Introduction: There are few systematic reports regarding safety and efficacy of the endoscopic approach for recurrent pituitary lesions.
Methods: 412 patients undergoing endoscopic transsphenoidal surgery from April, 2008 to November, 2011 were reviewed; including surgery for 81 recurrent lesions. Pre-operative tumor and clinical characteristics, intra-operative findings, post-operative outcomes and complications were evaluated.
Results: The mean interval between primary and re-operation was 5.1 years. There were significantly more patients with Cushing’s Disease (18.5%vs5.4%) and craniopharyngioma (8.6%vs2.7%), and fewer with prolactinoma (4.9%vs11.7%) compared to the primary tumor population. Operative indications included: visual loss (25.9%), endocrine abnormality (29.6%), headache (22.2%); tumor growth on imaging (23.5%). Intra-operative findings were: extensive scarring (61.9%), bony overgrowth (14.3%), septal perforations (10.7%), cement (7.1%), polyps (4.9%), titanium mesh (2.4%) and purulence(1.2%). 21% had conversion to the microscope, mostly due to distorted anatomy or bleeding. The average operative time was 221 +/- 61 minutes (201 +/- 55 minutes for de novo tumors) and length of stay was 3.9 +/- 3.5 days.
Gross total resection was achieved in 60.5% of the patients studied. One patient developed worsened vision after surgery. For recurrent endocrine active tumors, remission was achieved in 50% of acromegalics and 11/13(84.6%) Cushing’s patients.
Complications occurred in 23.4% of patients with recurrent tumors, compared to 19.9% with de novo tumors. These include: permanent DI (6.2%vs4.8%), delayed CSF leak (4.9% vs3.0%), epistaxis (2.4%vs5.1%), tumor bed hematoma (1.2% vs 0.9%), carotid injury (0 vs0.6%), CN deficit (2.4%vs0) and stroke (1.2%vs0.3%).
Conclusions: The endoscopic endonasal approach is a safe and efficacious approach for recurrent pituitary lesions. Difficult/distorted anatomy may provoke use of the microscope in the approach. Gross total resection and endocrine remission can be achieved in a majority of patients despite recurrent disease.
Patient Care: The recurrent pituitary lesions are difficult to treat surgically. There are very few data describing the use of endoscopic approach for the treatment of recurrent endoscopic lesions. Our data shows that endoscopic approach is a safe and effective treatment option for surgical removal of the recurrent pituitary lesions. The complication profile, the surgical cure rate and the length of the surgery and post-operative hospital stay is comparable to de novo pituitary tumors treated endoscopically.
Learning Objectives: By the conclusion of this session, participants should be able to
1) Describe the utility of endoscopic approach for recurrent pituitary lesions;
2) Discuss the complication profile of endoscopic approach to treat recurrent pituitary lesions compared to de novo pituitary lesions.
3) Identify the effective treatment options for various recurrent pituitary pathologies.