The Expanding Spectrum of Disease Treated by the Transnasal, Transsphenoidal Microscopic and Endoscopic Anterior Skull Base Approach: Single-center Experience 2008-2015 David J Cote BS; Robert Wiemann; Timothy R Smith MD PhD MPH; Ian F. Dunn MD; Ossama Al-Mefty MD; Edward R. Laws, Jr. MD FACS FAANS Brigham and Women's Hospital, Harvard Medical School, Boston, MA
Introduction Results References • Jane JA, Jr., Laws ER, Jr.: The surgical management of pituitary The transsphenoidal approach was initially developed 792 transnasal, transsphenoidal operations were adenomas in a series of 3,093 patients. J Am Coll Surg 193:651-659, in neurosurgical practice as an operative approach to performed by 9 neurosurgeons for 31 pathologies over 2001 • Kaptain GJ, Vincent DA, Sheehan JP, Laws ER, Jr.: Transsphenoidal the pituitary gland. The introduction of the operating a 7-year period. Pituitary adenomas (535, 67.55%) approaches for the extracapsular resection of midline suprasellar and endoscope has improved the versatility of the were the most common impetus for transsphenoidal anterior cranial base lesions. Neurosurgery 62:1264-1271, 2008 transsphenoidal approach, broadening the spectrum operation. 283 (52.90%) of these patients had non- of lesions effectively treated with this operative functioning adenomas, 88 had acromegaly (16.45%), Diseases Treated Transsphenoidally strategy. 69 harbored prolactinomas (12.90%), 55 had Cushing’s disease (10.28%), 19 harbored silent ACTH -secreting tumors (3.55%), 12 were found to have Methods mammosomatotroph tumors (2.24%), 5 harbored functioning gonadotroph adenomas (0.93%) and 4 We performed a retrospective review of all patients had TSH-secreting adenomas (0.75%). who underwent transnasal, transsphenoidal operations at Brigham and Women’s Hospital from Other sellar pathologies included Rathke’s cleft cysts April 2008 through February 2015 and categorized (86, 10.86%), craniopharyngiomas (25, 3.16%), each case based on pathological diagnosis. lympocytic hypophysitis/pituitary inflammation (21,
2.65%), arachnoid cysts (8, 1.01%), spindle cell
oncocytoma (4, 0.51%), colloid cysts (4, 0.51%), and Learning Objectives pituicytoma (2, 0.25%). Pituitary hyperplastic tissue By the conclusion of this session, participants should was removed in nine cases (1.14%), and pituitary be able to: apoplexy was treated in seven (0.88%). 19 operations were undertaken for CSF leak repairs (2.40%), and 3 1) describe the diverse group of lesions feasibly for abscesses (0.38%). treated by the transsphenoidal approach to the anterior skull base Other diseases treated transsphenoidally included 2) describe the history and major developments in chordomas (12, 1.52%), metastases (9, 1.14%), transsphenoidal surgery meningiomas (5, 0.63%), clival lesions (4, 0.51%), 3) identify cases that are suitable for granulomas (4, 0.51%), germinomas (3, 0.38%), transsphenoidal resection as opposed to more dermoid tumors (2, 0.25%), and one (0.13%) each of invasive transcranial approaches esthesioneuroblastoma, olfactory neuroblastoma, From top left, clockwise: dermoid, germinoma, abscess, glioneuronal tumor, chondromyxoid fibroma, epidermoid, pituicytoma, craniopharyngioma. epidermoid tumor, meningoencephalocele, aneurysm, Conclusions carcinoma, chondrosarcoma, and lymphoma. Although initially devised in neurosurgical practice as a route to tumors of the pituitary gland, developments in technology now make the transnasal, transsphenoidal approach an effective operative strategy for a wide range of midline anterior skull base lesions.