J Neurosurg 112:108–117, 2010. (DOI: 10.3171/2009.3.JNS0929)
The standard transsphenoidal approach has been successfully used to resect most pituitary adenomas. However, as a result of the limited exposure provided by this procedure, complete surgical removal of pituitary adenomas with parasellar or retrosellar extension remains problematic. By additional bone removal of the cranial base, the extended transsphenoidal approach provides better exposure to the parasellar and clival region compared with the standard approach. The authors describe their surgical experience with the extended transsphenoidal approach to remove pituitary adenomas invading the anterior cranial base, cavernous sinus (CS), and clivus. Methods. Retrospective analysis was performed in 126 patients with pituitary adenomas that were surgically treated via the extended transsphenoidal approach between September 1999 and March 2008. There were 55 male and 71 female patients with a mean age of 43.4 years (range 12–75 years). There were 82 cases of macroadenoma and 44 cases of giant adenoma. Results. Gross-total resection was achieved in 78 patients (61.9%), subtotal resection in 43 (34.1%), and partial resection in 5 (4%). Postoperative complications included transient cerebrospinal rhinorrhea (7 cases), incomplete cranial nerve palsy (5), panhypopituitarism (5), internal carotid artery injury (2), monocular blindness (2), permanent diabetes insipidus (1), and perforation of the nasal septum (2). No intraoperative or postoperative death was observed. Conclusions. The extended transsphenoidal approach provides excellent exposure to pituitary adenomas invading the anterior cranial base, CS, and clivus. This approach enhances the degree of tumor resection and keeps postoperative complications relatively low. However, radical resection of tumors that are firm, highly invasive to the CS, or invading multidirectionally remains a big challenge. This procedure not only allows better visualization of the tumor and the neurovascular structures but also provides significant working space under the microscope, which facilitates intraoperative manipulation. Preoperative imaging studies and new techniques such as the neuronavigation system and the endoscope improve the efficacy and safety of tumor resection.
DOI: 10.3171/2008.10.JNS0880
The aim of this study was to evaluate the results of surgical treatment of adult craniopharyngioma with a special focus on the endocrinological outcomes and tumor recurrence in cases of pituitary preservation.
Methods: Between 1993 and February 2008, 41 patients underwent 47 surgical procedures for craniopharyngioma. The male/female ratio was 26:15 and the median age was 45.8 years (range 17–65 years). The median follow-up period was 10.56 years (range 6.2–14.9 years). Patients presented with visual disturbance before 30 (63.8%) of 47 procedures and with endocrinological disturbance before 12 (26%) procedures. Surgery was performed via a subfrontal/pterional approach in 31 procedures (66%), bifrontal interhemispheric in 6 (12.8%), transcallosal/transventricular in 5 (10.6%), combined in 1 (2.1%), and transsphenoidal in 4 (8.5%). The tumor was totally removed in 36 procedures (76.6%), subtotally in 10 (21.3%), and partially in 1 (2.1%).
Results: Postoperatively, the rates of visual improvement and aggravation were 50 and 33.3%, respectively. Of 24 patients in whom the pituitary stalk was preserved, complete hormone replacement was needed in 14 (58.3%), partial replacement in 2 (8.3%), and no replacement in 8 (33.3%). The rate of tumor recurrence was 24.4%. The recurrence-free survival rate was significantly different between patients in whom complete tumor resection was accomplished and those in whom tumor resection was incomplete. Stalk preservation did not affect the recurrence-free survival rate. The morbidity and mortality rates were 8.5 and 2.1%, respectively.
Conclusions: The pituitary stalk must be preserved with maximal tumor resection whenever possible to increase the chance of intact anterior pituitary function being maintained. The results of the present study show that pituitary stalk preservation may not be related to increased recurrence rates.
J Neurosurg 111 (3)563-571. DOI: 10.3171/2008.4.17517
In residual nonfunctioning pituitary adenomas, reliable prognostic parameters indicating probability of tumor progression are needed. The Ki 67 expression/MIB-1 labeling index (LI) is considered to be a promising candidate factor. The aim in the present study was to analyze the clinical usefulness of MIB-1 LI for prognosis of tumor progression.
Methods: The authors studied a cohort of 92 patients with nonfunctioning pituitary adenomas. Based on sequential postoperative MR images, patients were classified as tumor free (51 patients) or as harboring residual tumor (41 individuals). The residual tumor group was further subdivided in groups with stable residual tumors (14 patients) or progressive residual tumors (27 patients). The MIB-1 LI was assessed in tumor specimens obtained in all patients, and statistical comparisons of MIB-1 LI of the various subgroups were performed.
Results: The authors found no significant difference of MIB-1 LI in the residual tumor group compared with the tumor-free group. However, MIB-1 LI was significantly higher in the progressive residual tumor group, compared with the stable residual tumor group. Additionally, the time period to second surgery was significantly shorter in residual adenomas showing an MIB-1 LI > 3%.
Conclusions: The data indicate that MIB-1 LI in nonfunctioning pituitary adenomas is a clinically useful prognostic parameter indicating probability of progression of postoperative tumor remnants. The MIB-1 LI may be helpful in decisions of postoperative disease management (for example, frequency of radiographic intervals, planning for reoperation, radiotherapy, and/or radiosurgery).
