Size does not matter. The intrigue of giant adenomas: a true surgical challenge

Abstract

Pituitary surgery is an evolving specialty of modern neurosurgery that requires precise anatomical knowledge, technical skill, and integrated appreciation of pituitary pathophysiology. Over the years, this field has made a well-noticed advantage of the evolving ideas and surgical tools, amongst them, the endoscope. This last, with the advent of the concept of minimally invasive and keyhole surgery, gained popularity as the sole visualizing instrument in many neurosurgical approaches, above all those for pituitary lesions. Nowadays, the endoscopic transsphenoidal approach is commonly used in many centers throughout the world under the same indications as the conventional microsurgical technique [1]. Transsphenoidal surgery, with either microscopic or endoscopic technique, is currently adopted in more than 95 % of surgical procedures to the sellar area and ca. 97 % of all surgery for the treatment of pituitary adenomas [2][3][4][5][6][7]. The wider and panoramic view offered by the endoscope together with the proposals and contributions of many active groups has expanded its applicability to the removal of different "pure" supradiaphragmatic lesions [8][9][10][11][12][13][14]. Indeed, the extended endoscopic approach is increasingly adopted for the treatment of pathologies such as craniopharyngiomas, midline skull base meningiomas, chordomas, and other skull base lesions. Though it has been reported that the extended endonasal approach may offer a greater extent of resection also in the case of pituitary macroadenomas with suprasellar symmetric and/or asymmetric extension, recurrent or residual dumbbell-shaped adenomas and/or fibrous macroadenomas, once considered all amenable to open transcranial surgery only [15]. The same principles are valid in cases of giant adenomas, where the extended approach has proved to facilitate, in most instances, a wider lesion exposure just after the dural opening over the sellar-suprasellar space, thus avoiding any retraction of neurovascular structures [16][17][18][19]. However, there are conditions that could render more troublesome the transsphenoidal approach, either related to the anatomy of the surgical route or to the inner features of the lesion itself, i.e., the size of the sella, its degree of ossification, the size and the pneumatization of the sphenoid sinus, and/or carotid arteries position and shape [1,6,20,21].On the other hand, transcranial surgery should be preferred when tumors present with extensive intracranial invasion, with asymmetric lateral development, into the anterior cranial fossa or lateral or posterior extension into the middle and posterior cranial fossa, particularly if major vessel involvement is present and/or whether transsphenoidal surgery has been already unsuccessful, and in these regards, several authors have reported surgical strategy and results, properly addressing indications, pros, and cons [22][23][24].When perceiving this controversial scenario, we moved backward through our series and analyzed the decisionmaking process, i.e., surgica...

Microscopic Transsphenoidal Resection of Giant Pituitary Adenomas: Analysis of the Factors Limiting the Degree of Resection in 73 Cases

“…Cappabianca et al proposed that the size of the tumor is not important, and the intracranial growth pattern of the tumor is the most important factor when evaluating the possibility of endoscopic surgery for large tumors and GPA ( 11 ). The results of the present study confirm this view.…”

The role of multimodal navigation in endoscopic endonasal surgery for giant pituitary adenomas

“…However, there are several factors that limit the radical resection of GPA. In evaluating endoscopic surgery for "big" adenomas, Cappabianca et al (24) noted that "size does not matter"; instead, attention should mostly be paid to the pattern of intracranial growth. Goel proposed a classification system of giant pituitary tumors that assists in indicating the nature of anatomic extensions of the tumor, ease of surgical resection, and possibilities of complete resection, in addition to assessing the need for adjuvant treatment and predicting long-term outcomes (5).…”

Giant pituitary incidentaloma

“…Clinical judgement should be used in determining the appropriate therapy for these adenomas: surgical resection, radiation therapy or expectant observation. Management remains a significant challenge despite improved surgical techniques, due to the risk of postoperative life-threatening complications,2 whereas the results of radiation therapy are inconsistent 3. In this case, potential risks of treatment outweighed possible benefits attending to the patient’s age, absence of life-threatening symptoms, longevity of the disease and tumour characteristics.…”