Elshazly Khaled, Kshettry Varun R, Farrell Christopher J, Nyquist Gurston, Rosen Marc, Evans James J
Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA; Department of Neurological Surgery, Ain Shams University Hospital, Cairo, Egypt.
Department of Neurological Surgery, Cleveland Clinic, Cleveland, Ohio, USA.
World Neurosurg. 2018 Jun;114:e447-e456. doi: 10.1016/j.wneu.2018.03.006. Epub 2018 Mar 12.
Giant pituitary adenomas represent a surgical challenge. We present the results of the endoscopic endonasal approach (EEA) for giant pituitary adenomas.
We retrospectively reviewed the medical records of 55 patients with giant pituitary adenomas (>4 cm in maximum diameter) who underwent surgery with an EEA between 2008 and 2016. Factors affecting the extent of resection were evaluated.
The mean patient age was 55.5 years. Tumors were nonfunctional in all but 4 patients, including 2 with growth hormone-secreting tumors, 1 with an adrenocorticotropic hormone-secreting tumor, and 1 with prolactinoma. Gross total resection was achieved in 24 patients (44%), and near-total resection (>90%) was achieved in 26 patients (47%). A multilobular configuration (P = 0.002) and cavernous sinus invasion (P = 0.044) negatively affected the extent of resection, whereas tumor size, intraventricular, and anterior or posterior fossa extension did not. Ten patients underwent adjuvant radiotherapy. All patients with hormone-secreting adenomas required adjuvant medical and/or radiotherapy to achieve biochemical remission. Postoperative vision was improved or normalized in 32 patients (66%), stable in 15 patients (31%), and worsened in 1 patient. A new hormonal deficit occurred in 8 patients (17%), whereas recovery of an existing hormonal deficit occurred in 6 patients (20%). The mean duration of follow-up was 41 months. Tumor recurrence/progression occurred in 6 patients (11%). Complications included apoplexy of residual tumor resulting in ischemic stroke in 1 patient, postoperative cerebrospinal fluid leak in 1 patient, and permanent diabetes insipidus in 4 patients (7%).
Surgery with the EEA is an excellent option for managing giant pituitary adenomas. It results in superior clinical outcomes to those obtained using traditional microscopic transsphenoidal and transcranial approaches as reported in the literature.
巨大垂体腺瘤是手术的一大挑战。我们展示了经鼻内镜入路（EEA）治疗巨大垂体腺瘤的结果。
我们回顾性分析了2008年至2016年间55例接受EEA手术的巨大垂体腺瘤（最大直径>4 cm）患者的病历。评估了影响切除范围的因素。
患者平均年龄为55.5岁。除4例患者外，所有肿瘤均无功能，其中2例为生长激素分泌型肿瘤，1例为促肾上腺皮质激素分泌型肿瘤，1例为催乳素瘤。24例患者（44%）实现了全切除，26例患者（47%）实现了近全切除（>90%）。多叶结构（P = 0.002）和海绵窦侵犯（P = 0.044）对切除范围有负面影响，而肿瘤大小、脑室内及前或后颅窝扩展则无影响。10例患者接受了辅助放疗。所有分泌激素的腺瘤患者均需要辅助药物和/或放疗以实现生化缓解。32例患者（66%）术后视力改善或恢复正常，15例患者（31%）视力稳定，1例患者视力恶化。8例患者（17%）出现了新的激素缺乏，而6例患者（20%）现有的激素缺乏得到恢复。平均随访时间为41个月。6例患者（11%）出现肿瘤复发/进展。并发症包括1例残留肿瘤卒中导致缺血性中风，1例术后脑脊液漏，4例患者（7%）出现永久性尿崩症。
EEA手术是治疗巨大垂体腺瘤的极佳选择。与文献报道的传统显微镜下经蝶窦和经颅入路相比，其临床效果更佳。
