With the development of micro-neurosurgery technology, two approaches, the microscopic transcranial approach and the transsphenoidal approach, are the mainstream surgical approaches at present. The choice of surgical approach generally depends on the volume of the tumor, the degree of invasion outside the saddle area and the operator’s proficiency in various approaches.
Transcranial approach: craniotomy to remove pituitary tumor has been used in clinical practice for a long time, and it is a very mature surgical procedure due to the full exposure of surgical field and large operation space. Pituitary tumors that are currently treated openly are generally more complex and difficult tumors.
The indications are as follows: 1, huge pituitary adenoma whose tumor obviously invades to the frontotemporal lobe or even the posterior cranial fossa; 2, pituitary adenoma whose tumor develops to the suprasellar part and the connection of the intersellar part is significantly narrowed; 3, pituitary adenoma whose tumor has fibrosis and hard texture and cannot be removed through the pterygoid sinus.
4. Pituitary adenomas that are not suitable for transsphenoidal surgery, such as giant pituitary adenomas, especially invasive ones; or patients who need combined access and staged surgery.
Transsphenoidal approach: It mainly includes microscopic transsphenoidal approach, endoscopic transsphenoidal approach and microscopic combined with endoscopic transsphenoidal approach, which are all very mature. With the promotion of the concept of minimally invasive and precise surgery, transsphenoidal surgery is the most commonly used surgical approach for pituitary adenoma. Even huge pituitary tumors with both intra- and supra-saddle invasion can be treated satisfactorily by staged surgery. In addition, the use of precise intraoperative nerve navigation is no longer a contraindication in cases of the mesenteric or anterior saddle sinus, which were previously thought to be contraindicated by transsphenoidal surgery.
The indications for transsphenoidal approach have also been expanded, and the current clinical indications are as follows: 1. tumor protrusion to the pterygoid sinus and confined to the saddle; 2. vertical growth of tumor to the saddle.
Stereotactic radiation therapy: is often used as an adjuvant treatment for pituitary tumor surgery. Conventional radiation therapy methods include gamma knife, X-ray radiotherapy, linear gas pedal X knife, etc. Among them, gamma knife stereotactic treatment is the most common. Since pituitary tumors are fixed in position and sensitive to radiation, while normal pituitary cells are insensitive to radiation, gamma knife can often effectively kill tumor tissue without damaging or mildly damaging normal pituitary cells. Some patients are found to have symptoms of compression of the visual pathway when pituitary tumors are detected, so the indications for gamma knife treatment should be grasped to avoid damage to the conduction nerve of the visual pathway, resulting in visual impairment or blindness.
The main indications for gamma knife treatment are as follows: 1, the visual nerve should be relatively far away from the edge of the pituitary tumor; 2, there are some residuals of adenoma without endocrine function after surgery; 3, microadenoma with high secretion function does not want surgery and drug therapy is ineffective or cannot be tolerated.