Acta Oto-Laryngologica. 2014; 134: 326–330

ORIGINAL ARTICLE

Endoscopic endonasal transsphenoidal approach for sellar tumors beyond the sellar turcica YEXUN SONG1, HEQING LI1, HUOWANG LIU1, WEI LI1, XIAOWEI ZHANG1, LIAN GUO2 & GUOLIN TAN1 1

Department of Otolaryngology-Head Neck Surgery, Third Xiangya Hospital of Central South University, Changsha, Hunan and 2Department of Otolaryngology-Head Neck Surgery, Xiangtan Central Hospital, Xiangtan, Hunan, China

Abstract Conclusions: The endoscopic endonasal transsphenoidal approach can be a choice for sellar tumors beyond the sellar turcica, but it is necessary to make the choice carefully because of the severe surgical risks. Objectives: To summarize our experience of removal of sellar tumors beyond the sellar turcica via the endoscopic endonasal transsphenoidal approach and to evaluate the surgical efficacy and complications. Methods: Between January 2007 and January 2012, 30 patients with sellar tumors beyond the sellar turcica underwent surgery using the endoscopic endonasal transsphenoidal approach. Results: Postoperative pathological examination demonstrated that pituitary adenoma occurred in 22 patients, craniopharyngioma in 5, and meningioma in 3. Total removal was achieved in 21 patients (70.0%) and subtotal removal was achieved in 8 patients (26.7%). After the surgery, cerebrospinal fluid leakage occurred in 3 patients, temporary diabetes insipidus occurred in 25 patients and persistent diabetes insipidus in 4 patients, intracranial infection occurred in 1 patient, frontal subdural effusion occurred in 1 patient, sinusitis occurred in 2 patients, epistaxis occurred in 3 patients, and 1 patient with a huge pituitary adenoma died of hypothalamic failure related to the operation.

Keywords: Endoscopy, sellar region, efficacy, complication, pituitary adenoma, craniopharyngioma, meningioma

Introduction The sellar turcica is located in a deep part of the middle skull base, and surgical approaches to the sellar region have presented a challenge to the surgeon for many years. Traditional craniotomy cannot expose the sellar lesions fully and produces severe surgical trauma in the patients; the microscopic sublabial transsphenoidal access has a poor view and cannot be applied to remove the sellar tumors beyond the sellar turcica. Endoscopic endonasal transsphenoidal surgery has many advantages over other surgerical approaches, for example, decreased morbidity, better panoramic visualization, and increased illumination and magnification, and has been widely introduced in the field of pituitary surgery [1–6]. Clinical practice has confirmed that tumors limited within the sellar

turcica can be totally removed with relatively low surgical risks under the endoscopic technique, but there will be more difficulties and risks in the surgical resection of tumors invading the important neurovascular structures around the sellar turcica. This report describes our experience using the endoscopic endonasal transsphenoidal technique for sellar tumors beyond the sellar turcica. Material and methods Patient selection From January 2007 to January 2012, a total of 30 patients (12 male, 18 female; age range 7–68 years) with sellar tumors beyond the sellar turcica were treated in the Third Xiangya Hospital. The study

Correspondence: Professor Guolin Tan MD PhD, Department of Otolaryngology-Head Neck Surgery, The Third Xiangya Hospital, Central South University, Changsha 410013, Hunan, China. Tel: + 86 731 881 68024. Fax: +86 731 886 18536. E-mail: [email protected]

(Received 24 August 2013; accepted 17 October 2013) ISSN 0001-6489 print/ISSN 1651-2251 online  2014 Informa Healthcare DOI: 10.3109/00016489.2013.857785

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and this operation were approved by Institutional Review Board of the Third Xiangya Hospital of Central South University, and an informed consent was obtained from all patients. There were 22 pituitary adenomas (20 prolactinomas, 2 acromegaly), 3 meningiomas, and 5 craniopharyngiomas. Of all the patients, 13 patients presented visual disturbance, 13 patients presented headache, amenorrhea and galactorrhea were presented in 20 patients, growth retardation in 2 patients, and impotence in 2 male patients. Imaging examination showed that the tumor diameter ranged from 2 to 7 cm, and all of the tumors were beyond the sellar turcica including the optic nerve, cavernous sinus, internal carotid artery, and suprasellar cistern. Of the 22 patients with pituitary adenomas, 20 showed elevated basal plasma prolactin (PRL) levels and a blunted response of PRL to intravenous thyrotropin releasing hormone (TRH), and 2 patients showed elevated serum insulin-like growth factor (IGF)-I levels and the inability to suppress serum growth hormone (GH) during the oral glucose tolerance test (OGTT). The five patients with craniopharyngioma and three with meningioma had no obvious endocrinological abnormality.

were coagulated with bipolar coagulation forceps, then a +-shaped incision was made on the dura to expose the tumor or pituitary. Intraoperative frozen section examination was performed after the tumor tissue was identified carefully. The intraoperative findings showed that most pituitary tumors felt soft and a total or subtotal tumorectomy could be achieved with minimally invasive suction-dissection instruments (Figure 1). For tuberculum sellae meningioma invading the sellar area, we chose sellar area access, but the planum sphenoidale had to be removed to expose the tuberculum sellae dura and tumor completely. For craniopharyngioma invading the sellar area, we chose sellar area access, but the bone window should be expanded forward and upwards to expose the dura and tumor. All the diaphragma sellae were exposed clearly and the surgical cavity was inspected with 0 and 30 endoscopes to avoid residual tumors after the resection of suprasellar and/or parasellar tumors was completed. Skull base closure was achieved with a combination of autologous fascia lata graft, fibrin glue, and nasoseptal flap(s) in all patients.

Surgical technique

Examination of the intraoperative frozen sections and postoperative paraffin-embedded sections of the 30 patients confirmed the preoperative diagnosis. The diagnostic coincidence rate attained 100% before and after operations. The operative time ranged from 1 to 3 h in the 30 patients. No blood loss (>300 ml) was found and blood transfusion was mostly unnecessary. The average length of hospital stay was 3–10 days. Except for one death related to the surgical procedure, 29 patients (96.7%) received follow-up for at least 1 year, and the follow-up ended 3 years after the operation if there was no recurrence. The success of the tumor removal is based on both MRI findings with contrast obtained 3 months after surgery and the surgeon’s intraoperative vision. The tumor is considered to be totally removed when the surgeon’s vision and MRI image examination document no residual tumor. The resection is considered subtotal when more than 80% of the lesion has been removed, and partial resection when less than 80% has been removed. Our data showed that total removal was achieved in 21 patients (70.0%) comprising 16 pituitary adenomas (Figure 2), 3 craniopharyngiomas (Figure 3), and 2 meningiomas. Subtotal removal was achieved in eight patients (26.7%). Of the 29 patients, 13 patients with visual disturbance had amelioration 1 month after operation (Table I). Of the 13 patients with headache, symptoms disappeared in 10 patients and were ameliorated

The procedure was performed under general anesthesia and oral intubation with the patient positioned supine. A 0 or 30 endoscope was used for the operation. The nasal mucosa of the middle turbinate was injected with a 1:100 000 epinephrine solution to induce vasoconstriction; the epinephrine solution soaked in cotton was also used to induce vasoconstriction of the whole nasal cavity mucosa. The decision as whether the right or left nostril should be chosen for operation was made by evaluation of the nasal cavity and the lesion localization. The posterior part of the middle turbinate was removed to expose the ostium and anterior wall of the sphenoid sinus, sphenoidotomy and removal of the posterior part of the nasal septum were performed, and a nasoseptal flap was harvested to aid in surgical reconstruction at the completion of the tumor resection. After exposure of the sellar floor and individuation of the landmarks of carotid and optical protuberances, the sellar floor, reduced to a thin film of bone, was fractured by simple pressure with a blunt instrument. The breach was widened to expose the sellar and parasellar dura completely. Partial sclerotin of the planum sphenoidale needed to be removed to expose the tuberculum sellae region in the patients with craniopharyngioma or meningioma. Small blood vessels on the surface of the dura

Results

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Figure 1. The minimally invasive suction-dissection instruments used in our surgical process.

A

in 3 patients. Of the 20 patients with elevated basal plasma PRL levels, 14 patients had postoperative recovery in 1 week and the PRL levels of the other 6 patients clearly decreased. All the patients presented with different degrees of diabetes insipidus postoperatively. The course was temporary in 25 patients with spontaneous resolution in 1 week, whereas in 4 patients it persisted and the symptoms were contained by vasopressin therapy in around 2 weeks. Three patients who had postoperative cerebrospinal fluid (CSF) leakage were reoperated for sellar reconstruction and cured finally. One patient suffered from intracranial infection after operation and recovered after intrathecal injection of vancomycin. Two patients who suffered from sinusitis were effectively treated with antibiotics. Three patients who had mild epistaxis were controlled with nasal tampons. Frontal subdural effusion was observed in one patient with meningioma that was totally removed (Figure 4), but the patient did not experience any pain or discomfort up to the end of follow-up. One patient with a huge pituitary adenoma who developed intractable fever and electrolyte disturbances after the operation was diagnosed with hypothalamic failure; although multidisciplinary rescue was carried out, he still died of respiratory and circulatory failure. Other complications such as

A

B

Figure 2. (A) Preoperative and (B) postoperative coronal MRI of a 27-year-old female with pituitary adenoma. Total resection has been performed.

B

Figure 3. (A) Preoperative and (B) postoperative sagittal MRI of a 7-year-old girl with craniopharyngioma. Total resection has been performed.

intracerebral hemorrhage and cranial nerve palsies were not observed in our series. Discussion The sellar area is located in a deep part of the cranial cavity. There are many important anatomic structures in its neighborhood. For the lesions located in this area, transcranial approaches continue to play a role today; in particular, the frontotemporal, so-called pterional, approach has been the most commonly used transcranial approach in neurosurgery. The frontotemporal approach has undergone variations, modifications, and extensions to expand its trajectory and increase the coverage of indications for more complex lesions with the contribution of many neurosurgeons over the past century. However, in our opinion, the nature of this surgical procedure, which mainly relates to brain retraction and manipulation of the neurovascular structures, means that its consequences (including severe trauma and postoperative reactions combined with many complications and increased length of hospital stay) are difficult to avoid. The endoscopic technique resolved most of the problems described above. The first studies on the endoscopic endonasal transsphenoidal approach to pituitary tumors were published in the 1990s [7–9]. This less traumatic procedure, avoiding the use of nasal retractors and postoperative nasal packing, was recognized as being more comfortable for the patient, providing a panoramic view of the surgical field, and enabling a shorter hospital stay [10,11]. During the past 10 years, better surgical quality for sellar tumors, which manifested the minimally invasive concept more, were attained with the improvement of the endoscopic technique, providing an opportunity for complete resection in patients with extensive sellar tumors [12]. Most authors using this technique reported an outcome comparable to that achieved with traditional

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Table I. Preoperative and postoperative visual outcomes of the 13 patients with visual disturbance. Preoperative Case no.

Age (years)/sex

Pathologic type

Visual acuity

Postoperative Visual field

Visual acuity

Visual field

1

28/F

Pituitary adenoma

0.08/left, 0.1/right

BTH

0.15/left, 0.15/right

Partial recovery

2

34/F

Pituitary adenoma

N/left, 0.3/right

N/left, TH/right

N/left, 0.5/right

Partial recovery

3

50/F

Pituitary adenoma

0.2/left, 0.2/right

BTH

0.25/left, 0.3/right

Partial recovery

4

65/M

Meningioma

LP/left, N/right

TH/left, N/right

LP/left, N/right

Partial recovery

5

41/F

Pituitary adenoma

0.1/left, 0.08/right

BTH

0.15/left, 0.15/right

Partial recovery

6

27/F

Pituitary adenoma

0.03/left, NLP/right

TH/left, N/right

0.03/left, LP/right

Partial recovery

7

43/F

Pituitary adenoma

N/left, NLP/right

N/left, –/right

N/left, HM/right

Partial recovery

8

45/M

Pituitary adenoma

0.5/left, 0.3/right

BNH

0.8/left, 0.4/right

Total recovery

9

60/F

Pituitary adenoma

0.06/left, 0.08/right

BTH

0.1/left, 0.1/right

Partial recovery

10

38/F

Craniopharyngioma

N/left, 0.3/right

N/left, TH/right

N/left, 0.4/right

Total recovery

11

47/F

Pituitary adenoma

HM/left, N/right

TH/left, N/right

CF/left, N/right

Partial recovery

12

55/M

Pituitary adenoma

N/left, N/right

BTH

N/left, N/right

Total recovery

13

40/F

Pituitary adenoma

0.1/left, N/right

TH/left, N/right

0.2/left, N/right

Partial recovery

BNH, binasal hemianopia; BTH, bitemporal hemianopia; CF, counting fingers; F, female; NLP, no light perception; HM, hand movement; LP, light perception; M, male; N, normal; NH, nasal hemianopia; NLP, no light perception; TH, temporal hemianopia.

transcranial surgery [13–18]. Few articles have discussed the indication for the endoscopic approach for sellar tumors beyond the sellar turcica. Dehdashti et al. [19] described the indication as follows: the boundaries of the endoscopic endonasal transsphenoidal approach are from the cribriform plate to the foramen magnum in the anteroposterior plane, and laterally, the medial orbital walls anteriorly, the cavernous sinus and carotid arteries in the sellar region, and the dorsum sella and posterior clinoids posteriorly. In our opinion, the indication described above can be used as a reference, but we believe that the size and extent of tumors are not the key points, the factors that really matter are the tumoral texture, blood supply of the tumor, and the skill of the surgeon.

A

B

Figure 4. (A) Preoperative and (B) postoperative sagittal T2-weighted MRI of a 50-year-old male with meningioma. Total resection has been performed.

All of the 30 patients with sellar tumors beyond the sellar turcica underwent endoscopic endonasal transsphenoidal surgery in the present study; with the exception of one death, the symptoms in the other patients ameliorated significantly. We summarize our experience as follows. (1) Make a careful evaluation of the tumors by the preoperative imaging characteristics and endocrinological examinations, including tumor size, invasion domain, involvement of surrounding structures; make a detailed analysis of the histological type and the blood supply of the tumors. (2) Removal of the posterior nasal septum can provide a better exposure of the bilateral wall of the sphenoidal sinus, sellar turcica, and planum sphenoidale, which is particularly important for the sellar tumors invading the cavernous sinus and internal carotid artery. (3) As regards the process of bleeding, conventional maneuvers such as curettage and suction are usually ineffective and resection of the tumor can be achieved with minimally invasive suction-dissection instruments, which played an important role in the surgical procedure. In most cases, bleeding from the tumor bed usually stopped after complete removal of the tumor was achieved. Even though most sellar tumors beyond the sellar turcica were totally removed via the endoscopic endonasal transsphenoidal approach, in 26.7% of the patients the procedure resulted in subtotal resection. The main reasons are summarized as follows. (1) The invasion domain of the sellar tumors was too extensive.

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One huge pituitary adenoma extended into the third ventricle and exceeded the bilateral internal carotid artery by 2 cm; the dead angle of the endoscope limited the possibility of total resection. (2) Hemorrhage induced by sufficient blood supply of the tumor disturbed the identification of the anatomic landmarks and resulted in subtotal removal. Of the 30 cases, due to fear of severe complications, we chose subtotal resection because of hemorrhage in 4 cases with fibrous pituitary adenomas induced by oral bromocriptine for more than 3 years. So, to further improve the total resection rate of the sellar tumors described above, we should improve the surgical technique and accumulate more experience in the future. In the present study, several complications such as diabetes insipidus, CSF leakage, sinusitis, epistaxis, and intracranial infection occurred after the operation. One patient with a huge pituitary adenoma died from hypothalamic failure; the main reason was that the intraoperative hemorrhage disturbed the identification of the anatomic landmarks and the hypothalamus might be damaged, which was mainly due to inadequate preoperative assessment of the blood supply of the tumor. For the patients with sellar tumors beyond the sellar turcica who underwent endoscopic endonasal transsphenoidal surgery, most postoperative complications could be cured or contained by positive symptomatic treatment. The key point is how to prevent fatal complications. Conclusions The endoscopic endonasal transsphenoidal approach can be a choice for sellar tumors beyond the sellar turcica, but it is necessary to make the choice carefully because of the severe surgical risks. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

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Endoscopic endonasal transsphenoidal approach for sellar tumors beyond the sellar turcica.

The endoscopic endonasal transsphenoidal approach can be a choice for sellar tumors beyond the sellar turcica, but it is necessary to make the choice ...
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