Long term outcome of patients undergoing combined transcranial and transsphenoidal resection of giant pituitary adenomas – a retrospective study

Abstract

Objective:

The extended endoscopic transsphenoidal approach for tackling giant pituitary adenomas, albeit safe and effective, is technically challenging and requires expertise. A widely adopted alternative is the “above and below” approach which combines the best of both transcranial and transsphenoidal approaches: it aids complete resection of large suprasellar lesions whilst reducing the risk of hemorrhage within the intradural space respectively. Here we present our experience in treating giant pituitary adenomas via a single-setting combined approach, with a focus on the long term outcomes and clinical implications on patient management.

Method: A retrospective review was carried out on patients undergoing combined approach for treatment of pituitary adenoma in our center during October 2000 – October 2017. Outcomes in terms of completeness of resection, surgical complications, permanent endocrine and visual deficits, resolution of presenting symptoms and presence of residual or recurrent tumors were reviewed.

Results: Our study included 25 patients, 16 women and 9 men with an average age of presentation at 49 years (range 17 – 85 years). 20 patients (80%) presented to us for the first time, whilst 5 patients (20%) had history of prior resection. Symptoms on presentation include visual disturbance (92%), obstructive hydrocephalus (8%), acute confusion (8%), acromegaly (4%), and cranial nerve palsy (4%). Tumor height range was 2.4 – 5.8cm.

There were three patients (12%) with CSF leakage, three incidents of cranial nerve injury (12%), two graft donor site complications (8%), one case of meningitis (4%), and one case of deep vein thrombosis and subsequent pulmonary embolism (4%). No post-operative intracranial hemorrhage or operative mortality was reported. Permanent hormonal deficit was noted in 21 patients (84%), whilst 14 patients (56%) had persistent visual defects. On discharge, 11 patients (44%) had complete resolution of presenting symptoms.

56% gross total removal was achieved: 10 patients remained tumor-free; 3 patients had residual disease of which 1 required radiotherapy for progressive disease; and 1 patient refused post-operative MRI resulting in unknown tumor status. Subtotal removal was performed in 44% of cases with 6 patients having static residual disease. 10 patients in total received post-operative radiotherapy whilst two patients are pending reassessment imaging before deciding if adjuvant therapy is needed.

Conclusion: With limited existing data, it is difficult to make direct comparisons on the safety and effectiveness of combined approaches in treating pituitary macroadenomas. However, from our results alone, we can conclude a 100% success rate in avoiding post-operative intracranial hemorrhage, which is an important advantage advocated by this technique. Furthermore, with the exception of one case, all our patients achieved either tumor-free status or static residual disease. The application of this surgical technique in clinical practice still requires further studies to analyze which group of patients would benefit the greatest from this approach.