In recent years, advancements in surgical techniques have revolutionized the management of pituitary neuroendocrine tumors (PitNETs), offering hope to patients diagnosed with these complex growths. Situated at the base of the brain, the pituitary gland plays a pivotal role in regulating an intricate hormonal network, influencing numerous vital bodily functions. However, when abnormal growths, known as PitNETs, develop within this tiny yet critical gland, they can disrupt hormonal balance and cause a wide range of neurological and systemic symptoms. While standard minimally invasive approaches like endoscopic endonasal surgery (EES) have become the mainstay of treatment for many PitNETs, giant and irregular pituitary neuroendocrine tumors (GIPitNETs) present formidable challenges that demand more innovative surgical strategies.

The complexity of GIPitNETs stems primarily from their substantial size—typically exceeding 4 centimeters in diameter—and their erratic morphology that often crosses normal anatomical boundaries. Unlike typical PitNETs confined within the sella turcica, the bony structure housing the pituitary, GIPitNETs frequently extend upward into the cranial cavity, encroaching upon sensitive neural tissues. This unusual extension drastically reduces the visibility and accessibility of the tumor through conventional endonasal corridors, impeding the effectiveness of endoscopic approaches and heightening the risk of incomplete resection.

Addressing these surgical obstacles, neurosurgeons have developed a combined endoscopic endonasal and transcranial surgery (CECS) technique, which merges the advantages of endoscopic precision with transcranial access. In CECS, two expert surgical teams operate simultaneously: one team navigates the tumor through the nasal and sinus passages using an endoscope, while the other gains direct access to intracranial tumor components by carefully drilling through the skull. This dual-pronged method allows for a more comprehensive tumor resection by overcoming the limited visualization and reach inherent in purely endonasal approaches.

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A recent retrospective cohort study led by Dr. Changzhen Jiang and Dr. Xiaorong Yan at Fujian Medical University’s Neurosurgery Research Institute in China sought to rigorously compare the clinical outcomes of CECS with those of purely endoscopic endonasal surgery for treating GIPitNETs. Their findings, published in the renowned Chinese Neurosurgical Journal, provide critical insights into the efficacy, safety, and limitations of each technique based on a five-year patient database from The First Affiliated Hospital of Fujian Medical University.

The study evaluated fifty patients diagnosed with GIPitNETs who underwent surgical treatment between March 2018 and May 2023. All participants exhibited tumor diameters exceeding 4 cm with extensive intracranial invasion, qualifying them for this specialized comparison. Key preoperative assessments included detailed hormonal profiling and high-resolution magnetic resonance imaging (MRI), ensuring accurate characterization of tumor burden and anatomical involvement. Postoperative evaluations incorporated endocrinological testing, neuro-ophthalmological assessments, and imaging to determine tumor resection extent and monitor potential complications.

Out of the cohort, twenty-seven patients received the simultaneous combined CECS approach, while the remaining twenty-three underwent the standard EES technique. Statistical analyses of the outcomes revealed a striking disparity in gross total resection (GTR) rates—a benchmark indicator of surgical success. The CECS group achieved a notable 66% GTR, substantially outperforming the EES group, which recorded only a 13% GTR rate. This difference underscores the enhanced capability of CECS to achieve more radical tumor removal in cases complicated by irregular morphology and intracranial extension.

Postoperative complications were also scrutinized, with particular attention paid to bleeding—a critical postoperative risk factor linked to morbidity. The incidence of postoperative hemorrhage was markedly higher in the EES group, affecting 65.2% of patients, whereas only 7.4% of those treated with CECS experienced similar complications. This considerable variance suggests that CECS may confer a protective advantage, potentially by affording superior tumor visualization and vascular control during resection.

In terms of symptom relief, particularly visual improvement, both surgical groups exhibited comparable outcomes. This finding is clinically significant, demonstrating that even partial tumor debulking accomplished via EES can sufficiently alleviate optic nerve compression and improve visual function. Dr. Xiaorong Yan highlighted that while complete removal remains ideal, partial resection addressing mass effect can yield meaningful symptomatic benefits for patients.

Despite the clinical advantages, CECS does entail certain drawbacks. The combined operation requires a prolonged surgical duration and entails more extensive trauma due to the transcranial component. Consequently, patients undergoing CECS experience longer hospital stays compared to those treated with EES. Importantly, however, the study reports no significant difference in postoperative infection rates between the two groups, reinforcing the safety profile of the more invasive technique when performed by experienced teams.

This research carries profound implications for the future management of GIPitNETs. By evidencing that CECS offers higher tumor clearance with fewer hemorrhagic events, it challenges the exclusive reliance on EES for all pituitary tumors and advocates for a tailored surgical approach depending on tumor characteristics. The complementary nature of combining endonasal and transcranial access may represent a paradigm shift for neurosurgeons tackling these complex lesions.

Looking ahead, Dr. Jiang’s team intends to expand their research through prospective, multicenter clinical trials incorporating longer follow-up periods to evaluate long-term tumor control, recurrence rates, and functional outcomes. Such investigations will be critical to validate preliminary findings and refine surgical guidelines. Additionally, technical refinements in neuronavigation, intraoperative imaging, and team coordination could further enhance CECS efficacy and patient recovery trajectories.

The stark contrast in outcomes between CECS and EES for giant pituitary tumors underscores the importance of innovation in neurosurgical technique to address anatomical and pathological challenges. The integration of complementary surgical pathways not only broadens access but also minimizes potential surgical blind spots that can hinder complete tumor excision. As surgical technology and expertise advance, approaches like CECS are poised to redefine standards of care for patients suffering from some of the most formidable brain tumors.

This evolving landscape of pituitary tumor surgery exemplifies the dynamic intersection of medical engineering, neuroanatomy, and clinical strategy. The implications extend beyond immediate operative success to impact hormonal regulation, neurological function, and overall quality of life. Patients confronting the daunting diagnosis of GIPitNETs can find encouragement in these scientific strides, signaling a future where even the most challenging tumors may be managed with precision and safety.

Subject of Research: People

Article Title: Giant and irregular pituitary neuroendocrine tumors surgery: comparison of simultaneous combined endoscopic endonasal and transcranial and purely endoscopic endonasal surgery at a single center

News Publication Date: 3-Feb-2025

Web References: https://cnjournal.biomedcentral.com/articles/10.1186/s41016-025-00389-4

References:
Jiang, C., Yan, X., et al. Giant and irregular pituitary neuroendocrine tumors surgery: comparison of simultaneous combined endoscopic endonasal and transcranial and purely endoscopic endonasal surgery at a single center. Chinese Neurosurgical Journal. DOI: 10.1186/s41016-025-00389-4

Image Credits: Life Science Databases (LSDB) via Creative Commons Search Repository

Keywords: Health and medicine, Surgery, Surgical procedures, Medical specialties, Diseases and disorders, Health care, Human health, Brain tumors, Pituitary gland, Endocrine glands, Endocrine system, Anatomy, Organismal biology

Tags: complex pituitary tumor managementcranial cavity tumor extensionendoscopic endonasal surgery advancementsgiant pituitary tumor challengeshormonal balance disruptionminimally invasive surgical approachesneurological symptom managementneurosurgery innovationspituitary gland surgery techniquespituitary neuroendocrine tumorssurgical strategies for pituitary tumorssurgical techniques for GIPitNETs