 36.

Surgical resection is the main treatment option for giant pituitary adenomas. The objectives in those cases are to achieve maximal tumor resection, improve visual function and other neurological deficits, and to preserve the hormonal function of the normal pituitary gland.

In the current report, we retrospectively review the surgical outcome of patients who underwent transsphenoidal endoscopic removal of giant pituitary adenomas in our department. In addition, we discuss the factors related to the operative approach and the complications related to this procedure.

Section snippets

Study Design

A retrospective analysis of all patients who underwent endoscopic transsphenoidal surgery for skull base lesions from January 1998 to December 2011 was performed. To evaluate the patients with giant adenomas, we only included in our study cases who presented with pituitary lesions greater than 4 cm who underwent surgical treatment by the transsphenoidal endoscopic approach. Exclusion criteria included patients who had been undergone transcranial procedures, patients younger than 18 years of

Epidemiology

From 1998 to 2011, a total of 480 patients underwent endoscopic transsphenoidal procedures for treatment of sellar lesions in our department. Fifty patients of this group (10.4%) had a giant pituitary adenoma. This group was composed of 33 (66%) males and 17 (34%) females (male to female ratio was 2:1). Most of the patients were in their third and fifth decades of life (18 to 78 years, mean age: 48.2). The mean follow-up period was 5 years (range, 4 months to 13 years).

Clinical History

The main clinical

Discussion

Pituitary adenomas are benign, slow-growing tumors 7, 43. They constitute approximately 2%–17% of all intracranial tumors 27, 45. Giant pituitary adenomas represent 5%–16% of all pituitary tumors 1, 6, 14, 16, 23, 24, 30, 40, 42, 44. Pituitary adenomas may reach such large dimensions without being detected for several reasons. Patients with silent corticotrophic adenoma, patients with nonfunctional adenoma, and male patients with prolactinomas have tumors that grow slowly without significant

Conclusion

Giant pituitary adenomas represent an important challenge to neurosurgeons. Transsphenoidal endoscopy surgery is a safe and effective procedure for the treatment of patients with giant pituitary tumor, if performed by a group of surgeons who specialize in pituitary surgery. The main goal of the surgical treatment of such lesions is to achieve maximum tumor resection with minimum side effects by careful preoperative planning of the operative approach. Additionally, radiotherapy, long-term

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    Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

    All authors contributed equally to the development of the manuscript.

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