The Role of the Le Fort I Maxillotomy in the Management of Incompletely Resected Pituitary Macroadenomas

ABSTRACT

Objective: The options available for the treatment of a nonsecreting pituitary macroadenoma that has been incompletely resected include reoperation, fractionated radiation therapy, and radiosurgery. Reoperation in this setting may be hindered by the same obstacles that prevented a complete resection during the initial surgical procedure, and should prompt consideration of an alternate approach or exposure. Methods: Between January 1998 and December 2003, 10 consecutive patients were referred to the Department of Neurosurgery at the University of Texas Southwestern Medical Center for the evaluation of a nonsecreting pituitary macroadenoma that measured 3 cm or greater in diameter despite having undergone an attempt at a complete resection elsewhere. Each of these patients was reoperated using a Le Fort I maxillotomy to enhance the exposure provided by a traditional transsphenoidal approach. Results: A total or near total (> 95%) resection was achieved in each case. One patient required reoperation for the repositioning of a fat graft to treat a cerebrospinal fluid fistula and one patient experienced a worsening of anterior pituitary function postoperatively. Five patients noted improved vision and no patient experienced further visual loss. Three patients have required subsequent treatment of small foci of recurrent or progressing tumor with stereotactic radiation therapy. No patient has received fractionated radiation therapy. Conclusion: The added exposure provided by a Le Fort I maxillotomy facilitates the resection of pituitary macroadenomas that have been incompletely resected by a traditional transnasal, trans-sphenoidal approach.

KEYWORDS

Le Fort I maxillotomy - macroadenoma - pituitary adenoma - trans-sphenoidal surgery

REFERENCES

• 1 Losa M, Valle M, Mortini P et al.. Gamma knife surgery for treatment of residual nonfunctioning pituitary adenomas after surgical debulking.  J Neurosurg. 2004;  100 438-444
• 2 Pollock B E, Carpenter P C. Stereotactic radiosurgery as an alternative to fractionated radiotherapy for patients with recurrent or residual nonfunctioning pituitary adenomas.  Neurosurgery. 2003;  53 1086-1094
• 3 Alleyne Jr C H, Barrow D L, Oyesiku N M. Combined trans-sphenoidal and pterional craniotomy approach to giant pituitary tumors.  Surg Neurol. 2002;  57 380-390
• 4 Barrow D L, Tindall G T, Tindall S C. Combined simultaneous transsphenoidal transcranial operative approach to selected sellar tumors.  Perspect Neurol Surg. 1992;  3 49
• 5 Landolt A M. Surgical management of recurrent pituitary tumors. In: Schmidek HH, Sweet WH Operative Neurosurgical Techniques. 4th ed. Philadelphia; WB Saunders 2000: 455-466
• 6 Loyo M, Kleriga E, Mateos H, de Leo R, Delgado A. Combined supra-infrasellar approach for large pituitary tumors.  Neurosurgery. 1984;  14 485-488
• 7 Saito K, Kuwayama A, Yamamoto N, Sugita K. The trans-sphenoidal removal of nonfunctioning pituitary adenomas with suprasellar extensions: the open sella method and intentionally staged operation.  Neurosurgery. 1995;  36 668-675 discussion 675-676
• 8 Fraioli B, Esposito V, Santoro A, Iannetti G, Giuffrè R, Cantore G. Transmaxillosphenoidal approach to tumors invading the medial compartment of the cavernous sinus.  J Neurosurg. 1995;  82 63-69
• 9 Petruson B, Jakobsson K E, Elfverson J, Bengtsson B A. Five-year follow-up of nonsecreting pituitary adenomas.  Arch Otolaryngol Head Neck Surg. 1995;  121 317-322
• 10 Myoken Y, Sugata T, Kiriyama T, Kiya K. Transoral approach for large pituitary adenoma using Le Fort I osteotomy with mandibulotomy: a case report.  Int J Oral Maxillofac Surg. 2000;  29 128-130
• 11 Uttley D, Moore A, Archer D J. Surgical management of midline skull-base tumors: a new approach.  J Neurosurg. 1989;  71 705-710
• 12 Benveniste R J, King W A, Walsh J, Lee J S, Delman B N, Post K D. Repeated trans-sphenoidal surgery to treat recurrent or residual pituitary adenoma.  J Neurosurg. 2005;  102 1004-1012
• 13 Tanaka Y, Hongo K, Tada T, Sakai K, Kakizawa Y, Kobayashi S. Growth pattern and rate in residual nonfunctioning pituitary adenomas: correlations among tumor volume doubling time, patient age, and MIB-1 index.  J Neurosurg. 2003;  98 359-365
• 14 Greenman Y, Ouaknine G, Veshchev I, Reider-Groswasser I I, Segev Y, Stern . Postoperative surveillance of clinically nonfunctioning pituitary macroadenomas: markers of tumour quiescence and regrowth.  Clin Endocrinol (Oxf). 2003;  58 763-769
• 15 Lillehei K O, Kirschman D L, Kleinschmidt-DeMasters B K, Ridgway E C. Reassessment of the role of radiation therapy in the treatment of endocrine-inactive pituitary macroadenomas.  Neurosurgery. 1998;  43 432-438 discussion 438-439
• 16 Park P, Chandler W F, Barkan A L et al.. The role of radiation therapy after surgical resection of nonfunctional pituitary macroadenomas.  Neurosurgery. 2004;  55 100-106 discussion 106-107
• 17 Hughes M N, Llamas K J, Yelland M E, Tripcony L B. Pituitary adenomas: long-term results for radiotherapy alone and post-operative radiotherapy.  Int J Radiat Oncol Biol Phys. 1993;  27 1035-1043
• 18 Yildiz F, Zorlu F, Erbas T, Atahan L. Radiotherapy in the management of giant pituitary adenomas.  Radiother Oncol. 1999;  52 233-237
• 19 Petrovich Z, Jozsef G, Ya C, Apuzzo M L. Radiotherapy and stereotactic radiosurgery for pituitary tumors.  Neurosurg Clin N Am. 2003;  14 147-166
• 20 Plowman P N. Pituitary adenoma radiotherapy: when, who and how?.  Clin Endocrinol (Oxf). 1999;  51 265-271
• 21 Cappabianca P, Cavallo L M, Colao A, de Divitiis E. Surgical complications associated with the endoscopic endonasal trans-sphenoidal approach for pituitary adenomas.  J Neurosurg. 2002;  97 293-298
• 22 Rudnik A, Zawadzki T, Galuszka-Ignasiak B et al.. Endoscopic trans-sphenoidal treatment in recurrent and residual pituitary adenomas: first experience.  Minim Invasive Neurosurg. 2006;  49 10-14
• 23 Goel A, Nadkarni T, Muzumdar D, Desai K, Phalke U, Sharma P. Giant pituitary tumors: a study based on surgical treatment of 118 cases.  Surg Neurol. 2004;  61 436-445 discussion 445-456
• 24 Lang J. Anatomy of the midline.  Acta Neurochir Suppl (Wien). 1985;  35 6-22
• 25 de Mol van Otterloo J J, Tuinzing D B, Greebe R B, van der Kwast W A. Intra- and early postoperative complications of the Le Fort I osteotomy: a retrospective study on 410 cases.  J Craniomaxillofac Surg. 1991;  19 217-222
• 26 Kramer F J, Baethge C, Swennen G et al.. Intra-and perioperative complications of the LeFort I osteotomy: a prospective evaluation of 1000 patients.  J Craniofac Surg. 2004;  15 971-977 discussion 978-979