Cavernous Sinus Surgery for Corticotroph Pituitary Adenomas: Distinctive Growth Patterns and Impact on Cushing Disease Remission

Document Type

Conference Proceeding

Publication Date

3-2026

Publication Title

Journal of Neurological Surgery, Part B: Skull Base

Abstract

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.

Volume

87

Issue

Suppl 1

First Page

S038

Comments

35th Annual Meeting North American Skull Base Society, March 5-8, 2026, San Diego, CA

Last Page

S038

DOI

10.1055/s-0046-1818678

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