Pituitary adenomas represent 10 to 15% of intracranial tumors. The clinical presentation
of such tumors may include headaches, visual aberrations, and endocrine disturbances.1 Contemporary management of functional adenomas, excluding prolactinomas, is well
established with gross total resection being the primary goal to attain chemical remission.2–4 Despite this, treatment of giant macroadenomas which represent only 5 to 14% of surgically
treated adenomas remains somewhat controversial.
The treatment paradigm for nonfunctioning adenomas is predicated on surgical decompression
of the optic apparatus. The majority of large and giant macroadenomas causing visual
symptoms are nonfunctioning.5 The best preoperative predictive factor for visual loss has been shown to be tumor
size5,6 and factors related to visual recovery include the degree of optic atrophy, the severity
of visual field (VF) defect, and the tumor size.6
Since the introduction of endoscopic endonasal transsphenoidal surgery (EETS) postoperative
visual outcomes have improved. Despite this there is a discrepancy within the published
literature of visual outcomes due to variations in treatment strategy and timing of
surgery. A recent meta-analysis showed that while visual field deficits improved after
EETS, complete recovery occurred in under half with a small proportion deteriorating.7 Despite these outcomes, current dogma encourages aggressive resections at the cost
of increased morbidity.
Between 2011 and 2016, more than 200 EETS procedures for pituitary adenomas were performed
with up to 5-year follow-up.
A retrospective pre- and postsurgical volumetric analysis was performed for the giant
macroadenomas to elucidate completeness of resection. Visual function for these patients
was assessed using visual acuity, Humphrey visual fields and OCT. Correlations were
then drawn as to the benefit of gross total resection over subtotal resection in terms
of improved visual function.
Preliminary analyses suggest subtotal resection of giant macroadenomas may be adequate
to decompress the optic apparatus and allow stabilization or improvement in visual
function in these large complex tumors.
