title: Endoscopic endonasal surgery for giant pituitary adenomas: advantages and limitations.
abstract: OBJECTIVE
  Giant pituitary adenomas (> 4 cm in maximum diameter) represent a significant surgical challenge. Endoscopic endonasal surgery (EES) has recently been introduced as a treatment option for these tumors. The authors present the results of EES for giant adenomas and analyze the advantages and limitations of this technique.
  
  
  METHODS
  The authors retrospectively reviewed the medical files and imaging studies of 54 patients with giant pituitary adenomas who underwent EES and studied the factors affecting surgical outcome.
  
  
  RESULTS
  Preoperative visual impairment was present in 45 patients (83%) and partial or complete pituitary deficiency in 28 cases (52%), and 7 patients (13%) presented with apoplexy. Near-total resection (> 90%) was achieved in 36 patients (66.7%). Vision was improved or normalized in 36 cases (80%) and worsened in 2 cases due to apoplexy of residual tumor. Significant factors that limited the degree of resection were a multilobular configuration of the adenoma (p = 0.002) and extension to the middle fossa (p = 0.045). Cavernous sinus invasion, tumor size, and intraventricular or posterior fossa extension did not influence the surgical outcome. Complications included apoplexy of residual adenoma (3.7%), permanent diabetes insipidus (9.6%), new pituitary insufficiency (16.7%), and CSF leak (16.7%, which was reduced to 7.4% in recent years). Fourteen patients underwent radiation therapy after EES for residual mass or, in a later stage, for recurrence, and 10 with functional pituitary adenomas received medical treatment. During a mean follow-up of 37.9 months (range 1-114 months), 7 patients were reoperated on for tumor recurrence. Three patients were lost to follow-up.
  
  
  CONCLUSIONS
  Endoscopic endonasal surgery provides effective initial management of giant pituitary adenomas with favorable results compared with traditional microscopic transsphenoidal and transcranial approaches.
authors.affiliation: Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213, USA.
authors.forename: Maria
authors.initials: M
authors.lastname: Koutourousiou
authors.forename: Paul A
authors.initials: PA
authors.lastname: Gardner
authors.forename: Juan C
authors.initials: JC
authors.lastname: Fernandez-Miranda
authors.forename: Alessandro
authors.initials: A
authors.lastname: Paluzzi
authors.forename: Eric W
authors.initials: EW
authors.lastname: Wang
authors.forename: Carl H
authors.initials: CH
authors.lastname: Snyderman
mesh_terms: D000236:Adenoma / Q000150:complications / Q000175:diagnosis* / Q000473:pathology / Q000601:surgery*; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003919:Diabetes Insipidus / Q000209:etiology; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007018:Hypopituitarism / Q000209:etiology; D015994:Incidence; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000517:prevention & control; D018365:Neoplasm, Residual / Q000517:prevention & control*; D044583:Neuroendoscopy / Q000009:adverse effects / Q000379:methods; D009666:Nose; D010911:Pituitary Neoplasms / Q000150:complications / Q000175:diagnosis* / Q000473:pathology / Q000601:surgery*; D018714:Radiotherapy, Adjuvant; D012189:Retrospective Studies; D012307:Risk Factors; D013101:Sphenoid Sinus; D020521:Stroke / Q000209:etiology; D016896:Treatment Outcome; D014786:Vision Disorders / Q000209:etiology