Endoscopic Endonasal Management of Nonfunctioning Pituitary Adenomas with Cavernous Sinus Invasion: Our Experience

Objectives: 1) Review the management of Non-Functioning Pituitary Adenoma (NFPA) invading the cavernous sinus (CS), currently in balance between radiotherapy, surgical decompression of neural structures, and wait-and-see policy. 2) Report our experience in the surgical removal of these lesions through an endoscopic endonasal trans-sphenoidal approach (EETSA). Methods: From 1999 to 2010, 56 cases of NFPA with CS invasion were treated through an EETSA. The Knosp classification was used to describe CS involvement as evidenced by preoperative magnetic resonance imaging (MRI) and intraoperatively. Extent of resection was evaluated on postoperative contrast-enhanced MRI, as well as the surgical and visual outcomes. Endocrinological remission was defined according to the most recent consensus criteria. Results: EETSA was performed using direct para-septal, transethmoidal, or trans-ethmoidal-pterygoidal approach. The surgical procedure was well tolerated by all patients. At discharge, visual disturbance was improved in 30 (81%) patients who had complained of visual impairment preoperatively. Normalization or improvement of previous hypopituitarism was obtained in 55% of cases. A gross-total or subtotal resection was reached in 51/56 patients. The recurrence-free survival was 87.5%, with a mean follow-up of 61 months. No major intraoperative or postoperative complications occurred. Conclusions: Surgical removal using an EETSA is a minimallyinvasive, safe, and effective procedure for the management of NFPA invading the CS, able to solve the mass effect, preserving or restoring visual function, and obtain an adequate longterm tumor control. However, close screening of pituitary function and appropriate neuroradiological follow-up should be performed after surgery for early detection of tumor recurrence or regrowth.