The pituitary gland, located at the base of the brain, secretes hormones that control vital bodily functions and also regulates the activity of other hormone-secreting glands. Pituitary neuroendocrine tumors (PitNETs), are abnormal growths or tumors in the pituitary gland. EES, a minimally invasive technique, has been widely used to treat these tumors in recent years. In this technique, the endoscope is inserted via the nose and sinuses, i.e., the endonasal route.
However, treating giant and irregular pituitary neuroendocrine tumors (GIPitNETs) proves to be far more challenging. These tumors are often larger in size (more than 4 cm) and extend beyond the sella, the body structure that houses the pituitary gland. These tumors extend upwards into the cranial cavity, the space within the skull that accommodates the brain. Due to this extension, the tumor is often not visible and accessible via the endoscopic endonasal surgery (EES).
One of the alternative and innovative strategies used to operate GIPitNETs is the combined endoscopic endonasal and transcranial surgery (CECS). In this technique, while one surgical team performs the surgery following the EES technique, another team simultaneously performs the transcranial surgery, where the tumor is accessed by drilling some holes in the skull.
To analyze and compare the efficacy and complications of CECS and EES for GIPitNETs treatment, a team of researchers from China conducted a retrospective observational single-center cohort study. The study led by Dr. Changzhen Jiang and Dr. Xiaorong Yan from the Neurosurgery Research Institute, Fujian Medical University, China, was published in the Chinese Neurosurgical Journal and made available online on February 03, 2025. "We wanted to define the limitations and benefits of the two surgical procedures in the management of GIPitNETs," says Dr. Jiang while explaining the aim of the study.
50 patients, who underwent either EES or CECS between March 2018 and May 2023 at The First Affiliated Hospital of Fujian Medical University, were considered for this study. All patients were diagnosed with PitNETs with diameters more than 4 cm and significant intracranial tumor extension. All the patients underwent pre- and postoperative endocrinal examination to evaluate the changes in the hormonal levels. Magnetic resonance imaging was done before and after the surgery to evaluate the size of the tumor and post-operative conditions, respectively. The hospital database was analyzed to understand preoperative symptoms and postoperative complications. Ophthalmologists performed vision related tests on all patients to evaluate the changes in visual outcomes.
27 out of the 50 patients enrolled for this study were treated by CECS, and EES was performed on the remaining 23 patients. The researchers compared the obtained data using statistical analysis.
The study result showed an improved gross tumor removal (GTR) rate in the CECS group. The GTR rate in the CECS group is 66%, which is superior to the 13% GTR rate in the EES group. Postoperative bleeding, one of the major postoperative complications, was higher in the EES group. 65.2% of the EES group reported postoperative bleeding, which was significantly higher compared to the 7.4% of the CECS group reporting the same. Four out of the 50 cases reported recurrence caused by residual tumor, and all of these were in the EES group.
The visual symptom improvement was similar in both groups, even though the tumor removal rate was higher in the CECS group. "Partial tumor removal can also alleviate the pressure on optic nerves and lead to symptom relief. Thus, visual symptom improvement is possible after undergoing EES," explains Dr. Yan.
"The CECS technique requires a longer operation time and has greater surgical trauma with similar postoperative infection rates, compared to EES," mentions Dr. Jiang as the disadvantages of the CECS technique. The study shows that the operation time and the hospital stay duration for the CECS group are much longer compared to the EES group. However, the reports of postoperative complications and infections were similar in both groups. This suggests that even though CECS is a more invasive, it is a safe and viable surgical technique and might be a more advantageous approach for GIPitNETs treatment.
To confirm the effectiveness of the CECS technique in GIPitNETs treatment, the team plans to conduct a more in-depth study, with the follow-up time extending into the future. The team also plans to analyze more case data, involving large-scale multicenter studies in the future. With improved surgical techniques like CECS, treating complex tumors like GIPitNETs might get less challenging.
