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The Journey of One Patient from Transcranial to Transsphenoidal to Endoscopic Pituitary Surgery
By Hrayr Shahinian, M.D.
In this issue of Headlines we present the case of a 70 year old, Caucasian, retired teacher and writer, from Montana who was referred to the Skull Base Institute for evaluation of a residual, non-secreting pituitary macroadenoma. His symptoms started in 1994 when he first experienced double vision and headaches. An MRI was performed and he was found to have a 3.5 x 2.5 cm macroadenoma. After a hormonal work-up he was recommended to undergo a frontopterional craniotomy. This procedure was complicated by him losing his sense of smell completely (anosmia). By October 1996 his annual MRI reported residual tumor and he was advised to undergo a traditional transsphenoidal resection. He underwent the procedure and there were no major perioperative complications except his significant complaints about the nasal packing. During his annual MRI on September of 1998 the patient demonstrated evidence of again recurrent/residual tumor.
A repeat MRI on January of 1999 showed that the tumor had enlarged significantly and was clearly once again a macroadenoma. Significant enlargement was quantified as 30% from the MRI of September 1998. At this point, the patient was recommended to receive stereotactic radiosurgery for management of his tumor. Having concerns for potential damage to his pituitary function and vision, the patient opted for alternative means. He was referred to the Skull Base Institute for another opinion. His most current MRI scan revealed an enhancing pituitary tumor, measuring 1.6 x 1.2 cm, with chiasmatic elevation and a displaced infundibulum. He was informed that his now twice residual/recurrent tumor was amenable to the fully endoscopic transnasal resection. After all the risks and possible complications were discussed, the patient agreed and wished to proceed with the surgery.
The patient was operated on May 19, 2004 where he underwent a fully endoscopic transnasal craniectomy, resection of his pituitary macroadenoma. His procedure lasted approximately 2 hours and he was in the hospital for less than 48 hours. His perioperative course was unremarkable, his vision was intact and he developed no perioperative hormonal dysfunction. After his surgery, he repeatedly claimed he was pleasantly surprised by the difference in his surgical experience this time compared to his previous procedures. He described his recovery as "quick and easy" on several occasions.
In his follow-up, unsolicited appreciation letter, he quotes, "Dear Doctor Shahinian, It's been more than three weeks since my operation, and I just wanted to let you know that my recovery has been quick and easy. In three months or so I'll have a follow-up MRI and will see to it that you get a copy of the film. I also want to take this opportunity to thank you. Your endoscopic technique and your surgical skills are truly miraculous gifts. I suppose a patient undergoing endoscopic removal of a pituitary tumor for the first time might not fully appreciate the great advantages of your surgical technique, not having had the dubious pleasure of experiencing other methods of tumor resection. But having undergone a craniotomy and then less than two years later, a standard, nose mutilating trassphenoidal – both methods leaving enough tumor behind to give life to new tumors-I can attest to the absolute superiority of what you have pioneered at the Skull Base Institute. So thank you, and thank you again. My gratitude is boundless."
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