Optimal Surgical Approaches for Giant Pituitary Adenomas

Introduction: Giant pituitary adenomas, defined as tumors larger than 4 cm, represent 5-14% of all pituitary adenomas and pose substantial surgical challenges due to their proximity to critical neurovascular structures. Surgical resection is the primary treatment, with the transsphenoidal and transcranial approaches as key options. Advances in endoscopic techniques have favored less invasive procedures, but optimal surgical strategies remain debated, especially for large and invasive tumors.

Methods: This review synthesizes findings from a range of clinical studies and case reports on surgical approaches for giant pituitary adenomas. Sources included cohorts with sample sizes from individual case studies to larger groups, covering patient demographics, tumor characteristics, surgical outcomes, and complications. Data on preoperative evaluations, surgical methods, postoperative outcomes, recurrence rates, and adjunctive treatments were analyzed to identify trends and insights into the most effective surgical practices.

Results: Preoperative visual impairment was present in 86.3% of cases, while cranial nerve palsies affected 5.3% of patients. The transsphenoidal approach was employed in 76.6% of surgeries, offering favorable visual outcomes, with 71.2% of patients reporting improved vision postoperatively. Complete visual recovery was noted in 15.2% of cases, while complications included cerebrospinal fluid (CSF) leakage (23.7%) and diabetes insipidus (16.9%). The postoperative mortality rate was 3.2%, primarily linked to pulmonary embolism. Recurrence rates were low (3.4%), with postoperative radiation therapy improving five-year recurrence-free survival to 89.6%.

Conclusion : Surgical intervention, particularly the endoscopic endonasal approach, has demonstrated positive outcomes for giant pituitary adenomas, enhancing visual recovery and minimizing invasiveness. However, transcranial surgery remains essential for complex cases involving extensive anatomical invasion. Adjunctive treatments like radiation therapy further reduce recurrence rates. Comprehensive preoperative planning and meticulous management of postoperative complications are crucial to optimize long-term patient outcomes.