Repeat Expanded Endoscopic Surgery for Residual Growth Hormone Producing Tumors and Persistent Acromegaly

Background: Surgical excision for growth-hormone producing tumors remains the preferred first line treatment for acromegaly. Surgical outcomes and biochemical remission rates depend on tumor location and approach taken—as nearly half of the tumors exhibit cavernoinvasive behavior. Nearly half of patients require adjuvant therapy, medical or radiotherapy, after surgery to achieve remission. The utilization of transcavernous surgery has enhanced surgical remission rates from approximately 50% to nearly 90%. However, transcavernous surgery for previously operated tumors with residual disease remains controversial and unstudied.

Objective: We aim to study the surgical outcomes after endoscopic transcavernous surgery for previously operated pituitary tumors with residual tumor and active disease.

Methods: A prospectively collected and retrospective cohort analysis of previously operated pituitary tumors with residual disease from two centers, between 2018 and 2023. We tabulated clinical outcomes and results of repeat surgery in patients with acromegaly undergoing reoperation for residual.

Results: A total of 28 consecutive patients with acromegaly undergoing repeat endonasal surgery at two centers were analyzed. 25 patients had undergone one prior surgery, 2 had two prior surgeries, and 1 patient had undergone three prior surgeries. There were 18 Knosp grade 0-2 tumors on preoperative imaging, 6 grade 3, and 4 grade 4. A transcavernous approach was done in 27 patients of which 25 (93%) had positive cavernous sinus disease. Three-month follow up data was available in 20 patients, of which, 16 (80%) had achieved biochemical remission with surgery alone and 19 (90%) with surgery and adjuvant therapy. There were no post-operative CSF leaks or unplanned return to the operating room. Five patients had postoperative diplopia, all of which recovered.

Conclusions: Surgery for acromegaly remains the mainstay modality of treatment. Results can vary depending on surgeon experience and approach taken. Transcavernous surgery offers enhanced gross total resection and remission rates. Repeat surgery with a transcavernous approach for patients with active disease and had undergone traditional transsphenoidal surgery is safe and efficacious in achieving biochemical remission.

No conflict of interest has been declared by the author(s).

Publication History

Article published online:
05 February 2024