Reoperative endoscopic endonasal surgery for residual or recurrent pituitary adenomas

Abstract

OBJECTIVE Regrowth of the lesion after surgical removal of pituitary adenomas is uncommon unless subtotal resection was originally achieved in the first surgery. Treatment for recurrent tumor can involve surgery or radiotherapy. Locations of residual tumor may vary based on the original approach. The authors evaluated the specific sites of residual or recurrent tumor after different transsphenoidal approaches and describe the surgical outcome of endoscopic endonasal transsphenoidal reoperation. METHODS The authors analyzed a prospectively collected database of a consecutive series of patients who had undergone endoscopic endonasal surgeries for residual or recurrent pituitary adenomas after an original transsphenoidal microscopic or endoscopic surgery. The site of the recurrent tumor and outcome after reoperation were noted and correlated with the primary surgical approach. The chi-square or Fisher exact test was used to compare categorical variables, and the Mann-Whitney U-test was used to compare continuous variables between surgical groups. RESULTS Forty-one patients underwent surgery for residual/recurrent pituitary adenoma from 2004 to 2015 at Weill Cornell Medical College. The previous treatment was a transsphenoidal microscopic (n = 22) and endoscopic endonasal (n = 19) surgery. In 83.3% patients (n = 30/36) there was postoperative residual tumor after the initial surgery. A residual tumor following endonasal endoscopic surgery was less common in the sphenoid sinus (10.5%; 2/19) than it was after microscopic transsphenoidal surgery (72.7%; n =16/22; p = 0.004). Gross-total resection (GTR) was achieved in 58.5%, and either GTR or near-total resection was achieved in 92.7%. Across all cases, the average extent of resection was 93.7%. The rate of GTR was lower in patients with Knosp-Steiner Grade 3-4 invasion (p< 0.0005). Postoperative CSF leak was seen in only one case (2.4%), which stopped with lumbar drainage. Visual fields improved in 52.9% (n = 9/17) of patients and were stable in 47% (n = 8/17). Endocrine remission was achieved in 77.8% (n = 14/18) of cases, 12 by surgery alone and 2 by adjuvant medical (n = 1) and radiation (n = 1) therapy. New diabetes insipidus occurred in 4.9% (n = 2/41) of patients-in one of whom an additional single anterior hormonal axis was compromised-and 9.7% (n = 4/41) of patients had a new anterior pituitary hormonal insufficiency. CONCLUSIONS Endonasal endoscopic reoperation is extremely effective at removing recurrent or residual pituitary adenomas that remain after a prior surgery, and it may be preferable to radiation therapy particularly in symptomatic patients. Achievement of GTR is less common when lateral cavernous sinus invasion is present. The locations of residual/recurrent tumor were more likely sphenoidal and parasellar following a prior microscopic transsphenoidal surgery and sellar following a prior endonasal endoscopic surgery.

ICAR: endoscopic skull‐base surgery

“…reviewed 59 revision pituitary endoscopic surgeries, demonstrating an overall postoperative CSF leak rate of 2.5%. Similarly, Negm et al . reported a 2.4% postoperative CSF leak rate in a retrospective review of 41 endoscopic pituitary surgeries.…”

“…A total of 15 studies met the inclusion and exclusion criteria . Overall, the evidence level was low with the majority of studies comprising level 4 evidence (Table ).…”

Pituitary Adenoma Surgery: Retrospective Analysis of My Personal Experience

“…Endoscopic technique is also helpful in recurrent and residual cases. 3 However, there seems pros and cons of both the techniques. We used microsurgical technique in all the cases, except in few where we used both, due to lack of appropriate endoscopes.…”

Postsurgical Salvage Radiosurgery for Nonfunctioning Pituitary Adenomas Touching/Compressing the Optic Chiasm: Median 13-Year Postirradiation Imaging Follow-up Results

“…Recently, based on 2 studies of 29 and 24 subjects, including patients with functional and nonfunctional tumors, postreoperative regrowth rates were 3.1% and 0%, respectively. 37,38 However, postreoperative observation periods were not sufficiently long, with a median of 17 (range; 12-108) mo in the former and a mean of 39 (range, 3-135) mo in the latter investigation. Most recently, Bakhsheshian et al 39 reported surgical treatment outcomes of 268 NFPA patients with a mean follow-up time of 38 (range, 3-235) mo.…”