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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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Meier M, Alomari A, Feldkamp J, Mann WA, Santen R, Ewald N, Knappe UJ. Predictive Value of Early Postoperative Course of Serum Cortisol
After Transsphenoidal Surgery for Cushing’s Disease. Exp Clin Endocrinol Diabetes 2022; 130:704-713. [DOI: 10.1055/a-1909-1639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Abstract
Objective To identify early available predictors for the long-term outcome
of patients after transsphenoidal surgery (TSS) in the management of
Cushing’s disease.
Methods This single-center, retrospective study included 93 consecutive
patients with Cushing’s disease (follow-up 12–129 months, mean
48, median 38) who underwent TSS (21 had previous operations elsewhere). Six
cases had early re-operation, and the resulting data were evaluated instead of
the respective first operation. During the postoperative course, serum cortisol
levels were assessed every four hours at least until the next morning. An
association of parameters with long-term outcomes was tested using binary
logistic regression. Receiver operating characteristic curves were used to
determine sensitivity, specificity, positive predictive value, and negative
predictive value of different cut-off values of serum cortisol in the
postoperative course in the event of recurrence after remission.
Results Eighty out of 93 patients (86%) showed postoperative
remission (after primary treatment, 60 out of 72 patients, 90.3%). Of
these, 8 patients (10%) developed recurrence of hypercortisolism.
Compared to patients with persisting long-term remission, those with recurrence
differed in cortisol levels starting from 4 pm on the day of surgery
plus an event of increasing cortisol during the early postoperative course
(“peak”). Binary logistic regression showed the association
between a peak of serum cortisol in the early postoperative course with an
increased probability of recurrence.
Conclusions Patients with a peak of serum cortisol in the early
postoperative course show an increased recurrence rate. A cut-off value of serum
cortisol for clear identification of patients with later recurrence could not be
determined.
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Affiliation(s)
- Matthias Meier
- Department of Neurosurgery, Johannes Wesling Klinikum, University
Hospital of the Ruhr-University Bochum, Minden, Germany
| | - Ali Alomari
- Department of Neurosurgery, Johannes Wesling Klinikum, University
Hospital of the Ruhr-University Bochum, Minden, Germany
| | - Joachim Feldkamp
- Department of General Internal Medicine, Endocrinology and Diabetes,
Infectious Diseases, Klinikum Bielefeld, Universitätsklinikum OWL,
Bielefeld, Germany
| | - W Alexander Mann
- Department of Endocrinology, Endokrinologikum Frankfurt,
Frankfurt/Main, Germany
| | - Reinhard Santen
- Deutsches Endokrinologisches Versorgungszentrum,
Frankfurt/Main, Germany
| | - Nils Ewald
- Institute of Endocrinology, Diabetology and Metabolism, Johannes
Wesling Klinikum, Minden, Germany
| | - Ulrich J Knappe
- Department of Neurosurgery, Johannes Wesling Klinikum, University
Hospital of the Ruhr-University Bochum, Minden, Germany
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Nasi-Kordhishti I, Grimm F, Giese S, Lörincz KN, Bender B, Honegger J. The importance of MRI quality and reader's experience for detecting an adenoma in Cushing's disease. Eur J Endocrinol 2022; 187:349-359. [PMID: 35895719 DOI: 10.1530/eje-22-0180] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 06/28/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVE In Cushing's disease (CD), detection of an adenoma by MRI is challenging. The aim of this study is to compare real-life MRI in the initial diagnostic workup of CD with high-quality MRI performed in a tertiary center for pituitary diseases. DESIGN AND METHODS We retrospectively analyzed 139 patients with CD who underwent primary transsphenoidal surgery (TSS) in our department and had both an MRI conducted at a different institution (external MRI; extMRI) and an MRI conducted at our institution (internal MRI; intMRI). Preoperative interpretation of MRI was performed independently by an external radiologist (extRAD), an internal neuroradiologist (intRAD) and a pituitary surgeon (SURG). Intraoperative detection of an adenoma and endocrinological remission provided proof of the true adenoma localization in 105 patients. RESULTS Interpretation of extMRI by extRAD and SURG was concordant in only 64% (89/139) of cases, while 74.1% (103/139) concordance was observed for interpretation of intMRI by intRAD and SURG. Based on extMRI, the true localization of the adenoma was correctly predicted in only 46.7% of the patients by extRAD and in 65.7% by SURG. In contrast, the sensitivity to correctly identify the adenoma on intMRI was 80.0% for intRAD and 94.3% for SURG. CONCLUSION Both the quality of MRI and the reader's experience are paramount for detection of microadenomas in CD. Every effort should be made to perform high-quality initial MRI according to current standards and to ensure rating by an expert in pituitary imaging.
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Affiliation(s)
| | - Florian Grimm
- Department of Neurosurgery, Eberhard-Karls-University, Tübingen, Germany
| | - Sabrina Giese
- Department of Neurosurgery, Eberhard-Karls-University, Tübingen, Germany
| | | | - Benjamin Bender
- Department of Diagnostic and Interventional Neuroradiology, Eberhard-Karls-University, Tübingen, Germany
| | - Jürgen Honegger
- Department of Neurosurgery, Eberhard-Karls-University, Tübingen, Germany
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Honegger J, Nasi-Kordhishti I. Surgery and perioperative management of patients with Cushing's disease. J Neuroendocrinol 2022; 34:e13177. [PMID: 35980172 DOI: 10.1111/jne.13177] [Citation(s) in RCA: 19] [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] [Received: 02/16/2022] [Revised: 05/09/2022] [Accepted: 05/31/2022] [Indexed: 11/29/2022]
Abstract
Transsphenoidal surgery (TSS) is the initial treatment modality of first choice in Cushing's disease (CD). With microscopic TSS and endoscopic TSS, two operative techniques with equally favourable remission rates and operative morbidity are available. On average, remission is achieved with primary TSS in 80% of patients with microadenomas and 60% of patients with macroadenomas. The current literature indicates that remission rates in repeat TSS for microadenomas can also exceed 70%. Experience with TSS in CD plays an important role in the success rate and centralization in Pituitary Centres of Excellence has been proposed. Microadenoma stage, imaging-visible adenoma, confirmation of ACTH-positive adenoma on histopathology and noninvasiveness are positive predictors for postoperative remission. In postoperative management, a steroid-sparing protocol with early postoperative assessment of remission status is recommended. Convincing evidence suggests that prolonged postoperative prophylactic antithrombotic measures can significantly reduce the risk of postoperative thromboembolic events in CD. Prevention or successful treatment of cortisol withdrawal syndrome remains an unsolved issue that should be a focus of future research. The further development and broad availability of functional imaging hold promise for improved preoperative detection of microadenomas. Intraoperative identification of microadenomas by specific fluorescent targeting could be a promising future avenue for the treatment of patients with negative imaging.
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Affiliation(s)
- Juergen Honegger
- Department of Neurosurgery, University of Tübingen, Tübingen, Germany
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Sabahi M, Shahbazi T, Maroufi SF, Vidal K, Recinos PF, Kshettry VR, Roser F, Adada B, Borghei-Razavi H. MRI-Negative Cushing's Disease: A Review on Therapeutic Management. World Neurosurg 2022; 162:126-137.e1. [PMID: 35338018 DOI: 10.1016/j.wneu.2022.03.076] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 03/15/2022] [Accepted: 03/16/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVES In this systematic review and meta-analysis, we review the literature regarding patients with Cushing's disease (CD) with negative or inconclusive magnetic resonance imaging (MRI). METHODS A quantitative systematic review was performed. Article selection was performed by searching MEDLINE (using PubMed), EMBASE, and Cochrane electronic bibliographic databases. RESULTS 28 articles described surgical management of inconclusive MRI or MRI-negative CD. A total of 858 patients underwent surgery for their Cushing adenoma. Different types of surgery, including endoscopic endonasal transsphenoidal surgery (EETS) (190 cases) and microscopic endonasal transsphenoidal surgery (METS) (488 cases), were performed on patients with MRI-negative CD. 7 studies, which included 164 patients, did not describe any surgery. EETS and METS are conducted to achieve selective adenomectomy (231 cases), partial adenomectomy (80 cases), total adenomectomy (13 cases), hemihypophysectomy (15 cases), or enlarged adenomectomy (48 cases). Based on available data on these studies, the remission rate, persistence rate, and recurrence rate after different types of surgeries on patients with MRI-negative CD were 72.97%, 27.03%, and 12.05%, respectively. There was no statistically significant difference between EETS and METS in the subanalysis regarding recurrence rate, remission rate, and persistence rate. However, the recurrence rate in the METS group is almost 3 times higher than in the EETS group. CONCLUSIONS Surgery has a good prognosis in patients with MRI-negative CD in terms of remission, and EETS has a lower rate of disease recurrence than METS; therefore, EETS seems to be the potential recommended treatment technique, while to confirm the therapeutic method of choice, further investigations should be done.
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Affiliation(s)
- Mohammadmahdi Sabahi
- 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
| | - 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
| | - 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
| | - Kevin Vidal
- Department of Neurological Surgery, Pauline Braathen Neurological Center, Cleveland Clinic Florida, Weston, Florida, USA
| | - Pablo F Recinos
- Department of Neurological Surgery and Rosa Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Varun R Kshettry
- Department of Neurological Surgery and Rosa Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Florian Roser
- Department of Neurosurgery, Cleveland Clinic, Abu Dhabi, UAE
| | - Badih Adada
- Department of Neurological Surgery, Pauline Braathen Neurological Center, Cleveland Clinic Florida, Weston, Florida, USA
| | - Hamid Borghei-Razavi
- Department of Neurological Surgery, Pauline Braathen Neurological Center, Cleveland Clinic Florida, Weston, Florida, USA.
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Perez-Vega C, Ramos-Fresnedo A, Tripathi S, Domingo RA, Ravindran K, Almeida JP, Peterson J, Trifiletti DM, Chaichana KL, Quinones-Hinojosa A, Samson SL. Treatment of recurrent and persistent Cushing's disease after first transsphenoidal surgery: lessons learned from an international meta-analysis. Pituitary 2022; 25:540-549. [PMID: 35508745 DOI: 10.1007/s11102-022-01215-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/09/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE Transsphenoidal surgery (TSS) is the first-line treatment for patients with Cushing's Disease (CD). Recurrence rates after a first TSS range between 3 and 22% within 3 years. Management of recurrent or persistent CD may include repeat TSS or stereotactic radiosurgery (SRS). We performed a meta-analysis to explore the overall efficacy of TSS and SRS for patients with CD after an initial surgical intervention. METHODS EMBASE, PubMed, SCOPUS, and Cochrane databases were searched from their dates-of-inception up to December 2021. Inclusion criteria were comprised of patients with an established diagnosis of CD who presented with persistent or biochemically recurrent disease after a first TSS for tumor resection and were treated with a second TSS or SRS. RESULTS Search criteria yielded 2,116 studies of which 37 articles from 15 countries were included for analysis. Mean age ranged between 29.9 and 47.9 years, and mean follow-up was 11-104 months. TSS was used in 669 (67.7%) patients, while SRS was used in 320 (32.4%) patients, and remission rates for CD were 59% (95%CI 0.49-0.68) and 74% (95%CI 0.54-0.88), respectively. There was no statistically significant difference in the remission rate between TSS and SRS (P = 0.15). The remission rate of patients with recurrent CD undergoing TSS was 53% (95%CI 0.32-0.73), and for persistent CD was 41% (95%CI 0.28-0.56) (P = 0.36). CONCLUSION Both TSS and SRS are possible approaches for the treatment of recurrent or persistent CD after a first TSS. Our data show that either TSS or SRS represent viable treatment options to achieve remission for this subset of patients.
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Affiliation(s)
- Carlos Perez-Vega
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | | | - Shashwat Tripathi
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Ricardo A Domingo
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | | | - Joao P Almeida
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Jennifer Peterson
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, USA
| | | | | | | | - Susan L Samson
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL, USA.
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Department of Neurologic Surgery, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL, 32224, USA.
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7
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Dai C, Feng M, Sun B, Bao X, Yao Y, Deng K, Ren Z, Zhao B, Lu L, Wang R, Kang J. Surgical outcome of transsphenoidal surgery in Cushing's disease: a case series of 1106 patients from a single center over 30 years. Endocrine 2022; 75:219-227. [PMID: 34415482 DOI: 10.1007/s12020-021-02848-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 08/05/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Transsphenoidal surgery (TSS) is the first-line treatment for patients with Cushing's disease (CD). However, the reported remission rates of patients who received TSS vary widely between different studies, and the predictors of surgical outcomes remain controversial. The present study analyzed the early outcome of TSS in a large population of patients with CD at a single center, and identified potential predictors of initial remission of TSS in patients with CD. METHODS The clinical features and surgical outcomes of CD patients who underwent TSS between 1988 and 2018 at Peking Union Medical College Hospital (PUMCH) were collected and analyzed from their medical records. RESULTS Of the 1604 CD patients who underwent TSS at PUMCH between February 1988 and October 2018, 1106 patients had complete medical data and pathological results. After surgery, the overall postoperative initial remission rate was 72.5, and 27.5% of patients maintained persistent hypercortisolism. The initial remission rate of patients with preoperative noninvasive adenoma based on MRI (77.1%), intraoperative noninvasiveness (72.5%), microadenoma (74.3%), pathological confirmation (76.4%), and first TSS (73.9%) was significantly higher than that in patients with preoperative invasive adenoma (53.0%), intraoperative invasiveness (60.7%), macroadenomas (65.9%), pathologically negative (49.7%), and repeat TSS (56.0%), respectively (all P < 0.05). The initial remission rate in patients with pseudocapsule-based extracapsular resection (88.1%), MRI-visible adenoma (74.2%) was higher than that in patients without pseudocapsule-based extracapsular resection (77.1%), and with MRI-negative results (64.5%), respectively, but did not reach statistical significance (All P > 0.05). Striking, there was no significant differences in initial remission rates between patients who underwent selective adenomectomy and enlarged adenomectomy (P > 0.05). Whereas, the initial remission rates in patients who underwent partial hypophysectomy only was 51.0%, which was much lower than that in patients underwent selective adenomectomy and enlarged adenomectomy (P < 0.05). CONCLUSION The TSS is a safe and effective procedure for the treatment of CD. Whereas, preoperative invasiveness based on MRI, intraoperative invasiveness, macroadenomas pathologically negative, and repeat TSS are related to lower initial remission rates.
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Affiliation(s)
- Congxin Dai
- Department of Neurosurgery, Beijing Tongren Hospital, Capital Medical University, Beijing, 100730, China
| | - Ming Feng
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bowen Sun
- Department of Neurosurgery, Beijing Tongren Hospital, Capital Medical University, Beijing, 100730, China
| | - Xinjie Bao
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yong Yao
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Kan Deng
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zuyuan Ren
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Binghao Zhao
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lin Lu
- Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Renzhi Wang
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Jun Kang
- Department of Neurosurgery, Beijing Tongren Hospital, Capital Medical University, Beijing, 100730, China.
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8
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Zhang T, Zhang B, Yuan L, Song Y, Wang F. Superiority of endoscopic transsphenoidal pituitary surgery to microscopic transseptal pituitary surgery for treatment of Cushing's disease. REVISTA DA ASSOCIACAO MEDICA BRASILEIRA (1992) 2021; 67:1687-1691. [PMID: 34909899 DOI: 10.1590/1806-9282.20210732] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 08/19/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE This study aims to compare the efficacy and safety of endoscopic transsphenoidal pituitary surgery and microscopic transseptal pituitary surgery in the treatment of Cushing's disease (CD). METHODS A total of 46 patients with CD were randomized into endoscopic group and microscopic group, with 23 cases in each group. The endoscopic group received the endoscopic transsphenoidal pituitary surgery, and the microscopic group received the microscopic transseptal pituitary surgery. The retrospective data, surgical outcomes, surgical cure rates, and complications in two groups were compared. RESULTS Compared with microscopic group, the operative time was significantly shorter (p<0.05), the estimated blood loss was significantly less (p<0.05), and the hospital stay was significantly shorter (p<0.05) in endoscopic group. The surgical cure rate in endoscopic and microscopic groups was 69.56% and 60.86%, respectively, with no significant difference between the two groups (p>0.05). The incidence of complications in endoscopic group was significantly lower than that in microscopic group (p<0.01). CONCLUSIONS For the treatment of CD, the efficacy of endoscopic transsphenoidal pituitary surgery is basically the same as that of traditional microscopic transseptal pituitary surgery. However, the endoscopic surgery can further shorten the operative time, reduce the estimated blood loss, shorten the hospital stay, and reduce the complications.
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Affiliation(s)
- Ting Zhang
- PLA Rocket Force Characteristic Medical Center, Department of Neurosurgery - Beijing, China
| | - Baozhong Zhang
- PLA Rocket Force Characteristic Medical Center, Department of Neurosurgery - Beijing, China
| | - Lei Yuan
- PLA Rocket Force Characteristic Medical Center, Department of Neurosurgery - Beijing, China
| | - Yan Song
- PLA Rocket Force Characteristic Medical Center, Department of Neurosurgery - Beijing, China
| | - Fei Wang
- PLA Rocket Force Characteristic Medical Center, Department of Neurosurgery - Beijing, China
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Abhinav K, Tyler M, Dale OT, Mohyeldin A, Fernandez-Miranda JC, Katznelson L. Managing complications of endoscopic transsphenoidal surgery in pituitary adenomas. Expert Rev Endocrinol Metab 2020; 15:311-319. [PMID: 32744080 DOI: 10.1080/17446651.2020.1800452] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 07/21/2020] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Over the last two decades there has been a gradual shift from the traditional microscopic approach toward the use of endoscopic endonasal approach for resection of pituitary adenomas. Multiple medical and surgical complications can occur following endoscopic transsphenoidal resection of adenomas. AREAS COVERED We discuss the evolution of the surgical practice from the use of the 'microscope' to the 'endoscope' in the resection of pituitary adenomas. We present a comprehensive review of the medical and surgical complications following surgery with particular emphasis on both the prevention and management of electrolyte disturbance, cerebrospinal fluid leak and the rare but dreaded complication of internal carotid injury (ICA). We also searched the PubMed database to identify relevant literature between 1984 and 2019. EXPERT OPINION Use of endoscope compared with microscope may be associated with better preservation of pituitary gland function with similar extent of resection. Overall medical and surgical complications can be safely managed in high volume centers in association with endocrinologists and skull base trained otolaryngologists. Understanding of anatomico-technical nuances and meticulous surgical technique are important toward preventing ICA injury. Ongoing surgical and technical developments coupled with imaging advances will likely lead to better future outcomes for patients with functioning and nonfunctioning adenomas.
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Affiliation(s)
- Kumar Abhinav
- Department of Neurosurgery, Institute of Clinical Neuroscience, Center for Endoscopic and Pituitary Skull Base Surgery, Southmead Hospital , Bristol, UK
| | - Matthew Tyler
- Department of Otolaryngology-Head and Neck Surgery, University of Minnesota , Minneapolis, MN, USA
| | - Oliver T Dale
- Department of ENT-Head and Neck Surgery, University Hospitals Bristol , Bristol, UK
| | - Ahmed Mohyeldin
- Department of Neurosurgery, Stanford University School of Medicine , Stanford, CA, USA
| | | | - Laurence Katznelson
- Department of Neurosurgery, Stanford University School of Medicine , Stanford, CA, USA
- Department of Medicine, Stanford University School of Medicine , Stanford, CA, USA
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10
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Serban AL, Del Sindaco G, Sala E, Carosi G, Indirli R, Rodari G, Giavoli C, Locatelli M, Carrabba G, Bertani G, Marfia G, Mantovani G, Arosio M, Ferrante E. Determinants of outcome of transsphenoidal surgery for Cushing disease in a single-centre series. J Endocrinol Invest 2020; 43:631-639. [PMID: 31773581 DOI: 10.1007/s40618-019-01151-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 11/19/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND First-line therapy of Cushing disease (CD) is transsphenoidal surgery (TSS) aimed to obtain a complete removal of the pituitary adenoma and remission of disease. PURPOSE To analyse the surgical outcome of patients with CD who underwent TSS in our Centre. METHODS Retrospective analysis on patients with CD who underwent TSS between 1990 and 2016. RESULTS We analysed 102 TSS that included: 84 first TSS and 18 second and third TSS. The overall remission rate after surgery was 76.5%, with a significant higher percentage of remitted patients after the first TSS compared to the subsequent TSS (82% vs 50%, p = 0.014). The remission after the first TSS was significantly higher when performed by a dedicated surgical team (DST) (89.8% vs 71% p = 0.04) and when the immunohistochemical examination confirmed the adrenocorticotropic adenoma (87% vs 55%, p = 0.04). Neuroradiological findings influenced the surgical outcome in a non-significant manner. Post-TSS complications were reported in 32 patients, with no significant variation when TSS was performed by DST. In case of reintervention, remission of disease was obtained in 72.7% of microadenoma, while no remitted patients were observed in case of macroadenomas. The DST did not significantly improve the outcome. CONCLUSION Cushing disease is characterized by a broad spectrum of neuroradiological presentation. Despite the availability of a DST make the TSS a safe and effective first-line treatment among all these patients, a precise pre-treatment evaluation is needed in order to define the aim of neurosurgery and to schedule the management of recurrent disease.
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Affiliation(s)
- A L Serban
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Endocrinology Unit, Via Francesco Sforza, 35, Milan, 20143, Italy
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - G Del Sindaco
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Endocrinology Unit, Via Francesco Sforza, 35, Milan, 20143, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - E Sala
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Endocrinology Unit, Via Francesco Sforza, 35, Milan, 20143, Italy
| | - G Carosi
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Endocrinology Unit, Via Francesco Sforza, 35, Milan, 20143, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - R Indirli
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Endocrinology Unit, Via Francesco Sforza, 35, Milan, 20143, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - G Rodari
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Endocrinology Unit, Via Francesco Sforza, 35, Milan, 20143, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - C Giavoli
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Endocrinology Unit, Via Francesco Sforza, 35, Milan, 20143, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - M Locatelli
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Neurosurgery Division, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - G Carrabba
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Neurosurgery Division, Milan, Italy
| | - G Bertani
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Neurosurgery Division, Milan, Italy
| | - G Marfia
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Neurosurgery Division, Milan, Italy
| | - G Mantovani
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Endocrinology Unit, Via Francesco Sforza, 35, Milan, 20143, Italy.
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.
| | - M Arosio
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Endocrinology Unit, Via Francesco Sforza, 35, Milan, 20143, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - E Ferrante
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Endocrinology Unit, Via Francesco Sforza, 35, Milan, 20143, Italy
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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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12
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Rubinstein G, Osswald A, Zopp S, Ritzel K, Theodoropoulou M, Beuschlein F, Reincke M. Therapeutic options after surgical failure in Cushing's disease: A critical review. Best Pract Res Clin Endocrinol Metab 2019; 33:101270. [PMID: 31036383 DOI: 10.1016/j.beem.2019.04.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Cushing's disease (CD) is the most common etiology of Cushing's syndrome (CD) due to corticotroph pituitary adenoma, which are in most cases small (80-90% microadenomas) and in about 40% cannot be visualized on imaging of the sella. First-line treatment for CD is transsphenoidal surgery (TSS) with the aim of complete adenoma removal and preservation of pituitary gland function. As complete adenoma resection is not always possible, surgical failure is a common problem. This can be the case either due to persistent hypercortisolism after first TSS or recurrence of hypercortisolism after initially achieving remission. For these scenarios exist several therapeutic options with their inherent characteristics, which will be covered by this review.
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Affiliation(s)
- German Rubinstein
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ludwig-Maximilians-Universität München, Germany
| | - Andrea Osswald
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ludwig-Maximilians-Universität München, Germany
| | - Stephanie Zopp
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ludwig-Maximilians-Universität München, Germany
| | - Katrin Ritzel
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ludwig-Maximilians-Universität München, Germany
| | - Marily Theodoropoulou
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ludwig-Maximilians-Universität München, Germany
| | - Felix Beuschlein
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ludwig-Maximilians-Universität München, Germany; Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, University Hospital, Zürich, Switzerland
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ludwig-Maximilians-Universität München, Germany.
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13
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Saini S, Kanwar J, Gupta S, Behari S, Bhatia E, Yadav S. Long-term outcome of trans-sphenoidal surgery for Cushing's disease in Indian patients. Acta Neurochir (Wien) 2019; 161:119-127. [PMID: 30465277 DOI: 10.1007/s00701-018-3736-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 11/09/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND The results of trans-sphenoidal surgery (TSS) in Cushing's disease (CD) vary widely depending upon patient characteristics as well as surgical experience. Patients in India are often referred late to referral centers. We studied the rates of remission and endocrine deficiencies after TSS in patients with CD presenting to a referral hospital in India. METHODS Sixty consecutive patients (45 females, median age 24.5 years) who underwent TSS between 2000 and 2015 were studied. The median (range) duration of follow-up was 40 (3-138) months. Initial and long-term remission and relapse rates and pituitary hypofunction post-TSS were evaluated. RESULTS Eighteen (30%) patients harbored macroadenomas. Twenty-eight (47%) patients achieved remission in the immediate post-operative period (8 AM serum cortisol < 140 nmol/l), while a higher remission rate was noted at 6 months (39/54 patients, 72%). At 1 year 70% patients and at final follow-up [median duration 40 (range 3-138) months], 58% of patients were in remission. No pre- or post-surgical variables were consistently associated with remission, except for the 8-AM serum cortisol level on the fifth day after surgery. Seven (18%) patients relapsed on follow-up, including five patients who had fifth post-operative day 8 AM serum cortisol < 140 nmol/l. Twelve (25%) patients newly developed hypothyroidism and one (1.6%) patient developed amenorrhoea after TSS. CONCLUSION Remission rate at 6 months was higher than immediately after TSS. A significant proportion of patients relapsed, thus necessitating life-long follow-up. New-onset hypothyroidism was frequent after TSS.
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Affiliation(s)
- S Saini
- Departments of Endocrinology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - J Kanwar
- Departments of Endocrinology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - S Gupta
- Department of Neurosurgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - S Behari
- Department of Neurosurgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - E Bhatia
- Departments of Endocrinology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Subhash Yadav
- Departments of Endocrinology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India.
- Department of Endocrinology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India.
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14
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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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15
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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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16
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Abstract
PURPOSE Surgical experience is considered paramount for excellent outcome of transsphenoidal surgery (TSS). However, objective data demonstrating the surgical success in relation to the experience of pituitary surgery units or individual experience of pituitary surgeons is sparse. METHODS Based on literature data, we have investigated the influence of experience with TSS for pituitary adenomas on endocrinological remission rates and on operative complications. The surgical experience was assessed by calculating the number of transsphenoidal operations per year. RESULTS For TSS of microprolactinomas, mean remission rates were 77% in centers with < 2 operations per year for microprolactinomas, 82% with 2-4 operations, 84% with 4-6 operations, and 91% with > 6 operations. A yearly experience with more than 10 initial operations for Cushing's disease (CD) warrants a remission rate exceeding 70%. Remission rates in CD exceeding 86% have only been reported for single surgeon series. Extraordinarily high complication rates were found in some series with < 25 yearly total operations for pituitary adenomas. Major vascular complications were less than 2% and revision rates for rhinorrhea usually < 2.5% in centers performing > 25 transsphenoidal operations per year. CONCLUSIONS We conclude that a center with experience of > 25 transsphenoidal operations for pituitary adenomas per year provides a high likelihood of safe TSS. Surgery for CD requires a particularly high level of practice to guarantee excellent remission rates. The endocrinologist has the unique opportunity to audit the surgical success by hormone measurement and to refer patients to neurosurgeons with proven excellence.
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Affiliation(s)
- Jürgen Honegger
- Department of Neurosurgery, University of Tuebingen, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany.
| | - Florian Grimm
- Department of Neurosurgery, University of Tuebingen, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
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17
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Brichard C, Costa E, Fomekong E, Maiter D, Raftopoulos C. Outcome of Transsphenoidal Surgery for Cushing Disease: A Single-Center Experience over 20 Years. World Neurosurg 2018; 119:e106-e117. [PMID: 30031194 DOI: 10.1016/j.wneu.2018.07.055] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 07/03/2018] [Accepted: 07/05/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND This study investigated the outcome of transsphenoidal surgery (TSS) for Cushing disease (CD) and the influence of our surgical strategy on remission rates and postoperative pituitary function. PATIENTS AND METHODS We retrospectively reviewed data from 71 patients with CD who underwent microscope navigation TSS (MN-TSS) in Saint-Luc Hospital between 1996 and 2017. True remission was defined as normal fasting cortisol level, normal 24-hour urinary free cortisol, or continued need for hydrocortisone replacement for 1 year after surgery. RESULTS Overall remission rate after 1 or repeated MN-TSS was 83%. Highest remission rate was found in patients with macroadenomas (92%). Successful first MN-TSS was correlated with a high final remission rate (95%), whereas failed first MN-TSS was correlated with a low final remission rate (36%). Although day 1 cortisol levels were significantly lower in patients with long-term remission, high levels were still observed in a few patients, especially those who had had CD for many years. We found a low rate of postoperative pituitary long-term hypofunction (9.7%). CONCLUSIONS MN-TSS is a safe and effective procedure to treat CD, allowing remission rates of 83%. One-year remission period after first surgery is correlated with a final remission rate of 95%. Although day 1 morning cortisol value is the most significant predictor for long-term remission, some patients with CD for many years may keep high postoperative cortisol levels and be in later remission, likely because of secondary adrenal hyperplasia. Our focused approach with microscope navigation resulted in low rates of postoperative pituitary hypofunction and kept a recurrence rate comparable to that in the literature.
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Affiliation(s)
- Camille Brichard
- Department of Neurosurgery, Saint-Luc Hospital, Université Catholique de Louvain, Brussels, Belgium
| | - Emmanuel Costa
- Department of Neurosurgery, Saint-Luc Hospital, Université Catholique de Louvain, Brussels, Belgium
| | - Edward Fomekong
- Department of Neurosurgery, Saint-Luc Hospital, Université Catholique de Louvain, Brussels, Belgium
| | - Dominique Maiter
- Department of Endocrinology, Saint-Luc Hospital, Université Catholique de Louvain, Brussels, Belgium
| | - Christian Raftopoulos
- Department of Neurosurgery, Saint-Luc Hospital, Université Catholique de Louvain, Brussels, Belgium.
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Zaidi HA, Wang AJ, Cote DJ, Smith TR, Prevedello D, Solari D, Cappabianca P, Quiroga M, Laws ER. Preoperative Stratification of Transsphenoidal Pituitary Surgery Patients Based on Surgical Urgency. Neurosurgery 2018; 81:659-664. [PMID: 28520927 DOI: 10.1093/neuros/nyx073] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 01/31/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Currently, there is no prioritization scale available to distinguish those patients with pituitary tumors who require urgent surgical intervention from those who are candidates for elective treatment. OBJECTIVE To develop a classification system that can help primary care physicians, endocrinologists, neurosurgeons, ancillary support staff, and hospital administrators identify high-priority surgical candidates. METHODS An expert international panel of clinicians consisting of endocrinologists and neurosurgeons who are involved in the diagnosis and management of sellar disease was convened. The panel retrospectively reviewed individual experiences, including a cohort of patients operated upon for pituitary related disease at the Brigham and Women's Hospital from January 2008 to November 2015. A risk stratification schema was developed to streamline patient care pathways. RESULTS We identified 4 groups of surgical candidates with varying levels of risk, and then assigned treatment timelines and different differential diagnoses to each. The 4 groups were as follows: group A: urgent-immediate; group B: prompt-initiate treatment within 1 to 2 weeks; group C: soon-initiate treatment within 3 months; group D: elective-as soon as indicated. Among 472 patients treated at Brigham and Women's Hospital for pituitary adenomas, each was assigned to 1 of the 4 predetermined subgroups: group A, 6.8%; group B, 30.1%; group C, 31.1%; group D, 32.0%. CONCLUSIONS We developed a risk stratification schema that may serve as a platform to streamline care to the patients at highest risk. The expert opinions presented provide a basis for future studies regarding the risk prioritization of patients.
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Affiliation(s)
- Hasan A Zaidi
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Amy J Wang
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - David J Cote
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Timothy R Smith
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Daniel Prevedello
- Department of Neurosurgery, The Ohio State University, Columbus, Ohio
| | | | | | - Monica Quiroga
- Department of Neurosurgery, Hospital Mexico, PINECOS, University of Costa Rica, San Jose, Costa Rica
| | - Edward R Laws
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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19
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Feng M, Liu Z, Liu X, Bao X, Yao Y, Deng K, Xing B, Lian W, Zhu H, Lu L, Wang R. Diagnosis and Outcomes of 341 Patients with Cushing's Disease Following Transsphenoid Surgery: A Single-Center Experience. World Neurosurg 2017; 109:e75-e80. [PMID: 28951275 DOI: 10.1016/j.wneu.2017.09.105] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Revised: 09/15/2017] [Accepted: 09/16/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Transsphenoid surgery (TSS) is a standard treatment modality for Cushing's disease (CD). However, postoperative remission and recurrence rates vary among studies. Here we analyze the diagnosis and outcomes of 341 patients with a preoperative diagnosis of CD undergoing TSS in a single center over a 3-year period. METHODS A total of 341 patients were enrolled. Clinical manifestations, imaging results, laboratory workups, and results of inferior petrosal sinus sampling (IPSS) were obtained. Outcomes were obtained with a follow-up length from 12 to 36 months. RESULTS The tumors were mainly of Knosp level 0 (68.57%). The sensitivity of MRI, combined low-dose and high-dose dexamethasone suppression test and IPSS in the diagnosis were 90.83%, 88.53% and 95.57%. The concordance of lateralization by MRI and by IPSS were 78.96% and 61.34% compared with surgery. 2. OUTCOMES The overall remission rate was 78.89% (N = 289). Patients undergoing the first TSS (N = 234) had a remission rate of 86.36% for macroadenomas (N = 22) and 83.2% for microadenomas (N = 212). Patients undergoing a second TSS (N = 55) had lower rate of remission of 50.00% for macroadenomas (N = 6) and 61.22% for microadenomas (N = 49). For patients with invasive tumors, the overall remission rate was 26.92% (N = 26), 20.0% for macroadenomas (n = 20) and 50.0% for microadenomas (N = 6). The recurrence rate was 2.42%. CONCLUSIONS Pituitary imaging, endocrinological workups and IPSS are sensitive and specific diagnostic modalities for CD, but the lateralization efficacy of MRI and IPSS are unsatisfactory. A higher rate of remission relies on gross resections of tumors.
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Affiliation(s)
- Ming Feng
- Department of Neurosurgery, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Ziyuan Liu
- Department of Neurosurgery, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Xiaohai Liu
- Department of Neurosurgery, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Xinjie Bao
- Department of Neurosurgery, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Yong Yao
- Department of Neurosurgery, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Kan Deng
- Department of Neurosurgery, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Bing Xing
- Department of Neurosurgery, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Wei Lian
- Department of Neurosurgery, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - 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, Beijing, China.
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20
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Nishioka H. Recent Evolution of Endoscopic Endonasal Surgery for Treatment of Pituitary Adenomas. Neurol Med Chir (Tokyo) 2017; 57:151-158. [PMID: 28239067 PMCID: PMC5409268 DOI: 10.2176/nmc.ra.2016-0276] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
For the treatment of pituitary tumors, microscopic transsphenoidal surgery has been considered the "gold standard" since the late 1960s. Over the last two decades, however, a worldwide shift towards endoscopic endonasal surgery is in progress for many reasons. These include a wide panoramic view, improved illumination, an ability to look around anatomical corners using angled tip and, in addition, application to the extended approaches for parasellar tumors. Both endoscopic and microscopic approaches appear equally effective for nonfunctioning adenomas without significant suprasellar or lateral extensions, whereas the endoscopic approach may improve outcomes associated with the extent of resection and postoperative complications for larger tumors. Despite many theoretical benefits in the endoscopic surgery, remission rates of functioning adenomas do not substantially differ between the approaches in experienced hands. The endoscopic approach is a valid alternative to the microscopic approach for adenomas. The benefits will be more appreciated in the extended surgery for parasellar tumors.
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Affiliation(s)
- Hiroshi Nishioka
- Department of Hypothalamic and Pituitary Surgery, Toranomon Hospital.,Okinaka Memorial Institute for Medical Research
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Knappe UJ, Jaspers C, Buschsieweke D, Reinbold WD, Alomari A, Saeger W, Ehlenz K, Mann WA, Kann PH, Feldkamp J. Ectopic Adrenocorticotropic Hormone–Secreting Pituitary Adenomas: An Underestimated Entity. Neurosurgery 2017; 80:525-533. [DOI: 10.1227/neu.0000000000001319] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2015] [Accepted: 03/21/2016] [Indexed: 01/16/2023] Open
Abstract
AbstractBACKGROUND: The diagnosis of Cushing disease is based on endocrinological pa-rameters, with no single test being specific. In some patients, dynamic thin-slice sellar magnetic resonance imaging fails to detect a pituitary tumor.OBJECTIVE: The purpose of this study is to investigate the role of ectopic pituitary adenoma in this situation.METHODS: In a retrospective chart review, 5 patients (6%) with ectopic adenomas were identified in 83 consecutive patients undergoing transsphenoidal surgery for adrenocorticotropic hormone (ACTH)-secreting pituitary adenomas by 1 surgeon.RESULTS: In all 5 patients (all female, 32-41 years of age), an exclusively extrasellar ACTH-secreting adenoma was excised. Three adenomas were located in the cavernous sinus, 1 in the sphenoid sinus, and 1 in the ethmoidal cells. Histologically, none of the tumors showed signs of aggressiveness. Three of the 5 adenomas specifically expressed somatostatin receptor 5. In 4 patients with Cushing disease, postoperative remission was obtained, with 1 recurrence after 14 months. In the patient with Nelson syndrome, ACTH decreased from >800 to <80 pg/mL. Three patients underwent previous surgery elsewhere, including 1 hypophysectomy. In this case, the ectopic adenoma (positive for somatostatin receptor 5) in the ethmoidal cells turned out to be positive on gallium 68 DOTATATE positron emission tomography/computed tomography.CONCLUSION: The incidence of primarily ectopic ACTH-secreting adenomas in this series was 6%. In cases of negative MRI findings, an ectopic ACTH-secreting adenoma should be taken into account. 68Ga DOTATATE positron emission tomography/computed tomography may identify ectopic pituitary adenomas. Hypophysectomy should always be avoided in primary surgery for CD.
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Affiliation(s)
- Ulrich J. Knappe
- Department of Neurosurgery, Johannes Wesling Klinikum, Minden, Germany
| | - Christian Jaspers
- Department of Endocrinology, Johannes Wesling Klinikum, Minden, Germany
| | | | | | - Ali Alomari
- Department of Neurosurgery, Johannes Wesling Klinikum, Minden, Germany
| | - Wolfgang Saeger
- Institute of Neuropathology, Univers-itätskrankenhaus Eppendorf, Hamburg, Germany
| | - Klaus Ehlenz
- Gesundheitszentrum Mar-tinshof, Giessen, Germany
| | | | - Peter Herbert Kann
- Department of Endocrinol-ogy, Philipps University, UKGM, Marburg, Germany
| | - Joachim Feldkamp
- Department of Endocr-inology, Klinikum Bielefeld, Bielefeld, Germany
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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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Pereira AM. Long-term effects of treatment of pituitary adenomas. HANDBOOK OF CLINICAL NEUROLOGY 2016; 124:361-71. [PMID: 25248599 DOI: 10.1016/b978-0-444-59602-4.00024-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Pituitary adenomas can be treated effectively in the vast majority of cases. After successful treatment for pituitary disease, many patients still report reduced quality of life in the presence of persistent morbidity and (slightly) increased mortality. At present, there is an increasing awareness that in many cases long-term remission of functioning or nonfunctioning adenomas does not equal cure. The causes are most probably multifactorial. Hypopituitarism, intrinsic imperfections of surgical or endocrine replacement therapy, but also persistent effects of treatment and of previous hormone excess on the central nervous system all affect long-term morbidity, general well-being, and mortality. This implies that treatment goals for patients with pituitary adenomas will shift from long-term cure to long-term care. Further research is therefore needed to get more insight into each of these factors of influence, such as the extent of reversibility of hormone excess syndromes on cardiovascular risk and behavior. The fact that coping strategies, despite long-term remission, are altered and illness perceptions are affected strongly suggests that long-term care should incorporate self-management interventions that might help to improve quality of life for patients.
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Affiliation(s)
- Alberto M Pereira
- Department of Endocrinology and Center for Endocrine Tumors, Leiden University Medical Center, Leiden, The Netherlands.
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24
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Resection of pituitary tumors: endoscopic versus microscopic. J Neurooncol 2016; 130:309-317. [DOI: 10.1007/s11060-016-2124-y] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2016] [Accepted: 04/07/2016] [Indexed: 11/27/2022]
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Abstract
Cushing's disease (CD) is the result of excess secretion of adrenocorticotropic hormone (ACTH) by a benign monoclonal pituitary adenoma. The excessive secretion of ACTH stimulates secretion of cortisol by the adrenal glands, resulting in supraphysiological levels of circulating cortisol. The pathophysiological levels of cortisol are associated with hypertension, diabetes, obesity, and early death. Successful resection of the CD-associated ACTH-secreting pituitary adenoma is the treatment of choice and results in immediate biochemical remission with preservation of pituitary function. Accurate and early identification of CD is critical for effective surgical management and optimal prognosis. The authors review the current pathophysiological principles, diagnostic methods, and management of CD.
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Affiliation(s)
- Russell R Lonser
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Lynnette Nieman
- Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland; and
| | - Edward H Oldfield
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
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26
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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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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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Smith TR, Hulou MM, Huang KT, Nery B, de Moura SM, Cote DJ, Laws ER. Complications after transsphenoidal surgery for patients with Cushing's disease and silent corticotroph adenomas. Neurosurg Focus 2015; 38:E12. [PMID: 25639314 DOI: 10.3171/2014.10.focus14705] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The purpose of this study was to describe complications associated with the endonasal, transsphenoidal approach for the treatment of adrenocorticotropic hormone (ACTH)-positive staining tumors (Cushing's disease [CD] and silent corticotroph adenomas [SCAs]) performed by 1 surgeon at a high-volume academic medical center. METHODS Medical records from Brigham and Women's Hospital were retrospectively reviewed. Selected for study were 82 patients with CD who during April 2008-April 2014 had consecutively undergone transsphenoidal resection or who had subsequent pathological confirmation of ACTH-positive tumor staining. In addition to demographic, patient, tumor, and surgery characteristics, complications were evaluated. Complications of interest included syndrome of inappropriate antidiuretic hormone secretion, diabetes insipidus (DI), CSF leakage, carotid artery injury, epistaxis, meningitis, and vision changes. RESULTS Of the 82 patients, 68 (82.9%) had CD and 14 (17.1%) had SCAs; 55 patients were female and 27 were male. Most common (n = 62 patients, 82.7%) were microadenomas, followed by macroadenomas (n = 13, 14.7%). A total of 31 (37.8%) patients underwent reoperation. Median follow-up time was 12.0 months (range 3-69 months). The most common diagnosis was ACTH-secreting (n = 68, 82.9%), followed by silent tumors/adenomas (n = 14, 17.1%). ACTH hyperplasia was found in 8 patients (9.8%). Of the 74 patients who had verified tumors, 12 (16.2%) had tumors with atypical features. The overall (CD and SCA) rate of minor complications was 35.4%; the rate of major complications was 8.5% (n = 7). All permanent morbidity was associated with DI (n = 5, 6.1%). In 16 CD patients (23.5%), transient DI developed. Transient DI was more likely to develop in CD patients who had undergone a second operation (37.9%) than in those who had undergone a first operation only (12.8%, p < 0.05). Permanent DI developed in 4 CD patients (5.9%) and 1 SCA patient (7.1%). For 1 CD patient, intraoperative carotid artery injury required endovascular sacrifice of the injured artery, but the patient remained neurologically intact. For another CD patient, aseptic meningitis developed and was treated effectively with corticosteroids. One CD patient experienced major postoperative epistaxis requiring another operative procedure to achieve hemostasis. For 2 CD patients, development of sinus mucoceles was managed conservatively. For 1 SCA patient, an abdominal wound dehisced at the fat graft site. No patients experienced postoperative CSF leakage, visual impairment, or deep vein thrombosis. CONCLUSIONS Transsphenoidal surgery is the treatment of choice for patients with CD and other ACTH-positive staining tumors. Recent advances in endoscopic technology and increasing surgeon comfort with this technology are making transsphenoidal procedures safer, faster, and more effective. Serious complications are uncommon and can be managed successfully.
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Affiliation(s)
- Timothy R Smith
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts
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29
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Shin SS, Gardner PA, Ng J, Faraji AH, Agarwal N, Chivukula S, Fernandez-Miranda JC, Snyderman CH, Challinor SM. Endoscopic Endonasal Approach for Adrenocorticotropic Hormone-Secreting Pituitary Adenomas: Outcomes and Analysis of Remission Rates and Tumor Biochemical Activity with Respect to Tumor Invasiveness. World Neurosurg 2015; 102:651-658.e1. [PMID: 26252984 DOI: 10.1016/j.wneu.2015.07.065] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Revised: 07/28/2015] [Accepted: 07/29/2015] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of this study was to analyze the outcomes and complications of the endoscopic endonasal approach (EEA) performed on patients with Cushing disease at our Pituitary Center during the past 11 years. METHODS Clinical information and imaging in electronic medical records were reviewed for patients who underwent EEA. Statistical analysis was performed with χ2 testing and Student's t-test. RESULTS Remission was achieved in 39 patients (79.6%) at initial evaluation within 2 weeks of surgery. At last follow-up, remission persisted in 70% of 50 patients with EEA alone (mean follow-up time, 37.5 ± 4.6 months; median, 26.2 months; range, 2.5-155.0 months). At last follow-up, remission rates were 80% among magnetic resonance imaging-negative adenomas, 70.6% among noninvasive or minimally invasive adenomas (Knosp 0, 1, 2), and 50% among invasive adenomas (Knosp 3, 4). There were no statistical differences in the remission rates among these categories (P = 0.444). Women had higher proportions of initial remission than men (P = 0.033) and patients who had no initial remission were older (P = 0.046). Higher preoperative normalized adrenocroticotropic hormone level was associated with a greater degree of invasiveness (P = 0.021). However, there was no association between preoperative normalized urine-free cortisol levels and degree of invasiveness (P = 0.582). Complications included panhypopituitarism (n = 3), hypothyroidism (n = 3), growth hormone deficiency (n = 1), hypogonadism (n = 1), postoperative cerebrospinal fluid leak (n = 2), and transient diabetes insipidus (n = 4). CONCLUSIONS The EEA for Cushing disease resulted in remission and complication rates comparable with previous analyses of EEA, as well as microsurgical series. Preoperative adrenocorticotropic hormone levels were associated with invasiveness.
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Affiliation(s)
- Samuel S Shin
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Paul A Gardner
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
| | - Jason Ng
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Amir H Faraji
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Nitin Agarwal
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Srinivas Chivukula
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Juan C Fernandez-Miranda
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Carl H Snyderman
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Sue M Challinor
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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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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Miller BA, Ioachimescu AG, Oyesiku NM. Contemporary indications for transsphenoidal pituitary surgery. World Neurosurg 2015; 82:S147-51. [PMID: 25496626 DOI: 10.1016/j.wneu.2014.07.037] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Accepted: 07/25/2014] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To analyze current indications for transsphenoidal pituitary surgery. METHODS The current literature regarding transsphenoidal surgery for all subtypes of pituitary adenomas and other sellar lesions was examined. Alternate approaches for pituitary surgery were also reviewed. RESULTS Transsphenoidal surgery continues to be the mainstay of surgical treatment for pituitary tumors, and has good outcomes in experienced hands. Pre- and postoperative management of pituitary tumors remains an important part of the treatment of patients with pituitary tumors. CONCLUSIONS Even as medical and surgical treatment for pituitary tumors evolves, transsphenoidal surgery remains a mainstay of treatment. Outcomes after transshenoidal surgery have improved over time. Neurosurgeons must be aware of the indications, risks and alternatives to transsphenoidal pituitary surgery.
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Affiliation(s)
- Brandon A Miller
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | | | - Nelson M Oyesiku
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA.
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Yamada S, Inoshita N, Fukuhara N, Yamaguchi-Okada M, Nishioka H, Takeshita A, Suzuki H, Ito J, Takeuchi Y. Therapeutic outcomes in patients undergoing surgery after diagnosis of Cushing's disease: A single-center study. Endocr J 2015; 62:1115-25. [PMID: 26477323 DOI: 10.1507/endocrj.15-0463] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
This study aimed to investigate early and late outcomes of patients who underwent neurosurgical procedures for the preoperative diagnosis of Cushing's disease (CD). Clinical, endocrine, imaging, and histologic data from 252 patients undergoing pituitary surgery at Toranomon Hospital through the end of 2012 were entered into a database and statistically analyzed. In 22 of these patients (8.7%; positive venous sampling in 15 and negative venous sampling in 7 patients), tumors were invisible on magnetic resonance imaging (MRI) and 42.9% of them achieved remission. In the remaining 230 patients, 93.5% of those with microadenomas (n=154) and 71.1% of those with macroadenomas (n=76) achieved early postoperative remission, with recurrence rates of 2.7% and 14.8%, respectively, during a 72.5-month median follow-up. In multivariate analyses, cavernous sinus invasion (CSI; odds ratio [OR], 13.0), type of surgery (OR, 4.0), and tumor size (OR, 2.7) were significant preoperative factors affecting early postoperative results, whereas peak cortisol levels ≥9.4 μg/dL in response to corticotropin-releasing hormone (CRH) and CSI were significant factors predicting recurrence. Tumor recurrence was more common in patients with non-densely granulated adenomas than in patients with densely granulated adenomas. We propose that the higher remission and lower recurrence rates in this series are due to our surgical strategies, including extracapsular tumor removal, aggressive resection of tumors with CSI, extended transsphenoidal surgery (TSS), or a combined approach for large/giant adenomas. Appropriate multimodal treatments, including radiotherapy, medication, and repeated surgery in patients with persistent or recurrent CD, could result in better overall outcomes than previously achieved.
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Affiliation(s)
- Shozo Yamada
- Department of Hypothalamic & Pituitary Surgery, Toranomon Hospital, Tokyo 105-8470, Japan
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Jeong I, Oh M, Kim JH, Cho JH, Choi JH, Yoo HW. Long-term follow-up on Cushing disease patient after transsphenoidal surgery. Ann Pediatr Endocrinol Metab 2014; 19:164-8. [PMID: 25346922 PMCID: PMC4208257 DOI: 10.6065/apem.2014.19.3.164] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Revised: 09/03/2014] [Accepted: 09/16/2014] [Indexed: 11/20/2022] Open
Abstract
Cushing disease is caused by excessive adrenocorticotropic hormone (ACTH) production by the pituitary adenoma. Transsphenoidal surgery is its first-line treatment. The incidence of Cushing disease in children and adolescents is so rare that long-term prognoses have yet to be made in most cases. We followed-up on a 16-year-old male Cushing disease patient who presented with rapid weight gain and growth retardation. The laboratory findings showed increased 24-hour urine free cortisol and lack of overnight cortisol suppression by low-dose dexamethasone test. The serum cortisol and 24-hour urine free cortisol, by high-dose dexamethasone test, also showed a lack of suppression, and a bilateral inferior petrosal sinus sampling suggested lateralization of ACTH secretion from the right-side pituitary gland. However, after a right hemihypophysectomy by the transsphenoidal approach, the 24-hour urine free cortisol levels were persistently high. Thus the patient underwent a total hypophysectomy, since which time he has been treated with hydrocortisone, levothyroxine, recombinant human growth hormone, and testosterone enanthate. Intravenous bisphosphonate for osteoporosis had been administered for three years. At his current age of 26 years, his final height had attained the target level range; his bone mineral density was normal, and his pubic hair was Tanner stage 4. This report describes the long-term treatment course of a Cushing disease patient according to growth profile, pubertal status, and responses to hormone replacement therapy. The clinical results serve to emphasize the importance of growth optimization, puberty, and bone health in the treatment management of Cushing disease patients who have undergone transsphenoidal surgery.
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Affiliation(s)
- Insook Jeong
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Moonyeon Oh
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Ja Hye Kim
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Ja Hyang Cho
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin-Ho Choi
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Han-Wook Yoo
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
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Dimopoulou C, Schopohl J, Rachinger W, Buchfelder M, Honegger J, Reincke M, Stalla GK. Long-term remission and recurrence rates after first and second transsphenoidal surgery for Cushing's disease: care reality in the Munich Metropolitan Region. Eur J Endocrinol 2014; 170:283-92. [PMID: 24217937 DOI: 10.1530/eje-13-0634] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Transsphenoidal surgery (TSS) presents the treatment of choice for Cushing's disease (CD). Remission and recurrence rates vary dependent on tumor size, extension, adenoma visibility on magnetic resonance imaging, and neurosurgical expertise. Other than published from single-surgeon neurosurgical series so far, we have aimed to describe long-term remission and recurrence rates of CD in a series incorporating different neurosurgeons, trying to reflect care reality in the Munich Metropolitan Region, which is accommodated by three tertiary university and multiple, smaller neurosurgical centers. DESIGN We conducted a retrospective analysis of 120 patients who underwent first and 36 patients who underwent second TSS as treatment for CD between 1990 and 2012. METHODS Patients were divided into three groups according to remission status. Potential risk factors for recurrence, pituitary function, and strategy in persistent disease were assessed. RESULTS THREE OUTCOME GROUPS WERE IDENTIFIED ACCORDING TO REMISSION STATUS AFTER FIRST TSS (MEAN FOLLOW-UP 79 MONTHS): remission, 71% (85/120), disease persistence, 29% (35/120), and disease recurrence, 34% (29/85) (mean time to recurrence 54 months). After second TSS (n=36, mean follow-up 62 months), we documented remission in 42% (15/36), disease persistence in 58% (21/36), and disease recurrence in 40% (6/15) (mean time to recurrence 42 months). Postoperative hypocortisolism after first, though not after second, TSS was associated with a lower risk of suffering disease recurrence (risk=0.72; 95% CI 0.60-0.88; exact significance (two-sided) P=0.035). CONCLUSIONS Our study shows higher recurrence rates of CD after first TSS than previously reported. Second TSS leads an additional 8% of the patients to long-term CD remission.
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Affiliation(s)
- C Dimopoulou
- Department of Endocrinology, Max Planck Institute of Psychiatry, Kraepelinstrasse 2-10, 80804 Munich, Germany
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Wagenmakers MAEM, Boogaarts HD, Roerink SHPP, Timmers HJLM, Stikkelbroeck NMML, Smit JWA, van Lindert EJ, Netea-Maier RT, Grotenhuis JA, Hermus ARMM. Endoscopic transsphenoidal pituitary surgery: a good and safe primary treatment option for Cushing's disease, even in case of macroadenomas or invasive adenomas. Eur J Endocrinol 2013; 169:329-37. [PMID: 23786985 DOI: 10.1530/eje-13-0325] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
CONTEXT Although the endoscopic technique of transsphenoidal pituitary surgery (TS) has been widely adopted, reports on its results in Cushing's disease (CD) are still scarce and no studies have investigated long-term recurrence rates. This is the largest endoscopic series published till now. OBJECTIVE To gain insight into the role of endoscopic TS as a primary treatment option for CD, especially in patients with magnetic resonance imaging (MRI)-negative CD and (invasive) macroadenomas. DESIGN Retrospective cohort study. PATIENTS AND METHODS The medical records of 86 patients with CD who underwent endoscopic TS were examined. Data on preoperative and postoperative evaluation, perioperative complications, and follow-up were collected. Remission was defined as disappearance of clinical symptoms with a fasting plasma cortisol level ≤ 50 nmol/l either basal or after 1 mg dexamethasone. RESULTS The remission rate in different adenoma subclasses varied significantly: 60% in MRI-negative CD (n=20), 83% in microadenomas (n=35), 94% in noninvasive macroadenomas (n=16), and 40% in macroadenomas that invaded the cavernous sinus (n=15). The recurrence rate was 16% after 71 ± 39 months of follow-up (mean ± S.D., range 10-165 months). CONCLUSIONS Endoscopic TS is a safe and effective treatment for all patients with CD. Recurrence rates after endoscopic TS are comparable with those reported for microscopic TS. Our data suggest that in patients with noninvasive and invasive macroadenomas, the endoscopic technique of TS should be the treatment of choice as remission rates seem to be higher than those reported for microscopic TS, although no comparative study has been performed.
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Affiliation(s)
- M A E M Wagenmakers
- Department of Medicine, Division of Endocrinology, Radboud University Nijmegen Medical Centre, Geert Grooteplein 8, PO Box 9101, 6500 HB Nijmegen, The Netherlands.
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Little AS, Chapple K. Predictors of resource utilization in transsphenoidal surgery for Cushing disease. J Neurosurg 2013; 119:504-11. [DOI: 10.3171/2013.1.jns121375] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The short-term cost associated with subspecialized surgical care is an increasingly important metric and economic concern. This study sought to determine factors associated with hospital charges in patients undergoing transsphenoidal surgery for Cushing disease in an effort to identify the drivers of resource utilization.
Methods
The authors analyzed the Nationwide Inpatient Sample (NIS) hospital discharge database from 2007 to 2009 to determine factors that influenced hospital charges in patients who had undergone transsphenoidal surgery for Cushing disease. The NIS discharge database approximates a 20% sample of all inpatient admissions to nonfederal US hospitals. A multistep regression model was developed that adjusted for patient demographics, acuity measures, comorbidities, hospital characteristics, and complications.
Results
In 116 hospitals, 454 transsphenoidal operations were performed. The mean hospital charge was $48,272 ± $32,060. A multivariate regression model suggested that the primary driver of resource utilization was length of stay (LOS), followed by surgeon volume, hospital characteristics, and postoperative complications. A 1% increase in LOS increased hospital charges by 0.60%. Patient charges were 13% lower when performed by high-volume surgeons compared with low-volume surgeons and 22% lower in large hospitals compared with small hospitals. Hospital charges were 12% lower in cases with no postoperative neurological complications. The proposed model accounted for 46% of hospital charge variance.
Conclusions
This analysis of hospital charges in transsphenoidal surgery for Cushing disease suggested that LOS, hospital characteristics, surgeon volume, and postoperative complications are important predictors of resource utilization. These findings may suggest opportunities for improvement.
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Milian M, Honegger J, Teufel P, Wolf A, Psaras T. Tuebingen CD-25 is a sensitive tool to investigate health-related quality of life in Cushing's disease patients in the course of the disease. Neuroendocrinology 2013; 98:188-99. [PMID: 24080783 DOI: 10.1159/000355622] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2013] [Accepted: 09/10/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND The primary object was to investigate whether the Tuebingen CD-25 captures changes in health-related quality of life (HRQoL) sensitively in Cushing's disease (CD) and to identify factors that favour postoperative HRQoL. METHODS 17 CD patients were scheduled for transsphenoidal tumour removal and filled out the inventory before and after surgery. The mean time elapsed after surgery was 14.4 ± 11.3 months. All patients were in remission at the second timepoint of investigation. RESULTS HRQoL as assessed with the Tuebingen CD-25 improved significantly after successful surgical tumour removal. A large effect size (Cohen's d = 0.84) in the total score indicates good sensitivity to change. 13 patients (76.5%) showed impaired HRQoL preoperatively compared with a general population sample. Postoperatively, 35.3% of the patients still suffered from an impaired HRQoL. Stepwise linear regression analysis revealed that less comorbidities (≤2) and greater morning cortisol decrease were promotive factors for better postoperative HRQoL (p < 0.05). The postoperative improvement in HRQoL could be best predicted by the presence of preoperative HRQoL impairment and age of the patients, i.e. patients who were younger were more likely to improve. Moreover, patients without postoperative pituitary deficiencies improved significantly more in the cognition scale. A tendency towards more improvement in overall HRQoL was observed in non-hypocortisolaemic patients. CONCLUSIONS The Tuebingen CD-25 has proved to be a capable and sensitive instrument to investigate HRQoL in the course of disease. The number of postoperative comorbidities had the greatest impact on postoperative well-being.
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Affiliation(s)
- Monika Milian
- Department of Neurosurgery, University Hospital Tuebingen, Tuebingen, Germany
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Starke RM, Reames DL, Chen CJ, Laws ER, Jane JA. Endoscopic Transsphenoidal Surgery for Cushing Disease. Neurosurgery 2012; 72:240-7; discussion 247. [DOI: 10.1227/neu.0b013e31827b966a] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
The efficacy of endoscopic transsphenoidal surgery (ETS) for Cushing disease has not been clearly established.
OBJECTIVE:
To assess efficacy of a pure endoscopic approach for treatment of Cushing disease and determine predictors of remission.
METHODS:
A prospectively acquired database of 61 patients undergoing ETS was reviewed. Remission was defined as postoperative morning serum cortisol of <5 μg/dL or normal or decreased 24-hour urine-free cortisol level in follow-up.
RESULTS:
Overall, hypercortisolemia resolved in 58 of 61 patients (95%) by discharge. Tumor size did not predict resolution of hypercortisolemia at discharge (microadenomas [97%], magnetic resonance imaging-negative Cushing [100%], macroadenomas [87%]). At 2- to 3-month evaluations, 45 of 49 patients (91.8%) were in remission. Fifty patients were followed for at least 12 months (mean, 28 months; range, 12–72). Forty-two (84%) achieved remission from a single ETS. In these patients, there was no significant difference in remission rates between microadenomas (93%), magnetic resonance imaging-negative (70%), and macroadenomas (77%). Patients with history of previous surgery (n = 14, 23%) were 9 times less likely to achieve follow-up remission (P = .021). In-house cortisol level of <5.7 μg/dL provided the best prediction of follow-up remission (sensitivity 88.6%, specificity 83.3%). Postoperative diabetes insipidus occurred transiently in 7 patients (9%) and permanently in 3 (5%). One patient experienced postoperative cerebrospinal fluid leak that resolved with further surgery.
CONCLUSION:
ETS for Cushing disease provides high rates of remission with low rates of complications regardless of size. Although patients with a history of previous surgery are less likely to achieve remission, the majority can still achieve remission following treatment.
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Affiliation(s)
- Robert M. Starke
- Department of Neurosurgery, University of Virginia Health Sciences Center, Charlottesville, Virginia
| | - Davis L. Reames
- Department of Neurosurgery, University of Virginia Health Sciences Center, Charlottesville, Virginia
| | - Ching-Jen Chen
- Department of Neurosurgery, University of Virginia Health Sciences Center, Charlottesville, Virginia
| | - Edward R. Laws
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - John A. Jane
- Department of Neurosurgery, University of Virginia Health Sciences Center, Charlottesville, Virginia
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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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Rizk A, Honegger J, Milian M, Psaras T. Treatment Options in Cushing's Disease. CLINICAL MEDICINE INSIGHTS-ONCOLOGY 2012; 6:75-84. [PMID: 22346367 PMCID: PMC3273924 DOI: 10.4137/cmo.s6198] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Endogenous Cushing’s syndrome is a grave disease that requires a multidisciplinary and individualized treatment approach for each patient. Approximately 80% of all patients harbour a corticotroph pituitary adenoma (Cushing’s disease) with excessive secretion of adrenocorticotropin-hormone (ACTH) and, consecutively, cortisol. The goals of treatment include normalization of hormone excess, long-term disease control and the reversal of comorbidities caused by the underlying pathology. The treatment of choice is neurosurgical tumour removal of the pituitary adenoma. Second-line treatments include medical therapy, bilateral adrenalectomy and radiation therapy. Drug treatment modalities target at the hypothalamic/pituitary level, the adrenal gland and at the glucocorticoid receptor level and are commonly used in patients in whom surgery has failed. Bilateral adrenalectomy is the second-line treatment for persistent hypercortisolism that offers immediate control of hypercortisolism. However, this treatment option requires a careful individualized evaluation, since it has the disadvantage of permanent hypoadrenalism which requires lifelong glucocorticoid and mineralocorticoid replacement therapy and bears the risk of developing Nelson’s syndrome. Although there are some very promising medical therapy options it clearly remains a second-line treatment option. However, there are numerous circumstances where medical management of CD is indicated. Medical therapy is frequently used in cases with severe hypercortisolism before surgery in order to control the metabolic effects and help reduce the anestesiological risk. Additionally, it can help to bridge the time gap until radiotherapy takes effect. The aim of this review is to analyze and present current treatment options in Cushing’s disease.
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Affiliation(s)
- Ahmed Rizk
- Department of Neurosurgery, University of Tuebingen, Germany
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