Management of Sellar Tumors
For sellar tumors, surgical resection via transsphenoidal approach is the primary treatment for most lesions except prolactinomas, which should be managed medically with dopamine agonists. 1, 2
Initial Diagnostic Approach
Obtain MRI with high-resolution pituitary protocols using thin-section imaging (≤0.5 cm slice thickness) with pre- and post-contrast T1-weighted sequences, as this is the gold standard for evaluating sellar masses and provides superior tissue characterization compared to CT 3, 1
Perform comprehensive hormonal screening including thyroid function tests, morning cortisol and ACTH, prolactin, sex hormones, and growth hormone/IGF-1 to identify functioning adenomas and baseline pituitary function 1
Complete ophthalmologic evaluation with visual acuity testing and visual field assessment is critical, particularly for macroadenomas, as visual recovery is unlikely after the first post-operative month 1
Treatment Algorithm by Tumor Type
Pituitary Adenomas (Most Common Sellar Tumor)
Prolactinomas: Dopamine agonist therapy (cabergoline or bromocriptine) should be first-line treatment rather than surgery 2
Non-functioning pituitary adenomas: Transsphenoidal resection is the mainstay of surgical therapy 2
Other functioning adenomas (ACTH-secreting, GH-secreting, TSH-secreting): Surgical resection is first-line treatment 3, 2
Surgical Considerations
Transsphenoidal approach has become increasingly widespread and represents the standard surgical technique for most pituitary adenomas and selected craniopharyngiomas 2
Avoid attempting complete resection when tumors envelop major vessels or involve vital neural structures, as risks outweigh benefits 1
Obtain histopathological assessment including immunostaining for pituitary hormones and Ki-67 proliferative index, as Ki-67 ≥3% combined with local invasion predicts 25% recurrence rate 1
Management of Residual or Recurrent Disease
For Non-Functioning Pituitary Adenomas
When no residual tumor or only small intrasellar tumor exists postoperatively, serial neuroimaging surveillance is recommended 3
For residual/recurrent sellar or parasellar tumor where repeat resection carries high risk, radiosurgery or radiation therapy is recommended 3
Radiosurgery with single-session doses ≥12 Gy or fractionated radiation therapy with 45-54 Gy achieves local tumor control rates ≥90% at 5 years 3
Repeat resection is recommended for symptomatic recurrent or residual non-functioning pituitary adenomas 3
Radiation Therapy Options
Both stereotactic radiosurgery and fractionated radiation therapy are recommended to lower the risk of subsequent tumor progression in residual or recurrent disease 3
Radiation therapy plays a crucial role when successful surgical resection is not achievable due to proximity of critical structures 4
Special Considerations
Granular Cell Tumors of Sellar Region
Tumor size <2.5 cm predicts better outcomes with 100% 5-year overall survival compared to 74% for larger tumors 5
Gross-total resection results in superior 5-year overall survival (95.7%) compared to subtotal resection (88.8%) or biopsy alone (75%) 5
Radiation therapy does not improve overall survival for granular cell tumors 5
Craniopharyngiomas
Radical surgery is appropriate in most patients but carries increased risks of postoperative morbidity, mortality, and endocrinopathy 2
Less invasive alternatives include intracavitary therapy and debulking followed by radiation therapy or stereotactic radiosurgery 2
Critical Pitfalls to Avoid
Do not delay surgical planning for resectable lesions, as younger patients have worse visual outcomes and visual recovery becomes unlikely after the first post-operative month 1
Do not overlook lifelong endocrine surveillance, as hormonal deficiencies may develop or progress over time following surgery or radiation 1
Assess proliferative index (Ki-67) and ACTH staining to identify silent corticotroph adenomas, as these provide guidance on adenoma progression risk and benefit of earlier adjuvant radiation 3
Ensure multidisciplinary approach involving neurosurgery, endocrinology, ophthalmology, and radiation oncology for optimal management 2, 6