Relationship between pneumatization of lateral recess in the sphenoid sinus and removal of cavernous sinus invasion in pituitary adenomas by endoscopic endonasal surgery
- Departments of Neurosurgery, Keio University School of Medicine, Shinjuku, Tokyo, Japan.
- Departments of Radiology, Keio University School of Medicine, Shinjuku, Tokyo, Japan.
Departments of Neurosurgery, Keio University School of Medicine, Shinjuku, Tokyo, Japan.
DOI:10.25259/SNI_169_2019Copyright: © 2019 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Kenzo Kosugi, Ryota Tamura, Taro Mase, Haruka Tamura, Masahiro Jinzaki, Kazunari Yoshida, Masahiro Toda. Relationship between pneumatization of lateral recess in the sphenoid sinus and removal of cavernous sinus invasion in pituitary adenomas by endoscopic endonasal surgery. 15-Nov-2019;10:222
How to cite this URL: Kenzo Kosugi, Ryota Tamura, Taro Mase, Haruka Tamura, Masahiro Jinzaki, Kazunari Yoshida, Masahiro Toda. Relationship between pneumatization of lateral recess in the sphenoid sinus and removal of cavernous sinus invasion in pituitary adenomas by endoscopic endonasal surgery. 15-Nov-2019;10:222. Available from: http://surgicalneurologyint.com/surgicalint-articles/9755/
Background: Endoscopic endonasal transsphenoidal surgery (EES) is the gold standard for pituitary adenoma (PA) resection. The sphenoid sinus (SS), a highly variable anatomic structure, is located in the center of the cranial base. It has previously been reported that poor pneumatization of the lateral recess of the SS (LRSS) increases the difficulty level of the surgery and the risk of neural and vascular injury. However, to date no studies have evaluated the association between LRSS volume and PAs removal rate by EES.
Methods: The present study analyzed 23 consecutive patients with new-onset PAs categorized as Knosp Grades 3 and 4 who underwent EES. A retrospective radiographic analysis was conducted on patients undergoing magnetic resonance imaging and high-resolution computed tomography scans.
Results: Among PA cases categorized as Knosp 3 and 4, no significant association was found between the whole tumor’s resection rate and LRSS volume (R = 0.08, P = 0.70). However, a significant association was found between cavernous sinus (CS) tumors’ removal rate and LRSS volume (R = 0.52, P = 0.011). The same results were achieved in PAs with a Knosp Grade 4, with a stronger correlation (R = 0.60, P = 0.014).
Conclusion: The development of LRSS pneumatization affects the removal rate of CS tumors in PAs. Preoperative analysis of LRSS development should be considered when planning EES against PA with CS invasion.
Keywords: Cavernous sinus, Endoscopic endonasal transsphenoidal surgery, Lateral recess of the sphenoid sinus, Pituitary adenoma
Pituitary gland and sellar region tumors account for approximately 15% of all brain tumors, with pituitary adenomas (PAs) being the most common. PAs are benign neuroendocrine neoplasms confined to the sella.[
The SS, a highly variable anatomic structure, is located in the center of the cranial base, surrounded by numerous neurovascular structures. Its pneumatization provides a dilating natural cavity through which the wide areas of the cranial base may be accessed. The sinus is bordered anteriorly by the ethmoidal air cells, posteriorly by the clivus, laterally by the CS, superiorly by the pituitary fossa and planum sphenoidale, and inferiorly by the choana.[
The Institutional Review Board of the Keio University School of Medicine approved this retrospective study. New-onset PA patients who underwent surgery through EES were retrospectively evaluated. CS invasion was reported according to the Knosp criteria, and only PAs with Knosp Grades 3 and 4 were included in the study.[
EES was performed with otolaryngologists using a binostril, two-surgeon technique.[
Measurements and data analysis
The volumes of the whole tumor, the tumor located in the bilateral CS, and the bilateral LRSS were measured. All pre and postoperative MRI and preoperative computed tomography (CT) images were retrospectively reviewed by three authors (Kenzo Kosugi, Taro Mase, and Haruka Tamura), who calculated the whole tumor and CS tumor removal rate [
The volumetric analysis of the lateral recess of the sphenoid sinus (a and b) and representative cases (c-e) using coronal computed tomography. The upper yellow arrow shows the foramen of rotundum, and the lower arrow shows the Vidian canal (a). A line was drawn through the two points and the area in the sphenoid sinus lateral side of the line on each slice was measured (b). Well-pneumatized case (c), moderately pneumatized case (d), and poorly pneumatized case (e).
Correlations between two ordinal parameters were investigated using the Pearson correlation test. A linear regression model was fitted for trend analysis. P < 0.05 was considered statistically significant. All statistical analyses were performed with the Statistical Package for the Social Sciences (SPSS) version 20.0 software (SPSS, Chicago, IL).
EES was performed for new-onset PA in 31 patients at the Keio University Hospital between July 2012 and March 2018. Among these patients, 23 with Knosp 3 and 4 PA who had available pre and postoperative MRI studies, including gadolinium-enhanced T1-weighted images and high-resolution CT studies, were included in the study. The patients’ average age was 59 (range 38−81) years and the study population had almost equal sex distribution (12 men and 11 women). Among 23 patients, 7 had only right side CS invasion, 6 had only left side CS invasion, and 10 had CS invasion on both sides. Four tumors were endocrinologically active with elevated plasma levels of growth hormone and prolactin [
Illustrative case with images and operation view. (a) Preoperative computed tomography in a coronal section showing the developed lateral recess of the sphenoid sinus (LRSS). (b) This intraoperative view shows the posterior wall of the SS from an endoscopic endonasal transsphenoidal approach, including the LRSS (※), septum of the SS (head arrow), and sella turcica (arrow). (c) Preoperative gadolinium-enhanced T1-weighted magnetic resonance imaging (Gd-T1WI MRI) in a coronal section showing a pituitary adenoma with cavernous sinus (CS) invasion. (d) Postoperative Gd-T1WI MRI showing that almost all of the tumor was removed but there was a small residual tumor on the internal carotid artery in the right CS (arrow).
Association between the degree of tumor resection and the volume of the LRSS
Among cases with PAs categorized as Knosp Grades 3 and 4, no significant association was found between the whole tumor’s resection rate and the bilateral LRSS volume (R = 0.08, P = 0.70) [
Correlation between the removal rates of pituitary adenomas and the volume of the lateral recess of the sphenoid sinus (LRSS). Linear regression models revealed no correlation between the whole tumor removal rate for tumors categorized as both Knosp Grades 3 and 4 (a) and Grade 4 (c), and the volume of LRSS (a: P = 0.70, c: P = 0.87). A significant correlation was found between the removal rate of the cavernous sinus tumor and the volume of the LRSS both in Knosp Grades 3 and 4 (b) and in Knosp Grade 4 (d) (b: R = 0.52, P < 0.05, d: R = 0.60, P < 0.05).
Advances in optics, endoscopic cameras and video monitors resolution, and computer-assisted navigation have significantly enhanced the resection potential of various cranial base lesions using minimal access surgery.[
In the present study, cases with substantial pneumatization tended to have a higher CS tumors’ removal rate, since LRSS pneumatization influences the manipulation of surgical instruments during resection. Furthermore, in cases with a poorly pneumatized sinus, the direct visualization of the internal carotid artery’s location and its relationship to the sella is basically impossible. Our results show that LRSS volumes are not associated with whole tumor removal rate and that LRSS pneumatization may not influence the removal of sellar tumors. In the present study, most cases presented with CS tumors in a small portion of the total tumor. Therefore, the whole tumor resection rate was not associated with LRSS volume. We believe that analyzing LRSS development preoperatively is useful to plan EES for CS tumor resection in PA patients.
Limitations of the present study include the retrospective design and the relatively small sample size. Prospective studies with a larger number of subjects are warranted to confirm the present findings. In the present study, several cases achieved a nearly total removal of the CS tumor despite a narrow LRSS [
The present study reveals a correlation between LRSS volume and tumor removal rate. Narrow LRSS is associated with difficulty in performing surgical procedures, resulting in a lower removal rate of the cavernous region of PAs. Preoperative evaluation of LRSS may help the neurosurgeon to plan an appropriate surgical strategy, including the selection of endoscopic instruments for PAs with CS invasion.
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