Исходы и осложнения хирургического лечения пациентов с аденомами гипофиза с инвазией в кавернозный синус

Хирургическое лечение аденом гипофиза (АГ) с  инвазией в  кавернозный синус (КС) при степени 3 и 4 по  шкале Knosp представляет собой серьезную проблему.

ЦЕЛЬ ИССЛЕДОВАНИЯ: представление результатов и  осложнений трансназального эндоскопического хирургического лечения пациентов с  АГ с инвазией в  КС 3 и  4 степени по  классификации Knosp.

МАТЕРИАЛЫ  И МЕТОДЫ : ретроспективно проанализированы результаты хирургического лечения 69 пациентов с  аденомами гипофиза с  инвазией в  кавернозный синус по  шкале Knosp 3 и  4, находившихся на   лечении в  отделении нейрохирургии ГАУЗ «МКДЦ» с  2008–2022 гг. Среди них первичные АГ наблюдались у   47 пациентов, рецидивирующие АГ — в  22 случаях, 1 пациент был оперирован после радиохирургического лечения.

РЕЗУЛЬТАТЫ.  Тотальная резекция опухоли была достигнута у   23 (33,4%) пациентов, субтотальная резекция опухоли— у  28   (40,6%) пациентов, частичная резекция опухоли— у  18 (26%) пациентов. Наиболее частыми ос-ложнениями были несахарный диабет 10% (n=7) и  назальная ликворея — 5,7% (n=4). У  2,8% (n=2) пациентов развился менингит, у   1,4% (n=1) — нейропатия глазодвигательного нерва, у  1,4% (n=1) — надпочечниковая не-достаточность, у  1,4% (n=1) — внутричерепные кровоизлияния. Повреждений внутренней сонной артерии (ВСА) и летальных исходов в данной группе пациентов не  было.

ЗАКЛЮЧЕНИЕ:  для хирургов с  достаточным опытом трансназальной эндоскопической хирургии резекция АГ с инвазией в  КС 3 и  4 степени по  Knosp может быть достаточно радикальной с хорошими показателями эффективности и безопасности.

1. Ostrom QT, Gittleman H, Farah P, Ondracek A, Chen Y, Wolinsky Y, et al. CBTRU S Statistical Report: Primary Brain and Central Nervous System Tumors Diagnosed in the United States in 2006–2010. Neuro Oncol (2013) 15 Suppl 2 (Suppl 2): ii1–56. doi: 10.1093/neuonc/not151. Erratum in: NeuroOncol (2014) 16(5):760.

2. Aflorei ED , Korbonits M. E pidemiology and Etiopathogenesis of Pituitary Adenomas. J Neurooncol (2014) 117:379–94. doi: 10.1007/s11060‑013‑1354‑5

3. Knosp E, Steiner E, Kitz K, Matula C. P ituitary Adenomas With Invasion of the Cavernous Sinus Space: A Magnetic Resonance Imaging Classification Compared With Surgical Findings. Neurosurgery (1993) 33:610–617; discussion 617–618. doi: 10.1227/00006123‑199310000‑00008

4. Cottier JP , Destrieux C, Brunereau L, Bertrand P, Moreau L, Jan M, et al. Cavernous Sinus Invasion by Pituitary Adenoma: MR Imaging. Radiology (2000) 215:463–9. doi: 10.1148/radiology.215.2.r00ap18463

5. P ontius AT, Ducic Y. E xtended Orbitozygomatic Approach to the Skull Base to Improve Access to the Cavernous Sinus and Optic Chiasm. Otolaryngol Head Neck Surg (2004) 130:519–25. doi:10.1016/j.otohns.2004.01.013

6. Spallone A, Vidal RV , Gonzales JG . Transcranial Approach to Pituitary Adenomas Invading the Cavernous Sinus: A Modification of the Classical Technique to be Used in a Low-Technology Environment. Surg Neurol Int (2010) 1:25. doi: 10.4103/2152–7806.65054

7. Knosp E, Steiner E, Kitz K, Matula C. P ituitary adenomas with invasion of the cavernous sinus space: a magnetic resonance imaging classification compared with surgical findings. Neurosurgery. 1993;33(4):610–618. doi:10.1227/00006123‑199310000‑00008

8. Fathalla H, Cusimano MD , Di Ieva A, Lee J, Alsharif O, Goguen J , et al. Endoscopic Versus Microscopic Approach for Surgical Treatment of Acromegaly. Neurosurg Rev (2015) 38:541–548; discussion 548–549. doi: 10.1007/s10143‑015‑0613‑7

9. G aillard S. The Transition From Microscopic to Endoscopic Transsphenoidal Surgery in High-Caseload Neurosurgical Centers: The Experience of Foch Hospital. World Neurosurg (2014) 82: S 116–120. doi: 10.1016/j.wneu.2014.07.033

10. Koutourousiou M, Gardner PA, Fernandez-Miranda JC, Paluzzi A, Wang EW, Snyderman CH. Endoscopic Endonasal Surgery for Giant Pituitary Adenomas: Advantages and Limitations. J Neurosurg (2013) 118:621–31. doi: 10.3171/2012.11.jns121190

11. Fernandez-Miranda JC, Zwagerman NT, Abhinav K, Lieber S, Wang E W, Snyderman CH, et al. Cavernous Sinus Compartments From the Endoscopic Endonasal Approach: Anatomical Considerations and Surgical Relevance to Adenoma Surgery. J Neurosurg (2018) 129:430–41. doi: 10.3171/2017.2.JNS162214

12. Hwang J, Seol HJ, Nam DH, Lee JI, Lee MH, Kong DS. Therapeutic Strategy for Cavernous Sinus-Invading Non-Functioning Pituitary Adenomas Based on the Modified Knosp Grading System. Brain Tumor Res Treat (2016) 4:63–9. doi: 10.14791/btrt.2016.4.2.63

13. Wu X , Xie SH, Tang B, Yang YQ , Yang L, Ding H, et al. Pituitary Adenoma With Posterior Area Invasion of Cavernous Sinus: Surgical Anatomy, Approach, and Outcomes. (2020). doi: 10.1007/s10143‑020‑01404‑1

14. Casanueva FF, Molitch ME , Schlechte JA, Abs R, Bonert V , Bronstein MD , et al. Guidelines of the Pituitary Society for the Diagnosis and Management of Prolactinomas. Clin Endocrinol (2006) 65:265–73. doi: 10.1111/j.1365–2265.2006.02562.x

15. Katznelson L, Laws ERJ r., Melmed S, Molitch ME , Murad MH, Utz A, et al. Acromegaly: An Endocrine Society Clinical Practice Guideline. J ClinEndocrinol Metab (2014) 99:3933–51. doi: 10.1210/jc.2014–2700

16. Nieman LK, Biller BM, Findling JW, Murad MH, Newell-Price J, Savage MO , et al. Treatment of Cushing’s Syndrome: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab (2015) 100:2807–31. doi: 10.1210/jc.2015–1818

17. Woodworth GF, Patel KS, Shin B, Burkhardt JK, Tsiouris AJ, McCoul ED , et al. Surgical Outcomes Using a Medial-to-Lateral Endonasal Endoscopic Approach to Pituitary Adenomas Invading the Cavernous Sinus. J Neurosurg (2014) 120:1086–94. doi:10.3171/2014.1.jns131228

18. Chabot JD , Chakraborty S, Imbarrato G, Dehdashti AR. Evaluation of Outcomes After Endoscopic Endonasal Surgery for Large and Giant Pituitary Macroadenoma: A Retrospective Review of 39 Consecutive Patients. World Neurosurg (2015) 84:978–88. doi:10.1016/j.wneu.2015.06.007

19. P aluzzi A, Fernandez-Miranda JC, Tonya Stefko S, Challinor S, Snyderman CH, Gardner PA. Endoscopic Endonasal Approach for Pituitary Adenomas: A Series of 555 Patients. Pituitary (2014) 17:307–19. doi: 10.1007/s11102‑013‑0502‑4

20. Bao X , Deng K, Liu X , Feng M, Chen CC, Lian W, et al. Extended Transsphenoidal Approach for Pituitary Adenomas Invading the Cavernous Sinus Using Multiple Complementary Techniques. Pituitary (2016) 19:1–10. doi: 10.1007/s11102‑015‑0675‑0

21. Kalinin PL , Sharipov OI, Pronin IN, Kutin MA, Fomichev DV , Kadashev BA, et al. Endoscopic Transsphenoidal Resection of Pituitary Adenomas Invading the Cavernous Sinus. Zh Vopr Neirokhir Im N N Burdenko (2016) 80:63–74. doi: 10.17116/neiro201680463–74

22. Chabot JD , Chakraborty S, Imbarrato G, Dehdashti AR. Evaluation of Outcomes After Endoscopic Endonasal Surgery for Large and Giant Pituitary Macroadenoma: A Retrospective Review of 39 Consecutive Patients. World Neurosurg (2015) 84:978–88. doi:10.1016/j.wneu.2015.06.007

23. Komotar RJ , Starke RM , Raper DM , Anand VK, Schwartz TH. Endoscopic Endonasal Compared With Microscopic Transsphenoidal and Open Transcranial Resection of Giant Pituitary Adenomas. Pituitary (2012) 15:150–9. doi: 10.1007/s11102‑011‑0359‑3

24. Hofstetter CP, Shin BJ, Mubita L, Huang C, Anand VK, Boockvar J A, et al. Endoscopic Endonasal Transsphenoidal Surgery for Functional Pituitary Adenomas. Neurosurg Focus (2011) 30: E 10. doi:10.3171/2011.1.FOCUS10317

25. Wu ZB, Su ZP, Wu JS, ZhengWM, Zhuge QC, Zhong M. Five Years Follow-Up of Invasive Prolactinomas With Special Reference to the Control of Cavernous Sinus Invasion. Pituitary (2008) 11:63–70. doi: 10.1007/s11102‑007‑0072‑4

26. Santoro A, Minniti G, Ruggeri A, Esposito V , Jaffrain-Rea ML , Delfini R. Biochemical Remission and Recurrence Rate of Secreting Pituitary Adenomas After Transsphenoidal Adenomectomy: Long-Term Endocrinologic Follow-Up Results. Surg Neurol (2007) 68:513–518. doi: 10.1016/j.surneu.2007.05.057

27. Cappabianca P, Solari D. The Endoscopic Endonasal Approach for the Treatment of Recurrent or Residual Pituitary Adenomas: Widening What to See Expands What to do? World Neurosurg (2012) 77:455–6. doi: 10.1016/j.wneu.2011.08.047

28. Chang EF, Zada G, Kim S, Lamborn KR, Quinones-Hinojosa A, Tyrrell JB, et al. Long-Term Recurrence and Mortality After Surgery and Adjuvant Radiotherapy for Nonfunctional Pituitary Adenomas. J Neurosurg (2008)108:736–45. doi: 10.3171/JNS/2008/108/4/0736

29. Chang EF, Sughrue ME , Zada G, Wilson CB, Blevins LSJr., Kunwar S. Long Term Outcome Following Repeat Transsphenoidal Surgery for Recurrent Endocrine-Inactive Pituitary Adenomas. Pituitary (2010) 13:223–9. doi: 10.1007/s11102–010–0221-z

30. D ehdashti AR, Ganna A, Karabatsou K, Gentili F. P ure Endoscopic Endonasal Approach for Pituitary Adenomas: Early Surgical Results in 200 Patients and Comparison With Previous Microsurgical Series. Neurosurgery (2008) 62:1006–15. doi: 10.1227/01.neu.0000325862.83961.12

31. Frank G, Pasquini E, Farneti G, Mazzatenta D, Sciarretta V , Grasso V , et al. The Endoscopic Versus the Traditional Approach in Pituitary Surgery. Neuroendocrinology (2006) 83:240–8. doi:10.1159/000095534

32. G ondim JA, Schops M, de Almeida JP , de Albuquerque LA, Gomes E , Ferraz T, et al. Endoscopic Endonasal Transsphenoidal Surgery: Surgical Results of 228 Pituitary Adenomas Treated in a Pituitary Center. Pituitary (2010) 13:68–77. doi: 10.1007/s11102–009–0195-x

33. R aithatha R, McCoul ED , Woodworth GF, Schwartz TH, Anand V K. Endoscopic Endonasal Approaches to the Cavernous Sinus. Int Forum Allergy Rhinol (2012) 2:9–15. doi: 10.1002/alr.20097

34. Kitano M, Taneda M, Shimono T, Nakao Y. E xtended Transsphenoidal Approach for Surgical Management of Pituitary Adenomas Invading the Cavernous Sinus. J Neurosurg (2008) 108:26–36. doi: 10.3171/jns/2008/108/01/0026