- Department of Clinical Neurosciences, Section of Neurosurgery, Neurological Centre of Latium “NCL”, Rome, Italy
- Calixto Garcia University Hospital, La Havana, Cuba
- Division of Neurosurgery, Hermanos Amejeiras Hospital, La Havana, Cuba
Division of Neurosurgery, Hermanos Amejeiras Hospital, La Havana, Cuba
DOI:10.4103/2152-7806.65054© 2010 Spallone A This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Spallone A, Vidal RV, Gonzales JG. Transcranial approach to pituitary adenomas invading the cavernous sinus: A modification of the classical technique to be used in a low-technology environment. Surg Neurol Int 01-Jul-2010;1:25
How to cite this URL: Spallone A, Vidal RV, Gonzales JG. Transcranial approach to pituitary adenomas invading the cavernous sinus: A modification of the classical technique to be used in a low-technology environment. Surg Neurol Int 01-Jul-2010;1:25. Available from: http://sni.wpengine.com/surgicalint_articles/transcranial-approach-to-pituitary-adenomas-invading-the-cavernous-sinus-a-modification-of-the-classical-technique-to-be-used-in-a-low-technology-environment-2/
Objective:Pituitary adenomas invading the cavernous sinus represent a therapeutic challenge. Those tumors have been traditionally treated with incomplete surgical removal, observation and/ or adjunctive medical therapy, and radiotherapy. In relatively recent years, some authors have suggested a main direct surgical approach to cavernous sinus (CS) with the aim of complete removal of the adenoma, either by a modified trans-sphenoidal route, using or not an endoscopy-assisted approach, or by a transcranial direct approach. The latter has the advantage of allowing direct exposure of the lesion with a view of the surgical field unhindered by important neurovascular structures.
Materials and Methods:We report a technical modification of the classical epidural approach for CS adenoma removal. This was used in 14 patients. Surgical technique included a fronto-orbito-zygomatic craniotomy with extradural anterior clinoidectomy, and intradural approach to the Hakuba’s triangle for intracavernous dissection. The tumors were removed under direct vision.
Results:Total macroscopical removal was achieved in all but one case. This patient required postoperative radiation therapy as well as adjuvant dopaminergic regime for achieving control of preoperatively increased hormonal values. No other case required radiotherapy. Hormonal and/ or clinical control was also achieved in all the remaining cases. Out of the remaining 13 cases, all appeared to be tumor free at an average postoperative observation at 78 months (34 to 90 months). Significant surgical sequels were detected in only 1 case (persistent 3rd nerve palsy and moderate hemiparesis).
Conclusions:This experience, though limited, would suggest that the transcranial limited CS exposure through the Hakuba’s triangle may allow adequate removal of intracavernous pituitary adenomas with very good long-term results and acceptable complication rate.
Keywords: Cavernous sinus surgery, fronto-orbito-zygomatic craniotomy (FOZ), Hakuba’s triangle, invasive adenoma, transcranial approach
Surgical management of pituitary adenomas is, as a rule, performed using the trans - sphenoidal route. However, 3% to 7% of pituitary adenomas grow laterally out of the sellar boundaries,[
In fact, invasion of the CS has been a reason for considering these lesions not amenable to radical surgery, at least until recent years,[
In relatively recent years, dissection of CS has been introduced mostly by Dolenc[
This reluctance to attempt radical surgical removal of these lesions is based on the consideration that adenoma, as a rule, does not present with an aggressive biological behavior; however, it is perhaps also related to the fact that direct CS surgery is a very demanding task. Actually inferior CS approaches would oblige the surgeon to work in very limited, deep, narrow spaces, where the view is hindered by crucial neurovascular structures. Endoscopy can help in overcoming this latter problem[
In an 8-year period (1997-2005), we managed 17 cases of pituitary adenoma with definite invasion of CS. The first 3 cases were operated using the epidural approach described by Dolenc[
The remaining 14 cases were operated using a modification of the subdural approach, which made, in our opinion, the surgery significantly easier though apparently not less effective than the original technique superbly illustrated and recently revised by Dolenc.[
In the 6-year period covered by the present study (1999-2005), 14 patients harboring a pituitary adenoma invading the CS were operated upon either in the Nuova Clinica Latina (presently Neurological Centre of Latium, NCL), Rome, Italy; or in the H. Amejeiras Hospital, La Havana, Cuba.
There were 10 women and 4 men aged 24 to 49 years (average, 40.5 years). The presenting symptoms were mostly headache, amenorrhea-galactorrhea and decreased libido. Total preoperative ophthalmoplegia was observed in 2 patients [
CT scan was performed in all the present cases; and MRI, in the most recent 10 cases. CS invasion was staged 3 in 8 cases, and 4 in 6 cases, according to the scale proposed by Knosp et al.,[
The goal of surgical management was to achieve total removal of the lesion in order to allow discharging the patient without any adjuvant postoperative treatment whenever possible. Postoperative clinical and neuroimaging data were available for all patients with a follow-up of 34 to 103 months (average, 83.1 + 3.4 months). In particular, serial clinical and neuroimaging follow-ups were performed at regular intervals in the two Italian patients, whilst a recent follow-up evaluation was conducted during the second half of the year 2009 in all Cuban patients.
A fronto-orbito-zygomatic (FOZ) approach, as described in a previous paper,[
Early postoperative results
There was no operative mortality. Total macroscopical tumor removal, as confirmed by immediate postoperative CT scanning [
Postoperative persistent (lasting more than 2 days) diabetes insipidus was not noticed in any of the present patients.
Late postoperative results
Immediate postoperative III CN palsy cleared within 2 months in all but one case. CSF leak required prolonged lumbar drainage and bed rest and resolved within 2 weeks in both patients in whom this complication had occurred [
Routine follow-ups, either CT scanning (8 cases) and/ or MRI (6 cases), were done 6-84 months after operation in order to check for possible tumor recurrence.
No case exhibited tumor remnants [Figures
An Italian patient, harboring an ACTH-secreting adenoma and showing a total ophthalmoplegia preoperatively [Figures
Diabetes insipidus was not recorded as a long-term complication. Control of increased preoperative hormonal levels was obtained in all but 3 patients, all of them harboring a PRL-secreting adenoma; however, serum PRL values were only mildly increased and significantly less than the preoperative ones. It should be noted that only 1 of these patients, the one who died of mesenteric thrombosis, was placed under DA treatment following surgery. One patient who had an ACTH-secreting tumor exhibited signs of mild hypopituitarism (FSH level, 0.3 µL/L). Four cases of non-secreting adenoma have shown no signs of recurrence until now. The remaining 6 cases showed no signs of increased hormonal values when last checked, 80 to 94 (average, 78) months after operation.
Pituitary adenomas invading the CS are rare, at least those tumors with clinically and/ or radiologically relevant CS invasion. They are detected mostly in female adults.[
Hormonal dysfunctions and headache represented the chief complaint in the present cases, whilst visual disturbances were under-represented when compared with other statistics.[
All patients in the present study represented a high-grade (3 or 4) case according to this classification.
As a rule, routine trans-sphenoidal surgery does not allow radical removal of a CS pituitary adenoma.[
Medical therapy with DA, and possibly also somatostatin, may be effective in controlling hormone-secreting pituitary adenomas.
Radiotherapy can be also administrated for incompletely removed pituitary adenomas.[
The present experience was a result of our working mainly in an environment where modern LINAC radiotherapy was available in only a few centers, where quite logically priority was given to patients harboring malignant tumors. We decided that, it was worthwhile trying to cure these lesions with radical surgery, these being CS adenoma benign lesions, and we acted accordingly. This philosophy is obviously hardly recommendable on a routine basis in a high-tech environment.
Widened inferior approaches did not appear to have significantly increased the possibility of radical removal of a pituitary tumor invading the CS,[
Our experience with craniobasal approaches[
The technique described in this report was the result of the natural evolution of our surgical experience during the course of 6 years. Our group’s philosophy included objective evaluation of postoperative results. As far as CS pituitary adenomas are concerned, early experience led us to change our approach from an epidural one to the one here described due to the following considerations:
a- Epidural CS dissection gave nice exposure of the bulging intracavernous adenoma, as a rule, between the III and the IV cranial nerves; however, the sellar content could not be visualized (maybe also due to lack of experience). This led to early tumor recurrence in 2 cases (as we have stated above) operated upon with an epidural approach and not included in the present study.
b- Epidural dissection invariably led to significant bleeding, particularly when dissecting at the level of the confluence of the Sylvian veins.[
c- Extended CS dissection requires release of the dural ring (a not risk-free maneuver unless performed by extremely experienced surgeons) and mostly, as a rule, more CS packing.
The facts mentioned above under b- and c- together may well explain the routine occurrence of — though as a rule, temporary — oculomotor palsy in the cases operated upon using an epidural CS dissection, which to our surprise was detected in only 50% of the CS adenoma patients operated upon using the technique herein described. The occurrence of III nerve palsy is obviously a major problem for the patient. However, this is, as a rule, temporary, lasts approximately only 3 months and is commonly present preoperatively.
Basically, we attempted as much as possible to simplify the operative steps of CS dissection as described by master surgeons.[
The present technique does not require extensive opening of the dura propria of the optic nerve, and this simplifies the dural closure. As stated above, using the precautions routinely utilized in craniobasal surgery — such as fat grafting complemented by fibrin glue, postoperative lumbar drainage and slight head elevation — was strict routine in our cases.
We were obliged to perform some blind maneuvers in order to remove portions of the tumor from hidden corners; however, this is routine in pituitary adenoma surgery. We want to stress that, as stated above, most relevant neurovascular structures were well exposed and consequently were under control when performing any blind maneuver for tumor removal.
We want to stress also that this technique does not require a sophisticated technological environment, but only a reasonably good microscope and a few micro-instruments, as well as good training in neurosurgical craniobasal anatomy. All these are concrete possibilities also in low-technology neurosurgical environments, as found routinely in less developed countries.
Our study follow-up averages 82 months. Such a period of time does not allow definitive conclusions regarding possible tumor recurrence at a later stage, although such an evidence would seem to be extremely unlikely.[
Total macroscopical tumor removal, achieved in all but one case, was assessed by routine early postoperative CT scanning and late postoperative either CT scan and/ or MRI. This matched well with the positive evolution of clinical symptoms following the operation. In 1 case, increase in postoperative hormonal serum levels led us to consider prophylactic, lately administrated radiation therapy, in spite of the lack of signs of recurrence at the serial neuroimaging controls. Recommendation for radiotherapy was ultimately withdrawn following a further hormonal checkup 4 months later, at which ACTH and cortisol serum levels appeared to be well within the normal range.
Surgical cure of an invasive adenoma is always a challenge because these tumors spread extradurally without a real capsule, and neoplastic cells can be easily left behind.[
Surgical complications were not negligible: 13% of patients had postoperative CSF leak; 50% had oculomotor palsy; in addition to a postoperative hematoma and related complications occurring, however, in an extremely difficult case. However, in all but one case, complications either regressed spontaneously, as in the case of oculomotor palsy, or were easily dealt with routine postoperative maneuvers, as in the case of CSF leak.
Pituitary adenomas invading the CS represent a challenge for neurosurgeons. However, several treatment modalities are presently available, including preoperative medical treatment with the aim of reducing the tumor in size in order to make it amenable to radical trans-sphenoidal surgery; and radiosurgery, whether or not preceded by partial surgical removal.
However, it must not be forgotten that these are benign tumors, possibly amenable to surgical cure. On the basis of this consideration, some authors have described their experiences with direct approaches to CS, either from below or transcranially, and have recommended these approaches. All the techniques used for possible radical surgery have obvious advantages and disadvantages, as expected, but also have in common the peculiarity of being definitely technically demanding ones. We have described here a transcranial approach that does not necessarily require sophisticated equipment, can be used also in a relatively less sophisticated technological environment and apparently make cavernous sinus adenoma surgery a little less demanding when compared with the classically described techniques for CS surgical dissection; this approach, at the same time, allows the adenoma to be, at least apparently, totally removed in the vast majority of cases. This is particularly a relevant issue in a low-tech environment and/ or in a developing country, where postoperative adjuvant therapy cannot be easily administered to any patient, and regular follow-ups are relatively difficult. Certainly, endoscopic trans-sphenoidal removal of CS adenomas represents the future. However, the present result should be considered as a bottom line to be reached, as far as radicality of tumor removal by the new techniques of minimally invasive craniobasal surgery is concerned.
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