1Department of Neurosurgery, Henry Ford Health, Detroit, Michigan.
Departments of2Neurosurgery.
J Neurosurg. 2023 Apr 28;139(5):1216-1224. doi: 10.3171/2023.3.JNS221949. Print 2023 Nov 1.
Pituitary tumors (PTs) continue to present unique challenges given their proximity to the cavernous sinus, whereby invasive behavior can limit the extent of resection and surgical outcome, especially in functional tumors. The aim of this study was to elucidate patterns of cavernoinvasive behavior by PT subtype.
A total of 169 consecutive first-time surgeries for PTs were analyzed; 45% of the tumors were functional. There were 64 pituitary transcription factor-1 (PIT-1)-expressing, 62 steroidogenic factor-1 (SF-1)-expressing, 38 T-box transcription factor (TPIT)-expressing, and 5 nonstaining PTs. The gold standard for cavernous sinus invasion (CSI) was based on histopathological examination of the cavernous sinus medial wall and intraoperative exploration.
Cavernous sinus disease was present in 33% of patients. Of the Knosp grade 3 and 4 tumors, 12 (19%) expressed PIT-1, 7 (11%) expressed SF-1, 8 (21%) expressed TPIT, and 2 (40%), were nonstaining (p = 0.36). PIT-1 tumors had a significantly higher predilection for CSI: 53% versus 24% and 18% for TPIT and SF-1 tumors, respectively (OR 6.08, 95% CI 2.86-13.55; p < 0.001). Microscopic CSI-defined as Knosp grade 0-2 tumors with confirmed invasion-was present in 44% of PIT-1 tumors compared with 7% and 13% of TPIT and SF-1 tumors, respectively (OR 11.72, 95% CI 4.35-35.50; p < 0.001). Using the transcavernous approach to excise cavernous sinus disease, surgical biochemical remission rates for patients with acromegaly, prolactinoma, and Cushing disease were 88%, 87%, and 100%, respectively. The granule density of PIT-1 tumors and corticotroph functional status did not influence CSI.
The likelihood of CSI differed by transcription factor expression; PIT-1-expressing tumors had a higher predilection for invading the cavernous sinus, particularly microscopically, compared with the other tumor subtypes. This elucidates a unique cavernoinvasive behavior absent in cells from other lineages. Innovative surgical techniques, however, can mitigate tumor behavior and achieve robust, reproducible biochemical remission and gross-total resection rates. These findings can have considerable implications on the surgical management and study of PT biology and behavior.
由于垂体肿瘤（PTs）靠近海绵窦，具有侵袭性，因此仍然存在独特的挑战，这可能会限制切除范围和手术结果，尤其是在功能性肿瘤中。本研究旨在通过 PT 亚型阐明海绵窦侵袭的模式。
分析了 169 例首次接受垂体肿瘤手术的连续病例；45%的肿瘤为功能性。其中，64 例为 Pituitary transcription factor-1（PIT-1）表达，62 例为 steroidogenic factor-1（SF-1）表达，38 例为 T-box transcription factor（TPIT）表达，5 例为非染色 PT。海绵窦侵袭（CSI）的金标准基于海绵窦内侧壁的组织病理学检查和术中探查。
33%的患者存在海绵窦疾病。Knosp 3 级和 4 级肿瘤中，12 例（19%）表达 PIT-1，7 例（11%）表达 SF-1，8 例（21%）表达 TPIT，2 例（40%）为非染色（p=0.36）。PIT-1 肿瘤的 CSI 发生率明显更高：分别为 53%、24%和 18%，TPIT 和 SF-1 肿瘤（OR 6.08，95%CI 2.86-13.55；p<0.001）。显微镜下 CSI 定义为 Knosp 0-2 级肿瘤，伴有确证性侵袭，在 PIT-1 肿瘤中占 44%，而在 TPIT 和 SF-1 肿瘤中分别占 7%和 13%（OR 11.72，95%CI 4.35-35.50；p<0.001）。采用经海绵窦入路切除海绵窦疾病，肢端肥大症、催乳素瘤和库欣病患者的手术生化缓解率分别为 88%、87%和 100%。PIT-1 肿瘤的颗粒密度和促肾上腺皮质激素功能状态并不影响 CSI。
转录因子表达的不同导致 CSI 的可能性不同；与其他肿瘤亚型相比，PIT-1 表达的肿瘤更倾向于侵袭海绵窦，特别是显微镜下。这阐明了一种独特的海绵窦侵袭行为，在其他谱系的细胞中不存在。然而，创新性的手术技术可以减轻肿瘤行为，实现强大、可重复的生化缓解和大体全切除率。这些发现对垂体肿瘤的手术管理和研究具有重要意义。
