Endoscopic Endonasal Transsphenoidal Removal of Recurrent and Regrowing Pituitary Adenomas: Experience on a 59-Patient Series

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Endoscopic Endonasal Transsphenoidal Removal of Recurrent and Regrowing Pituitary Adenomas: Experience on a 59-Patient Series TUMOR

Luigi M. Cavallo1, Domenico Solari1, Anastasia Tasiou 2, Felice Esposito1, Michelangelo de Angelis1, Alfonso Iodice D’Enza3, Paolo Cappabianca1

Key words 䡲 Endoscopic endonasal surgery 䡲 Endoscopy 䡲 Pituitary adenomas 䡲 Recurrences 䡲 Skull base 䡲 Transsphenoidal surgery Abbreviations and Acronyms CSF: Cerebrospinal fluid CT: Computerized tomography MRI: Magnetic resonance imaging From the 1Department of Neurological Sciences, Division of Neurosurgery, Università degli Studi di Napoli Federico II, Naples, Italy; 2Department of Neurosurgery, University Hospital of Larissa, University of Thessaly School of Medicine, Larissa, Greece; and 3Department of Economic Science, Università degli Studi di Cassino, Cassino, Italy To whom correspondence should be addressed: Domenico Solari, M.D. [E-mail: [email protected]] Citation: World Neurosurg. (2013) 80, 3/4:342-350. http://dx.doi.org/10.1016/j.wneu.2012.10.008 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter © 2013 Elsevier Inc. All rights reserved.

INTRODUCTION Pituitary tumors represent approximately 10% of all intracranial tumors, although in autopsy studies the incidence is higher; despite their benign behavior, pituitary tumors can extend and spread throughout the boundaries of the sella to reach the supra or infrasellar areas and/or cavernous sinuses (4, 6, 33, 37, 55, 81). Transsphenoidal surgery is considered the most effective treatment for nonfunctioning pituitary adenomas and also the primary therapeutic option for secreting pituitary adenomas, with the exception of prolactinomas. During the last century, pituitary surgery has been developed through innovations and technological progress to grant the lowest rates of morbidity and mortality in a safe, feasible, and practical way (14, 21, 29, 40-42, 51, 56, 61, 78). It was ultimately revolutionized, in the mid 1990s,

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䡲 OBJECTIVE: The nature of the pituitary adenomas itself exposes the possibility of a recurrence of the tumor. The aim of this study was to evaluate the effectiveness of the endoscopic endonasal transsphenoidal approach for the removal of recurrent and residual pituitary adenomas, already treated by a microscopic or endoscopic transsphenoidal approach or by a transcranial route. 䡲 METHODS: A total of 59 adult patients with a recurrent or regrowing pituitary adenoma underwent surgery using a pure endoscopic endonasal transsphenoidal approach. Of these patients, 31 were previously operated on by a microsurgical transsphenoidal approach, 22 by means of an endoscopic transsphenoidal route, and 6 via a transcranial route. The patient series has been divided into 3 tiers according to the primary surgery, and the results were evaluated accordingly. 䡲 RESULTS: Gross total removal was achieved in 37 of our cases (62.7%). According to prior surgery at primary disease, we found that in the subgroup of patients who underwent a microsurgical transsphenoidal approach we achieved gross total removal in 23 cases (74.2%; 23 of 31), whereas in the group of patients who underwent the endoscopic endonasal approach, gross total removal was attained respectively in 13 cases (59.1%; 13 of 22) and in only 1 case of those who underwent the transcranial approach (16.7%; 1 of 6). Postoperative complications included 1 case (1.7%) of cerebrospinal fluid leak and meningitis, and 1 with an hematoma in the tumor field (1.7%); both needed surgical reoperation. 䡲 CONCLUSIONS: The endoscopic endonasal approach is a safe and effective procedure for the management of recurrent and/or regrowing pituitary tumors previously treated by either a microsurgical or an endoscopic approach.

by the introduction of the endoscope in transsphenoidal technique, this latter being the result of ear-nose-throat surgery expertise with functional endoscopic sinus surgery (1, 5, 46, 53, 82). It represents a minimally invasive approach commonly used in many centers throughout the world, under the same indications as the conventional microsurgical technique, mainly for the treatment of sellar diseases (8, 11, 13, 15, 48, 49). The efficacy of the endoscopic endonasal approach for the management of pituitary tumors has been reported in the literature (8-10, 25, 38, 43, 50, 73), with results and complications rates at least comparable with larger microsurgical se-

ries (2, 3, 16-20, 22, 23, 32, 34, 36, 43, 45, 50, 51, 58-60, 62, 63, 69, 73, 76, 84, 86, 87). This technique provides several advantages, above all a better visualization of the surgical field and a lesser degree of nasal trauma, resulting in a more comfortable postoperative stay for the patient. Despite the advantages brought by the endoscope itself for both the patients and the surgeons, inner features of the pituitary adenomas that depict its biological behavior, i.e., labeling index, cavernous sinus invasiveness, young age at diagnosis, etc., expose the possibility of a recurrence of the tumor (2, 3, 16-18, 22, 34, 36, 39, 43, 50, 58-60, 62, 63, 70, 72, 73, 76, 84, 86).

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Pituitary adenomas can recur even after an initial gross total removal, so the occurrence of tumor recurrence is not rare. Surgery for the removal of a recurrent lesion regrown from a residual is burdened by an increased risk of mortality and morbidity, and more often it results in incomplete resections compared with the primary surgery (2, 3, 16-18, 22, 34, 36, 43, 50, 58-60, 62, 63, 73, 76, 84, 86). For that reason, a series of different alternative therapeutic modalities, among them gamma knife and stereotactic radiosurgery, are increasingly used to obtain long-term control of the lesions (17, 44, 64, 66-68, 74, 80). Therefore, given the actual continuous expanding indications of the endoscopic endonasal transsphenoidal approach (12, 24, 27, 30, 47, 54, 87), we evaluated the advantages and limits of using this technique in surgical reintervention for pituitary adenomas already operated on via a transsphenoidal approach, either microsurgical or endoscopic, and/or a transcranial route.

MATERIALS AND METHODS This study retrospectively analyzed the data of a series of patients who underwent an endoscopic endonasal approach for the removal of a recurrent or regrowing lesion from a residual pituitary lesion at the Division of Neurosurgery of the Università degli Studi di Napoli Federico II, Naples, Italy. All patients underwent a full endocrinological evaluation preoperatively and postoperatively at 1 month; patients with secreting adenomas and/or patients with postoperative failure of 1 or multiple axes had repeated endocrinological serum tests every 6 months. Neuroradiological evaluation consisted of a sellar magnetic resonance image (MRI), before and after intravenous paramagnetic contrast agent (gadolinium-diethylenetriaminepentaacetic acid) administration, for every patient. Furthermore, a computed tomography (CT) scan of the craniofacial bones and of the sellar area was conducted in selected cases to provide better definition and clarify the relationships of the sphenoid, the sella, and the other bone structures involved in the procedure. The use of preoperative image guidance was carefully evaluated according to sphenoidal sinus pneumatization degree and to nasal, ethmoidal, and sphenoidal anatomy as revealed by preoperative MRI

REMOVAL OF RECURRENT AND REGROWING PITUITARY ADENOMAS

and CT scans. The percentage of neuronavigator usage though accounted for approximately 30%. Postoperative neuroradiological evaluation by means of MRI examination was performed at 3 months to confirm the tumor removal rate. MRI scans were then repeated every year to monitor eventual lesion regrowth (pituitary tumor already seen at least at first postoperative MRI scan) and/or recurrence (pituitary tumor not seen at least at first postoperative MRI). From January 2000 to January 2010, 59 patients (27 male, 32 female; mean age 49.6 years, range 23 to 82 years) harboring a recurrence or regrowth of a pituitary adenoma, underwent a pure endoscopic endonasal transsphenoidal approach, according to our technique, already previously reported in the literature (8, 11, 13, 15, 24, 48, 49). In the same time frame, a total of 643 endoscopic endonasal procedures were performed for the removal of a pituitary adenoma. Demographic data, preoperative assessment, tumor features (i.e., size and extension), cavernous sinus invasion, and prior treatments such as surgical interventions and/or medical and/or radiotherapy were retrieved from our electronic database (Filemaker Pro 11, File Maker Inc., Santa Clara, California, USA) (Tables 1 and 2). The series consisted of 31 cases of regrowth (24 nonfunctioning and 7 functioning) and 28 cases of recurrence (17 nonfunctioning and 11 functioning). The interval between the initial surgery and tumor recurrence/regrowth ranged from 6 to 155 months (mean 57.6 months). The patient series was divided into subgroups according to hormonal status, i.e., functioning and nonfunctioning, and based on the original surgical procedure: patients who had undergone surgery via a transsphenoidal microsurgical approach, a transsphenoidal endoscopic approach, or a transcranial approach (Tables 1 and 2). Thirty-one patients had been previously treated by microsurgical transnasal transsphenoidal approach, 22 using the transnasal endoscopic technique, and 6 by a transcranial approach. The group of nonfunctioning adenomas accounted for 41 patients; all of them had macroadenomas, of which 32 had a suprasellar extension and 11 had an evident cavernous sinus invasion (26.8%) (Table 3).

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Concerning the hormone-active adenomas, there were 8 adrenocorticotropic hormone– secreting adenomas, 6 growth hormone– secreting adenomas, 3 growth hormone/ prolactin–secreting adenomas, and 1 prolactinoma; 9 of them were macroadenomas, whereas 9 were microadenomas (Table 1). Overall, 67.2% of patients were affected by lesions with suprasellar extension, whereas 17 lesions were infiltrating the cavernous sinus (35%). Eight patients received a supplemental radiotherapeutic treatment after the first surgery. The grade of cavernous sinus invasion was defined preoperatively according to Knosp classification, as observed by the investigators and the referring neuroradiologist, but was definitely established according to cavernous sinus invasion as observed during surgical procedure. Concerning the endocrinological symptoms, 17 patients presented a hypersecretion-related syndrome, whereas 16 had a single axis defect, 2 had a 2-axes defect, and 6 had panhypopituitarism. In these latter 24 cases, hormone replacement therapy had been administered preoperatively. Preoperative visual examination revealed 34 patients with visual defect. Finally, we would like to underline that no complication occurred at first surgery that hindered the procedure or affected the removal rate achieved.

Surgical Technique The patient was placed supine, under general anesthesia, with the head in a neutral position or slightly extended (approximately 5° to 10°); a 15° rotation to the right and tilt to the left are added to allow direct surgical access. A Mayfield-Kees rigid 3-pin skeletal head fixation is used only if an image guidance system (neuronavigation) is required; usually the head is placed in a horseshoe rest. The procedure is performed mainly with a 0° endoscope, 4 mm in diameter and 18 cm in length.

Operative Nuances After Previous Microscopic Transsphenoidal Surgery The middle turbinates are usually lateralized in both nostrils, although one of these turbinates may be removed in one side in those cases in which an extended approach is performed. Thereafter, the previous ante-

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TUMOR www.SCIENCEDIRECT.com

Case Number Age/Sex

Tumor Size/Type (Hormonal Subset)

Cavernous Sinus Surgical Invasion

Previous Surgical Procedures

Recurrence-Free Period (months)

Medical Therapy

Radiation Recurrence/ Therapy Regrowth

24, M

Micro ACTH

No

ETA

6

–

–

2

49, F

Macro GH

No

ETA

41

Sandostatin LAR

–

3

23, F

Macro GH-PRL

No

MTA

27

Bromocriptine, octreotide, DDAVP

–

4

43, F

Macro GH

Yes

ETA

81

Somatostatine

–

5

47, F

Macro PRL

Yes

MTA (⫻2) ETA

47 (never disease free)

Bromocriptine

6

44, F

Micro ACTH

No

MTA

93

7

47, F

Micro ACTH

No

MTA

137

8

24, F

Micro ACTH

No

ETA

9

54, F

Macro GH-PRL

Yes

10

40, F

Micro ACTH

11

39, M

12

Regrowth

Preoperative Visual Symptoms –

Recurrence

Acromegaly 11GH, IGF-1

–

Recurrence

Amenorrhea, 11GH, PRL

–

Recurrence

Acromegaly 11GH, IGF-1

Bitemporal hemianopia

SRS

Regrowth

Amenorrhea, galactorrhea 11GH, PRL

Right profound vision loss; III, V, VI CN palsies

–

–

Recurrence

Cushing

–

Levotiroxine

–

Recurrence

Cushing 1ACTH

–

8

–

–

Regrowth

Cushing 11ACTH, pCortisol

–

MTA (⫻5)

9 (never disease free)

Bromocriptine, somatostatine, levotiroxine

GK, SRS

Regrowth

Acromegaly, amenorrhea 11GH, PRL

Bitemporal hemianopia; left III CN palsy

No

ETA

67

Cabergoline, ketoconazole

–

Recurrence

Cushing 11ACTH, pCortisol

–

Micro GH

No

MTA

94

Lanreotide, pegvisomant

–

Recurrence

Acromegaly 11GH, IGF-1

–

49, M

Macro ACTH

No

ETA

59

Cabergoline

–

Recurrence

Cushing 11ACTH, pCortisol

–

13

45, M

Micro GH

No

ETA

15

Longastatine LAR

–

Recurrence

Acromegaly 11GH, IGF-1

–

14

38, F

Micro ACTH

No

MTA

155

–

–

Recurrence

Cushing

–

15

33, F

Macro GH

Yes

ETA

35

Pegvisomant

–

Regrowth

Acromegaly, 11GH, IGF-1

Left temporal quadrantopia

16

44, F

Micro ACTH

No

MTA

51

–

–

Recurrence

Cushing hypogonadism 1 pCortisol

–

17

75, M

Macro GH-PRL

Yes

ETA, TCA

63

Cabergoline, sandostatine LAR

SRS

Regrowth

Panhypopituitarism 11GH, Right III CN palsy PRL

18

40, F

Macro GH

Yes

TCA

49 (never desease free)

Cabergoline LAR

–

Regrowth

Acromegaly 11GH, IGF-1

–

M, male; F, female; ACTH, adrenocroticotroph hormone; pCortisol, plasmatic cortisol; ETA, endoscopic transsphenoidal approach; GH, growth hormone; LAR, long-acting release; IGF, insulin-like growth factor; PRL, prolactin; MTA, microsurgical transsphenoidal approach; DDAVP, desmopressin; TCA, transcranial approach; SRS, stereotactic radiosurgery; R, disease remission (according to current criteria for the specific subset of secreting adenoma); CN, cranial nerve; GK, gamma knife; 2, slight reduction; 22, moderate reduction; 1, slight increase; 11, moderate increase; 111, significant increase.

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Cushing 11ACTH, pCortisol

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1

Preoperative Endocrinological Symptoms

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Table 1. Patient Series with Secreting Adenomas (Preoperative Data)

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Table 3. Patient Series with Nonfunctioning Adenomas (Postoperative Data)

Table 2. Patient Series with Nonfunctioning Adenomas (Preoperative Data) Number of Cases Previous surgical procedures*

Number of Cases Tumor removal

Transsphenoidal microscopic

25

Gross total

Transsphenoidal endoscopic

13

Near total (⬎90%)

28 6

Transcranial

6

Subtotal (⬎70%)

4

Radiaton therapy

5

Partial (⬍70%)

3

Recurrence/regrowth

Complications

Regrowth

24

Cerebrospinal fluid leak

Recurrence

17

VI cranial nerve palsy (transient)

2

Sellar hematoma

1

Meningitis

1

Preoperative visual symptoms Bitemporal hemianopia Quadrantopia

22 7

Preoperative endocrinological symptoms Panypopituitarism

Postoperative visual symptoms Improved

5

Two-axis defect

2

Hypocortisolism

2

Hypogonadism

3

*Three patients had 2 surgical procedures before the endoscopic endonasal procedure for the treatment of the recurrence.

rior sphenoid bony breach, partially reclosed, should be enlarged to create a wider corridor to achieve good exposure of the posterior wall of the sphenoid sinus and an easier identification of the previous osteodural defect on the sellar floor. The endoscopic endonasal approach offers the possibility of managing safely the posterior portion of the nasal corridor and the sphenoid sinus anterior wall opening. Compared with the microsurgical route, it makes it easier to identify the anatomical structures of this area, including the main vascular feeders, so that an adequate corridor may be created. The widening of the sphenoidotomy allows easier identification of the cleavage plane between scar tissue and anatomical structures on the posterior wall of the sphenoid sinus, especially above the sellar floor. The bone opening is then circumferentially widened, and the fibrous scar tissue is gently dissected from the dura. In those cases in which the identification of the cleavage plane was troublesome, a micro-Doppler probe was used to insonate the major intradural vessels, above all the intra-

1

Unchanged

21 8

Postoperative endocrinological symptoms (if present) Improved

4

Unchanged

8

Two-axis defect (new onset)

1

Hypocortisolism (new onset)

1

Hypogonadism (new onset)

1

cavernous C-shaped tract of the internal carotid artery, to safely define the dural opening. In case of lesions with a relevant suprasellar component, the tuberculum sellae and the planum sphenoidale could be removed following the same principles already described for the extended transplanum approach (52). We adopted this route, which allowed us to use 2 surgical corridors, the conventional endosellar extraarachnoidal and a suprasellar trans-arachnoidal (27), in 11 cases, 4 harboring a functioning lesion and 7 a nonfunctioning one. Concerning the reconstruction, it must be highlighted that the presence of nasal mucosal adherences due to absence of septal bone makes, when necessary, the elevation of a nasoseptal mucosal flap troublesome, so that free mucosal flaps can be harvested more easily from the middle turbinates.

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Operative Nuances After Previous Endoscopic Transsphenoidal Surgery Even in such cases, the procedure starts with the management of eventual nasal synechiae, especially between the nasal septum and the turbinates. Again, the lateralization of the middle turbinates is performed or, in selected cases, a middle turbinectomy is performed in 1 nostril. Notwithstanding the previous anterior sphenoidotomy was narrowing down, in a majority of cases a wide communication between the nasal and sphenoidal cavities is present. However, upon the insertion of the endoscope, simply sliding along the nasal cavities, the sella is reached without dissecting any structures along the surgical path. Once again, any further refinement of the corridor, tailored to each case, could be easily done under direct view; the surgical procedure is faster because the anterior sphenoid wall has been already widely opened in the previous endoscopic surgery, whereas it had not in microsurgical ones. Once adequate surgical room in the sphenoid sinus is obtained, the osteodural opening is tailored to lesion characteristics. The tumor removal is performed as for the primary endoscopic procedure.

Operative Nuances After Previous Transcranial Surgery In cases in which a previous transcranial approach had been performed, the procedure followed the same steps of a primary endoscopic transsphenoidal approach. Most of the advantages of the endonasal endoscopic technique we have noticed are related to the fact that a naive route is accessed. This is particularly true for tumor dissection maneuvers: the transcranial route does not allow reaching the most inferior and posterior portions of the tumor, which conversely are easily managed when approached from below. In these cases, there is an increased risk of intraoperative cerebrospinal fluid (CSF) leakage because of the opening of the optochiasmatic cisterns during the original transcranial surgery. Of utmost importance is the preoperative neuroradiological study with both CT and MRI scans, also integrated with 3-dimensional reconstructions, to define the anatomical relationships between the lesion and the optic chiasm and anterior circulation vessels and to eventually identify

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TUMOR

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REMOVAL OF RECURRENT AND REGROWING PITUITARY ADENOMAS

Table 4. Patient Series with Secreting Adenomas (Postoperative Data) Postoperative Case Tumor Endocrinological Number Removal Outcome

Postoperative Visual Outcome

Follow-Up Complications/Recurrence (months)

TUMOR

1

Gross total R 2 FSH, LH (new onset)

Unchanged (normal) –

2

2

Near total 2 GH, IGF-1 (⬎90%)

Unchanged (normal) –

30

3

Gross total 22 PRL 1GH, IGF-1 22 FSH, LH (new onset)

Unchanged (normal) –

149

4

Near total 2 GH, IGF-1 (⬎90%)

Improved

–

15

5

Subtotal (⬎70%)

N/A

Unchanged

–

N/A

6

Subtotal (⬎70%)

Unchanged

Unchanged (normal) –

5

7

Gross total R

Unchanged (normal) –

56

8

Subtotal (⬎70%)

Unchanged

Unchanged (normal) Transient DI

54

9

Partial (⬍70%)

Unchanged

N/A

3

10

Gross total 22 pCortisol

11 12

Disease progression; Death

Unchanged (normal) –

39

Gross total 22 GH, IGF-1

Unchanged (normal) –

27

Gross total R

Unchanged (normal) –

13

13

Gross total R

Unchanged (normal) –

9

14

Gross total R

Unchanged (normal) Transient DI

62

15

Subtotal (⬎70%)

Unchanged

40

16

Gross total R

Unchanged (normal) Transient DI

27

17

Partial (⬍70%)

Unchanged

Unchanged

30

18

Subtotal (⬎70%)

2 GH, IGF-1

Unchanged (normal) –

Worsened 11GH, IGF-1

–

Disease progression; death

24

R, disease remission (according to current criteria for the specific subset of secreting adenoma); FSH, follicle-stimulating hormone; LH, luteinizing hormone; GH, growth hormone; IGF, insulin-like growth factor; PRL, prolactin; N/A, not applicable; DI, diabetes insipidus; pCortisol: plasmatic cortisol; 2, slight reduction; 22, moderate reduction; 1, slight increase; 11, moderate increase; 111, significant increase.

the displacement of any of these structures inside the sella.

RESULTS The removal rate of the endoscopic endonasal approach for recurrent pituitary adenomas in our series was first evaluated according to intraoperative endoscopic exploration and thereafter confirmed at 3-month MRI scans. An overall gross total removal was achieved in 37 patients

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(62.7%), and in 8 patients (13.8%) a near total removal (⬎95%); subtotal removal (⬎70%) was attained in 9 (15.5%) patients, and in 5 patients (8.6%) the tumor removal was only partial. In our series we noted a mean rate of 38.4% of gross total in regrowing lesions (60.8% nonfunctioning adenomas, 15 of 24; 14.3% secreting adenomas, 1 of 7) whereas it reached 74.6% in cases of recurrent tumors (76.5% nonfunctioning adenomas, 13 of 17; 72.7% secreting adenomas, 8 of 11).

The results and complications data and the postoperative clinical assessment were analyzed separately, according to the division in subgroups. According to hormonal status classification, in the group of nonfunctioning adenomas the tumor removal rate was gross total in 28 cases (60.4%), near-total in 6 (15%), subtotal in 4 (10%), and partial in 3 patients (7.5%). The surgical outcome concerning tumor invading the cavernous sinus accounted for 2 cases of gross total removal (22.2%; 2 of 9), 2 of near total (22.2%; 2 of 9), 3 of subtotal (33.3%; 3 of 9), and 2 of partial removal (22.2%; 2 of 9) (Table 3). In this group, visual defects improved in 72.4% of cases (21 of 29), and remained unchanged in 8 cases (27.6%). Concerning the endocrinological outcome, 4 patients (33.3%; 4 of 12) reported a significant improvement of their endocrinological functions. New onset of a single-axis defect was disclosed in 2 patients (5%), and of a 2-axes defect only in 1 patient (2.5%). Regarding complications, we observed only 1 case (2.5%) of postoperative CSF leak, further complicated by the occurrence of meningitis in a patient with a nonfunctioning adenoma. A hemorrhage in tumor residual cavity occurred in 1 patient (2.5%) with a nonfunctioning pituitary lesion. In both cases an early successful endoscopic reintervention was performed, respectively to remove the blood clot and to revise the cranial base graft. There were 2 cases (5%) reported of transient VI central nerve palsy, both in regrowing nonfunctioning lesions (Table 3). In the secreting adenomas group, gross total tumor removal was achieved in 9 patients (50%), near-total in 2 (11%), subtotal in 5 (27.8%), and partial in 2 (11%). The overall remission rate (according to current criteria for specific secreting adenoma subset) of endocrinological disease was 33.3% (6 of 18). Regarding lesions invading the cavernous sinus, we achieved near total removal in 1 case (16.7%; 1 of 6), and subtotal and partial removal respectively in 3 (50%; 3 of 6) and 2 (33.3%; 2 of 6) cases (Table 4). Visual defect improved in only 1 case (5.5%). Transient diabetes insipidus was reported as the only complication in this group, and occurred in 3 cases (16.7%) (Table 4). None of the patients of both groups with a normal preoperative visual

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Table 5. Postoperative Data According to Previous Surgical Procedure Postoperative Visual Symptoms

Postoperative Endocrinological Symptoms

Previous Surgical Procedures*

Gross Total

Near Total (>90%)

Transsphenoidal microscopic (31)

23

2

4

2

9

11

8

5

2†

Transsphenoidal endoscopic (22)

13

5

3

1

13

8

7

3

2ⴱ

1

1

2

2

1

1

Transcranial (5)

Subtotal Partial (>70%) (<70%) Improved Unchanged Worsened Improved Unchanged Worsened

In case of multiple procedures, we considered only the surgery for the removal of the primary tumor. *Hypogonadism. †1 patient with 1 new axis deficit, 1 patient with 2 new axis deficits.

assessment experienced any postoperative worsening. However, according to prior surgery at primary diagnosis, we found that in the subgroup of patients who underwent a microsurgical transsphenoidal approach we achieved gross total removal in 23 cases (74.2%; 23 of 31). In the group of patients who underwent an endoscopic endonasal approach, gross total removal was attained in 13 cases (59.1%; 13 of 22). Finally, concerning the group of patients who previously underwent a transcranial approach, gross total (⬎95%) removal was accomplished in 1 case (16.7%; 1 of 6) (Table 5). A total of 11 patients underwent a radiotherapeutic treatment after the removal of recurrent and/or residual tumor by means of the endoscopic endonasal approach (4 of 18 of the secreting adenomas group and 7 of 41 of the nonfunctioning group; overall rate of 18.9%). There was no death related to the procedure. No carotid injury, epistaxis from sphenopalatine artery, or airways difficulties were observed. All such data concerning the functional outcome were confirmed at the latest follow-up observation.

DISCUSSION The features of the endoscopic endonasal transsphenoidal approach are well known and have been previously reported in the main literature (8, 11, 13, 15, 20, 24, 28, 45, 48, 49, 60, 75). The technique offers a close-up view of the relevant anatomy, especially at the tumor-gland interface; an enlarged working angle; and an increased panoramic vision inside the surgical area. Complication rates are at least similar or

comparable to those reported in the major microsurgical transsphenoidal series (2, 3, 16-18, 22, 34, 36, 43, 50, 58-60, 62, 63, 73, 76, 84, 86). Additionally, transsphenoidal endoscopy brings valuable advantages for the patients: it does not require nasal packing in the majority of cases, being less traumatic for the nasal anatomy with less postoperative pain and better relief after surgery, thus resulting in a short hospital stay (9, 11, 25, 31, 35, 79, 87). Nevertheless, the endoscope is not a magic wand capable of modifying the biological behavior of the adenoma. These lesions are definitely considered benign, although they often extend beyond sellar boundaries, into the suprasellar area, the cavernous sinus, and/or less frequently the clival and retrosellar space. In the relevant literature, recurrence rates for pituitary adenomas vary between 6% and 21%; it is clear that regrowth after incomplete tumor removal turned out to be a very likely event, being reported between 39% and 75% (2, 3, 16-18, 22, 34, 36, 39, 43, 50, 58-60, 62, 63, 70, 72, 73, 76, 84, 86). In our experience, 59 of 635 pituitary adenoma surgeries at our department between 2000 and 2010 were for recurrent or regrowing lesions; retrospectively analyzing such a series, we noticed that at primary surgery 38.9% of the population (23 of 59 patients) had a lesion with negative predictive factors, such as a cavernous sinus invasion, high labeling index, or young age at diagnosis (16, 17, 39, 71, 72, 85). In fact, there are only few publications in the literature reporting results and complications of the endoscopic endonasal transsphenoidal approach for the treatment of pituitary adenoma recurrence/regrowth. The prelim-

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inary experience reported by our group (7) on a series of 12 recurrent adenoma surgeries using the endoscopic endonasal technique disclosed a total removal rate of 41.6% (5 of 12 patients). Lasio et al. (57) analyzed the difference in using an image-guided system during the endoscopic endonasal approach, reporting an overall total removal rate of 73.7% (14 of 19 patients), namely 75% (6 of 8 patients) in the group who underwent surgery without the aid of a neuronavigation system and 72.7% (8 of 11 patients) in the group who had procedures assisted by an imageguided system. The series accounts for the absence of both morbidity and mortality. Rudnik et al. (77) analyzed 20 patients who underwent surgery by the endoscopic endonasal technique because of recurrent and residual pituitary adenomas. The total removal rate was 42.8% for the nonfunctioning adenomas, 0% for the growth hormone–secreting tumors, and 100% for the adrenocorticotropic hormone and the prolactinomas. Dehdashti et al. (26) reported the experience of Toronto’s group with the endoscopic endonasal approach for the secondary treatment of Cushing disease: they achieved an excellent 80% rate of remission (20 of 25 patients) with a single case of CSF leakage and no other major morbidities. More recently, Wagenmakers et al. (83) presented their series of 14 patients with recurrent or persistent Cushing disease; they reported a remission rate of 71% (10 of 14 patients), overburdened by a high rate of morbidity: 6 cases with CSF leakage (42.8%), 2 of which required further surgery for CSF leak repair; 1 postoperative hemorrhage due to massive sphenopalatine bleeding, requiring reoperation for coagu-

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lation; and 6 cases of transient diabetes insipidus (42.8%). In our series, we had an overall gross total removal rate of 62.1%, with a morbidity rate of 12.5% and a mortality rate of 0%; in particular, for functioning adenomas we observed a remission rate (according to current criteria for a specific secreting adenoma subset) of 33.3%, with a morbidity rate of 11%. Our results seem to be comparable with the data retrieved from the literature concerning a microsurgical transsphenoidal approach for recurrent pituitary adenomas, in which the rate of total removal in recurrent lesions varies from 26% to 77% (2, 3, 16-18, 22, 34, 36, 43, 50, 5860, 62, 63, 73, 76, 84, 86). However, we aimed to underline the safety and efficacy of our surgical technique, also in regard to the different original surgery for the primary tumor, because we noticed certain variations in terms of outcome according to this factor. Additionally, we reported several advantages brought in by the endoscopic technique along the approach. Especially in those cases in which the corridor has not been properly refined, the use of the endoscope in the management of the posterior portion of the nasal cavity and in the opening of the sphenoid sinus anterior wall allowed the identification of the major anatomical structures along this region, including the main mucosal feeders. In the patients who were previously treated by traditional microsurgical transnasal transsphenoidal approach, the rate of gross total removal (74.2%; 23 of 31) was higher than in the patients previously treated by endoscopic endonasal approach (59.1%; 13 of 22) and by transcranial approach (16.7%; 1 of 6). The higher removal rate in those patients who already underwent surgery via a microsurgical transsphenoidal approach could be assigned to several reasons; among them it could be said that the anterior sphenoidotomy performed in the endoscopic endonasal approach is wider compared with the previous microsurgical one. This allows a better dissection of scar tissue within the sphenoid sinus, thus permitting an easier and wider opening of the sellar floor (65). Forty-two patients presented with visual disturbance, and we found that 22 (52%) of these patients experienced improved vision with the second surgery via the endoscopic

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endonasal approach. More importantly, no one with normal vision complained of any worsening. The first advantage in using an endoscopic endonasal approach for the treatment of a recurrent pituitary adenoma after a first transcranial surgery is obviously related to the use of a naive route. Furthermore, an inverse view of the surgical field is provided, thus permitting reaching, in a direct way, some anatomical areas that presumably had not been reached or manipulated in the first transcranial surgery. Nevertheless, the lower rate of total removal in patients who already underwent surgery via transcranial approaches could depend on the inner features of these lesions, such as the higher rate of cavernous sinus, suprasellar, and retrosellar extension and/or middle fossa invasion. All of them were large lesions, extensively invading the cavernous sinus, and furthermore, 3 of them underwent more than 1 procedure before the endoscopic one. Indeed, during surgery for a recurrence, results were further complicated as compared with the primary procedure, especially for nonfunctioning lesions, as our experience also revealed, for several reasons. Most were related to inner features of the lesions, namely a fibrous and rubbery consistency, and an irregular dumbbellshaped and/or suprasellar/parasellar extension (27).

CONCLUSIONS The management of recurrent or regrowing adenomas involves a cogent balance between further surgical treatment, a waitand-see attitude, and radiation therapy; it requires cleverness, great versatility, and collaboration of different specialists to improve patient outcome and reduce morbidity. The endoscopic endonasal approach is a safe, minimally invasive method for resection of recurrent or regrowing pituitary tumors previously treated by either a microsurgical or an endoscopic approach, and is associated with a small number of complications.

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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Received 11 November 2011; accepted 2 October 2012; published online 6 October 2012 Citation: World Neurosurg. (2013) 80, 3/4:342-350. http://dx.doi.org/10.1016/j.wneu.2012.10.008 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter © 2013 Elsevier Inc. All rights reserved.

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