Dr. Shahrokh Yousefzadeh Chabok

Transsphenoidal Pituitary Tumors27 Nov 2014

ESBS 2007

Neurosurgery has changed !

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