A Giant Pituitary Adenoma: Surgical Excision via a Staged Endoscopic and Open Approach

Oluwafikayo Fayeye, Amjad Shad

Department Neurosurgery, University Hospital of Coventry and Warwickshire, Coventry, UK.

DOI: 10.4236/wjns.2014.45048                

Abstract

The operative management of giant pituitary adenomas represents a significant challenge for neurosurgeons. This challenge is amplified by the degree of local tumour infiltration into adjacent structures such as the cavernous sinus. The degree of parasellar tumour extension can be classified according to the Knosp grading system’ while suprasellar extension is qualified in accordance with the Modified Hardys classification system. We report a 59 year male with a Knosp grade 4, Hardys C giant pituitary adenoma in which two-stage near total surgical resection via an expanded endoscopic transphenoidal approach and subsequent bifrontal craniotomy was achieved. Typically, resection rates of less than 50% have been reported following surgery on giant pituitary adenomas. Traditionally multi-modal treatment strategies with adjuvant stereotactic radiotherapy or radio surgery, has been the gold standard in the management of these locally aggressive tumours. This case serves to illustrate that even in the presence of significant suprasellar and parasellar extension, radical resection of giant pituitary adenomas can be achieved.

Keywords

Pituitary Adenoma, Giant, Endoscopy

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	Matsuyama, J., Kawase, T., Yoshida, K., Hasegawa, M., Hirose, Y., Nagahisa, S., Watanabe, S. and Sano, H. (2010) Management of Large and Giant Pituitary Adenomas with Suprasellar Extensions. Asian Journal of Neurosurgery, 5, 48-53.
[2]	De PaivaNeto, M.A., Vandergrift, A., Fatemi, N., Gorgulhot, A., DeSalles, A., Cohan, P., Wang, C., Swerdloff, R. and Kelly, D. (2010) Endonasaltranssphenoidal Surgery and Multimodality Treatment for Giant Pituitary Adenomas. Clinical Endocrinology, 72, 512-519. http://dx.doi.org/10.1111/j.1365-2265.2009.03665.x
[3]	Sinha, S. and Sharma, B.S. (2010) Giant Pituitary Adenomas—An Enigma Revisited. Microsurgical Treatment Strategies and Outcome in a Series of 250 Patients. British Journal of Neurosurgery, 24, 31-39. http://dx.doi.org/10.3109/02688690903370305
[4]	Jefferson, A. (1969) Chromophobe Pituitary Adenomata—The Size of the Suprasellar Portion in Relation to the Safety of Operation. Journal of Neurology, Neurosurgery & Psychiatry, 32, 633.
[5]	Shrestha, R., Bao, G., Wei, W. and Wang, M. (2012) Risk Factor Analysis on the Predictors of the Transsphenoidal Pituitary Surgery on Marco-Adenomas: A Multivariate Logistic Regression Analysis. Nepal Journal of Neuroscience, 9, 10-16.
[6]	Fahlbusch, R. and Buchfelder, M. (1988) Transsphenoidal Surgery of Parasellar Pituitary Adenomas. Acta Neurochirurgica, 92, 93-99. http://dx.doi.org/10.1007/BF01401978
[7]	Saito, K., Kuwayama, A., Yamamoto, N., et al. (1995) The Transsphenoidal Removal of Non-Functioning Pituitary Adenomas with Suprasellar Extensions: The Open Sella Method and Intentionally Staged Operation. Neurosurgery, 36, 668-676.http://dx.doi.org/10.1227/00006123-199504000-00005
[8]	Goel, A., Nadkarni, T., Muzumdar, D., et al. (2004) Giant Pituitary Tumours: A Study Based on Surgical Treatment of 118 Cases. Surgical Neurology, 61, 436-445. http://dx.doi.org/10.1016/j.surneu.2003.08.036
[9]	Mortini, P., Barzaghi, R., Losa, M., et al. (2007) Surgical Treatment of Giant Pituitary Adenomas: Strategies and Results in a Series of 95 Consecutive Patients. Neurosurgery, 60, 993-1004. http://dx.doi.org/10.1227/01.NEU.0000255459.14764.BA
[10]	Fatemi, N., Dusick, J.R., De Paiva Neto, M.A., et al. (2008) The Endonasal Microscopic Approach for Pituitary Adenomas and Other Parasellartumors: A 10-Year Experience. Neurosurgery, 63, 244-56. http://dx.doi.org/10.1227/01.NEU.0000327025.03975.BA
[11]	Dusick, J.R., Esposito, F., Kelly, D.F., et al. (2005) The Extended Direct Endonasaltranssphenoidal Approach for Nonadenomatoussuprasellar Tumours. Journal of Neurosurgery, 102, 832-841. http://dx.doi.org/10.3171/jns.2005.102.5.0832
[12]	Garibi, J., Pomposo, I., Villar, G. and Gaztambide, S. (2002) Giant Pituitary Adenomas: Clinical Characteristics and Surgical Results. British Journal of Neurosurgery, 16, 133-139. http://dx.doi.org/10.1080/02688690220131723
[13]	Zhang, X., Fei, Z., Zhang, J., Fu, L., Zhang, Z., Liu, W., et al. (1999) Management of Non-Functioning Pituitary Adenomas with Suprasellar Extensions by Transsphenoidal Microsurgery. Surgical Neurology, 52, 380-385. http://dx.doi.org/10.1016/S0090-3019(99)00120-2
[14]	Mortini, P. and Giovanelli, M. (2002) Transcranial Approaches to Pituitary Tumours. Operative Techniques in Neurosurgery, 5, 239-251. http://dx.doi.org/10.1053/otns.2002.36326
[15]	Youssef, A.S., Agazzi, S. and Van Loveren, H.R. (2005) Transcranial Surgery for Pituitary Adenomas. Neurosurgery, 57, 168-75. http://dx.doi.org/10.1227/01.NEU.0000163602.05663.86