Cushing’s Disease and Macroadenoma: Pitfalls

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This procedure demonstrates techniques for resection of pituitary macroadenomas causing Cushing's disease and also maneuvers that can improve gross total resection and cure of such tumors. This is a 43 year-old female who presented with longstanding Cushing's disease and on MRI evaluation, harbors a relatively cystic and solid pituitary macroadenoma. One of the specific features of this tumor is this extension over the tuberculum sellae and beyond the boundaries of the sella turcica. You can also appreciate that this tumor most likely has penetrated through the diaphragma sellae and has found its way through the suprasellar space. These details are extremely important during exploration of the tumor and maximizing its resection due to the breadth of this tumor beyond the usual boundaries of the sella and extended transfemoral approach through their transtuberculum route, was deemed necessary to expose the tumor adequately. Here's our transsphenoidal transnasal approach and opening of the dura. You can see a portion of the tuberculum is removed. Pituitary rongeur is used to remove the intrasellar component of the tumor as much as possible. There is plenty of tumor to remove. Ring curette is used. The resection cavity looks relatively clean, hydroscopy confirms the gross total resection of the mass. Based on preoperative findings on imaging, I continue to further inspect the resection cavity, open the dura toward the air of the tuberculum to assure myself that gross total resection has been secured. Further inspection over the diaphragma does not reveal any obvious tumor. You saw it, portion of it, chiasm a moment ago. Further inspection again reveals the chiasm but no obvious tumor. I persisted and I see some unusual piece of tissue that could represent tumor. Sharp dissection was used to open some of the arachnoid bands over the diaphragma. And you can see careful close inspection reveals the location of the tumor just above the optic nerve and chiasm. Diaphragma was opened as previously promised, you can see the optic nerve is intimately related to the bands. Now I can inspect the area just above the optic nerve and chiasm, plenty of tumors left behind and now angled ring curettes and endoscopes are used to further visualize the operative field and remove tumor under direct vision. You can see A1 just behind the tumor. The tumor over the optic nerve is dissected. Here's the piece of the tumor that seems relatively small at the beginning, however further dissection reveals that this tumor is much bigger than I initially thought. So this tumor was not only suprasellar and above the diaphragma but also above the optic nerve. If I had not carefully inspected the area above the chiasm, this very large portion of the tumor could have been left behind and one can argue that some of our failures after resection relate to residual tumor around the optic apparatus that was not carefully inspected. Here's the final resection cavity, the optic nerve on the left side and the chiasm and the vessels. There's no residual tumor apparent. A piece of fat was using this case to reconstruct the opening. Since the opening was relatively small, the fat and dural allograft were deemed adequate without using the gasket seal technique. The nasoseptal flap was also used to complete the score-based reconstruction, post operative MRI, reveal score store resection of the mass, and a portion of the mass over the tuberculum sellae without any residual tumor. There is preservation of the intact pituitary gland. This patient went on to have a complete cure of her Cushing's disease with a relief of most of her preoperative symptoms, thank you.

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