Pituitary Adenoma

"A surgical innovation for achieving a long-term cure"



Overview

Pituitary adenomas originate within the “master” or pituitary gland, located at the center of the skull base, between a deep air sinus cavity (sphenoid sinus) and the intracranial space (where the brain sits). They are classified as functioning or non-functioning adenomas based on whether they produce excess hormones or not. They are also categorized according to their size into microadenomas (less than 1cm in diameter), macroadenomas (more than 1 cm), and giant adenomas (more than 4 cm). While most adenomas are slow-growing benign tumors, many will invade into neighboring structures, such as the cavernous sinus, clival bone, and intracranial space, becoming difficult to treat and cure.

The Stanford Pituitary Center is aimed at integration of care in a patient-friendly setting for people with pituitary disorders. This multidisciplinary approach allows for total care, from initial triage through surgical intervention and post-operative follow-up. Our surgical team at Stanford, leaded by Dr. Fernandez-Miranda, has pioneered surgical techniques to improve the remission and resection rates in pituitary surgery, while minimizing complications. Patients with the most complex tumors and from several continents have traveled to Stanford to have their pituitary tumor successfully treated.

Selective Resection of the Medial Wall of the Cavernous Sinus

Pituitary adenomas often invade the medial wall of the cavernous sinus, but this structure is generally not surgically removed because of the risk of vascular and cranial nerve injury.  This results on incomplete tumor resections and persistent disease in functional tumors.

Dr. JFM has meticulously investigated the medial wall of the cavernous sinus introducing a classification of the parasellar ligaments and their role in anchoring the medial wall, and has developed an innovative technique for selective resection of the medial wall when invaded by tumor.

At Stanford Pituitary Center, tumors invading the medial wall of the cavernous sinus can now be removed safely and effectively, with minimal morbidity and excellent resection and remission rates in hormonal-secreting adenomas causing Cushing's disease, Acromegaly, or Hyperprolactinemia.

Journal of Neurosurgery Publication
The medial wall of the cavernous sinus. Part 1: Surgical anatomy, ligaments, and surgical technique for its mobilization and/or resection.

Journal of Neurosurgery Publication
The medial wall of the cavernous sinus. Part 2: Selective medial wall resection in 50 pituitary adenoma patients.

Transoculomor Triangle Approach for Adenomas Invading the Roof of the Cavernous Sinus

Pituitary adenomas may extend into the parapeduncular space by invading through the roof of the cavernous sinus. Currently, a transcranial approach is the preferred choice, with or without the combination of an endonasal approach.

Dr. Juan Fernandez-Miranda has described a novel surgical approach that takes advantage of the natural corridor provided by the tumor to further open the oculomotor triangle and resect tumor extension into the parapeduncular space.

The endoscopic endonasal transoculomotor approach is an original alternative for removal of tumor extension into the parapeduncular space in a single procedure.

Complex Adenomas with Multilobular Shape and Subarachnoid Invasion

While most pituitary adenomas do not require extracapsular subarachnoidal dissection, there are complex adenomas with subarachnoidal invasion and multilobulated morphology, that require a combination of internal debulking, extracapsular and subarachnoidal dissection. The technique presented here allows for complete tumor resection, avoiding the risk of postoperative apoplexy of residual adenoma, and facilitates identification of perforating branches and neural structures that require meticulous preservation.