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Giant pituitary adenomas.ppt

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Giant pituitary adenomas is treated by the best neurosurgeon in Gurgaon dr Sumit Sinha.

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Giant pituitary adenomas.ppt

  1. 1. GIANT PITUITARY ADENOMAS Sumit Sinha M.S.; D.N.B.; M.Ch Assistant Professor Deptartment of Neurosurgery All India Institute of Medical Sciences New Delhi
  2. 2. GIANT PITUITARY ADENOMAS ➢ Pituitary adenomas – 7-17% of all the intracranial tumors ➢ 3rd commonest tumors after Gliomas and Meningiomas ➢ Mostly benign- limited to the sella ➢ Produce symptoms due to hormone production, local mass effect or both
  3. 3. GIANT PITUITARY ADENOMAS ➢ About 15% of them grow considerably to significant size- spread to the extrasellar compartment- GIANT PITUITARY ADENOMAS ➢ Formidable surgical problem ➢ Identified as a separate category- aggressive behavior, higher prevalence of neuro-ophthalmologic deficits and poorer response to surgery and radiotherapy ➢ Raise distinct and complex management issues
  4. 4. GIANT PITUITARY ADENOMAS Definition- AMBIGOUS No distinct histopatholgical features Rigid criterion are lacking Symon and Jakuwoski (1979) *– MOST ACCEPTED DEFINITION: ➢ >40 mm above the planum sphnoidale in any direction ➢ < 6 mm from the highest point of the tumor to the FM ➢ Multidirectional spread in >2 directions *Symon L, Jakuwoski J. Surgical treatment of giant pituitary adenomas. J Neurol Neurosurg Psychiatry 1979; 42: 973-82
  5. 5. GIANT PITUITARY ADENOMAS ➢ Guiot et al – SS extension of >30 mm above the tuberculum sellae ➢ Mohr et al (1990) – SS extension >20 mm above the jugum sphenoidale in any direction regardless of the intrasellar volume ➢ Garibi et al (2002) – Tumors >30 mm in diameter (Hardy Type D) ➢ Yildiz et al (1999) – Tumors > 40 mm in size Other Definitions:
  6. 6. GIANT PITUITARY ADENOMAS Grade 0- Intrapituitary adenoma, <1 cm, normal sella Grade 1- Intrapituitary adenoma, <1 cm, focal bulging sella Grade 2- Intrasellar adenoma, >1 cm, enlarged sella, no erosion Grade 3- Diffuse adenoma, >1 cm, enlarged sella, localized erosion/ destruction Grade 4- Invasive adenoma, >1 cm, ghost sella Tumors with SS extension: A: extending to SS cistern B: extending to the IIIrd ventricle recess C: extending to involve whole of the anterior IIIrd ventricles Pituitary adenomas- Classification
  7. 7. GIANT PITUITARY ADENOMAS Hardy and Vezina (1976)- (on the basis of PEG): ➢ Type A- SS extension bulges into chiasmatic cisterns ➢ Type B- Tumor reaches the floor of the IIIrd ventricle ➢ Type C- Tumor bulges into the IIIrd ventricle ➢ Type D- frontal or temporal fossa extensions GPA- CLASSIFICATION:
  8. 8. GIANT PITUITARY ADENOMAS Hashimoto et al (1981) – included ➢ Grade C- SS extension with gross III ventricle displacement ➢ Grade D- intracranial, intradural and parasellar extension ➢ Grade E- extradural extension into and beneath the CS GPA- CLASSIFICATION:
  9. 9. GIANT PITUITARY ADENOMAS Goel et al (2004) – ➢ Grade I- confined to the elevated diaphgrama/ bordered laterally by the intact medial wall of the CS ➢ Grade II- Transgression and invasion into the medial wall of the CS ➢ Grade III- Elevation of the supr wall of the CS, with multicompartmental extension ➢ Grade IV- Supradiaphgramatic subarachnoid extension GPA- CLASSIFICATION:
  10. 10. GIANT PITUITARY ADENOMAS Alleyne et al (2002) – ➢ Type A- SS extension with dumb-bell configuration ➢ Type B- Asymmetric SS extension in sagittal plane anteriorly ➢ Type C- Asymmetric SS extension in sagittal plane posteriorly ➢ Type D- Asymmetric SS extension in coronal plane into the middle fossa GPA- CLASSIFICATION:
  11. 11. GIANT PITUITARY ADENOMAS Local mass effects Endocrinopathy Visual deficits Acromegaly Headache FA syndrome Hypopituitarism CS Seizures FND CN palsies Extension into the sph sinus- Extension into the nasopharynx CLINICAL FEATURES:
  12. 12. GIANT PITUITARY ADENOMAS Hormonal assessment: ➢ Non- functioning- MC ➢ Prolactinomas- MC functioning GPA ➢ GH secreting adenomas ➢ ACTH secreting adenomas
  13. 13. GIANT PITUITARY ADENOMAS CT Scan – Detailed information about the bony involvement and tumor calcification ➢ Homogenous with increased attenuation or mixed high or isodense attenuation ➢ Enhances after IV contrast ➢ Occasionally, low attenuation/ nonenhancing areas inside the lesion – cystic/ necrotic changes ➢ Absence of perilesional edema (more common in SS meningiomas) RADIOLOGICAL FEATURES
  14. 14. GIANT PITUITARY ADENOMAS MRI – Best technique to assess the tumor extent ➢ Variable findings- depend on the presence of infarction, necrosis, cyst formation, hemorrhage or calcification ➢ Typically, hypo-iso on T1WI ; Iso- hyper on T2WI ➢ Figure of 8 appearance ➢ Mild to moderate heterogeneous contrast enhancement ➢ More invasive than PA- invade the skull base, PNS, ACF or MCF ➢ Displace/ encircle rather than constrict the vessel ➢ Helpful in determining the consistency of the tumor preoperatively- 70% of the fibrous tumors are iso on T2
  15. 15. GIANT PITUITARY ADENOMAS The main difference from small PA- ➢ High prevalence of macrocysts ➢ More invasive behavior ➢ Mass effect Features indicating the presence of GPA: ➢ Infrasellar extension ➢ Absence of calcification ➢ Low signal intensity on T1WI
  16. 16. GIANT PITUITARY ADENOMAS Radiological D/D: ➢ Craniopharyngiomas ➢ Meningiomas ➢ Germ cell tumors ➢ Fungal granuloma ➢ PNS neoplasms ➢ Chordoma ➢ chondrosarcoma
  17. 17. GIANT PITUITARY ADENOMAS Craniopharyngiomas: ➢ CT – heterogenous density mass centered in the SS region/ cysts/ calcification at the cyst margins. Solid part enhances on contrast ➢ MRI – hypo (serous content)/ hyper (machine oil - more common) – Intense cyst on T1WI. Calcification – signal dropout ➢ Large SS mass with a variety of components and extensions – CP likely
  18. 18. GIANT PITUITARY ADENOMAS Meningiomas: ➢ CT - iso/ hyperdense extraaxial lesion, well marginated, intensely and homogenous enhance . Broad based dural attachment. Calcification- clumpy,amorphous/ diffuse (psammomatous). Bony erosion + ➢ MRI – iso to hypo on T1WI; iso (50%), hyper (40%) and hypo (10%- fibrotic/Ca ) on T2WI . Dural tail. Enhance intensely. Constrict the vessel lumen
  19. 19. GIANT PITUITARY ADENOMAS Chordoma ➢ CT - Destructive, locally infiltrative midline mass expanding the clivus and breaching the posterior clival cortex. Foci of sequestered bone/irregular calcification/ destroyed BM ➢ MRI – iso to hypo on T1WI replace the bright BM; heterogenous hyperintense on T2WI; variable enhancement Chondroasarcomas: Radiologically indistinguishable. Occur laterally, centered on the petroclival suture
  20. 20. GIANT PITUITARY ADENOMAS Fungal granulomas: ➢ CT – low density lesions, enhancement +/-. Perilesional edema. Chronic abcesses – ring and homogenous enhancement. Paranasal sinusitis. Areas of bony destruction ➢ MRI – hypointense on T2WI with perilesional edema.
  21. 21. GIANT PITUITARY ADENOMAS ➢ Medical ➢ Surgical ➢ Radiotherapy ➢ Radiosurgery MANAGEMENT
  22. 22. GIANT PITUITARY ADENOMAS ➢ Giant prolactinomas- distinctively hyper-responsive ➢ Giant PRLomas- S PRL > 3000 ng/ml/ with invasive growth ➢ 0.5% of all pituitary tumors DOPAMINE AGONISTS- TOC by many authors MEDICAL MANAGEMENT
  23. 23. GIANT PITUITARY ADENOMAS First line of treatment except in- ➢ Pituitary apoplexy ➢ Visual deterioration- (several reports indicate equal if not efficacious improvement on DA agonists) ➢ Resistance / intolerance to medical tt Dopamine Agonists:
  24. 24. GIANT PITUITARY ADENOMAS DA agonists: Mechanism of action- ➢ Bind to the D2 receptors on the lactotroph membrane- inhibit the synthesis and release of PRL ➢ Inhibit the proliferation of lactotroph cells in the anterior pituitary- reduce cellular cytoplasmic volume and tumor size ➢ Involution of the RER and GA – inhibits the PRL synthesis ➢ Reduce the PRL gene transcription and translation DA reduce the S PRL levels in 75% of the pts with macroPRLomas, reduce the tumor size by >50% and restore the gonadal function
  25. 25. GIANT PITUITARY ADENOMAS DA – agents used: ➢ Bromocriptine ➢ Cabergoline ➢ Quinagolide ➢ Pergolide ➢ lisuride
  26. 26. GIANT PITUITARY ADENOMAS Bromocriptine: (2 bromo-ergocryptine) – ergot alkaloid ➢ Dosage – 5-20 mg/day TDS ➢ Dose increased gradually- reduces the side effects ➢ S/E: nausea/ vomiting (30%) numbness/ tingling of toes and fingers weakness of legs muscle pains hypotension visual and auditory hallucinations orofacial dyskinesias erythromalalgia CSF RHINORRHOEA
  27. 27. GIANT PITUITARY ADENOMAS DA – Problems: ➢ Resistance to treatment – 10-25% of the pts ➢ Intolerance – 5-10% pts ➢ Several reports- use of DA leads to hemorrhage, inflammatory infarction, increased tumor fibrosis- tumor excision difficult ➢ Not tumoricidal- require lifelong treatment ➢ CSF rhinorrhoea HENCE THE FIRST LINE OF TREATMENT OF PRL IS STILL CONTROVERSIAL
  28. 28. GIANT PITUITARY ADENOMAS ➢ 5-20% chance of a macroPRLoma to increase in size during pregnancy ➢ No known teratogenic effects of bromocriptine ➢ TO BE CONTINUED DURING PREGNANCY ➢ Long acting depot injection / 28 days – PARLODEL LAR ➢ Slow release oral preparation – PARLODEL SRO ➢ Bromocriptine patch ➢ Per rectal administration
  29. 29. GIANT PITUITARY ADENOMAS Cabergoline: Long acting DA Dosage – 0.2-3.5 mg/wk, twice or thrice a wk Less S/E
  30. 30. GIANT PITUITARY ADENOMAS ➢ Transsphenoidal approach ➢ Transcranial approach ➢ Combined TS and TC approach ➢ Complex skull base approaches SURGICAL MANAGEMENT
  31. 31. GIANT PITUITARY ADENOMAS ➢ Regained popularity after Guiot, Hardy and Wiser used it with the advent of operating microscope and image intensifier ➢ The preferred approach to pituitary tumors by most authors– lesser morbidity; more direct trajectory ➢ Only recommended by most of the authors in – lesions confined to the sella larger lesions with a significant SS extension and intact diaphgrama ➢ *Goel et al – radical surgery by TS route is indicated and possible in Grade I-III tumors, while biopsy + RT is the only option for Grade IV tumors Transsphenoidal Approach:
  32. 32. GIANT PITUITARY ADENOMAS Indications- ➢ Multicompartmental tumors ➢ Large dumbbell suprasellar extension ➢ Large residual tumor/ postoperative hematoma ➢ Uncertain diagnosis ➢ Abandoned TS d/t distorted anatomy Transcranial Approach:
  33. 33. GIANT PITUITARY ADENOMAS ➢ Most of the authors prefer TC route in all the patients – subfrontal/ combined subfrontal- subtemporal route ➢ Primary aim to decompress the intradural portion of the tumor to relieve the chiasma and hypothalamus- best achieved by attack on the largest extrasellar part of the tumor by the TC route ➢ Partial excision inadvisable – postoperative pituitary apoplexy
  34. 34. GIANT PITUITARY ADENOMAS Indications- ➢ Dumbbell shaped tumors ( Type A tumors) ➢ Alleyne Type B/C/D tumors ➢ Firm, fibrous tumors ➢ SS extension of the tumors with a prefixed chiasma ➢ In tumors with multiple extensions extradurally or laterally *Alleyne et al – combined simultaneous TS and pterional craniotomy approach Combined TS and TC approach:
  35. 35. GIANT PITUITARY ADENOMAS ➢ Midline Transfacial approach with osteoplastic maxillotomy and palatal division and posterior pharyngeal incision (Anson 1995): Indications- Large midline tumors with large cranio-caudal extensions and limited width and cranial base or clival involvement ➢ Lee Fort I maxillotomy approach (Crockard 1993): Good exposure to middle and upper thirds of clivus but limited in reaching the tumor superoinferiorly Complex skull base approaches:
  36. 36. GIANT PITUITARY ADENOMAS Surgical Complications ➢ Poor surgical outcome- mortality 4.2-18% in various series ➢ TS approach less morbid than TC approaches ➢ High surgical mortality d/t: ischemia of the hypothalamus/ brainstem/ cerebral hemispheres; vessel traction; postoperative apoplexy- compression of vital structures and hydrocephalus
  37. 37. GIANT PITUITARY ADENOMAS ➢ General consensus – RT following surgery gives the best results ➢ Various series report – local control rates in macroadenomas of 50-70% with surgery alone and 80-90% with surgery and RT ➢ Some authors have suggested that the risk of regrowth of the adenomas was lower than the complications of radiation ➢ Yildiz et al- local control rates and PFS after Sx + RT – 73% and 65% ➢ Goel et al – suggested postoperative RT in Grade II tumors with significant residual tumor/ Grade III tumors with asymptomatic residual and in all Grade IV tumors. No RT for Grade I tumors b/c of the ease of surgical excision RADIOTHERAPY

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