Adenomas invasores, presentación de caso, revisión de la literatura y propuesta de clasificación según su extensión / Invasive adenomas, case report, literature review and proposal for classification according to their extensión

Los adenomas hipofisiarios invasores constituyen una patología de baja frecuencia dentro de los tumores del sistema nervioso central, su nombre hace referencia a aquellas lesiones que se extienden hacia estructuras adyacentes a la región selar y que en algunas ocasiones pueden alcanzar tamaños gigantes. Representan un importante reto quirúrgico considerando la posibilidad de daño de las estructuras comprometidas o rodeadas por el tumor. Son lesiones que se manifiestan de forma tardía y generalmente más por su efecto compresivo que por un compromiso hormonal secundario. Existen múltiples clasificaciones partiendo de la extensión del tumor, además de las que hacen referencia a las características histológicas. En este artículo se exponen los sistemas de clasificación así como algunos de los abordajes reportados en la literatura. Se muestra el caso de una de nuestras pacientes a quien se le diagnosticó tardíamente un adenoma invasor de gran tamaño, después de varios años de cursar con importantes alteraciones del comportamiento y quien posteriormente fue llevada a cirugía para resección del tumor por vía transcranial. Se expone la complejidad anatómica de la región selar y se propone un nuevo sistema de clasificación que contempla el compromiso diferencial de espacios y estructuras neurales y vasculares adyacentes a la región selar con el fin de guiar a los cirujanos sobre los procedimientos quirúrgicos más adecuados y disponibles en el momento.

Invasive pituitary adenomas constitute a low-frequency disease within the central nervous system tumors, the name refers to those lesions involving adjacent structures to the sellar region and who can reach giant sizes. The invasive adenomas represent a major challenge considering surgical morbidity due to the commitment of structures that may be involved given the extent of these lesions. These tumors usually are belatedly manifested and their manifestations are most often secondary to the compressive effect than hormonal involvement. There are multiple classifications based on the extent of the tumor, besides those that referring to the histologic features. This article shows a case of a patient who was diagnosed lately, with a big invasive adenoma who had had major behavioral disturbances in previous years and was subsequently taken to surgery for resection of the tumor. We present the anatomical complexity of the sellar region and we propose a new classification system to guide surgeons on the surgical procedure most suitable and available at the time.

Cirugía en tumores de la región selar: informe de una serie de 15 casos / Surgery for tumors of the sellar region: report a series of 15 cases

Introducción: La región selar es considerada por algunos autores como el tercer sitio en orden de aparición de lesiones tumorales en la cavidad craneal. Método: Se realizó un estudio descriptivo de 15 pacientes que fueron intervenidos quirúrgicamente en el Hospital “Roberto Rodríguez”, de la ciudad de Morón, provincia de Ciego de Ávila, Cuba, en el período comprendido entre enero de 1996 y diciembre del 2008, con el diagnóstico de tumor selar, con crecimiento supraselar dependiente o no de la silla turca, el diagnóstico fue obtenido con la tomografía axial computarizada (TAC) simple y contrastada de cráneo y silla turca, así como por imágenes de resonancia magnética nuclear (RMN). Resultados: Las principales manifestaciones clínicas al momento de la cirugía fueron la cefalea, presente en todos los casos y los trastornos visuales en 10 (66,67 por ciento), en todos se pudo demostrar crecimiento supraselar excéntrico. En seis pacientes (40 por ciento), se realizaron abordajes combinados, transcraneal-transesfenoidal o viceversa, en tiempos quirúrgicos diferentes, en otros seis (40 por ciento) solo transesfenoidal y en tres (20 por ciento) solo transcraneal. Las complicaciones fueron tres casos (20 por ciento) con anosmia, luego de un corredor bifrontal, una crisis convulsiva tónicoclónica generalizada en el post operatorio inmediato (6,67 por ciento), un sangrado transoperatorio con infarto cerebral secundario a vasospasmo cerebral (6,67 por ciento). Los resultados fueron excelentes en 10 (66,66 por ciento), en tres casos (20 por ciento) buenos, en uno (6,67 por ciento), regular y una paciente falleció (6,67 por ciento).

Introduction: The sellar region is considered the third site of brain tumors. Methods: A retrospective descriptive study was carried out in 15 patients operated on of sellar region tumor by transeptal transsphenoidal microsurgery and transcranialapproaches. Results: 10 giants pituitary adenoma by transesphenoidal or transcranial approaches, 2 craneopharyngiomas by transsphenoidal approach, 2 meningiomas and 1 dermoid tumor by transcranial approach. Complete resection was obtained in 73,33% of cases. The most frecuent complication was anosmia related with transcranial approaches. Results were excellent in 10 patients and with a mortality of 6,67%.

Penetrating Retrobulbar Orbital Foreign Body: A Transcranial Approach

We report the successful removal of a retrobulbar foreign body using a transcranial approach in a 63-year-old patient with a penetrating injury to the left eye. Initial ocular examination revealed a corneoscleral laceration, hyphema, a traumatic cataract, and vitreous hemorrhage. Visual acuity consisted only of the perception of hand motion. Computed tomography demonstrated an orbital foreign body in the retrobulbar area. Emergency corneoscleral suturing, phacoemulsification of the cataract, and vitrectomy with posterior vitreous detachment were performed. Fifteen days after the emergency operation, we successfully removed the orbital foreign body using a transcranial approach, although the foreign body was very close to the optic nerve. On fundus examination 6 months later, a white, fibrous lesion was seen inferior to the optic disc, and the corrected visual acuity was 20/30. These positive results may be due to the complete vitrectomy at the correct time performed by a retina specialist and the minimal pressure on the eyeball while removing the foreign body, which resulted from the use of a transcranial approach.

Vasospasm of Proximal Internal Carotid Artery Following Transcranial Removal of a Pituitary Adenoma

We report a case of proximal internal carotid arterial spasm following pterional removal of pituitary adenoma. We discuss the possible mechanism of vasospasm associated with tumor resection.

Frontal Sinus Mucocele with Massive Skull Destruction

A 63-year-old female complained of left frontal headache and swelling for several months. Physical examination revealed a left supraorbital soft, nontender, nonpulsatile mass without bruit. The left eye was displaced downward with respect to the normal right globe. Based on the clinical and radiological findings, the patient was diagnosed as a mucocele arising from the left frontal sinus. The patient underwent a transcranial approach through coronal incision. In this patient, large portions of the anterior and posterior frontal sinus walls were destroyed in association with epidural spread, so we performed cranialization of the frontal sinus and removed the mucosal wall with the aid of a microscope. With a brief review we present a patient with mucocele of the frontal sinus extending into the intracranial and intraorbital region, which was successfully treated by a transcranial approach.

Surgical Management of Giant Pituitary Adenomas

OBJECTIVE: Giant pituitary adenomas are rare. The location of these adenomas are close to vital neural and vascular structures with widespread extensions that makes the radical surgical management difficult. METHODS: From October 1994 to August 1998, we experienced 20 patients with giant pituitary adenomas out of 178 surgically treated pituitary adenoma patients. Giant pituitary adenoma was diagnosed on the basis of the longest diameter of being more than 4cm in MRI scan. We reviewed the clinical presentation, types of tumor, size and degree of suprasellar or parasellar extension, routes of surgical approach, postoperative surgical outcomes and complications. RESULTS: The incidence of giant pituitary adenomas was 11%. The most common chief complaint was visual disturbance(n=16). The non-functioning adenoms(n=16) were the majority and the other 4 patients were functioning adenomas(prolactinoma n=2, acromegaly n=1, cushing's disease n=1). The patients underwent transsphenoidal approach(TSA)(n=15) or transcranial approach(TCA)(n=5). Gross total or subtotal removal were achieved in 60% of TSA group(9 of 15) and 40% of TCA group(2 of 5). Postoperative complications were in 6 patients with TSA; cerebrospinal fluid(CSF) leakages(n=2), postoperative bleeding(n=2), transient diabetes insipidus(DI)(n=2). Visual function was improved in 69%(9 of 13) after TSA and 40% after TCA. Surgical results in the TSA group were better than those in transcranial approach group, and there were fewer and less severe postoperative complications. CONCLUSION: Even in the giant pituitary adenomas, conventional transsphenoidal approach was effective as the initial treatment modality in terms of effective decompression, functional recovery, and low morbidity.

Transcranial Approach for Removal of Pleomorphic Adenoma of Lacrimal Gland

Pleomorphic adenoma in lacrimal gland is a rare disease. Injuries to capsule surrounding the tumor lead to recurrence or malignant transformation of tumor by seeding of tumor cells into adjacent tissues. Therefore complete removal of tumor without any injury to capsule is important. We present 2 cases of pleomorphic adenoma of lacrimal gland with symptoms of exophthalmos, hypophthalmos and supraduction limitation. We performed frontatemporal craniotomy and removed orbital roof for the exposure of the tumor located at superior portion of orbit. We removed the tumor with intact capsule avoiding any damage to superior levator palebral muscle and superior rectus muscle microscopically. Periosteum of superior orbital roof was repaired and frontal bone was repositioned. As a result, patients had no symptoms of exophthalmos, hypophthalmos and supraduction limitation. There are no complications of ptosis, diplopia, dry eye syndrome, symblepharon and scar on the face. Transcranial approach for removal of pleomorphic adenoma of lacrimal gland provides wide exposure of the tumor for complete removal of the mass without any damage to surrounding tissues and good cosmetic effects.

Surgical Tacties for Large Sellar and Parasellar Tumors

We analyzed 56 operations in 45 patients with sellar and parasellar tumors from March, 1990 to May, 1995, to evaluate the determining factors in selecting the surgical approaches for large and giant sellar and suprasellar tumors, based on clinical, endocrinological and radiological findings. The definition of "large" is when the longest diameter of the tumor is more than 20mm on radiographic studies and the term "small" is applied to tumor of diameter below 19mm. The results were as follows: 1) Number of the patients with small tumor was 14(31.1%) and all of them were treated with single stage transsphenoidal approach, and 42 operations were performed in 31(68.9%) patients with large tumors. 2) The approaches for large tumors were: transsphenoidal approach in 32 cases: pterional approach 5 cases: subfrontal interhemispheric approach 4 cases; and subfrontal paramedian approach 1 case. 3) The rate of complete removal for large and giant tumors in the first operation was 29.0%; in second operation, 72.7%; overall the rate was 54.8%. 4) Complications were; transient type diabetes insipidus in 24 cases; meningitis 2 cases; hypothalamic injury 3 cases; CSF rhinorrhea 1 case; and cerebral infarction 1 case; and death 1 case. 5) There was significant relationship between the size of the tumor and tumor types(p0.05) but not wih destruction of the sellar floor(p0.05). 7) In case of incomplete removal with first transsphenoidal approach, a second operation seems to be helpful. 8) In second stage transcranial approach following first transsphenoidal approach, it is easier to remove the tumor due to the decreased tumor size and thus, a reduced need for marked brain retraction. From our findings, we suggest guidelines in choosing the surgical approach for sellar and parasellar tumors as follows: 1) Many of the tumors in the sellae and suprasellar area can be removed successfully by transsphenoidal approach. 2) Taranssphenoidal approach can be repeated safely in stage O, A, B and C, if the diaphragm sella remains intact. 3) Tanscranial approach is recommended primarily in stage D & E, if intrasellar portion of the tumor is not significant or opening of the diaphragm sella is narrow. 4) Transsphenoidal approach followed by transcranial approach is adequate in stage D & E, if significant amount of the tumor remaining in the sella or sellar floor is severely destructed(Grage III, IV).

Neurosurgical Treatment of Giant Pituitary Adenoma

In order to establish a more reasonable therapeutic guide line for giant pituitary adenomas, the authors analyzed 31 cases of giant pituitary adenoma which were operated on between January, 1985 and July, 1987. The term, 'giant' applies primarily to a pituitary adenoma with a size of 4 cm or more in diameter. The two most common chief complaints were visual disturbance(18 cases) and headache(6 cases). Endocrinoloically, 17 cases(55%) were non-functioning and 14 cases(45%) produced hypersecretion syndrome:prolactionoma(8 cases), acromegaly(5 cases), and Nelson's syndrome(1 case). Twenty-eight cases showed marked suprasellar extension. Surgical treatment was given to 16 cases by transphenoidal approach and 15 cases by transcranial approach. Postoperative radiation therapy was given to 22 cases. Surgical results in the transsphenoidal group were better than in the transcranial group as there were fewer and less severe postoperative complications without a deterioration of vision. For the treatment of the giant pituitary adenoma, decompression of the tumor through transsphenoidal approach at first followed by postoperative radiation therapy, was effective. The transcranial approach was considered to be recommendable in cases of recurrence.

A Case of Optic Sheath Meningioma associated with Skull Hemangioma

Optic sheath meningioma arises from the arachnoid "cap" cell of optic nerve sheath and comprises most of primary orbital meningioma. It usually brings early visual loss, papilledema, and proptosis. The authors expericenced a case of intraorbital optic sheath meningioma associated with a small skull hemangioma in the right parietal area, who presented only mild visual disturbance. The meningioma was removed transcranially without visual or cosmetic deformities except transient ptosis.