2026 Proffered Presentations
S091: THE EMERGING ROLE OF ENDOSCOPIC ENDONASAL TRANSCAVERNOUS SURGERY IN THE MANAGEMENT OF NON-FUNCTIONING PITUITARY ADENOMAS WITH CAVERNOUS SINUS INVASION
Taishi Nakase, MS; Felipe Constanzo, MD; Vera Vigo, MD; Juan C Fernandez-Miranda, MD; Stanford University
Introduction: Transcavernous surgery for resection of non-functioning pituitary adenomas (NFPAs) with cavernous sinus (CS) invasion is often not performed due to concern that the risk of neurovascular injury outweighs the risk posed by tumor progression or adjuvant radiosurgery. However, advances in endoscopic endonasal surgery (EES) techniques for safe and effective CS exploration have shown great promise to increase remission rates and reduce the likelihood of additional therapies without increasing morbidity for functional adenomas. To better understand the emerging role of first-line transcavernous surgery for resection of NFPAs with CS invasion, we examined surgical outcomes in patients with recurrent or newly diagnosed NFPAs treated with contemporary EES techniques.
Methods: Surgical outcomes were retrospectively analyzed for 190 consecutive patients (102 males, median 58 years) with NFPAs who underwent EES. Multivariable logistic regression with adjustment for tumor diameter, Knosp grade and presence of CS invasion was used to compare outcomes between newly diagnosed (n=161) and recurrent adenomas (n=29).
Results: While there were similar proportions of macroadenomas (100% vs. 99%, P=1.00), recurrent adenomas had more CS invasion (76% vs. 32%, P=<.001) and were more likely to be Knosp grades 3 or 4 (52% vs. 24%, P=<.01) compared to new adenomas. Overall, gross total resection (GTR) was achieved in 170 (89%) patients (Figure 1). Moreover, GTR was demonstrated in 56 of 74 (76%) patients with CS invasion, including all 10 patients with isolated medial wall invasion and 46 of 64 (72%) of patients with CS compartment invasion. Recurrent adenomas had a lower GTR rate than newly diagnosed adenomas (66% vs. 94%), which remained significant in multivariable logistic regression (OR=0.22, 95% CI: 0.07-0.68, P<.01). Similar results were obtained when restricting to patients with CS invasion (OR=0.28, P=0.031), where 83% of new adenomas achieved GTR compared to 59% of recurrent adenomas. All 7 (4%) cases of abducens (n=6) or oculomotor nerve palsy (n=1) were transient with full recovery. The rate of new transient cranial nerve palsy after surgery was significantly higher for patients with recurrent adenomas (14%) compared to patients with new adenomas (2%) in the multivariable model (OR=5.63, P=0.036). There were no cases of internal carotid artery injury. For newly diagnosed adenomas, all 10 patients who did not achieve GTR had stable residual disease without growth after median follow-up of 17 months, although there were 3 (2%) cases of tumor recurrence among the 151 patients that demonstrated GTR. For recurrent adenomas, 3 of 10 (30%) patients with subtotal resection (STR) showed tumor progression.
Conclusion: We observed high GTR rates, low risk of transient cranial nerve palsy, and no permanent neurological morbidity in patients with newly diagnosed adenomas with and without CS invasion. Moreover, we showed that previous surgery is a significant independent predictor of poor surgical outcomes. While we caution against a broad indiscriminate surgical approach, we emphasize that advances in EES techniques may warrant a shift towards a lower surgical threshold for transcavernous surgery of symptomatic NFPAs with CS invasion to minimize the challenges posed by repeat surgeries.
Figure 1: Surgical outcomes.
