← Back to Previous Page

 

S038: CAVERNOUS SINUS SURGERY FOR CORTICOTROPH PITUITARY ADENOMAS: DISTINCTIVE GROWTH PATTERNS AND IMPACT ON CUSHING DISEASE REMISSION
Ana Sofia Alvarez, MD¹; Jonathan B Lamano, MD, PhD¹; Matei A Banu, MD¹; Ali Palejwala¹; Christine K Lee, MD, PhD²; Vladimir A Ljubimov, MD³; Karam P Asmaro, MD⁴; Vera Vigo, MD¹; Juan Carlos Fernandez-Miranda, MD¹; ¹Stanford University; ²Brown University; ³Cedars-Sinai Medical Center; ⁴Henry Ford Hospital

Introduction: Corticotroph pituitary adenomas can be silent or functioning, with distinct growth behavior, cavernous sinus (CS) invasion patterns, and clinical impact.  ACTH-secreting tumors cause severe morbidity, and standard endonasal endoscopic approach achieves remission in only 60-80 % of cases with frequent recurrences. Reoperation offers limited benefits and higher complication risk. Understanding CS-invasion patterns and improving CS exploration techniques are essential to achieve remission in CS-invasive corticotroph adenomas.

Objective: To characterize the invasion patterns of silent and ACTH-secreting adenomas and to determine how surgical resection of CS-invasive disease influences remission in Cushing disease.

Methods: 100 consecutive TPIT-positive corticotroph pituitary adenomas resected with curative intent (2018-2024) were reviewed. Cavernous sinus medial wall resection and CS exploration were performed when invasion was suspected. 

Results:

• Silent corticotroph adenomas (SCA) are larger and more invasive, often with medial wall destruction and invasion into the CS compartments  (52.4%, p < 0.01) and/or subarachnoid extension (19%, p < 0.05) [Fig. 1 A-B]. The more aggressive growth pattern of SCAs, combined with more conservative surgery in non-functioning adenomas, results in lower but not statistically significant GTR rates.
• ACTH-secreting adenomas have similar CS invasion rates but are typically confined to the medial wall (43.1%, p < 0.0001) [Fig. 2]

No differences in extent of resection or complications were observed between patients with and without CS invasion in both SCAs and Cushing disease [Fig. 3]. No ICA injuries occurred.

• In newly diagnosed Cushing patients, 92.3% achieved remission. An increase of 23.1% in remission rates can be achieved through medial wall resection, and a further 5.1% with CS compartment surgery [Fig 4].
• In recurrent Cushing disease, remission was achieved in 57.9% and CS surgery was needed to achieve remission in almost half of patients (36.9% medial-wall resection, 10.2% CS-compartment exploration) [Fig. 5, Fig. 1 C-D].

Conclusion: SCAs and ACTH-secreting adenomas have similar CS invasion rates but differ in growth patterns. SCAs often destroy the medial wall and invade multiple CS compartments, complicating resection. ACTH-secreting tumors are typically confined to the medial wall, and its resection substantially improves remission. CS surgery improves remission rates without increasing complications.

Fig. 1

Preoperative coronal T1 MRI showing typical invasive patterns of SCAs: (A) extensive CS invasion with medial wall destruction and multicompartment involvement, and (B) subarachnoid extension. Preoperative coronal T1 MRI of two cases of recurrent Cushing disease with CS-medial wall invasion achieving remission after medial wall resection (C-D).

Fig. 2

Fig 3

Fig. 4

 

← Back to Previous Page