Surgical Strategies in Complex Giant Pituitary Adenomas: Single Approach? Staged Approach? Or Combined Approach?

Introduction: Surgical treatment of complex giant pituitary adenomas (GPAs) presents significant challenges. The study aims to test the efficacy and safety of combining transsphenoidal and transcranial approaches for these tumors. The study also aims to develop a Multiparametric Radiomic derived and tumor Perfusion and consIsTency based surgical difficulty (MR-PIT) stratification to identity patients who might benefit from the combined approach over non-combined approach.

Methods: This was a multicenter cohort study conducted at 13 neurosurgical centers in China, including the largest cohort of patients with complex GPAs. Consecutive patients who received a combined approach, a single approach and a staged approach for complex GPAs were enrolled. The primary outcome was gross total resection. Radiomic features were used to predict tumor perfusion and consistency, which were then used to create MR-PIT stratification.

Results: Out of 647 patients (46.1% women, mean age: 48.5 years) with complex GPAs, 91 were in the combined group and 556 were in the non-combined group (including a single approach or a staged approach). Compared with the non-combined strategy, the combined strategy was associated with a higher probability of gross total resection (50.5% vs. 40.6%, OR 2.18, 95% CI 1.30–3.63, p = 0.003). The proportion of patients with life-threatening complications was lower in the combined group than in the non-combined group (4.4% vs. 11.2%, OR 0.25, 95% CI 0.08–0.78, p = 0.017). However, the combined strategy exhibited a longer surgery duration of 1.3 h and higher surgical costs of 3,000 USD compared with the non-combined strategy. Additionally, the multiparametric radiomic derived tumor perfusion and consistency, were combined with tumor size, Knosp grade, lateral extension, and suprasellar extension to stratify surgical difficulty. Patients in the high-difficulty group might benefit from a combined strategy.

Conclusion : The combined strategy offered increased rates of total resection and decreased incidence of life-threatening complications, which might be recommended as the first-line choice for these patients in centers with qualified surgeons and sufficient equipment. The surgical difficulty stratification could assist surgeons in deciding surgical strategies.