Transsphenoidal Pituitary Tumors Dr. Shahrokh Yousefzadeh Chabok 27 Nov 2014

Neurosurgery has changed ! ESBS 2007

Evolution of Skull base Neurosurgery Early 20th Century Harvey Cushing(1869-1939) Walter Dandy (1886-1946) Hertbert Olivecrona(1891-1980) Charles Frazier(1870-1936)

Evolution of Skull Base Surgery Contemporary Skull Base Surgery Al-Mefty Dolenc Jannetta Rhoton Samii Sen Sekhar Spetzler Yasargil many more !

Quantification of exposure with endoscopic and microscopic approach to sellar- and supra sellar region

Quantification of exposure with endoscopic and microscopic approach to sellar- and supra sellar region

Pituitary Adenoma

Evaluation MRI Visual field assessment Endocrine evaluation Tests of normal gonadal, thyroid, and adrenal function Radioimmunoassays – for hormone levels

Classifying Imaging/surgical classification Clinical/endocrine – functional vs. nonfunctional Pathological classification WHO classification – reconciles the three systems above

Pathologic Classification Benign or malignant Chromophobic - Non-functioning Basophilic - Cushing’s Acidophilic - Acromegaly Mixed

Natural History Pituitary adenomas have long natural history Vary in size and direction of spread Microadenomas < 10 mm – may cause focal bulging Macroadenomas > 10 mm – cause problems due to mass effect

Classification Microadenomas – Grades 0 and I Macroadenomas – Grades II to IV Grade 0: Intrapituitary microadenoma with normal sellar appearance Grade I: Nml-sized sella with asymmetric floor Grade II: Enlarged sella with an intact floor Grade III: Localized erosion of sellar floor Grade IV: Diffuse destruction of floor

Classification Type A: Tumor bulges into the chiasmatic cistern Type B: Tumor reaches the floor of the 3rd ventricle Type C: Tumor is more voluminous with extension into the 3rd ventricle up to the foramen of Monro Type D: Tumor extends into temporal or frontal fossa

WHO Classification Five-tiered system Clinical presentation and secretory activity Size and invasiveness (e.g. Hardy) Histology (typical vs. atypical) Immunohistologic profile Ultrasturctural subtype

Goal of treatment Reversing endocrinopathy and restoring normal pituitary Function. Eliminating mass effect and restoring normal neurological Function. Eliminating or minimizing the possibility of tumor recurrence. Obtaining a definitive histologic diagnosis.

Normal histology white and firmness paucicellular and acinar pattern with pleomorphism Histopathology yellow - gray or purple soft fluid to creamy texture Hypocellularity, monomorphism, uniform cytoplasm staining.

Surgical Indication Apoplasy Progressive mass effect (PRL , PRL ) Hyper functioning of P.T Unresponsive prolactinoma Histologic confirmation

Surgical contraindication Profound hypopituitarism Active sinus infection Ectatic and tortuous carotid

Choice of Surgical approach Size of sella Size of pneumatization of SS Position and tortuous of carotid Direction of intracranial tumor extension uncertainly about pathology Prior therapy

Complication cavernous sinus injury iatrogenic hypopituitarism Hypothalamic injury Visual damage Vascular complication Brain stem injury CSF leaks Nasal complication

Pituitary Adenoma Endonasal Sublabial

Mile stone of modern and contemporary neurosurgery in the treatment of pituitary tumors

Pituitary Adenoma

Pituitary Adenoma

Pituitary Adenoma

Pituitary Adenoma

Appropriate for GKS