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Case of the Month
By Hrayr Shahinian, M.D.
E.S. is a sixteen-year-old white female who presented with a history of sinus headaches and visual complaints. An M.R.I. revealed a massive tumor centered on the sella turcica invading the sphenoid sinus and the bone of the clivus, extending to the suprasellar and retroclival areas. The tumor also invaded both the right and left cavernous sinus. The patient presented to the Skull Base Institute where a physical exam confirmed a bitemporal hemianopsia. Her laboratory and hormonal profile revealed increased levels of prolactin and growth hormone.
She underwent a complete endocrinologic evaluation followed by a multi-disciplinary conference, in which her case was discussed. Per our recommendations, on December 22, 1997, we performed a transsphenoidal approach to resect the intrasellar portion of the tumor. Also included in this operation was the resection of the portion that was extending through the sphenoid sinus.
Post-operatively, we discharged her after a 48-hour stay with no deficits and no evidence of hypo-pituitarism. The pathology report confirmed that this was an aggressive pituitary adenoma. We informed the patient and the parents that we would post-operatively start adjuvant hormonal therapy with Dostinex and continue to follow and monitor her prolactin and growth hormone levels. We also informed them that she would need a second transcranial approach to address the portions of the tumor within the cavernous sinuses and the retroclival areas. She responded partially to the hormonal therapy. We brought her back to the operating room five months later on May 27, 1998. She underwent a fronto-orbitopterional approach, and resection of tumor from the right cavernous sinus, the supra-sellar and retroclival areas, and large amounts of tumor from within the left cavernous sinus. Postoperatively, she had no neurologic deficits, except for a partial left oculomotor paresis manifested by anisocoria with the left pupil being 3-4 mm and reactive while the right pupil was 2 mm. Following her stay in the intensive care unit for 36 hours, we transferred her to the floor and we discharged her home on post-op day five. She will undergo a hormonal evaluation two weeks post-operatively and a repeat radiologic evaluation in 2-3 months time. Throughout this ordeal, this case illustrates the integration of our surgical efforts with our colleagues in endocrinology and neuroradiology through constant and continuous discussions with both teams and the family.
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