40 Diagnosis Giant non-functioning pituitary adenoma Problems and Tactics A giant non-functioning pituitary adenoma with subfrontal and interhemispheric extension was completely removed by a subfrontal–bilateral approach. Despite the tumor size a selective adenomectomy without new endocrine deficits was possible. Complete tumor removal has been confirmed by repeated magnetic resonance imaging (MRI) studies. The tumor recurred after 8 years, showing signs of focal invasivness on the MRI. Nevertheless, there were no clinical signs of recurrence. The tumor was again surgically treated, this time by a transsphenoidal approach followed by conventional three-dimensional (3D)-volume-rendered, fractionated radiotherapy. This case illustrates key problems in the clinical management of giant non-functioning pituitary adenomas, especially concerning the issue of recurrence and the timing of reoperation and radiotherapy. Keywords Giant pituitary adenoma, management, recurrency, radiotherapy This 45-year-old male patient complained of progressive frontal headaches. In addition, he suffered from blurring vision over the last 3 month. He also noticed a loss of his energy level as well as decreased libido and virility. Cranial magnetic resonance imaging (MRI) showed a tumor mass in the sella turcica with an extremely large, partially cystic, suprasellar interhemispheric and subfrontal extension into the third ventricle. The foramen of Monro blocked. Cerebrospinal Fluid (CSF) was trapped in the frontal horns of the lateral ventricles. Four-fifths of the tumor mass extended outside of the sella turcica, and only one-fifth of the adenoma was localized in the sella itself (Fig. 40–1). Compression of the optic chiasm was confirmed by the ophthalmologists, showing a decreased vision of 0.1 on the right eye and a bitemporal hemianopia. A neuroendocrinological blood test excluded a hormonal hypersecretion. Of note, the serum prolactin level was normal. An incomplete anterior pituitary lobe deficiency was found: hypogonadism [low testosterone, luteinizing hormone (LH), and follicle-stimulating hormone (FSH)], hypothyroidism [low thyroid-stimulating hormone (TSH), free (fT3) and fT4], but normal serum cortisol levels. The large tumor mass was therefore suspected to be a giant non-functioning pituitary adenoma. The patient was placed in the supine position. A bitemporal coronal skin incision was performed. Burr holes were placed at the root of the zygomatic process of the frontal bone on both sides, above the glabella and ~3 cm higher. A subfrontal bilateral craniotomy was performed. The frontal sinuses were opened, the mucosa removed completely, and the sinuses packed with antibiotic gauze. FIGURE 40–1 Male, 45 years, M.H.-O., initial presentation, diagnosis: nonsecreting pituitary adenoma (1988). After opening of the dura, careful frontal lobe retraction was performed, opening the arachnoid and draining the CSF. Nevertheless the small parts of the right frontal pole had to be resected to facilitate an accurate overview of the anatomy and the subfrontal tumor parts. After resection of the subfrontal tumor parts we were able to identify both olfactory tracts (which must be preserved), the position of the optic chiasm and its anatomical relationship with regard to the tumor mass. The right optic nerve was carefully decompressed while resecting the suprasellar tumor parts. Whenever possible the pituitary stalk has to be identified and preserved on its way into the sella turcica itself. The bifrontal approach offered a multidirectional visualization of all adherent tumor parts, including the interhemispheric adenoma extension and the opticocarotid space on both sides. Additionally, this approach offers good access to the lamina terminalis, whenever necessary (especially in cases where the main part of the tumor has developed retro-chiasmatically.) Finally, the pituitary stalk could be preserved. Complete removal of the extrasellar tumor parts was facilitated. The intrasellar parts were removed after drilling of the tuberculum sellae. A galea-periosteal flap was used to close the frontal sinuses. Repeated MRI studies confirmed complete tumor removal postoperatively. The ophthalmological deficits, especially visiual acuity, were markedly improved. There were no new endocrine deficits, especially no diabetes insipidus. Taking this into account and also the postoperative MRI presentation without any suspicous areas with regard to tumor remnants (Fig. 40–2), we did not see an indication for radiotherapy at that time despite the diagnosis of a giant pituitary adenoma. Despite the excellent results after the first operation the adenoma recurred after 8 years without any clinical signs. Meanwhile the endocrine deficits had resolved almost completely, except the necessary hormone therapy with L-thyroxine. On MRI the recurrent tumor showed growth extension into the sphenoid sinus and again into the suprasellar space. In addition, there were signs of focal invasiveness concerning the left cavernous sinus (Fig. 40–3).
Giant Nonsecreting Pituitary Adenoma
Clinical Presentation 1
Surgical Technique 1
Outcome 1
Clinical Presentation 2
Related posts:
28 Dominant Hemisphere Insular Tumor
9 Large Aneurysm of the Internal Carotid Artery Obliterated with Seven Fenestrated Clips under Intraoperative Monitoring of Anterior Choroidal Arterial Blood Flow Insufficiency
20 Collateralization via Vasa Vasorum: A Determinant of Therapeutic Efficacy of Coil Embolization of the Thrombosed Giant Aneurysm of the Vertebral Artery
19 Partially Thrombosed Giant Dissecting Aneurysm of the Vertebral Artery—Treatment Strategies
45 Clinoidal Meningioma Encasing the Internal Carotid Artery
70 Fibrous Dysplasia of the Paranasal Sinuses and Anterior Cranial Base
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
