Clinical and Radiographic Characteristics and Postoperative Outcomes of a Single-Center Experience of Combined Endoscopic and Transcranial Approach for Giant Pituitary Neuroendocrine Tumors

Introduction: Endoscopic transsphenoidal surgery (ETSS) remains the gold standard approach for resection of pituitary neuroendocrine tumors (PitNETs). Giant PitNETs, however, remain a surgical challenge as extension of the tumor into the parasellar compartments often limits resection via an endoscopic approach. Addition of a transcranial (TC) approach, either in the same setting or as a staged approach offers improved visualization and working angles for resection of tumor extending beyond the midline skull base or third ventricle and decompression of neurovascular structures of the parasellar region.

Methods: An IRB-approved, single-center, retrospective cohort study of patients undergoing combined TC and ETSS for resection of PitNETs at the University of Washington between 2011 and 2022 was performed. The electronic medical record was queried for demographic, clinical, radiographic, pathologic, and surgical data. Descriptive statistics were used for analysis.

Results: A total of 13 patients underwent a combined TC and ETSS approach. Ten (76.9%) patients underwent the combined approach simultaneously while 3 (23.1%) underwent a staged approach. A total of 8 (61.5%) patients presented with nonfunctional PitNETs, three (23.1%) with acromegaly, and two (15.3%) with Cushing’s disease. The average tumor volume was 19.9 cm³. Cavernous sinus invasion was identified in 92.3% of patients (Knosp grade 2: n = 4, grade 3A: n = 1, grade 3B: n = 1, grade 4: n = 6). Gross total resection was achieved in six patients (46.3%) with residual tumor being present in those patients undergoing subtotal resection in the cavernous sinus (85.7%) or suprasellar compartments (42.9%). Average ICU and hospital length of the stay were 6.2 and 13.4 days, respectively. Complications of the combined approach included postoperative CSF leak (30.8%), symptomatic vasospasm (15.4%), meningitis (15.4%), hemorrhage (23.1%), and postoperative hydrocephalus (7.7%). A total of 5 (38.5%) patients required readmission within 30 days, for reasons of CSF leak (n = 4) and delayed onset of hydrocephalus (n = 1). Recurrence/progression occurred in five patients (38.5%), and of those, three underwent repeat resection and two underwent radiosurgery. One patient died in the postoperative period secondary to extensive vasospasm and stroke (7.7%).

Conclusion: The combined TC and ETSS approach for resection of giant pituitary adenomas provides the benefit of enhanced intraoperative visualization and improved working angles, especially for tumor extending beyond the midline skull base. For giant pituitary adenomas, it increases the likelihood of achieving gross total resection though residual tumor within the cavernous sinus or adherent to critical midline or parasellar neurovascular structures is often the limiting compartments from achieving a complete resection.

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Artikel online veröffentlicht:
05. Februar 2024