Endoscopic endonasal transoculomotor triangle approach for adenomas invading the parapeduncular space: surgical anatomy, technical nuances, and case series

Nunes, Cristian Ferrareze; Lieber, Stefan; Truong, Huy Q.; Zenonos, Georgios A.; Wang, Eric; Snyderman, Carl H.; Gardner, Paul A.; Fernández-Miranda, Juan C.

doi:10.3171/2017.10.jns17779

Cited by 29 publications

(19 citation statements)

References 17 publications

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“…Since the long‐term surgical remission rate is highly dependent on cavernous sinus invasion and the extent of resection, 16,20 proactive surgery with an intent to cure should be planned to achieve local control and endocrinological remission, especially for SG tumours. Encouragingly, in recent years, transsphenoidal surgery has shown good results in treating pituitary adenomas with a high Knosp grade and cavernous sinus invasion 5‐11,21 . Despite refinement in surgical and monitoring techniques, operative risk from radical resection should still be kept in mind during the surgical plan.…”

Section: Discussionmentioning

confidence: 99%

“…The favoured corridor for tumour resection is via the transsphenoidal route, using either a microscope or an endoscope. With advances in extended endonasal surgery, pituitary tumours invading the cavernous sinus could be directly removed by opening the medial, anterior, inferior walls of the cavernous sinus and different compartments inside it 5‐11 . Even the medial wall of the cavernous sinus invaded by the tumour could be removed with a microsurgical technique under endoscopy 5,7 .…”

Section: Introductionmentioning

confidence: 99%

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Preoperative prediction of granulation pattern subtypes in GH‐secreting pituitary adenomas

Heng

Liu

Dong

et al. 2021

Clinical Endocrinology

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Objective The aim of this study was to establish a preoperative prediction method for sparsely granulated (SG) growth hormone (GH)‐secreting pituitary adenoma, an aggressive tumour subtype with high recurrence risk, in acromegaly patients. Methods Eighty‐three patients with GH‐secreting pituitary adenomas were included in this study. GH measurements, cytokeratin immunostaining and electron microscopy were performed to detect granulation patterns. Preoperative factors, including general, radiological and endocrinological features and acute octreotide suppression test outcomes, were compared between SG and densely granulated (DG) groups. The predictive capabilities of these features were analysed using a receiver operating characteristic (ROC) curve, and the most predictive features were combined to establish a grading scale. Results Thirty‐nine of the 83 patients had SG GH‐secreting pituitary adenomas; 44 had DG tumours. SG tumours tended to occur in younger patients and have larger diameters and volumes, higher Knosp grades, lower GH indexes and normalized insulin‐like growth factor‐1 (IGF‐1) level, and a lower ∆GH% after octreotide treatment. The tumour size, Knosp grade, GH index and ∆GH% after octreotide treatment had good predictive performance, with area under the curve (AUC) values ranging from 0.70 to 0.80. Combining four parameters, including diameter, Knosp grade, GH index and ∆GH% after octreotide treatment, we established a grading scale for predicting SG GH‐secreting pituitary adenomas with an AUC of 0.84 and relatively high sensitivity and specificity. Conclusions We propose a predictive method for distinguishing SG and DG GH‐secreting pituitary adenomas preoperatively. This method will help physicians identify candidates for presurgical medical treatment and neurosurgeons determine radical surgical strategies for high‐risk tumours.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Preoperative prediction of granulation pattern subtypes in GH‐secreting pituitary adenomas

Heng

Liu

Dong

et al. 2021

Clinical Endocrinology

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“…Kawase et al found three weak points of CS: at the level of venous plexus of SOF, at the medial wall of pituitary gland, and at the cisternal segment of the intracavernous portion of IIIrd and Vth cranial nerves [48]. According to some authors, macro-PAs may indeed show a preferential growth pathway extending into the parapeduncular space through the oculomotor triangle [49][50][51][52]. The dural layer of the cistern of the oculomotor nerve could be thin or even lacking, representing a possible point of diffusion exploitable by PAs [49].…”

Section: Anatomy Of the Sellar And Parasellar Regionmentioning

confidence: 99%

Pituitary Adenomas and Invasiveness from Anatomo-Surgical, Radiological, and Histological Perspectives: A Systematic Literature Review

Serioli

Doglietto

Fiorindi

et al. 2019

Cancers

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Invasiveness in pituitary adenomas has been defined and investigated from multiple perspectives, with varying results when its predictive value is considered. A systematic literature review, following PRISMA guidelines, was performed, searching PubMed and Scopus databases with terms that included molecular markers, histological, radiological, anatomical and surgical data on invasiveness of pituitary adenomas. The results showed that differing views are still present for anatomical aspects of the sellar region that are relevant to the concept of invasiveness; radiological and histological diagnoses are still limited, but might improve in the future, especially if they are related to surgical findings, which have become more accurate thanks to the introduction of the endoscope. The aim is to achieve a correct distinction between truly invasive pituitary adenomas from those that, in contrast, present with extension in the parasellar area through natural pathways. At present, diagnosis of invasiveness should be based on a comprehensive analysis of radiological, intra-operative and histological findings.

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“…For example, when the tumor breaks through the superior triangle and enters the parapeduncular space, the trajectory of the posterior communicating artery runs medial and nearly parallel to the oculomotor nerve in most cases. 5 When the tumor breaks through the posterior triangle, the superior cerebellar artery and other basilar artery branches will be encountered. An awareness of intracavernous and intracranial neurovascular structure relationships involved in tumor invasion can potentially prevent vascular injuries.…”

Section: Discussionmentioning

confidence: 99%

Intracranial Breakthrough Through Cavernous Sinus Compartments: Anatomic Study and Implications for Pituitary Adenoma Surgery

Mohyeldin²,

Asmaro³

et al. 2022

Operative Neurosurgery

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BACKGROUND:Pituitary adenomas (PAs) with cavernous sinus (CS) invasion can extend into the intradural space by breaking through the CS walls.OBJECTIVE:To elaborate on the potential breakthrough route through CS compartments for invasive PAs and describe relevant surgical anatomy and technical nuances, with an aim to improve resection rates.METHODS:Twelve colored silicon-injected human head specimens were used for endonasal and transcranial dissection of the CS walls; ligaments, dural folds, and cranial nerves on each compartment were inspected. Two illustrative cases of invasive PA are also presented.RESULTS:The potential breakthrough routes through the CS compartments had unique anatomic features. The superior compartment breakthrough was delimited by the anterior petroclinoidal ligament laterally, posterior petroclinoidal ligament posteriorly, and interclinoidal ligament medially; tumor extended into the parapeduncular space with an intimate spatial relationship with the oculomotor nerve and posterior communicating artery. The lateral compartment breakthrough was limited by the anterior petroclinoidal ligament superiorly and ophthalmic nerve inferiorly; tumor extended into the middle fossa, displacing the trochlear nerve and inferolateral trunk to reach the medial temporal lobe. The posterior compartment breakthrough delineated by the Gruber ligament, petrosal process of the sphenoid bone, and petrous apex inferiorly, posterior petroclinoidal ligament superiorly, and dorsum sellae medially; tumor displaced or encased the abducens nerve and inferior hypophyseal artery and compressed the cerebral peduncle.CONCLUSION:The superior lateral and posterior components of the CS are potential routes for invasion by PAs. Better identification of CS breakthrough patterns is crucial for achieving higher gross total resection and remission rates.

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Endoscopic endonasal transoculomotor triangle approach for adenomas invading the parapeduncular space: surgical anatomy, technical nuances, and case series

Cited by 29 publications

References 17 publications

Preoperative prediction of granulation pattern subtypes in GH‐secreting pituitary adenomas

Preoperative prediction of granulation pattern subtypes in GH‐secreting pituitary adenomas

Pituitary Adenomas and Invasiveness from Anatomo-Surgical, Radiological, and Histological Perspectives: A Systematic Literature Review

Intracranial Breakthrough Through Cavernous Sinus Compartments: Anatomic Study and Implications for Pituitary Adenoma Surgery

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