Abstract. Stereotactic radiosurgery is being used with in- creased frequency in the treatment of residual or recur- rent pituitary adenomas. The major risk ...
Pituitary 5: 169–173, 2002 C 2003 Kluwer Academic Publishers. Manufactured in The Netherlands.
Hypophysopexy Technique for Radiosurgical Treatment of Cavernous Sinus Pituitary Adenoma William T. Couldwell1 , Joshua M. Rosenow2 , Richard L. Rovit2 , and Deborah L. Benzil2 1 Department
of Neurosurgery, The University of Utah, Salt Lake City, UT, USA; 2 Department of Neurosurgery, New York Medical College, Valhalla and New York, NY, USA
Abstract. Stereotactic radiosurgery is being used with increased frequency in the treatment of residual or recurrent pituitary adenomas. The major risk associated with radiosurgical treatment of residual or recurrent pituitary tumor adjacent to normal functional pituitary gland is radiation of the pituitary, which frequently leads to the development of hypopituitarism. The authors describe a technique of pituitary transposition to reduce the radiation dose to the normal pituitary gland in cases of planned radiosurgical treatment of residual pituitary adenoma within the cavernous sinus. A sellar exploration for tumor resection is performed, the pituitary gland is transposed from the region of the cavernous sinus, and a fat and fascia graft is interposed between the normal pituitary gland and the residual tumor in the cavernous sinus. The residual tumor may then be treated with stereotactic radiosurgery. The increased distance between the normal pituitary gland and the residual tumor facilitates treatment of the tumor with radiosurgery and reduces the radiation to the normal pituitary gland. An illustrative case of a young female with recurrent acromegaly and a pituitary adenoma invading the cavernous sinus is described. Key Words. pituitary, adenoma, hypopituitarism, stereotactic radiosurgery
Introduction Stereotactic radiosurgery for residual cavernous pituitary tumors is an increasingly popular treatment modality [1–7]. The results of growth control and normalization of hypersecretory syndromes with this methodology, while somewhat preliminary, are promising [1–4,6]. The major risk associated with radiosurgical treatment of residual or recurrent pituitary tumor adjacent to normal functional pituitary gland is radiation of the pituitary, which frequently leads to the development of hypopituitarism. The authors present here a simple technical method for increasing the distance between the normal pituitary gland and residual tumor to facilitate treatment of the tumor with radiosurgery and reduce radiation to the normal pituitary gland.
Illustrative Case Report Case history This previously healthy Caucasian female presented originally at age 16 years with increased growth, amen-
orrhea, and coarsening of facial features. An endocrinologic evaluation that included assessment of pituitary hormones found the levels of growth hormone (GH) and prolactin to be elevated. Ophthalmologic examination revealed normal visual acuity but disclosed a superior temporal field defect in the right eye. Magnetic resonance (MR) imaging revealed a large sellar and suprasellar lesion compatible with pituitary adenoma. The patient underwent an uncomplicated sublabial transsphenoidal resection of the macroadenoma at another institution. The operating surgeon felt that there was subtotal resection of the lesion with residual tumor in the left cavernous sinus. Pathologic examination revealed a typical pituitary adenoma that immunostained positive for GH. Postoperatively, the prolactin level normalized (
