Abstract
INTRODUCTION Giant (4-cm) pituitary macroadenomas are complex tumors that require resection for decompression of optic nerves, relief of mass effect, and improvement in symptomatology. Management of these lesions presents a significant challenge for surgeons given the lack of surgical accessibility, the lateral extent of the lesions, and the invasion of the cavernous sinus. Transsphenoidal, transcranial, and combined approaches have been viable options for resection. METHODS The authors reviewed 742 patients who underwent resection of pituitary adenomas. From this group, 100 consecutive patients with giant pituitary adenomas (defined as maximum diameter ≥4 cm) who underwent resection between January 1, 2002 and December 31, 2019, were identified for inclusion in the study. RESULTS The mean preoperative tumor diameter in this cohort was 4.6 cm, with a mean volume of 25.9 cm3. Gross-total resection was achieved in 30 (34.5%) patients. Surgical cure without a need for additional therapy was achieved in 63 (68.5%) patients, with 14 patients (16.9%) undergoing subsequent adjuvant therapy in the form of repeat operation or adjuvant radiation therapy because of recurrent progression of tumor. Overall, the morbidity associated with removal of these lesions was 10.0%; the most common morbidities were cerebrospinal fluid leak (5 patients, 5.0%) and hydrocephalus (3 patients, 3.0%). One death because of postoperative pituitary apoplexy of the residual tumor and malignant cerebral edema occurred in this cohort. CONCLUSION Surgical goals for removal of giant pituitary tumors should include attempts at removal of the majority of the tumor tissue to minimize the risk of residual tumor apoplexy, which can be done by tailoring the approach along the axis of the tumor. These lesions are difficult to manage, with low rates of gross-total resection and high rates of morbidity. Experience with both transsphenoidal and transcranial techniques is necessary for minimizing complications and improving outcomes.