Giant Pituitary Adenomas Surgery: What Is the Best Route?

Presentation Number: SAT-0655
Date of Presentation: June 21st, 2014

Thomas Graillon*1, Frederic Castinetti2, Thierry Brue3, Isabelle Morange4, Tarek Adetchessi5, Philippe Metellus5, Stephane Fuentes5, Régis Gras5 and Henry Dufour6
1CHU Timone, Marseilles, France, 2La Conception Hospital, Marseille, France, 3Centre de Recherche en Neurobiologie et Neurophysiologie de Marseille, France, 4CHU Timone, Marseille - CDX 05, France, 5Hopital La Timone, Marseilles, France, 6Aix Marseille University, Marseille, France


Introduction: Giant pituitary adenomas (PA) remain rare and challenging tumors. Transsphenoidal (TS) and/or transcranial (TC) approaches can be performed.

Objective: May recent advances in endonasal endoscopy for PA surgery change surgical results?

Material and Methods: Among a prospective clinical data base of 1700 PA, 17 cases of PA responding to the definition of giant PA (diameter > 40 mm) were operated via TC approach. 9 patients required TC approach first. Indication for a complementary TS approach was retained in 6 of these cases. 8 patients underwent TS approach first. Indication for a complementary TC approach was retained in all of these 8 cases. TS approach was performed via endoscopy in 7 cases and via microscopy in 7 cases. Pre and postoperative characteristics of the patients and PA were collected. Each approach,  their complications, advantages, and disadvantages were studied to define optimal indications. Maximal diameter average in our cohort was 51.5mm. Visual disturbance was obvious in 88% of cases and was the most frequent revealing symptom. Most part of these giant PA was benign and non-secreting.

Results: In most of these giant PA collected cases, TC or TS approaches alone were not sufficient to provide a satisfying tumor removal. Combination of TS and TC approach was required in 82 % in order to improve tumor removal. Resection was total in 24% of cases and subtotal in 70% of cases. The use of endoscopic endonasal technique increased the amount of removal but did not increase the cure rate of giant adenoma. Cavernous sinus invasion decreased total tumor removal rate from 50% to 9%. Visual outcome: TC approach provided more frequent and with a higher quality visual improvement, than TS approach. But, paradoxically, visual impairment rate was higher after TC approach than TS approach (17.5% versus 7%), related to ischemic and/or traumatic chiasm lesion. Postoperative panhypopituitarism occurred in 35% of cases without difference between TC and TS approaches. Inversely, postoperative diabetes insipidus occurred in 47% of TC approaches versus only 8% of TS approaches. Postoperative ischemia was observed in 23.5% of TC approach with clinical symptoms varying from none to severe hemiparesia. Half cases equally presented chiasm ischemic lesion. Postoperative intratumoral bleeding was more frequent after TS approach related to residue apoplexy, involving risk of visual impairment, subarachnoid bleeding, hydrocephalus and vasospasm.

Conclusion: Despite a high morbidity, TC approach remains mandatory in current management of giant PA combined or not with endoscopic TS approach in order to provide maximal tumor removal. Surgical approach decision is mostly related to the PA morphology, and the shape of suprasellar extension. Endoscopic endonasal approach vs microscopic approach does not lower the amount of complication and does not increase the cure rate in giant PA.


Disclosure: TG: Clinical Researcher, Novartis Pharmaceuticals. TB: Clinical Researcher, Pfizer, Inc., Clinical Researcher, Novo Nordisk, Clinical Researcher, Novartis Pharmaceuticals, Clinical Researcher, Ipsen, Clinical Researcher, Serono, Clinical Researcher, Sandoz. Nothing to Disclose: FC, IM, TA, PM, SF, RG, HD