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Sabahi M, Ghasemi-Nesari P, Maroufi SF, Shahbazi T, Yousefi O, Shahtaheri SA, Bin-Alamer O, Dabecco R, Velasquez N, Arce KM, Adada B, Benjamin CG, Borghei-Razavi H. Recurrent Cushing Disease: An Extensive Review on Pros and Cons of Different Therapeutic Approaches. World Neurosurg 2023; 172:49-65. [PMID: 36739900 DOI: 10.1016/j.wneu.2023.01.108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 01/27/2023] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Recurrent Cushing disease (CD) is characterized by the reappearance of clinical and hormonal aspects of hypercortisolism that occur more than 6 months after an initial post-treatment remission. METHODS We performed a systematic review and meta-analysis to synthesize the evidence about remission and complication rates after transsphenoidal surgery (TSS) radiotherapy (RT) and medical therapy (MT) in recurrent CD patients. A quantitative systematic review was performed. Article selection was performed by searching MEDLINE (using PubMed), and Cochrane electronic bibliographic databases through 2020. RESULTS We noted 61 articles described therapeutic management of recurrent CD patients with representative outcome. A total of 723 patients received different therapeutic modality for their recurrent CD. The remission rates were 0.65 (95% confidence interval [CI] 0.60-0.70), 0.57 (95% CI 0.51-0.63), and 0.75 (95% CI 0.60-0.86) in the TSS, RT, and MT subgroups, respectively. The total remission rate after therapeutic approaches on recurrent CD patients was 0.64 (95% CI 0.60-0.68). A test for subgroup differences revealed there was a statistically significant difference between different subgroups (P = 0.01). The post hoc test showed that in comparison with RT, TSS (P = 0.0344) and MT (P = 0.0149) had a higher rate of remission. However, there was no statistically significant difference between separate therapeutic modalities in terms of complications including diabetes insipidus (P = 1.0) and hypopituitarism (P = 0.28). CONCLUSIONS Compared MT and TSS, RT has a statistically lower rate of remission. Although there is robust superiority of surgery over RT, interpretation of MT data must considered with caution due to the small number of included cases and wide CI range.
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Affiliation(s)
- Mohammadmahdi Sabahi
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Paniz Ghasemi-Nesari
- Neurosurgery Research Group (NRG), Student Research Committee, Hamadan University of Medical Sciences, Hamadan, Iran; Brain and Spinal Cord Injury Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Farzad Maroufi
- Brain and Spinal Cord Injury Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran; Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Taha Shahbazi
- Neurosurgery Research Group (NRG), Student Research Committee, Hamadan University of Medical Sciences, Hamadan, Iran; Brain and Spinal Cord Injury Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Omid Yousefi
- Trauma Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Seyed Alireza Shahtaheri
- Neurosurgery Research Group (NRG), Student Research Committee, Hamadan University of Medical Sciences, Hamadan, Iran; Brain and Spinal Cord Injury Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Othman Bin-Alamer
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Rocco Dabecco
- Department of Neurological Surgery, Pauline Braathen Neurological Centre, Cleveland Clinic Florida, Weston, Florida, USA
| | - Nathalia Velasquez
- Department of Otolaryngology/Head and Neck Surgery, Cleveland Clinic Florida, Weston, Florida, USA
| | - Karla M Arce
- Department of Endocrinology, Diabetes and Metabolism, Cleveland Clinic Florida, Weston, Florida, USA
| | - Badih Adada
- Department of Neurological Surgery, Pauline Braathen Neurological Centre, Cleveland Clinic Florida, Weston, Florida, USA
| | | | - Hamid Borghei-Razavi
- Department of Neurological Surgery, Pauline Braathen Neurological Centre, Cleveland Clinic Florida, Weston, Florida, USA.
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Yang AB, Henderson F, Schwartz TH. Surgical strategies in the treatment of MR-negative Cushing's Disease: a systematic review and treatment algorithm. Pituitary 2022; 25:551-562. [PMID: 35710682 DOI: 10.1007/s11102-022-01239-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/31/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE Several surgical strategies have been proposed to treat MRI-negative Cushing's Disease. These include tumor removal, if identified, and if a tumor is not identified, resection of varying degrees of the pituitary gland, often guided by inferior petrosal sinus sampling (IPSS). The relative risks and benefits of each strategy have never been compared. METHODS This systematic review of the literature included only studies on the results of surgery for MRI-negative patients with Cushing's Disease in which the surgical strategy was clearly described and associated remission and/or hypopituitarism rates detailed for each strategy. RESULTS We identified 12 studies that met inclusion criteria for remission rates and 5 studies for hypopituitarism rates. We divided cases into 6 resection strategies. Remission and hypopituitarism rates for each strategy were: (1) tumor identified, resect tumor only (68%, 0%); (2) resect tumor and surrounding capsule (85%, 0%); and if the tumor was not identified (3) resect inferior 1/3 of gland (78%, no data); (4) resect 30-50% of gland based on IPSS (68%, 13%); (5) resect > 50% but < 100% of gland (65%, 9%); (6) resect entire gland (66%, 67%). Strategy 3 only contained 9 patients. CONCLUSION Remission rates for MRI-negative Cushing's Disease support surgery as a reasonable approach. Results are best if a tumor is found. If a tumor is not identified, one can either remove one-third of the gland guided by IPSS lateralization, or remove both lateral portions along with the inferior portion leaving sufficient central gland to preserve function. Our recommendations are limited by the lack of rigorous and objective data.
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Affiliation(s)
| | - Fraser Henderson
- Department of Neurological Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, 525 East 68th St., Box #99, New York, NY, 10065, USA
| | - Theodore H Schwartz
- Department of Neurological Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, 525 East 68th St., Box #99, New York, NY, 10065, USA.
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Masui K, Wajima D, Aketa S, Nishimura F. Efficacy of endoscopic transsphenoidal surgery for cushing's disease: Case series and review of the literature. Neurol India 2021; 68:403-406. [PMID: 32415015 DOI: 10.4103/0028-3886.284363] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background This study was performed to examine the efficacy of endoscopic transsphenoidal surgery (ETS) for Cushing's disease at a single institute and to review past reports. Material and Methods We studied eight consecutive patients who underwent ETS for Cushing's disease. The radiological evaluation comprised a detailed examination of preoperative magnetic resonance images (MRIs), including inferior petrosal sinus sampling, for cases with normal renal function. Remission was evaluated at least three months after surgery and was defined by the presence of hypocortisolemia that required steroid replacement therapy or eucortisolemia with suppression to <1.8 μg/dL after 1mg of dexamethasone. Results In all cases preoperative MRI was abnormal and included two macroadenomas (25 %). Pathological confirmation of an adenoma was possible in all patients. The mean follow-up period was 5.6 (2-7) years. Remission was confirmed in 75.0% of the cases and was higher in rate for microadenoma (100%) than for macroadenoma (50%). Postoperatively , no cerebrospinal fluid rhinorrhea occurred, but new endocrine deficits were noted in 25% of patients. Conclusion Based on this study, ETS enhanced the intrasellar identification of adenomatous tissue, which led to low remission and complication rates that were comparable with those of traditional microsurgery for Cushing's disease.
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Affiliation(s)
- Katsuya Masui
- Department of Neurosurgery, Nara Prefecture General Medical Center, Nara; Department of Neurosurgery, Nara Medical University, Kashihara, Japan
| | - Daisuke Wajima
- Department of Neurosurgery, Nara Medical University, Kashihara, Japan
| | - Shuta Aketa
- Department of Neurosurgery, Osaka Police Hospital, Osaka, Japan
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4
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Stroud A, Dhaliwal P, Alvarado R, Winder MJ, Jonker BP, Grayson JW, Hamizan A, Harvey RJ, McCormack A. Outcomes of pituitary surgery for Cushing's disease: a systematic review and meta-analysis. Pituitary 2020; 23:595-609. [PMID: 32691356 DOI: 10.1007/s11102-020-01066-8] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE Transsphenoidal surgery (TSS) is the first-line treatment for Cushing's disease (CD). This review aimed to synthesize the remission and recurrence rates following TSS for CD and identify predictors of these outcomes. METHODS Medline (1946-) and Embase (1947-) were searched until 23rd January 2019 for original studies. A meta-analysis was performed of remission and recurrence rates. Studies were excluded if patients had prior radiosurgery/radiotherapy, mixed pathologies or interventions without separated data, follow-up not reported or population size < 20. For recurrence rate syntheses, studies with follow-up < 6 months were excluded. RESULTS The search produced 2663 studies, of which n = 68 were included, involving 5664 patients. Remission rates after primary and revision TSS were 80% [77-82] and 58% [50-66] at last follow-up. After primary TSS, predictors of remission were micro- v macroadenomas (83% v 68%, p < 0.01), imaging-visible adenomas (81% v 69%, p < 0.01), adenomas confirmed on histopathology (87% v 45%, p < 0.01), absence of cavernous sinus invasion (80% v 30%, p < 0.01), postoperative serum cortisol (MSeC) nadir < 2 μg/dL (< 55 nmol/L; 95% v 46%, p < 0.01) and lower preoperative 24-h urine free cortisol (1250 nmol v 1726 nmol, p < 0.01). For revision TSS, predictors of remission were postoperative MSeC nadir < 2 μg/dL (< 55 nmol/L; 100% v 38%, p < 0.01) and operations for recurrence v persistence (80% v 54%, p < 0.01). Recurrence rates after primary and revision TSS were 18% [14-22] and 28% [16-42]. CONCLUSIONS TSS is most effective in primary microadenomas, visible on preoperative imaging and without CS invasion, lower preoperative 24-h urine free cortisol and postoperative MSeC nadir < 2 μg/dL (< 55 nmol/L).
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Affiliation(s)
- Anna Stroud
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, Sydney, NSW, Australia.
- St Vincent's Clinical School, Faculty of Medicine, UNSW Sydney, Sydney, NSW, Australia.
- Hormones and Cancer Group, Garvan Institute of Medical Research, Sydney, NSW, Australia.
| | - Pearl Dhaliwal
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, Sydney, NSW, Australia
- St Vincent's Clinical School, Faculty of Medicine, UNSW Sydney, Sydney, NSW, Australia
| | - Raquel Alvarado
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, Sydney, NSW, Australia
| | - Mark J Winder
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, Sydney, NSW, Australia
- St Vincent's Clinical School, Faculty of Medicine, UNSW Sydney, Sydney, NSW, Australia
- Faculty of Medicine, Notre Dame University, Sydney, NSW, Australia
- Department of Endocrinology, St Vincent's Hospital, Sydney, NSW, Australia
| | - Benjamin P Jonker
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, Sydney, NSW, Australia
- Department of Endocrinology, St Vincent's Hospital, Sydney, NSW, Australia
- Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Jessica W Grayson
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, Sydney, NSW, Australia
| | | | - Richard J Harvey
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, Sydney, NSW, Australia
- Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia
| | - Ann McCormack
- St Vincent's Clinical School, Faculty of Medicine, UNSW Sydney, Sydney, NSW, Australia
- Department of Endocrinology, St Vincent's Hospital, Sydney, NSW, Australia
- Hormones and Cancer Group, Garvan Institute of Medical Research, Sydney, NSW, Australia
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5
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Nadezhdina EY, Rebrova OY, Grigoriev AY, Ivaschenko OV, Azizyan VN, Melnichenko GA, Dedov II. Prediction of recurrence and remission within 3 years in patients with Cushing disease after successful transnasal adenomectomy. Pituitary 2019; 22:574-580. [PMID: 31506907 DOI: 10.1007/s11102-019-00985-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Some laboratory and clinical features are associated with a probability of recurrence after transnasal adenomectomy for Cushing disease (CD). However, there is no consensus on a set of predictors. Rules for prediction of recurrence were not proposed earlier. AIM To develop prediction model of recurrence/remission after successful neurosurgical treatment for CD. METHODS Retrospective single-site comparative study included 349 patients (52 men and 297 women) with a verified diagnosis of CD who underwent effective endoscopic transsphenoidal adenomectomy between 2007 and 2014. Clinical and laboratory parameters were evaluated. Laboratory tests were performed using immunochemiluminescent method. Time-to-event analysis and ROC-analysis were applied. Multivariate models were developed using logistic regression and artificial neural network (ANN). RESULTS Postoperative cortisol and ACTH levels and their combinations cannot be used for prediction of recurrence. ANN for prediction of recurrence within 3 years after successful surgery was developed. Input variables are age, duration of the disease, MRI data on adenoma, morning postoperative levels of ACTH and cortisol, output variable is binary (recurrence/remission). Predictive value for remission is 93%, 95% CI [89%; 96%], and predictive value for recurrence is 85%, 95% CI [71%; 94%]. Web-calculator based on the model is developed and free for use. CONCLUSION Effective method for prediction of recurrence and long-term remission within 3 years after successful endoscopic transsphenoidal adenomectomy is proposed.
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Affiliation(s)
- Elena Y Nadezhdina
- Endocrinology Research Centre, 11 Dm. Ulyanova str., 117036, Moscow, Russia.
| | - Olga Yu Rebrova
- National Research University Higher School of Economics, 20 Myasnitskaya Ul., 101000, Moscow, Russia
- Pirogov Russian National Research Medical University, 1 Ostrovitianov str., 117997, Moscow, Russia
| | - Andrey Y Grigoriev
- Endocrinology Research Centre, 11 Dm. Ulyanova str., 117036, Moscow, Russia
| | | | - Vilen N Azizyan
- Endocrinology Research Centre, 11 Dm. Ulyanova str., 117036, Moscow, Russia
| | | | - Ivan I Dedov
- Endocrinology Research Centre, 11 Dm. Ulyanova str., 117036, Moscow, Russia
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6
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Nishioka H, Yamada S. Cushing's Disease. J Clin Med 2019; 8:jcm8111951. [PMID: 31726770 PMCID: PMC6912360 DOI: 10.3390/jcm8111951] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Revised: 11/04/2019] [Accepted: 11/06/2019] [Indexed: 12/11/2022] Open
Abstract
In patients with Cushing's disease (CD), prompt diagnosis and treatment are essential for favorable long-term outcomes, although this remains a challenging task. The differential diagnosis of CD is still difficult in some patients, even with an organized stepwise diagnostic approach. Moreover, despite the use of high-resolution magnetic resonance imaging (MRI) combined with advanced fine sequences, some tumors remain invisible. Surgery, using various surgical approaches for safe maximum tumor removal, still remains the first-line treatment for most patients with CD. Persistent or recurrent CD after unsuccessful surgery requires further treatment, including repeat surgery, medical therapy, radiotherapy, or sometimes, bilateral adrenalectomy. These treatments have their own advantages and disadvantages. However, the most important thing is that this complex disease should be managed by a multidisciplinary team with collaborating experts. In addition, a personalized and individual-based approach is paramount to achieve high success rates while minimizing the occurrence of adverse events and improving the patients' quality of life. Finally, the recent new insights into the pathophysiology of CD at the molecular level are highly anticipated to lead to the introduction of more accurate diagnostic tests and efficacious therapies for this devastating disease in the near future.
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Affiliation(s)
- Hiroshi Nishioka
- Department of Hypothalamic and Pituitary surgery, Toranomon Hospital, Tokyo 1058470, Japan;
- Okinaka Memorial Institute for Medical Research, Tokyo 1058470, Japan
| | - Shozo Yamada
- Hypothalamic and Pituitary Center, Moriyama Neurological Center Hospital, Tokyo 1340081, Japan
- Okinaka Memorial Institute for Medical Research, Tokyo 1058470, Japan
- Correspondence: ; Tel.: +81-336-751-211
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7
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Abstract
Cushing's disease (CD) is caused by a pituitary tumour that secretes adrenocorticotropin (ACTH) autonomously, leading to excess cortisol secretion from the adrenal glands. The condition is associated with increased morbidity and mortality that can be mitigated by treatments that result in sustained endocrine remission. Transsphenoidal pituitary surgery (TSS) remains the mainstay of treatment for CD but requires considerable neurosurgical expertise and experience in order to optimize patient outcomes. Up to 90% of patients with microadenomas (tumour below 1 cm in largest diameter) and 65% of patients with macroadenomas (tumour at or above 1 cm in greatest diameter) achieve endocrine remission after TSS by an experienced surgeon. Patients who are not in remission postoperatively or those who relapse may benefit from undergoing a second pituitary operation. Alternatively, radiation therapy to the sella with interim medical therapy, or bilateral adrenalectomy, can be effective as definitive treatments of CD. Medical therapy is currently adjunctive in most patients with CD and is generally prescribed to patients who are about to receive radiation therapy and will be awaiting its salutary effects to occur. Available treatment options include steroidogenesis inhibitors, centrally acting agents and glucocorticoid receptor antagonists. Several novel agents are in clinical trials and may eventually constitute additional treatment options for this serious condition.
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Affiliation(s)
- N A Tritos
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - B M K Biller
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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Pasternak-Pietrzak K, Moszczyńska E, Szalecki M. Treatment challenges in pediatric Cushing's disease: Review of the literature with particular emphasis on predictive factors for the disease recurrence. Endocrine 2019; 66:125-136. [PMID: 31701434 PMCID: PMC6838046 DOI: 10.1007/s12020-019-02036-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 07/26/2019] [Indexed: 11/17/2022]
Abstract
Cushing's disease (CD) is a rare endocrine condition caused by a corticotroph pituitary tumor that produces adrenocorticotropic hormone. The current state of knowledge of CD treatment is presented in this article including factors that can be helpful in predicting remission and/or recurrence of the disease. The primary goals in CD treatment are quick diagnosis and effective, prompt treatment as the persistent disease is associated with increased morbidity and mortality. Cooperation of a team consisting of experienced pediatrician/adult endocrinologist, neuroradiologist, transsphenoidal neurosurgeon and (if necessary) radiotherapist contribute to the best treatment effects.
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Affiliation(s)
- Katarzyna Pasternak-Pietrzak
- Department of Endocrinology and Diabetology, The Children's Memorial Health Institute (CMHI), Al. Dzieci Polskich 20, 04-730, Warsaw, Poland.
| | - Elżbieta Moszczyńska
- Department of Endocrinology and Diabetology, The Children's Memorial Health Institute (CMHI), Al. Dzieci Polskich 20, 04-730, Warsaw, Poland
| | - Mieczysław Szalecki
- Department of Endocrinology and Diabetology, The Children's Memorial Health Institute (CMHI), Al. Dzieci Polskich 20, 04-730, Warsaw, Poland
- The Medicine and Health Sciences Faculty, University of Jan Kochanowski, Al. IX Wieków Kielc 19A, 25-317, Kielce, Poland
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Abellán-Galiana P, Fajardo-Montañana C, Riesgo-Suárez P, Pérez-Bermejo M, Ríos-Pérez C, Gómez-Vela J. Prognostic usefulness of ACTH in the postoperative period of Cushing's disease. Endocr Connect 2019; 8:1262-1272. [PMID: 31394502 PMCID: PMC6733365 DOI: 10.1530/ec-19-0297] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 08/05/2019] [Indexed: 11/08/2022]
Abstract
OBJECTIVES To analyze the usefulness of plasma ACTH in predicting CD remission after surgery and to evaluate the prognostic usefulness of ACTH measurement after the cortisol and ACTH nadir (48 h prior to discharge). DESIGN A prospective study was made of 65 patients with CD operated upon between 2005 and 2016. METHODS Postsurgery plasma ACTH and cortisol were measured every 6 h, in the absence of corticosteroid coverage. Hydrocortisone was started in the presence of adrenal insufficiency or cortisol <55.2 nmol/L. Plasma ACTH was again determined before discharge. MAIN OUTCOME MEASURE Usefulness of plasma ACTH in predicting CD remission. RESULTS Remission at 3 months of CD was achieved in 56 of 65 cases, with late recurrence in 18 of 58 cases. Following resection, the ACTH nadir was significantly lower referred to late remission (2.8 vs 6.5 pmol/L; P = 0.031) and higher for recurrence (2.1 vs 4.8 pmol/L; P < 0.001), and identical results were obtained for the ACTH values before discharge. In the analysis of the ROC curves, nadir and before discharge ACTH values <1.9 pmol/L and <2.6 pmol/L were respectively indicative of early remission (AUC 0.827; P < 0.001); <6.2 pmol/L of remission at 3 months (AUC 0.847; P = 0.001) and >3.2 pmol/L of recurrence (AUC 0.810; P < 0.001) in both ACTH values. A time to ACTH nadir <46 h was indicative of early remission (AUC 0.751; P = 0.001), while a time >39 h was indicative of recurrence (AUC 0.773; P = 0.001). CONCLUSIONS We propose an ACTH value <3.3 pmol/L as a good long-term prognostic marker in the postoperative period of CD. Reaching the ACTH nadir in less time is associated to a lesser recurrence rate.
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Affiliation(s)
- Pablo Abellán-Galiana
- Department of Endocrinology, Hospital General Universitari de Castelló, Castellón, Spain
- Department of Medicine, Universidad Cardenal Herrera-CEU, Castellón, Spain
| | - Carmen Fajardo-Montañana
- Department of Endocrinology, Hospital Universitario de la Ribera, Alzira, Spain
- Correspondence should be addressed to C Fajardo-Montañana:
| | - Pedro Riesgo-Suárez
- Department of Neurosurgery, Hospital Universitario de la Ribera, Alzira, Spain
| | | | - Celia Ríos-Pérez
- Centro de Salud Tavernes de la Valldigna, Hospital Comarcal Francesc de Borja, Gandía, Spain
| | - José Gómez-Vela
- Department of Endocrinology, Hospital Universitario de la Ribera, Alzira, Spain
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Mayberg M, Reintjes S, Patel A, Moloney K, Mercado J, Carlson A, Scanlan J, Broyles F. Dynamics of postoperative serum cortisol after transsphenoidal surgery for Cushing's disease: implications for immediate reoperation and remission. J Neurosurg 2018; 129:1268-1277. [PMID: 29271716 DOI: 10.3171/2017.6.jns17635] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 06/05/2017] [Indexed: 01/01/2023]
Abstract
OBJECTIVESuccessful transsphenoidal surgery for adrenocorticotropin hormone (ACTH)-producing pituitary tumors is associated with subnormal postoperative serum cortisol levels, which may guide decisions regarding immediate reoperation. However, little is known about the detailed temporal course of changes in serum cortisol in the immediate postoperative period, and the relationship of postoperative cortisol dynamics to remission and late recurrence.METHODSA single-center retrospective cohort analysis was performed for all patients undergoing pituitary surgery from 2007 through 2015. Standardized diagnostic and treatment algorithms were applied to all patients with potential Cushing's disease (CD), including microsurgical transsphenoidal adenomectomy (TSA) by a single surgeon. All patients had serum cortisol levels drawn at 6-hour intervals for 72 hours after surgery, and were offered reoperation within 3 days for normal or supranormal postoperative cortisol levels. Primary outcomes were 6-month remission and late recurrence; secondary outcomes were persistent postoperative hypocortisolism and surgical morbidity. Discriminatory levels of postoperative serum cortisol for predicting remission were calculated at various intervals after surgery using receiver operating characteristic (ROC) curves.RESULTSAmong 89 patients diagnosed with CD, 81 underwent initial TSA for a potentially curable lesion; 23 patients (25.8%) underwent an immediate second TSA. For the entire cohort, 6-month remission was achieved in 77.8% and late recurrences occurred in 9.5%, at a mean of 43.5 months. Compared with patients with a single surgery, those with an immediate second TSA had similar rates of remission (78.3% vs 77.6%) and late recurrence (5.6% vs 11.1%). The rate of hypocortisolism for patients with 2 surgeries (12/23, 52.2%) was significantly greater than that for patients with single surgeries (13/58, 22.4%; p < 0.001). There was no difference in the incidence of CSF leaks between the first and second operations. Remission was achieved in 58 (92.1%) of 64 patients who completed the 2-surgery protocol. The temporal course of postoperative serum cortisol levels among patients varied considerably, with subnormal nadir levels < 2 μg/dl occurring between 12 hours and 66 hours. Patients achieving remission had significantly lower mean serum cortisol levels at every time point after surgery (p < 0.01). By ROC curve analysis, nadir cortisol levels < 2.1 μg/dl were predictive of 6-month remission for the entire cohort over 3 days (positive predictive value [PPV] = 94%); discriminating cortisol levels for predicting remission on postoperative day (POD) 2 were < 5.4 μg/dl (PPV = 97%), although patients with remission after postoperative cortisol levels of 2-5 μg/dl had a significantly higher rate of late recurrence.CONCLUSIONSThere is substantial variation in the temporal course of serum cortisol levels over the first 72 hours after TSA for CD, with nadir levels predictive for remission occurring as late as POD 3. Although a cortisol level of 2.1 μg/dl at any point was an accurate predictor of 6-month remission, levels less than 5.4 μg/dl on POD 2 were reasonably accurate. These data may enable decisions regarding the efficacy of an immediate second surgical procedure performed during the same hospitalization; immediate reoperation is associated with excellent remission rates and low recurrence rates in patients otherwise unlikely to achieve remission, but carries a higher risk of permanent hypocortisolism.
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Affiliation(s)
- Marc Mayberg
- 4Department of Neurological Surgery, University of Washington, Seattle, Washington; and
| | - Stephen Reintjes
- 3Department of Neurological Surgery, University of South Florida, Tampa, Florida
| | - Anika Patel
- 1Swedish Pituitary Center, Swedish Neuroscience Institute
| | - Kelley Moloney
- 1Swedish Pituitary Center, Swedish Neuroscience Institute
| | | | - Alex Carlson
- 2Swedish Center for Research and Innovation; and
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11
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Carr SB, Kleinschmidt-DeMasters BK, Kerr JM, Kiseljak-Vassiliades K, Wierman ME, Lillehei KO. Negative surgical exploration in patients with Cushing's disease: benefit of two-thirds gland resection on remission rate and a review of the literature. J Neurosurg 2018; 129:1260-1267. [PMID: 29219752 DOI: 10.3171/2017.5.jns162901] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Accepted: 05/15/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThe authors report their single-institution experience with the pathological findings, rates of remission, and complications in patients with presumed Cushing's disease (CD) who underwent a two-thirds pituitary gland resection when no adenoma was identified at the time of transsphenoidal surgery (TSS). The authors also review the literature on patients with CD, negative surgical exploration, and histological findings.METHODSThis study is a retrospective analysis of cases found in neurosurgery and pathology department databases between 1989 and 2011. In all cases, patients had been operated on by the same neurosurgeon (K.O.L.). Twenty-two (13.6%) of 161 patients who underwent TSS for CD had no adenoma identified intraoperatively after systematic exploration of the entire gland; these patients all underwent a two-thirds pituitary gland resection. A chart review was performed to assess treatment data points as well as clinical and biochemical remission status.RESULTSOf the 22 patients who underwent two-thirds gland resection, 6 (27.3%) ultimately had lesions found on final pathology. All 6 patients were found to have a distinct adrenocorticotropic hormone (ACTH) cell adenoma. Sixteen (72.7%) of the patients had no tumor identified, with 3 of these patients suspected of having ACTH cell hyperplasia. The follow-up duration for the entire group was between 14 and 315 months (mean 98.9 months, median 77 months). Remission rates were 100% (6/6 patients) for the ACTH cell adenoma group and 75% (12/16) for the group without adenoma. Overall, 18 (81.8%) of the 22 patients had no evidence of hypercortisolism at last follow-up, and 4 patients (18%) had persistent hypercortisolism, defined as a postoperative cortisol level > 5 μg/dl. Of these 4 patients, 1 was suspected of harboring a cavernous sinus adenoma, 2 were found to have lung tumors secreting ACTH, and 1 remained with an undiagnosed etiology. Rates of postoperative complications were low.CONCLUSIONSThe diagnosis and treatment of CD can be challenging for neurosurgeons, endocrinologists, and pathologists alike. Failure to find a discrete adenoma at the time of surgery occurs in at least 10%-15% of cases, even in experienced centers. The current literature provides little guidance regarding rational intraoperative approaches in such cases. The authors' experience with 161 patients with CD, when no intraoperative tumor was localized, demonstrates the utility of a two-thirds pituitary gland resection with a novel and effective surgical strategy, as suggested by a high initial remission rate and a low operative morbidity.
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Affiliation(s)
| | | | - Janice M Kerr
- 3Division of Endocrinology, Department of Medicine, University of Colorado Denver School of Medicine, Denver, Colorado
| | - Katja Kiseljak-Vassiliades
- 3Division of Endocrinology, Department of Medicine, University of Colorado Denver School of Medicine, Denver, Colorado
| | - Margaret E Wierman
- 3Division of Endocrinology, Department of Medicine, University of Colorado Denver School of Medicine, Denver, Colorado
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12
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Broersen LHA, Biermasz NR, van Furth WR, de Vries F, Verstegen MJT, Dekkers OM, Pereira AM. Endoscopic vs. microscopic transsphenoidal surgery for Cushing's disease: a systematic review and meta-analysis. Pituitary 2018; 21:524-534. [PMID: 29767319 PMCID: PMC6132967 DOI: 10.1007/s11102-018-0893-3] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
PURPOSE Systematic review and meta-analysis comparing endoscopic and microscopic transsphenoidal surgery for Cushing's disease regarding surgical outcomes (remission, recurrence, and mortality) and complication rates. To stratify the results by tumor size. METHODS Nine electronic databases were searched in February 2017 to identify potentially relevant articles. Cohort studies assessing surgical outcomes or complication rates after endoscopic or microscopic transsphenoidal surgery for Cushing's disease were eligible. Pooled proportions were reported including 95% confidence intervals. RESULTS We included 97 articles with 6695 patients in total (5711 microscopically and 984 endoscopically operated). Overall, remission was achieved in 5177 patients (80%), with no clear difference between both techniques. Recurrence was around 10% and short term mortality < 0.5% for both techniques. Cerebrospinal fluid leak occurred more often in endoscopic surgery (12.9 vs. 4.0%), whereas transient diabetes insipidus occurred less often (11.3 vs. 21.7%). For microadenomas, results were comparable between both techniques. For macroadenomas, the percentage of patients in remission was higher after endoscopic surgery (76.3 vs. 59.9%), and the percentage recurrence lower after endoscopic surgery (1.5 vs. 17.0%). CONCLUSIONS Endoscopic surgery for patients with Cushing's disease reaches comparable results for microadenomas, and probably better results for macroadenomas than microscopic surgery. This is present despite the presumed learning curve of the newer endoscopic technique, although confounding cannot be excluded. Based on this study, endoscopic surgery may thus be considered the current standard of care. Microscopic surgery can be used based on neurosurgeon's preference. Endocrinologists and neurosurgeons in pituitary centers performing the microscopic technique should at least consider referring Cushing's disease patients with a macroadenoma.
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Affiliation(s)
- Leonie H A Broersen
- Department of Medicine, Division of Endocrinology, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands.
- Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands.
| | - Nienke R Biermasz
- Department of Medicine, Division of Endocrinology, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
- Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Wouter R van Furth
- Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
- Department of Neurosurgery, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Friso de Vries
- Department of Medicine, Division of Endocrinology, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
- Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Marco J T Verstegen
- Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
- Department of Neurosurgery, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Olaf M Dekkers
- Department of Medicine, Division of Endocrinology, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Alberto M Pereira
- Department of Medicine, Division of Endocrinology, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
- Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
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13
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Machado MC, Fragoso MCBV, Moreira AC, Boguszewski CL, Vieira Neto L, Naves LA, Vilar L, Araújo LAD, Musolino NRC, Miranda PAC, Czepielewski MA, Gadelha MR, Bronstein MD, Ribeiro-Oliveira A. A review of Cushing's disease treatment by the Department of Neuroendocrinology of the Brazilian Society of Endocrinology and Metabolism. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2018; 62:87-105. [PMID: 29694638 PMCID: PMC10118687 DOI: 10.20945/2359-3997000000014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 10/02/2017] [Indexed: 11/23/2022]
Abstract
The treatment objectives for a patient with Cushing's disease (CD) are remission of hypercortisolism, adequate management of co-morbidities, restoration of the hypothalamic-pituitary-adrenal axis, preservation of fertility and pituitary function, and improvement of visual defects in cases of macroadenomas with suprasellar extension. Transsphenoidal pituitary surgery is the main treatment option for the majority of cases, even in macroadenomas with low probability of remission. In cases of surgical failure, another subsequent pituitary surgery might be indicated in cases with persistent tumor imaging at post surgical magnetic resonance imaging (MRI) and/or pathology analysis of adrenocorticotropic hormone-positive (ACTH+) positive pituitary adenoma in the first procedure. Medical treatment, radiotherapy and adrenalectomy are the other options when transsphenoidal pituitary surgery fails. There are several options of medical treatment, although cabergoline and ketoconazole are the most commonly used alone or in combination. Novel treatments are also addressed in this review. Different therapeutic approaches are frequently needed on an individual basis, both before and, particularly, after surgery, and they should be individualized. The objective of the present review is to provide the necessary information to achieve a more effective treatment for CD. It is recommended that patients with CD be followed at tertiary care centers with experience in treating this condition.
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Affiliation(s)
- Márcio Carlos Machado
- Unidade de Neuroendocrinologia, Serviço de Endocrinologia e Metabologia, Hospital das Clínicas da Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Maria Candida Barisson Vilares Fragoso
- Unidade de Neuroendocrinologia, Serviço de Endocrinologia e Metabologia, Hospital das Clínicas da Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Ayrton Custódio Moreira
- Divisão de Endocrinologia e Metabologia, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
| | - César Luiz Boguszewski
- Serviço de Endocrinologia e Metabologia (SEMPR), Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR, Brasil
| | - Leonardo Vieira Neto
- Serviço de Endocrinologia, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
| | - Luciana A Naves
- Serviço de Endocrinologia, Hospital Universitário de Brasília, Universidade de Brasília, Brasília, DF, Brasil
| | - Lucio Vilar
- Serviço de Endocrinologia, Hospital de Clínicas, Universidade Federal de Pernambuco, Recife, PE, Brasil
| | | | - Nina Rosa Castro Musolino
- Divisão de Neurocirurgia Funcional, Hospital das Clínicas da Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | | | - Mauro A Czepielewski
- Serviço de Endocrinologia, Hospital de Clínicas de Porto Alegre, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brasil
| | - Monica R Gadelha
- Serviço de Endocrinologia, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
| | - Marcello Delano Bronstein
- Unidade de Neuroendocrinologia, Serviço de Endocrinologia e Metabologia, Hospital das Clínicas da Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Antônio Ribeiro-Oliveira
- Serviço de Endocrinologia, Hospital de Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brasil
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14
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Erfe JM, Perry A, McClaskey J, Inzucchi SE, James WS, Eid T, Bronen RA, Mahajan A, Huttner A, Santos F, Spencer D. Long-term outcomes of tissue-based ACTH-antibody assay-guided transsphenoidal resection of pituitary adenomas in Cushing disease. J Neurosurg 2017; 129:629-641. [PMID: 29027854 DOI: 10.3171/2017.3.jns162245] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Cushing disease is caused by a pituitary micro- or macroadenoma that hypersecretes adrenocorticotropic hormone (ACTH), resulting in hypercortisolemia. For decades, transsphenoidal resection (TSR) has been an efficacious treatment but with certain limitations, namely precise tumor localization and complete excision. The authors evaluated the novel use of a double-antibody sandwich assay for the real-time quantitation of ACTH in resected pituitary specimens with the goals of augmenting pathological diagnosis and ultimately improving long-term patient outcome. METHODS This study involved a retrospective review of records and an analysis of assay values, pathology slides, and MRI studies of patients with Cushing disease who had undergone TSR in the period from 2009 to 2014 and had at least 1 year of follow-up in coordination with an endocrinologist. In the operating room, biopsy specimens from the patients had been analyzed for tissue ACTH concentration. Additional samples were simultaneously sent for frozen-section pathological analysis. The ACTH assay performance was compared against pathology assessments of surgical tumor samples using receiver operating characteristic (ROC) analysis and against pre- and postoperative MRI studies. RESULTS Fourteen patients underwent TSR with guidance by ACTH-antibody assay and pathological assessment of 127 biopsy samples and were followed up for an average of 3 years. The ACTH threshold for discriminating adenomatous from normal tissue was 290,000 pg/mg of tissue, based on jointly maximized sensitivity (95.0%) and specificity (71.3%). Lateralization discordance between preoperative MRI studies and surgical visualization was noted in 3 patients, confirming the impression that MRI alone may not achieve optimal localization. A majority of the patients (85.7%) attained long-term disease remission based on urinary free cortisol levels, plasma cortisol levels, and long-term corticosteroid therapy. Comparisons of patient-months of remission and treatment failure showed that the remission rate in the study sample statistically exceeds the rate in historical controls (71.9%; p = 0.0007, Fisher's exact test). Long-term unexpected hormonal deficiencies were statistically similar between study patients (29%) and those in a meta-analysis (25%; p = 0.7596, Fisher's exact test). CONCLUSIONS These preliminary findings reflect the promising potential of tissue-based ACTH-antibody-guided assay for improving the cure rates of Cushing disease patients undergoing TSR. Further studies with larger sample sizes, further refinements of assay interpretation, and longer-term follow-ups are needed.
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Affiliation(s)
- J Mark Erfe
- 1Yale School of Medicine, New Haven, Connecticut
| | - Avital Perry
- 2Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota
| | - John McClaskey
- 3Department of Pathology, Mount Sinai Hospital, New York, New York; and
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15
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Sarkar S, Rajaratnam S, Chacko G, Mani S, Hesargatta AS, Chacko AG. Pure endoscopic transsphenoidal surgery for functional pituitary adenomas: outcomes with Cushing's disease. Acta Neurochir (Wien) 2016; 158:77-86; discussion 86. [PMID: 26577636 DOI: 10.1007/s00701-015-2638-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Accepted: 11/05/2015] [Indexed: 12/01/2022]
Abstract
BACKGROUND This study was performed to examine patient outcomes following pure endoscopic transsphenoidal surgery (ETS) for Cushing's disease (CD). METHOD We studied 64 consecutive patients who underwent 69 endoscopic transsphenoidal procedures. Radiological evaluation comprised detailed examination of preoperative magnetic resonance images (MRI), including positron emission tomography (PET) for select cases. Inferior petrosal sinus sampling (IPSS) was not performed for any patient. Remission was defined by the presence of hypocortisolemia with requirement for steroid replacement therapy or eucortisolemia with suppression to <1.8 μg/dl after 1 mg dexamethasone on evaluation at least 3 months after surgery. RESULTS Preoperative MRI was abnormal in 87.5 % of cases and included 11 macroadenomas (17.2 %). PET was used to localize the adenoma in four cases. For microadenomas, operative procedures executed were as follows: selective adenomectomy (n = 15), enlarged adenomectomy (n = 21) and subtotal/hemihypophysectomy (n = 17). Overall, pathological confirmation of an adenoma was possible in 58 patients (90.6 %). Forty-nine patients (76.6 %) developed hypocortisolemia (<5 μg/dl) in the early postoperative period. Mean follow-up was 20 months (range 6-18 months). Remission was confirmed in 79.7 % of the 59 cases followed up for >3 months and was superior for microadenomas (86.4 %) versus macroadenomas (55.6 %) and equivocal MRI adenomas (66.7 %). Postoperative CSF rhinorrhea occurred in five patients, and new endocrine deficits were noted in 17.1 % patients. A nadir postoperative cortisol <2 μg/dl in the 1st week after surgery was highly predictive of remission (p = 0.001). CONCLUSION ETS allows for enhanced intrasellar identification of adenomatous tissue, providing remission rates that are comparable to traditional microsurgery for CD. The best predictor of remission remains induction of profound hypocortisolemia in the early postoperative period.
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Affiliation(s)
- Sauradeep Sarkar
- Sections of Neurosurgery Department of Neurological Sciences, Christian Medical College, Vellore, India
| | - Simon Rajaratnam
- Department of Endocrinology, Diabetes & Metabolism, Christian Medical College, Vellore, India
| | - Geeta Chacko
- Neuropathology, Department of Neurological Sciences, Christian Medical College, Vellore, India
| | - Sunithi Mani
- Department of Radiodiagnosis, Christian Medical College, Vellore, India
| | - Asha S Hesargatta
- Department of Endocrinology, Diabetes & Metabolism, Christian Medical College, Vellore, India
| | - Ari George Chacko
- Sections of Neurosurgery Department of Neurological Sciences, Christian Medical College, Vellore, India.
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Pivonello R, De Leo M, Cozzolino A, Colao A. The Treatment of Cushing's Disease. Endocr Rev 2015; 36:385-486. [PMID: 26067718 PMCID: PMC4523083 DOI: 10.1210/er.2013-1048] [Citation(s) in RCA: 292] [Impact Index Per Article: 32.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Accepted: 05/13/2015] [Indexed: 12/23/2022]
Abstract
Cushing's disease (CD), or pituitary-dependent Cushing's syndrome, is a severe endocrine disease caused by a corticotroph pituitary tumor and associated with increased morbidity and mortality. The first-line treatment for CD is pituitary surgery, which is followed by disease remission in around 78% and relapse in around 13% of patients during the 10-year period after surgery, so that nearly one third of patients experience in the long-term a failure of surgery and require an additional second-line treatment. Patients with persistent or recurrent CD require additional treatments, including pituitary radiotherapy, adrenal surgery, and/or medical therapy. Pituitary radiotherapy is effective in controlling cortisol excess in a large percentage of patients, but it is associated with a considerable risk of hypopituitarism. Adrenal surgery is followed by a rapid and definitive control of cortisol excess in nearly all patients, but it induces adrenal insufficiency. Medical therapy has recently acquired a more important role compared to the past, due to the recent employment of novel compounds able to control cortisol secretion or action. Currently, medical therapy is used as a presurgical treatment, particularly for severe disease; or as postsurgical treatment, in cases of failure or incomplete surgical tumor resection; or as bridging therapy before, during, and after radiotherapy while waiting for disease control; or, in selected cases, as primary therapy, mainly when surgery is not an option. The adrenal-directed drug ketoconazole is the most commonly used drug, mainly because of its rapid action, whereas the glucocorticoid receptor antagonist, mifepristone, is highly effective in controlling clinical comorbidities, mainly glucose intolerance, thus being a useful treatment for CD when it is associated with diabetes mellitus. Pituitary-directed drugs have the advantage of acting at the site responsible for CD, the pituitary tumor. Among this group of drugs, the dopamine agonist cabergoline and the somatostatin analog pasireotide result in disease remission in a consistent subgroup of patients with CD. Recently, pasireotide has been approved for the treatment of CD when surgery has failed or when surgery is not an option, and mifepristone has been approved for the treatment of Cushing's syndrome when associated with impairment of glucose metabolism in case of the lack of a surgical indication. Recent experience suggests that the combination of different drugs may be able to control cortisol excess in a great majority of patients with CD.
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Affiliation(s)
- Rosario Pivonello
- Dipartimento Di Medicina Clinica E Chirurgia, Sezione Di Endocrinologia, Universita' Federico II di Napoli, 80131 Naples, Italy
| | - Monica De Leo
- Dipartimento Di Medicina Clinica E Chirurgia, Sezione Di Endocrinologia, Universita' Federico II di Napoli, 80131 Naples, Italy
| | - Alessia Cozzolino
- Dipartimento Di Medicina Clinica E Chirurgia, Sezione Di Endocrinologia, Universita' Federico II di Napoli, 80131 Naples, Italy
| | - Annamaria Colao
- Dipartimento Di Medicina Clinica E Chirurgia, Sezione Di Endocrinologia, Universita' Federico II di Napoli, 80131 Naples, Italy
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Petersenn S, Beckers A, Ferone D, van der Lely A, Bollerslev J, Boscaro M, Brue T, Bruzzi P, Casanueva FF, Chanson P, Colao A, Reincke M, Stalla G, Tsagarakis S. Therapy of endocrine disease: outcomes in patients with Cushing's disease undergoing transsphenoidal surgery: systematic review assessing criteria used to define remission and recurrence. Eur J Endocrinol 2015; 172:R227-39. [PMID: 25599709 DOI: 10.1530/eje-14-0883] [Citation(s) in RCA: 98] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Accepted: 01/15/2015] [Indexed: 11/08/2022]
Abstract
OBJECTIVE A number of factors can influence the reported outcomes of transsphenoidal surgery (TSS) for Cushing's disease - including different remission and recurrence criteria, for which there is no consensus. Therefore, a comparative analysis of the best treatment options and patient management strategies is difficult. In this review, we investigated the clinical outcomes of initial TSS in patients with Cushing's disease based on definitions of and assessments for remission and recurrence. METHODS We systematically searched PubMed and identified 44 studies with clear definitions of remission and recurrence. When data were available, additional analyses by time of remission, tumor size, duration of follow-up, surgical experience, year of study publication and adverse events related to surgery were performed. RESULTS Data from a total of 6400 patients who received microscopic TSS were extracted and analyzed. A variety of definitions of remission and recurrence of Cushing's disease after initial microscopic TSS was used, giving broad ranges of remission (42.0-96.6%; median, 77.9%) and recurrence (0-47.4%; median, 11.5%). Better remission and recurrence outcomes were achieved for microadenomas vs macroadenomas; however, no correlations were found with other parameters, other than improved safety with longer surgical experience. CONCLUSIONS The variety of methodologies used in clinical evaluation of TSS for Cushing's disease strongly support the call for standardization and optimization of studies to inform clinical practice and maximize patient outcomes. Clinically significant rates of failure of initial TSS highlight the need for effective second-line treatments.
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Affiliation(s)
- Stephan Petersenn
- ENDOC Center for Endocrine TumorsAltonaer Strasse 59, 20357 Hamburg, GermanyDepartment of EndocrinologyCHU de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, BelgiumEndocrinology UnitDepartment of Internal Medicine and Medical Specialties (DiMI), Center of Excellence for Biomedical Research, IRCCS AOU San Martino-IST, University of Genova, Genova, ItalyDepartment of MedicineErasmus University MC, PO Box 2040, 3000 CA Rotterdam, The NetherlandsSection of Specialized EndocrinologyFaculty of Medicine, Oslo University Hospital, University of Oslo, Oslo, NorwayDivision of EndocrinologyDepartment of Medicine (DIMED), University of Padua, Padua, ItalyAix-Marseille UniversitéCNRS, CRN2M UMR 7286, 13344 Marseille Cedex 15, FranceAPHMHôpital Timone, Service d'Endocrinologie, Diabète et Maladies Métaboliques, 13385 Marseille Cedex 15, FranceDepartment of Epidemiology and PreventionIRCCS AOU San Martino-IST, Genova, ItalySantiago de Compostela University and CIBERobnSantiago de Compostela, SpainUniv Paris-SudFaculté de Médecine Paris-Sud, UMR-S1185, Le Kremlin Bicêtre, F-94276, FranceAssistance Publique-Hôpitaux de ParisHôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Le Kremlin Bicêtre, F-94275, FranceInstitut National de la Santé et de la Recherche Médicale U1185Le Kremlin Bicêtre, F-94276, FranceDipartimento di Medicina Clinica e ChirurgiaSezione di Endocrinologia, Università Federico II di Napoli, Naples, ItalyMedizinische Klinik und Poliklinik IV-InnenstadtUniversity Hospital Munich, D-80336 Munich, GermanyDepartment of EndocrinologyMax Planck Institute of Psychiatry, Munich, GermanyDepartment of EndocrinologyDiabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Albert Beckers
- ENDOC Center for Endocrine TumorsAltonaer Strasse 59, 20357 Hamburg, GermanyDepartment of EndocrinologyCHU de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, BelgiumEndocrinology UnitDepartment of Internal Medicine and Medical Specialties (DiMI), Center of Excellence for Biomedical Research, IRCCS AOU San Martino-IST, University of Genova, Genova, ItalyDepartment of MedicineErasmus University MC, PO Box 2040, 3000 CA Rotterdam, The NetherlandsSection of Specialized EndocrinologyFaculty of Medicine, Oslo University Hospital, University of Oslo, Oslo, NorwayDivision of EndocrinologyDepartment of Medicine (DIMED), University of Padua, Padua, ItalyAix-Marseille UniversitéCNRS, CRN2M UMR 7286, 13344 Marseille Cedex 15, FranceAPHMHôpital Timone, Service d'Endocrinologie, Diabète et Maladies Métaboliques, 13385 Marseille Cedex 15, FranceDepartment of Epidemiology and PreventionIRCCS AOU San Martino-IST, Genova, ItalySantiago de Compostela University and CIBERobnSantiago de Compostela, SpainUniv Paris-SudFaculté de Médecine Paris-Sud, UMR-S1185, Le Kremlin Bicêtre, F-94276, FranceAssistance Publique-Hôpitaux de ParisHôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Le Kremlin Bicêtre, F-94275, FranceInstitut National de la Santé et de la Recherche Médicale U1185Le Kremlin Bicêtre, F-94276, FranceDipartimento di Medicina Clinica e ChirurgiaSezione di Endocrinologia, Università Federico II di Napoli, Naples, ItalyMedizinische Klinik und Poliklinik IV-InnenstadtUniversity Hospital Munich, D-80336 Munich, GermanyDepartment of EndocrinologyMax Planck Institute of Psychiatry, Munich, GermanyDepartment of EndocrinologyDiabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Diego Ferone
- ENDOC Center for Endocrine TumorsAltonaer Strasse 59, 20357 Hamburg, GermanyDepartment of EndocrinologyCHU de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, BelgiumEndocrinology UnitDepartment of Internal Medicine and Medical Specialties (DiMI), Center of Excellence for Biomedical Research, IRCCS AOU San Martino-IST, University of Genova, Genova, ItalyDepartment of MedicineErasmus University MC, PO Box 2040, 3000 CA Rotterdam, The NetherlandsSection of Specialized EndocrinologyFaculty of Medicine, Oslo University Hospital, University of Oslo, Oslo, NorwayDivision of EndocrinologyDepartment of Medicine (DIMED), University of Padua, Padua, ItalyAix-Marseille UniversitéCNRS, CRN2M UMR 7286, 13344 Marseille Cedex 15, FranceAPHMHôpital Timone, Service d'Endocrinologie, Diabète et Maladies Métaboliques, 13385 Marseille Cedex 15, FranceDepartment of Epidemiology and PreventionIRCCS AOU San Martino-IST, Genova, ItalySantiago de Compostela University and CIBERobnSantiago de Compostela, SpainUniv Paris-SudFaculté de Médecine Paris-Sud, UMR-S1185, Le Kremlin Bicêtre, F-94276, FranceAssistance Publique-Hôpitaux de ParisHôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Le Kremlin Bicêtre, F-94275, FranceInstitut National de la Santé et de la Recherche Médicale U1185Le Kremlin Bicêtre, F-94276, FranceDipartimento di Medicina Clinica e ChirurgiaSezione di Endocrinologia, Università Federico II di Napoli, Naples, ItalyMedizinische Klinik und Poliklinik IV-InnenstadtUniversity Hospital Munich, D-80336 Munich, GermanyDepartment of EndocrinologyMax Planck Institute of Psychiatry, Munich, GermanyDepartment of EndocrinologyDiabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Aart van der Lely
- ENDOC Center for Endocrine TumorsAltonaer Strasse 59, 20357 Hamburg, GermanyDepartment of EndocrinologyCHU de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, BelgiumEndocrinology UnitDepartment of Internal Medicine and Medical Specialties (DiMI), Center of Excellence for Biomedical Research, IRCCS AOU San Martino-IST, University of Genova, Genova, ItalyDepartment of MedicineErasmus University MC, PO Box 2040, 3000 CA Rotterdam, The NetherlandsSection of Specialized EndocrinologyFaculty of Medicine, Oslo University Hospital, University of Oslo, Oslo, NorwayDivision of EndocrinologyDepartment of Medicine (DIMED), University of Padua, Padua, ItalyAix-Marseille UniversitéCNRS, CRN2M UMR 7286, 13344 Marseille Cedex 15, FranceAPHMHôpital Timone, Service d'Endocrinologie, Diabète et Maladies Métaboliques, 13385 Marseille Cedex 15, FranceDepartment of Epidemiology and PreventionIRCCS AOU San Martino-IST, Genova, ItalySantiago de Compostela University and CIBERobnSantiago de Compostela, SpainUniv Paris-SudFaculté de Médecine Paris-Sud, UMR-S1185, Le Kremlin Bicêtre, F-94276, FranceAssistance Publique-Hôpitaux de ParisHôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Le Kremlin Bicêtre, F-94275, FranceInstitut National de la Santé et de la Recherche Médicale U1185Le Kremlin Bicêtre, F-94276, FranceDipartimento di Medicina Clinica e ChirurgiaSezione di Endocrinologia, Università Federico II di Napoli, Naples, ItalyMedizinische Klinik und Poliklinik IV-InnenstadtUniversity Hospital Munich, D-80336 Munich, GermanyDepartment of EndocrinologyMax Planck Institute of Psychiatry, Munich, GermanyDepartment of EndocrinologyDiabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Jens Bollerslev
- ENDOC Center for Endocrine TumorsAltonaer Strasse 59, 20357 Hamburg, GermanyDepartment of EndocrinologyCHU de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, BelgiumEndocrinology UnitDepartment of Internal Medicine and Medical Specialties (DiMI), Center of Excellence for Biomedical Research, IRCCS AOU San Martino-IST, University of Genova, Genova, ItalyDepartment of MedicineErasmus University MC, PO Box 2040, 3000 CA Rotterdam, The NetherlandsSection of Specialized EndocrinologyFaculty of Medicine, Oslo University Hospital, University of Oslo, Oslo, NorwayDivision of EndocrinologyDepartment of Medicine (DIMED), University of Padua, Padua, ItalyAix-Marseille UniversitéCNRS, CRN2M UMR 7286, 13344 Marseille Cedex 15, FranceAPHMHôpital Timone, Service d'Endocrinologie, Diabète et Maladies Métaboliques, 13385 Marseille Cedex 15, FranceDepartment of Epidemiology and PreventionIRCCS AOU San Martino-IST, Genova, ItalySantiago de Compostela University and CIBERobnSantiago de Compostela, SpainUniv Paris-SudFaculté de Médecine Paris-Sud, UMR-S1185, Le Kremlin Bicêtre, F-94276, FranceAssistance Publique-Hôpitaux de ParisHôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Le Kremlin Bicêtre, F-94275, FranceInstitut National de la Santé et de la Recherche Médicale U1185Le Kremlin Bicêtre, F-94276, FranceDipartimento di Medicina Clinica e ChirurgiaSezione di Endocrinologia, Università Federico II di Napoli, Naples, ItalyMedizinische Klinik und Poliklinik IV-InnenstadtUniversity Hospital Munich, D-80336 Munich, GermanyDepartment of EndocrinologyMax Planck Institute of Psychiatry, Munich, GermanyDepartment of EndocrinologyDiabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Marco Boscaro
- ENDOC Center for Endocrine TumorsAltonaer Strasse 59, 20357 Hamburg, GermanyDepartment of EndocrinologyCHU de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, BelgiumEndocrinology UnitDepartment of Internal Medicine and Medical Specialties (DiMI), Center of Excellence for Biomedical Research, IRCCS AOU San Martino-IST, University of Genova, Genova, ItalyDepartment of MedicineErasmus University MC, PO Box 2040, 3000 CA Rotterdam, The NetherlandsSection of Specialized EndocrinologyFaculty of Medicine, Oslo University Hospital, University of Oslo, Oslo, NorwayDivision of EndocrinologyDepartment of Medicine (DIMED), University of Padua, Padua, ItalyAix-Marseille UniversitéCNRS, CRN2M UMR 7286, 13344 Marseille Cedex 15, FranceAPHMHôpital Timone, Service d'Endocrinologie, Diabète et Maladies Métaboliques, 13385 Marseille Cedex 15, FranceDepartment of Epidemiology and PreventionIRCCS AOU San Martino-IST, Genova, ItalySantiago de Compostela University and CIBERobnSantiago de Compostela, SpainUniv Paris-SudFaculté de Médecine Paris-Sud, UMR-S1185, Le Kremlin Bicêtre, F-94276, FranceAssistance Publique-Hôpitaux de ParisHôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Le Kremlin Bicêtre, F-94275, FranceInstitut National de la Santé et de la Recherche Médicale U1185Le Kremlin Bicêtre, F-94276, FranceDipartimento di Medicina Clinica e ChirurgiaSezione di Endocrinologia, Università Federico II di Napoli, Naples, ItalyMedizinische Klinik und Poliklinik IV-InnenstadtUniversity Hospital Munich, D-80336 Munich, GermanyDepartment of EndocrinologyMax Planck Institute of Psychiatry, Munich, GermanyDepartment of EndocrinologyDiabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Thierry Brue
- ENDOC Center for Endocrine TumorsAltonaer Strasse 59, 20357 Hamburg, GermanyDepartment of EndocrinologyCHU de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, BelgiumEndocrinology UnitDepartment of Internal Medicine and Medical Specialties (DiMI), Center of Excellence for Biomedical Research, IRCCS AOU San Martino-IST, University of Genova, Genova, ItalyDepartment of MedicineErasmus University MC, PO Box 2040, 3000 CA Rotterdam, The NetherlandsSection of Specialized EndocrinologyFaculty of Medicine, Oslo University Hospital, University of Oslo, Oslo, NorwayDivision of EndocrinologyDepartment of Medicine (DIMED), University of Padua, Padua, ItalyAix-Marseille UniversitéCNRS, CRN2M UMR 7286, 13344 Marseille Cedex 15, FranceAPHMHôpital Timone, Service d'Endocrinologie, Diabète et Maladies Métaboliques, 13385 Marseille Cedex 15, FranceDepartment of Epidemiology and PreventionIRCCS AOU San Martino-IST, Genova, ItalySantiago de Compostela University and CIBERobnSantiago de Compostela, SpainUniv Paris-SudFaculté de Médecine Paris-Sud, UMR-S1185, Le Kremlin Bicêtre, F-94276, FranceAssistance Publique-Hôpitaux de ParisHôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Le Kremlin Bicêtre, F-94275, FranceInstitut National de la Santé et de la Recherche Médicale U1185Le Kremlin Bicêtre, F-94276, FranceDipartimento di Medicina Clinica e ChirurgiaSezione di Endocrinologia, Università Federico II di Napoli, Naples, ItalyMedizinische Klinik und Poliklinik IV-InnenstadtUniversity Hospital Munich, D-80336 Munich, GermanyDepartment of EndocrinologyMax Planck Institute of Psychiatry, Munich, GermanyDepartment of EndocrinologyDiabetes and Metabolism, Evangelismos Hospital, Athens, Greece ENDOC Center for Endocrine TumorsAltonaer Strasse 59, 20357 Hamburg, GermanyDepartment of EndocrinologyCHU de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, BelgiumEndocrinology UnitDepartment of Inter
| | - Paolo Bruzzi
- ENDOC Center for Endocrine TumorsAltonaer Strasse 59, 20357 Hamburg, GermanyDepartment of EndocrinologyCHU de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, BelgiumEndocrinology UnitDepartment of Internal Medicine and Medical Specialties (DiMI), Center of Excellence for Biomedical Research, IRCCS AOU San Martino-IST, University of Genova, Genova, ItalyDepartment of MedicineErasmus University MC, PO Box 2040, 3000 CA Rotterdam, The NetherlandsSection of Specialized EndocrinologyFaculty of Medicine, Oslo University Hospital, University of Oslo, Oslo, NorwayDivision of EndocrinologyDepartment of Medicine (DIMED), University of Padua, Padua, ItalyAix-Marseille UniversitéCNRS, CRN2M UMR 7286, 13344 Marseille Cedex 15, FranceAPHMHôpital Timone, Service d'Endocrinologie, Diabète et Maladies Métaboliques, 13385 Marseille Cedex 15, FranceDepartment of Epidemiology and PreventionIRCCS AOU San Martino-IST, Genova, ItalySantiago de Compostela University and CIBERobnSantiago de Compostela, SpainUniv Paris-SudFaculté de Médecine Paris-Sud, UMR-S1185, Le Kremlin Bicêtre, F-94276, FranceAssistance Publique-Hôpitaux de ParisHôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Le Kremlin Bicêtre, F-94275, FranceInstitut National de la Santé et de la Recherche Médicale U1185Le Kremlin Bicêtre, F-94276, FranceDipartimento di Medicina Clinica e ChirurgiaSezione di Endocrinologia, Università Federico II di Napoli, Naples, ItalyMedizinische Klinik und Poliklinik IV-InnenstadtUniversity Hospital Munich, D-80336 Munich, GermanyDepartment of EndocrinologyMax Planck Institute of Psychiatry, Munich, GermanyDepartment of EndocrinologyDiabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Felipe F Casanueva
- ENDOC Center for Endocrine TumorsAltonaer Strasse 59, 20357 Hamburg, GermanyDepartment of EndocrinologyCHU de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, BelgiumEndocrinology UnitDepartment of Internal Medicine and Medical Specialties (DiMI), Center of Excellence for Biomedical Research, IRCCS AOU San Martino-IST, University of Genova, Genova, ItalyDepartment of MedicineErasmus University MC, PO Box 2040, 3000 CA Rotterdam, The NetherlandsSection of Specialized EndocrinologyFaculty of Medicine, Oslo University Hospital, University of Oslo, Oslo, NorwayDivision of EndocrinologyDepartment of Medicine (DIMED), University of Padua, Padua, ItalyAix-Marseille UniversitéCNRS, CRN2M UMR 7286, 13344 Marseille Cedex 15, FranceAPHMHôpital Timone, Service d'Endocrinologie, Diabète et Maladies Métaboliques, 13385 Marseille Cedex 15, FranceDepartment of Epidemiology and PreventionIRCCS AOU San Martino-IST, Genova, ItalySantiago de Compostela University and CIBERobnSantiago de Compostela, SpainUniv Paris-SudFaculté de Médecine Paris-Sud, UMR-S1185, Le Kremlin Bicêtre, F-94276, FranceAssistance Publique-Hôpitaux de ParisHôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Le Kremlin Bicêtre, F-94275, FranceInstitut National de la Santé et de la Recherche Médicale U1185Le Kremlin Bicêtre, F-94276, FranceDipartimento di Medicina Clinica e ChirurgiaSezione di Endocrinologia, Università Federico II di Napoli, Naples, ItalyMedizinische Klinik und Poliklinik IV-InnenstadtUniversity Hospital Munich, D-80336 Munich, GermanyDepartment of EndocrinologyMax Planck Institute of Psychiatry, Munich, GermanyDepartment of EndocrinologyDiabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Philippe Chanson
- ENDOC Center for Endocrine TumorsAltonaer Strasse 59, 20357 Hamburg, GermanyDepartment of EndocrinologyCHU de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, BelgiumEndocrinology UnitDepartment of Internal Medicine and Medical Specialties (DiMI), Center of Excellence for Biomedical Research, IRCCS AOU San Martino-IST, University of Genova, Genova, ItalyDepartment of MedicineErasmus University MC, PO Box 2040, 3000 CA Rotterdam, The NetherlandsSection of Specialized EndocrinologyFaculty of Medicine, Oslo University Hospital, University of Oslo, Oslo, NorwayDivision of EndocrinologyDepartment of Medicine (DIMED), University of Padua, Padua, ItalyAix-Marseille UniversitéCNRS, CRN2M UMR 7286, 13344 Marseille Cedex 15, FranceAPHMHôpital Timone, Service d'Endocrinologie, Diabète et Maladies Métaboliques, 13385 Marseille Cedex 15, FranceDepartment of Epidemiology and PreventionIRCCS AOU San Martino-IST, Genova, ItalySantiago de Compostela University and CIBERobnSantiago de Compostela, SpainUniv Paris-SudFaculté de Médecine Paris-Sud, UMR-S1185, Le Kremlin Bicêtre, F-94276, FranceAssistance Publique-Hôpitaux de ParisHôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Le Kremlin Bicêtre, F-94275, FranceInstitut National de la Santé et de la Recherche Médicale U1185Le Kremlin Bicêtre, F-94276, FranceDipartimento di Medicina Clinica e ChirurgiaSezione di Endocrinologia, Università Federico II di Napoli, Naples, ItalyMedizinische Klinik und Poliklinik IV-InnenstadtUniversity Hospital Munich, D-80336 Munich, GermanyDepartment of EndocrinologyMax Planck Institute of Psychiatry, Munich, GermanyDepartment of EndocrinologyDiabetes and Metabolism, Evangelismos Hospital, Athens, Greece ENDOC Center for Endocrine TumorsAltonaer Strasse 59, 20357 Hamburg, GermanyDepartment of EndocrinologyCHU de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, BelgiumEndocrinology UnitDepartment of Inter
| | - Annamaria Colao
- ENDOC Center for Endocrine TumorsAltonaer Strasse 59, 20357 Hamburg, GermanyDepartment of EndocrinologyCHU de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, BelgiumEndocrinology UnitDepartment of Internal Medicine and Medical Specialties (DiMI), Center of Excellence for Biomedical Research, IRCCS AOU San Martino-IST, University of Genova, Genova, ItalyDepartment of MedicineErasmus University MC, PO Box 2040, 3000 CA Rotterdam, The NetherlandsSection of Specialized EndocrinologyFaculty of Medicine, Oslo University Hospital, University of Oslo, Oslo, NorwayDivision of EndocrinologyDepartment of Medicine (DIMED), University of Padua, Padua, ItalyAix-Marseille UniversitéCNRS, CRN2M UMR 7286, 13344 Marseille Cedex 15, FranceAPHMHôpital Timone, Service d'Endocrinologie, Diabète et Maladies Métaboliques, 13385 Marseille Cedex 15, FranceDepartment of Epidemiology and PreventionIRCCS AOU San Martino-IST, Genova, ItalySantiago de Compostela University and CIBERobnSantiago de Compostela, SpainUniv Paris-SudFaculté de Médecine Paris-Sud, UMR-S1185, Le Kremlin Bicêtre, F-94276, FranceAssistance Publique-Hôpitaux de ParisHôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Le Kremlin Bicêtre, F-94275, FranceInstitut National de la Santé et de la Recherche Médicale U1185Le Kremlin Bicêtre, F-94276, FranceDipartimento di Medicina Clinica e ChirurgiaSezione di Endocrinologia, Università Federico II di Napoli, Naples, ItalyMedizinische Klinik und Poliklinik IV-InnenstadtUniversity Hospital Munich, D-80336 Munich, GermanyDepartment of EndocrinologyMax Planck Institute of Psychiatry, Munich, GermanyDepartment of EndocrinologyDiabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Martin Reincke
- ENDOC Center for Endocrine TumorsAltonaer Strasse 59, 20357 Hamburg, GermanyDepartment of EndocrinologyCHU de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, BelgiumEndocrinology UnitDepartment of Internal Medicine and Medical Specialties (DiMI), Center of Excellence for Biomedical Research, IRCCS AOU San Martino-IST, University of Genova, Genova, ItalyDepartment of MedicineErasmus University MC, PO Box 2040, 3000 CA Rotterdam, The NetherlandsSection of Specialized EndocrinologyFaculty of Medicine, Oslo University Hospital, University of Oslo, Oslo, NorwayDivision of EndocrinologyDepartment of Medicine (DIMED), University of Padua, Padua, ItalyAix-Marseille UniversitéCNRS, CRN2M UMR 7286, 13344 Marseille Cedex 15, FranceAPHMHôpital Timone, Service d'Endocrinologie, Diabète et Maladies Métaboliques, 13385 Marseille Cedex 15, FranceDepartment of Epidemiology and PreventionIRCCS AOU San Martino-IST, Genova, ItalySantiago de Compostela University and CIBERobnSantiago de Compostela, SpainUniv Paris-SudFaculté de Médecine Paris-Sud, UMR-S1185, Le Kremlin Bicêtre, F-94276, FranceAssistance Publique-Hôpitaux de ParisHôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Le Kremlin Bicêtre, F-94275, FranceInstitut National de la Santé et de la Recherche Médicale U1185Le Kremlin Bicêtre, F-94276, FranceDipartimento di Medicina Clinica e ChirurgiaSezione di Endocrinologia, Università Federico II di Napoli, Naples, ItalyMedizinische Klinik und Poliklinik IV-InnenstadtUniversity Hospital Munich, D-80336 Munich, GermanyDepartment of EndocrinologyMax Planck Institute of Psychiatry, Munich, GermanyDepartment of EndocrinologyDiabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Günter Stalla
- ENDOC Center for Endocrine TumorsAltonaer Strasse 59, 20357 Hamburg, GermanyDepartment of EndocrinologyCHU de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, BelgiumEndocrinology UnitDepartment of Internal Medicine and Medical Specialties (DiMI), Center of Excellence for Biomedical Research, IRCCS AOU San Martino-IST, University of Genova, Genova, ItalyDepartment of MedicineErasmus University MC, PO Box 2040, 3000 CA Rotterdam, The NetherlandsSection of Specialized EndocrinologyFaculty of Medicine, Oslo University Hospital, University of Oslo, Oslo, NorwayDivision of EndocrinologyDepartment of Medicine (DIMED), University of Padua, Padua, ItalyAix-Marseille UniversitéCNRS, CRN2M UMR 7286, 13344 Marseille Cedex 15, FranceAPHMHôpital Timone, Service d'Endocrinologie, Diabète et Maladies Métaboliques, 13385 Marseille Cedex 15, FranceDepartment of Epidemiology and PreventionIRCCS AOU San Martino-IST, Genova, ItalySantiago de Compostela University and CIBERobnSantiago de Compostela, SpainUniv Paris-SudFaculté de Médecine Paris-Sud, UMR-S1185, Le Kremlin Bicêtre, F-94276, FranceAssistance Publique-Hôpitaux de ParisHôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Le Kremlin Bicêtre, F-94275, FranceInstitut National de la Santé et de la Recherche Médicale U1185Le Kremlin Bicêtre, F-94276, FranceDipartimento di Medicina Clinica e ChirurgiaSezione di Endocrinologia, Università Federico II di Napoli, Naples, ItalyMedizinische Klinik und Poliklinik IV-InnenstadtUniversity Hospital Munich, D-80336 Munich, GermanyDepartment of EndocrinologyMax Planck Institute of Psychiatry, Munich, GermanyDepartment of EndocrinologyDiabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Stelios Tsagarakis
- ENDOC Center for Endocrine TumorsAltonaer Strasse 59, 20357 Hamburg, GermanyDepartment of EndocrinologyCHU de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, BelgiumEndocrinology UnitDepartment of Internal Medicine and Medical Specialties (DiMI), Center of Excellence for Biomedical Research, IRCCS AOU San Martino-IST, University of Genova, Genova, ItalyDepartment of MedicineErasmus University MC, PO Box 2040, 3000 CA Rotterdam, The NetherlandsSection of Specialized EndocrinologyFaculty of Medicine, Oslo University Hospital, University of Oslo, Oslo, NorwayDivision of EndocrinologyDepartment of Medicine (DIMED), University of Padua, Padua, ItalyAix-Marseille UniversitéCNRS, CRN2M UMR 7286, 13344 Marseille Cedex 15, FranceAPHMHôpital Timone, Service d'Endocrinologie, Diabète et Maladies Métaboliques, 13385 Marseille Cedex 15, FranceDepartment of Epidemiology and PreventionIRCCS AOU San Martino-IST, Genova, ItalySantiago de Compostela University and CIBERobnSantiago de Compostela, SpainUniv Paris-SudFaculté de Médecine Paris-Sud, UMR-S1185, Le Kremlin Bicêtre, F-94276, FranceAssistance Publique-Hôpitaux de ParisHôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Le Kremlin Bicêtre, F-94275, FranceInstitut National de la Santé et de la Recherche Médicale U1185Le Kremlin Bicêtre, F-94276, FranceDipartimento di Medicina Clinica e ChirurgiaSezione di Endocrinologia, Università Federico II di Napoli, Naples, ItalyMedizinische Klinik und Poliklinik IV-InnenstadtUniversity Hospital Munich, D-80336 Munich, GermanyDepartment of EndocrinologyMax Planck Institute of Psychiatry, Munich, GermanyDepartment of EndocrinologyDiabetes and Metabolism, Evangelismos Hospital, Athens, Greece
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Pendharkar AV, Sussman ES, Ho AL, Hayden Gephart MG, Katznelson L. Cushing's disease: predicting long-term remission after surgical treatment. Neurosurg Focus 2015; 38:E13. [DOI: 10.3171/2014.10.focus14682] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Cushing's disease (CD) is a state of excess glucocorticoid production resulting from an adrenocorticotropic hormone (ACTH)–secreting pituitary adenoma. The gold-standard treatment for CD is transsphenoidal adenomectomy. In the hands of an experienced neurosurgeon, gross-total resection is possible in the majority of ACTH-secreting pituitary adenomas, with early postoperative remission rates ranging from 67% to 95%. In contrast to the strong data in support of resection, the clinical course of postsurgical persistent or recurrent disease remains unclear. There is significant variability in recurrence rates, with reports as high as 36% with a mean time to recurrence of 15–50 months. It is therefore important to develop biochemical criteria that define postsurgical remission and that may provide prognosis for long-term recurrence. Despite the use of a number of biochemical assessments, there is debate regarding the accuracy of these tests in predicting recurrence. Here, the authors review the various biochemical criteria and assess their utility in predicting CD recurrence after resection.
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Affiliation(s)
| | | | | | | | - Laurence Katznelson
- Departments of 1Neurosurgery and
- 2Medicine, Stanford University School of Medicine, Stanford, California
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Abstract
A case of possible recurrent Cushing's disease (CD) is presented and data on current definitions of CD remission, persistence, and recurrence are reviewed. While prevailing guidelines recommend the use of serum cortisol in the first post-operative week for defining initial remission and predicting sustained remission, with the use of 24 h urinary free cortisol measurements if serum cortisol values are equivocal, there is debate as to which methods and thresholds best define CD remission and predict successful outcomes. Other methods used to define remission (and hence persistence and recurrence) include restoration of cortisol suppression after dexamethasone and physiologic diurnal cortisol rhythm as measured by midnight salivary free cortisol. However, the number and degree of abnormal test results needed to define recurrence, and the determination of which biochemical test has more significance when there are discrepancies between markers is inconsistent among studies. Further inquiry is warranted to examine if patients in apparent CD remission who have subtle hypothalamic pituitary adrenal (HPA) axis abnormalities represent distinctive remission subtypes versus mild or early recurrence. Additional investigation could also explore the degree to which these HPA axis abnormalities, such as alterations in cortisol circadian rhythm or partial resistance to dexamethasone, are associated with persistence of CD morbidities, including neuropsychiatric impairments, alterations in body composition, and cardiovascular risk.
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Affiliation(s)
- Eliza B. Geer
- Assistant Professor of Medicine and Neurosurgery, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1055, New York, NY 10029, Tel: 212-241-6139, Faxt: 212-423-0508,
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van den Bosch OFC, Stades AME, Zelissen PMJ. Increased long-term remission after adequate medical cortisol suppression therapy as presurgical treatment in Cushing's disease. Clin Endocrinol (Oxf) 2014; 80:184-90. [PMID: 23841642 DOI: 10.1111/cen.12286] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Revised: 02/26/2013] [Accepted: 07/08/2013] [Indexed: 11/27/2022]
Abstract
OBJECTIVE In the last decade, pre-operative medical cortisol suppression therapy has frequently been used in Cushing's disease to normalize cortisol concentrations pre-operatively. Our aim was to assess the efficacy of presurgical medical cortisol suppression therapy in Cushing's disease. DESIGN AND METHODS We retrospectively assessed the medical files of all patients with Cushing's disease that received presurgical cortisol suppression therapy with ketoconazole or metyrapone and underwent subsequent transsphenoidal surgery between 1990 and 2010 at our centre. We retrieved the pretreatment regimen, adequacy of pretreatment, early postoperative serum cortisol levels, adverse effects and long-term remission status. RESULTS Nineteen of 33 patients (58%) obtained long-term remission after pituitary surgery without additional postoperative therapy. Thirteen of 16 patients with adequate presurgical cortisol suppression therapy had postoperative cortisol concentrations <50 nmol/l. The 16 patients with adequate presurgical cortisol suppression had a higher long-term remission rate after primary surgery compared with the 13 patients with borderline or inadequate pretreatment (81% vs 38%; P < 0·05). CONCLUSIONS Adequate presurgical cortisol suppression treatment with ketoconazole or metyrapone in Cushing's disease seems to be associated with suppressed postoperative cortisol concentrations and an increased long-term remission rate.
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Affiliation(s)
- O F C van den Bosch
- Department of Internal Medicine, Section of Endocrinology, University Medical Center Utrecht, Utrecht, The Netherlands
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Sheth SA, Bourne SK, Tritos NA, Swearingen B. Neurosurgical Treatment of Cushing Disease. Neurosurg Clin N Am 2012; 23:639-51. [DOI: 10.1016/j.nec.2012.06.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Roelfsema F, Biermasz NR, Pereira AM. Clinical factors involved in the recurrence of pituitary adenomas after surgical remission: a structured review and meta-analysis. Pituitary 2012; 15:71-83. [PMID: 21918830 PMCID: PMC3296023 DOI: 10.1007/s11102-011-0347-7] [Citation(s) in RCA: 232] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
To study the currently available data of recurrence rates of functioning and nonfunctioning pituitary adenomas following surgical cure and to analyze associated predisposing factors, which are not well established. A systematic literature search was conducted using Medline, Embase, Web of Science and the Cochran Library for studies reporting data on recurrence of pituitary adenoma after surgery, in nonfunctioning adenoma (NF), prolactinoma (PRL) acromegaly (ACRO) and Cushing's disease (CUSH). Of 557 initially retrieved potential relevant studies 143 were selected. Recurrence in NFA was defined as reappearance of tumor on MRI or CT. Increase of hormone levels above normal limits as set by the authors after initial remission was used to indicate recurrence in the functioning tumor types. Remission percentage was lowest in NFA compared with other tumor types (P < 0.001). Surgery-related hypopituitarism was more frequent in CUSH than in the other tumors (P < 0.001). Recurrence, expressed as percentage of the cured population or as ratio of recurrence and total patient years of follow-up was highest in PRL (P < 0.001). The remission percentage did not improve over 3 decades of publications, but there was a modest decrease in recurrence rate (P = 0.04). Recurrences peaked between 1 and 5 years after surgery. Most of the studies with a sufficient number of recurrences did not apply multivariate statistics, and mentioned at best associated factors. Age, gender, tumor size and invasion were generally unrelated to recurrence. For functioning adenomas a low postoperative hormone concentration was a prognostically favorable factor. In NFA no specific factor predicted recurrence. Recurrence rate differs between pituitary adenomas, being highest in patients with prolactinoma, with the highest incidence of recurrence between 1 and 5 years after surgery in all adenomas. Patients with NFA have a lower chance of remission than patients with functioning adenomas. The postoperative basal hormone level is the most important predictor for recurrence in functioning adenomas, while in NFA no single convincing factor could be identified.
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Affiliation(s)
- Ferdinand Roelfsema
- Department of Endocrinology and Metabolic Diseases, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands.
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Ciric I, Zhao JC, Du H, Findling JW, Molitch ME, Weiss RE, Refetoff S, Kerr WD, Meyer J. Transsphenoidal surgery for Cushing disease: experience with 136 patients. Neurosurgery 2012; 70:70-80; discussion 80-1. [PMID: 21772221 PMCID: PMC4051420 DOI: 10.1227/neu.0b013e31822dda2c] [Citation(s) in RCA: 89] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND This is a retrospective study of 136 patients with Cushing disease treated with transsphenoidal microsurgery. OBJECTIVE To evaluate factors influencing immediate postoperative results and long-term outcomes. METHODS Data regarding clinical presentation, endocrine evaluation, imaging studies, surgical technique, immediate postoperative biochemical remission (IPBR), and long-term results were entered into a database and analyzed statistically. IPBR was based on biochemical evidence of adrenal cortical insufficiency and clinical evidence of such insufficiency. RESULTS IPBR for the entire series was 83.4%. In microadenomas, IPBR was 89.8% with a mean immediate postoperative plasma cortisol (IPPC) of 2.1 μg/dL (range, <0.5-5.3). Positive magnetic resonance imaging (MRI) was associated with 18 times greater odds of finding microadenoma at surgery (P < .001) and with 4.1 times greater odds of IPBR (P = .07). In patients with a negative MRI, a positive inferior petrosal sinus sampling (IPSS) test was associated with 93% of IPBR (P = .004). IPBR in macroadenomas was 30.7%. Of patients followed for 12 months or longer, 34.8% required glucocorticoid replacement for the duration of follow-up. The mean follow-up in microadenomas was 68.4 months with a 9.67% incidence of recurrences. The estimated actuarial incidence of recurrences increased with the passage of time and IPPC of greater than 2 μg/dL was associated with higher incidence of recurrences, although without statistical significance (P = .08). CONCLUSION In microadenomas, a positive MRI and positive IPSS test were associated with a higher incidence of IPBR. Recurrences increased with the passage of time, and an IPPC of greater than 2 μg/dL may be associated with higher incidence of recurrences.
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Affiliation(s)
- Ivan Ciric
- NorthShore University HealthSystem, University of Chicago, Pritzker School of Medicine, Evanston, Illinois 60201, USA.
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Lindsay JR, Oldfield EH, Stratakis CA, Nieman LK. The postoperative basal cortisol and CRH tests for prediction of long-term remission from Cushing's disease after transsphenoidal surgery. J Clin Endocrinol Metab 2011; 96:2057-64. [PMID: 21508126 PMCID: PMC3135190 DOI: 10.1210/jc.2011-0456] [Citation(s) in RCA: 101] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Selective adenomectomy via transsphenoidal surgery induces remission of Cushing's disease (CD) in most patients. Although an undetectable postoperative serum cortisol (<2 μg/dl) has been advocated as an index of remission, there is no consensus on predictors of recurrence. OBJECTIVE We hypothesized that patients with subnormal cortisol (2-4.9 μg/dl) might achieve long-term remission and that postoperative responses to CRH might predict recurrence. DESIGN, SETTING, AND PARTICIPANTS We prospectively studied CD patients with initial remission after adenomectomy or hemihypophysectomy (n = 14). Long-term recurrence (n = 39) or remission (n = 293) was assigned by laboratory results, glucocorticoid dependence, or patient survey at a mean of 10.6 yr after surgery. INTERVENTION AND MAIN OUTCOME MEASURES Postoperatively, morning cortisol was measured on d 3-5, and cortisol and ACTH responses to ovine CRH were assessed around d 10. RESULTS Follow-up duration was median 11 yr (range 1-22.8 yr). Fewer patients achieved a cortisol nadir below 2 μg/dl (87%) than below 5 μg/dl (98%), yet recurrence rates were similar (<2 μg/dl, 9.5%; <5 μg/dl, 10.4%; 2-4.9 μg/dl, 20%; not significant). CRH-stimulated cortisol (P < 0.002) and ACTH (P = 0.04) values were higher for the recurrence than the remission group. However, no basal or stimulated ACTH or serum or urine cortisol cutoff value predicted all who later recurred. CONCLUSIONS A postoperative cortisol below 2 μg/dl predicts long-term remission after transsphenoidal surgery in CD. Remission in those with intermediate d 3-5 postoperative cortisol values (2-4.9 μg/dl) suggests that these patients do not require immediate reoperation. However, because no single cortisol cutoff value excludes all patients with recurrence, all require long-term clinical follow-up.
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Affiliation(s)
- John R Lindsay
- National Institute of Neurologic Disorders and Stroke, National Institutes of Health, Bethesda, Maryland 20892, USA
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Abstract
Cushing disease is caused by a corticotroph tumor of the pituitary gland. Patients with Cushing disease are usually treated with transsphenoidal surgery, as this approach leads to remission in 70-90% of cases and is associated with low morbidity when performed by experienced pituitary gland surgeons. Nonetheless, among patients in postoperative remission, the risk of recurrence of Cushing disease could reach 20-25% at 10 years after surgery. Patients with persistent or recurrent Cushing disease might, therefore, benefit from a second pituitary operation (which leads to remission in 50-70% of cases), radiation therapy to the pituitary gland or bilateral adrenalectomy. Remission after radiation therapy occurs in ∼85% of patients with Cushing disease after a considerable latency period. Interim medical therapy is generally advisable after patients receive radiation therapy because of the long latency period. Bilateral adrenalectomy might be considered in patients who do not improve following transsphenoidal surgery, particularly patients who are very ill and require rapid control of hypercortisolism, or those wishing to avoid the risk of hypopituitarism associated with radiation therapy. Adrenalectomized patients require lifelong adrenal hormone replacement and are at risk of Nelson syndrome. The development of medical therapies with improved efficacy might influence the management of this challenging condition.
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Affiliation(s)
- Nicholas A Tritos
- Neuroendocrine Unit, Zero Emerson Place, Suite 112, Massachusetts General Hospital, Boston, MA 02114, USA.
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Hofstetter CP, Shin BJ, Mubita L, Huang C, Anand VK, Boockvar JA, Schwartz TH. Endoscopic endonasal transsphenoidal surgery for functional pituitary adenomas. Neurosurg Focus 2011; 30:E10. [DOI: 10.3171/2011.1.focus10317] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The purpose of this study was to analyze preoperative predictors of endocrinological remission following endonasal endoscopic resection of therapy-resistant prolactin-, growth hormone (GH)–, and adrenocorticotropic hormone (ACTH)–secreting pituitary adenomas and to establish benchmarks for cure by using the most recent consensus criteria.
Methods
The authors reviewed a prospective database of 86 consecutive functional pituitary adenomas that were resected by a purely endoscopic endonasal transsphenoidal technique. Extent of resection was evaluated on postoperative contrast-enhanced MR imaging. Endocrinological remission was defined according to the most recent consensus criteria.
Results
The majority of functional adenomas (62.8%) were classified as macroadenomas (> 1 cm in maximum diameter), and 20.9% of lesions had invaded the cavernous sinus (CS) at the time of surgery. A gross-total resection was achieved in 75.6% of all patients. The rate of endocrinological remission differed between various types of functional adenomas. Cure rates were 92.3% (microadenomas) and 57.1% (macroadenomas) for prolactinomas, 75% (microadenomas) and 40% (macroadenomas) for GH-secreting tumors, and 54.5% (microadenomas) and 71.4% (macroadenomas) for ACTH-secreting tumors. Lower rates of cure occurred in GH-secreting macroadenomas due to a high rate of CS invasion, and in ACTH-secreting adenomas due to a high rate of lesions that were not visible on preoperative MR imaging. Whereas univariate analysis showed that macroadenoma, suprasellar, cavernous extension, or extent of resection correlated with cure, on multivariate analysis, only extent of resection and suprasellar extension predicted cure. One patient developed postoperative meningitis that was complicated by hydrocephalus requiring a ventriculoperitoneal shunt. Two patients developed postoperative panhypopituitarism, and 2 patients suffered from CSF leaks, which were treated with lumbar CSF diversion.
Conclusions
This paper reports benchmarks for endocrinological cure as well as complications in a large series of purely endoscopic pituitary surgeries by using the most recent consensus criteria. The advantages of extended endonasal approaches are most profound in tumors with suprasellar extension and CS invasion.
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Affiliation(s)
| | | | | | | | | | | | - Theodore H. Schwartz
- 1Departments of Neurological Surgery,
- 2Otolaryngology, and
- 3Neurology and Neuroscience, Weill Cornell Medical College, New York–Presbyterian Hospital, New York, New York
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Tratamiento de la enfermedad de Cushing. Cirugía transesfenoidal y radioterapia hipofisaria. ACTA ACUST UNITED AC 2009; 56:123-31. [DOI: 10.1016/s1575-0922(09)70842-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2008] [Accepted: 02/02/2009] [Indexed: 11/20/2022]
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Fomekong E, Maiter D, Grandin C, Raftopoulos C. Outcome of transsphenoidal surgery for Cushing's disease: a high remission rate in ACTH-secreting macroadenomas. Clin Neurol Neurosurg 2009; 111:442-9. [PMID: 19200645 DOI: 10.1016/j.clineuro.2008.12.011] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2008] [Revised: 12/02/2008] [Accepted: 12/24/2008] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Although numerous studies have shown that transsphenoidal surgery is the best initial treatment for Cushing disease offering 59-95% of success, fewer information is available on the long-term outcome in the subgroup of patients harboring ACTH-secreting macroadenomas. The aims of this study were to analyze our 10-year experience with transsphenoidal surgery in Cushing's disease and to examine whether remission rates were different between micro- and macroadenomas. PATIENTS AND METHODS Forty consecutive patients with proven Cushing's disease (28 microadenomas, 12 macroadenomas [diameter: 10-25 mm], 3 patients with no visible adenoma at MRI) underwent transsphenoidal surgery (TSS) assisted by neuronavigation in our center between 1996 and 2007. The diagnosis was made using standard endocrinological criteria including bilateral inferior petrosal sinus sampling (BIPSS) with CRH stimulation in all patients with discordant or equivocal biochemical and radiological testing. Morning serum cortisol was measured during the first week postoperatively, and a complete endocrine evaluation was made in all patients at 6-8 weeks. Remission at follow-up was defined as a normal postoperative 24-h urinary free cortisol (UFC) or continued need for glucocorticoid hormone replacement after TSS. RESULTS Overall, 32/40 patients (80%) were in remission after one or more TSS. Interestingly, a very good remission rate (92%) was observed in the subset of macroadenomas, similar to that found in the group of microadenomas (84%, NS), while no post-surgical remission was observed in the 3 patients with no visible adenoma at MRI (p<0.01). Of the 8 patients not in remission after repeated TSS surgery, 3 underwent radiation therapy and three had bilateral adrenalectomy, allowing remission of their hypercortisolism. There was minor morbidity and no death. CONCLUSION While our overall results are in accordance with other published series, we show here that ACTH-secreting pituitary macroadenomas are usually not associated with a bad outcome, in contrast with patients with no visible adenoma at preoperative MRI.
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Affiliation(s)
- Edward Fomekong
- Department of Neurosurgery, Cliniques, Cliniques Universitaires Saint Luc Brussels, Université Catholique de Louvain, Belgium
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30
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Rollin G, Ferreira NP, Czepielewski MA. Prospective evaluation of transsphenoidal pituitary surgery in 108 patients with Cushing's disease. ACTA ACUST UNITED AC 2008; 51:1355-61. [PMID: 18209874 DOI: 10.1590/s0004-27302007000800022] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2007] [Accepted: 10/10/2007] [Indexed: 11/22/2022]
Abstract
Transsphenoidal pituitary surgery (TSS) remains the treatment of choice for Cushing's disease (CD). Despite the widespread acceptance of this procedure as the first line treatment in CD, the indication of a second TSS in not cured or relapsed DC patients is not consensus. We report the results of TSS in 108 patients with CD (a total of 117 surgeries). The mean postoperative follow-up period was 6 years. Remission was defined as clinical and laboratorial signs of adrenal insufficiency, period of glucocorticoid dependence, serum cortisol suppression on oral 1-mg dexamethasone overnight suppression test and clinical remission of hypercortisolism. We evaluated 103 patients with CD by the time of the first TSS. Fourteen patients underwent second TSS (5 had already been operated in others centers; in 5 patients the first surgery was not curative; in 4 patients CD relapsed). Remission rates were 85.4% and 28.6% (p < 0.001) after first and second TSS, respectively. In microadenomas, remission rates were higher than macroadenomas (94.9% vs. 73.9%; p = 0.006). In patients with negative pituitary imaging remission rates were 71.4% (p = 0.003; vs. microadenomas). Postoperative complications were: transient diabetes insipidus, definitive diabetes insipidus, hypopituitarism, stroke and one death. Only hypopituitarism was more frequent after second TSS (p = 0.015). In conclusion, TSS for CD is an effective and safe treatment. The best remission rates were observed at the first surgery and in microadenomas. The low remission rates after a second TSS suggest that this approach could not be a good therapeutic choice when the first one was not curative.
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Affiliation(s)
- Guilherme Rollin
- Division of Endocrinology, Hospital de Clínicas de Porto Alegre, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS.
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Albiger NME, Scaroni CM, Mantero F. Cyclic Cushing's syndrome: an overview. ACTA ACUST UNITED AC 2008; 51:1253-60. [PMID: 18209863 DOI: 10.1590/s0004-27302007000800011] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2007] [Accepted: 09/21/2007] [Indexed: 11/22/2022]
Abstract
Cyclic Cushing's syndrome (CS) is a disorder in which glucocorticoid levels are alternately normal and high, the latter occurring in episodes that can last from a few days to several months. It is more common in children than in adults. Cyclic CS may be either of the two different forms of CS (ACTH-dependent or -independent CS). Clinically, it may present with one or many symptoms, depending on the duration of disease activity and the timing of the fluctuations. A serotoninergic influence, cyclic changes in central dopaminergic tone, spontaneous episodic hemorrhage in the tumor, and the action of inflammatory cytokines with antitumor properties are some of the mechanisms suggested to explain the physiopathology of this phenomenon but the exact mechanism remains to be clarified. The cyclic pattern of hypercortisolism can delay the final diagnosis of CS and make it difficult to interpret the results of dynamic tests. Patients may have paradoxical responses to dexamethasone that can reflect increasing or decreasing levels of endogenous activity. Hormone assessments have to be repeated periodically when a diagnosis of CS is suspected. The cyclic pattern can also interfere with medical treatment because patients may show unexpected clinical and biochemical signs of hypocortisolism when cortisol secretion cyclically returns to normal, so an accurate follow-up is mandatory in these patients.
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Prevedello DM, Pouratian N, Sherman J, Jane JA, Vance ML, Lopes MB, Laws ER. Management of Cushing's disease: outcome in patients with microadenoma detected on pituitary magnetic resonance imaging. J Neurosurg 2008; 109:751-9. [PMID: 18826366 DOI: 10.3171/jns/2008/109/10/0751] [Citation(s) in RCA: 100] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Outcomes of therapy for Cushing's disease (CD) vary depending on different aspects of presentation and diagnostic studies. The authors designed this study to verify the remission rate and outcomes after transsphenoidal surgery (TSS) for patients with CD who had positive findings on MR imaging. METHODS Patients who had presented with CD at the University of Virginia for initial treatment between July 1992 and December 2005 were retrospectively reviewed. The patients included in the study were considered to be optimal surgical candidates, defined as an adult (>18 years of age) with classic clinical features of CD, laboratory studies confirming a central (pituitary/hypothalamic) adrenocorticotropic hormone-dependent source of disease, and an MR imaging study revealing a microadenoma in the sella turcica. RESULTS A total of 167 patients fulfilled the criteria. Thirty were men (18%) and 137 were women (82%). The mean age was 42.3 years (range 18.2-77 years). All patients underwent TSS. Surgical remission was achieved in 148 patients (88.6%), which was correlated with the surgeon's intraoperative identification of an adenoma (p=0.03). Histopathological confirmation of an adrenocorticotropic hormone-secreting adenoma strongly correlated with remission (p=0.0001). Three patients (1.8%) had postoperative cerebrospinal fluid leaks, and 1 patient had meningitis. Transient diabetes insipidus was diagnosed and treated in 10 patients (6%), whereas permanent diabetes insipidus occurred in 8 patients (4.8%). Panhypopituitarism followed the surgery in 14 patients (8.3%), 13 of whom underwent total hypophysectomy (9 initially and 4 with early reoperations), and in 1 of 10 patients who underwent subtotal hypophysectomy. Nineteen patients (12.8%) who were initially in remission developed recurrent CD after an average of 50 months. The mean follow-up for the 167 patients was 39 months (range 6-157 months). Gamma Knife surgery was the most common modality of radiotherapy used to treat 31 patients (18.5%) who did not achieve remission or later presented with recurrent disease. Bilateral adrenalectomies were performed in 10 patients in the series (6%), 2 of whom developed Nelson's syndrome. The overall posttreatment remission rate was 95.8%. CONCLUSIONS Even in patients with ideal diagnostic criteria of CD, there remain a significant number of cases in which TSS alone is not adequate to assure long-lasting remission. A multidisciplinary approach is essential to the achievement of satisfactory overall remission rates.
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Affiliation(s)
- Daniel M Prevedello
- Department of Neurological Surgery, University of Pittsburgh, School of Medicine, Pittsburgh, Pennsylvania, USA
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Dehdashti AR, Ganna A, Karabatsou K, Gentili F. PURE ENDOSCOPIC ENDONASAL APPROACH FOR PITUITARY ADENOMAS. Neurosurgery 2008; 62:1006-15; discussion 1015-7. [PMID: 18580798 DOI: 10.1227/01.neu.0000325862.83961.12] [Citation(s) in RCA: 324] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Amir R Dehdashti
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada.
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Dehdashti AR, Ganna A, Karabatsou K, Gentili F. PURE ENDOSCOPIC ENDONASAL APPROACH FOR PITUITARY ADENOMAS. Neurosurgery 2008. [DOI: 10.1227/01.neu.0000297072.75304.89] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Patil CG, Prevedello DM, Lad SP, Vance ML, Thorner MO, Katznelson L, Laws ER. Late recurrences of Cushing's disease after initial successful transsphenoidal surgery. J Clin Endocrinol Metab 2008; 93:358-62. [PMID: 18056770 DOI: 10.1210/jc.2007-2013] [Citation(s) in RCA: 236] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Few studies have systematically analyzed the long-term recurrence rates of Cushing's disease after initial successful transsphenoidal surgery. SETTING This was a retrospective review of patients treated at the University of Virginia Medical Center. PATIENTS A total of 215 subjects with Cushing's disease who underwent initial transsphenoidal surgery for resection of a presumed pituitary microadenoma from 1992-2006 were included. MAIN OUTCOME MEASURES Remission and recurrence rates of Cushing's disease were examined. Recurrence was defined as an elevated 24-h urine free cortisol with clinical symptoms consistent with Cushing's disease. RESULTS Of the 215 patients who underwent transsphenoidal surgery for Cushing's disease, surgical remission was achieved in 184 (85.6%). The mean length of follow-up was 45 months. Actuarial recurrence rates of Cushing's disease after initially successful transsphenoidal surgery at 1, 2, 3, and 5 yr were 0.5, 6.7, 10.8, and 25.5%, respectively. Among the 184 patients who achieved remission, 32 (17.4%) patients followed for more than 6 months ultimately had a recurrence of Cushing's disease. The median time to recurrence was 39 months. Immediate postoperative hypocortisolemia (serum cortisol < or = 2 microg/dl within 72-h surgery) was achieved in 97 (45.1%) patients. Patients who had postoperative serum cortisol of more than 2 microg/dl were 2.5 times more likely to have a recurrence than patients who had serum cortisol less than or equal to 2 microg/dl (odds ratio = 2.5; 95% confidence interval 1.12-5.52; P = 0.022). CONCLUSIONS A quarter of the patients with Cushing's disease who achieve surgical remission after transsphenoidal surgery, recur with long-term follow-up. This finding emphasizes the need for continued biochemical and clinical follow-up to ensure remission after surgery.
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Affiliation(s)
- Chirag G Patil
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California 94305, USA.
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Biochemical remission and recurrence rate of secreting pituitary adenomas after transsphenoidal adenomectomy: long-term endocrinologic follow-up results. ACTA ACUST UNITED AC 2008; 68:513-8; discussion 518. [PMID: 17961741 DOI: 10.1016/j.surneu.2007.05.057] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2007] [Accepted: 05/28/2007] [Indexed: 11/20/2022]
Abstract
BACKGROUND Transsphenoidal surgery is safe and effective in patients with secreting pituitary adenomas; however, variable outcomes have been reported according to the different criteria used to define the biochemical remission of hormone hypersecretion. We report the long-term endocrinologic follow-up results of a large cohort of patients who underwent TSS for secreting pituitary adenomas according to the most recent stringent criteria of cure. METHODS Two hundred ten consecutive patients were operated on by TSS between 1995 and 2004 for a secreting pituitary adenoma (65 PRL-, 109 GH-, and 36 ACTH-secreting adenomas) and were considered for the study. RESULTS The overall remission rate was 65% for the whole series, being 64%, 61%, and 75% for PRL-, GH-, and ACTH-secreting adenomas, respectively. Eighty-six percent of microadenomas and 53% of macroadenomas were cured by surgery. Remission rates were significantly higher in GH- and ACTH-secreting pituitary macroadenomas than in macroprolactinomas. At a median follow-up of 56 months, tumor recurrence was 0%, 11%, and 14% for GH-, ACTH-, and PRL-secreting tumors. Tumor size, cavernous sinus invasion, and high hormone levels were negatively correlated to the outcome. CONCLUSION Transsphenoidal surgery remains an effective treatment for secreting pituitary tumors according to the most recent criteria of cure. Patients with PRL- or ACTH-secreting adenomas may recur after apparently successful surgery, thereby justifying long-term careful endocrinologic follow-up.
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Abstract
✓ A contemporary review of the use of stereotactic radiosurgery in the treatment of Cushing disease (CD) is presented with information drawn from a literature review and from the author's experience. Stereotactic radiosurgery is an effective and safe therapeutic alternative for treating CD in carefully selected cases. Improvements in imaging, dose planning, and general understanding of radiobiology are likely to yield better results in the future.
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Czepielewski MA, Rollin GA, Casagrande A, Ferreira NP. Criteria of cure and remission in Cushing's disease: an update. ACTA ACUST UNITED AC 2007; 51:1362-72. [DOI: 10.1590/s0004-27302007000800023] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2007] [Accepted: 10/30/2007] [Indexed: 11/22/2022]
Abstract
We review the clinical and biochemical criteria used for evaluation of the transsphenoidal pituitary surgery results in the treatment of Cushing's disease (CD). Firstly, we discuss the pathophysiology of the hypothalamic-pituitary-adrenal axis in normal subjects and patients with CD. Considering the series published in the last 25 years, we observed a significant variation in the remission or cure criteria, including the choice of biochemical tests, timing, threshold values to define remission, and the interference of glucocorticoid replacement or previous treatment. In this context we emphasize serum cortisol levels obtained early (from hours to 12 days) in the postoperative period without any glucocorticoid replacement or treatment. Our experience demonstrates that: (i) early cortisol < 5 to 7 µg/dl, (ii) a period of glucocorticoid dependence > 6 mo, (iii) absence of response of cortisol/ACTH to CRH or DDAVP, (iv) return of dexamethasone suppression, and circadian rhythm of cortisol are appropriate indices of remission of CD. In patients with undetectable cortisol levels early after surgery, recurrence seems to be low. Finally, although certain biochemical patterns are more suggestive of remission or surgical failure, none has been proven to be completely accurate, with recurrence observed in approximately 10 to 15% of the patients in long-term follow-up. We recommended that patients with CD should have long-term monitoring of the CRH-ACTH-cortisol axis and associated co-morbidities, especially hypopituitarism, diabetes mellitus, hypertension, cardiovascular disturbances, and osteoporosis.
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Dehdashti AR, Gentili F. Current state of the art in the diagnosis and surgical treatment of Cushing disease: early experience with a purely endoscopic endonasal technique. Neurosurg Focus 2007; 23:E9. [DOI: 10.3171/foc.2007.23.3.11] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Transsphenoidal pituitary surgery is the primary therapy for Cushing disease because of its potential to produce lasting remission without the need for long-term drug or hormone replacement therapy. The authors evaluated the current role of pure endoscopic endonasal pituitary surgery in the treatment of Cushing disease.
Methods
Twenty-five patients underwent pure endoscopic surgery for confirmed Cushing disease. Thirteen patients had microadenomas and seven had macroadenomas; magnetic resonance images obtained in five patients were only suspicious or nondiagnostic, and thus they underwent inferior petrosal sinus sampling. Two patients had evidence of cavernous sinus involvement. Final histological results were consistent with adrenocorticotropin hormone (ACTH)–secreting adenoma in 20 patients.
Results
Twenty patients (80%) had clinical remission and laboratory confirmation of hypocortisolemia (serum cortisol < 100 nmol/L requiring substitution therapy), suppression to low-dose dexamethasone, and normal 24-hour urinary free cortisol. The median follow-up period was 17 months (range 3–32 months). There was no recurrence at the time of the last follow-up. Three patients presented with new anterior pituitary deficiency, but no one had permanent diabetes insipidus. In one patient a cerebrospinal fluid leak developed but later resolved following lumbar drainage. Treatment failure was attributable to involvement of the cavernous sinus in two patients, incomplete tumor removal in one, negative exploration in one, and nodular corticotroph hyperplasia of the pituitary gland in one.
Conclusions
Early results indicated that endoscopic endonasal surgery is a safe and effective treatment for ACTH-producing adenomas. The rate of remission in this study is comparable to those in previous series, and the rate of major postoperative complications is extremely low. Further studies with a larger number of patients and longer follow-ups are required to determine whether this more minimally invasive pure endoscopic approach should become the standard of care for the surgical treatment of Cushing disease.
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Pouratian N, Prevedello DM, Jagannathan J, Lopes MB, Vance ML, Laws ER. Outcomes and management of patients with Cushing's disease without pathological confirmation of tumor resection after transsphenoidal surgery. J Clin Endocrinol Metab 2007; 92:3383-8. [PMID: 17595252 DOI: 10.1210/jc.2007-0208] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
CONTEXT Despite the success of transsphenoidal surgery (TSS) for the treatment of Cushing's disease, in a number of cases, an ACTH-staining pituitary adenoma is not identified histologically. The clinical significance of lack of histological confirmation remains unclear. SETTING This was a retrospective review of patients treated at the University of Virginia Medical Center. PATIENTS Of 490 TSS procedures for Cushing's disease between 1993 and 2004, we identified 111 cases without histological adenoma confirmation. MAIN OUTCOME MEASURE Remission and recurrence of Cushing's disease were measured. RESULTS Overall, 50% of these patients achieved remission, a figure lower than for our entire series (79%) and for patients with histological confirmation of an ACTH-staining adenoma (88%) (P < 0.001). Patients with a history of two prior TSS achieved remission less often than patients with a history of fewer TSS (P = 0.026). No other factors influenced remission rates. Although the overall recurrence rate (21%, seven of 33 evaluated) was not different from previously published long-term studies, in three of seven cases of recurrence, early recurrences were noted between 2 and 4 months after remission. In patients who did not achieve remission, the most common and effective treatment options were repeat TSS, gamma-knife radiosurgery, and bilateral adrenalectomy. CONCLUSION The lower remission rate in patients without histological evidence of an adenoma is most likely a result of a decreased rate of adenoma extirpation. The incidence of early recurrence may be a unique feature of this patient population; patients without histological confirmation of tumor resection therefore require close and consistent monitoring postoperatively.
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Affiliation(s)
- Nader Pouratian
- Department of Neurological Surgery, University of Virginia, Box 800212, Charlottesville, Virginia 22903, USA.
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Liu W, Kunishio K, Matsumoto Y, Okada M, Nagao S. Matrix metalloproteinase-2 expression correlates with cavernous sinus invasion in pituitary adenomas. J Clin Neurosci 2006; 12:791-4. [PMID: 16198918 DOI: 10.1016/j.jocn.2005.03.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2004] [Accepted: 03/17/2005] [Indexed: 11/23/2022]
Abstract
UNLABELLED The aim of this study was to evaluate the relationship between expression of matrix metalloproteinase-2 (MMP-2) and cavernous sinus invasion in pituitary adenoma. METHOD Tissue samples from 54 pituitary adenomas were examined for expression of MMP-2 protein by immunohistochemistry. In sixteen tumors, the expression of MMP-2 mRNA was also examined by RT-PCR. Immunostaining was semiquantatively scored based on intensity (0-3) and distribution (0-3). RESULTS There were 34 women and 20 men, with a mean age of 49.9 years (range 18-76). There were 12 tumors with cavernous sinus invasion, and 42 noninvasive cases. The MMP-2 score of pituitary adenomas with cavernous sinus invasion (3.9 +/- 0.5) was significantly higher than those without invasion (2.3 +/- 0.2; P < 0.01). There was no difference in MMP-2 score between macroadenomas (3.0 +/- 0.3) and microadenomas (2.1 +/- 0.4; P > 0.05), and also, no difference between the functioning adenomas (2.8 +/- 0.3) and non-functioning adenomas (2.8 +/- 0.3; P > 0.05). We found no correlation between the MMP-2 score and the Ki-67 labeling index (r2 = -0.05; P = 0.72). MMP-2 mRNA expression was also intense in invasive pituitary adenomas and was significantly higher in invasive pituitary adenomas than those without invasion (68.2 +/- 15.3; 21.8 +/- 8.2; P < 0.05). CONCLUSION This study suggests that MMP-2 may be associated with aggressiveness and invasion in pituitary adenoma but is not related to tumor size or secretory function. MMP-2 may be a useful tool for assessing the invasive potential.
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Affiliation(s)
- Weiping Liu
- Department of Neurological Surgery, Kagawa Medical University, Kawaga, Japan
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Nieman LK, Ilias I. Evaluation and treatment of Cushing's syndrome. Am J Med 2005; 118:1340-6. [PMID: 16378774 DOI: 10.1016/j.amjmed.2005.01.059] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2004] [Revised: 01/28/2005] [Accepted: 01/28/2005] [Indexed: 10/25/2022]
Abstract
Cushing's syndrome results from sustained pathologic hypercortisolism caused by excessive corticotropin (ACTH) secretion by tumors in the pituitary gland (Cushing's disease, 70%) or elsewhere (15%), or by ACTH-independent cortisol secretion from adrenal tumors (15%). The clinical features are variable, and no single pattern is seen in all patients. Those features most specific for Cushing's syndrome include abnormal fat distribution, particularly in the supraclavicular and temporal fossae, proximal muscle weakness, wide purple striae, and decreased linear growth with continued weight gain in a child. Patients with characteristics of glucocorticoid excess should be screened with measurements of saliva or urine cortisol or dexamethasone suppression testing. The diagnosis of Cushing's syndrome should be followed by the measurement of plasma ACTH concentration to determine whether the hypercortisolism is ACTH-independent. In ACTH-dependent patients, bilateral inferior petrosal sinus sampling with measurement of ACTH before and after administration of ACTH-releasing hormone most accurately distinguishes pituitary from ectopic ACTH secretion. Surgical resection of tumor is the optimal treatment for all forms of Cushing's syndrome; bilateral adrenalectomy, medical treatment, or radiotherapy are sought in inoperable or recurrent cases. The medical treatment of choice is ketoconazole. The prognosis is better for Cushing's disease and benign adrenal causes of Cushing's syndrome than adrenocortical cancer and malignant ACTH-producing tumors.
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Affiliation(s)
- Lynnette K Nieman
- Reproductive Biology and Medicine Branch, National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Md, USA.
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Liu W, Matsumoto Y, Okada M, Miyake K, Kunishio K, Kawai N, Tamiya T, Nagao S. Matrix metalloproteinase 2 and 9 expression correlated with cavernous sinus invasion of pituitary adenomas. THE JOURNAL OF MEDICAL INVESTIGATION 2005; 52:151-8. [PMID: 16167532 DOI: 10.2152/jmi.52.151] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECT Matrix metalloproteinase (MMP) 2 and 9 are important for tissue breakdown in the process of tumor invasion. The aim of this study is to evaluate the relationship between the expression of MMP-2, MMP-9, MIB-1 LI and cavernous sinus invasion in pituitary adenomas. METHODS Tissue samples from 54 patients with pituitary adenomas were studied. Expression of MMP-2, MMP-9, and MIB-1 labeling index (LI) were evaluated by immunohistochemical method. In sixteen cases, the expression of MMP-2 and MMP-9 mRNA was also examined by RT-PCR assay. RESULTS Thirty-four patients were women and 20 were men, with a mean age of 49.9 years old (range 18-76 years). There were 12 cases with cavernous sinus invasion, and 42 were noninvasive cases. MMP-2 and MMP-9 score of invasive case (3.9 +/- 0.5,4.1 +/- 0.4) were significantly higher than those (2.3 +/- 0.2; p < 0.01; 2.6 +/- 0.2; p < 0.01) without invasion. The MIB-1 LI of this study presented no significantly difference between the invasive and noninvasive pituitary adenomas. The percentage of MMP-2 mRNA/beta-actin mRNA and MMP-9 mRNA/beta-actin mRNA were also observed significantly higher in invasive pituitary adenomas (68.2 +/- 15.3%; 59.7 +/- 12.5%) than noninvasive pituitary adenomas (21.8 +/- 8.2%, p < 0.05; 33.3 +/- 5.4%, p < 0.05). CONCLUSIONS Our study suggests that the expression of MMP-2 and MMP-9 may have a value to assess the invasive pituitary adenomas, and proliferation and invasion of pituitary adenomas may present a different mechanism.
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Affiliation(s)
- Weiping Liu
- Department of Neurological Surgery, Faculty of Medicine, Kagawa Medical University, Miki-cho, Kita-gun, Kagawa 761-0793, Japan
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Utz AL, Swearingen B, Biller BMK. Pituitary surgery and postoperative management in Cushing's disease. Endocrinol Metab Clin North Am 2005; 34:459-78, xi. [PMID: 15850853 DOI: 10.1016/j.ecl.2005.01.007] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Transsphenoidal pituitary surgery is the therapy for most Cushing's disease patients. This article describes the surgical technique, efficacy, perioperative management, and complications associated with this procedure. Numerous biochemical tests of cortisol status have been studied for the evaluation of the postoperative patient. Factors that predict postoperative remission and future relapse of Cushing's disease are addressed. Secondary interventions for persistent or recurrent disease include repeat transsphenoidal resection, pituitary radiation, medical therapy, and bilateral adrenalectomy
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Abstract
The majority of pituitary tumors that cause Cushing's disease are small (<1 cm diameter), and most disease morbidity is due to the effects of elevated, non-suppressible, ACTH levels that these tumors secrete. Tumor-derived ACTH leads to adrenal-derived steroid hypersecretion and results in many disabling and sometimes life-threatening symptoms including abnormal fat deposition, skin thinning, psychological disturbances, hypertension, diabetes, osteoporosis and muscle weakness. Cushing's disease is associated with high morbidity and ultimately mortality. In experienced specialized centers, 70% of corticotroph microadenomas can be successfully resected by transsphenoidal pituitary surgery. However, surgical "cure" rates for larger ACTH-secreting pituitary tumors are achieved in only 30% of cases, and recent reports highlight a significant recurrence rate after longer term follow-up even in smaller tumors. Post-surgical persistence of ACTH hypersecretion may require pituitary-directed radiation, but this treatment may take some time to be effective, and like extensive surgical pituitary tumor resection, ultimately leads to partial- or total hypopituitarism in approximately 80% of cases. Although hypercortisolism may be completely resolved by adrenalectomy, this procedure does not suppress, and may act as a stimulus to pituitary tumor growth, and is associated with other co-morbidity. Although some currently available drug-based treatments for Cushing's disease effectively control hypercortisolism, their drawback has been that they do not impact on pituitary tumor growth. Recent studies have identified the potential utility of peroxisome-proliferator activating receptor-gamma (PPAR-gamma) novel ligands in in vitro, and in vivo Cushing's disease models, and have paved the way for early clinical studies to develop novel therapeutic approaches in Cushing's disease.
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Affiliation(s)
- Anthony P Heaney
- Division of Endocrinology, Cedars-Sinai Research Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California 90048, USA.
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