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

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Dr. Shahrokh Yousefzadeh Chabok Transsphenoidal Pituitary Tumors 27 Nov 2014

Transcript of Dr. Shahrokh Yousefzadeh Chabok Transsphenoidal Pituitary Tumors 27 Nov 2014.

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Dr. Shahrokh Yousefzadeh Chabok

Transsphenoidal Pituitary Tumors27 Nov 2014

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ESBS 2007

Neurosurgery has changed !

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Evolution of Skull base Neurosurgery

Early 20th Century

Harvey Cushing(1869-1939) Walter Dandy (1886-1946) Hertbert Olivecrona(1891-1980) Charles Frazier(1870-1936)

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Evolution of Skull Base Surgery

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

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

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

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Pituitary Adenoma

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Evaluation

MRI Visual field assessment Endocrine evaluation

Tests of normal gonadal, thyroid, and adrenal function

Radioimmunoassays – for hormone levels

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Classifying

Imaging/surgical classification Clinical/endocrine – functional vs.

nonfunctional Pathological classification WHO classification – reconciles the three

systems above

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Pathologic Classification

Benign or malignant Chromophobic - Non-functioning Basophilic - Cushing’s Acidophilic - Acromegaly Mixed

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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

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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

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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

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WHO Classification

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

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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.

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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.

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Surgical Indication

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

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Surgical contraindication

Profound hypopituitarism

Active sinus infection

Ectatic and tortuous carotid

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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

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Complication cavernous sinus injury iatrogenic hypopituitarism

Hypothalamic injury

Visual damage

Vascular complication

Brain stem injury

CSF leaks

Nasal complication

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Pituitary Adenoma

•Endonasal •Sublabial

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

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Pituitary Adenoma

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Pituitary Adenoma

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Pituitary Adenoma

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Pituitary Adenoma

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Appropriate for GKS

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