Improvement in visual field defects in Pituitary tumor excision versus size

of tumor in Endoscopic Transsphenoidal approach

By
Dr. Junaid Nawaz
For
M.S. (Neurosurgery)

Under supervision of

Prof. Dr. Hafiz Abdul Majid

M.B.B.S ; FCPS (Neurosurgery)
Head of Department Neurosurgery Unit- II
Punjab Institute of Neurosciences,
Post Graduate Medical Institute,
Lahore General Hospital, Lahore.

Post Graduate Medical Institute, Punjab Institute of Neurosciences,

Lahore General Hospital, Lahore.
 UNIVERSITY OF HEALTH
SCIENCES, LAHORE
SYNOPSIS PROFORMA
Title of Research Project:
Improvement in visual field defects in Pituitary tumor excision versus size of tumor in
Endoscopic Transsphenoidal approach
Synopsis submitted for: Discipline:

M.S. Neurosurgery

Name of the Applicant: Junaid Nawaz D.O.B.

28-02-1993
Nationality: CNIC #
Pakistani 31202-1401498-5

Address: UHS Registration Number:

House no. 118E, Pak Arab Housing Society, 2011-QAMC-0209-UHS
Lahore.
PMC Registration Number:
90706-P
Phone #: Email:
03228259790 junaid.malik1999@gmail.com
Qualifications (list all; with date of graduation):

Matriculation 2009

F.Sc. (Pre-medical) 2011

MBBS 21st Feb 2017

ii
Name of Post Graduate Institution:

Post Graduate Medical Institute

Punjab Institute of Neurosciences
Lahore General Hospital, Lahore

Name of Research Supervisor: Signature: Date:

Prof. Dr. Hafiz Abdul Majid

Name of Head of Department: Signature: Date:

Prof. Dr. Hafiz Abdul Majid

Name of Principal / Dean of Institution: Signature: Date:

Prof. Dr. Sardar Muhammad Al-fareed Zafar

Convener Signature: Date:

(Institutional Ethical Review Committee)

Prof Dr Farah Shafi

iii
Table of Contents
LIST OF ABBREVIATIONS......................................................................................................v
PROJECT SUMMARY...............................................................................................................1
INTRODUCTION.......................................................................................................................3
LITERATURE REVIEW............................................................................................................6
HYPOTHESIS.............................................................................................................................9
OBJECTIVES............................................................................................................................10
OPERATIONAL DEFINITION:...............................................................................................11
MATERIAL AND METHODS.................................................................................................13
METHODOLOGY:...................................................................................................................18
DATA ANALYSIS:..................................................................................................................20
OUTCOME UTILIZATION.....................................................................................................21
LIMITATIONS:........................................................................................................................22
REFERENCES..........................................................................................................................23
Annexure I.................................................................................................................................24
Annexure II................................................................................................................................25
Annexure III...............................................................................................................................27
Annexure IV..............................................................................................................................28
Annexure V................................................................................................................................29

iv
LIST OF ABBREVIATIONS

Abbreviations Full name

PA Pituitary adenoma
CT Scan Computerized Tomographic Scan
TSE trans-sphenoidal
GCS Glasgow coma scale
VA Visual acquity
MRI Magnetic Resonance Imaging
C&E Craniotomy and excision
OPD Out patient department

v
PROJECT SUMMARY 
Primary tumors arising in the sella turcica and the suprasellar region

comprise approximately 10% of all primary brain tumors. Depending on the site

of origin and the size of the lesions, a wide range of clinical presentations is

encountered. Pituitary dysfunction and visual difficulties are the most common,

while asymptomatic lesions (“incidentalomas”) are occasionally uncovered

during MR examinations performed for other indications.

The present study is being conducted to test the hypothesis that pituitary

tumors which are smaller in size have better visual outcome as compared to

larger ones when removed endoscopically via Transsphenoidal approach. The

objectives of the present study To compare the visual outcomes of sellar supra

sellar tumor surgery viz size of the tumor when removed by endoscopic

endonasal surgery.

This will be a Quasi-experimental study, conducted in department of

Neurosurgery Unit III, Punjab Institute of Neurosciences for a period of one

year after approval of synopsis. Patients who fulfill our predefined inclusion

criteria will be included in this study. A total of 96 subjects will be included

and will be randomized into 2 groups. Group A will contain microadenomas

(tumor size less than 1 cm whereas group B will contain macroadenomas (tumor

size equal to or greater than 1 cm) sellar supra sellar tumors. The patients will

be kept on follow-up for six months and all study parameters will be

documented on pro-forma.

1
 All the data will be entered and analyzed using SPSS 25. Quantitative data

like age, pathology will be presented by the mean and standard deviation.

Qualitative data, like outcomes, will be presented by frequency and percentages.

Stratification will be done based on age, gender and size of the tumor to see its

effect on the final outcome i.e. visual outcomes. Qualitative & Quantitative data

will be tabulated, and a Comparison of the two groups will be made. Chi-Square

test will be performed and a p-value ≤ 0.05 will take as significant.

Pakistan is low-income country with over 200 million populations, with

only a few specialized neurosurgery centers. The Neurosurgery department of

Punjab Institute of Neurosciences, Lahore General Hospital is the tertiary

neurosurgery referral center for neurosurgical patients including those with

sellar suprasellar tumors. Rationale of this study is to compare that pituitary

tumors which are smaller in size have better visual outcome as compared to

larger ones when removed endoscopically via Transsphenoidal approach. . In

literature, it has been reported that endoscopic approach is more successful and

effective in removing sellar supra sellar tumors as compared to open transcranial

microscopic approach. As there is no local evidence available in this regard, so

we want to conduct this study. This will help to improve our practice.

This study will not be blinded as all concerned will know about the

intervention, leading to a lack of allocation concealment and subjecting the

study to selection bias.

Keywords: Sellar supra sellar tumors; pituitary tumors ; endoscopic endonasal

surgery; Adenomas

2
INTRODUCTION
Primary tumors arising in the sella turcica and the suprasellar region

comprise approximately 10% of all primary brain tumors. Depending on the site

of origin and the size of the lesions, a wide range of clinical presentations is

encountered. Pituitary dysfunction and visual difficulties are the most common,

while asymptomatic lesions (“incidentalomas”) are occasionally uncovered

during MR examinations performed for other indications (Ju et al., 2019).

Pituitary adenomas are tumors that occur in the pituitary gland. Pituitary

adenomas are generally divided into three categories dependent upon their

biological functioning: benign adenoma, invasive adenoma, and carcinomas,

with carcinomas accounting for 0.1% to 0.2%, approximately 35% being

invasive adenomas and most being benign adenomas. Pituitary adenomas

represent from 10% to 25% of all intracranial neoplasms and the estimated

prevalence rate in the general population is approximately 17% (Barkhoudarian

and Kelly, 2019) . Pituitary adenomas are associated with increased morbidity

and mortality.

In the late nineteenth century, the resection of a pituitary tumor via an

open craniotomy was first described by Horsley. Since then, the field of

pituitary surgery has undergone constant evolution. Schloffer et al. were the

first to report the transsphenoidal approach in a sella tumor in 1907. It was

Cushing et al. who abandoned external incisions and popularized the sublabial

transseptal transsphenoidal technique. In the 1960s, Hardy perfected Cushing’s

approach with the introduction of the operative microscope. The traditional

3
transseptal / translabial approach has long been considered as the standard

approach because it is associated with minimal morbidity and mortality. In

recent years, with the development of endoscopic instruments and techniques,

Jankowski proposed a fully endoscopic approach to pituitary surgery in 1992.

Currently, endoscopic transsphenoidal pituitary surgery has become a preferred

alternative option because of its advantages of improved visualization and

minimal invasiveness, which allows surgeons to gain access to central skull base

lesions (Muskens et al., 2017).

Pituitary surgery has seen a recent shift from a microscopic to an

endoscopic trans-sphenoidal approach. Microscopic trans-sphenoidal surgery

remains the benchmark for future surgical techniques.It is suggested that

endoscopic trans-sphenoidal surgery provides favourable results in both tumour

resection and control of secreting tumours in comparison with microscopic

surgery. Endoscopic transsphenoidal pituitary adenoma surgery is a safe and

effective treatment for all patients with Cushing’s disease. Recurrence rates

after endoscopic transsphenoidal pituitary adenoma surgery are comparable with

those reported for microscopic transsphenoidal pituitary adenoma surgery.

Endoscopic transsphenoidal pituitary surgery has become increasingly more

popular for the removal of pituitary adenomas. It is also widely recognised that

transsphenoidal microscopic removal of pituitary adenomas is a well-established

procedure with good outcomes

4
 LITERATURE REVIEW

Open transcranial approaches (TCAs) to ventral midline pathology of the

anterior skull base are limited by a necessarily circuitous trajectory, requiring

significant brain retraction in order to provide sufficient illumination to

visualize the full extent of the tumor. These open approaches generally utilize a

corridor which passes directly around cranial nerves and vascular structures,

which lie between the surgeon and the tumor, in order to reach the pathology.

Some authors still advocate a standard endoscope-based trans-sphenoidal (TSE)

to achieve these goals for giant PAs (Karki et al., 2017). However, visualization

into the supra-sellar cistern is limited. For this reason, some authors have

recommended TCA or combined TCA-TSE approaches which carry a higher risk

of optic nerve and vascular injury as well as panhypopituitarism (Han et al.,

2017). In contrast, TSE, midline approaches avoid these structures by

approaching the tumor from below, with compressed neurovascular structures

lying beyond the tumor from the surgeon’s trajectory. These approaches have

been associated with lower morbidity than open transcranial surgery for

intrasellar and subdiaphragmatic lesions (Labib et al., 2019). Similarly, for

lesions with suprasellar extension, TSE microscopic techniques have been used,

though the longer working distance and distant illumination can make complete

5
and safe resection difficult through the narrow corridor provided by the Hardy

retractor.

Li et al., (2020) conducted a meta-analysis to compare microscopic and

endoscopic pituitary surgeries for visual improvement. They concluded that the

endoscopic and microscopic approaches show similar effects and complication

rates. The endoscopic technique could be adopted as a reasonable alternative in

pituitary surgery.

Suri et al., (2008) conducted a study to assess the visual outcome after

surgery in patients with suprasellar tumors who experienced preoperative

blindness in 1 or both eyes. All patients with suprasellar tumors and no

perception of light in 1 or both eyes and who underwent surgery between May

2002 and May 2006 were included in this retrospective study. Outcome was

analyzed at discharge from the hospital and at follow-up. There were a total of

79 patients (51 males and 28 females, age range 5–70 years). There were 37

cases of pituitary adenomas, 19 craniopharyngiomas, 18 meningiomas, and 5

other tumors. Preoperatively 61 patients had uniocular blindness and 18 patients

had binocular blindness. Of all 158 eyes, 97 (61.4%) were blind at admission

and these eyes were analyzed. Sixty-three patients (79.7%) presented with

headache and 14 (17.7%) with hypothalamic symptoms. Nearly one fourth (24%)

of patients with a pituitary adenoma had a history of apoplexy. The duration of

visual decline ranged from 3 days to 7 years, and the duration of blindness

ranged from 1 day to 3 years. Patients underwent either transcranial or

transsphenoidal tumor decompression. At discharge from the hospital visual

6
improvement was exhibited in 23 (29%) of 79 patients and 27 (27.8%) of 97

eyes. Improvement to serviceable vision occurred in 7 (8.9%) of 79 patients and

in 8 (8.2%) of 97 eyes with pre-operative blindness. After surgery, visual

improvement was noted in 15 (24.6%) of 61 patients with uniocular blindness

and 8 (44.4%) of 18 patients with binocular blindness. However, serviceable

vision was restored in 5 (8.2%) of 61 patients with uniocular and 2 (11.1%) of

18 patients with binocular blindness. Bivariate analysis revealed male sex,

shorter duration of blindness, presence of apoplexy, sellar tumor extension, soft

tumor consistency, operative evidence of hemorrhage in tumor, and tumor

histopathology (pituitary adenoma) to have significant impact on the outcome.

Multivariate analysis revealed duration of blindness for > 12 weeks, apoplexy,

and sellar extension to have a significant impact on visual outcome.

7
HYPOTHESIS

H (Null Hypothesis) = Improvements in visual field defects are the same in

0

pituitary tumors which are smaller in size as well as the larger ones when

removed endoscopically via Transsphenoidal approach.

H (Alternate Hypothesis) = The smaller tumors have more improvement in

1

visual field defects as compared to the larger ones when removed endoscopically

via Transsphenoidal approach .

8
OBJECTIVES

The objective of this study is:

To compare the improvements in visual field defects in Pituitary tumor excision

versus size of tumor in Endoscopic Transsphenoidal approach

9
OPERATIONAL DEFINITION:

Visual Outcomes:

It will be measured as per the UK guidelines

Endoscopic Endonasal Transsphenoidal surgery:

Transsphenoidal surgery (TSE) is a type of surgery in which an endoscope

and/or surgical instruments are inserted into part of the brain by going through

the nose and the sphenoid bone (a butterfly-shaped bone forming the anterior

inferior portion of the brain case) into the sphenoidal sinus cavity.
10
11
MATERIAL AND METHODS

Study Design: Quasi-Experimental

Study Settings: Department of Neurosurgery Unit II, Punjab Institute of

Neurosciences, Lahore General Hospital, Lahore.

Study Duration: One year after the approval of synopsis.

Follow Up: Six Months.

Sample Size: The sample size was calculated using n = (Zα/2+Zβ)2 * (p1(1-p1)+p2(1-

p2)) / (p1-p2)2,

Here,  n = 96 patients randomized into two groups

12
 Group A: will contain microadenomas (tumor size less than 1 cm

n=48

 Group B: will contain macroadenomas (tumor size equal to or greater than

1 cm

n=48

13
Sampling Technique and Randomization: 

Consecutive Sampling.

Patient fulfilling the inclusion criteria will be included, and informed

consent will be taken. The procedure to be performed will be decided after

history, examination and neurological assessment. Group A will undergo TCA

for sellar supra sellar tumors, whereas group B will undergo Endoscopic

Endonasal approach for sellar supra sellar tumors. Post operatively,

complications and outcomes will be documented in proforma as per operational

definition.

14
Sample Selection

Inclusion Criteria:

1. Patients between 18-65 years

2. Patients willing and able to consistently return for required follow-up

3. Patients willing and able to comply with postoperative management

program

4. Patient from both genders

5. Patients giving informed consent

6. Patients presenting with;

a. Sudden onset headache

b. Nausea

c. Vomiting

d. Acute reduction of visual acuity

e. Visual field defect

7. Patients in the ASA II category

Exclusion Criteria:

1. Refuse to give informed consent.

2. Patients <12 or >70 years

3. Previously operated for brain tumors

4. Nasal septal injury due to trauma, previous surgery.

5. Tumors that infiltrate the nasal septum, pterygoid fossa, or the anterior

wall of sphenoid sinus

15
6. Non pneumitization of conchal floor of sphenoid sinus

7. Sphenoid Sinusitis

8. Intrasellar vascular anomalies

9. Ectatic midline carotid arteries

10. Significant lateral suprasellar extension of tumor

11. Patients with increased surgical risk

a. Circulatory Pathology

b. Cardiac Pathology

c. Pulmonary pathology

d. Uncontrolled diabetes mellitus

e. Pregnancy

f. Morbid obesity

g. Malignancy

12. Anticoagulant Medications

13.

16
METHODOLOGY:
After approval of my synopsis from institutional review board, 96 patients

in fulfilling the inclusion criteria will be enrolled in the study. Patients will be

recruited from the indoor and the emergency department of Punjab Institute of

Neurosciences. Written and informed consent will be taken from each patient.

The demographic information will be recorded on Pro-forma ( Annexure I). A

proper history and neurological examination will be carried out. Sellar

suprasellar tumor will be diagnosed based on history, examination, neurology

and radiological findings. Each patient will undergo MRI brain plain and

contrast and visual examination (which will be performed by ophthalmologist)

The patient will be assessed by an anesthesiologist and will be optimized for

surgery.

The patient will be assigned to either group A or group B as elaborated

supra. Group A will undergo TCA for sellar supra sellar tumors, whereas group

B will undergo Endoscopic Endonasal approach for sellar supra sellar tumors.

Procedure will be done as per operational definitions and an experienced

Neurosurgeon will execute all surgical procedures in the elective list. A single

shot broad-spectrum antibiotic (intravenously) will be given to all patients when

induction & GA will be administered to the patient.

All the patients will be shifted to an intensive care unit. Postoperatively,

patients will be monitored for complications. The patients will be re-evaluated

on the first post-operative day, at the time of discharge, and then at their OPD

Follow-up Visits as per pro-forma. Visual assessment will be done by visual

17
acuity using Snellen chart. All the results will be collected and recorded on a

Pro-forma (attached).

18
DATA ANALYSIS:
All the data will be entered and analyzed using SPSS 25. Quantitative data

like age, pathology will be presented by the mean and standard deviation.

Qualitative data, like outcomes, will be presented by frequency and percentages.

Stratification will be done based on age, gender, type of procedure, to see its

effect on the final outcome ie visual outcomes. Qualitative & Quantitative data

will be tabulated, and a Comparison of the two groups will be made. Chi-Square

test will be performed and a p-value ≤ 0.05 will take as significant.

19
OUTCOME UTILIZATION
Pakistan is low-income country with over 200 million populations, with

only a few specialized neurosurgery centers. The Neurosurgery department of

Punjab Institute of Neurosciences, Lahore General Hospital is the apex

neurosurgery referral center for neurosurgical patients including those with

sellar suprasellar tumors. This study has been planned to compare 2 surgical

modalities for the treatment of giant pituitary adenomas. The results will

provide future guidelines for the surgical treatment of giant pituitary adenomas

in Pakistan.

20
LIMITATIONS:
1. The present study is limited by small study durations due to which the

followup duration has been decreased. Although the principal

investigator will stop following the patients after stipulated duration as

per study protocols, yet the patients will be kept on followup from the

department through outpatient department.

2. This study will not be blinded as all concerned will know about the

intervention, leading to a lack of allocation concealment and subjecting

the study to selection bias.

21
REFERENCES

Barkhoudarian, G. and Kelly, D. F. (2019) ‘Pituitary Apoplexy’, Neurosurgery Clinics of North

America, 30(4), pp. 457–463. doi: 10.1016/j.nec.2019.06.001.
Finger, T. et al. (2020) ‘Secondary tethered cord syndrome in adult patients: retethering rates,
long-term clinical outcome, and the effect of intraoperative neuromonitoring’, Acta
Neurochirurgica, 162(9), pp. 2087–2096. doi: 10.1007/s00701-020-04464-w.
Han, S. et al. (2017) ‘How to deal with giant pituitary adenomas: transsphenoidal or transcranial,
simultaneous or two-staged?’, Journal of Neuro-Oncology, 132(2), pp. 313–321. doi:
10.1007/s11060-017-2371-6.
Ju, D. G. et al. (2019) ‘Clinical Significance of Tumor-Related Edema of Optic Tract Affecting
Visual Function in Patients with Sellar and Suprasellar Tumors’, World Neurosurgery, 132, pp.
e862–e868. doi: 10.1016/j.wneu.2019.07.218.
Karki, M. et al. (2017) ‘Large and giant pituitary adenoma resection by microscopic trans-
sphenoidal surgery: Surgical outcomes and complications in 123 consecutive patients’, Journal
of Clinical Neuroscience, 44, pp. 310–314. doi: 10.1016/j.jocn.2017.07.015.
Labib, M. A. et al. (2019) ‘The side door and front door to the upper retroclival region: a
comparative analysis of the open pretemporal and the endoscopic endonasal transcavernous
approaches.’, Journal of neurosurgery, pp. 1–13. doi: 10.3171/2019.6.JNS19964.
Li, K. et al. (2020) ‘A systematic review of effects and complications after transsphenoidal
pituitary surgery: endoscopic versus microscopic approach’, Minimally Invasive Therapy and
Allied Technologies, 29(6), pp. 317–325. doi: 10.1080/13645706.2019.1660369.
Muskens, I. S. et al. (2017) ‘Visual outcomes after endoscopic endonasal pituitary adenoma
resection: a systematic review and meta-analysis’, Pituitary, 20(5), pp. 539–552. doi:
10.1007/s11102-017-0815-9.
Shukla, M. et al. (2018) ‘Adult versus pediatric tethered cord syndrome: Clinicoradiological
differences and its management’, Asian Journal of Neurosurgery, 13(2), p. 264. doi:
10.4103/1793-5482.228566.
Suri, A. et al. (2008) ‘Visual outcome after surgery in patients with suprasellar tumors and
preoperative blindness’, Journal of Neurosurgery JNS, 108(1), pp. 19–25. doi:
10.3171/JNS/2008/108/01/0019.
Yang, S. et al. (2017) ‘Systematic review with meta-analysis of intraoperative neuromonitoring
during thyroidectomy’, International Journal of Surgery, 39, pp. 104–113. doi:
10.1016/j.ijsu.2017.01.086.
Zuccaro, M. et al. (2017) ‘Intraoperative neuromonitoring alerts in a pediatric deformity center’,
Neurosurgical Focus, 43(4). doi: 10.3171/2017.7.FOCUS17364.

22
Annexure I

PROFORMA

Visual improvement in sellar supra sellar tumor surgery by open C&E vs endoscopic trans
sphenoidal approach
Biodata
Name
Father’s Name
MR Number
Date of Admission
Date of Surgery
Procedure Details

Date of Discharge
Group: A B
Visual Acuity
Pre Operative
Immediate Post operative
24 hour post op
OPD follow up
Follow Up
1. 12 Hour Post Op
2. 1st Week
3. 2nd Week
4. 4th Week
5. 8th Week
6. 12th Week
7. 16th Week
8. 20th Week
9. 24th Week

23
Annexure II
CONSENT FORM
I.D. Number _________________________________

I _________________________________________ acknowledge that Dr. Junaid Nawaz has informed me about

his research titled “Visual improvement in sellar supra sellar tumor surgery by open C&E vs endoscopic trans

sphenoidal approac” under supervision of Prof. Dr. Muhammad Anwar Ch. 

I am also informed regarding the purpose, nature, aims, and objectives of the Study / Procedure as well as the

expected risks and benefits of the surgery and other materials being used during this study. I have also been

explained the procedure of random allocation to any of the study groups and the fact that surgical procedures

being conducted for either group are different but standardized.

All the information in this process will be kept confidential, and my name and other data will be utilized only for

research purposes. I have been informed that I can ask any type of question-related to the study. I have also been

informed that this research is not just for the benefit of a single person but for humanity at large.

If, after the briefing, I refuse to participate, there will be no obligation on my side, and I shall be treated in routine. I

may withdraw from the study at any time during the course of the study, and I shall not be forced to continue. I give

my full consent and willingness to participate in this study.

Signature of Participant                                Signature of Doctor / Researcher

24
URDU CONSENT FORM

25
Annexure III
ESTIMATED COST OF RESEARCH PROJECT

Cost of Baseline Tests: 96 x 400 = 38’400 PKR

Cost of MRI Scans: 96 x 5000 = 480’000 PKR

Since Punjab Institute of Neurosciences, Lahore General Hospital is a public sector Institution,

all the surgical and admission charges are free of cost, and the patient will incur no cost.

26
Annexure IV
GANTT CHART (Plan of Work)
Task Time Line (Months)
01 02 03 04 05 06 07 08 09 10 11 12 13 14 15
Data Collection
Randomization
Follow-up
Literature Search
Statistical Analysis
Final Write-up
Supervisor Review
Thesis Submission

27
Annexure V

Article / Research Review Committee

Post Graduate Medical Institute / Ameer-ud-Din Medical College /
Lahore General Hospital, Lahore
AMC / PGMI / LGH / Article / Research No / _______________ / Date / ______________ /

Approval from Ethical Review Committee

It is certified that we have read the Article / Research titled:

Visual improvement in sellar supra sellar tumor surgery by open
C&E vs endoscopic trans sphenoidal approach
Submitted by:
DR. JUNAID NAWAZ
Resident, M.S. (Neurosurgery)
Post Graduate Medical Institute, Punjab Institute of Neurosciences,
Lahore General Hospital, Lahore
 Email:  Junaid.malik1999@gmail.com     Phone No: 03228259790 PMC No: 90706-P
We have found it acceptable ethically and hence approved for further submission.
Chairman
Professor Dr. Farah Shafi
Professor of Medicine Department Unit II
PGMI / AMC / LGH Lahore
Member
Professor Dr. Khalid Waheed
Professor of Pulmonology Department
PGMI / AMC / LGH Lahore
Member
Professor Dr. Faiqa Saleem Baig
Professor of Gynecology Unit II
PGMI / AMC / LGH Lahore
Member
Professor Dr. Muhammad Hanif Mian
Professor of Orthopedics
PGMI / AMC / LGH Lahore
Member
Dr. Ghazala Rubi
Director Research PGMI / AMC / LGH Lahore
PGMI / AMC / LGH Lahore

28