CLINICAL STUDY-PATIENT STUDIES Safety and efficacy of the direct endonasal transsphenoidal approach for challenging sellar tumors Nader Sanai Æ Alfredo Quin ˜ ones-Hinojosa Æ Jared Narvid Æ Sandeep Kunwar Received: 14 July 2007 / Accepted: 5 December 2007 / Published online: 19 December 2007 Ó Springer Science+Business Media, LLC. 2007 Abstract Introduction The direct endonasal approach to pituitary microadenomas is relatively atraumatic, rapid, and carries a lower complication rate than the sublabial approach. Large macroadenomas (3–4 cm) can still be addressed with this simple, unmodified direct endonasal approach. We present our experience with this unique and challenging patient population. Methods About 64 con- secutive patients with large (3–4 cm) pituitary adenomas and craniopharyngiomas were treated by the senior author (SK) using the direct endonasal approach from May 2001 to July 2004. The hospital course, endocrinological func- tion, radiographic imaging, and outpatient follow-up were retrospectively reviewed for each patient. Results The mean volume of these lesions was 31.5 cm 3 (range, 10.3– 168 cm 3 ). Tumor pathologies included 2 craniopharyn- giomas, 16 functional, and 46 nonfunctional pituitary adenomas. Suprasellar extension of tumor was evident in all patients and 10 had cavernous sinus invasion. Gross total resection was achieved in 30 patients, near-gross total in 6 patients, and subtotal resection in 26 patients. Eight patients (12.5%) demonstrated postoperative complica- tions, with diabetes insipidus for less than 1 year (n = 4) being the most common. There was no incidence of CSF leak, new panhypopituitarism, or worsened vision. Five patients (7.8%) had tumor residual requiring radiation therapy. Additionally, after a mean clinical follow-up of 24.5 months, 4 patients (6.3%) demonstrated recurrent disease. Conclusions Direct endonasal transsphenoidal surgery enables safe and effective resection of large sellar masses while maintaining a favorable morbidity profile. Keywords Pituitary adenoma Á Transsphenoidal Á Endonasal Á Endoscopic Á Extended Introduction The sublabial transsphenoidal approach has been the favored route for the resection of intrasellar tumors in prior years [1–4]. However, more recently, the endonasal trans- sphenoidal approach [5, 6] has steadily gained popularity in the resection of microadenomas [5, 7]. This modified approach avoids much of the soft tissue dissection, opera- tive time, and postoperative complications (epistaxis, facial ecchymosis, and upper lip dysesthesia) associated with the traditional sublabial transsphenoidal technique, but allows for a quicker approach and closure [8–10]. Giant intrasellar tumors ( [ 4 cm), however, often neces- sitate a modified surgical strategy in order to gain wider exposure. Traditionally, this meant a combined approach, employing transsphenoidal access along with a pterional or subfrontal craniotomy [11–13]. Others have advocated an ‘‘extended’’ sublabial transsphenoidal approach with the additional bony removal of the tuberculum sellae and proximal planum sphenoidale, which abrogated the need for a craniotomy [14]. Similarly, as the endonasal route has gained popularity, an ‘‘extended’’ endonasal transsphenoidal has also been effective in resecting giant intrasellar tumors N. Sanai (&) Á J. Narvid Á S. Kunwar Department of Neurological Surgery, University of California at San Francisco, 505 Parnassus Avenue, M-779, P.O. Box 0112, San Francisco, CA 94143, USA e-mail: sanain@neurosurg.ucsf.edu A. Quin ˜ones-Hinojosa Department of Neurological Surgery, The Johns Hopkins Hospital, Brain Tumor Surgery Program & Pituitary Center, Baltimore, MD, USA 123 J Neurooncol (2008) 87:317–325 DOI 10.1007/s11060-007-9512-2