الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
Abstract
Background
Pituitary adenomas are benign neoplasms that represent 10 to 15% of all intracranial lesions, it’s classified according to tumor size and to functionality. Nonfunctioning macro-adenomas are those who are more than 1cm in maximum diameter and characterized by the absence of clinical and biochemical evidence of pituitary hormonal overproduction in vivo.
Surgical resection is the first line of management for symptomatic nonfunctioning pituitary macroadenomas. The transsphenoidal midline route represents the standard approach. Purely endoscopic endonasal approach has evolved in the last two decades and is now considered the gold standard surgical method for management of this tumors.
Further refinements of the technique by many endoscopic skull base centers, the endoscopic endonasal technique has continuously evolved, extending gross total resection to pituitary adenomas that previously would have been considered only for surgical debulking, transcranial approaches and adjuvant radiotherapy. The introduction of truly ‘extended endonasal’ approaches has enabled the pituitary surgeon to safely achieve a more radical resection.
Patients and methods
This is a prospective observational study conducted at Ain Shams University hospitals, Cairo, Egypt and Thomas Jefferson university hospital, Philadelphia, USA from the time period of May 2014 to January 2017.
45 patients were enrolled in this study, we prospectively observed the preoperative medical history, imaging studies, visual assessment tests and laboratories investigations.
Purely endoscopic endonasal approach was used as the primary surgical management for all the patients. Staged endonasal surgeries and extended endonasal approach were planned in some cases, method of reconstruction after surgery varied depending on the approach used and the incidence of intraoperative CSF leak.
Postoperative assessment of resection rate, clinical outcome and correlation with different tumor parameters, duration of symptoms and other factors was done.
Postoperative assessment of different complications related to surgery as well as follow up of tumor control and tumor progression, recurrence rate and adjuvant radiotherapy was also done.
Results
The mean age was 58.5 (range 33-79) years, with a male predominance (53%). Visual affection was present preoperatively in 73% of patients. Preoperative endocrine evaluation revealed partial pituitary deficiency in 11 patients (24%), pan-hypopituitarism in three patients (6%).
Standard trans-sellar approach was performed in 34 (76%) cases, extended trans-planum approach in nine (20%) patients, and trans-clival approach in two (4%) patients. Three (7%) cases were planned for staged endonasal surgeries due to extensive tumor size and extension. Adjuvant radiotherapy as part of the initial management plan occurred in three (7%) patients.
Post-operative vision was improved or normalized in 76% of patients, stable in 21%, and only one case developed transient deterioration of vision after surgery. Significant factor that affected the visual outcome after surgery was the duration of symptom, more than 6 months was associated with less incidence of recovery (P value= 0.0002). Recovery of pituitary deficiency occurred in five patients (32%) and a new hormonal deficit occurred in five patients. Large tumors (more than 3 cm in maximum diameter) were associated with more incidence of preoperative hormone deficiency and less chance of hormone recovery after surgery (P= 0.011). Complications included apoplexy of the residual tumor in one case which resulted in an ischemic stroke. Cerebrospinal fluid leaks occurred in two patients, one underwent a successful endoscopic repair, and the other was managed by lumbar drain alone. Permanent diabetes insipidus (DI) occurred in one patient.
Gross total resection (GTR) was achieved in 35 (78%) patients, Near total resection (NTR) in eight (18%) patients, subtotal or partial resection in two (4%) patients. Significant factors that limited the degree of resection were Tumor size (P value= 0.003), cavernous sinus invasion (P value= 0.048), multi-lobular configuration of the adenoma (P value= 0.003), and extension into the anterior cranial fossa (P value= 0.016). In a mean follow-up period of 8.8 (range 3-12) months, one patient had tumor progression of the residual part, which was managed by fractionated stereotactic radiotherapy.
Conclusion
Endoscopic endonasal approach was found in our study to be an effective and safe approach for management of non-functioning pituitary macroadenomas in regards to resection rate, clinical outcome and postoperative complications.