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Sadhwani N, Bora SK, Deepa S, Katiyar V, Raheja A, Garg A, Suri V, Tandon N, Sharma MC, Khadgawat R, Suri A. Clinicoradiological Parameters and Biochemical and Molecular Alterations Predicting Remission and Recurrence After Surgical Treatment of Corticotroph Adenomas-Cushing Disease. World Neurosurg 2024:S1878-8750(24)00767-8. [PMID: 38734175 DOI: 10.1016/j.wneu.2024.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Revised: 05/03/2024] [Accepted: 05/04/2024] [Indexed: 05/13/2024]
Abstract
OBJECTIVE Endonasal endoscopic transsphenoidal surgery (TSS) and resection of pituitary adenomas are considered the gold standard treatment for Cushing disease (CD). Even with various recent advances in management, disease persistence and recurrence are common in these patients. The remission rate in the global population after surgery has been reported to vary widely from 64% to 93%. This study aims to determine the various clinical, biochemical, radiological, and histological factors that correlate with persistence and recurrence in patients with CD. This study also aims to understand the clinicopathological significance of EGFR-MAPK, NF-κB, and SHH pathway activation and to study the protein expression of activation markers of these pathways (i.e., c-Fos, c-Jun, GLI-1, pMEK, NR4A1, and p44) in functioning corticotroph pituitary adenomas. METHODS From January 2009 to September 2022, the clinical data of 167 patients who underwent surgical treatment (n = 174 surgeries) for CD with a median follow-up of 8.1 years (range, 1-13.29 years) were ambispectively analyzed. The preoperative clinical, biochemical, and radiological features, operative findings, postoperative clinical and biochemical data, and histopathological and molecular profiles were retrieved from the electronic medical records. The patients were followed up to assess their remission status. RESULTS Among the 174 surgeries performed, 140 were primary surgeries, 22 were revision surgeries, 24 surgeries were for pediatric patients, and 12 surgeries were for patients with Nelson syndrome. In the primary surgery cohort, 74.3% were female, and the average age was 28.73 ± 10.15 years. Of the primary surgery cohort, 75% of the patients experienced remission compared with 47.4% after revision surgery. The remission rate for the pediatric patients was 55.5%. The postoperative day 1 plasma cortisol (P < 0.001; area under the curve, 0.8894; range, 0.8087-0.9701) and adrenocorticotropic hormone (P < 0.001; area under the curve, 0.9; range, 0.7386-1) levels were seen to be strong independent predictors of remission in the primary surgery cohort. The remission rate after endoscopic TSS was greater than that after microscopic TSS in patients undergoing primary surgery (81.08% vs. 57.14%; P = 0.008). The presence of adenoma on histopathological examination (HPE) was also a strong predictor of disease remission (P = 0.020). On stratifying by surgical approach and HPE, microscopically operated patients without histopathological evidence of adenoma had significantly higher odds of nonremission (odds ratio, 38.1; 95% confidence interval, 4.2-348.3) compared with endoscopically operated patients with adenoma found on HPE. A lower immunoreactivity score for NR4A1 was found to correlate with higher remission rates (P = 0.074). However, none of the molecular markers studied (i.e., c-Fos, c-Jun, GLI-1, pMEK, and p44) showed a significant correlation with the preoperative cortisol values. CONCLUSIONS The remission rate after primary surgery is higher than that after revision surgery and is lower for pediatric patients than for adults. The postoperative day 1 plasma cortisol and adrenocorticotropic hormone levels are strong independent predictors of remission in the primary surgery cohort. An endoscopic approach with histopathological evidence of adenoma is associated with a higher remission rate; thus, endoscopy should be the approach of choice for these patients with the goal of identification of an adenoma on HPE.
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Affiliation(s)
- Nidhisha Sadhwani
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Santanu Kumar Bora
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - S Deepa
- Department of Neuropathology, All India Institute of Medical Sciences, New Delhi, India
| | - Varidh Katiyar
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Amol Raheja
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Ajay Garg
- Department of Neuroradiology, All India Institute of Medical Sciences, New Delhi, India
| | - Vaishali Suri
- Department of Neuropathology, All India Institute of Medical Sciences, New Delhi, India
| | - Nikhil Tandon
- Department of Endocrinology, All India Institute of Medical Sciences, New Delhi, India
| | - Mehar Chand Sharma
- Department of Neuropathology, All India Institute of Medical Sciences, New Delhi, India
| | - Rajesh Khadgawat
- Department of Endocrinology, All India Institute of Medical Sciences, New Delhi, India
| | - Ashish Suri
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India.
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Sumisławski P, Piffko A, Huckhagel T, Ryba A, Burkhardt T, Aberle J, Saeger W, Flitsch J, Rotermund R. Exoscopic vs. microscopic transsphenoidal surgery for Cushing's disease: a retrospective single-center study on 388 patients. Neurosurg Rev 2022; 45:3675-3681. [PMID: 36136255 DOI: 10.1007/s10143-022-01866-5] [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: 05/21/2022] [Revised: 08/02/2022] [Accepted: 09/14/2022] [Indexed: 11/26/2022]
Abstract
Microscopic and endoscopic transsphenoidal surgeries represent the standard treatment for Cushing's disease (CD). At our institution a new exoscopic approach was implemented. After proof of the general use for transsphenoidal pituitary surgery, the aim of this study was to compare the exoscopic 4K3D video microscope with the microscopic transsphenoidal surgery for patients with CD. We conducted a retrospective analysis on 388 patients with CD treated in our medical center via microscopic transsphenoidal surgery (MTS) between January 2008 and July 2019 or via exoscopic transsphenoidal surgery (ExTS) between May 2019 and May 2021. Parameters investigated included histology, pre- and postoperative MRI with tumor size, pre- and postoperative ACTH and cortisol levels, duration of surgery, perioperative and postoperative complications as well as clinical outcome. Patients who underwent ExTS in CD experienced a lower incidence of SIADH/diabetes insipidus (p = 0.0164), a higher rate of remission (p = 0.0422), and a shorter duration of surgery (p < 0.0001), compared to MTS. However, there was no significant difference regarding new postoperative pituitary insufficiency and intraoperative CSF space opening. We found that ExTS had multiple benefits compared to MTS for tumor resection in case of CD. These results are in line with our previous publication on the general applicability of an exoscope in pituitary surgery. To our knowledge, this is the first clinical study proving the superiority of ExTS in CD. These results are promising, nevertheless further studies comparing exoscopic with the endoscopic approach are necessary to finally evaluate the utility of the new technique.
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Affiliation(s)
- Piotr Sumisławski
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistr.52, 20246, Hamburg, Germany
- Department of Neurosurgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - Andras Piffko
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistr.52, 20246, Hamburg, Germany
| | - Torge Huckhagel
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistr.52, 20246, Hamburg, Germany
- Department of Neuroradiology, University Medical Center Gottingen, Göttingen, Germany
| | - Alice Ryba
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistr.52, 20246, Hamburg, Germany
| | - Till Burkhardt
- Department of Neurosurgery, Friedrich-Ebert-Krankenhaus, Neumuenster, Germany
| | - Jens Aberle
- Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Wolfgang Saeger
- Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jörg Flitsch
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistr.52, 20246, Hamburg, Germany
| | - Roman Rotermund
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistr.52, 20246, Hamburg, Germany.
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Guignat L, Bertherat J. Long-term follow-up and predictors of recurrence of Cushing's disease. J Neuroendocrinol 2022; 34:e13186. [PMID: 35979714 DOI: 10.1111/jne.13186] [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: 04/03/2022] [Revised: 06/27/2022] [Accepted: 07/09/2022] [Indexed: 11/29/2022]
Abstract
Transsphenoidal surgery is the first-line treatment for Cushing's disease to selectively remove the tumor. The rate of postoperative remission is estimated around 70%-80% in expert centers. However, the long-term remission rate is lower because of recurrence during follow-up that can be observed in 15% to 25% of the patients depending on the studies and duration of follow-up. There is no significant predictive factor of recurrence before surgery, but postoperative corticotroph insufficiency and its duration has been found to be a protective factor for recurrence in many studies. The persistence of a positive response to desmopressin after surgery is associated with a higher rate of recurrence. Long term monitoring for recurrence with annual clinical and hormonal investigations after the hypothalamic-pituitary-adrenal axis postoperative recovery is advised. The biological tests used for the diagnosis of Cushing's syndrome (24 h-urinary-free cortisol [UFC], late-night salivary or serum cortisol, 1 mg dexamethasone suppression test) can be used to screen for recurrence. Several studies report that increased late night cortisol and alterations of dynamic testing can be observed before the increased 24 h-UFC. For this reason it is suggested that late-night salivary cortisol would be a very sensitive tool to diagnose recurrence, pending the realization of several assays in case of borderline or discrepant result. This review will summarize the knowledge about recurrence of Cushing's disease after pituitary surgery and the current recommendations for its monitoring and diagnosis.
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Affiliation(s)
- Laurence Guignat
- Department of Endocrinology and National Reference Center for Rare Adrenal Disorders, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Jérôme Bertherat
- Department of Endocrinology and National Reference Center for Rare Adrenal Disorders, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, Paris, France
- Université de Paris Cité, Institut Cochin, Inserm U1016, CNRS UMR8104, Paris, France
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Kuritsyna NV, Tsoy UA, Cherebillo VY, Paltsev AA, Ryzhkov AV, Ryazanov PA, Ryzhkov VK, Grineva EN. A Comprehensive Approach to Predicting the Outcomes of Transsphenoidal Endoscopic Adenomectomy in Patients with Cushing’s Disease. J Pers Med 2022; 12:jpm12050798. [PMID: 35629220 PMCID: PMC9144911 DOI: 10.3390/jpm12050798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 05/03/2022] [Accepted: 05/11/2022] [Indexed: 12/10/2022] Open
Abstract
Persistent and recurrent hypercortisolism after transsphenoidal endoscopic surgery (TSS) is considered to be an urgent issue prompting the search for Cushing’s disease (CD) remission predictors. The goal was to find a combination of predictors that can forecast the remission of CD after TSS. A total of 101 patients with CD who had undergone TSS were included. One year after surgery, CD remission status was evaluated. Preoperative pituitary magnetic resonance imaging (MRI) data, preoperative results of a high-dose dexamethasone suppression test (HDDST) and morning serum cortisol level collected 24 h after TSS (24 h MSeC) were compared in patients with and without remission of hypercortisolism. Remission one year after TSS was confirmed in 63 patients. CD remission predictors one year after TSS were: adenoma size ≥ 3 mm in the absence of invasive growth and the suppression of serum cortisol ≥ 74% in the HDDST, 24 h MSeC ≤ 388 nmol/L. A total of 38 patients had three favorable values of detected predictors; all of them had CD remission one year after TSS. With long-term follow-up, 36 of them remained in remission. Patients who had no one favorable predictor had no remission of hypercortisolism one year after TSS. Our data confirmed the prospects of using a combination of selected predictors to forecast CD remission after TSS.
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Tabarin A, Assié G, Barat P, Bonnet F, Bonneville JF, Borson-Chazot F, Bouligand J, Boulin A, Brue T, Caron P, Castinetti F, Chabre O, Chanson P, Corcuff JB, Cortet C, Coutant R, Dohan A, Drui D, Espiard S, Gaye D, Grunenwald S, Guignat L, Hindie E, Illouz F, Kamenicky P, Lefebvre H, Linglart A, Martinerie L, North MO, Raffin-Samson ML, Raingeard I, Raverot G, Raverot V, Reznik Y, Taieb D, Vezzosi D, Young J, Bertherat J. Consensus statement by the French Society of Endocrinology (SFE) and French Society of Pediatric Endocrinology & Diabetology (SFEDP) on diagnosis of Cushing's syndrome. ANNALES D'ENDOCRINOLOGIE 2022; 83:119-141. [PMID: 35192845 DOI: 10.1016/j.ando.2022.02.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Cushing's syndrome is defined by prolonged exposure to glucocorticoids, leading to excess morbidity and mortality. Diagnosis of this rare pathology is difficult due to the low specificity of the clinical signs, the variable severity of the clinical presentation, and the difficulties of interpretation associated with the diagnostic methods. The present consensus paper by 38 experts of the French Society of Endocrinology and the French Society of Pediatric Endocrinology and Diabetology aimed firstly to detail the circumstances suggesting diagnosis and the biologic diagnosis tools and their interpretation for positive diagnosis and for etiologic diagnosis according to ACTH-independent and -dependent mechanisms. Secondly, situations making diagnosis complex (pregnancy, intense hypercortisolism, fluctuating Cushing's syndrome, pediatric forms and genetically determined forms) were detailed. Lastly, methods of surveillance and diagnosis of recurrence were dealt with in the final section.
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Affiliation(s)
- Antoine Tabarin
- Service Endocrinologie, Diabète et Nutrition, Université, Hôpital Haut-Leveque CHU de Bordeaux, 33604 Pessac, France.
| | - Guillaume Assié
- Centre de Référence Maladies Rares de la Surrénale (CRMRS), Service d'Endocrinologie, Hôpital Cochin, AP-HP, Université de Paris, Paris, France
| | - Pascal Barat
- Unité d'Endocrinologie-Diabétologie-Gynécologie-Obésité Pédiatrique, Hôpital des Enfants CHU Bordeaux, Bordeaux, France
| | - Fidéline Bonnet
- UF d'Hormonologie Hôpital Cochin, Université de Paris, Institut Cochin Inserm U1016, CNRS UMR8104, Paris, France
| | | | - Françoise Borson-Chazot
- Fédération d'Endocrinologie, Hôpital Louis-Pradel, Hospices Civils de Lyon, INSERM U1290, Université Lyon1, 69002 Lyon, France
| | - Jérôme Bouligand
- Faculté de Médecine Paris-Saclay, Unité Inserm UMRS1185 Physiologie et Physiopathologie Endocriniennes, Paris, France
| | - Anne Boulin
- Service de Neuroradiologie, Hôpital Foch, 92151 Suresnes, France
| | - Thierry Brue
- Aix-Marseille Université, Institut National de la Recherche Scientifique (INSERM) U1251, Marseille Medical Genetics, Marseille, France; Assistance publique-Hôpitaux de Marseille, Service d'Endocrinologie, Hôpital de la Conception, Centre de Référence Maladies Rares HYPO, 13005 Marseille, France
| | - Philippe Caron
- Service d'Endocrinologie et Maladies Métaboliques, Pôle Cardiovasculaire et Métabolique, CHU Larrey, 24, chemin de Pouvourville, TSA 30030, 31059 Toulouse cedex, France
| | - Frédéric Castinetti
- Aix-Marseille Université, Institut National de la Recherche Scientifique (INSERM) U1251, Marseille Medical Genetics, Marseille, France; Assistance publique-Hôpitaux de Marseille, Service d'Endocrinologie, Hôpital de la Conception, Centre de Référence Maladies Rares HYPO, 13005 Marseille, France
| | - Olivier Chabre
- Université Grenoble Alpes, UMR 1292 INSERM-CEA-UGA, Endocrinologie, CHU Grenoble Alpes, 38000 Grenoble, France
| | - Philippe Chanson
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, Assistance publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de l'Hypophyse HYPO, Le Kremlin-Bicêtre, France
| | - Jean Benoit Corcuff
- Laboratoire d'Hormonologie, Service de Médecine Nucléaire, CHU Bordeaux, Laboratoire NutriNeuro, UMR 1286 INRAE, Université de Bordeaux, Bordeaux, France
| | - Christine Cortet
- Service d'Endocrinologie, Diabétologie, Métabolisme et Nutrition, CHU de Lille, Lille, France
| | - Régis Coutant
- Service d'Endocrinologie Pédiatrique, CHU Angers, Centre de Référence, Centre Constitutif des Maladies Rares de l'Hypophyse, CHU Angers, Angers, France
| | - Anthony Dohan
- Department of Radiology A, Hôpital Cochin, AP-HP, 75014 Paris, France
| | - Delphine Drui
- Service Endocrinologie-Diabétologie et Nutrition, l'institut du Thorax, CHU Nantes, 44092 Nantes cedex, France
| | - Stéphanie Espiard
- Service d'Endocrinologie, Diabétologie, Métabolisme et Nutrition, INSERM U1190, Laboratoire de Recherche Translationnelle sur le Diabète, 59000 Lille, France
| | - Delphine Gaye
- Service de Radiologie, Hôpital Haut-Lêveque, CHU de Bordeaux, 33604 Pessac, France
| | - Solenge Grunenwald
- Service d'Endocrinologie, Hôpital Larrey, CHU Toulouse, Toulouse, France
| | - Laurence Guignat
- Centre de Référence Maladies Rares de la Surrénale (CRMRS), Service d'Endocrinologie, Hôpital Cochin, AP-HP, Université de Paris, Paris, France
| | - Elif Hindie
- Service de Médecine Nucléaire, CHU de Bordeaux, Université de Bordeaux, Bordeaux, France
| | - Frédéric Illouz
- Centre de Référence Maladies Rares de la Thyroïde et des Récepteurs Hormonaux, Service Endocrinologie-Diabétologie-Nutrition, CHU Angers, 49933 Angers cedex 9, France
| | - Peter Kamenicky
- Assistance publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de l'Hypophyse, 94275 Le Kremlin-Bicêtre, France
| | - Hervé Lefebvre
- Service d'Endocrinologie, Diabète et Maladies Métaboliques, CHU de Rouen, Rouen, France
| | - Agnès Linglart
- Paris-Saclay University, AP-HP, Endocrinology and Diabetes for Children, Reference Center for Rare Disorders of Calcium and Phosphate Metabolism, Filière OSCAR, and Platform of Expertise for Rare Disorders, INSERM, Physiologie et Physiopathologie Endocriniennes, Bicêtre Paris-Saclay Hospital, Le Kremlin-Bicêtre, France
| | - Laetitia Martinerie
- Service d'Endocrinologie Pédiatrique, CHU Robert-Debré, AP-HP, Paris, France; Université de Paris, Paris, France
| | - Marie Odile North
- Service de Génétique et Biologie Moléculaire, Hôpital Cochin, AP-HP, Université de Paris, Paris, France
| | - Marie Laure Raffin-Samson
- Service d'Endocrinologie Nutrition, Hôpital Ambroise-Paré, GHU Paris-Saclay, AP-HP Boulogne, EA4340, Université de Versailles-Saint-Quentin, Paris, France
| | - Isabelle Raingeard
- Maladies Endocriniennes, Hôpital Lapeyronie, CHU Montpellier, Montpellier, France
| | - Gérald Raverot
- Fédération d'Endocrinologie, Centre de Référence Maladies Rares Hypophysaires, "Groupement Hospitalier Est", Hospices Civils de Lyon, Lyon, France
| | - Véronique Raverot
- Hospices Civils de Lyon, LBMMS, Centre de Biologie Est, Service de Biochimie et Biologie Moléculaire, 69677 Bron cedex, France
| | - Yves Reznik
- Department of Endocrinology and Diabetology, CHU Côte-de-Nacre, 14033 Caen cedex, France; University of Caen Basse-Normandie, Medical School, 14032 Caen cedex, France
| | - David Taieb
- Aix-Marseille Université, CHU La Timone, AP-HM, Marseille, France
| | - Delphine Vezzosi
- Service d'Endocrinologie, Hôpital Larrey, CHU Toulouse, Toulouse, France
| | - Jacques Young
- Assistance publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de l'Hypophyse, 94275 Le Kremlin-Bicêtre, France
| | - Jérôme Bertherat
- Centre de Référence Maladies Rares de la Surrénale (CRMRS), Service d'Endocrinologie, Hôpital Cochin, AP-HP, Université de Paris, Paris, France
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Stroud A, Dhaliwal P, Harvey RJ, Alvarado R, Jonker BP, Winder MJ, Grayson JW, McCormack A. Low but not undetectable early postoperative nadir serum cortisol predicts sustained remission in Cushing's disease. ENDOCRINE ONCOLOGY (BRISTOL, ENGLAND) 2022; 2:19-31. [PMID: 37435446 PMCID: PMC10259300 DOI: 10.1530/eo-21-0026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 04/06/2022] [Indexed: 07/13/2023]
Abstract
Objective Transsphenoidal surgery (TSS) is the first-line treatment for Cushing's disease. The objectives of the study were to determine remission and recurrence rates after TSS for Cushing's disease, identify factors that predict these outcomes, and define the threshold for postoperative morning serum cortisol (MSeC) that most accurately predicts sustained remission. Methods Records were retrospectively reviewed for consecutive adults undergoing TSS for Cushing's disease at a tertiary centre (1990-2019). Remission was defined as MSeC <138 nmol/L by 6 weeks postoperatively. Recurrence was defined as elevated 24-h urine free cortisol, lack of suppression after dexamethasone or elevated midnight salivary cortisol. Results In this study, 42 patients (age 47 ± 13 years, 83% female) were assessed with 55 ± 56 months of follow-up. Remission occurred after 77% of primary (n = 30) and 42% of revision operations (n = 12). After primary surgery, remission was associated with lower MSeC nadir (26 ± 36 nmol/L vs 347 ± 220 nmol/L, P < 0.01) and lower adrenocorticotropin nadir (2 ± 3 pmol/L vs 6 ± 3 pmol/L, P = 0.01). Sustained remission 5 years after surgery was predicted by MSeC <92 nmol/L within 2 weeks postoperatively (sensitivity 100% and specificity 100%). After revision surgery, remission was predicted by lower MSeC nadir (70 ± 45 nmol/L vs 408 ± 305 nmol/L, P = 0.03), smaller tumour diameter (3 ± 2 mm vs 15 ± 13 mm, P = 0.05) and absence of cavernous sinus invasion (0% vs 71%, P = 0.03). Recurrence after primary and revision surgery occurred in 17% and 20% of patients respectively. Conclusions Lower postoperative MSeC nadir strongly predicted remission after both primary and revision surgery. Following primary surgery, an MSeC <92 nmol/L within 2 weeks predicted sustained remission at 5 years. MSeC nadir was the most important prognostic marker following TSS for Cushing's disease.
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Affiliation(s)
- Anna Stroud
- Rhinology and Skull Base Research Group, St Vincent’s Centre for Applied Medical Research, Sydney, Australia
- St Vincent’s Hospital Clinical School, Faculty of Medicine, UNSW Sydney, Sydney, Australia
- Garvan Institute of Medical Research, Sydney, Australia
| | - Pearl Dhaliwal
- Rhinology and Skull Base Research Group, St Vincent’s Centre for Applied Medical Research, Sydney, Australia
- St Vincent’s Hospital Clinical School, Faculty of Medicine, UNSW Sydney, Sydney, Australia
- Garvan Institute of Medical Research, Sydney, Australia
| | - Richard J Harvey
- Rhinology and Skull Base Research Group, St Vincent’s Centre for Applied Medical Research, Sydney, Australia
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Raquel Alvarado
- Rhinology and Skull Base Research Group, St Vincent’s Centre for Applied Medical Research, Sydney, Australia
| | - Benjamin P Jonker
- Rhinology and Skull Base Research Group, St Vincent’s Centre for Applied Medical Research, Sydney, Australia
- Faculty of Medicine, Notre Dame University, Sydney, Australia
- Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, Australia
| | - Mark J Winder
- Rhinology and Skull Base Research Group, St Vincent’s Centre for Applied Medical Research, Sydney, Australia
- St Vincent’s Hospital Clinical School, Faculty of Medicine, UNSW Sydney, Sydney, Australia
- Faculty of Medicine, Notre Dame University, Sydney, Australia
| | - Jessica W Grayson
- Rhinology and Skull Base Research Group, St Vincent’s Centre for Applied Medical Research, Sydney, Australia
- Department of Otolaryngology Head and Neck Surgery, University of Alabama Birmingham, Birmingham, Alabama, USA
| | - Ann McCormack
- St Vincent’s Hospital Clinical School, Faculty of Medicine, UNSW Sydney, Sydney, Australia
- Garvan Institute of Medical Research, Sydney, Australia
- Department of Endocrinology, St Vincent’s Hospital, Sydney, Australia
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7
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Dutta A, Gupta N, Walia R, Bhansali A, Dutta P, Bhadada SK, Pivonello R, Ahuja CK, Dhandapani S, Hajela A, Simeoli C, Sachdeva N, Saikia UN. Remission in Cushing's disease is predicted by cortisol burden and its withdrawal following pituitary surgery. J Endocrinol Invest 2021; 44:1869-1878. [PMID: 33453019 DOI: 10.1007/s40618-020-01495-z] [Citation(s) in RCA: 3] [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] [Received: 09/17/2020] [Accepted: 12/26/2020] [Indexed: 12/16/2022]
Abstract
AIM To ascertain the predictors of remission and relapse in patients of Cushing's disease (CD) undergoing pituitary transsphenoidal surgery (TSS). METHODS Patients with CD subjected to TSS over 35 years at a tertiary care center were included. Patients were grouped into remission and persistent disease at 1 year after surgery, and were further followed up for relapse. Demographic, clinical, biochemical, histological, radiological and post-operative follow-up parameters were analyzed. RESULTS Of the 152 patients of CD, 145 underwent TSS. Remission was achieved in 95 (65.5%) patients at 1 year. Patients in remission had shorter duration of symptoms prior to presentation (p = 0.009), more frequent presence of proximal myopathy (p = 0.038) and a tumor size of < 2.05 cm (p = 0.016) in comparison to those with persistent disease. Post-TSS, immediate post-operative 0800-h cortisol (< 159.85 nmol/L; p = 0.001), histological confirmation of tumor (p = 0.045), duration of glucocorticoid replacement (median 90 days; p = 0.001), non-visualization of tumor on MRI (p = 0.003), new-onset hypogonadism (p = 0.001), 3-month 0800-h cortisol (< 384.9 nmol/L; p = 0.001), resolution of diabetes (p = 0.001) and hypertension (p = 0.001), and recovery of hypothalamic-pituitary-adrenal axis (p = 0.018) favored remission. In logistic regression model, requirement of glucocorticoid replacement (p = 0.033), and resolution of hypertension post-TSS (p = 0.003) predicted remission. None of the parameters could predict relapse. CONCLUSION The study could ascertain the predictors of remission in CD. Apart from the tumor characteristics, surgical aspects and low post-operative 0800-h cortisol, the results suggest that baseline clinical parameters, longer glucocorticoid replacement, and resolution of metabolic complications post-TSS predict remission in CD. Long-term follow-up is essential to look for relapse.
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Affiliation(s)
- A Dutta
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research (PGIMER), Nehru Extension block, Chandigarh, 160012, India
| | - N Gupta
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research (PGIMER), Nehru Extension block, Chandigarh, 160012, India
| | - R Walia
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research (PGIMER), Nehru Extension block, Chandigarh, 160012, India.
| | - A Bhansali
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research (PGIMER), Nehru Extension block, Chandigarh, 160012, India
| | - P Dutta
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research (PGIMER), Nehru Extension block, Chandigarh, 160012, India
| | - S K Bhadada
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research (PGIMER), Nehru Extension block, Chandigarh, 160012, India
| | - R Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - C K Ahuja
- Department of Radiology, PGIMER, Chandigarh, India
| | - S Dhandapani
- Department of Neurosurgery, PGIMER, Chandigarh, India
| | - A Hajela
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research (PGIMER), Nehru Extension block, Chandigarh, 160012, India
| | - C Simeoli
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - N Sachdeva
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research (PGIMER), Nehru Extension block, Chandigarh, 160012, India
| | - U N Saikia
- Department of Histopathology, PGIMER, Chandigarh, India
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8
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Fan Y, Li Y, Bao X, Zhu H, Lu L, Yao Y, Li Y, Su M, Feng F, Feng S, Feng M, Wang R. Development of Machine Learning Models for Predicting Postoperative Delayed Remission in Patients With Cushing's Disease. J Clin Endocrinol Metab 2021; 106:e217-e231. [PMID: 33000120 DOI: 10.1210/clinem/dgaa698] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 09/24/2020] [Indexed: 12/14/2022]
Abstract
CONTEXT Postoperative hypercortisolemia mandates further therapy in patients with Cushing's disease (CD). Delayed remission (DR) is defined as not achieving postoperative immediate remission (IR), but having spontaneous remission during long-term follow-up. OBJECTIVE We aimed to develop and validate machine learning (ML) models for predicting DR in non-IR patients with CD. METHODS We enrolled 201 CD patients, and randomly divided them into training and test datasets. We then used the recursive feature elimination (RFE) algorithm to select features and applied 5 ML algorithms to construct DR prediction models. We used permutation importance and local interpretable model-agnostic explanation (LIME) algorithms to determine the importance of the selected features and interpret the ML models. RESULTS Eighty-eight (43.8%) of the 201 CD patients met the criteria for DR. Overall, patients who were younger, had a low body mass index, a Knosp grade of III-IV, and a tumor not found by pathological examination tended to achieve a lower rate of DR. After RFE feature selection, the Adaboost model, which comprised 18 features, had the greatest discriminatory ability, and its predictive ability was significantly better than using Knosp grading and postoperative immediate morning serum cortisol (PoC). The results obtained from permutation importance and LIME algorithms showed that preoperative 24-hour urine free cortisol, PoC, and age were the most important features, and showed the reliability and clinical practicability of the Adaboost model in DC prediction. CONCLUSIONS Machine learning-based models could serve as an effective noninvasive approach to predicting DR, and could aid in determining individual treatment and follow-up strategies for CD patients.
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Affiliation(s)
- Yanghua Fan
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yichao Li
- DHC Software Co. Ltd, Beijing, China
| | - Xinjie Bao
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Huijuan Zhu
- Department of Endocrinology, 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
| | - Yong Yao
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | | | | | - Feng Feng
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shanshan Feng
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ming Feng
- Department of Neurosurgery, 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
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9
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Dai C, Fan Y, Liu X, Bao X, Yao Y, Wang R, Feng M. Predictors of Immediate Remission after Surgery in Cushing's Disease Patients: A Large Retrospective Study from a Single Center. Neuroendocrinology 2021; 111:1141-1150. [PMID: 32512562 DOI: 10.1159/000509221] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 06/08/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Transsphenoidal surgery (TSS) is the first-line treatment of patients with Cushing's disease (CD). However, biochemical remission rates after TSS for CD vary from 59 to 95%, and the predictors of surgical outcomes remain unclear. The aim of this study was to identify the predictors of early outcomes in patients with CD treated with TSS. METHODS The clinical features and outcomes of CD patients who underwent TSS between February 2000 and September 2019 at the Peking Union Medical College Hospital were collected from medical records and analyzed. Uni- and multivariate odds ratio (OR) analyses were performed to identify the predictors of early outcomes in patients with CD. RESULTS A total of 1,045 patients were included. The median age at TSS was 34.0 years (IQR 26.0-45.0), with a female:male ratio of 4.2:1 (844/201). The median duration of symptoms was 46.0 months (IQR 24.0-72.0). After surgery, the overall postoperative immediate remission rate was 73.3%, and 26.7% of patients had persistent hypercortisolism. Univariate analysis demonstrated that the number of operations was correlated with a lower immediate remission rate (OR 0.393, 95% CI 0.266-0.580, p = 0.000), as was tumor size (OR 0.462, 95% CI 0.334-0.639, p = 0.000), the duration of disease (OR 0.996, 95% CI 0.993-0.999, p = 0.003), and preoperative ACTH concentration (0.998, 95% CI 0.996-0.999, p = 0.003). Cavernous sinus invasion has also been identified as an important factor associated with a lower immediate remission rate (OR 0.275, 95% CI 0.166-0.456, p = 0.000). No correlations were detected between the immediate outcomes and age, gender, BMI, the combination of a low- and high-dose dexamethasone suppression test, preoperative morning serum cortisol level, or 24-h urinary free cortisol level (all p > 0.05). The results of multivariate analysis were similar to those of univariate analysis. Preoperative ACTH ≤67.35 ng/L predicted remission with 60.9% sensitivity and 49.5% specificity (AUC 0.553; p = 0.008). A cutoff of ≤64.5 months for disease duration predicted immediate remission with 40.5% sensitivity and 71.0% specificity (AUC 0.552; p = 0.01). CONCLUSION Early outcomes of TSS in CD patients can be predicted by factors including the number of operations, duration of disease, tumor invasion, tumor size, and preoperative ACTH concentration. These predictors can be used to improve the perioperative management of CD patients.
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Affiliation(s)
- Congxin Dai
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Department of Neurosurgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Yanghua Fan
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaohai Liu
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, 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
| | - Renzhi Wang
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ming Feng
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China,
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10
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Stroud A, Dhaliwal P, Alvarado R, Winder MJ, Jonker BP, Grayson JW, Hamizan A, Harvey RJ, McCormack A. Outcomes of pituitary surgery for Cushing's disease: a systematic review and meta-analysis. Pituitary 2020; 23:595-609. [PMID: 32691356 DOI: 10.1007/s11102-020-01066-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE Transsphenoidal surgery (TSS) is the first-line treatment for Cushing's disease (CD). This review aimed to synthesize the remission and recurrence rates following TSS for CD and identify predictors of these outcomes. METHODS Medline (1946-) and Embase (1947-) were searched until 23rd January 2019 for original studies. A meta-analysis was performed of remission and recurrence rates. Studies were excluded if patients had prior radiosurgery/radiotherapy, mixed pathologies or interventions without separated data, follow-up not reported or population size < 20. For recurrence rate syntheses, studies with follow-up < 6 months were excluded. RESULTS The search produced 2663 studies, of which n = 68 were included, involving 5664 patients. Remission rates after primary and revision TSS were 80% [77-82] and 58% [50-66] at last follow-up. After primary TSS, predictors of remission were micro- v macroadenomas (83% v 68%, p < 0.01), imaging-visible adenomas (81% v 69%, p < 0.01), adenomas confirmed on histopathology (87% v 45%, p < 0.01), absence of cavernous sinus invasion (80% v 30%, p < 0.01), postoperative serum cortisol (MSeC) nadir < 2 μg/dL (< 55 nmol/L; 95% v 46%, p < 0.01) and lower preoperative 24-h urine free cortisol (1250 nmol v 1726 nmol, p < 0.01). For revision TSS, predictors of remission were postoperative MSeC nadir < 2 μg/dL (< 55 nmol/L; 100% v 38%, p < 0.01) and operations for recurrence v persistence (80% v 54%, p < 0.01). Recurrence rates after primary and revision TSS were 18% [14-22] and 28% [16-42]. CONCLUSIONS TSS is most effective in primary microadenomas, visible on preoperative imaging and without CS invasion, lower preoperative 24-h urine free cortisol and postoperative MSeC nadir < 2 μg/dL (< 55 nmol/L).
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Affiliation(s)
- Anna Stroud
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, Sydney, NSW, Australia.
- St Vincent's Clinical School, Faculty of Medicine, UNSW Sydney, Sydney, NSW, Australia.
- Hormones and Cancer Group, Garvan Institute of Medical Research, Sydney, NSW, Australia.
| | - Pearl Dhaliwal
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, Sydney, NSW, Australia
- St Vincent's Clinical School, Faculty of Medicine, UNSW Sydney, Sydney, NSW, Australia
| | - Raquel Alvarado
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, Sydney, NSW, Australia
| | - Mark J Winder
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, Sydney, NSW, Australia
- St Vincent's Clinical School, Faculty of Medicine, UNSW Sydney, Sydney, NSW, Australia
- Faculty of Medicine, Notre Dame University, Sydney, NSW, Australia
- Department of Endocrinology, St Vincent's Hospital, Sydney, NSW, Australia
| | - Benjamin P Jonker
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, Sydney, NSW, Australia
- Department of Endocrinology, St Vincent's Hospital, Sydney, NSW, Australia
- Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Jessica W Grayson
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, Sydney, NSW, Australia
| | | | - Richard J Harvey
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, Sydney, NSW, Australia
- Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia
| | - Ann McCormack
- St Vincent's Clinical School, Faculty of Medicine, UNSW Sydney, Sydney, NSW, Australia
- Department of Endocrinology, St Vincent's Hospital, Sydney, NSW, Australia
- Hormones and Cancer Group, Garvan Institute of Medical Research, Sydney, NSW, Australia
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11
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Ragnarsson O. Cushing's syndrome - Disease monitoring: Recurrence, surveillance with biomarkers or imaging studies. Best Pract Res Clin Endocrinol Metab 2020; 34:101382. [PMID: 32139169 DOI: 10.1016/j.beem.2020.101382] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Pituitary surgery is the first-line treatment for patients with Cushing's disease. For patients who are not considered candidates for pituitary surgery, pituitary radiation and bilateral adrenalectomy are further treatment alternatives. Not all patients are cured with pituitary surgery, and a substantial number of patients develop recurrence, sometimes many years after an apparently successful treatment. The same applies to patients treated with radiotherapy. Far from all patients are cured, and in many cases the disease recurs. Bilateral adrenalectomy, although always curative, causes chronic adrenal insufficiency and the remaining pituitary tumour can continue to grow and cause symptoms due to pressure on adjacent tissues, a phenomenon called Nelson's syndrome. In this paper the rate of recurrence of hypercortisolism, as well as the rate of development of Nelson's syndrome, following treatment of patients with Cushing's syndrome, will be reviewed. The aim of the paper is also to summarize clinical and biochemical factors that are associated with recurrence of hypercortisolism and how the patients should be monitored following treatment.
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Affiliation(s)
- Oskar Ragnarsson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg and The Department of Endocrinology, Sahlgrenska University Hospital, Göteborg, SE-41302, Sweden.
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12
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Nishioka H, Yamada S. Cushing's Disease. J Clin Med 2019; 8:jcm8111951. [PMID: 31726770 PMCID: PMC6912360 DOI: 10.3390/jcm8111951] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Revised: 11/04/2019] [Accepted: 11/06/2019] [Indexed: 12/11/2022] Open
Abstract
In patients with Cushing's disease (CD), prompt diagnosis and treatment are essential for favorable long-term outcomes, although this remains a challenging task. The differential diagnosis of CD is still difficult in some patients, even with an organized stepwise diagnostic approach. Moreover, despite the use of high-resolution magnetic resonance imaging (MRI) combined with advanced fine sequences, some tumors remain invisible. Surgery, using various surgical approaches for safe maximum tumor removal, still remains the first-line treatment for most patients with CD. Persistent or recurrent CD after unsuccessful surgery requires further treatment, including repeat surgery, medical therapy, radiotherapy, or sometimes, bilateral adrenalectomy. These treatments have their own advantages and disadvantages. However, the most important thing is that this complex disease should be managed by a multidisciplinary team with collaborating experts. In addition, a personalized and individual-based approach is paramount to achieve high success rates while minimizing the occurrence of adverse events and improving the patients' quality of life. Finally, the recent new insights into the pathophysiology of CD at the molecular level are highly anticipated to lead to the introduction of more accurate diagnostic tests and efficacious therapies for this devastating disease in the near future.
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Affiliation(s)
- Hiroshi Nishioka
- Department of Hypothalamic and Pituitary surgery, Toranomon Hospital, Tokyo 1058470, Japan;
- Okinaka Memorial Institute for Medical Research, Tokyo 1058470, Japan
| | - Shozo Yamada
- Hypothalamic and Pituitary Center, Moriyama Neurological Center Hospital, Tokyo 1340081, Japan
- Okinaka Memorial Institute for Medical Research, Tokyo 1058470, Japan
- Correspondence: ; Tel.: +81-336-751-211
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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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14
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Pasternak-Pietrzak K, Moszczyńska E, Szalecki M. Treatment challenges in pediatric Cushing's disease: Review of the literature with particular emphasis on predictive factors for the disease recurrence. Endocrine 2019; 66:125-136. [PMID: 31701434 PMCID: PMC6838046 DOI: 10.1007/s12020-019-02036-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 07/26/2019] [Indexed: 11/17/2022]
Abstract
Cushing's disease (CD) is a rare endocrine condition caused by a corticotroph pituitary tumor that produces adrenocorticotropic hormone. The current state of knowledge of CD treatment is presented in this article including factors that can be helpful in predicting remission and/or recurrence of the disease. The primary goals in CD treatment are quick diagnosis and effective, prompt treatment as the persistent disease is associated with increased morbidity and mortality. Cooperation of a team consisting of experienced pediatrician/adult endocrinologist, neuroradiologist, transsphenoidal neurosurgeon and (if necessary) radiotherapist contribute to the best treatment effects.
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Affiliation(s)
- Katarzyna Pasternak-Pietrzak
- Department of Endocrinology and Diabetology, The Children's Memorial Health Institute (CMHI), Al. Dzieci Polskich 20, 04-730, Warsaw, Poland.
| | - Elżbieta Moszczyńska
- Department of Endocrinology and Diabetology, The Children's Memorial Health Institute (CMHI), Al. Dzieci Polskich 20, 04-730, Warsaw, Poland
| | - Mieczysław Szalecki
- Department of Endocrinology and Diabetology, The Children's Memorial Health Institute (CMHI), Al. Dzieci Polskich 20, 04-730, Warsaw, Poland
- The Medicine and Health Sciences Faculty, University of Jan Kochanowski, Al. IX Wieków Kielc 19A, 25-317, Kielce, Poland
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15
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Abellán-Galiana P, Fajardo-Montañana C, Riesgo-Suárez P, Pérez-Bermejo M, Ríos-Pérez C, Gómez-Vela J. Prognostic usefulness of ACTH in the postoperative period of Cushing's disease. Endocr Connect 2019; 8:1262-1272. [PMID: 31394502 PMCID: PMC6733365 DOI: 10.1530/ec-19-0297] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 08/05/2019] [Indexed: 11/08/2022]
Abstract
OBJECTIVES To analyze the usefulness of plasma ACTH in predicting CD remission after surgery and to evaluate the prognostic usefulness of ACTH measurement after the cortisol and ACTH nadir (48 h prior to discharge). DESIGN A prospective study was made of 65 patients with CD operated upon between 2005 and 2016. METHODS Postsurgery plasma ACTH and cortisol were measured every 6 h, in the absence of corticosteroid coverage. Hydrocortisone was started in the presence of adrenal insufficiency or cortisol <55.2 nmol/L. Plasma ACTH was again determined before discharge. MAIN OUTCOME MEASURE Usefulness of plasma ACTH in predicting CD remission. RESULTS Remission at 3 months of CD was achieved in 56 of 65 cases, with late recurrence in 18 of 58 cases. Following resection, the ACTH nadir was significantly lower referred to late remission (2.8 vs 6.5 pmol/L; P = 0.031) and higher for recurrence (2.1 vs 4.8 pmol/L; P < 0.001), and identical results were obtained for the ACTH values before discharge. In the analysis of the ROC curves, nadir and before discharge ACTH values <1.9 pmol/L and <2.6 pmol/L were respectively indicative of early remission (AUC 0.827; P < 0.001); <6.2 pmol/L of remission at 3 months (AUC 0.847; P = 0.001) and >3.2 pmol/L of recurrence (AUC 0.810; P < 0.001) in both ACTH values. A time to ACTH nadir <46 h was indicative of early remission (AUC 0.751; P = 0.001), while a time >39 h was indicative of recurrence (AUC 0.773; P = 0.001). CONCLUSIONS We propose an ACTH value <3.3 pmol/L as a good long-term prognostic marker in the postoperative period of CD. Reaching the ACTH nadir in less time is associated to a lesser recurrence rate.
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Affiliation(s)
- Pablo Abellán-Galiana
- Department of Endocrinology, Hospital General Universitari de Castelló, Castellón, Spain
- Department of Medicine, Universidad Cardenal Herrera-CEU, Castellón, Spain
| | - Carmen Fajardo-Montañana
- Department of Endocrinology, Hospital Universitario de la Ribera, Alzira, Spain
- Correspondence should be addressed to C Fajardo-Montañana:
| | - Pedro Riesgo-Suárez
- Department of Neurosurgery, Hospital Universitario de la Ribera, Alzira, Spain
| | | | - Celia Ríos-Pérez
- Centro de Salud Tavernes de la Valldigna, Hospital Comarcal Francesc de Borja, Gandía, Spain
| | - José Gómez-Vela
- Department of Endocrinology, Hospital Universitario de la Ribera, Alzira, Spain
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16
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Serban AL, Sala E, Carosi G, Del Sindaco G, Giavoli C, Locatelli M, Arosio M, Mantovani G, Ferrante E. Recovery of Adrenal Function after Pituitary Surgery in Patients with Cushing Disease: Persistent Remission or Recurrence? Neuroendocrinology 2019; 108:211-218. [PMID: 30636245 DOI: 10.1159/000496846] [Citation(s) in RCA: 5] [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] [Received: 08/16/2018] [Accepted: 01/12/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Cushing disease (CD) represents the principal cause of endogenous hypercortisolism. The first-line therapy of CD is surgical removal of the ACTH-secreting pituitary adenoma, which is generally followed by adrenal insufficiency (AI). OBJECTIVE To analyze the recovery of AI in patients with CD after pituitary surgery in relation with recurrence and persistent remission of CD. PATIENTS AND METHODS We performed a retrospective analysis of patients with CD who met the following inclusion criteria: adult age, presence of AI 2 months after the surgical intervention, and a minimum follow-up of 3 years after the surgical intervention. RESULTS Sixty-one patients were followed for a median of 6 years. Ten (16.4%) patients recurred during follow-up. The patients who restored adrenal function did so after a median time of 19 months, with a significantly shorter time in the recurrence group (12.5 vs. 25 months, p = 0.008). All 10 patients who recurred recovered their adrenal function within 22 months. The recovery rate of AI in the persistent remission group was 37.3% (19/51) at 3 years and 55.8% (24/43) at 5 years. In all patients the duration of AI was negatively associated with disease recurrence. CONCLUSION The duration of postsurgical AI in patients with recurrent CD is significantly shorter than that in patients with persistently remitted CD, and this parameter may be a useful predictor of recurrence. Patients showing a normal pituitary-adrenal axis within 2 years after surgery should be strictly monitored as they are at higher risk of disease relapse.
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Affiliation(s)
- Andreea Liliana Serban
- Endocrinology Unit, Ospedale Maggiore Policlinico, Fondazione IRCCS Ca' Granda, Milan, Italy,
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy,
| | - Elisa Sala
- Endocrinology Unit, Ospedale Maggiore Policlinico, Fondazione IRCCS Ca' Granda, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Giulia Carosi
- Endocrinology Unit, Ospedale Maggiore Policlinico, Fondazione IRCCS Ca' Granda, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Giulia Del Sindaco
- Endocrinology Unit, Ospedale Maggiore Policlinico, Fondazione IRCCS Ca' Granda, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Claudia Giavoli
- Endocrinology Unit, Ospedale Maggiore Policlinico, Fondazione IRCCS Ca' Granda, Milan, Italy
| | - Marco Locatelli
- Neurosurgery Division, Ospedale Maggiore Policlinico, Fondazione IRCCS Ca' Granda, Milan, Italy
| | - Maura Arosio
- Endocrinology Unit, Ospedale Maggiore Policlinico, Fondazione IRCCS Ca' Granda, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Giovanna Mantovani
- Endocrinology Unit, Ospedale Maggiore Policlinico, Fondazione IRCCS Ca' Granda, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Emanuele Ferrante
- Endocrinology Unit, Ospedale Maggiore Policlinico, Fondazione IRCCS Ca' Granda, Milan, Italy
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17
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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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18
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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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Ioachimescu AG. Prognostic Factors of Long-Term Remission After Surgical Treatment of Cushing's Disease. Endocrinol Metab Clin North Am 2018; 47:335-347. [PMID: 29754635 DOI: 10.1016/j.ecl.2018.02.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Transsphenoidal surgery is the main treatment of patients with adrenocorticotropic hormone (ACTH)-secreting pituitary adenomas. Although biochemical remission occurs in most patients undergoing operations at specialized centers, the recurrence risk is significant. Visualization of microadenomas on preoperative imaging and confirmation of ACTH-positive adenomas have been associated with higher remission rates. Low cortisol levels in the first 2 weeks postoperatively have been associated with durable remission; however, recurrence cannot be excluded by any cortisol threshold. The decision to perform a pituitary reoperation is based on this parameter; the protocols are institution specific. Patients with Cushing's disease warrant lifelong endocrinologic surveillance.
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Affiliation(s)
- Adriana G Ioachimescu
- Department of Medicine (Endocrinology) and Neurosurgery, Emory University School of Medicine, 1365 B Clifton Road Northeast, B6209, Atlanta, GA 30322, USA.
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20
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Vassiliadi DA, Tsagarakis S. DIAGNOSIS OF ENDOCRINE DISEASE: The role of the desmopressin test in the diagnosis and follow-up of Cushing's syndrome. Eur J Endocrinol 2018; 178:R201-R214. [PMID: 29472379 DOI: 10.1530/eje-18-0007] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Accepted: 02/19/2018] [Indexed: 11/08/2022]
Abstract
Desmopressin is a vasopressin analogue selective for type 2 vasopressin receptors that mediate renal water retention. In contrast to the native hormone arginine vasopressin, a well-known ACTH secretagogue, desmopressin, exerts minimal or no activity on ACTH excretion. However, in a substantial proportion of patients with ACTH-dependent Cushing's syndrome (CS), desmopressin elicits an ACTH and cortisol response, which contrasts with the minimal responses obtained in healthy subjects. The mechanism underlying this paradoxical response involves upregulation of vasopressin type 3 and/or the aberrant expression of type 2 receptors by neoplastic ACTH-producing cells. This makes desmopressin administration a suitable test enabling the distinction between neoplastic from functional (formerly termed 'pseudo-Cushing syndrome') ACTH-dependent cortisol excess. Several studies have now established an adjunctive role of desmopressin in the initial diagnostic workup of CS. Despite some early data indicating that this test may also have a role in distinguishing between Cushing's disease (CD) and ectopic ACTH secretion, subsequent studies failed to confirm this observation. The ability of the paradoxical response to desmopressin to depict the presence of neoplastic ACTH-secreting cells was also exploited in the follow-up of patients with CD undergoing surgery. Loss of the desmopressin response, performed in the early postoperative period, was a good predictor for a favorable long-term outcome. Moreover, during follow-up, reappearance of desmopressin paradoxical response was an early indicator for recurrence. In conclusion, the desmopressin test is a valid tool in both the diagnosis and follow-up of patients with CD and should be more widely applied in the workup of these patients.
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Ironside N, Chatain G, Asuzu D, Benzo S, Lodish M, Sharma S, Nieman L, Stratakis CA, Lonser RR, Chittiboina P. Earlier post-operative hypocortisolemia may predict durable remission from Cushing's disease. Eur J Endocrinol 2018; 178:255-263. [PMID: 29330227 PMCID: PMC5812811 DOI: 10.1530/eje-17-0873] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Accepted: 01/08/2018] [Indexed: 12/21/2022]
Abstract
CONTEXT Achievement of hypocortisolemia following transsphenoidal surgery (TSS) for Cushing's disease (CD) is associated with successful adenoma resection. However, up to one-third of these patients recur. OBJECTIVE We assessed whether delay in reaching post-operative cortisol nadir may delineate patients at risk of recurrence for CD following TSS. METHODS A retrospective review of 257 patients who received 291 TSS procedures for CD at NIH, between 2003 and 2016. Early biochemical remission (serum cortisol nadir <5 μg/dL) was confirmed with endocrinological and clinical follow-up. Recurrence was detected by laboratory testing, clinical stigmata or medication dependence during a median follow-up of 11 months. RESULTS Of the 268 unique admissions, remission was recorded in 241 instances. Recurrence was observed in 9% of these cases with cortisol nadir ≤5 μg/dL and 6% of cases with cortisol nadir ≤2 μg/dL. The timing of hypocortisolemia was critical in detecting late recurrences. Morning POD-1 cortisol <3.3 μg/dL was 100% sensitive in predicting durable remission and morning POD-3 cortisol ≥18.5 μg/dL was 98.6% specific in predicting remote recurrence. AUROC analysis revealed that hypocortisolemia ≤5 µg/dL before 15 h (post-operative) had 95% sensitivity and an NPV of 0.98 for durable remission. Serum cortisol level ≤2 µg/dL, when achieved before 21 h, improved sensitivity to 100%. CONCLUSIONS In our cohort, early, profound hypocortisolemia could be used as a clinical prediction tool for durable remission. Achievement of hypocortisolemia ≤2 µg/dL before 21 post-operative hours appeared to accurately predict durable remission in the intermediate term.
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Affiliation(s)
- Natasha Ironside
- Surgical Neurology BranchNational Institute of Neurological Diseases and Stroke, Bethesda, Maryland, USA
- Department of NeurosurgeryAuckland City Hospital, Auckland, New Zealand
| | - Gregoire Chatain
- Neurosurgery Unit for Pituitary and Inheritable DiseasesNational Institute of Neurological Diseases and Stroke, Bethesda, Maryland, USA
| | - David Asuzu
- Surgical Neurology BranchNational Institute of Neurological Diseases and Stroke, Bethesda, Maryland, USA
- Yale School of MedicineNew Haven, Connecticut, USA
| | - Sarah Benzo
- Surgical Neurology BranchNational Institute of Neurological Diseases and Stroke, Bethesda, Maryland, USA
| | - Maya Lodish
- Section on Endocrinology and GeneticsEunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland, USA
| | - Susmeeta Sharma
- Pituitary Endocrinology SectionMedStar Washington Hospital Center, Washington, District of Columbia, USA
| | - Lynnette Nieman
- National Institute of Diabetes and Digestive and Kidney DiseasesNational Institutes of Health, Bethesda, Maryland, USA
| | - Constantine A Stratakis
- Section on Endocrinology and GeneticsEunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland, USA
| | - Russell R Lonser
- Department of Neurological SurgeryWexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Prashant Chittiboina
- Surgical Neurology BranchNational Institute of Neurological Diseases and Stroke, Bethesda, Maryland, USA
- Neurosurgery Unit for Pituitary and Inheritable DiseasesNational Institute of Neurological Diseases and Stroke, Bethesda, Maryland, USA
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22
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Qiao N. Outcome of endoscopic vs microsurgical transsphenoidal resection for Cushing's disease. Endocr Connect 2018; 7:R26-R37. [PMID: 29311226 PMCID: PMC5763281 DOI: 10.1530/ec-17-0312] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 11/28/2017] [Indexed: 11/08/2022]
Abstract
INTRODUCTION It is unclear whether the proportions of remission and the recurrence rates differ between endoscopic transsphenoidal surgery (TS) and microscopic TS in Cushing's disease (CD); thus, we conducted a systematic review and meta-analysis to evaluate studies of endoscopic TS and microscopic TS. METHODS We conducted a comprehensive search of PubMed to identify relevant studies. Remission and recurrence were used as outcome measures following surgical treatment of CD. RESULTS A total of 24 cohort studies involving 1670 adult patients were included in the comparison. Among these studies, 702 patients across 9 studies underwent endoscopic TS, and 968 patients across 15 studies underwent microscopic TS. Similar baseline characteristics were observed in both groups. There was no significant difference in remission between the two groups: 79.7% (95% CI: 73.1-85.0%) in the endoscopic group and 76.9% (95% CI: 71.3-81.6%) in the microscopic group (P = 0.485). It appears that patients who underwent endoscopic surgery experience recurrence less often than patients who underwent microscopic surgery, with recurrence proportions of 11.0% and 15.9%, respectively (P = 0.134). However, if follow-up time is taken into account, both groups had a recurrence rate of approximately 4% per person per year (95% CI: 3.1-5.4% and 3.6-5.1%, P = 0.651). CONCLUSIONS We found that remission proportion and recurrence rate were the same in patients who underwent endoscopic TS as in patients who underwent microscopic TS. The definition of diagnosis, remission and recurrence should always be considered in the studies assessing therapeutic efficacy in CD.
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Affiliation(s)
- Nidan Qiao
- Department of NeurosurgeryHuashan Hospital, Fudan University, Shanghai, China
- Harvard Medical SchoolBoston, Massachusetts, USA
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23
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Erfe JM, Perry A, McClaskey J, Inzucchi SE, James WS, Eid T, Bronen RA, Mahajan A, Huttner A, Santos F, Spencer D. Long-term outcomes of tissue-based ACTH-antibody assay-guided transsphenoidal resection of pituitary adenomas in Cushing disease. J Neurosurg 2017; 129:629-641. [PMID: 29027854 DOI: 10.3171/2017.3.jns162245] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Cushing disease is caused by a pituitary micro- or macroadenoma that hypersecretes adrenocorticotropic hormone (ACTH), resulting in hypercortisolemia. For decades, transsphenoidal resection (TSR) has been an efficacious treatment but with certain limitations, namely precise tumor localization and complete excision. The authors evaluated the novel use of a double-antibody sandwich assay for the real-time quantitation of ACTH in resected pituitary specimens with the goals of augmenting pathological diagnosis and ultimately improving long-term patient outcome. METHODS This study involved a retrospective review of records and an analysis of assay values, pathology slides, and MRI studies of patients with Cushing disease who had undergone TSR in the period from 2009 to 2014 and had at least 1 year of follow-up in coordination with an endocrinologist. In the operating room, biopsy specimens from the patients had been analyzed for tissue ACTH concentration. Additional samples were simultaneously sent for frozen-section pathological analysis. The ACTH assay performance was compared against pathology assessments of surgical tumor samples using receiver operating characteristic (ROC) analysis and against pre- and postoperative MRI studies. RESULTS Fourteen patients underwent TSR with guidance by ACTH-antibody assay and pathological assessment of 127 biopsy samples and were followed up for an average of 3 years. The ACTH threshold for discriminating adenomatous from normal tissue was 290,000 pg/mg of tissue, based on jointly maximized sensitivity (95.0%) and specificity (71.3%). Lateralization discordance between preoperative MRI studies and surgical visualization was noted in 3 patients, confirming the impression that MRI alone may not achieve optimal localization. A majority of the patients (85.7%) attained long-term disease remission based on urinary free cortisol levels, plasma cortisol levels, and long-term corticosteroid therapy. Comparisons of patient-months of remission and treatment failure showed that the remission rate in the study sample statistically exceeds the rate in historical controls (71.9%; p = 0.0007, Fisher's exact test). Long-term unexpected hormonal deficiencies were statistically similar between study patients (29%) and those in a meta-analysis (25%; p = 0.7596, Fisher's exact test). CONCLUSIONS These preliminary findings reflect the promising potential of tissue-based ACTH-antibody-guided assay for improving the cure rates of Cushing disease patients undergoing TSR. Further studies with larger sample sizes, further refinements of assay interpretation, and longer-term follow-ups are needed.
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Affiliation(s)
- J Mark Erfe
- 1Yale School of Medicine, New Haven, Connecticut
| | - Avital Perry
- 2Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota
| | - John McClaskey
- 3Department of Pathology, Mount Sinai Hospital, New York, New York; and
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24
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Carroll TB, Javorsky BR, Findling JW. POSTSURGICAL RECURRENT CUSHING DISEASE: CLINICAL BENEFIT OF EARLY INTERVENTION IN PATIENTS WITH NORMAL URINARY FREE CORTISOL. Endocr Pract 2016; 22:1216-1223. [PMID: 27409817 DOI: 10.4158/ep161380.or] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To assess the performance of biochemical markers in the detection of recurrent Cushing disease (CD), as well as the potential benefit of early intervention in recurrent CD patients with elevated late-night salivary cortisol (LNSC) and normal urinary free cortisol (UFC). METHODS The design was a single-center, retrospective chart review. Patients treated by the authors from 2008-2013 were included. Recurrence was defined by postsurgical remission of CD with subsequent abnormal LNSC, UFC, or dexamethasone suppression test (DST). RESULTS We identified 15 patients with postsurgical recurrent CD after initial remission; all but one underwent testing with LNSC, DST, and UFC. Although 12 of 15 patients had normal UFC at time of recurrence, DST was abnormal in 11 of 15, and all 14 patients with LNSC results had ≥1 elevated measurement. Nine patients (7 with normal UFC) showed radiologic evidence of a pituitary tumor at time of recurrence. Among the 14 patients with available follow-up data, 12 have demonstrated significant improvement since receiving treatment. Five patients underwent repeat pituitary surgery and 4 achieved clinical and biochemical remission. Eight patients received mifepristone or cabergoline, and 6 showed clinical and/or biochemical improvement. Three patients (2 with prior mifepristone) underwent bilateral adrenalectomy and 2 demonstrated significant clinical improvements. CONCLUSION LNSC is more sensitive than UFC or DST for detection of CD recurrence. Prompt intervention when LNSC is elevated, despite normal UFC, may yield significant clinical benefit for many patients with CD. Early treatment for patients with recurrent CD should be prospectively evaluated, utilizing LNSC elevation as an early biochemical marker. ABBREVIATIONS ACTH = adrenocorticotropic hormone CD = Cushing disease CS = Cushing syndrome CV = coefficient of variation DST = dexamethasone suppression test IPSS = inferior petrosal sinus sampling LNSC = late-night salivary cortisol QoL = quality of life TSS = transsphenoidal adenoma resection UFC = urinary free cortisol.
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Lonser RR, Nieman L, Oldfield EH. Cushing's disease: pathobiology, diagnosis, and management. J Neurosurg 2016; 126:404-417. [PMID: 27104844 DOI: 10.3171/2016.1.jns152119] [Citation(s) in RCA: 98] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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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Nellesen D, Truong HL, Neary MP, Ludlam WH. Economic burden of multiple chronic comorbidities associated with Cushing’s disease, a rare endocrine disorder. Expert Opin Orphan Drugs 2016. [DOI: 10.1517/21678707.2016.1135049] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Le Marc'hadour P, Muller M, Albarel F, Coulon AL, Morange I, Martinie M, Gay E, Graillon T, Dufour H, Conte-Devolx B, Chabre O, Brue T, Castinetti F. Postoperative follow-up of Cushing's disease using cortisol, desmopressin and coupled dexamethasone-desmopressin tests: a head-to-head comparison. Clin Endocrinol (Oxf) 2015; 83:216-22. [PMID: 25660243 DOI: 10.1111/cen.12739] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2014] [Revised: 02/01/2015] [Accepted: 02/04/2015] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Predicting the outcome of patients operated on for Cushing's disease (CD) is a challenging task. Our objective was to assess the accuracy of immediate postsurgical plasma cortisol, desmopressin test and the coupled dexamethasone-desmopressin test (CDDT) as predictors of outcome. DESIGN AND PATIENTS Sixty-seven patients with initial remission and a minimal postsurgical follow-up greater than 18 months were included in this retrospective bicentre study. MEASUREMENTS Follow-up included 3-6 months followed by yearly 24-h urinary-free cortisol, ACTH and cortisol plasmatic levels, a 1-mg overnight dexamethasone suppression test (1-mg DST), desmopressin test and the CDDT. ROC curves were performed to define the optimal threshold of immediate postsurgical cortisol level and 3- to 6-month desmopressin test and CDDT, as predictors of final outcome in comparison with classical biological markers of recurrence. RESULTS Eleven patients presented recurrence. The patient's median follow-up was 52 months (range, 18-180). As early predictors of outcome, immediate postsurgical plasma cortisol level <35 nmol/l predicted the lack of recurrence with 93% negative predictive value (NPV), whereas predictive positive value (PPV) was 25%. During the follow-up, the CDDT was more precise than the desmopressin test in predicting the lack of recurrence (100% NPV) when performed in the first 3 years after surgery. Positivity of the CDDT was defined based on ROC curves by ACTH and cortisol increments >50%. The CDDT was highly reproducible, as the same response was observed every year in 91% of the patients. CONCLUSIONS Adding the CDDT the first 3 years after surgery to immediate postsurgical cortisol evaluation should allow obtaining an optimal follow-up management of patients operated for Cushing's disease.
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Affiliation(s)
- Pauline Le Marc'hadour
- Department of Endocrinology, CHU La Timone, APHM and CRN2M-UMR 7286- Faculte de Medecine Secteur Nord, Aix Marseille Université, Marseille, France
| | - Marie Muller
- Department of Endocrinology, Diabetology and Nutrition, CHU de Grenoble - Hôpital Albert Michallon, Grenoble, France
| | - Frederique Albarel
- Department of Endocrinology, CHU La Timone, APHM and CRN2M-UMR 7286- Faculte de Medecine Secteur Nord, Aix Marseille Université, Marseille, France
| | - Anne-Laure Coulon
- Department of Endocrinology, Diabetology and Nutrition, CHU de Grenoble - Hôpital Albert Michallon, Grenoble, France
| | - Isabelle Morange
- Department of Endocrinology, CHU La Timone, APHM and CRN2M-UMR 7286- Faculte de Medecine Secteur Nord, Aix Marseille Université, Marseille, France
| | - Monique Martinie
- Department of Endocrinology, Diabetology and Nutrition, CHU de Grenoble - Hôpital Albert Michallon, Grenoble, France
| | - Emmanuel Gay
- Department of Neurosurgery, CHU de Grenoble - Hôpital Albert Michallon, Grenoble, France
| | - Thomas Graillon
- Department of Neurosurgery, CHU La Timone, Marseille, France
| | - Henri Dufour
- Department of Neurosurgery, CHU La Timone, Marseille, France
| | - Bernard Conte-Devolx
- Department of Endocrinology, CHU La Timone, APHM and CRN2M-UMR 7286- Faculte de Medecine Secteur Nord, Aix Marseille Université, Marseille, France
| | - Olivier Chabre
- Department of Endocrinology, Diabetology and Nutrition, CHU de Grenoble - Hôpital Albert Michallon, Grenoble, France
| | - Thierry Brue
- Department of Endocrinology, CHU La Timone, APHM and CRN2M-UMR 7286- Faculte de Medecine Secteur Nord, Aix Marseille Université, Marseille, France
| | - Frederic Castinetti
- Department of Endocrinology, CHU La Timone, APHM and CRN2M-UMR 7286- Faculte de Medecine Secteur Nord, Aix Marseille Université, Marseille, France
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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: 282] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Accepted: 05/13/2015] [Indexed: 12/23/2022]
Abstract
Cushing's disease (CD), or pituitary-dependent Cushing's syndrome, is a severe endocrine disease caused by a corticotroph pituitary tumor and associated with increased morbidity and mortality. The first-line treatment for CD is pituitary surgery, which is followed by disease remission in around 78% and relapse in around 13% of patients during the 10-year period after surgery, so that nearly one third of patients experience in the long-term a failure of surgery and require an additional second-line treatment. Patients with persistent or recurrent CD require additional treatments, including pituitary radiotherapy, adrenal surgery, and/or medical therapy. Pituitary radiotherapy is effective in controlling cortisol excess in a large percentage of patients, but it is associated with a considerable risk of hypopituitarism. Adrenal surgery is followed by a rapid and definitive control of cortisol excess in nearly all patients, but it induces adrenal insufficiency. Medical therapy has recently acquired a more important role compared to the past, due to the recent employment of novel compounds able to control cortisol secretion or action. Currently, medical therapy is used as a presurgical treatment, particularly for severe disease; or as postsurgical treatment, in cases of failure or incomplete surgical tumor resection; or as bridging therapy before, during, and after radiotherapy while waiting for disease control; or, in selected cases, as primary therapy, mainly when surgery is not an option. The adrenal-directed drug ketoconazole is the most commonly used drug, mainly because of its rapid action, whereas the glucocorticoid receptor antagonist, mifepristone, is highly effective in controlling clinical comorbidities, mainly glucose intolerance, thus being a useful treatment for CD when it is associated with diabetes mellitus. Pituitary-directed drugs have the advantage of acting at the site responsible for CD, the pituitary tumor. Among this group of drugs, the dopamine agonist cabergoline and the somatostatin analog pasireotide result in disease remission in a consistent subgroup of patients with CD. Recently, pasireotide has been approved for the treatment of CD when surgery has failed or when surgery is not an option, and mifepristone has been approved for the treatment of Cushing's syndrome when associated with impairment of glucose metabolism in case of the lack of a surgical indication. Recent experience suggests that the combination of different drugs may be able to control cortisol excess in a great majority of patients with CD.
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Affiliation(s)
- Rosario Pivonello
- Dipartimento Di Medicina Clinica E Chirurgia, Sezione Di Endocrinologia, Universita' Federico II di Napoli, 80131 Naples, Italy
| | - Monica De Leo
- Dipartimento Di Medicina Clinica E Chirurgia, Sezione Di Endocrinologia, Universita' Federico II di Napoli, 80131 Naples, Italy
| | - Alessia Cozzolino
- Dipartimento Di Medicina Clinica E Chirurgia, Sezione Di Endocrinologia, Universita' Federico II di Napoli, 80131 Naples, Italy
| | - Annamaria Colao
- Dipartimento Di Medicina Clinica E Chirurgia, Sezione Di Endocrinologia, Universita' Federico II di Napoli, 80131 Naples, Italy
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Petersenn S, Beckers A, Ferone D, van der Lely A, Bollerslev J, Boscaro M, Brue T, Bruzzi P, Casanueva FF, Chanson P, Colao A, Reincke M, Stalla G, Tsagarakis S. Therapy of endocrine disease: outcomes in patients with Cushing's disease undergoing transsphenoidal surgery: systematic review assessing criteria used to define remission and recurrence. Eur J Endocrinol 2015; 172:R227-39. [PMID: 25599709 DOI: 10.1530/eje-14-0883] [Citation(s) in RCA: 98] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Accepted: 01/15/2015] [Indexed: 11/08/2022]
Abstract
OBJECTIVE A number of factors can influence the reported outcomes of transsphenoidal surgery (TSS) for Cushing's disease - including different remission and recurrence criteria, for which there is no consensus. Therefore, a comparative analysis of the best treatment options and patient management strategies is difficult. In this review, we investigated the clinical outcomes of initial TSS in patients with Cushing's disease based on definitions of and assessments for remission and recurrence. METHODS We systematically searched PubMed and identified 44 studies with clear definitions of remission and recurrence. When data were available, additional analyses by time of remission, tumor size, duration of follow-up, surgical experience, year of study publication and adverse events related to surgery were performed. RESULTS Data from a total of 6400 patients who received microscopic TSS were extracted and analyzed. A variety of definitions of remission and recurrence of Cushing's disease after initial microscopic TSS was used, giving broad ranges of remission (42.0-96.6%; median, 77.9%) and recurrence (0-47.4%; median, 11.5%). Better remission and recurrence outcomes were achieved for microadenomas vs macroadenomas; however, no correlations were found with other parameters, other than improved safety with longer surgical experience. CONCLUSIONS The variety of methodologies used in clinical evaluation of TSS for Cushing's disease strongly support the call for standardization and optimization of studies to inform clinical practice and maximize patient outcomes. Clinically significant rates of failure of initial TSS highlight the need for effective second-line treatments.
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Affiliation(s)
- Stephan Petersenn
- ENDOC Center for Endocrine TumorsAltonaer Strasse 59, 20357 Hamburg, GermanyDepartment of EndocrinologyCHU de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, BelgiumEndocrinology UnitDepartment of Internal Medicine and Medical Specialties (DiMI), Center of Excellence for Biomedical Research, IRCCS AOU San Martino-IST, University of Genova, Genova, ItalyDepartment of MedicineErasmus University MC, PO Box 2040, 3000 CA Rotterdam, The NetherlandsSection of Specialized EndocrinologyFaculty of Medicine, Oslo University Hospital, University of Oslo, Oslo, NorwayDivision of EndocrinologyDepartment of Medicine (DIMED), University of Padua, Padua, ItalyAix-Marseille UniversitéCNRS, CRN2M UMR 7286, 13344 Marseille Cedex 15, FranceAPHMHôpital Timone, Service d'Endocrinologie, Diabète et Maladies Métaboliques, 13385 Marseille Cedex 15, FranceDepartment of Epidemiology and PreventionIRCCS AOU San Martino-IST, Genova, ItalySantiago de Compostela University and CIBERobnSantiago de Compostela, SpainUniv Paris-SudFaculté de Médecine Paris-Sud, UMR-S1185, Le Kremlin Bicêtre, F-94276, FranceAssistance Publique-Hôpitaux de ParisHôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Le Kremlin Bicêtre, F-94275, FranceInstitut National de la Santé et de la Recherche Médicale U1185Le Kremlin Bicêtre, F-94276, FranceDipartimento di Medicina Clinica e ChirurgiaSezione di Endocrinologia, Università Federico II di Napoli, Naples, ItalyMedizinische Klinik und Poliklinik IV-InnenstadtUniversity Hospital Munich, D-80336 Munich, GermanyDepartment of EndocrinologyMax Planck Institute of Psychiatry, Munich, GermanyDepartment of EndocrinologyDiabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Albert Beckers
- ENDOC Center for Endocrine TumorsAltonaer Strasse 59, 20357 Hamburg, GermanyDepartment of EndocrinologyCHU de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, BelgiumEndocrinology UnitDepartment of Internal Medicine and Medical Specialties (DiMI), Center of Excellence for Biomedical Research, IRCCS AOU San Martino-IST, University of Genova, Genova, ItalyDepartment of MedicineErasmus University MC, PO Box 2040, 3000 CA Rotterdam, The NetherlandsSection of Specialized EndocrinologyFaculty of Medicine, Oslo University Hospital, University of Oslo, Oslo, NorwayDivision of EndocrinologyDepartment of Medicine (DIMED), University of Padua, Padua, ItalyAix-Marseille UniversitéCNRS, CRN2M UMR 7286, 13344 Marseille Cedex 15, FranceAPHMHôpital Timone, Service d'Endocrinologie, Diabète et Maladies Métaboliques, 13385 Marseille Cedex 15, FranceDepartment of Epidemiology and PreventionIRCCS AOU San Martino-IST, Genova, ItalySantiago de Compostela University and CIBERobnSantiago de Compostela, SpainUniv Paris-SudFaculté de Médecine Paris-Sud, UMR-S1185, Le Kremlin Bicêtre, F-94276, FranceAssistance Publique-Hôpitaux de ParisHôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Le Kremlin Bicêtre, F-94275, FranceInstitut National de la Santé et de la Recherche Médicale U1185Le Kremlin Bicêtre, F-94276, FranceDipartimento di Medicina Clinica e ChirurgiaSezione di Endocrinologia, Università Federico II di Napoli, Naples, ItalyMedizinische Klinik und Poliklinik IV-InnenstadtUniversity Hospital Munich, D-80336 Munich, GermanyDepartment of EndocrinologyMax Planck Institute of Psychiatry, Munich, GermanyDepartment of EndocrinologyDiabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Diego Ferone
- ENDOC Center for Endocrine TumorsAltonaer Strasse 59, 20357 Hamburg, GermanyDepartment of EndocrinologyCHU de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, BelgiumEndocrinology UnitDepartment of Internal Medicine and Medical Specialties (DiMI), Center of Excellence for Biomedical Research, IRCCS AOU San Martino-IST, University of Genova, Genova, ItalyDepartment of MedicineErasmus University MC, PO Box 2040, 3000 CA Rotterdam, The NetherlandsSection of Specialized EndocrinologyFaculty of Medicine, Oslo University Hospital, University of Oslo, Oslo, NorwayDivision of EndocrinologyDepartment of Medicine (DIMED), University of Padua, Padua, ItalyAix-Marseille UniversitéCNRS, CRN2M UMR 7286, 13344 Marseille Cedex 15, FranceAPHMHôpital Timone, Service d'Endocrinologie, Diabète et Maladies Métaboliques, 13385 Marseille Cedex 15, FranceDepartment of Epidemiology and PreventionIRCCS AOU San Martino-IST, Genova, ItalySantiago de Compostela University and CIBERobnSantiago de Compostela, SpainUniv Paris-SudFaculté de Médecine Paris-Sud, UMR-S1185, Le Kremlin Bicêtre, F-94276, FranceAssistance Publique-Hôpitaux de ParisHôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Le Kremlin Bicêtre, F-94275, FranceInstitut National de la Santé et de la Recherche Médicale U1185Le Kremlin Bicêtre, F-94276, FranceDipartimento di Medicina Clinica e ChirurgiaSezione di Endocrinologia, Università Federico II di Napoli, Naples, ItalyMedizinische Klinik und Poliklinik IV-InnenstadtUniversity Hospital Munich, D-80336 Munich, GermanyDepartment of EndocrinologyMax Planck Institute of Psychiatry, Munich, GermanyDepartment of EndocrinologyDiabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Aart van der Lely
- ENDOC Center for Endocrine TumorsAltonaer Strasse 59, 20357 Hamburg, GermanyDepartment of EndocrinologyCHU de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, BelgiumEndocrinology UnitDepartment of Internal Medicine and Medical Specialties (DiMI), Center of Excellence for Biomedical Research, IRCCS AOU San Martino-IST, University of Genova, Genova, ItalyDepartment of MedicineErasmus University MC, PO Box 2040, 3000 CA Rotterdam, The NetherlandsSection of Specialized EndocrinologyFaculty of Medicine, Oslo University Hospital, University of Oslo, Oslo, NorwayDivision of EndocrinologyDepartment of Medicine (DIMED), University of Padua, Padua, ItalyAix-Marseille UniversitéCNRS, CRN2M UMR 7286, 13344 Marseille Cedex 15, FranceAPHMHôpital Timone, Service d'Endocrinologie, Diabète et Maladies Métaboliques, 13385 Marseille Cedex 15, FranceDepartment of Epidemiology and PreventionIRCCS AOU San Martino-IST, Genova, ItalySantiago de Compostela University and CIBERobnSantiago de Compostela, SpainUniv Paris-SudFaculté de Médecine Paris-Sud, UMR-S1185, Le Kremlin Bicêtre, F-94276, FranceAssistance Publique-Hôpitaux de ParisHôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Le Kremlin Bicêtre, F-94275, FranceInstitut National de la Santé et de la Recherche Médicale U1185Le Kremlin Bicêtre, F-94276, FranceDipartimento di Medicina Clinica e ChirurgiaSezione di Endocrinologia, Università Federico II di Napoli, Naples, ItalyMedizinische Klinik und Poliklinik IV-InnenstadtUniversity Hospital Munich, D-80336 Munich, GermanyDepartment of EndocrinologyMax Planck Institute of Psychiatry, Munich, GermanyDepartment of EndocrinologyDiabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Jens Bollerslev
- ENDOC Center for Endocrine TumorsAltonaer Strasse 59, 20357 Hamburg, GermanyDepartment of EndocrinologyCHU de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, BelgiumEndocrinology UnitDepartment of Internal Medicine and Medical Specialties (DiMI), Center of Excellence for Biomedical Research, IRCCS AOU San Martino-IST, University of Genova, Genova, ItalyDepartment of MedicineErasmus University MC, PO Box 2040, 3000 CA Rotterdam, The NetherlandsSection of Specialized EndocrinologyFaculty of Medicine, Oslo University Hospital, University of Oslo, Oslo, NorwayDivision of EndocrinologyDepartment of Medicine (DIMED), University of Padua, Padua, ItalyAix-Marseille UniversitéCNRS, CRN2M UMR 7286, 13344 Marseille Cedex 15, FranceAPHMHôpital Timone, Service d'Endocrinologie, Diabète et Maladies Métaboliques, 13385 Marseille Cedex 15, FranceDepartment of Epidemiology and PreventionIRCCS AOU San Martino-IST, Genova, ItalySantiago de Compostela University and CIBERobnSantiago de Compostela, SpainUniv Paris-SudFaculté de Médecine Paris-Sud, UMR-S1185, Le Kremlin Bicêtre, F-94276, FranceAssistance Publique-Hôpitaux de ParisHôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Le Kremlin Bicêtre, F-94275, FranceInstitut National de la Santé et de la Recherche Médicale U1185Le Kremlin Bicêtre, F-94276, FranceDipartimento di Medicina Clinica e ChirurgiaSezione di Endocrinologia, Università Federico II di Napoli, Naples, ItalyMedizinische Klinik und Poliklinik IV-InnenstadtUniversity Hospital Munich, D-80336 Munich, GermanyDepartment of EndocrinologyMax Planck Institute of Psychiatry, Munich, GermanyDepartment of EndocrinologyDiabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Marco Boscaro
- ENDOC Center for Endocrine TumorsAltonaer Strasse 59, 20357 Hamburg, GermanyDepartment of EndocrinologyCHU de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, BelgiumEndocrinology UnitDepartment of Internal Medicine and Medical Specialties (DiMI), Center of Excellence for Biomedical Research, IRCCS AOU San Martino-IST, University of Genova, Genova, ItalyDepartment of MedicineErasmus University MC, PO Box 2040, 3000 CA Rotterdam, The NetherlandsSection of Specialized EndocrinologyFaculty of Medicine, Oslo University Hospital, University of Oslo, Oslo, NorwayDivision of EndocrinologyDepartment of Medicine (DIMED), University of Padua, Padua, ItalyAix-Marseille UniversitéCNRS, CRN2M UMR 7286, 13344 Marseille Cedex 15, FranceAPHMHôpital Timone, Service d'Endocrinologie, Diabète et Maladies Métaboliques, 13385 Marseille Cedex 15, FranceDepartment of Epidemiology and PreventionIRCCS AOU San Martino-IST, Genova, ItalySantiago de Compostela University and CIBERobnSantiago de Compostela, SpainUniv Paris-SudFaculté de Médecine Paris-Sud, UMR-S1185, Le Kremlin Bicêtre, F-94276, FranceAssistance Publique-Hôpitaux de ParisHôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Le Kremlin Bicêtre, F-94275, FranceInstitut National de la Santé et de la Recherche Médicale U1185Le Kremlin Bicêtre, F-94276, FranceDipartimento di Medicina Clinica e ChirurgiaSezione di Endocrinologia, Università Federico II di Napoli, Naples, ItalyMedizinische Klinik und Poliklinik IV-InnenstadtUniversity Hospital Munich, D-80336 Munich, GermanyDepartment of EndocrinologyMax Planck Institute of Psychiatry, Munich, GermanyDepartment of EndocrinologyDiabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Thierry Brue
- ENDOC Center for Endocrine TumorsAltonaer Strasse 59, 20357 Hamburg, GermanyDepartment of EndocrinologyCHU de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, BelgiumEndocrinology UnitDepartment of Internal Medicine and Medical Specialties (DiMI), Center of Excellence for Biomedical Research, IRCCS AOU San Martino-IST, University of Genova, Genova, ItalyDepartment of MedicineErasmus University MC, PO Box 2040, 3000 CA Rotterdam, The NetherlandsSection of Specialized EndocrinologyFaculty of Medicine, Oslo University Hospital, University of Oslo, Oslo, NorwayDivision of EndocrinologyDepartment of Medicine (DIMED), University of Padua, Padua, ItalyAix-Marseille UniversitéCNRS, CRN2M UMR 7286, 13344 Marseille Cedex 15, FranceAPHMHôpital Timone, Service d'Endocrinologie, Diabète et Maladies Métaboliques, 13385 Marseille Cedex 15, FranceDepartment of Epidemiology and PreventionIRCCS AOU San Martino-IST, Genova, ItalySantiago de Compostela University and CIBERobnSantiago de Compostela, SpainUniv Paris-SudFaculté de Médecine Paris-Sud, UMR-S1185, Le Kremlin Bicêtre, F-94276, FranceAssistance Publique-Hôpitaux de ParisHôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Le Kremlin Bicêtre, F-94275, FranceInstitut National de la Santé et de la Recherche Médicale U1185Le Kremlin Bicêtre, F-94276, FranceDipartimento di Medicina Clinica e ChirurgiaSezione di Endocrinologia, Università Federico II di Napoli, Naples, ItalyMedizinische Klinik und Poliklinik IV-InnenstadtUniversity Hospital Munich, D-80336 Munich, GermanyDepartment of EndocrinologyMax Planck Institute of Psychiatry, Munich, GermanyDepartment of EndocrinologyDiabetes and Metabolism, Evangelismos Hospital, Athens, Greece ENDOC Center for Endocrine TumorsAltonaer Strasse 59, 20357 Hamburg, GermanyDepartment of EndocrinologyCHU de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, BelgiumEndocrinology UnitDepartment of Inter
| | - Paolo Bruzzi
- ENDOC Center for Endocrine TumorsAltonaer Strasse 59, 20357 Hamburg, GermanyDepartment of EndocrinologyCHU de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, BelgiumEndocrinology UnitDepartment of Internal Medicine and Medical Specialties (DiMI), Center of Excellence for Biomedical Research, IRCCS AOU San Martino-IST, University of Genova, Genova, ItalyDepartment of MedicineErasmus University MC, PO Box 2040, 3000 CA Rotterdam, The NetherlandsSection of Specialized EndocrinologyFaculty of Medicine, Oslo University Hospital, University of Oslo, Oslo, NorwayDivision of EndocrinologyDepartment of Medicine (DIMED), University of Padua, Padua, ItalyAix-Marseille UniversitéCNRS, CRN2M UMR 7286, 13344 Marseille Cedex 15, FranceAPHMHôpital Timone, Service d'Endocrinologie, Diabète et Maladies Métaboliques, 13385 Marseille Cedex 15, FranceDepartment of Epidemiology and PreventionIRCCS AOU San Martino-IST, Genova, ItalySantiago de Compostela University and CIBERobnSantiago de Compostela, SpainUniv Paris-SudFaculté de Médecine Paris-Sud, UMR-S1185, Le Kremlin Bicêtre, F-94276, FranceAssistance Publique-Hôpitaux de ParisHôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Le Kremlin Bicêtre, F-94275, FranceInstitut National de la Santé et de la Recherche Médicale U1185Le Kremlin Bicêtre, F-94276, FranceDipartimento di Medicina Clinica e ChirurgiaSezione di Endocrinologia, Università Federico II di Napoli, Naples, ItalyMedizinische Klinik und Poliklinik IV-InnenstadtUniversity Hospital Munich, D-80336 Munich, GermanyDepartment of EndocrinologyMax Planck Institute of Psychiatry, Munich, GermanyDepartment of EndocrinologyDiabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Felipe F Casanueva
- ENDOC Center for Endocrine TumorsAltonaer Strasse 59, 20357 Hamburg, GermanyDepartment of EndocrinologyCHU de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, BelgiumEndocrinology UnitDepartment of Internal Medicine and Medical Specialties (DiMI), Center of Excellence for Biomedical Research, IRCCS AOU San Martino-IST, University of Genova, Genova, ItalyDepartment of MedicineErasmus University MC, PO Box 2040, 3000 CA Rotterdam, The NetherlandsSection of Specialized EndocrinologyFaculty of Medicine, Oslo University Hospital, University of Oslo, Oslo, NorwayDivision of EndocrinologyDepartment of Medicine (DIMED), University of Padua, Padua, ItalyAix-Marseille UniversitéCNRS, CRN2M UMR 7286, 13344 Marseille Cedex 15, FranceAPHMHôpital Timone, Service d'Endocrinologie, Diabète et Maladies Métaboliques, 13385 Marseille Cedex 15, FranceDepartment of Epidemiology and PreventionIRCCS AOU San Martino-IST, Genova, ItalySantiago de Compostela University and CIBERobnSantiago de Compostela, SpainUniv Paris-SudFaculté de Médecine Paris-Sud, UMR-S1185, Le Kremlin Bicêtre, F-94276, FranceAssistance Publique-Hôpitaux de ParisHôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Le Kremlin Bicêtre, F-94275, FranceInstitut National de la Santé et de la Recherche Médicale U1185Le Kremlin Bicêtre, F-94276, FranceDipartimento di Medicina Clinica e ChirurgiaSezione di Endocrinologia, Università Federico II di Napoli, Naples, ItalyMedizinische Klinik und Poliklinik IV-InnenstadtUniversity Hospital Munich, D-80336 Munich, GermanyDepartment of EndocrinologyMax Planck Institute of Psychiatry, Munich, GermanyDepartment of EndocrinologyDiabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Philippe Chanson
- ENDOC Center for Endocrine TumorsAltonaer Strasse 59, 20357 Hamburg, GermanyDepartment of EndocrinologyCHU de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, BelgiumEndocrinology UnitDepartment of Internal Medicine and Medical Specialties (DiMI), Center of Excellence for Biomedical Research, IRCCS AOU San Martino-IST, University of Genova, Genova, ItalyDepartment of MedicineErasmus University MC, PO Box 2040, 3000 CA Rotterdam, The NetherlandsSection of Specialized EndocrinologyFaculty of Medicine, Oslo University Hospital, University of Oslo, Oslo, NorwayDivision of EndocrinologyDepartment of Medicine (DIMED), University of Padua, Padua, ItalyAix-Marseille UniversitéCNRS, CRN2M UMR 7286, 13344 Marseille Cedex 15, FranceAPHMHôpital Timone, Service d'Endocrinologie, Diabète et Maladies Métaboliques, 13385 Marseille Cedex 15, FranceDepartment of Epidemiology and PreventionIRCCS AOU San Martino-IST, Genova, ItalySantiago de Compostela University and CIBERobnSantiago de Compostela, SpainUniv Paris-SudFaculté de Médecine Paris-Sud, UMR-S1185, Le Kremlin Bicêtre, F-94276, FranceAssistance Publique-Hôpitaux de ParisHôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Le Kremlin Bicêtre, F-94275, FranceInstitut National de la Santé et de la Recherche Médicale U1185Le Kremlin Bicêtre, F-94276, FranceDipartimento di Medicina Clinica e ChirurgiaSezione di Endocrinologia, Università Federico II di Napoli, Naples, ItalyMedizinische Klinik und Poliklinik IV-InnenstadtUniversity Hospital Munich, D-80336 Munich, GermanyDepartment of EndocrinologyMax Planck Institute of Psychiatry, Munich, GermanyDepartment of EndocrinologyDiabetes and Metabolism, Evangelismos Hospital, Athens, Greece ENDOC Center for Endocrine TumorsAltonaer Strasse 59, 20357 Hamburg, GermanyDepartment of EndocrinologyCHU de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, BelgiumEndocrinology UnitDepartment of Inter
| | - Annamaria Colao
- ENDOC Center for Endocrine TumorsAltonaer Strasse 59, 20357 Hamburg, GermanyDepartment of EndocrinologyCHU de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, BelgiumEndocrinology UnitDepartment of Internal Medicine and Medical Specialties (DiMI), Center of Excellence for Biomedical Research, IRCCS AOU San Martino-IST, University of Genova, Genova, ItalyDepartment of MedicineErasmus University MC, PO Box 2040, 3000 CA Rotterdam, The NetherlandsSection of Specialized EndocrinologyFaculty of Medicine, Oslo University Hospital, University of Oslo, Oslo, NorwayDivision of EndocrinologyDepartment of Medicine (DIMED), University of Padua, Padua, ItalyAix-Marseille UniversitéCNRS, CRN2M UMR 7286, 13344 Marseille Cedex 15, FranceAPHMHôpital Timone, Service d'Endocrinologie, Diabète et Maladies Métaboliques, 13385 Marseille Cedex 15, FranceDepartment of Epidemiology and PreventionIRCCS AOU San Martino-IST, Genova, ItalySantiago de Compostela University and CIBERobnSantiago de Compostela, SpainUniv Paris-SudFaculté de Médecine Paris-Sud, UMR-S1185, Le Kremlin Bicêtre, F-94276, FranceAssistance Publique-Hôpitaux de ParisHôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Le Kremlin Bicêtre, F-94275, FranceInstitut National de la Santé et de la Recherche Médicale U1185Le Kremlin Bicêtre, F-94276, FranceDipartimento di Medicina Clinica e ChirurgiaSezione di Endocrinologia, Università Federico II di Napoli, Naples, ItalyMedizinische Klinik und Poliklinik IV-InnenstadtUniversity Hospital Munich, D-80336 Munich, GermanyDepartment of EndocrinologyMax Planck Institute of Psychiatry, Munich, GermanyDepartment of EndocrinologyDiabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Martin Reincke
- ENDOC Center for Endocrine TumorsAltonaer Strasse 59, 20357 Hamburg, GermanyDepartment of EndocrinologyCHU de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, BelgiumEndocrinology UnitDepartment of Internal Medicine and Medical Specialties (DiMI), Center of Excellence for Biomedical Research, IRCCS AOU San Martino-IST, University of Genova, Genova, ItalyDepartment of MedicineErasmus University MC, PO Box 2040, 3000 CA Rotterdam, The NetherlandsSection of Specialized EndocrinologyFaculty of Medicine, Oslo University Hospital, University of Oslo, Oslo, NorwayDivision of EndocrinologyDepartment of Medicine (DIMED), University of Padua, Padua, ItalyAix-Marseille UniversitéCNRS, CRN2M UMR 7286, 13344 Marseille Cedex 15, FranceAPHMHôpital Timone, Service d'Endocrinologie, Diabète et Maladies Métaboliques, 13385 Marseille Cedex 15, FranceDepartment of Epidemiology and PreventionIRCCS AOU San Martino-IST, Genova, ItalySantiago de Compostela University and CIBERobnSantiago de Compostela, SpainUniv Paris-SudFaculté de Médecine Paris-Sud, UMR-S1185, Le Kremlin Bicêtre, F-94276, FranceAssistance Publique-Hôpitaux de ParisHôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Le Kremlin Bicêtre, F-94275, FranceInstitut National de la Santé et de la Recherche Médicale U1185Le Kremlin Bicêtre, F-94276, FranceDipartimento di Medicina Clinica e ChirurgiaSezione di Endocrinologia, Università Federico II di Napoli, Naples, ItalyMedizinische Klinik und Poliklinik IV-InnenstadtUniversity Hospital Munich, D-80336 Munich, GermanyDepartment of EndocrinologyMax Planck Institute of Psychiatry, Munich, GermanyDepartment of EndocrinologyDiabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Günter Stalla
- ENDOC Center for Endocrine TumorsAltonaer Strasse 59, 20357 Hamburg, GermanyDepartment of EndocrinologyCHU de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, BelgiumEndocrinology UnitDepartment of Internal Medicine and Medical Specialties (DiMI), Center of Excellence for Biomedical Research, IRCCS AOU San Martino-IST, University of Genova, Genova, ItalyDepartment of MedicineErasmus University MC, PO Box 2040, 3000 CA Rotterdam, The NetherlandsSection of Specialized EndocrinologyFaculty of Medicine, Oslo University Hospital, University of Oslo, Oslo, NorwayDivision of EndocrinologyDepartment of Medicine (DIMED), University of Padua, Padua, ItalyAix-Marseille UniversitéCNRS, CRN2M UMR 7286, 13344 Marseille Cedex 15, FranceAPHMHôpital Timone, Service d'Endocrinologie, Diabète et Maladies Métaboliques, 13385 Marseille Cedex 15, FranceDepartment of Epidemiology and PreventionIRCCS AOU San Martino-IST, Genova, ItalySantiago de Compostela University and CIBERobnSantiago de Compostela, SpainUniv Paris-SudFaculté de Médecine Paris-Sud, UMR-S1185, Le Kremlin Bicêtre, F-94276, FranceAssistance Publique-Hôpitaux de ParisHôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Le Kremlin Bicêtre, F-94275, FranceInstitut National de la Santé et de la Recherche Médicale U1185Le Kremlin Bicêtre, F-94276, FranceDipartimento di Medicina Clinica e ChirurgiaSezione di Endocrinologia, Università Federico II di Napoli, Naples, ItalyMedizinische Klinik und Poliklinik IV-InnenstadtUniversity Hospital Munich, D-80336 Munich, GermanyDepartment of EndocrinologyMax Planck Institute of Psychiatry, Munich, GermanyDepartment of EndocrinologyDiabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Stelios Tsagarakis
- ENDOC Center for Endocrine TumorsAltonaer Strasse 59, 20357 Hamburg, GermanyDepartment of EndocrinologyCHU de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, BelgiumEndocrinology UnitDepartment of Internal Medicine and Medical Specialties (DiMI), Center of Excellence for Biomedical Research, IRCCS AOU San Martino-IST, University of Genova, Genova, ItalyDepartment of MedicineErasmus University MC, PO Box 2040, 3000 CA Rotterdam, The NetherlandsSection of Specialized EndocrinologyFaculty of Medicine, Oslo University Hospital, University of Oslo, Oslo, NorwayDivision of EndocrinologyDepartment of Medicine (DIMED), University of Padua, Padua, ItalyAix-Marseille UniversitéCNRS, CRN2M UMR 7286, 13344 Marseille Cedex 15, FranceAPHMHôpital Timone, Service d'Endocrinologie, Diabète et Maladies Métaboliques, 13385 Marseille Cedex 15, FranceDepartment of Epidemiology and PreventionIRCCS AOU San Martino-IST, Genova, ItalySantiago de Compostela University and CIBERobnSantiago de Compostela, SpainUniv Paris-SudFaculté de Médecine Paris-Sud, UMR-S1185, Le Kremlin Bicêtre, F-94276, FranceAssistance Publique-Hôpitaux de ParisHôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Le Kremlin Bicêtre, F-94275, FranceInstitut National de la Santé et de la Recherche Médicale U1185Le Kremlin Bicêtre, F-94276, FranceDipartimento di Medicina Clinica e ChirurgiaSezione di Endocrinologia, Università Federico II di Napoli, Naples, ItalyMedizinische Klinik und Poliklinik IV-InnenstadtUniversity Hospital Munich, D-80336 Munich, GermanyDepartment of EndocrinologyMax Planck Institute of Psychiatry, Munich, GermanyDepartment of EndocrinologyDiabetes and Metabolism, Evangelismos Hospital, Athens, Greece
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Pendharkar AV, Sussman ES, Ho AL, Hayden Gephart MG, Katznelson L. Cushing's disease: predicting long-term remission after surgical treatment. Neurosurg Focus 2015; 38:E13. [DOI: 10.3171/2014.10.focus14682] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Cushing's disease (CD) is a state of excess glucocorticoid production resulting from an adrenocorticotropic hormone (ACTH)–secreting pituitary adenoma. The gold-standard treatment for CD is transsphenoidal adenomectomy. In the hands of an experienced neurosurgeon, gross-total resection is possible in the majority of ACTH-secreting pituitary adenomas, with early postoperative remission rates ranging from 67% to 95%. In contrast to the strong data in support of resection, the clinical course of postsurgical persistent or recurrent disease remains unclear. There is significant variability in recurrence rates, with reports as high as 36% with a mean time to recurrence of 15–50 months. It is therefore important to develop biochemical criteria that define postsurgical remission and that may provide prognosis for long-term recurrence. Despite the use of a number of biochemical assessments, there is debate regarding the accuracy of these tests in predicting recurrence. Here, the authors review the various biochemical criteria and assess their utility in predicting CD recurrence after resection.
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Affiliation(s)
| | | | | | | | - Laurence Katznelson
- Departments of 1Neurosurgery and
- 2Medicine, Stanford University School of Medicine, Stanford, California
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Aranda G, Enseñat J, Mora M, Puig-Domingo M, Martínez de Osaba MJ, Casals G, Verger E, Ribalta MT, Hanzu FA, Halperin I. Long-term remission and recurrence rate in a cohort of Cushing's disease: the need for long-term follow-up. Pituitary 2015; 18:142-9. [PMID: 24748528 DOI: 10.1007/s11102-014-0567-8] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Transsphenoidal surgery is the procedure of choice in Cushing disease (CD), with immediate post-operative remission rates ranging between 59 and 94% and recurrence rates between 3 and 46%, both depending upon the definition criteria and the duration of the follow-up. Our aim was to assess the rate of remission, recurrence and persistence of the disease after the first treatment and to identify predictors of remission in the CD population of our center. METHODS Retrospective cohort study of the patients diagnosed of CD and with follow-up in our center between 1974 and 2011. We analyzed 41 patients (35 women and 6 men) with a mean age at diagnosis of 34 ± 13 years. The mean follow-up was 14 ± 10 years (range 1-37 years) and the median of follow-up period was 6.68 years. RESULTS Thirty-five (85.4%) patients underwent transsphenoidal surgery as first treatment option. Histopathological evidence of a pituitary adenoma was registered in 17 (48.5%) patients. Thirty-two (78%) patients achieved disease remission after the first treatment, 21 (65.6%) of them presented disease recurrence. Persistent disease was observed in 9 (22%) patients. Twelve (29.3%) subjects developed post-surgical adrenal insufficiency, 7 of which (70%) achieved stable remission. Two parameters were found to be significant predictors of remission after the first treatment: age at disease diagnosis and the development of adrenal insufficiency (cortisol <3 μg/dl) in the immediate post-operative state. CONCLUSIONS We report a high recurrence rate, at least partially attributable to the long follow-up time. Early post-surgery adrenal insufficiency predicts remission. Hypopituitarism was also very prevalent, and strongly associated with radiotherapy. These results lead us to the conclusion that CD needs a life-long strict follow-up.
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Affiliation(s)
- G Aranda
- Department of Endocrinology and Nutrition, Hospital Clinic, Barcelona, Spain
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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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Truong HL, Nellesen D, Ludlam WH, Neary MP. Budget impact of pasireotide for the treatment of Cushing's disease, a rare endocrine disorder associated with considerable comorbidities. J Med Econ 2014; 17:288-95. [PMID: 24617917 DOI: 10.3111/13696998.2013.877470] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVES Cushing's disease (CD) is a rare condition with a prevalence of roughly 39 cases per million in the general population. Healthcare costs are substantial for CD patients with either untreated or inadequately controlled disease. This study assesses the 3-year budget impact of pasireotide on a US managed care health plan following pasireotide (Signifor) availability. METHODS Two scenarios were evaluated to understand the differences in costs associated with the introduction of pasireotide. The first scenario evaluates the budget impact of pasireotide from the perspective of an entire health plan (total budget impact) and the second from the perspective of the pharmacy budget (pharmacy budget impact). Both scenarios evaluate the annual incremental budget impact with and without pasireotide. Scenario 1 includes costs for medical procedures, drug therapies, monitoring, surgical complications, comorbidities for patients with controlled or uncontrolled CD, and adverse events. Procedures include transsphenoidal surgery, bilateral adrenalectomy, radiotherapy and radiosurgery. Drugs include pasireotide (indicated for CD), mifepristone (indicated to control hyperglycemia secondary to hypercortisolism in patients with Cushing's syndrome) as well as several off-label treatments (ketoconazole, cabergoline, mitotane). Scenario 2 considers costs solely from the perspective of a health plan pharmacy. Costs are in $2013. RESULTS The estimated total budget impact is $0.0115 per-member per-month (PMPM) in the first year following FDA approval, $0.0184 in the second year, and $0.0194 in the third year. Introduction of pasireotide is expected to increase the pharmacy budget by $0.0257 PMPM in the first year, $0.0363 in the second year, and $0.0360 in the third year. LIMITATIONS Model inputs rely on the small body of literature available for Cushing's disease. CONCLUSIONS Cushing's disease is severe disease with debilitating comorbidities and substantial healthcare costs when untreated or inadequately controlled. The inclusion of pasireotide in a health plan formulary appears to have only a small impact on the total health plan or pharmacy budget.
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van den Bosch OFC, Stades AME, Zelissen PMJ. Increased long-term remission after adequate medical cortisol suppression therapy as presurgical treatment in Cushing's disease. Clin Endocrinol (Oxf) 2014; 80:184-90. [PMID: 23841642 DOI: 10.1111/cen.12286] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Revised: 02/26/2013] [Accepted: 07/08/2013] [Indexed: 11/27/2022]
Abstract
OBJECTIVE In the last decade, pre-operative medical cortisol suppression therapy has frequently been used in Cushing's disease to normalize cortisol concentrations pre-operatively. Our aim was to assess the efficacy of presurgical medical cortisol suppression therapy in Cushing's disease. DESIGN AND METHODS We retrospectively assessed the medical files of all patients with Cushing's disease that received presurgical cortisol suppression therapy with ketoconazole or metyrapone and underwent subsequent transsphenoidal surgery between 1990 and 2010 at our centre. We retrieved the pretreatment regimen, adequacy of pretreatment, early postoperative serum cortisol levels, adverse effects and long-term remission status. RESULTS Nineteen of 33 patients (58%) obtained long-term remission after pituitary surgery without additional postoperative therapy. Thirteen of 16 patients with adequate presurgical cortisol suppression therapy had postoperative cortisol concentrations <50 nmol/l. The 16 patients with adequate presurgical cortisol suppression had a higher long-term remission rate after primary surgery compared with the 13 patients with borderline or inadequate pretreatment (81% vs 38%; P < 0·05). CONCLUSIONS Adequate presurgical cortisol suppression treatment with ketoconazole or metyrapone in Cushing's disease seems to be associated with suppressed postoperative cortisol concentrations and an increased long-term remission rate.
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Affiliation(s)
- O F C van den Bosch
- Department of Internal Medicine, Section of Endocrinology, University Medical Center Utrecht, Utrecht, The Netherlands
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Abstract
BACKGROUND Cushing disease (CD) constitutes a challenging condition for the pituitary surgeon. Given the variety of factors affecting outcomes in CD, it is uncertain whether the newer endoscopic technique improves the results of surgery. METHODS A review was conducted of CD cases at our institution between 2000 and 2010. Analysis was done to: determine if surgical technique had an effect on outcome, identify the predictors of outcome and provide details of failed cases. Remission was defined as normal postoperative 24-hour urinary free cortisol (24-h UFC), suppression of morning serum cortisol to <50 nmol/L after 1mg of dexamethasone or being dependent on steroid replacement. RESULTS Forty-two patients met our inclusion criteria. Average follow-up period was 33 months. There were 15 macroadenomas and 27 microadenomas. Seventeen patients had an endoscopic transsphenoidal surgery and twenty-five patients had a microscopic transsphenoidal procedure. Long-term overall remission was achieved in 26 (62%) patients. There was no significant difference in remission rates between the two techniques (p value 0.757). Patient's subjective symptomatic improvement and drop of morning serum cortisol in the postoperative period to less than 100 nmol/L correlated with long-term remission (p value 0.0031 and 0.0101, respectively) while repeat surgery was the only predictor of the lack of postoperative remission (p value 0.0008). CONCLUSIONS Revision surgery predicted poor remission rate for CD. Within the power of our study size, there was no difference in outcome between the endoscopic and microscopic approaches. Surgical outcomes should be reviewed in association with remission criteria used in a study.
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Hameed N, Yedinak CG, Brzana J, Gultekin SH, Coppa ND, Dogan A, Delashaw JB, Fleseriu M. Remission rate after transsphenoidal surgery in patients with pathologically confirmed Cushing's disease, the role of cortisol, ACTH assessment and immediate reoperation: a large single center experience. Pituitary 2013; 16:452-8. [PMID: 23242860 DOI: 10.1007/s11102-012-0455-z] [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: 10/27/2022]
Abstract
Postoperative serum cortisol is used as an indicator of Cushing's disease (CD) remission following transsphenoidal surgery (TSS) and guides (controversially) the need for immediate adjuvant treatment for CD. We investigated postoperative cortisol and adrenocorticotropic hormone (ACTH) levels as predictors of remission/recurrence in CD in a large retrospective cohort of patients with pathologically confirmed CD, over 6 years at a single institution. Midnight and morning cortisol, and ACTH at 24-48 h postoperatively (>24 h after last hydrocortisone dose) were measured. Remission was defined as normal 24-h urine free cortisol, normal midnight salivary cortisol, a normal dexamethasone-corticotropin releasing hormone (CRH) test or continued need for hydrocortisone, assessed periodically. Statistical analysis was performed using PASW 18. Follow up data was available for 52 patients (38 females and 14 males), median follow up was 16.5 month (range 2-143 months), median age was 45 years (range 21-72 years), 28 tumors were microadenomas and 16 were macroadenomas, and in eight cases no tumor was observed on magnetic resonance imaging. No patient with postoperative cortisol levels >10 mcg/dl were found to be in remission. Ten of the 52 patients with cortisol >10 mcg/dl by postoperative day 1-2 underwent a second TSS within 7 days. Forty-three patients (82.7%) achieved CD remission (36 after one TSS and 7 after a second early TSS) and six patients suffered disease recurrence (mean 39.2 ± 52.4 months). An immediate second TSS induced additional hormonal deficiencies (diabetes insipidus) in three patients with no surgical complications. Persistent disease was noted in nine patients despite three patients having an immediate second TSS. Positive predictive value for remission of cortisol <2 mcg/dl and ACTH <5 pg/ml was 100%. Cortisol and ACTH levels (at all postoperative time points and at 2 months) were correlated (r = 0.37, P < 0.001). Nadir serum cortisol of ≤2 mcg/dl and ACTH <5 pg/ml predicted remission (P < 0.005), but no level predicted lack of recurrence. Immediate postoperative ACTH/cortisol did not predict length of remission. No patients with postoperative cortisol >10 mcg/dl were observed to have delayed remission; all required additional treatment. There was no significant difference in age, body mass index, tumor size and length of follow-up between postoperative cortisol groups: cortisol ≤2 mcg/dl, cortisol >5 mcg/dl and cortisol >10 mcg/dl. Immediate postoperative cortisol levels should routinely be obtained in CD patients post TSS, until better tools to identify early remission are available. Immediate repeat TSS could be beneficial in patients with cortisol >10 mcg/dl and positive CD pathology: our combined (micro- and macroadenomas) remission rate with this approach was 82.7%. ACTH measurements correlate well with cortisol. However, because no single cortisol or ACTH cutoff value excludes all recurrences, patients require long-term clinical and biochemical follow-up. Further research is needed in this area.
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Affiliation(s)
- Nadia Hameed
- Department of Medicine, Oregon Health & Science University, Portland, OR, USA
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Berker M, Işikay I, Berker D, Bayraktar M, Gürlek A. Early promising results for the endoscopic surgical treatment of Cushing's disease. Neurosurg Rev 2013; 37:105-114. [PMID: 24233258 DOI: 10.1007/s10143-013-0506-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2012] [Revised: 01/21/2013] [Accepted: 07/27/2013] [Indexed: 11/25/2022]
Abstract
High levels of endogenous cortisol due to Cushing's disease cause significant mortality and morbidity. Treatment of Cushing's disease is challenging. For many years, transsphenoidal microsurgical resection of the adenoma has been the treatment of choice. However, recently, neuroendoscope has taken its place in the neurosurgeon's armamentarium, and the endoscopic transsphenoidal resection of pituitary tumors has become a familiar approach. Our aim was to present the results of pure endoscopic surgery in the treatment of corticotropinomas for comparison with the results of previous endoscopic and microsurgical series. We present a retrospective analysis of 90 patients with diagnosis of Cushing's disease who were operated between 2006 and 2012. Among 90 patients, a total of 81 (90.0 %) had a remission (28 out of 29 macroadenomas (96.6 %) and 53 out of 61 microadenoma patients (86.9 %)). Of note is that 66 out of 69 (95.7 %) primary patients (i.e., those who were operated in our center) and 15 out of 21 (71.4 %) patients previously operated in other centers reached a hypo/eucortisolemic state. A remission rate comparable with previous endoscopic series was achieved. In nine patients, it was not possible to achieve remission at all. On the other hand, only four of our cases (5.6 %) had a recurrence, and with reoperation, all of these patients entered a re-remission. To our knowledge, our series is the largest series studying endoscopically operated adrenocorticotropic hormone-secreting adenomas. Our results suggest that the endoscopic approach has opened a new avenue in the treatment of Cushing's disease, previously a therapeutic challenge for both the clinician and the neurosurgeon. Endoscopic approach in the treatment of Cushing's disease is clearly better for patients because of its low morbidity rates and short duration of hospital stay. On the other hand, long-term follow-up of our patients will show whether these favorable observations will persist.
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Affiliation(s)
- Mustafa Berker
- Department of Neurosurgery, Faculty of Medicine, Hacettepe University, 06100, Sihhiye, Ankara, Turkey,
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Fleseriu M, Molitch ME, Gross C, Schteingart DE, Vaughan TB, Biller BMK. A new therapeutic approach in the medical treatment of Cushing's syndrome: glucocorticoid receptor blockade with mifepristone. Endocr Pract 2013; 19:313-26. [PMID: 23337135 DOI: 10.4158/ep12149.ra] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Cushing's syndrome (CS) is a serious endocrine disorder caused by prolonged exposure to high cortisol levels. Initial treatment of this condition is dependent upon the cause, but is generally surgical. For patients whose hypercortisolism is not cured by surgery, medical therapy is often required. Drugs that have typically been used for CS medical therapy act by decreasing cortisol levels. Mifepristone is a glucocorticoid receptor antagonist now available for use in patients with CS. Unlike other agents, mifepristone does not decrease cortisol levels, but directly antagonizes its effects. Our objective is to review the pharmacology and clinical use of this novel agent and to discuss detailed guidance on the management of CS patients treated with mifepristone. METHODS We review the literature regarding mifepristone use in CS and recently published clinical trial data. Detailed information related to clinical assessment of mifepristone use, potential drug interactions, drug initiation and dose titration, and monitoring of drug tolerability are provided. RESULTS Clinical trial data have shown that mifepristone improves glycemic control and blood pressure, causes weight loss and a decrease in waist circumference, lessens depression, and improves overall wellbeing. However, adverse effects include adrenal insufficiency, hypokalemia, and endometrial thickening with vaginal bleeding. These findings are supported by the earlier literature case reports. CONCLUSION This article provides a review of the pharmacology and clinical use of mifepristone in Cushing's syndrome, as well as detailed guidance on the management of patients treated with this novel agent.
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Affiliation(s)
- Maria Fleseriu
- Oregon Health & Science University, Portland, OR 97239, USA.
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Abellán Galiana P, Fajardo Montañana C, Riesgo Suárez PA, Gómez Vela J, Escrivá CM, Lillo VR. Factores pronósticos de remisión a largo plazo tras cirugía transesfenoidal en la enfermedad de Cushing. ACTA ACUST UNITED AC 2013; 60:475-82. [DOI: 10.1016/j.endonu.2012.09.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2012] [Revised: 09/06/2012] [Accepted: 09/07/2012] [Indexed: 10/27/2022]
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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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Abstract
The purpose was to review the use of mifepristone in the treatment of Cushing's syndrome (CS) in the context of other recently published studies. We review the use of mifepristone, as published in the recent Study of the Efficacy and Safety of Mifepristone in the Treatment of Endogenous Cushing's Syndrome (SEISMIC). We also review the multiple case reports and case series of mifepristone use in CS. A review of other medications used in the treatment of Cushing's disease (CD), including pasireotide and cabergoline also provides context for the discussion of the role of mifepristone in the treatment of CD. The results show that the treatment of CD has been primarily surgical with medical therapy reserved for adjuvant therapy when primary treatment fails or other therapies require time for optimal efficacy. Two recent large prospective studies, using pasireotide and mifepristone provide new clinical insights to the medical treatment of CD in particular. Mifepristone has been used to treat excessive cortisol production by blocking the action of cortisol at the level of the glucocorticoid receptor. Until recently, the majority of clinical experience with mifepristone on the treatment of excess cortisol was derived from case reports and small case series. Based on the SEISMIC study, mifepristone was FDA approved for hyperglycemia associated with CS. In conclusion the role of mifepristone in the treatment of CD remains one of adjuvant therapy. Its place among other choices for medical therapy has yet to be firmly established and an evidenced-based approach toward the use of novel medications in the treatment of CD has not been made. Selection of medication depends on drug approval and availability in individual countries and requires cautious assessment of potential adverse effects, consideration of patient comorbidities, and efficacy.
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Affiliation(s)
- John D Carmichael
- Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA, 90048, USA,
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Roelfsema F, Biermasz NR, Pereira AM. Clinical factors involved in the recurrence of pituitary adenomas after surgical remission: a structured review and meta-analysis. Pituitary 2012; 15:71-83. [PMID: 21918830 PMCID: PMC3296023 DOI: 10.1007/s11102-011-0347-7] [Citation(s) in RCA: 231] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
To study the currently available data of recurrence rates of functioning and nonfunctioning pituitary adenomas following surgical cure and to analyze associated predisposing factors, which are not well established. A systematic literature search was conducted using Medline, Embase, Web of Science and the Cochran Library for studies reporting data on recurrence of pituitary adenoma after surgery, in nonfunctioning adenoma (NF), prolactinoma (PRL) acromegaly (ACRO) and Cushing's disease (CUSH). Of 557 initially retrieved potential relevant studies 143 were selected. Recurrence in NFA was defined as reappearance of tumor on MRI or CT. Increase of hormone levels above normal limits as set by the authors after initial remission was used to indicate recurrence in the functioning tumor types. Remission percentage was lowest in NFA compared with other tumor types (P < 0.001). Surgery-related hypopituitarism was more frequent in CUSH than in the other tumors (P < 0.001). Recurrence, expressed as percentage of the cured population or as ratio of recurrence and total patient years of follow-up was highest in PRL (P < 0.001). The remission percentage did not improve over 3 decades of publications, but there was a modest decrease in recurrence rate (P = 0.04). Recurrences peaked between 1 and 5 years after surgery. Most of the studies with a sufficient number of recurrences did not apply multivariate statistics, and mentioned at best associated factors. Age, gender, tumor size and invasion were generally unrelated to recurrence. For functioning adenomas a low postoperative hormone concentration was a prognostically favorable factor. In NFA no specific factor predicted recurrence. Recurrence rate differs between pituitary adenomas, being highest in patients with prolactinoma, with the highest incidence of recurrence between 1 and 5 years after surgery in all adenomas. Patients with NFA have a lower chance of remission than patients with functioning adenomas. The postoperative basal hormone level is the most important predictor for recurrence in functioning adenomas, while in NFA no single convincing factor could be identified.
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Affiliation(s)
- Ferdinand Roelfsema
- Department of Endocrinology and Metabolic Diseases, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands.
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Alwani RA, de Herder WW, de Jong FH, Lamberts SWJ, van der Lely AJ, Feelders RA. Rapid decrease in adrenal responsiveness to ACTH stimulation after successful pituitary surgery in patients with Cushing's disease. Clin Endocrinol (Oxf) 2011; 75:602-7. [PMID: 21623858 DOI: 10.1111/j.1365-2265.2011.04130.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The aim of this study was to investigate the effects of transsphenoidal surgery (TS) on the adrenal sensitivity to ACTH (adrenocorticotropin) stimulation in patients with Cushing's disease (CD). METHODS We measured the cortisol response to 1 μg synthetic ACTH (1-24) 6 days after pituitary surgery in 45 patients with CD. Mean follow-up period was 56·5 months (SE 4·7). RESULTS In 24 of 28 patients in sustained remission after pituitary surgery, peak cortisol concentrations below 774 nm (28·0 μg/dl) were recorded after stimulation with 1 μg synthetic ACTH (86%). Two patients with recurrent disease after initial remission (late relapse) also showed ACTH-stimulated peak cortisol levels below 774 nM. Fourteen of 15 patients with persistent CD after surgery (early failure) showed absolute peak cortisol levels >774 nm in response to ACTH stimulation. CONCLUSION Patients in remission after pituitary surgery for CD showed a rapid decrease of adrenal responsiveness to exogenous ACTH stimulation. This phenomenon may be explained by ACTH-receptor down-regulation in the adrenal cortex after complete removal of the pituitary corticotroph adenoma. In our study, the postoperative low-dose ACTH stimulation test had a sensitivity of 93% and a specificity of 87% in predicting immediate remission of CD after pituitary surgery.
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Affiliation(s)
- R A Alwani
- Department of Internal Medicine, Endocrine section, Erasmus Medical Centre, Rotterdam, The Netherlands.
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