Surgical Tacties for Large Sellar and Parasellar Tumors

Ha, Sang Soo; Kim, Hyung Dong; Kim, Ki Uk; Kim, Ku Hong

Abstract

We analyzed 56 operations in 45 patients with sellar and parasellar tumors from March, 1990 to May, 1995, to evaluate the determining factors in selecting the surgical approaches for large and giant sellar and suprasellar tumors, based on clinical, endocrinological and radiological findings. The definition of "large" is when the longest diameter of the tumor is more than 20mm on radiographic studies and the term "small" is applied to tumor of diameter below 19mm. The results were as follows: 1) Number of the patients with small tumor was 14(31.1%) and all of them were treated with single stage transsphenoidal approach, and 42 operations were performed in 31(68.9%) patients with large tumors. 2) The approaches for large tumors were: transsphenoidal approach in 32 cases: pterional approach 5 cases: subfrontal interhemispheric approach 4 cases; and subfrontal paramedian approach 1 case. 3) The rate of complete removal for large and giant tumors in the first operation was 29.0%; in second operation, 72.7%; overall the rate was 54.8%. 4) Complications were; transient type diabetes insipidus in 24 cases; meningitis 2 cases; hypothalamic injury 3 cases; CSF rhinorrhea 1 case; and cerebral infarction 1 case; and death 1 case. 5) There was significant relationship between the size of the tumor and tumor types(p<0.05) and the degree of suprasellar extension(p>0.05) but not wih destruction of the sellar floor(p<0.05). 6) There was significant relationship between the surgical approaches and size of the tumors(p>0.05). 7) In case of incomplete removal with first transsphenoidal approach, a second operation seems to be helpful. 8) In second stage transcranial approach following first transsphenoidal approach, it is easier to remove the tumor due to the decreased tumor size and thus, a reduced need for marked brain retraction. From our findings, we suggest guidelines in choosing the surgical approach for sellar and parasellar tumors as follows: 1) Many of the tumors in the sellae and suprasellar area can be removed successfully by transsphenoidal approach. 2) Taranssphenoidal approach can be repeated safely in stage O, A, B and C, if the diaphragm sella remains intact. 3) Tanscranial approach is recommended primarily in stage D & E, if intrasellar portion of the tumor is not significant or opening of the diaphragm sella is narrow. 4) Transsphenoidal approach followed by transcranial approach is adequate in stage D & E, if significant amount of the tumor remaining in the sella or sellar floor is severely destructed(Grage III, IV).