# Management Approaches and Patient Outcomes for Giant Pituitary Neuroendocrine Tumors Classified as Knosp Grade 3 and 4

## TL;DR

This study examines surgical outcomes and management strategies for large pituitary tumors, highlighting challenges and the need for personalized treatment approaches.

## Contribution

The study provides insights into the surgical management and outcomes of giant pituitary neuroendocrine tumors classified as Knosp grade 3 and 4.

## Key findings

- Gross total resection was achieved in 24% of patients, with tumors invading the middle fossa negatively affecting resection extent.
- Postoperative vision improved or normalized in 64% of patients, while 28% experienced new hormonal deficits.
- Complications included cerebrospinal fluid leakage, diabetes insipidus, and oculomotor nerve palsy in a small percentage of cases.

## Abstract

Background

Treatment of patients with a giant pituitary neuroendocrine tumor (GPitNET) is challenging. Here, we present the methods used for the clinical management of patients who underwent GPitNET resection mainly via endoscopic endonasal surgery along with multimodal support to avoid surgical complications, which can affect the outcomes.

Methodology

The medical records of 25 patients with a GPitNET who underwent endonasal endoscopic surgery were retrospectively reviewed. Complications were analyzed and factors affecting the extent of resection were evaluated.

Results

Gross total resection was achieved in six (24%), near-total resection (>90%) in nine (36%), and partial resection in 10 (40%) patients. Multivariate analyses revealed that tumors invading the middle fossa had negative effects on the extent of resection (odds ratio = 0.092, p = 0.047). Postoperative vision improved or normalized in 16 (64%), remained stable in eight (32%), and worsened in one (4%), while a new hormonal deficit was noted in seven (28%) patients. Complications included permanent oculomotor nerve palsy in one (4%) and transient oculomotor palsy in one (4%), apoplexy of the residual tumor resulting in ischemic stroke in one (4%), postoperative cerebrospinal fluid leakage in one (4%), and permanent diabetes insipidus in six (24%) patients.

Conclusions

For GPitNETs that extend into the middle fossa, our study underscored the difficulties in surgical extraction and the necessity for tailored treatment approaches. To ensure the safest and most complete removal possible, the surgical strategy must be specifically adapted to each case. Additionally, employing a comprehensive support approach is essential to reduce the chance of complications in patients impacted by this condition.