Marginal dissection for mid-sized pituitary adenomas Andrew Law Marginal dissection for mid-sized pituitary adenomas

Goals Maximise tumour resection Maximise functional cure rates Minimise recurrence Reduce need for Radiotherapy Not affect rates of hypopituitarism Minimise complication rates

Pure endoscopic technique Began in 2000 - Endoscopic approach / Septal pushover  Microscope for tumour resection Progression to - Pure endoscopic surgery 2007 Technique Improved camera / monitor systems Liquid coagulants Approx 50% with ENT - Functioning - Difficult cases

Complications of Transsphenoidal Surgery: Results of a National Survey, Review of the Literature, and Personal Experience Ciric, Ivan MD; Ragin, Ann PhD; Baumgartner, Craig PA-C, MBA; Pierce, Debi BS Neurosurgery Issue: Volume 40(2), February 1997, pp 225-237

Exposure Utilisation of pseudo-capsule Actual dissection of adenomas Utilisation of pseudo-capsule E Oldfield Using sublabial / microscopic approach Extending to Endoscopic approach

Surgical Management of Cushing’s Disease: A Personal Perspective Edward H. Oldfield, MD Clinical Neurosurgery Volume 58, 2011

Pituitary Series 2000-2015 Andrew Law 681 Pituitary Tumour Operations (to Sept 15) (Excluding meningiomas/craniopharyngiomas/others) Non Functioning 460 Functioning 221 FU 3m-15yrs

GH secreting tumours

GH secreting tumour operations 2000-2011 68 2012-15 38 Total 106

GH 2012-2015 38 Operations (34 patients) 4 repeat surgery 2 cured / 2 ongoing Biochem cure (Surgery alone) – 20 (54%) Biochem cure (Surgery +/- Octreotide LAR +/- DXT) - 30 (88%) (2 cases awaiting response to Rx) 1 uncontrolled progression  Death 2000-2011 Long term remission rate – 80%

Issues Mixed tumours GH-PL Preoperative medications Difficult tumours Cabergoline Octreotide Some evidence that may improve cure rates But increases surgical difficulty Difficult tumours Size Cavernous sinus invasion Sphenoid anatomy

ACTH Tumours 2000-2011 59 Remission 50 85% Total 78 Visible microadenomas 100% Cavernous sinus invasion Stereotactic radiosurgery “Invisible microadenomas” Near total “85%”gland resection Tumour outside pituitary fossa

Non-Functioning Adenomas 2012-15 Early MRI (3/12) – 0 cases of significant residual (sellar/suprasellar) Postoperative DXT – 3 patients Recurrence rates?

CSF Leaks Intraoperative 46% Postoperative 4.8% 2000-2011 8.8% (Req repacking surgery) Includes extended procedures 0 last 2 years 2000-2011 8.8%

Complications 2012-2015 No perioperative deaths SIADH “Approx 30%” – At least Late postop abscess (post extended) - 1 Carotid puncture – Clipped - 1 Visual decline – 2 (Both for recurrence) Surgery abandoned due to sinus infection - 1 Sphenoid mucocoele - 1 Sinusitis – Common

Technique Exposure Arachnoid knife Rhoton dissector Ring curettes Bony margins Stopping instrument contact. “Touch” Arachnoid knife Rhoton dissector Ring curettes Malleable endoscopic instruments Water dissection Micro patties Patience Microsurgical approach

Videos of the actual transphenoidal surgery are available to view. If you are interested in seeing some real life action, please email Catherine@acromegaly.org.nz

Followup Imaging (MRI) Work in progress!! Functioning Non Functioning Only if fail to cure – Biochemically Non Functioning (3m),1yr, 2yr, 4yr, 4yr More frequent if residual / recurrent tumour evident Work in progress!!