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ObjectiveLarge and giant pituitary adenomas (L- and G-PAs) continue to remain a surgical challenge. The diaphragm may have a role in determining the shape of the tumor and therefore influencing the extent of resection. Our study aims to analyze our surgical series of L- and G-PAs according to their relationship with the diaphragm and invasion of cavernous sinus (CS).Material and methodsWe performed a retrospective analysis of our surgical series of patients operated for L- and G-PAs. We categorized the tumors into four grades according to their relationship with the diaphragm: grade 1 (supradiaphragmatic component with a wide incompetent diaphragm), grade 2 (purely infra-diaphragmatic tumor with a competent diaphragm), grade 3 (dumbbell-shape tumors), and grade 4 (multilobulated tumor with invasion of the subarachnoid space).ResultsA total of 37 patients were included in our analysis. According to our classification, 43.3% of patients had grade 1 tumors, 27% had grade 2, 5.4% had grade 3, and 24.3% had grade 4 tumors. CS invasion was confirmed intraoperatively in 17 out of 37 patients (46%). The gross total resection (GTR) was obtained in 19% of the cases, near-total resection in 46%, and subtotal resection in 35%. All the patients who achieved GTR had grade 1 tumors and the lowest rate of CS invasion (p < 0.01).ConclusionRadiological evaluation of the tumor relationship with the diaphragm, invasion of CS, and invasion of the subarachnoid space are crucial to plan the surgical strategy and maximize the possibilities of achieving GTR in L- and G-PAs.

To the Editor:We read with great interest the article by Laxpati et al 1 discussing spinal arachnoid webs (SAWs) in a series of 38 patients. In their single largest case series, the authors detail conservative and operative management and their respective outcomes to better comprehend the possible advantage of surgical therapy. Importantly, they found that one of the most common preoperative presenting symptoms was myelopathy, which was further less usual in postoperative patients. Laxpati et al 1 nicely conclude that in the case of this rare entity, which is SAW, surgery stabilizes or improves preoperative symptoms. Moreover, a conservative management will not evolve toward spontaneous alleviation. We would like to suggest several aspects that are, in our opinion, important in relationship with SAWs and would deserve further detailing.The initial preoperative clinical and radiological diagnosis is of crucial importance. In particular, the initial anamnesis should exclude other potential pathologies, including (but not limited to) subarachnoid hemorrhage, previous surgeries, infections, or trauma. Moreover and of importance, another