|Year : 2019 | Volume
| Issue : 2 | Page : 89-96
Management of suprasellar tumors in the era of endoscopic surgery: Presidential Oration 2019
Suresh K Sankhla
Head, Department of Neurosurgery, Global Hospital, Parel, Mumbai, Mumbai, Maharashtra, India
|Date of Web Publication||10-Jan-2020|
Dr. Suresh K Sankhla
A-503, Chaitanya Towers, Appasaheb Marathe Marg, Prabhadevi, Mumbai - 400 012, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Sankhla SK. Management of suprasellar tumors in the era of endoscopic surgery: Presidential Oration 2019. Int J Neurooncol 2019;2:89-96
Suprasellar tumors continue to pose formidable challenges in the clinical management because of their unique location and proximity to the critical neurovascular structures, such as the optic nerves and chiasm, internal carotid arteries and their branches, pituitary gland and infundibulum, hypothalamus and anterior third ventricle, oculomotor nerve and midbrain, and basilar artery and its branches. A diverse group of extradural and intradural lesions may occur in this region [Table 1], requiring different management planning and surgical strategies. Surgical resection remains the main therapeutic option as it provides immediate decompression of the compressed neurovascular structures, helps establish histopathological diagnosis, relieves raised intracranial pressure by restoring normal cerebrospinal fluid (CSF) pathways, and allows for a possible complete cure.
Surgical removal of suprasellar tumor, however, is technically difficult and demands an optimal approach that provides the shortest route, adequate access, proper visualization, and multidirectional views, with no brain retraction or traction/injury to the vital neurovascular structures. Historically, the surgical routes to approach suprasellar tumors varied between transcranial and transnasal corridors. The transcranial approach is the oldest and a well-known treatment option since the time brain surgery itself was established in the early part of the last century. The transnasal skull base approach was brought into the spotlight of modern medical practice with the contributions of Harvey Cushing and Oskar Hirsch in the early 1900s., Cushing, however, abandoned the transsphenoidal surgery completely in 1929 due to poor visibility in the operative field and high surgical mortality. With simultaneous developments in neurosurgical techniques and technologies, the transcranial microsurgical approaches gained more popularity in the mid-1900s for sellar and parasellar tumor surgery, replacing the transnasal approaches completely for a long time.
Since the introduction of operative microscopy and intraoperative fluoroscopy by Guiot et al. and Hardy in the 1960s, microsurgery via a transnasal transsphenoidal route became the gold standard for pituitary surgery, representing the technique of choice for about 99% of pituitary adenomas.,, However, with the development of high-definition cameras and refined telescopes, sophisticated light sources, and cables, the endoscopic skull base surgery returned as a simple, safe, and minimally invasive technique, first as an adjunct to microscope in 1970s and then as a pure endoscopic technique in 1990s.,, Recent progress in the technology such as intraoperative navigation, and techniques like expanded/extended transsphenoidal exposures,,,,, has not only improved surgical efficiency but has also widened the scope and indications of the endoscopic endonasal surgery further.
The advantages of endoscope in the surgery at suprasellar region are several including, improved visualization of blind spots via panoramic and angled views and the ability to achieve close-up magnification. The wide visualization of surrounding anatomical landmarks helps to orient surgeons to the location of critical structures while avoiding irradiation exposure from intraoperative fluoroscopy. The two-dimensional (2D) images provided by the static endoscope and the consequent loss of depth perception, in contrast to the 3D images provided by microscopy, could be overcome by the dynamic movement of endoscopic vision. These features have driven changes in surgical approach trends, and favorable results have been published over the last 2 decades. The endonasal endoscopic surgery is also cosmetically accepted well as there is no visible scar and is appealing to the patients because it is perceived as being less invasive than the conventional transcranial surgery. Moreover, the morbidities attributed to transcranial resection such as hematomas, seizures, and injuries to surrounding neurological structures are lower in patients treated with a transnasal endoscopic approach.
| Pituitary Adenoma|| |
Nonfunctioning pituitary adenomas comprise the gonadotrophic (follicle-stimulating hormone, luteinizing hormone (LH), and alpha-subunit immunostaining), immunonegative (no immunostaining), and silent adenomas (prolactin, thyroid-stimulating hormone, adrenocorticotropic hormone, and GH-immunostaining without clinical symptoms). These tumors, for which there is no efficient medical therapy, should be removed via radical surgery. Better illumination and clear view of the sellar–suprasellar region provided by the modern endoscopy permits differentiation between the adenoma and the normal pituitary gland, and between the diaphragma sellae and the suprasellar arachnoid membrane, thus allowing complete resection of the adenoma with preservation of the normal pituitary gland and a lower incidence of complications like CSF leak., The tumor control rates in the published studies appear far superior with endoscopic surgery (56%–93%) when compared with those with microscopic surgery (35%–74%).,,,,, [Table 2].
|Table 2: Literature review comparing surgical outcome of pituitary adenoma (endoscopy versus microscopy)|
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Endoscopy is especially advantageous when control over the lateral extensions of the pituitary adenomas is required. The use of angled endoscopes widens exploration of the surgical field laterally and improves safe and efficient tumor removal from the cavernous sinus region. Knosp Grade 0–1 tumors are essentially intrasellar tumors and are amenable to >90% removal in both techniques., However, in cases of Grade 2 and 3 tumors, results obtained with endoscopy (gross-total resection [GTR] 88% and 67.9%, respectively) and microscopy (GTR 47.8% and 16.7%, respectively) are interesting and clearly demonstrate the additional advantage of the endoscopic surgery in achieving increased lateral exposure and a greater degree of adenoma removal in comparison to the microscopic surgery.
Endoscopy also appears to improve immediate clinical outcome with fewer postoperative complications. With regard to the ophthalmic outcome, the endoscopic surgery has few added benefits over the transcranial surgery. Since it provides adequate exposure to allow aggressive tumor resection from the lateral extension, it offers a great opportunity for sufficient decompression of the optic apparatus and oculomotor nerve. More importantly, the endoscopic vision offers greater chances to preserve vascular supply of the optic chiasm and nerves through branches from the hypophyseal arteries [Figure 1] and [Figure 2]. These findings are in accordance with reports of the visual outcome in the literature. Frank et al. reported 94.7% normalization or improvement in vision, 3.8% stabilization, and 1.2% worsening. Tabaee et al. showed 92% complete resolution in visual symptoms with no worsening, and Dehdashti et al., reported 91% normalization or improvement and 9% stabilization of the visual functions.
|Figure 1: Endoscopic photograph of the sellar–suprasellar region after complete removal of the pituitary macroadenoma, showing small perforating branches arising from the right inferior hypophyseal and supraclinoidal segment of the right ICA, supplying the inferior aspect of the optic chiasm and nerves, and pituitary gland and infundibulum|
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|Figure 2: Intraoperative view of suprasellar region from endonasal approach, showing under surface of the optic nerves and chiasm, bilateral ICAs, and pituitary gland and stalk after pituitary tumor removal. Note small perforating arteries supplying dorsal part of the chiasm from above and ventral part from below|
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The ability to introduce tip of the scope into the sellar cavity during surgery is a unique feature of the endonasal endoscopic surgery. It improves identification of the compressed/displaced pituitary gland and stalk, and preservation of its blood supply, which is essential to maintain normal pituitary function. Comparing the postoperative endocrinological outcome, Messerer et al. demonstrated normalization of endocrinological status with endoscopic surgery in 86.5% and 50% of patients with preoperative eupituitarism and partial anterior pituitary insufficiency (PAPI), respectively, as opposed to 71% and 15% with microsurgery. The best rates of normalization or improvement in PAPI with microsurgery have been described in the literature as 49.7%, 35%, and 27%.
CSF leaks seem to be the most common and disturbing complication of transsphenoidal pituitary surgery, observed in 12.1% and 8.5% patients in endoscopic and microsurgery, respectively. It is now clearly evident that the percentage risk of CSF leakage can be dramatically decreased with experience, and this learning curve is unavoidable. According to the recent largest endoscopic studies in the literature, the percentage of CSF leaks ranges from 1.6% to 5.2% and is still decreasing.,, With increasing experience in the endoscopic pituitary surgery, there is also reduction in the duration of surgery, the amount of mucosal trauma and the consequent postoperative discomfort, and the length of hospital stay.
| Suprasellar Meningioma|| |
Meningiomas of the anterior cranial fossa and parasellar regions have traditionally been removed via various transcranial subfrontal/pterional approaches. Since the pioneering work of Jho almost 2 decades back, the endonasal endoscopic approach (EEA) has been used more regularly for a variety of suprasellar lesions including meningiomas. Advantages of this approach over transcranial approaches for suprasellar meningiomas are several and include lack of brain retraction, minimal manipulation of the optic apparatus, and early identification of the pituitary stalk and gland. Aggressive removal of the involved bone and dura at the base provides an opportunity to achieve radical tumor resection (Simpson Grade 1), which is often the goal of surgery. Moreover, the tumor vascularity can be reduced in the early part of the operation by coagulating branches from the posterior ethmoidal arteries and parasellar meningeal vessels, which usually facilitates rapid removal of the devascularized tumor without any significant blood loss [Figure 3].
|Figure 3: Endoscopic view of removal of tuberculum sellae meningioma through an extended endonasal endoscopic approach, showing anterior cerebral arteries in the midline above, optic chiasm and nerves in front, and separated tumor capsule below|
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When the optic canal is involved by the tumor, a 270° bony decompression can be performed by removing the medial wall, floor, and roof of the canal to remove the intracanalicular tumor [Figure 4]. The falciform ligament and the intracanalicular dura are also incised to facilitate tumor removal from the canal without much manipulation of the optic nerve. The midline transnasal approach is the ideal approach for bilateral decompression of the optic canals without the need to remove orbital roof/medial wall, as required in the transcranial approaches. The pattern of optic canal involvement by meningiomas, especially in the medial, inferior, or superior parts, often favors the midline endoscopic approach. It allows early extradural optic canal decompression, even in the case of extensive hyperostosis due to bone invasion by meningioma.
|Figure 4: Operative photograph showing removal of the intracanalicular meningioma and optic nerve decompression following 2700 opening of the right optic canal using pure endoscopic exposure|
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Direct comparison of the rates of GTR between transcranial and endoscopic surgery is not feasible because of the uncomparable sample characteristics and inadequate available data. Generally, the transnasal surgery is reserved for smaller tumors, while transcranial surgery is preferred for the larger and complex tumors that require wider exposure. Overall, the GTR rates for endoscopic surgery are reported as 81%–91% and for transcranial surgery as 70%–100% [Table 3].
|Table 3: Literature review comparing surgical outcome in the largest published series of suprasellar meningiomas|
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Visual improvement is more commonly observed in 70%–80% of patients who present with deterioration of vision preoperatively, and nearly, 7%–12% of patients experience worsening of vision after surgery., The rates of postoperative visual improvement and deterioration vary from 85.7%–96.6% to 0%–3.6%, respectively, in endoscopic endonasal approach, as compared to 44.4%–90.6% and 3.6%–24.2%, respectively, in transcranial approaches for parasellar meningiomas., Koutourousiou et al. reported visual improvement in transnasal surgery to be over 94% in patients in whom the tumor was extending into the optic canal. They believed the recovery in vision was primarily due to the adequate optic canal decompression and radical resection of the intracanalicular tumor which was possible only because of the wide exposure achieved by the endoscopic approach. The ability of unroofing the optic canal in transcranial exposures, on the other hand, is limited, especially in the medial and inferomedial aspects where tumor most commonly invades. The relative lower rate of visual improvement (74% ) in patients who underwent transcranial tumor removal, clearly reflects limitations in achieving adequate optic nerve decompression in this group of patients. The optic canals are more easily accessible from an endonasal route, than the transcranial route, making the optic decompression safe and effective. Early optic nerve decompression and release from the tumor also avoid trauma due to the manipulation of tethered optic nerves during tumor dissection. This early optic canal decompression may be another reason for the higher rate of visual improvement with endoscopic endonasal procedure.,,
| Craniopharyngioma|| |
Craniopharyngioma is a slow-growing tumor originating from Rathke's pouch, representing approximately 2%–5% of all primary brain tumors, and has a bimodal age distribution (age, 5–14 years and 55–65 years). The optimal management of craniopharyngiomas has been debated for decades. Although surgical resection of these tumors can be associated with considerable risks of morbidity due to their intimate involvement with critical neurovascular structures, surgery remains the first line of therapy and offers the best chance of radical resection and oncological cure.,,,,,,
Advances in skull base approaches, modern microsurgical and endoscopic techniques, neuroimaging, and hormonal replacement therapy have allowed for safer gross total or near-total resection in the modern neurosurgical era with GTR rates ranging from 72.7% to 90%.,, In the past, craniotomy and microsurgical tumor removal was considered a gold standard in the management of craniopharyngiomas and the only surgical technique to achieve a GTR. Majority of craniopharyngiomas, however, are located in the retrochiasmatic region, under the chiasm and extending up into the third ventricle. A tumor in this location can often be hidden from the operative view, especially with a prefixed chiasm, when approached from above via the transcranial route, and may therefore require extra brain retraction, manipulation of the optic nerves and other neurovascular structures, and additional exposure through lamina terminalis to access the tumor. Moreover, the transcranial exposure provides poor visualization of the undersurface of the chiasm where critical perforators supply the visual apparatus. Furthermore, the critical plane between the tumor capsule and the stalk and hypothalamus is poorly visualized from above, and a blind dissection in this region often increases the risk of potential injury. Results of the published studies with transcranial approaches have demonstrated perioperative mortality rate risk of 0%–20%,, and pituitary-related endocrinopathy risk of up to 100%. Hypothalamic obesity has been reported in as many as 70% of patients.
In recent years, the extended EEA has been advocated for suprasellar–retrochiasmatic craniopharyngiomas.,,,,, In contrast to the traditional extended transsphenoidal microscopic speculum-based technique, which allows tumor resection from the sellar and subdiaphragmatic regions through expanded sella turcica, the pure endoscopic-extended endonasal approach permits removal of more extensive craniopharyngiomas associated with normal-sized sella and supradiaphragmatic–suprasellar extensions.
The main advantage of pure endoscopy over transcranial microscopic approach includes its ability to provide direct visualization of the undersurface of the optic nerves and chiasm, pituitary stalk and its blood supply, hypothalamus, and anterior third ventricle using bimanual sharp microdissection techniques from below,, [Figure 5], [Figure 6], [Figure 7], [Figure 8]. By avoiding blind manipulation near critical structures in the retrochiasmatic region, the endoscopic approach has improved our ability to avoid or minimize visual and hypothalamic complications., Evident data in the literature clearly suggest that in comparison with the transcranial approach, endonasal endoscopic resection can result in better visual outcomes, higher GTR rate, and stable quality of life, with comparable complication rates.,,,, This technique has become arguably the preferred approach in the treatment of craniopharyngiomas.
|Figure 5: Endoscopic approach to a suprasellar–retrochiasmatic craniopharyngioma. Intraoperative photograph showing separation of the pituitary stalk from the tumor by working in the well-defined arachnoid plane|
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|Figure 6: Endoscopic photograph showing bimanual microdissection in the arachnoid plane for mobilization of the tumor capsule from the left oculomotor nerve, and basilar artery and its branches|
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|Figure 7: Endoscopic view after complete removal of the retrochiasmal craniopharyngioma using extended endonasal endoscopic approach. Note hypothalamus and anterior third ventricle|
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|Figure 8: Intraoperative endoscopic view of the anterior third ventricular cavity, showing both foramina of Monro, choroid plexus at the roof of the third ventricle, massa intermedia, cerebral aqueduct, and mammillary bodies|
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The endonasal endoscopic technique has major limitations when the craniopharyngioma is extending laterally into the sylvian fissure and superiorly into the interhemispheric fissure. Even with the aid of angled endoscopes and instrumentation, the maneuverability is severely restricted. Furthermore, direct microvascular repair, in the event of a vessel injury during tumor dissection, is difficult to perform with this approach. The problem of CSF leakage, despite regular use of vascularized pedicled nasoseptal flap and multilayered reconstruction techniques, still remains as a major postoperative morbidity.
In conclusion, the endoscopic skull base surgery has emerged recently as a viable alternative to the traditional transcranial surgery for the patients presenting with suprasellar lesions. It has great potentials and abilities to achieve the goal of radical tumor resection under direct vision with minimal complications and can be perceived as a minimally invasive technique. The steep learning curve needs to be addressed on a priority basis, to be able to make this technological advancement available to more skull base neurosurgeons and to help more and more of our patients. At present, we need larger clinical studies and more elaborate data, as well as the long-term results, to evaluate true efficacy and effectiveness of this method in the management of suprasellar pathologies.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
[Table 1], [Table 2], [Table 3]