This is the second case discussion in The Pituitary Frontier_Global Webinar.
For webinar background and clinical context, please view:
The Pituitary Frontier Webinar (1)：https://www.medprin.com/de/article/index/article_id/493.html
Case 2: 45-year-old female with clinical acromegaly, suspected GH-secreting pituitary adenoma involving the cavernous sinus
Clinical and imaging findings (from Dr. Rajkumar):
A 45-year-old female developed typical features of acromegaly over months to years: deepened voice, coarse facial features, enlargement of the hands, and increase in shoe size.
She also has metabolic comorbidities, including diabetes mellitus and hypertension.
Because the MRI scanner at the hospital was out of service, only CT was available as preoperative imaging. CT demonstrated a sellar lesion extending toward one cavernous sinus, but without the detail that MRI would provide.
The CMJAH team planned a transsphenoidal pituitary surgery, and their main questions concerned whether and how to address tumor extending toward or into the medial wall of the cavernous sinus.
Key questions raised by the CMJAH team:
For functioning pituitary adenomas, particularly those invading the cavernous sinus, should the surgeon enter the cavernous sinus and actively deal with tumor along the medial wall, or focus more on debulking and rely on medical therapy and radiotherapy?
In the absence of MRI, is it safe and reasonable to proceed with surgery based on CT alone? If surgery is undertaken, how should the approach and exposure be planned in advance?
Prof. Zan’s perspective :
(1) On preoperative imaging and cavernous sinus assessment:
For acromegaly and GH-secreting adenomas, he considers it ideal to understand the cavernous sinus status preoperatively: the course of the internal carotid artery, whether the medial wall is invaded, and how the adenoma is molded and displaced.
Once the medial wall of the cavernous sinus is truly invaded, simple intradural or intrasellar debulking rarely achieves durable biochemical remission.
He noted that in his own cases, when medial wall invasion is confirmed, they may perform a “selective medial wall resection of the cavernous sinus” to achieve more complete resection and more reliable biochemical control.
(2) On the goal of the first surgery:
He emphasized that the first operation is crucial for these patients: it is often the best chance to achieve good biochemical control or remission.
If the first surgery is designed only as a simple decompression without aiming at functional cure, the patient will likely move into a pathway of re-operations, stereotactic radiotherapy, or long-term medical treatment (such as SSA), with a significantly increased long-term burden.
Therefore, his view is that for functioning pituitary adenomas, the first surgical plan should be designed “toward cure” rather than merely palliative decompression.
(3) On decision-making without MRI:
When Dr. Rajkumar explained that their MRI scanner was down and the patient’s symptoms were worsening, making it difficult to wait, Prof. Zan did not say that surgery must be avoided. Rather, he stressed that if surgery is undertaken without MRI, the surgeon must plan preoperatively as if medial wall involvement could be present.
This means designing the approach with sufficient exposure of the cavernous sinus region (for example, wider sphenoidotomy and sellar opening) so that, if necessary, the surgeon can address the medial wall during the operation.
It also requires preparing in advance for the possibility of selective medial wall resection: understanding the anatomy of the medial wall, identifying the internal carotid artery, and planning for hemostasis and protection.
In other words, he was not suggesting “do not operate without MRI,” but highlighting that under resource-limited conditions, surgeons must prepare for the “worst-case anatomical scenario” before going to the operating room, because the success or failure of the first operation is decisive for the patient’s subsequent course.
(4) On preoperative endocrine and general optimization:
Dr. Rajkumar mentioned that medications such as Sandostatin (SSA) are not always available locally.
Prof. Zan described the routine practice at West China Hospital for reference: for acromegaly patients with poor cardiac or metabolic status, they are first admitted to the endocrinology department under an MDT framework for evaluation and medical treatment.
If medications are available, short-term SSA therapy (for example, 2–3 months) may be used to optimize the patient’s condition before surgery.
Surgery is then scheduled after joint evaluation and approval by endocrinology, anesthesia, and neurosurgery.
Key points:
For acromegaly and other functioning pituitary adenomas, the first operation should, as far as possible, be designed with the aim of biochemical remission, not just mass decompression.
When the cavernous sinus is involved, especially the medial wall, and cure is the goal, the surgeon should seriously consider entering the cavernous sinus and selectively treating the medial wall, rather than universally avoiding the cavernous sinus.
In settings with imperfect MRI access and limited medications, standards should not automatically be lowered: if surgery is undertaken, the plan should be based on the assumption of complex anatomy—extending the approach, and planning in advance for possible medial wall management and vascular protection—instead of oscillating between simple decompression and curative intent.