1. Transsphenoidal Pituitary Tumors
Dr. Shahrokh Yousefzadeh Chabok
27 Nov 2014

2. Neurosurgery has changed !
ESBS 2007

3. Evolution of Skull base Neurosurgery
Early 20th Century
Harvey Cushing( )
Walter Dandy ( )
Hertbert Olivecrona( )
Charles Frazier( )

4. Evolution of Skull Base Surgery
Contemporary Skull Base Surgery
Al-Mefty
Dolenc
Jannetta
Rhoton
Samii
Sen
Sekhar
Spetzler
Yasargil
many more !

5. Quantification of exposure with endoscopic and microscopic approach to sellar- and supra sellar region

6. Quantification of exposure with endoscopic and microscopic approach to sellar- and supra sellar region

7. Pituitary Adenoma

8. Evaluation MRI Visual field assessment Endocrine evaluation
Tests of normal gonadal, thyroid, and adrenal function
Radioimmunoassays – for hormone levels

9. Classifying Imaging/surgical classification
Clinical/endocrine – functional vs. nonfunctional
Pathological classification
WHO classification – reconciles the three systems above

10. Pathologic Classification
Benign or malignant
Chromophobic - Non-functioning
Basophilic - Cushing’s
Acidophilic - Acromegaly
Mixed

11. 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

12. 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

13. 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

14. WHO Classification Five-tiered system
Clinical presentation and secretory activity
Size and invasiveness (e.g. Hardy)
Histology (typical vs. atypical)
Immunohistologic profile
Ultrasturctural subtype

15. 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.

16. 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.

17. Surgical Indication Apoplasy Progressive mass effect (PRL , PRL )
Hyper functioning of P.T
Unresponsive prolactinoma
Histologic confirmation

18. Surgical contraindication
Profound hypopituitarism
Active sinus infection
Ectatic and tortuous carotid

19. 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

20. Complication cavernous sinus injury iatrogenic hypopituitarism
Hypothalamic injury
Visual damage
Vascular complication
Brain stem injury
CSF leaks
Nasal complication

24. Pituitary Adenoma
Endonasal
Sublabial

25. Mile stone of modern and contemporary neurosurgery in the treatment of pituitary tumors

26. Pituitary Adenoma

42. Pituitary Adenoma

43. Pituitary Adenoma

46. Pituitary Adenoma

67. Appropriate for GKS