Acta Neurochir (2009) 151:843–847 DOI 10.1007/s00701-009-0336-z

CASE REPORT

Combined trans-sphenoidal and simultaneous trans-ventricular-endoscopic decompression of a giant pituitary adenoma: case report Bal Krishna Ojha & Mazhar Husain & Manu Rastogi & Anil Chandra & Ashish Chugh & Nuzahat Husain

Received: 26 May 2008 / Accepted: 29 December 2008 / Published online: 28 April 2009 # Springer-Verlag 2009

Abstract Objective This is the first report of the simultaneous combined use of trans-sphenoidal and trans-ventricularendoscopic route for decompression of a giant pituitary adenoma. Method A 38 year old man presented to us with symptoms of raised intracranial pressure along with visual and hypothalamic disturbances. The CT scan revealed destruction of the sella by a large (5×3.5×2.5 cm) well defined enhancing mass in the sella and suprasellar region extending laterally up to the cavernous sinuses and both carotid arteries and superiorly into the lumen of the 3rd ventricle producing obstructive hydrocephalus. On T2WI of the noncontrast MRI scan the mass was iso-intense to grey matter suggesting the possibility of a firm nature of the adenoma. The tumour was first approached by the standard transsphenoidal route and as predicted from the pre-operative MRI, the tumour was found to be firm and not amenable to suction. After decompression of the intra-sellar part of the tumour, the intracranial pressure was raised in an attempt to make the remainder of the tumour descend into the sella but without success. The suprasellar part of the tumour was then simultaneously addressed via a trans-ventricularendoscopic route but the firm tumour did not yield to endoscopic instruments viz. biopsy forceps, angiographic B. K. Ojha (*) : M. Husain : M. Rastogi : A. Chandra : A. Chugh Department of Neurosurgery, CSM (Earlier King George’s) Medical University, Lucknow 226003, India e-mail: [email protected] N. Husain Department of Pathology, CSM (Earlier King George’s) Medical University, Lucknow 226003, India

catheter and electrosurgical probes. It was then gently pushed down towards the sella and decompressed piecemeal by using trans-sphenoidal instruments. The sellar cavity was reconstructed using fat, fascia lata graft and a piece of septal bone. Results Post-operatively, the patient showed a remarkable improvement of his symptoms of raised intracranial pressure, hypothalamic dysfunction and visual disturbances. Follow-up imaging at 2 months and 1 year, did not show any residual or recurrent tumour. Conclusions This novel technique of the combined transsphenoidal and simultaneous trans-ventricular-endoscopic approach is a viable option for patients with giant fibrous pituitary adenoma when the tumour is not yielding to the trans-sphenoidal route alone. Keywords Transventricular-endoscopic . Fibrous . Giant pituitary adenoma . Transsphenoidal

Introduction Most pituitary tumours are histologically benign and represent 10–12% of all intracranial neoplasms [14, 16]. Many of these tumours are readily resectable using the trans-sphenoidal approach as they are soft and remain limited in size and location to the sella and suprasellar regions. Rarely, they can attain a large size and about 5– 13.5% of large pituitary tumours may be fibrous [15, 19]. Surgical resection of these giant and fibrous tumours by traditional approaches is difficult and rarely complete [2, 3, 6–8, 14, 15]. We report a patient with a firm, fibrous and giant pituitary adenoma that was successfully excised using a novel technique -combined trans-sphenoidal (TS) and simultaneous trans-ventricular-endoscopic (TVE) approach.

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Clinical report This 38 year old man presented with symptoms of raised intracranial pressure along with visual and hypothalamic disturbances. Ophthalmic examination revealed visual acuity of 6/18, bi-temporal hemianopia and bilateral papilloedema. The neurological examination was otherwise unremarkable. The contrast enhanced CT scan of the head revealed destruction of the sella by a large (5×3.5× 2.5 cm) well defined enhancing mass in the sellar and suprasellar region extending into the lumen of the 3rd ventricle and producing obstructive hydrocephalus. On T2WI of the non-contrast MRI scan the mass was hypo-to iso-intense to grey matter suggesting the possibility of the firm nature of the adenoma [21, 22]. In addition, Fig. 1a showed invasion of the cavernous sinuses, more than 50% encasement of both carotid arteries and superior extension of tumour into the third ventricle [23]. The biochemical parameters and hormonal status (T3, T4, TSH, Prolactin, GH, FSH and LH) were normal except for a low cortisol level. Based on the MRI finding of a giant and possibly firm tumour, we planned to excise this tumour initially via the trans-sphenoidal route and, if needed, to be assisted by a simultaneous trans-ventricular-endoscopic approach to deal with its suprasellar portion. The operative planning of this

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novel technique and the possible outcomes were explained to the patient and his relatives and written consent was obtained. Topical nasal antibiotic drops and steroids were commenced pre-operatively. Surgical technique The patient was placed supine on the operation table and general anaesthesia was induced. The head was supported on a Horseshoe frame (OMI Medical, Cincinnati, OH) in the neutral position. A baseline lateral skull film was performed and the position of C-arm was adjusted to have the best view of sellar outline. The scalp and nose were prepared and draped separately to facilitate a right coronal burr hole for the trans-ventricular-endoscopic procedure and simultaneously for the trans-sphenoidal approach (Fig. 2). The right lateral thigh was prepared for harvesting fat and fascia grafts. Trans-sphenoidal stage The surgeon standing to the right side of the patient used a standard sub-labial mid-rhinoseptal approach to expose the anterior wall of the sphenoid sinus. After placement of Hardy’s speculum, the sphenoid ostia were located using the operating microscope. The sphenoid sinus was widely opened so that most of the

Fig. 1 a Pre-operative MRI T1 sagittal, T1& T2 coronal sections showing giant dumbbell pituitary tumour; lesion is hypo-intense to brain parenchyma on T2WI. b Post-operative MR (at 2 months) T1 sagittal, T1 & T2 coronal section showing no residual tumour

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tumour were decompressed. The suprasellar part of the tumour was not amenable to curetting nor did it come down with a Valsalva manoeuvre. It was firm, rubbery and slipping out of the grasp of the tumour forceps. At this stage, the endoscopic surgeon (MH) joined to perform the simultaneous trans-ventricular-endoscopic procedure.

Fig. 2 Set up for simultaneous trans-sphenoidal and trans-ventricular endoscopic approach for decompression of giant pituitary adenoma

superior, inferior and lateral aspects of the sellar walls became visible. The anterior wall and floor were removed to obtain a wide exposure of the dura of the sellar floor. A cruciate incision was made in the dura to expose the tumour. The adenoma was found to be firm, fibrous and not removable with suction. It had no capsule and appeared to be invading the dura of the sella. Using a combination of curettes and gentle traction with tumour grasping forceps the grossly visible intra-sellar and cavernous parts of the Fig. 3 Endoscopic pictures of trans-ventricular tumour excision. a Tumour is visualised through foramen of Monro using 4 mm 30° telescope (CP = Choroid plexus, S = septum, T = Tumour). b Attempted fragmentation and suction of tumour using angiographic catheter with 4 mm 30° telescope (Ch = catheter, T = Tumour). c Attempted tumour decompression using biopsy forceps through working channel of 2.7 mm 0° telescope (BF = biopsy forceps, T = Tumour). d Attempted dissection of tumour capsule using angiographic catheter with 4 mm 30° telescope (Ch = catheter, T = tumour capsule)

Trans-ventricular-endoscopic stage A standard right precoronal burr hole was made to approach the ventricular cavity [11, 12]. A Gaab Universal Endoscope System (Karl-Storz, Tuttlingen, Germany) was used in conjunction with rigid 2.7 mm 6º and 4 mm 30° telescopes (Aesculap, Germany). On entering the cavity of the lateral ventricle, the foramen of Monro was found to be enlarged and the greyish white tumour was seen bulging from the floor and filling the third ventricle (Fig. 3a). The 3rd ventricle was entered, the tumour was defined, fine vessels over its surface were coagulated and the capsule of the lesion opened with an electrosurgical probe. Even this portion of the tumour was firm and not removable with a suction catheter (Fig. 3b) and only small pieces could be removed with endoscopic biopsy forceps (Fig. 3c). The whole mass of suprasellar tumour was seen moving up and down when it was gently pushed or pulled by the trans-sphenoidal surgeon. The endoscope was then used to stabilise the firm and rubbery tumour by gently pushing it towards the sella (Fig. 3d). Without this manouevre the tumour was slipping

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out from the grip of the curette used at the trans-sphenoidal end. After this it became possible to curettage the tumour from below. The lump was decompressed internally and finally removed via the trans-sphenoidal route. Bipolar coagulation was used as and when required to control bleeding. We used continuous irrigation with Ringer’s solution, which maintained a clear view and intermittent increase in ventricular pressure by increasing irrigant flow also helped in pushing down the fragmented tumour. Gross tumour removal was achieved by this combined approach and at the end of the procedure there was free flow of CSF and irrigation fluid from the cranial to nasal cavities. To prevent post-operative CSF rhinorrhoea, a fascia lata graft was placed on the sella dura and secured with biological glue. The sella was packed with fat and a septal bone graft was used to reconstruct the floor. In addition, a prophylactic external ventricular drain was in place for 4 days and drained 100– 200 ml of slightly haemorrhagic CSF daily. After surgery, the patient showed a remarkable improvement in the symptoms of raised intracranial pressure, hypothalamic dysfunction and visual disturbances. The nasal packs and ventricular drain were removed on the 2nd and 4th post-operative days respectively. There was no CSF rhinorrhoea and he was discharged from the hospital on the 8th post-operative day.

Histopathological examination “The tumour was composed of sheets of uniform cells with round to oval nuclei, finely dispersed chromatin and moderate amount of cytoplasm and a few cells had clear cytoplasm. There was no cellular atypia or mitosis. The findings were consistent with a diagnosis of pituitary adenoma.” Immunohistochemistry revealed that the tumour was negative for any of the hormone markers. The follow-up radiology after 2 months (Fig. 2b), and 1 year did not show any residual or recurrent tumour. The hormonal status became normalised after 2 months and replacement hormonal therapy was discontinued.

Discussion The microsurgical trans-cranial and trans-sphenoidal routes are two of the most important approaches used for excision of pituitary tumours [2]. Although the former came into use earlier than the trans-sphenoidal route, the latter is preferred by most of the neurosurgeons due to lesser morbidity and more direct trajectory [14, 16, 20]. Most pituitary tumours are amenable to traditional trans-sphenoidal decompression and excision because they are soft and confined to the sellar and suprasellar regions [3, 15]. For the removal of the

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suprasellar component, the trans-sphenoidal approach may be assisted by intra-operative manouevres, such as Valsalva, elevation of jugular venous pressure and the infusion of air, normal saline or Ringers solution through a lumbar catheter [18]. Giant pituitary tumours, especially if firm, pose a problem as the suprasellar portion is not accessible via the trans-sphenoidal method and result in residual tumour [2, 3, 14, 15]. When a satisfactory decompression of a pituitary tumour is not possible via the traditional trans-sphenoidal approach, the options are (1) Staged trans-sphenoidal surgery with or without using the open sella method [1, 14, 15, 18]. (2) Staged or combined microsurgical trans-cranial with trans-sphenoidal surgery [7, 8, 16, 20]. (3) Various modifications of transsphenoidal surgery [3, 6]. (4) Intra-operative MRI guidance and post-operative Gamma knife treatment for residual tumour are newly emerging modalities to help the management of giant pituitary tumours [4, 5, 13, 17, 19]. Combined pterional and simultaneous trans-sphenoidal approach has also been used [2]. Combining the advantages of both microsurgical trans-cranial and trans-sphenoidal approaches may achieve the goal of tumour resection and reduce the need for multiple operations. Alleyne et al have recently reported their experience of ten patients who underwent simultaneous pterional craniotomy and transsphenoidal surgery for a subset of pituitary tumours in which size, configuration, consistency or prior treatment precluded removal by one approach alone [2]. Usually the pituitary tumours are soft in consistency and on MRI they produce low signals (hypo-intense to grey matter) on T1WI and high signal (hyper-intense to grey matter) on T2WI.It is said that softness of the tumour correlates to a high signal on T2WI [21, 22]. In our patient, the tumour produced a hypo-to iso-intense signal, suggesting the possibility of a firm consistency. At operation also, the tumour was found to be firm and after decompression of the sellar portion, the supra-sellar part was not descending towards the sella and could not be held firmly for dissection. At this stage, we decided to use the trans-cranial route to assist in dealing with excision. Since the senior author (MH) had a vast experience in neuroendoscopy [9–12], instead of a simultaneous pterional craniotomy, we chose the less invasive trans-ventricular-endoscopic approach to deal with the 3rd ventricular portion of the tumour and successfully decompressed the tumour. The main advantage of this combined approach for firm and fibrous tumours is that it potentiates the advantages of two minimally invasive procedures and improves the likelihood of a single stage resection for a giant, dumbbell or firm tumour with reduced time and morbidity as compared to staged or simultaneous open cranial surgery. It is emphasised that combined transsphenoidal and simultaneous endoscopic trans-ventricular approach is useful for only those giant pituitary adenomas

Giant pituitary adenoma - a novel technique of decompression

which predominantly grow upwards in the direction of the 3rd ventricle and cause hydrocephalus and dilatation of lateral ventricles. It is also emphasised that the transventricular/endoscopic approach for decompression of tumours has its limitations and should only be used judiciously by experts in the field.

Conclusions With the assistance of an endoscopic neurosurgeon, a combined trans-sphenoidal and simultaneous transventricular/endoscopic approach is a safe and useful option for selected patients with a giant pituitary adenoma in which size, configuration, consistency or prior treatment precluded removal by one approach alone. This innovative technique may help to achieve the goal of tumour decompression with minimal invasion and avoids the need for multiple sequential open operations and adjuvant treatment modalities.

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847 11. Husain M, Rastogi M, Jha DK, Husain N, Gupta RK (2007) Endoscopic trans-aqueductal removal of fourth ventricular neurocysticercosis with an angiographic catheter. Neurosurgery 60(4 Suppl 2):249–253. discussion 254 12. Husain M, Jha D, Vatsal DK, Thaman D, Gupta A, Husain N, Gupta RK (2003) Neuroendoscopic surgery—experience and outcome analysis of 102 consecutive procedures in a busy neurosurgical centre of India. Acta Neurochir (Wien) 145:369–376 13. Ikeda H, Jokura H, Yoshimoto T (2001) Trans-sphenoidal surgery and adjuvant gamma knife treatment for growth hormonesecreting pituitary adenoma. J Neurosurg 95:285–291 14. Kim YZ, Song YJ, Kim HD (2005) Preliminary surgical results of open sella method with intentionally staged trans-sphenoidal approach for patients with giant pituitary adenomas. J Korean Neuro surg Soc 37:16–19 15. Naganuma H, Satoh E, Nukui H (2002) Technical considerations of trans-sphenoidal removal of fibrous pituitary adenomas and evaluation of collagen content and subtype in the adenomas. Neurol Med Chir (Tokyo) 42:202–213. doi:10.2176/nmc.42.202 16. Oruckaptan HH, Senmevsim O, Ozcan OE, Ozgen T (2000) Pituitary adenomas: results of 684 surgically treated patients and review of the literature. Surg Neurol 53:211–219. doi:10.1016/ S0090-3019(00) 00171-3 17. Petrovich Z, Yu C, Giannotta SL, Zee CS, Apuzzo ML (2003) Gamma knife radiosurgery for pituitary adenoma: early results. Neurosurgery 53:51–61. doi:10.1227/01.NEU.0000068702.00330.47 18. Saito K, Kuwayama A, Yamamoto N, Sugita K (1995) The transsphenoidal removal of non-functioning pituitary adenomas with suprasellar extensions: the open sella method and intentionally staged operation. Neurosurgery 36:668–676. doi:10.1097/ 00006123-199504000-00005 19. Sheehan JP, Kondziolka D, Flickinger J, Lunsford LD (2002) Radiosurgery for residual or recurrent non-functioning pituitary adenoma. J Neurosurg 97:408–414 20. Zhang X, Fei Z, Zhang J, Fu L, Zhang Z, Liu W, Chen Y (1999) Management of non-functioning pituitary adenomas with suprasellar extensions by trans-sphenoidal microsurgery. Surg Neurol 52:380–385. doi:10.1016/S0090-3019(99) 00120-2 21. Luchi T, Saeki N, Tanaka M, Sunami K, Yamaura A, Fahlbusch R (1998) MRI prediction of fibrous pituitary adenomas. Acta Neurochir (Wien) 140(8):779–786. doi:10.1007/s007010050179 Commentary 22. Naganuma H, Satoh E, Nukui H (2002) Technical considerations of trans-sphenoidal removal of fibrous pituitary adenomas and evaluation of collagen content and subtype in the adenomas. Neurol Med Chir (Tokyo) 42:202–213. doi:10.2176/nmc.42.202 23. Vieira J Jr, Cukiert A, Liberman B (2006) Evaluation of magnetic resonance imaging criteria for cavernous sinus invasion in patients with pituitary adenomas: logistic regression analysis and correlation with surgical findings. Surg Neurol 65(2):130–135. doi:10.1016/j. surneu.2005.05.021

Comment This rather resourceful approach deals with the dual challenge of a firm tumor that resisted curettage from below, extended into the third ventricle and failed to descend with all other maneuvers. The transventricular endoscopic route allowed pressure to be applied from above while holding the tumor in place to allow curettage from the transsphenoidal exposure below. The result was good and spared the patient the possibility of a craniotomy. This strategy may be invoked in the future by surgeons facing a similar operative challenge. Nelson M Oyesiku Emory University, USA