dr. shahrokh yousefzadeh chabok transsphenoidal pituitary tumors 27 nov 2014
TRANSCRIPT
Dr. Shahrokh Yousefzadeh Chabok
Transsphenoidal Pituitary Tumors27 Nov 2014
ESBS 2007
Neurosurgery has changed !
Evolution of Skull base Neurosurgery
Early 20th Century
Harvey Cushing(1869-1939) Walter Dandy (1886-1946) Hertbert Olivecrona(1891-1980) Charles Frazier(1870-1936)
Evolution of Skull Base Surgery
Contemporary Skull Base Surgery Al-Mefty Dolenc Jannetta Rhoton Samii Sen Sekhar Spetzler Yasargil many more !
Quantification of exposure with endoscopic and microscopic approach to sellar- and supra sellar region
Quantification of exposure with endoscopic and microscopic approach to sellar- and supra sellar region
Pituitary Adenoma
Evaluation
MRI Visual field assessment Endocrine evaluation
Tests of normal gonadal, thyroid, and adrenal function
Radioimmunoassays – for hormone levels
Classifying
Imaging/surgical classification Clinical/endocrine – functional vs.
nonfunctional Pathological classification WHO classification – reconciles the three
systems above
Pathologic Classification
Benign or malignant Chromophobic - Non-functioning Basophilic - Cushing’s Acidophilic - Acromegaly Mixed
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
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
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
WHO Classification
Five-tiered system Clinical presentation and secretory activity Size and invasiveness (e.g. Hardy) Histology (typical vs. atypical) Immunohistologic profile Ultrasturctural subtype
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.
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.
Surgical Indication
Apoplasy Progressive mass effect (PRL , PRL ) Hyper functioning of P.T Unresponsive prolactinoma Histologic confirmation
Surgical contraindication
Profound hypopituitarism
Active sinus infection
Ectatic and tortuous carotid
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
Complication cavernous sinus injury iatrogenic hypopituitarism
Hypothalamic injury
Visual damage
Vascular complication
Brain stem injury
CSF leaks
Nasal complication
Pituitary Adenoma
•Endonasal •Sublabial
Mile stone of modern and contemporary neurosurgery in the treatment of pituitary tumors
Pituitary Adenoma
Pituitary Adenoma
Pituitary Adenoma
Pituitary Adenoma
Appropriate for GKS