Cavernous Sinus Medial Wall Resection: A Retrospective Single-Institution Study on Outcomes in Functional Pituitary...

Surgery remains first-line therapy for most functioning pituitary adenomas (FPA). Remission rates are lower in some patients due to cavernous sinus invasion. Medial wall resection (MWR) may improve biochemical remission but remains largely underutilized. Our objective is to assess outcomes of MWR in patients with FPA at Oregon Health & Science University performed by a single neurosurgeon.

Retrospective, Institutional Review Board-approved study: patients ≥18 years, FPA after MWR with ≥ 3-months follow-up. Remission: normal prolactin, insulin-like growth factor-1, and either adrenal insufficiency or normal cortisol at 3 months for prolactinoma, acromegaly and Cushing disease (CD), respectively. Arginine vasopressin deficiency (AVP-D) defined as needing desmopressin at the last follow-up. Logistic regression identified predictors of biochemical remission.

Sixty-four patients, mean age 41.2 years and adenoma size 12.6 mm; CD (39.1%), prolactinoma (37.5%), acromegaly (23.4%). Knosp grade 0 (31.2%), 1 (32.81%), 3 (14%) and 4 (12.5%). Overall remission rate was 82.8%, CD (92%), prolactinoma (87.5%), and acromegaly (60%). Acromegaly (odd ratio 0.035, 95% CI [0.0034, 0.345], P = .004) compared with CD and tumor size (odd ratio 0.87 per mm increase, 95% CI 0.79-0.96, P = .007) were negative predictors of remission. The mean operative time showed significant increase in Crooke (357 ± 128 minutes) vs non-Crooke corticotroph (243 ± 39.7 minutes, P = .012, 95% CI [14.9, 213]), lactotroph (243.1 ± 65.1 minutes, P = .009, 95% CI [17.2, 210.5]), or somatotroph (232.5 ± 45.8 minutes, P = .031, 95% CI [5.9, 243.1]) tumors. Complications include new hypopituitarism (9.4%): adrenal insufficiency 12.8% (prolactinoma and acromegaly), hypothyroidism (1.5%), hypogonadism (1.5%); arginine vasopressin deficiency (20.3%), and transient syndrome of inappropriate antidiuretic hormone (4.7%), 1 cerebrospinal fluid leak and carotid injury (1.5%) repaired with direct coagulation without neurological sequelae.

MWR is safe and effective for the surgical management of FPA, particularly in CD and prolactinomas. Despite a steep learning curve, the high remission rates, and low complications support its use in well-selected patients by experienced multidisciplinary teams.