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Ragate DC, Memon SS, Sarathi V, Lila AR, Channaiah CY, Patil VA, Karlekar M, Barnabas R, Thakkar H, Shah NS, Bandgar TR. Pituitary apoplexy in cushing's disease: a single center study and systematic literature review. Pituitary 2024; 27:335-344. [PMID: 38850401 DOI: 10.1007/s11102-024-01411-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/27/2024] [Indexed: 06/10/2024]
Abstract
INTRODUCTION Pituitary apoplexy (PA) in Cushing's disease (CD) is rare with data limited to case reports/series. METHODS We retrospectively reviewed case records of PA in CD managed at our center from 1987 to 2023 and performed a systematic literature review. RESULTS We identified 58 patients (44 females), including twelve from our center (12/315 CD, yielding a PA prevalence in CD of 3.8%) and forty six from systematic review. The median age at PA diagnosis was 35 years. The most common presentation was type A (79.3%) and symptom was headache (89.6%), with a median Pituitary Apoplexy Score (PAS) of 2. Median cortisol and ACTH levels were 24.9 µg/dl and 94.1 pg/ml, respectively. Apoplexy was the first manifestation of underlying CD in 55.2% of cases, with 31.1% (14/45) presenting with hypocortisolemia (serum cortisol ≤ 5.0 µg/dl), underscoring the importance of recognizing clinical signs/symptoms of hypercortisolism. The median largest tumor dimension was 1.7 cm (53/58 were macroadenomas). PA was managed surgically in 57.8% of cases, with the remainder conservatively managed. All five PA cases in CD with microadenoma achieved remission through conservative management, though two later relapsed. Among treatment-naïve CD patients with macroadenoma, PA-related neuro-deficit improvement was comparable between surgical and conservative groups. However, a greater proportion of surgically managed patients remained in remission longer (70% vs. 38.5%; p = 0.07), for an average of 31 vs. 10.5 months. CONCLUSION PA in CD is more commonly associated with macroadenomas, may present with hypocortisolemia, and surgical treatment tends towards higher and longer-lasting remission rates.
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Affiliation(s)
- Divya C Ragate
- Department of Endocrinology, Seth G.S. Medical College & KEM hospital, Parel, Mumbai, 4000012, Maharashtra, India
| | - Saba Samad Memon
- Department of Endocrinology, Seth G.S. Medical College & KEM hospital, Parel, Mumbai, 4000012, Maharashtra, India
| | - Vijaya Sarathi
- Department of Endocrinology, Vydehi institute of medical sciences and research Centre, Bangalore, Karnataka, India
| | - Anurag Ranjan Lila
- Department of Endocrinology, Seth G.S. Medical College & KEM hospital, Parel, Mumbai, 4000012, Maharashtra, India.
| | - Chethan Yami Channaiah
- Department of Endocrinology, Seth G.S. Medical College & KEM hospital, Parel, Mumbai, 4000012, Maharashtra, India
| | - Virendra A Patil
- Department of Endocrinology, Seth G.S. Medical College & KEM hospital, Parel, Mumbai, 4000012, Maharashtra, India
| | - Manjiri Karlekar
- Department of Endocrinology, Seth G.S. Medical College & KEM hospital, Parel, Mumbai, 4000012, Maharashtra, India
| | - Rohit Barnabas
- Department of Endocrinology, Seth G.S. Medical College & KEM hospital, Parel, Mumbai, 4000012, Maharashtra, India
| | - Hemangini Thakkar
- Department of Radiodiagnosis, Seth G.S Medical College & KEM Hospital, Mumbai, Maharashtra, India
| | - Nalini S Shah
- Department of Endocrinology, Seth G.S. Medical College & KEM hospital, Parel, Mumbai, 4000012, Maharashtra, India
| | - Tushar R Bandgar
- Department of Endocrinology, Seth G.S. Medical College & KEM hospital, Parel, Mumbai, 4000012, Maharashtra, India
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Yami Channaiah C, Memon SS, Sarathi V, Lila AR, Sankhe S, Arya S, Karlekar M, Patil VA, Shah N, Bandgar T. Pediatric Macrocorticotropinoma: Do They Differ from Microcorticotropinoma? Neuroendocrinology 2023; 114:42-50. [PMID: 37634509 DOI: 10.1159/000533770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 11/29/2022] [Indexed: 08/29/2023]
Abstract
INTRODUCTION Cushing's disease (CD) due to macrocorticotropinoma (MC) in children and adolescents is a rare entity with limited information regarding its characteristics. The objective of the study is to describe the clinical, biochemical, imaging, management, outcome, and genetic characteristics of children and adolescents with CD due to MC and compare them with those of microcorticotropinoma (mc). METHODS This retrospective study was conducted at a single tertiary care center. Thirty-two patients with CD and MC (maximum tumor dimension ≥10 mm on imaging) and 65 patients with mc (<10 mm on imaging) aged ≤20 years at presentation were enrolled. RESULTS Nineteen girls and 13 boys with MC presented at a median (IQR) age of 14.5 (12.0-17.9) years. Patients with MC had higher body mass index-standard deviation score (BMI-SDS) (3.70 ± 2.60 vs. 2.59 ± 2.01, p = 0.04), more frequent neuro-ophthalmic symptoms (25% vs. 9% p = 0.04) and short stature (59% vs. 34%, p = 0.049) but less frequent livid striae (53% vs. 77%, p = 0.01), hypokalemia (12% vs. 36%, p = 0.04), and lower cortisol (nmol/L) to corticotropin (pmol/L) ratio (41.20 vs. 55.74, p = 0.04) than those with mc. The remission (59% vs. 64%, p = 1.0) and relapse (53% vs. 37%, p = 0.26) rates after first-line surgery and remission rate after radiotherapy (RT) were comparable between the two cohorts, whereas time to remission after RT (27 vs. 13 months, p = 0.05) was longer in the MC group. A patient with MC had a pathogenic germline variant in CDH23. CONCLUSION In this large monocentric series of pediatric CD, frequent mass effect symptoms and short stature, higher BMI-SDS, less frequent livid striae, and hypokalemia with lower effective cortisol secretion characterize the MC cohort. The outcomes of surgery and RT were similar between the groups except for a longer time to remission after RT in the MC cohort. Germline variants are rare (4%) in pediatric MC.
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Affiliation(s)
| | - Saba Samad Memon
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Vijaya Sarathi
- Department of Endocrinology, Vydehi Institute of Medical Sciences and Research Centre, Bengaluru, India
| | - Anurag Ranjan Lila
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Shilpa Sankhe
- Department of Radiology, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Sneha Arya
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Manjiri Karlekar
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Mumbai, India
| | | | - Nalini Shah
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Tushar Bandgar
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Mumbai, India
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Viecceli C, Mattos ACV, Hirakata VN, Garcia SP, Rodrigues TDC, Czepielewski MA. Ketoconazole as second-line treatment for Cushing's disease after transsphenoidal surgery: systematic review and meta-analysis. Front Endocrinol (Lausanne) 2023; 14:1145775. [PMID: 37223017 PMCID: PMC10200879 DOI: 10.3389/fendo.2023.1145775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 04/07/2023] [Indexed: 05/25/2023] Open
Abstract
Introduction The first-line treatment for Cushing's disease is transsphenoidal surgery for pituitary tumor resection. Ketoconazole has been used as a second-line drug despite limited data on its safety and efficacy for this purpose. The objective of this meta-analysis was to analyze hypercortisolism control in patients who used ketoconazole as a second-line treatment after transsphenoidal surgery, in addition to other clinical and laboratory criteria that could be related to therapeutic response. Methods We searched for articles that evaluated ketoconazole use in Cushing's disease after transsphenoidal surgery. The search strategies were applied to MEDLINE, EMBASE, and SciELO. Independent reviewers assessed study eligibility and quality and extracted data on hypercortisolism control and related variables such as therapeutic dose, time, and urinary cortisol levels. Results After applying the exclusion criteria, 10 articles (one prospective and nine retrospective studies, totaling 270 patients) were included for complete data analysis. We found no publication bias regarding reported biochemical control or no biochemical control (p = 0.06 and p = 0.42 respectively). Of 270 patients, biochemical control of hypercortisolism occurred in 151 (63%, 95% CI 50-74%) and no biochemical control occurred in 61 (20%, 95% CI 10-35%). According to the meta-regression, neither the final dose, treatment duration, nor initial serum cortisol levels were associated with biochemical control of hypercortisolism. Conclusion Ketoconazole can be considered a safe and efficacious option for Cushing's disease treatment after pituitary surgery. Systematic review registration https://www.crd.york.ac.uk/prospero/#searchadvanced, (CRD42022308041).
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Affiliation(s)
- Camila Viecceli
- Graduate Program in Medical Sciences: Endocrinology, Faculty of Medicine, UFRGS, Porto Alegre, Brazil
| | - Ana Carolina Viana Mattos
- Graduate Program in Medical Sciences: Endocrinology, Faculty of Medicine, UFRGS, Porto Alegre, Brazil
| | - Vânia Naomi Hirakata
- Graduate Program in Medical Sciences: Endocrinology, Faculty of Medicine, UFRGS, Porto Alegre, Brazil
| | - Sheila Piccoli Garcia
- Graduate Program in Medical Sciences: Endocrinology, Faculty of Medicine, UFRGS, Porto Alegre, Brazil
| | - Ticiana da Costa Rodrigues
- Graduate Program in Medical Sciences: Endocrinology, Faculty of Medicine, UFRGS, Porto Alegre, Brazil
- Endocrinology Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
- Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Mauro Antônio Czepielewski
- Graduate Program in Medical Sciences: Endocrinology, Faculty of Medicine, UFRGS, Porto Alegre, Brazil
- Endocrinology Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
- Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
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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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Gupta R, Jain N, Bhansali A, Bhadada SK, Walia R. Demystifying the Relevance of Size Amongst Macro- and Micro-Corticotropinoma: Experience in 206 Patients. Indian J Endocrinol Metab 2022; 26:275-281. [PMID: 36248045 PMCID: PMC9555381 DOI: 10.4103/ijem.ijem_134_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 05/16/2022] [Accepted: 05/29/2022] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE In individuals with adrenocorticotrophic hormone (ACTH)-dependent Cushing's syndrome (CS), to estimate the differences between micro-corticotropinoma (size ≤6 mm and 6-10 mm), macro-corticotropinoma (>10 mm) and ectopic Cushing's syndrome (ECS), in relation to their epidemiological, clinical and biochemical parameters. METHODS In individuals with CS, the clinical and hormonal parameters, and magnetic resonance imaging of sella were collected from 1984 to 2019. A total of 138 cases of micro-corticotropinoma, 47 cases of macro-corticotropinoma and 21 cases of ECS were compared. RESULTS Except for size, there were no differences in biochemical and hormonal parameters of macro- and micro-corticotropinoma, irrespective of their size (≤6 mm, 6-10 mm and >10 mm). In comparison to Cushing's disease (CD), individuals with ECS had a male predominance (F:M ratio of 2.4:1 vs. 0.5:1), shorter duration from onset of symptoms to diagnosis (24 vs. 12 months). They also had a higher ACTH (139 vs. 65.8 pg/ml), 0800h cortisol (1200 vs. 880 nmol/l), 2300h cortisol (1100 vs. 700 nmol/l) and cortisol levels after high dose dexamethasone suppression test (1050 vs. 244.5 nmol/l). CONCLUSION The biochemical phenotype of macro-corticotropinoma resembles that of micro-corticotropinoma despite their larger tumour size, suggesting that the former is relatively less functional. Micro-corticotropinoma ≤6 mm and 6-10 mm have a similar clinical and biochemical profile. As compare to CD, ECS is characterised by a higher disease burden as reflected in their higher cortisol, more autonomicity and loss of rhythmicity.
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Affiliation(s)
- Rahul Gupta
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Nimisha Jain
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Anil Bhansali
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sanjay K. Bhadada
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rama Walia
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Viecceli C, Mattos ACV, Costa MCB, de Melo RB, Rodrigues TDC, Czepielewski MA. Evaluation of ketoconazole as a treatment for Cushing's disease in a retrospective cohort. Front Endocrinol (Lausanne) 2022; 13:1017331. [PMID: 36277689 PMCID: PMC9585352 DOI: 10.3389/fendo.2022.1017331] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 09/06/2022] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE The first-line treatment for Cushing's disease is transsphenoidal surgery, after which the rates of remission are 60 to 80%, with long-term recurrence of 20 to 30%, even in those with real initial remission. Drug therapies are indicated for patients without initial remission or with surgical contraindications or recurrence, and ketoconazole is one of the main available therapies. The objective of this study was to evaluate the safety profile of and the treatment response to ketoconazole in Cushing's disease patients followed up at the endocrinology outpatient clinic of a Brazilian university hospital. PATIENTS AND METHODS This was a retrospective cohort of Cushing's disease patients with active hypercortisolism who used ketoconazole at any stage of follow-up. Patients who were followed up for less than 7 days, who did not adhere to treatment, or who were lost to follow-up were excluded. RESULTS Of the 172 Cushing's disease patients who were followed up between 2004 and 2020, 38 received ketoconazole. However, complete data was only available for 33 of these patients. Of these, 26 (78%) underwent transsphenoidal surgery prior to using ketoconazole, five of whom (15%) had also undergone radiotherapy; seven used ketoconazole as a primary treatment. Ketoconazole use ranged from 14 days to 14.5 years. A total of 22 patients had a complete response (66%), three patients had a partial response (9%), and eight patients had no response to treatment (24%), including those who underwent radiotherapy while using ketoconazole. Patients whose hypercortisolism was controlled or partially controlled with ketoconazole had lower baseline 24-h urinary free cortisol levels than the uncontrolled group [times above the upper limit of normal: 0.62 (SD, 0.41) vs. 5.3 (SD, 8.21); p < 0.005, respectively] in addition to more frequent previous transsphenoidal surgery (p < 0.04). The prevalence of uncontrolled patients remained stable over time (approximately 30%) despite ketoconazole dose adjustments or association with other drugs, which had no significant effect. One patient received adjuvant cabergoline from the beginning of the follow-up, and it was prescribed to nine others due to clinical non-response to ketoconazole alone. Ten patients (30%) reported mild adverse effects, such as nausea, vomiting, dizziness, and loss of appetite. Only four patients had serious adverse effects that warranted discontinuation. There were 20 confirmed episodes of hypokalemia among 10/33 patients (30%). CONCLUSION Ketoconazole effectively controlled hypercortisolism in 66% of Cushing's disease patients, being a relatively safe drug for those without remission after transsphenoidal surgery or whose symptoms must be controlled until a new definitive therapy is carried out. Hypokalemia is a frequent metabolic effect not yet described in other series, which should be monitored during treatment.
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Affiliation(s)
- Camila Viecceli
- Graduate Program in Medical Sciences: Endocrinology, Faculty of Medicine, UFRGS, Porto Alegre, Brazil
- Endocrinology Division, Hospital de Clínicas de Porto Alegre, UFRGS, Porto Alegre, Brazil
| | - Ana Carolina Viana Mattos
- Graduate Program in Medical Sciences: Endocrinology, Faculty of Medicine, UFRGS, Porto Alegre, Brazil
| | | | | | - Ticiana da Costa Rodrigues
- Graduate Program in Medical Sciences: Endocrinology, Faculty of Medicine, UFRGS, Porto Alegre, Brazil
- Endocrinology Division, Hospital de Clínicas de Porto Alegre, UFRGS, Porto Alegre, Brazil
- Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Mauro Antonio Czepielewski
- Graduate Program in Medical Sciences: Endocrinology, Faculty of Medicine, UFRGS, Porto Alegre, Brazil
- Endocrinology Division, Hospital de Clínicas de Porto Alegre, UFRGS, Porto Alegre, Brazil
- Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- *Correspondence: Mauro Antonio Czepielewski,
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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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Zheng X, Wang H, Zhang W, Feng S, Liu Y, Li S, Bao X, Lu L, Zhu H, Feng M, Wang R. Diagnosis, Manifestations, Laboratory Investigations, and Prognosis in Pediatric and Adult Cushing's Disease in a Large Center in China. Front Endocrinol (Lausanne) 2021; 12:749246. [PMID: 34867792 PMCID: PMC8640923 DOI: 10.3389/fendo.2021.749246] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 10/19/2021] [Indexed: 11/13/2022] Open
Abstract
PURPOSE Cushing's disease (CD) is a rare disease that contributes to 70-80% hypercortisolemia, which presents similarities and differences between pediatric and adult patients, and even between male and female patients. However, the comparative study of CD between different age groups and different genders is still insufficient. The aim of the study is to make a systematic comparison to reveal the gender differences in children and adult patients of CD, helping clinicians to provide optimal treatment for different groups of patients. METHODS We conducted a retrospective research consisting of 30 pediatric and 392 adult CD patients in a single center in Peking Union Medical College Hospital. All 422 patients showed symptoms related to hypercortisolism and received adenoma excision surgery in the department of neurosurgery between 2014 and 2020. RESULTS For the accuracy of diagnosis, the sensitivity of BIPSS at baseline in pediatric patients was lower than in adults (75 vs. 91%, P = 0.054) but increased greatly after desmopressin stimulation (94 vs. 95%). However, the accuracy of lateralization for BIPSS was not preferred for prediction. As for clinical manifestations, growth retardation, weight gain, hirsutism, and acne were more prevalent for children, while for adults, hypertension, osteopenia, glucometabolic disorder, easy bruising, hair loss, and weight loss were more frequently seen. As previously reported, we observed a significant difference between the male prevalence of pediatric and adult patients (50 vs. 17%, P < 0.001), which was possibly caused by the more severe and earlier onset of a series of symptoms. Gender-related comparison showed greater morbidity of nephrolithiasis, hypokalemia, hypertension, easy bruising, osteopenia, and striae for male patients, while irregular menses, hirsutism, and hair loss were more common for female patients. Further analysis showed that the secretory activity of the PA axis was higher for males, presenting as the more remarkable alteration of laboratory parameters and contributing to the more severe clinical manifestations. For patients treated with transsphenoidal pituitary surgery (TSS), the immediate prognosis could be predicted by operation history, invasiveness, Ki-67, and information provided by MRI, including tumor size and Knosp grading. However, we still lack methods to predict long-term prognosis. CONCLUSIONS Our study is the first detailed and systematic comparison between pediatric and adult CD patients. Further exploration of the impact of CD on different genders reveals a more severe and probably an earlier-onset pattern of CD for male patients.
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Affiliation(s)
- Xueqing Zheng
- Department of Neurosurgery, Pituitary Centre, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
- Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - He Wang
- Department of Neurosurgery, Pituitary Centre, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
- Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Wentai Zhang
- Department of Neurosurgery, Pituitary Centre, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Shanshan Feng
- Department of Neurosurgery, Pituitary Centre, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yifan Liu
- Department of Neurosurgery, Pituitary Centre, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
- Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Shuo Li
- Department of Neurosurgery, Pituitary Centre, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Xinjie Bao
- Department of Neurosurgery, Pituitary Centre, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Lin Lu
- Department of Endocrinology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Huijuan Zhu
- Department of Endocrinology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Ming Feng
- Department of Neurosurgery, Pituitary Centre, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
- *Correspondence: Ming Feng,
| | - Renzhi Wang
- Department of Neurosurgery, Pituitary Centre, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
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Neurosurgical treatment of Cushing disease in pediatric patients: case series and review of literature. Childs Nerv Syst 2019; 35:2127-2132. [PMID: 30488233 DOI: 10.1007/s00381-018-4013-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 11/22/2018] [Indexed: 10/27/2022]
Abstract
AIM Pituitary adenomas are rare in childhood in contrast with adults. Adrenocorticotropic hormone (ACTH)-secreting adenomas account for Cushing's disease (CD) which is the most common form of ACTH-dependent Cushing's syndrome (CS). Treatment strategies are generally based on data of adult CD patients, although some difficulties and differences exist in pediatric patients. The aim of this study is to share our experience of 10 children and adolescents with CD. PATIENTS AND METHOD Medical records, images, and operative notes of 10 consecutive children and adolescents who underwent transsphenoidal surgery for CD between 1999 and 2014 in Cerrahpasa Faculty of Medicine were retrospectively reviewed. Mean age at operation was 14.8 ± 4.2 years (range 5-18). The mean length of symptoms was 24.2 months. The mean follow-up period was 11 years (range 4 to 19 years). RESULTS Mean preoperative cortisol level was 23.435 μg/dl (range 8.81-59.8 μg/dl). Mean preoperative ACTH level was 57.358 μg/dl (range 28.9-139.9 μg/dl). MR images localized microadenoma in three patients (30%), macroadenoma in four patients (40%) in our series. Transsphenoidal microsurgery and endoscopic transsphenoidal surgery were performed in 8 and 2 patients respectively. Remission was provided in 8 patients (80%). Five patients (50%) met remission criteria after initial operations. Three patients (30%) underwent additional operations to meet remission criteria. CONCLUSION Transsphenoidal surgery remains the mainstay therapy for CD in pediatric patients as well as adults. It is an effective treatment option with low rate of complications. Both endoscopic and microscopic approaches provide safe access to sella and satisfactory surgical results.
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10
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Zhuang Z, Liu X, Bao X, Pan B, Deng K, Yao Y, Lian W, Xing B, Zhu H, Lu L, Wang R, Feng M. Invasive ACTH-secreting pituitary macroadenoma in remission after transsphenoidal resection: A case report and literature review. Medicine (Baltimore) 2018; 97:e13148. [PMID: 30431585 PMCID: PMC6257388 DOI: 10.1097/md.0000000000013148] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Knosp grade 4 adrenocorticotropic hormone (ACTH)-secreting pituitary adenoma is a rare cause of Cushing disease. After the 1st surgery, the remission rate among these patients is extremely low. PATIENT CONCERNS We presented a case of a 33-year-old female with classical Cushingoid symptoms. Further investigations revealed ATCH-dependent hypercortisolemia, as well as a Knosp grade 4 pituitary macroadenoma. DIAGNOSIS Cushing disease, caused by a Knosp grade 4 pituitary macroadenoma. INTERVENTIONS The patient underwent endoscopic endonasal transsphenoidal surgery with the assistance of intraoperative transsphenoidal Doppler and image-guidance devices. OUTCOMES Pathologic examinations confirmed that the lesion was an ACTH-secreting pituitary adenoma. The patient was in biochemical remission after surgery. Her postoperative magnetic resonance imaging showed gross-total tumor resection. There was no evidence of recurrence during the 1-year follow-up. LESSONS With intraoperative Doppler and image-guidance, gross-total resection and biochemical remission can be achieved in Cushing disease when the internal carotid artery is completely encased by the pituitary adenoma.
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Affiliation(s)
- Zhe Zhuang
- Department of Neurosurgery, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital
- School of Medicine, Tsinghua University
| | - Xiaohai Liu
- Department of Neurosurgery, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital
| | - Xinjie Bao
- Department of Neurosurgery, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital
| | | | - Kan Deng
- Department of Neurosurgery, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital
| | - Yong Yao
- Department of Neurosurgery, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital
| | - Wei Lian
- Department of Neurosurgery, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital
| | - Bing Xing
- Department of Neurosurgery, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital
| | - Huijuan Zhu
- Department of Endocrinology, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Lin Lu
- Department of Endocrinology, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Renzhi Wang
- Department of Neurosurgery, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital
| | - Ming Feng
- Department of Neurosurgery, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital
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Sarkar S, Philip VJ, Cherukuri SK, Chacko AG, Chacko G. Implications of the World Health Organization definition of atypia on surgically treated functional and non-functional pituitary adenomas. Acta Neurochir (Wien) 2017; 159:2179-2186. [PMID: 28573325 DOI: 10.1007/s00701-017-3223-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 05/11/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND The World Health Organization (WHO) defines atypical pituitary adenomas as tumours with a MIB-1 labelling index ≥3%, p53 positivity and increased mitotic activity. Although a few reports have described the clinical and radiological correlates of atypia in pituitary adenomas, its impact on postoperative outcomes is not clearly defined. METHOD We reviewed preoperative and postoperative records of patients undergoing surgery for pituitary adenomas. Postoperative outcomes for functional adenomas (FPAs) were assessed according to contemporary definitions of remission and recurrence. For non-functional pituitary adenomas (NFPAs), extent of resection and disease progression were defined on the basis of postoperative magnetic resonance imaging. RESULTS Of 394 patients included for analysis, 29 cases (7.4%) fulfilled criteria for atypia. Patients with atypical tumours were significantly younger than those with typical adenomas. Remission was possible in 47.4% of FPAs, and was unrelated to the presence of atypia. In NFPAs, local invasiveness was negatively associated with extent of resection (OR, 0.255; 95% CI, 0.086-0.753; p < 0.001). In 93 NFPAs followed postoperatively with serial imaging over a mean duration of 37.5 months, disease progression/recurrence was significantly associated with the presence of atypia (OR, 5.058; 95% CI, 1.273-20.098; p = 0.021) on multivariate analysis. CONCLUSIONS Patients with atypical non-functional pituitary adenomas are at risk for postoperative recurrence and disease progression, suggesting a need for adjuvant therapy. However, only a small fraction of pituitary tumours demonstrate atypia, as defined by the WHO, limiting its clinical utility.
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12
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Machado MC, Alcantara AEE, Pereira ACL, Cescato VAS, Castro Musolino NR, de Mendonça BB, Bronstein MD, Fragoso MCBV. Negative correlation between tumour size and cortisol/ACTH ratios in patients with Cushing's disease harbouring microadenomas or macroadenomas. J Endocrinol Invest 2016; 39:1401-1409. [PMID: 27363699 DOI: 10.1007/s40618-016-0504-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 06/10/2016] [Indexed: 11/29/2022]
Abstract
PURPOSE Pituitary macroadenomas (MACs) represent 10-30 % of Cushing's disease (CD) cases. The aim of this study was to report the clinical, laboratorial and imaging features and postsurgical outcomes of microadenoma (MIC) and MAC patients. METHODS Retrospective study with 317 CD patients (median 32 years old, range 9-71 years) admitted between 1990 and 2014, 74 (23.3 %) of whom had MAC. RESULTS Hirsutism, plethora facial, muscular weakness and muscular atrophy were more frequent in the MIC patients. Nephrolithiasis, osteopenia, hyperprolactinaemia and galactorrhoea were more prevalent in MAC patients. The morning serum cortisol (Fs), nocturnal salivary cortisol (NSC), nocturnal Fs (Fs 2400 h), low- and high-dose dexamethasone suppression test results and CRH and desmopressin test results were similar between the subgroups. MIC patients showed higher urinary cortisol at 24 h (UC), and MAC patients presented higher ACTH levels but lower Fs/ACTH, Fs 2400 h/ACTH, NSC/ACTH and UC/ACTH ratios. There were negative correlations of tumour size with Fs/ACTH, Fs 2400 h/ACTH, NSC/ACTH and UC/ACTH ratios. Overall, the postsurgical remission and recurrence rates were similar between MIC and MAC. However, patients in remission (MIC + MAC) showed smaller tumour diameters and a lower prevalence of invasion and extension on MRI. CONCLUSIONS Despite exhibiting higher plasma ACTH levels, CD patients with MAC presented lower cortisol/ACTH ratios than did patients with MIC, with a negative correlation between tumour size and cortisol/ACTH ratios. The overall postsurgical remission and recurrence rates were similar between MIC and MAC patients, with those with larger and/or invasive tumours showing a lower remission rate.
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Affiliation(s)
- M C Machado
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, University of Sao Paulo Medical School, São Paulo, SP, Brazil.
- Laboratory of Cellular and Molecular Endocrinology LIM-25, University of Sao Paulo Medical School, São Paulo, SP, Brazil.
- Endocrinology Division, AC Camargo Cancer Center, São Paulo, SP, Brazil.
| | - A E E Alcantara
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, University of Sao Paulo Medical School, São Paulo, SP, Brazil
| | - A C L Pereira
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, University of Sao Paulo Medical School, São Paulo, SP, Brazil
| | - V A S Cescato
- Division of Neurosurgery, University of Sao Paulo Medical School, São Paulo, SP, Brazil
| | - N R Castro Musolino
- Division of Neurosurgery, University of Sao Paulo Medical School, São Paulo, SP, Brazil
| | - B B de Mendonça
- Laboratório de Hormônios e Genética Molecular LIM-42, University of Sao Paulo Medical School, São Paulo, SP, Brazil
| | - M D Bronstein
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, University of Sao Paulo Medical School, São Paulo, SP, Brazil
- Laboratory of Cellular and Molecular Endocrinology LIM-25, University of Sao Paulo Medical School, São Paulo, SP, Brazil
| | - M C B V Fragoso
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, University of Sao Paulo Medical School, São Paulo, SP, Brazil
- Laboratório de Hormônios e Genética Molecular LIM-42, University of Sao Paulo Medical School, São Paulo, SP, Brazil
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13
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Abstract
PURPOSE Pasireotide is the only pituitary targeted medication registered for the treatment of Cushing's disease. Drug efficacy data are largely based on a major prospective study in which the vast majority of patients had microadenomas. The purpose of this study was to summarize results of pasireotide treatment of ACTH secreting macroadenomas from our center. METHODS Retrospective review of data extracted from clinical files. RESULTS Three patients presented with large and invasive macroadenomas that required several surgical interventions and radiotherapy treatments. Patient 1 is a 57 year-old male who developed an extreme (27-fold) paradoxical response of urinary free cortisol (UFC) levels as measured 2 weeks after pasireotide institution, which increased further (71-fold) in response to dose increment but decreased to baseline levels after treatment interruption. Patient 2 is a 44 year old woman with a long standing (26 years) ACTH-secreting carcinoma metastatic to bone and after bilateral adrenalectomy. After an initial excellent response to pasireotide treatment, ACTH levels escaped suppression and a further rebound was noted 6 weeks after treatment interruption. Patient 3 is a 53 year old man that after escape from temozolomide therapy was started on pasireotide and rapidly responded by almost normalizing UFC excretion after 4 weeks, but returned to baseline UFC levels after four additional weeks of treatment. CONCLUSIONS We describe as yet unreported atypical responses to pasireotide treatment in patients with aggressive ACTH-secreting tumors. Increased vigilance is recommended during pasireotide treatment of such patients.
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Affiliation(s)
- Yona Greenman
- Institute of Endocrinology, Metabolism and Hypertension, Tel Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann Street, 64239, Tel Aviv, Israel.
| | - Naftali Stern
- Institute of Endocrinology, Metabolism and Hypertension, Tel Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann Street, 64239, Tel Aviv, Israel
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14
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Cannavo S, Messina E, Albani A, Ferrau F, Barresi V, Priola S, Esposito F, Angileri F. Clinical management of critically ill patients with Cushing's disease due to ACTH-secreting pituitary macroadenomas: effectiveness of presurgical treatment with pasireotide. Endocrine 2016; 52:481-7. [PMID: 25877016 DOI: 10.1007/s12020-015-0601-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Accepted: 04/07/2015] [Indexed: 12/11/2022]
Abstract
The management of critically ill Cushing's disease (CD) patients is extremely challenging. Pasireotide is indicated for the treatment of CD patients when pituitary surgery is unfeasible or has not been curative, but no data are available about the use of this drug as pre-operative treatment in critically ill patients. We report the effects of presurgical pasireotide therapy in CD patients in whom hypercortisolism caused life-threatening hypokalemia, alkalosis, and cardio-respiratory complications precluding surgical approach. Clinical, biochemical, and radiological data of two critically ill patients with ACTH-secreting pituitary macroadenoma, before and during first-line presurgical pasireotide treatment (600 μg s.c. bid). During the first 21 days of treatment, pasireotide therapy induced a rapid, partial decrease of plasma ACTH, serum cortisol, and urinary free cortisol levels, with the consequent normalization of serum potassium concentration and arterial blood gases parameters, in both the patients. They did not experience unmanageable side effects and underwent endoscopic transsphenoidal surgery after 4 weeks of effective treatment. Pre-operative MRI evaluation did not show pituitary tumor shrinkage. Surgical cure of CD was obtained in the first patient, while debulking allowed the pharmacological control of hypercortisolism in the second case. We suggest that pasireotide can induce a rapid improvement of clinical and metabolic conditions in critically ill CD patients in whom surgical approach is considered hazardous and need to be delayed.
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Affiliation(s)
- S Cannavo
- Department of Clinical and Experimental Medicine - Endocrinology Unit, University of Messina, Messina, Italy
| | - E Messina
- Department of Clinical and Experimental Medicine - Endocrinology Unit, University of Messina, Messina, Italy
| | - A Albani
- Department of Clinical and Experimental Medicine - Endocrinology Unit, University of Messina, Messina, Italy
| | - F Ferrau
- Department of Clinical and Experimental Medicine - Endocrinology Unit, University of Messina, Messina, Italy.
| | - V Barresi
- Department of Human Pathology Gaetano Barresi - Section of Anatomic Pathology, University of Messina, Messina, Italy
| | - S Priola
- Department of Neuroscience - Neurosurgery Unit, University of Messina, Messina, Italy
| | - F Esposito
- Department of Neuroscience - Neurosurgery Unit, University of Messina, Messina, Italy
| | - F Angileri
- Department of Neuroscience - Neurosurgery Unit, University of Messina, Messina, Italy
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15
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Witek P, Zieliński G, Szamotulska K, Maksymowicz M, Kamiński G. Clinicopathological predictive factors in the early remission of corticotroph pituitary macroadenomas in a tertiary referral centre. Eur J Endocrinol 2016; 174:539-49. [PMID: 26811407 PMCID: PMC4763091 DOI: 10.1530/eje-15-1226] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 01/25/2016] [Indexed: 12/02/2022]
Abstract
OBJECTIVE Corticotroph macroadenomas are a rare cause of Cushing's disease (CD), but their properties are not well-recognised. The aim of this study was to evaluate the clinical and pathological aspects of corticotroph macroadenomas with particular emphasis on proliferation markers and their associations with the efficacy of surgical treatment. DESIGN A prospective cohort study was conducted in a tertiary referral centre in Poland. METHODS In total, 59 patients with CD (20 macroadenomas and 39 microadenomas) were included in this study. Hormonal and imaging parameters, histopathological and ultrastructural features of the corticotroph tumours and the early surgical outcomes were evaluated. RESULTS ACTH and ACTH/cortisol ratios were higher in macroadenomas (P<0.001 and P=0.002 respectively). Greater tumour volumes were associated with higher Ki-67 and p53 expression (Ptrend=0.009 and Ptrend=0.024 respectively) and the rates of sparsely granulated adenomas (Ptrend=0.036). Immediate postoperative remission and early biochemical remission rates were lower in macroadenomas compared to microadenomas (P<0.001). A logistic regression model showed that the immediate postoperative remission or early biochemical remission depended on tumour volume (P=0.005 and P=0.006 respectively) and invasiveness based on Knosp grades 3 and 4 for macroadenomas and a lack of surgical pseudocapsule for microadenomas (P=0.004 and P=0.007 respectively). CONCLUSION Corticotroph macroadenomas differ from the more common microadenomas not only in terms of hormonal and imaging characteristics but also in terms of immunohistochemical and ultrastructural features and proliferation markers. The early effectiveness of surgery depends primarily on tumour volume and invasiveness.
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Affiliation(s)
- Przemysław Witek
- Departments of Endocrinology and Isotope TherapyNeurosurgeryMilitary Institute of Medicine, ul. Szaserów 128, 04-141 Warsaw, PolandDepartment of Epidemiology and BiostatisticsInstitute of Mother and Child, ul. Kasprzaka 17a, 01-211 Warsaw, PolandDepartment of PathologyM. Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, ul. Roentgena 5, 02-781 Warsaw, Poland
| | - Grzegorz Zieliński
- Departments of Endocrinology and Isotope TherapyNeurosurgeryMilitary Institute of Medicine, ul. Szaserów 128, 04-141 Warsaw, PolandDepartment of Epidemiology and BiostatisticsInstitute of Mother and Child, ul. Kasprzaka 17a, 01-211 Warsaw, PolandDepartment of PathologyM. Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, ul. Roentgena 5, 02-781 Warsaw, Poland
| | - Katarzyna Szamotulska
- Departments of Endocrinology and Isotope TherapyNeurosurgeryMilitary Institute of Medicine, ul. Szaserów 128, 04-141 Warsaw, PolandDepartment of Epidemiology and BiostatisticsInstitute of Mother and Child, ul. Kasprzaka 17a, 01-211 Warsaw, PolandDepartment of PathologyM. Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, ul. Roentgena 5, 02-781 Warsaw, Poland
| | - Maria Maksymowicz
- Departments of Endocrinology and Isotope TherapyNeurosurgeryMilitary Institute of Medicine, ul. Szaserów 128, 04-141 Warsaw, PolandDepartment of Epidemiology and BiostatisticsInstitute of Mother and Child, ul. Kasprzaka 17a, 01-211 Warsaw, PolandDepartment of PathologyM. Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, ul. Roentgena 5, 02-781 Warsaw, Poland
| | - Grzegorz Kamiński
- Departments of Endocrinology and Isotope TherapyNeurosurgeryMilitary Institute of Medicine, ul. Szaserów 128, 04-141 Warsaw, PolandDepartment of Epidemiology and BiostatisticsInstitute of Mother and Child, ul. Kasprzaka 17a, 01-211 Warsaw, PolandDepartment of PathologyM. Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, ul. Roentgena 5, 02-781 Warsaw, Poland
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16
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Outcome of Microscopic Transsphenoidal Surgery in Cushing Disease: A Case Series of 96 Patients. World Neurosurg 2016; 87:170-5. [DOI: 10.1016/j.wneu.2015.11.046] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 11/19/2015] [Accepted: 11/19/2015] [Indexed: 11/20/2022]
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Kulubya ES, Donoho DA, Carmichael JD, Zada G. Surgical management of adrenocorticotropic hormone-secreting pituitary adenomas. INTERNATIONAL JOURNAL OF ENDOCRINE ONCOLOGY 2016. [DOI: 10.2217/ije.15.26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Cushing's disease is defined as hypercortisolemia caused by secretion of adrenocorticotropic hormone from a pituitary adenoma. The diagnosis of Cushing's disease is based on clinical symptoms, laboratory and imaging findings. Once an adrenocorticotropic-hormone-secreting adenoma is found, the standard of care is transsphenoidal adenomectomy. MRI negative microadenomas and large, invasive macroadenomas provide a surgical and clinical challenge and are best handled at high volume centers. Multiple options exist for refractory disease or recurrence, including repeat surgery, radiosurgery and radiotherapy, medical management and bilateral adrenalectomy.
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Affiliation(s)
- Edwin S Kulubya
- Department of Neurosurgery, Keck School of Medicine of USC, 1200 North State Street, Suite 5046, Los Angeles, CA 90089, USA
| | - Daniel A Donoho
- Department of Neurosurgery, Keck School of Medicine of USC, 1200 North State Street, Suite 5046, Los Angeles, CA 90089, USA
| | - John D Carmichael
- USC Pituitary Center, Keck School of Medicine of USC, Los Angeles, CA 90089, USA
| | - Gabriel Zada
- Department of Neurosurgery, Keck School of Medicine of USC, 1200 North State Street, Suite 5046, Los Angeles, CA 90089, USA
- USC Pituitary Center, Keck School of Medicine of USC, Los Angeles, CA 90089, USA
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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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Di Ieva A, Davidson JM, Syro LV, Rotondo F, Montoya JF, Horvath E, Cusimano MD, Kovacs K. Crooke's cell tumors of the pituitary. Neurosurgery 2015; 76:616-22. [PMID: 25635886 DOI: 10.1227/neu.0000000000000657] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Crooke's cell adenomas are a rare type of pituitary neoplasm. They produce adrenocorticotropic hormone causing Cushing's disease or may be endocrinologically silent. These tumors are usually invasive, may exhibit aggressive clinical behavior, and often recur with a low success of cure after reoperation and/or radiotherapy. Due to their rarity, they present great difficulties in assessing prognosis, treatment, and clinical management. Neurosurgeons and physicians dealing with pituitary adenomas diagnosed as Crooke's cell adenomas have to be aware of their potential clinical aggressiveness to plan strict follow-up of patients and eventual multimodality treatment. We review here the published cases of Crooke's cell tumors, as well as the clinical and histopathological characteristics of these unusual neoplasms.
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Affiliation(s)
- Antonio Di Ieva
- ‡Division of Neurosurgery, Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada; §Department of Neurosurgery, Hospital Pablo Tobon Uribe and Clinica Medellin, Medellin, Colombia; ¶Division of Pathology, Department of Laboratory Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada; ‖Division of Endocrinology, Hospital Pablo Tobon Uribe and Universidad de Antioquia, Medellin, Colombia
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20
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Abstract
BACKGROUND Transsphenoidal selective adenomectomy is the first-line treatment for Cushing's disease. At experienced centers, early remission rates after transsphenoidal surgery range from 65 to 98%, however disease relapse frequently occurs with rates ranging from 2 to 35% at long-term follow up. METHODS This article discusses recently reported studies on the surgical outcomes from transsphenoidal surgery for Cushing's disease. CONCLUSIONS One of the keys to a successful long-term surgical outcome is meticulous dissection using the adenoma's pseudocapsule as a surgical plane for complete resection. MRI-negative and invasive ACTH-secreting adenomas pose particular challenges for pituitary surgeons.
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Affiliation(s)
- Robert F Dallapiazza
- Department of Neurosurgery, University of Virginia, PO Box 800212, Charlottesville, VA, 22908-0711, USA,
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