Elsevier

Surgical Neurology

Volume 52, Issue 4, October 1999, Pages 380-385
Surgical Neurology

Neoplasm
Management of nonfunctioning pituitary adenomas with suprasellar extensions by transsphenoidal microsurgery

https://doi.org/10.1016/S0090-3019(99)00120-2Get rights and content

Abstract

BACKGROUND

We evaluated the feasibility and therapeutic effectiveness of transsphenoidal microsurgical removal of nonfunctioning pituitary adenomas with suprasellar extensions. The diagnostic modes, surgical technique, and outcome were reviewed in 208 patients with pituitary adenomas extending beyond the sella turcica who were treated by transsphenoidal microsurgery. All patients except three presented with significantly diminished visual acuity and visual field defects.

METHODS

Diagnosis was confirmed by skull X-ray plain films, CT, or MRI scanning. Operations were performed via a transsphenoidal approach under microscope. A subarachnoid catheter was preoperatively inserted in the lumbar cistern, through which saline was slowly injected during operation to increase the intracranial pressure so as to move the suprasellar tumor into the operative field to aid the removal.

RESULTS

In this series, gross total removal of an adenoma in 146 cases (70.2%) and subtotal removal in 50 cases (24.0%) was achieved; partial removal was carried out in the remaining 12 cases (5.8%) of fibrous or dumbbell-shaped adenomas. There were no deaths in this group. Follow-up review (median 3.8 years) in 187 patients revealed that 97.8% of those with preoperative diminished visual acuity had postoperative improvement; 2.2% had no change, and none deteriorated significantly. Among 181 patients with preoperative visual field defects, postoperative improvement was good in 169 (93.4%), and poor in 12 (6.6%). The major complications were diabetes insipidus and cerebrospinal fluid rhinorrhea, which occurred in 13.5% and 4.8% of patients, respectively. The tumors recurred in 12 patients (6.4%) who were considered to have a macroscopically complete removal at surgery. Continuing growth of residual tumors was found in 31 (16.6%) based on visual acuity decrease, visual field defects, and CT or MRI examination. Of the recurrent and residual tumors, 4, 9, 17, and 13 cases belonged to Grades A, B, C, and D, respectively.

CONCLUSIONS

Comparison with transfrontal surgery suggests that these results are as good as those of transfrontal procedures and that the incidence of serious side effects is considerably lower. We consider that the microsurgical removal of pituitary tumors by the transsphenoidal approach is safe and effective even in very large or giant adenomas, since it allows rapid and adequate decompression of the optic nerves and chiasm.

Section snippets

Patients and methods

From July 1982 to July 1997, we operated on 536 patients for pituitary adenomas by the transsphenoidal approach. A total of 208 patients had NPASE—soft adenomas in 196 cases and hard fibrous or dumbbell-shaped adenomas in 12 cases. Recurrence after transsphenoidal microsurgery occurred in seven patients; five of these had undergone radiotherapy. There were 98 males (47.1%) and 110 females (52.9%) aged from 16 to 71 (mean 47.5). Fifty-six patients (26.9%) were aged between 16 and 30 years, and

Results

In this series, total removal was achieved in 146 patients (70.2%), which included 137 Grades A and B, and 9 Grades C and D (Fig. 2). Subtotal removal was achieved in 50 patients (24.0%), which included 17 Grades A and B, 26 Grade C, and 7 Grade D. Partial removal was done in the remaining 12 patients including 3 Grade C and 9 Grade D (5.8%), because the tumors were dumbbell-shaped or fibrous and it was difficult to remove the suprasellar portion of the tumour via the transsphenoidal approach.

Discussion

NPASE are difficult to diagnose in the early stage because of the lack of endocrine symptoms. Only when the tumor mass is large enough to extend beyond the sella turcica and result in visual field defect or loss of visual acuity does the patient seek treatment [4]. The diagnosis of NPASE can be suspected according to the clinical manifestations and can be confirmed by radiological evidence of a mass in the sellar region and its boundaries, and abnormalities of the parasellar and suprasellar

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