Endoscopic transsphenoidal surgery offers excellent visualization for a giant pituitary adenoma removed at UCSF. Case study by Manish Aghi, MD, PhD.
A 74-year-old man hospitalized with pneumonia was found to be hyponatremic with low cortisol levels. An MRI scan revealed a 4.8-cm giant pituitary adenoma.
The patient had a history of blindness in the right eye, but he now had progressive vision loss in the left eye with central 20/100 acuity. Hormonal workup showed pan-hypopituitarism and he
was started on cortisol replacement therapy.
The patient was referred to the CCPD where specialized neurosurgery and neuroendocrine consultation led to a decision to move forward with surgery. An endoscopic endonasal approach was undertaken by neurosurgeon Manish Aghi, MD, PhD, and otolaryngologist Ivan El-Sayed, MD. Through the use of 30-degree angled endoscopes, they were able to visualize the anterior extent of the tumor.
While the tumor extended anterior from the sellar/suprasellar space into the frontal lobe, it did not grow along the bony tuberculum and planum of the anterior skull base. Instead, there was a cuff of frontal lobe below the anterior extent of the tumor. Aghi used the angled endoscope to clean out all of the anterior tumor, working at a 30 degree angle without causing any trauma to the frontal lobe underneath the tumor.
The patient was hospitalized for a total of 3 days. He has needed synthroid replacement in the postoperative period to combat fatigue. His vision is slightly improved as compared to preoperatively. His energy is expected to improve over the next few months as the empty resection cavity collapses over time, further decompressing the frontal lobes.
Image: Left (preoperative) MRI shows a giant pituitary adenoma extending into the frontal lobe. Right (postoperative) MRI shows near total resection.