Expanded Endoscopic Endonasal Approach for Complex Functioning Tumors with Cavernous Sinus, Suprasellar, and Clival Invasion: Technical Nuances for Maximizing Extent of Resection and Biochemical Remission

Objectives: Expanded endoscopic endonasal approach (EEA) is used for the resection of complex functioning pituitary micro- or macroadenomas. These may abut or invade different cavernous sinus (CS) compartments and the relevant internal carotid artery (ICA) segments with para- or infrasellar growth or invade clival/petrous bone and the petrous ICA in the infrasellar direction. Successful resection requires the use of different para-, supra-, and infrasellar surgical adjuncts to facilitate maximal resection.

Subjects: Twenty-two consecutive complex functioning adenomas underwent surgical resection.

Methods: Of more than 180 surgically resected pituitary adenomas, 22 consecutive complex functioning adenomas (11–77 years; female = 12) underwent surgical resection without any exclusion criteria toward achieving remission, decompressing the optic chiasm when applicable and ensuring maximal surgical resection by the senior author.

Results: Of the 22 adenomas, 5 were recurrent and 17 were primary (Cushing’s syndrome = 2; acromegaly = 16; TSHoma = 2; prolactinoma = 2). One patient with recurrent invasive prolactinoma and another with recurrent acromegaly with medial wall invasion had a partial response and required pharmacological therapy to achieve remission. One patient with primary acromegaly with multicompartmental invasion and fibrotic disease despite improved control required pharmacological treatment and consideration for radiotherapy. No patient suffered cranial nerve paresis or CSF leak. Although all adenomas abutted different ICA segments, true CS invasion was confirmed intraoperatively in 12. Of 22, 4 had significant suprasellar extension and 7 had mid-clival invasion including petrous ICA in two. Key adjuncts included: paraclinoidal ICA exposure in all; medial wall resection in 4; upper paraclival ICA exposure in 10 to access posterior and inferior CS compartments; transtuberculum transchiasmatic sulcus approach in 4; trans mid-clival approach in 7 with additional transpterygoid approach to access disease around petrous ICA/ foramen lacerum in two. One patient with giant extrasellar TSHoma required a second-stage open transsylvian approach for further debulking.

Conclusion: These adjuncts facilitate maximal resection including for adenomas invading the CS. These adjuncts need to be “stacked” together and individualized according to the tumor morphology to maximize resection. Complex acromegaly lesions frequently require the use of EEA to achieve biochemical cure.

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Artikel online veröffentlicht:
07. Februar 2025