Cavernous Sinus Involvement by Pituitary Adenomas: Clinical Implications and Outcomes of Endoscopic Endonasal Resection

Abdulrazag Ajlan; Achal S. Achrol; Abdulrahman Albakr; Abdullah H. Feroze; Erick M. Westbroek; Peter Hwang; Griffith R. Harsh IV

doi:10.1055/s-0036-1598022

Journal of Neurological Surgery Part B: Skull Base, Table of Contents

J Neurol Surg B Skull Base 2017; 78(03): 273-282
DOI: 10.1055/s-0036-1598022

Original Article

Georg Thieme Verlag KG Stuttgart · New York

Cavernous Sinus Involvement by Pituitary Adenomas: Clinical Implications and Outcomes of Endoscopic Endonasal Resection

Authors

Abdulrazag Ajlan

¹Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, United States

²Department of Neurosurgery, King Saud University, Riyadh, Kingdom of Saudi Arabia
Achal S. Achrol

¹Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, United States
Abdulrahman Albakr

²Department of Neurosurgery, King Saud University, Riyadh, Kingdom of Saudi Arabia
Abdullah H. Feroze

¹Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, United States
Erick M. Westbroek

³Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
Peter Hwang

⁴Department of Otolaryngology, Stanford University School of Medicine, California, United States
Griffith R. Harsh IV

¹Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, United States

Abstract

Background Parasellar invasion of pituitary adenomas (PAs) into the cavernous sinus (CS) is common. The management of the CS component of PA remains controversial.

Objective The objective of this study was to analyze CS involvement in PA treated with endoscopic endonasal approaches, including incidence, surgical risks, surgical strategies, long-term outcomes, and our treatment algorithm.

Methods We reviewed a series of 176 surgically treated PA with particular attention to CS involvement and whether the CS tumor was approached medial or lateral to the internal carotid artery.

Results The median duration of follow-up was 36 months. Macroadenomas and nonfunctional adenomas represented 77 and 60% of cases, respectively. CS invasion was documented in 23% of cases. CS involvement was associated with a significantly diminished odds of gross total resection (47 vs. 86%, odds ratio [OR]: 5.2) and increased the need for subsequent intervention (4 vs. 40%, OR: 14.4). Hormonal remission was achieved in 15% of hormonally active tumors. Rates of surgical complication were similar regardless of CS involvement.

Conclusion Our tailored strategy beginning with a medial approach and adding lateral exposure as needed resulted in good outcomes with low morbidity in nonfunctional adenomas. Functional adenomas involving the CS were associated with low rates of hormonal remission necessitating higher rates of additional treatment.

Keywords

endoscopic - cavernous sinus - pituitary adenomas

Full Text

References

References
1 Ahmadi J, North CM, Segall HD, Zee CS, Weiss MH. Cavernous sinus invasion by pituitary adenomas. AJR Am J Roentgenol 1986; 146 (02) 257-262
2 Fahlbusch R, Buchfelder M. Transsphenoidal surgery of parasellar pituitary adenomas. Acta Neurochir (Wien) 1988; 92 (1-4): 93-99
3 Sol YL, Lee SK, Choi HS, Lee YH, Kim J, Kim SH. Evaluation of MRI criteria for cavernous sinus invasion in pituitary macroadenoma. J Neuroimaging 2014; 24 (05) 498-503
4 Trouillas J, Roy P, Sturm N. , et al; members of HYPOPRONOS. A new prognostic clinicopathological classification of pituitary adenomas: a multicentric case-control study of 410 patients with 8 years post-operative follow-up. Acta Neuropathol 2013; 126 (01) 123-135
5 Vieira Jr JO, Cukiert A, Liberman B. Evaluation of magnetic resonance imaging criteria for cavernous sinus invasion in patients with pituitary adenomas: logistic regression analysis and correlation with surgical findings. Surg Neurol 2006; 65 (02) 130-135 , discussion 135
6 Dolenc VV. Transcranial epidural approach to pituitary tumors extending beyond the sella. Neurosurgery 1997; 41 (03) 542-550 , discussion 551–552
7 Kitano M, Taneda M, Shimono T, Nakao Y. Extended transsphenoidal approach for surgical management of pituitary adenomas invading the cavernous sinus. J Neurosurg 2008; 108 (01) 26-36
8 Frank G, Pasquini E. Endoscopic endonasal cavernous sinus surgery, with special reference to pituitary adenomas. Front Horm Res 2006; 34: 64-82
9 Teo C, Wait S. Cavernous sinus invasion by pituitary adenomas: not an issue. Skull Base 2011; 21 (S01): A058
10 Woodworth GF, Patel KS, Shin B. , et al. Surgical outcomes using a medial-to-lateral endonasal endoscopic approach to pituitary adenomas invading the cavernous sinus. J Neurosurg 2014; 120 (05) 1086-1094
11 Zhao B, Wei YK, Li GL. , et al. Extended transsphenoidal approach for pituitary adenomas invading the anterior cranial base, cavernous sinus, and clivus: a single-center experience with 126 consecutive cases. J Neurosurg 2010; 112 (01) 108-117
12 Ajlan A, Achrol A, Soudry E, Hwang PH, Harsh G. Spontaneous sphenoid wing meningoencephaloceles with lateral sphenoid sinus extension: the endoscopic transpterygoid approach. J Neurol Surg B Skull Base 2014; 75 (05) 314-323
13 Campero A, Campero AA, Martins C, Yasuda A, Rhoton Jr AL. Surgical anatomy of the dural walls of the cavernous sinus. J Clin Neurosci 2010; 17 (06) 746-750
14 Dietemann JL, Kehrli P, Maillot C. , et al. Is there a dural wall between the cavernous sinus and the pituitary fossa? Anatomical and MRI findings. Neuroradiology 1998; 40 (10) 627-630
15 Laws Jr ER. Pituitary pseudocapsule. J Neurosurg 2006; 104 (01) 1-2 , 2–3
16 Oldfield EH, Vortmeyer AO. Development of a histological pseudocapsule and its use as a surgical capsule in the excision of pituitary tumors. J Neurosurg 2006; 104 (01) 7-19
17 Knosp E, Steiner E, Kitz K, Matula C. Pituitary adenomas with invasion of the cavernous sinus space: a magnetic resonance imaging classification compared with surgical findings. Neurosurgery 1993; 33 (04) 610-617 , discussion 617–618
18 Saeger W, Lüdecke DK, Buchfelder M, Fahlbusch R, Quabbe HJ, Petersenn S. Pathohistological classification of pituitary tumors: 10 years of experience with the German Pituitary Tumor Registry. Eur J Endocrinol 2007; 156 (02) 203-216
19 Scheithauer BW, Gaffey TA, Lloyd RV. , et al. Pathobiology of pituitary adenomas and carcinomas. Neurosurgery 2006; 59 (02) 341-353 , discussion 341–353
20 Thapar K, Scheithauer BW, Kovacs K, Pernicone PJ, Laws Jr ER. p53 expression in pituitary adenomas and carcinomas: correlation with invasiveness and tumor growth fractions. Neurosurgery 1996; 38 (04) 765-770 , discussion 770–771
21 Zada G, Woodmansee WW, Ramkissoon S, Amadio J, Nose V, Laws Jr ER. Atypical pituitary adenomas: incidence, clinical characteristics, and implications. J Neurosurg 2011; 114 (02) 336-344
22 Ceylan S, Koc K, Anik I. Endoscopic endonasal transsphenoidal approach for pituitary adenomas invading the cavernous sinus. J Neurosurg 2010; 112 (01) 99-107
23 Isolan GR, Krayenbühl N, de Oliveira E, Al-Mefty O. Microsurgical Anatomy of the Cavernous Sinus: Measurements of the Triangles in and around It. Skull Base 2007; 17 (06) 357-367
24 Koutourousiou M, Vaz Guimaraes Filho F, Fernandez-Miranda JC, Wang EW, Snyderman CH, Gardner PA. Endoscopic endonasal surgery for tumors of the cavernous sinus: experience of 234 cases. J Neurol Surg B Skull Base 2014; 75 (S01): A111
25 DeMonte F, Smith HK, al-Mefty O. Outcome of aggressive removal of cavernous sinus meningiomas. J Neurosurg 1994; 81 (02) 245-251
26 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 2010; 1: 25
27 Tamiya T, Ono Y, Date I, Kawauchi M, Matsumoto K, Ohmoto T. Extradural temporopolar approach for giant pituitary adenomas invading the cavernous sinus and parasellar regions. No Shinkei Geka 1998; 26 (09) 803-811
28 Yasuda A, Campero A, Martins C, Rhoton Jr AL, de Oliveira E, Ribas GC. Microsurgical anatomy and approaches to the cavernous sinus. Neurosurgery 2005; 56 (1, Suppl): 4-27 , discussion 4–27
29 Kim M, Paeng S, Pyo S, Jeong Y, Lee S, Jung Y. Gamma Knife surgery for invasive pituitary macroadenoma. J Neurosurg 2006; 105 (Suppl): 26-30
30 Laws ER, Sheehan JP, Sheehan JM, Jagnathan J, Jane Jr JA, Oskouian R. Stereotactic radiosurgery for pituitary adenomas: a review of the literature. J Neurooncol 2004; 69 (1-3): 257-272
31 Shin M, Kurita H, Sasaki T. , et al. Stereotactic radiosurgery for pituitary adenoma invading the cavernous sinus. J Neurosurg 2000; 93 (Suppl. 03) 2-5
32 Tinnel BA, Henderson MA, Witt TC. , et al. Endocrine response after gamma knife-based stereotactic radiosurgery for secretory pituitary adenoma. Stereotact Funct Neurosurg 2008; 86 (05) 292-296
33 Ferreli F, Turri-Zanoni M, Canevari FR. , et al. Endoscopic endonasal management of non-functioning pituitary adenomas with cavernous sinus invasion: a 10- year experience. Rhinology 2015; 53 (04) 308-316
34 Nishioka H, Fukuhara N, Horiguchi K, Yamada S. Aggressive transsphenoidal resection of tumors invading the cavernous sinus in patients with acromegaly: predictive factors, strategies, and outcomes. J Neurosurg 2014; 121 (03) 505-510
35 Mohr G, Hardy J, Comtois R, Beauregard H. Surgical management of giant pituitary adenomas. Can J Neurol Sci 1990; 17 (01) 62-66
36 Zoli M, Milanese L, Bonfatti R. , et al. Cavernous sinus invasion by pituitary adenomas: role of endoscopic endonasal surgery. J Neurosurg Sci 2016; 60 (04) 485-494
37 Micko AS, Wöhrer A, Wolfsberger S, Knosp E. Invasion of the cavernous sinus space in pituitary adenomas: endoscopic verification and its correlation with an MRI-based classification. J Neurosurg 2015; 122 (04) 803-811

Supplementary Material

Supplementary Fig. 1, Supplementary Table 1 and Supplementary Table 2 (PDF)