Aggressive transsphenoidal resection of tumors invading the cavernous sinus in patients with acromegaly: predictive factors, strategies, and outcomes

Abstract

Cavernous sinus invasion is the most significant, independent predictor of unfavorable outcome. Confirmation of invasion requires direct observation within the CS regardless of the microscope or endoscope used. Particularly in cases in which only the medial wall is involved, histological verification is always necessary to detect the occult invasion. Direct removal of the invading tumor, by sharp excision of the medial wall of the CS, is effective and safe and increases the chance of remission.

Low insulin resistance after surgery predicts poor GH suppression one year after complete resection for acromegaly: a retrospective study

“…In our hospital, 84.7% of postoperative patients with acromegaly are in remission [28]. However, in a biochemical evaluation of clinically controlled postoperative patients with acromegaly, some patients showed normalized IGF-1 (SD) and a GH nadir between 0.4-1.0 ng/mL during a 75gOGTT.…”

Editorial: Management of invasion by pituitary adenomas

“…13 Their results suggest that more aggressive surgery than is commonly practiced will increase the fraction of patients with acromegaly who are in remission after surgery.…”

“…It is worth noting that 22 of the 23 patients who were not in remission after surgery in the series of Nishioka et al were in remission after introduction of adjuvant therapies. 13 Thus, even in the absence of "curative" surgery, adjuvant therapy produced remission of acromegaly and eliminated the adverse effects of the exposure to excess GH and IGF-I in these patients. In patients with extensive invasion and tumor filling the cavernous sinus, patients who clearly will have at least microscopic residual tumor even with the most aggressive surgery, what is the value of surgical removal of the medial wall of the cavernous sinus?…”

“…This strategy produces immediate remission in most tumors with invasion that is limited to a portion of the medial wall, whether it is with Cushing's disease 12 or a growth hormone (GH)-secreting adenoma. 13 …”

“…Over the past 3 decades several authors have described techniques for removal of tumor from the cavernous sinus region. 2,4,[11][12][13]16 Almost all patients with acromegaly today, even those with a postoperative GH level of < 15-20 ng/ml, are in remission after treatment, either as a result of surgery alone or as a result of adding other therapies after the surgery. It is worth noting that 22 of the 23 patients who were not in remission after surgery in the series of Nishioka et al were in remission after introduction of adjuvant therapies.…”