Transsphenoidal microsurgical management of Cushing's disease. Report of 100 cases

Bilateral and simultaneous venous sampling of inferior petrosal sinuses for ACTH and PRL determination: preoperative localization of ACTH-secreting microadenomas

We report our experience on venous sampling of the inferior petrosal sinuses for basal and CRH-stimulated ACTH and PRL gradients in 8 patients with surgically proven Cushing's disease who had normal preoperative neuroradiological studies. In 7 patients basal plasma ACTH concentrations in the inferior petrosal sinus ipsilateral to the tumor were higher than in the contralateral sinus; the gradients were enhanced by oCRH administration. In one out of two patients who had previously undergone unsuccessful pituitary microsurgery, neither basal nor oCRH-induced ACTH increases led to correct localization of the microadenoma within the pituitary. In 4 out of 7 patients basal serum PRL concentrations in the inferior petrosal sinus ipsilateral to the tumor were higher than in the contralateral; only two out of 4 showed an increase in PRL levels after oCRH injection. Our study confirms that simultaneous and bilateral venous sampling of inferior petrosal sinuses is a valuable means to identify the site of microadenomas in patients with Cushing's disease without neuroradiological evidence of the tumor. This procedure may give misleading results in patients previously operated on. Unilateral or predominant increases of PRL concentration during catheterization of the inferior petrosal sinuses, when present, always lateralize to the side of the corticotroph adenoma, providing a possible additional signal of the presence of the tumor.

Bilateral inferior petrosal sinus sampling as a routine procedure in ACTH-dependent Cushing's syndrome

Bilateral inferior petrosal sinus sampling was successfully performed in 12 of 13 consecutive patients with ACTH-dependent Cushing's syndrome. Ten of the patients subsequently had transsphenoidal pituitary microsurgery. Eight patients in whom the inferior petrosal sinus to peripheral vein ACTH level ratio was 1.5 or greater were found to have a pituitary adenoma. One of the remaining two patients who had ratios less than 1.5 had pituitary hyperplasia while the other had no identified abnormality. In five of the patients with pituitary tumour a ratio above 1.5 was present on only one side. Bilateral petrosal sampling is therefore always necessary. Tumour localization within the pituitary was only poorly predicted by either petrosal sinus sampling (four of eight) or computed tomography scanning (three of eight). If petrosal sinus sampling is used early in the differential diagnosis of ACTH-dependent hypercortisolism, then the use of other differential diagnostic tests may not always be necessary.

Diseases of the adrenal cortex

The adrenal cortex is functionally a three-dimensional gland that secretes glucocorticoids, mineralocorticoids, and sex steroids. Of these three classes of steroids only the gluco- and mineralocorticoid hormones are necessary to sustain life. The availability of sensitive and specific radioimmunoassays has permitted accurate measurement of practically every steroid hormone secreted by the adrenal cortex. As in other endocrinopathies, suppression studies are employed when hyperfunction is suspected, while provocative tests are used to detect hypofunction. These dynamic studies enable the clinician to evaluate the functional status of the adrenal cortex. The anatomic configuration of the adrenal cortices is delineated by high-resolution computed tomography (and magnetic resonance imaging), obviating the need for invasive procedures such as venography or arteriography. The disorders of the adrenal cortex can be viewed from the dual perspectives of hyperfunction and hypofunction. Clinical expressions of hyperfunctional adrenocortical syndromes include Cushing's syndrome, primary hyperaldosteronism, and the adrenogenital syndrome. The expressions of hypofunctional syndromes include Addison's disease and selective hypoaldosteronism. The diagnosis and treatment of these disorders are outlined in this issue.

Surgery of adrenal disorders

The surgical management of patients with adrenal disease depends on the functional nature of the endocrinopathy. It requires a thorough knowledge of adrenal anatomy and command of the various surgical approaches to the gland. Included for discussion are Cushing's syndrome, adrenal adenoma and adenocarcinoma, adrenocortical carcinoma, primary aldosteronism, and pheochromocytoma.

The hypothalamic anterior pituitary relationships and their tumors. A review

The hypothalamic pituitary axis is reviewed in relation to the regulation of the secretion of prolactin, growth, and adrenocorticotrophic hormones by the anterior pituitary lactotrophic, somatotrophic, and corticotrophic cells, respectively. The signs and symptoms, diagnosis, and treatment of tumors arising from these three separate anterior pituitary cells are discussed in the context of current literature.

The management of pituitary tumours and post-operative visual deterioration

The indications and results of transsphenoidal surgery for pituitary adenomas are analysed. The advantages and disadvantages of Bromocriptine and radiotherapy are considered. Transsphenoidal surgery does not damage pre-existing pituitary function. It produces excellent results in micro and mesoadenomas, curing about 70-80% of patients irrespective whether the tumour produces ACTH, prolactin or growth hormone. Moreover there is a very small relapse rate. Macroadenomas of non-functioning type are also well treated by transphenoidal surgery, with a small recurrence rate as judged by CT scan follow-up. But macroadenomas secreting prolactin or growth hormone are less effectively treated by transsphenoidal surgery, only about 40% being cured. Invasive macro prolactinomas are not helped by surgery and should be treated with Bromocriptine and radiotherapy. Radiotherapy should be used sparingly and has inevitable complications. Post-operative delayed visual deterioration is caused either by recurrent tumour or radiotherapy. There is no good evidence to support the secondary empty sella syndrome as a cause of such delayed visual deterioration.

Pituitary adenomas in Cushing's disease: do they arise from the intermediate lobe?

Pituitary adenomas from 15 patients with Cushing's disease were studied histopathologically. The tumors were examined for the presence of neural axons by the Bodian silver impregnation technique and a specific immunohistologic technique based on a monoclonal antibody to axonal neurofilaments. Axons were not seen in any of the surgical specimens. This finding suggests that most, if not all, adrenocorticotropin-secreting pituitary adenomas are of anterior lobe origin.

CRF in the differential diagnosis of Cushing's syndrome: a comparison with the dexamethasone suppression test

Accurate differential diagnosis of the precise cause of Cushing's syndrome can be difficult, and conventional tests such as those based on the use of dexamethasone may be misleading. We have therefore studied the cortisol and ACTH responses to ovine corticotrophin-releasing factor (CRF-41) in 28 consecutive patients with Cushing's syndrome, and compared the diagnostic value of this test with that of the high-dose dexamethasone suppression test (8 mg/day for 48 h). Of 20 patients with confirmed Cushing's disease (pituitary-dependent Cushing's syndrome), only 16 (80%) showed the expected 50% or more suppression of serum cortisol following high-dose dexamethasone administration. Four patients each with adrenal adenomas and three patients with the ectopic ACTH syndrome failed to suppress, while a child with probable Cushing's disease showed a variable response depending on the dose used. Following CRF stimulation, 15 out of the 20 patients (75%) with Cushing's disease showed an excessive rise in serum cortisol, outside the normal range, while in five the response to CRF-41 was normal on at least one occasion. None of the patients with adrenal adenomas or the ectopic ACTH syndrome showed a cortisol response to CRF. Thus, either test on its own may be misleading in differentiating Cushing's disease from other causes of the syndrome. Every patient with Cushing's disease, however, showed either suppression in response to high-dose dexamethasone or an excessive cortisol response to CRF testing. It appears, therefore, that the combination of the high-dose dexamethasone and the CRF test, with measurement of serum cortisol, is superior to either test alone in the differential diagnosis of Cushing's syndrome.

Pituitary gland

This review summarizes current knowledge on pathology of proliferative lesions of the human pituitary. The morphologic classification of pituitary adenomas--based on histology, immunohistochemistry and electron microscopy--has now been firmly established. It has been conclusively proven that all presently recognized adenohypophysial cell types give rise to adenoma and all known pituitary hormones may be secreted in excess. Evidence is accumulating that hyperplasia of various adenohypophysial cell types can lead to hypersecretory syndromes similar to those associated with the corresponding adenomas. Owing to the rarity of studies on pituitary hyperplasia, the condition is still incompletely defined. The difficulties regarding morphologic diagnosis of pituitary hyperplasia are discussed. Despite major advances in the field of pituitary pathology, several problems concerning structure-function relationship, as well as pathogenesis of proliferative lesions are still unresolved. There is strong circumstantial evidence suggesting that the cytological mapping of the pituitary is incomplete and there are still cell types waiting to be discovered.

Cushing's syndrome due to primary multinodular corticotrope hyperplasia

In this report, a case of Cushing's syndrome due to primary multinodular corticotrope hyperplasia is described. The patient had typical features of Cushing's syndrome and dynamic pituitary-adrenal testing, which suggested an ectopic adrenocorticotropic hormone (ACTH) syndrome. Results of petrosal sinus catheterization indicated that the pituitary gland was the source of excess ACTH. Total hypophysectomy resulted in complete remission of Cushing's syndrome. Light microscopic and immunohistochemical studies revealed multinodular corticotrope hyperplasia. Plasma corticotropin releasing hormone (CRH) was undetectable, and computed tomography of the chest and abdomen disclosed no neoplastic source of CRH. We speculate that either an abnormality in hypothalamic CRH secretion or corticotrope hypersensitivity to CRH might have been responsible for Cushing's syndrome in this patient.

Usefulness of inferior petrosal sinus venous endocrine markers in Cushing's disease

Bilateral and simultaneous sampling of the inferior petrosal sinuses in patients with Cushing's disease has been used to establish the presence and laterality of adrenocorticotropic hormone (ACTH)-producing microadenomas prior to transsphenoidal surgery. Successful preoperative lateralization depends upon equivalent dilution of pituitary venous blood on the two sides since samples which are diluted by unequal amounts of non-pituitary blood may lead to erroneous results. To assure valid sampling results, the use of other pituitary hormones, measured simultaneously, has been proposed to correct the ACTH concentrations from the inferior petrosal sinuses against unequal dilution by non-pituitary venous blood. This proposal presumes that ACTH-secreting microadenomas will not cause unequal delivery of the other pituitary hormones into the two inferior petrosal sinuses. The inferior petrosal sinus concentrations of prolactin (PRL), thyrotropin (TSH), and the alpha subunit of human chorionic gonadotropin (alpha-HCG) were evaluated as indicators of pituitary venous blood dilution in 11 patients with Cushing's disease. Four patients with ectopic ACTH syndrome served as controls. Blood was withdrawn simultaneously from catheters in both inferior petrosal sinuses and from a peripheral vein for measurement of ACTH, PRL, TSH, and alpha-HCG. The ACTH concentrations were then corrected for dilution by non-pituitary blood by dividing the ACTH concentration from each side by the ratio of the inferior petrosal sinus to peripheral blood concentrations of PRL, TSH, and alpha-HCG for that side. At surgery, all 11 patients had ACTH-secreting microadenomas on the side predicted by the uncorrected ACTH concentrations. However, in three patients the corrected ACTH values would have led to erroneous results. Among the 18 sets of corrected inferior petrosal sinus measurements in these three patients, the corrected ACTH values failed to show an inferior petrosal sinus gradient in six and localized the tumor to the side opposite the adenoma in four. Incorrect lateralization was obtained with each of the hormones (PRL, TSH, and alpha-HCG) used for correction. Furthermore, the ipsilateral (side of tumor)-to-contralateral inferior petrosal sinus gradient of ACTH in patients with Cushing's disease was generally paralleled by a significant inferior petrosal sinus gradient of PRL, TSH, and alpha-HCG to the side of the tumor, whereas patients with the ectopic ACTH syndrome tended not to exhibit lateralizing (side-to-side) gradients.(ABSTRACT TRUNCATED AT 400 WORDS)

Development of Nelson's syndrome in a patient with recurrent Cushing's disease. Analysis of secretory behavior of the pituitary tumor

A markedly cushingoid 32-year-old man presented to Queens Hospital Center with headache, hyperpigmentation, and visual field loss. Twelve years earlier, he had undergone subtotal adrenalectomy for Cushing's disease, but symptoms of hypercortisolemia promptly recurred. Workup revealed the presence of a large, expanding intrasellar mass, plasma ACTH levels between 3,000 and 10,000 pg/ml, and markedly elevated cortisol levels. The secretion of ACTH (mainly ACTH 1-39-like peptide) by the pituitary tumor showed neither diurnal periodicity nor response to a variety of pharmacologic agents known to affect ACTH secretion. The patient demonstrates a rarely observed presentation of Nelson's syndrome, with aggressive adrenotropic pituitary tumor growth even in the presence of chronic hypercortisolemia.

Usefulness of preoperative inferior petrosal vein sampling in Cushing's disease

Adrenocorticotropic hormone (ACTH) levels from the inferior petrosal sinuses and peripheral veins were measured in 10 patients with Cushing's disease. All patients had normal or indeterminate computed tomography scans. In 9 of the 10 patients the petrosal vein sampling showed a gradient between pituitary ACTH and peripheral ACTH verifying the supposition of pituitary dependent hypercortisolism. In seven cases preoperative ACTH levels lateralized tumor to one side of the gland. In six of these cases tumor was found at that location at surgery. In the seventh case, no tumor was identified at surgery and that half of the gland was resected. Nine patients were cured following transsphenoidal excision of tumor.

Pituitary adenomas

This review highlights various aspects of the new functional classification of pituitary adenomas which is based on detailed immunohistochemical and ultrastructural analysis and correlation with clinical and biochemical findings. In addition, current investigation of the non-hormonal aspects of these tumours is discussed, including the application of flow cytometry in tumour ploidy studies.

Surgical treatment of Cushing's disease

The endocrinological, radiological, surgical, and pathological experience with 34 consecutive patients operated on for Cushing's disease is presented. Preoperative endocrine evaluation demonstrated that 19 patients had "typical" endocrine patterns for pituitary adrenocorticotropic hormone (ACTH)-dependent hypercortisolism and 11 had "atypical" testing. Pituitary pathology was found in 95% of the patients with typical preoperative endocrine testing but in only 55% of those with atypical testing. Eight of 34 preoperative computerized tomography scans demonstrated tumors, which correlated in all instances with the surgical findings. Microadenomas were removed from 25 patients, 22 of whom achieved postoperative remission of endocrine symptoms. Macroadenomas were found in three patients, only one of whom achieved remission after surgery. One patient had removal of an adenoma in the pharyngeal pituitary, and in another an ectopic lung carcinoid was excised; both of these patients were in postoperative remission. Four patients underwent transsphenoidal exploration but no definitive explanation was found for their hypercortisolism; these patients were not in remission. Immunohistochemical staining was performed on every specimen and all tumors showed excessive ACTH-secreting cells. A new rapid stain of the fibrovascular stroma is described.

Cushing disease: successful preoperative lateralization of an ACTH-producing pituitary microadenoma by simultaneous bilateral inferior petrosal venous sinus sampling with corticotropin-releasing hormone stimulation

A 5 10/12-year-old girl with clinical and laboratory signs of endogenous hypercortisolism had evidence of ACTH hypersecretion in a standardized dexamethasone suppression test but had surprisingly low plasma ACTH concentrations before and after ovine corticotropin releasing hormone (oCRH) stimulation. To establish the diagnosis of pituitary disease and to localize the suspected microadenoma, we performed bilateral simultaneous inferior sinus petrosus blood sampling under CRH stimulation (oCRH 1 microgram/kg as an i.v. bolus). No major side effects were noted. Inferior petrosal blood ACTH concentrations did not differ from peripheral blood under basal sampling conditions but were higher in the effluent of the left half of the pituitary 5 min after oCRH stimulation. During transsphenoidal exploration of the sella an ACTH-producing microadenoma was removed from the left portion of the anterior pituitary gland. Signs of hypercortisolism remitted after surgery. Simultaneous bilateral sinus petrosus blood sampling under oCRH stimulation is a useful lateralization procedure even with small ACTH-producing adenomas. This technique may help to avoid unsuccessful surgical exploration in children with Cushing disease.

Corticotrophin-releasing factor-test used with bilateral, simultaneous inferior petrosal sinus blood-sampling for the diagnosis of pituitary-dependent Cushing's disease

Bilateral, simultaneous inferior petrosal sinus blood-sampling for determinations of ACTH levels has improved the ability to establish a differential diagnosis of Cushing's disease, particularly in patients whose endocrinological studies show equivocal results and whose computed tomography scans yield negative or inconclusive findings. Individual anatomical variations in the configuration of the sinus and insignificant differences between the ACTH levels obtained from its two sides may be a problem. Seven patients with clinically and biochemically typical Cushing's disease and one with atypical Cushing's disease were examined. An alternative approach for catheterization of the inferior petrosal sinus through the deep vertebral venous plexus was used in those patients who did not have direct connections between the sinus and the internal jugular vein. In two of the eight patients, only ACTH secretion stimulated with corticotrophin-releasing factor could unmask a significant difference between the ACTH levels on the two sides which was not obvious from the basal ACTH levels. Beta-lipotrophin values showed a behaviour similar to that of ACTH values, but because of a slower turn-over rate, the CRF-induced peaks were better visible. The aetiology of Cushing's disease was established from the results of this examination and corresponded with the surgical findings in this series, with the exception of one in which the patient had a highly atypical form of the disease. The abnormal ACTH source was found later to be a thymus carcinoid.

Successful control of Cushing's disease in the elderly with long term metyrapone

A 77-year old woman with pituitary-driven Cushing's disease is described. The condition was completely controlled on long-term treatment with metyrapone.

Transsphenoidal surgery for Cushing's disease

A series of 101 patients with Cushing's disease underwent transsphenoidal surgery. Diagnosis was fundamentally based on dynamic testing, mainly on the dosage-dependent suppression of cortisol after dexamethasone. The effect of surgery was monitored by intraoperative ACTH measurements. In 96 out of 101 patients a microadenoma of the pituitary was identified and removed selectively. In 74% of patients there was a clinical and endocrinological remission of Cushing's disease. Four 'operative failures' after selective adenomectomy underwent hypophysectomy in a second operation and each remitted. Thus the overall remission rate was 77%. In general, bilateral adrenalectomy was performed in patients who had failed to remit after selective adenomectomy. Although there is a considerable mortality and morbidity in patients with Cushing's syndrome, complications attributed to surgery were low. Two patients died postoperatively. In general, an improvement of disturbed pituitary function was noted after selective adenomectomy.

Cushing's syndrome: update of diagnosis and management

Although considerable advances have been made in the understanding of Cushing's syndrome in the recent past, many difficulties persist in the diagnosis and management of patients with hypercortisolism. Precision in the diagnosis of Cushing's syndrome and the differentiation of its various forms have gradually improved, but a substantial number of cases have laboratory or radiologic findings that can be misleading or at least difficult to interpret. Furthermore, other conditions may mimic Cushing's syndrome and add to the diagnostic difficulties. Surgical extirpation of primary adrenal lesions that cause the hypercortisolism or of the neoplasms responsible for the ectopic production of adrenocorticotropic hormone remains the treatment of choice for these problems. Currently, transsphenoidal surgical exploration is the treatment of choice for Cushing's disease.

Long-term culture of human corticotropin-secreting adenomas on extracellular matrix and evaluation of serum-free conditions. Secretory aspects

Tissues from 12 human corticotropin-secreting adenomas, obtained during surgery for Cushing's disease (CD, ten cases) or Nelson's Syndrome (NS, two cases), were exclusively mechanically dispersed. Single cells and cell aggregates were plated on extracellular matrix derived from bovine corneal endothelia. Functional responses to physiological stimuli were analyzed by measuring human beta-endorphin (beta h-EP) immunoreactivity (IR) by radioimmunoassay in the culture medium. All adenomas responded with stimulated secretory activity to arginine vasopressin (AVP), corticotropin-releasing factor (CRF), or both. Cortisol higher than 10(-8) M suppressed basal secretion and CRF- or AVP-stimulated beta h-EP-IR secretion. There was no consistent difference in response of the cells when cultured in medium containing 10% fetal calf serum (FCS) or in serum-free conditions. A change of cells from serum to serum-free conditions usually resulted in 10%-50% reduction in the basal secretion level that remained stable for at least 2 weeks and, in one case (NS), 10 weeks. In cells maintained in medium supplemented with 5% serum obtained from the respective patients 40 min after adenoma removal, basal secretion was suppressed to 60% of the baseline level in a 10% FCS control. Long-term incubation with CRF (10(-9) M) showed sustained stimulation of hormone secretion. No remarkable cell proliferation was observed under basal conditions or during long-term, low-dose incubation with cholera toxin (10(-12) M) in two cases (CD), or CRF (10(-9) M) in two cases (NS, CD). Parallel beta-EP-IR and adrenocorticotropin secretion was verified in selected cases.

Transsphenoidal surgery following unsuccessful prior therapy. An assessment of benefits and risks in 158 patients

The authors report the results of a retrospective study conducted in an effort to define the results and risks of transsphenoidal surgery for patients whose prior therapy had failed. In a series of 1210 patients undergoing transsphenoidal surgery during a 10-year period, 158 had received prior therapy: 127 for pituitary adenoma, 20 for craniopharyngioma, and 11 for other lesions. Prior therapy was considered "direct" when it consisted of craniotomy or transsphenoidal surgery (either open or stereotaxic), and "indirect" when it consisted of radiation therapy, adrenalectomy, or bromocriptine therapy. The current transsphenoidal operation was performed for persistent hyperfunctioning endocrinopathy in 63 patients, for visual loss in 72 patients, and for cerebrospinal fluid (CSF) rhinorrhea in 21 patients. Success rates were as follows: normalization of endocrinopathy was achieved in 35% of cases; improvement or stabilization of vision in 59%; and successful repair of CSF rhinorrhea in 74%. The risks associated with repeat transsphenoidal surgery are significantly greater than the same procedure in a previously untreated patient.

Histopathology of the pituitary

The cytoplasmic secretory granules of corticotrophs in the anterior pituitary are basophil in trichrome stains and periodic acid-Schiff positive in the histochemical stain for glycoprotein due to their content of the glycosylated 16 000 N-terminal fragment of the precursor protein proopiomelanocorticotrophin (POC). The granules show a positive immunocytochemical reaction to antibodies raised against ACTH, beta-endorphin and N-terminal fragments of POC. A small subset of corticotrophs contains immunoreactive alpha MSH in addition. Immunocytochemistry shows the corticotrophs to constitute about 15-20% of the anterior pituitary cells arranged both singly and in clumps. They are distributed in the median wedge and anteriorly, laterally and posteriorly adjacent to the pars nervosa which is often 'invaded' by corticotroph basophils. The alpha MSH subset is prominent in the rudimentary intermediate lobe and is scattered anteriorly in the pituitary of the human fetus. Crooke cell hyalinization is associated with pathologically maintained hypercortisolaemia and with glucosteroid therapy. The hyalinization is demonstrated in ultrastructure to be due to massive accumulation of intermediate cytoplasmic filaments 7-8 nm in diameter that are normally present in only small number. The change is associated with a varying degree of loss of secretory granules. In untreated Addison's disease there is a marked increase in the number of corticotrophs, many of which are arranged in distended alveoli to form micronodules. The vast majority of cases of pituitary-dependent Cushing's disease and all cases of Nelson's syndrome are associated with a basophil or chromophobe adenoma. These give a positive immunocytochemical reaction with anti-ACTH, beta-endorphin and N-terminal POC. In ultrastructure the cells of the chromophobe adenomas are seen to contain sparse secretory granules that are usually smaller than those in the chromophil adenomas. There are only very few reports of pituitary-dependent Cushing's disease found to be due to immunocytochemically confirmed corticotroph hyperplasia with or without a corticotroph adenoma. A few cases have been described in which the adenoma cells show Crooke's hyalinization, associated in one example with secretion of a big ACTH found more typically in ectopic ACTH-secreting tumours. A group of cases due to corticotroph adenoma has been reported whose excessive ACTH secretion is reduced by treatment with the dopamine agonist bromocriptine, in which it is suggested that the tumour cells arise from a subset of corticotrophs of pars intermedia origin.(ABSTRACT TRUNCATED AT 400 WORDS)

Current topics in neuropathology. Cushing's disease

The application of modern investigative techniques, particularly electron microscopy and immunohistochemistry, to the pituitary gland in Cushing's disease have confirmed that in the majority of cases (up to 90% in some series) the disease is due to a corticotroph microadenoma. It has also been shown that the tumours may produce not only ACTH, but also other peptides derived from the same precursor molecule, pro-opiomelanocortin and, in a small minority of cases, other pituitary hormones (e.g. prolactin). Since these peptides are known to have physiological actions they may account for some of the varied symptoms and signs of Cushing's disease. Because of the high incidence of single tumours the treatment of choice in many centres has become selective adenomectomy by the transsphenoidal route. However, a minority of cases appear to be the result of primary hypothalamic or central abnormalities and this may account for the identification of a normal pituitary gland or of corticotroph hyperplasia (with or without tumour formation). It is not possible at the present to identify these groups of patients on the basis of biochemical testing. It is hoped that detailed prospective studies correlating hormone secretion, responses to biochemical testing and detailed investigation of pathological tissue will provide further insight into the pathogenesis of particular variants of the disease.

Pathological diversity in clinical syndromes of pituitary hypersecretion: its significance in evaluating their surgical treatment

Through pathological examination disclosed considerable diversity of abnormal cell types and correspondingly different surgical correction rates among patients with apparently similar syndromes of pituitary hypersecretion. The surgical correction of acromegaly in patients with densely granulated growth hormone tumours was threefold that in patients whose tumours showed sparse granulation. Two non-prolactinoma tumour types associated with hyperprolactinemia have aggressive growth patterns; their special therapeutic management is discussed. Of 33 patients with Cushing's disease solitary adenomas were found in only 14, while six patients had proven corticotroph cell hyperplasia. Elective hypophysectomy should replace selective adenomectomy in selected cases of Cushing's disease.

Diagnosis, treatment and postoperative results of Cushing's disease

One hundred patients with Cushing's disease were operated on in Nagoya University Hospital between January 1977 and January 1984. Pituitary adenomas were found and resected in 93 cases and complete clinical remissions were observed in 89 treated by operation alone and in two additional cases by operation followed with radiotherapy. The clinical features, pre-operative endocrine data, radiological findings including high resolution CT with coronal and sagittal reconstructions, data of selective venous sampling, operative findings, tumour pathology, postoperative clinical course, postoperative endocrine results and follow-up findings are presented and discussed.

Long-term follow up of trans-sphenoidal hypophysectomy for Cushing's disease

Fourteen patients with Cushing's disease treated by trans-sphenoidal hypophysectomy between 1962 and 1975 were reviewed in 1983. Complete ablation had been attempted. There were no surgical deaths and one episode of bacterial meningitis. Two patients required a second operation for a cerebrospinal fluid leak. There have been three late deaths from unrelated causes. All patients had a biochemical remission of their Cushing's disease postoperatively and no relapse has been recorded. Most patients need some hormone replacement but residual pituitary function and sella radiography have remained stable. This treatment seems satisfactory and the evidence implies a pituitary aetiology of the syndrome.

The clinical response to treatment in adult Cushing's syndrome following remission of hypercortisolaemia

The clinical response of 57 adult patients with Cushing's syndrome due to bilateral adrenocortical hyperplasia or adrenocortical adenoma is documented following resolution of hypercortisolaemia by various forms of treatment. Despite satisfactory biochemical remission of the disease the clinical result was far less satisfactory when assessed by persistence of obesity (55%), menstrual irregularity (41%), hypertension (29%) and insulin-dependent diabetes (22%). Myopathy, hirsuitism and psychological abnormalities persisted to a lesser extent. The mortality rate of the series over a 30 year follow-up period was 4 times that of a general population matched for sex, age and year of entry into the series. Cardiovascular disease was the cause of death in 85%. Irreparable cardiovascular disease is produced early in the course of hypercortisolaemia, emphasizing the vital importance of the earliest possible recognition and treatment of this disease.

Characterization of immunoreactive beta-endorphin secreted from cultured human corticotropin-secreting adenomas

Seven human corticotropin-secreting adenomas causing Cushing's disease or Nelson's syndrome were maintained in long-term culture. Pooled media from the individual adenomas were analyzed for the composition of their secretory products. From a radioimmunoassay (RIA) with 100% cross-reactivity for human beta-endorphin (beta h-EP) and beta-lipotropin (beta h-LPH), immunoreactive beta h-EP (IR X beta h-EP) was found to be the predominant secretory product after Sephadex G-50 analysis in 4 cases (40-80% of total IR), immunoreactive beta h-LPH (IR X beta h-LPH) predominated in 1 case, and both were equipresent in 2-cases. IR X beta h-EP was further purified by high-performance liquid chromatography (HPLC) and analyzed in 4 cases with ion-exchange chromatography on SP-Sephadex C-25 and a RIA which completely cross-reacts with beta h-EP, [N alpha-Ac]-beta h-EP, beta h-EP-(1-27) and [N alpha-Ac]-beta h-EP-(1-27). In all cases, the IR X beta h-EP was the main component (40-70%); the remaining IR material was attributable partially to [N alpha-Ac]-beta h-EP or other, less defined immunoreactive material. In 3 cases, enough IR X beta h-EP material was available for HPLC and to perform a radioreceptor assay using tritiated beta h-EP as primary ligand. The displacing potency of these preparations relative to synthetic beta h-EP was related to the content of the immunoreactive component eluting in the position of synthetic beta h-EP.

Transsphenoidal microsurgery for Cushing's disease

Nineteen patients thought to have Cushing's disease were treated by transsphenoidal microsurgery; the type of operation performed depended upon the findings in the individual patient. Seventeen patients remitted. Failures occurred in a patient with an invasive macroadenoma and in a patient who was subsequently found to have a thymic carcinoid tumour secreting ACTH. One patient who remitted suffered a recurrence during pregnancy, 30 months after operation. The ten patients (Group I) who had a selective removal of a microadenoma or a limited resection of the gland were often GH deficient, but seven regained cortisol reserve and all ten regained normal pituitary-thyroid and pituitary-gonadal responses. By contrast abnormalities of pituitary function were common in nine patients who had a radical or total hypophysectomy. We conclude that transsphenoidal microsurgery is the best treatment for Cushing's disease and that, when feasible, a selective microadenomectomy is the most appropriate operation.

A decade of pituitary microsurgery. The Herbert Olivecrona lecture

The author reviews his experience with surgical treatment of 1000 pituitary tumors, the majority of which were endocrine-active. The criteria of grading, the microsurgical technique used, and the postoperative results are presented. The mortality rate was 0.2% overall, with no deaths in the group of 774 patients with endocrine-active adenomas.

Dissociation between plasma adrenal androgens and cortisol in Cushing's disease and ectopic ACTH-producing tumour: relation to adrenarche

To assess the effect of chronic hypersecretion of corticotropin (ACTH) and other peptides derived from proopiomelanocortin , and of cortisol, on plasma adrenal androgen concentration, plasma dehydroepiandrosterone sulphate (DHEA-S), dehydroepiandrosterone (DHEA), androstenedione (delta 4 A), and cortisol were measured in 14 children and adolescents with Cushing's disease, a 9-year-old boy with an ectopic ACTH-producing tumour, and a group of normal, age-related individuals. The plasma DHEA-S concentration was normal for chronological age in 9 of 12 patients and for bone age in 7 of 10 patients. The plasma DHEA level was normal for chronological age in 12 of 14 patients and for bone age in 8 of 10 patients. In contrast, the concentration of plasma delta 4 A was raised for chronological age in 6 of 13 patients and for bone age in 7 of 10 patients. All patients had raised plasma cortisol levels in the afternoon and other laboratory and clinical signs of hypercortisolism. In the boy with an ectopic ACTH-producing tumour, plasma DHEA-S was moderately raised, plasma DHEA was normal, and plasma delta 4 A was very high. This patient's plasma ACTH levels ranged from 1340 to 1520 pg/ml and the cortisol levels from 51 to 95 micrograms/dl. The findings suggest that a factor other than ACTH is also required for adrenal androgen secretion. Since the other proopiomelanocortin -related peptides--ie, the N-terminal peptide (1-76), beta-endorphin (beta-EP), beta-lipotropin (beta-LPH), and gamma-lipotropin (gamma-LPH)--are raised in the plasma of patients with Cushing's disease, one of these is unlikely to be that putative factor.

Hyperadrenalism in childhood and adolescence

Hyperadrenalism in childhood and adolescence has unique features that influence diagnosis and management. We reviewed our experience with 18 patients, ranging in age from 18 months to 18 years. Nine had bilateral adrenal hyperplasia, eight had adrenal neoplasms, and one had micronodular hyperplasia. Patients with congenital adrenal hyperplasia and hyperaldosteronism were excluded. Six patients with Cushing's disease diagnosed in earlier years were treated by total adrenalectomy and recently two patients underwent transsphenoidal removal of pituitary tumors. Bilateral adrenalectomy was carried out in one patient with micronodular hyperplasia and in a second because of elevated adrenocorticotrophic hormone (ACTH) levels from an undefined source. Eight patients had adrenal neoplasms, including five adenomas and three carcinomas. We found no reliable criteria to differentiate before surgery between adrenal adenomas and adrenal carcinomas. The most recognizable characteristic of malignancy was tumor size, specifically weight greater than 75 gms. Of the three patients with adrenal carcinoma, one expired 20 months after adrenalectomy and 8 months after receiving palliative partial hepatectomy for liver metastasis. Two patients are well with normal growth and development at 11 and 20 years following adrenalectomy. With the exception of one patient who died 6 years after surgery from a glioblastoma multiforme, all patients with adrenal adenomas are well. Eight patients underwent bilateral adrenalectomy for hypercortisolism. Five of the six who have reached their adult stature are significantly stunted. Four of six patients with Cushing's disease, treated by total adrenalectomy, have developed Nelson's syndrome at 2, 6, 10, and 12 years after surgery. Of the two patients undergoing transsphenoidal surgery, one had recurrent disease at 2 years and was treated by pituitary irradiation with recovery. The patients undergoing adrenalectomy for micronodular hyperplasia and ectopic ACTH are well at 2 and 4 years, respectively. Cushing's disease in children and adolescents is best treated by transsphenoidal removal of the pituitary adenoma. Adrenalectomy, once the most accepted approach, plays a secondary role and is indicated primarily in micronodular adrenal hyperplasia, in patients with ectopic ACTH production of an undefined source, and in recurrent Cushing's disease following prior pituitary irradiation. The high incidence of Nelson's syndrome in children treated by adrenalectomy mandates that patients at risk be monitored lifelong for the progression of a pituitary tumor.(ABSTRACT TRUNCATED AT 400 WORDS)

Treatment of Cushing's disease in childhood and adolescence by transsphenoidal microadenomectomy

Fifteen unselected children and adolescents with Cushing's disease were treated by transsphenoidal exploration and microadenomectomy. In only three patients was radiographic examination of the sella turcica, including computed tomography, useful in indicating the presence and location of a pituitary microadenoma. Transsphenoidal microadenomectomy corrected hypercortisolism in 14 of the 15 patients; no adenoma was detected in one patient, and one required a second operation six months after the first because of incomplete removal of the adenoma. All 14 lost weight and cushingoid stigmata and had normal or catch-up growth (if epiphyses were not fused) and progression of puberty. In one patient, a recurrence was successfully treated by repeat microadenomectomy six years after the first procedure. The low morbidity and failure rate of the procedure, the low recurrence rate, the rapid amelioration of signs of hypercortisolism, and the preservation of pituitary function in the present study support transsphenoidal microadenomectomy as a low-risk approach to the initial treatment of Cushing's disease in childhood and adolescence.