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Tarçın G, Çatlı G, Çetinkaya S, Eren E, Kardelen AD, Akıncı A, Böber E, Kara C, Yıldırım R, Er E, Polat R, Özhan B, Yıldız M, Kor Y, Evliyaoğlu O, Dündar B, Ercan O. Clinical features, diagnosis and treatment outcomes of Cushing's disease in children: A multicenter study. Clin Endocrinol (Oxf) 2024; 100:19-28. [PMID: 37814958 DOI: 10.1111/cen.14980] [Citation(s) in RCA: 1] [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: 01/19/2023] [Revised: 05/18/2023] [Accepted: 10/02/2023] [Indexed: 10/11/2023]
Abstract
OBJECTIVE Since Cushing's disease (CD) is less common in the paediatric age group than in adults, data on this subject are relatively limited in children. Herein, we aim to share the clinical, diagnostic and therapeutic features of paediatric CD cases. DESIGN National, multicenter and retrospective study. PATIENTS All centres were asked to complete a form including questions regarding initial complaints, physical examination findings, diagnostic tests, treatment modalities and follow-up data of the children with CD between December 2015 and March 2017. MEASUREMENTS Diagnostic tests of CD and tumour size. RESULTS Thirty-four patients (M:F = 16:18) from 15 tertiary centres were enroled. The most frequent complaint and physical examination finding were rapid weight gain, and round face with plethora, respectively. Late-night serum cortisol level was the most sensitive test for the diagnosis of hypercortisolism and morning adrenocorticotropic hormone (ACTH) level to demonstrate the pituitary origin (100% and 96.8%, respectively). Adenoma was detected on magnetic resonance imaging (MRI) in 70.5% of the patients. Transsphenoidal adenomectomy (TSA) was the most preferred treatment (78.1%). At follow-up, 6 (24%) of the patients who underwent TSA were reoperated due to recurrence or surgical failure. CONCLUSIONS Herein, national data of the clinical experience on paediatric CD have been presented. Our findings highlight that presenting complaints may be subtle in children, the sensitivities of the diagnostic tests are very variable and require a careful interpretation, and MRI fails to detect adenoma in approximately one-third of cases. Finally, clinicians should be aware of the recurrence of the disease during the follow-up after surgery.
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Affiliation(s)
- Gürkan Tarçın
- Department of Pediatric Endocrinology, Cerrahpaşa Faculty of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Türkiye
| | - Gönül Çatlı
- Department of Pediatric Endocrinology, Faculty of Medicine, Izmir Katip Çelebi University, İzmir, Türkiye
- Department of Pediatric Endocrinology, Faculty of Medicine, Istinye University, Istanbul, Türkiye
| | - Semra Çetinkaya
- Department of Pediatric Endocrinology, Dr. Sami Ulus Obstetrics and Gynecology, Children's Health and Disease Training and Research Hospital, University of Health Sciences, Ankara, Türkiye
| | - Erdal Eren
- Department of Pediatric Endocrinology, Faculty of Medicine, Uludag University, Bursa, Türkiye
| | - Aslı Derya Kardelen
- Department of Pediatric Endocrinology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Türkiye
| | - Ayşehan Akıncı
- Department of Pediatric Endocrinology, Faculty of Medicine, Inonu University, Malatya, Türkiye
| | - Ece Böber
- Department of Pediatric Endocrinology, Faculty of Medicine, Dokuz Eylül University, İzmir, Türkiye
| | - Cengiz Kara
- Department of Pediatric Endocrinology, Faculty of Medicine, Istinye University, Istanbul, Türkiye
- Department of Pediatric Endocrinology, Faculty of Medicine, Ondokuz Mayıs University, Samsun, Türkiye
| | - Ruken Yıldırım
- Department of Pediatric Endocrinology, Faculty of Medicine, Dicle University, Diyarbakır, Türkiye
- Department of Pediatric Endocrinology, Diyarbakir Children's Hospital, Diyarbakır, Türkiye
| | - Eren Er
- Department of Pediatric Endocrinology, Faculty of Medicine, Izmir Katip Çelebi University, İzmir, Türkiye
- Department of Pediatric Endocrinology, Faculty of Medicine, Ege University, İzmir, Türkiye
| | - Recep Polat
- Department of Pediatric Endocrinology, Faculty of Medicine, Karadeniz Technical University, Trabzon, Türkiye
| | - Bayram Özhan
- Department of Pediatric Endocrinology, Faculty of Medicine, Pamukkale University, Denizli, Türkiye
| | - Melek Yıldız
- Department of Pediatric Endocrinology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Türkiye
- Department of Pediatric Endocrinology, Kanuni Sultan Suleyman Training and Research Hospital, University of Health Sciences, Istanbul, Türkiye
| | - Yılmaz Kor
- Department of Pediatric Endocrinology, Adana Numune Training and Research Hospital, Adana, Türkiye
| | - Olcay Evliyaoğlu
- Department of Pediatric Endocrinology, Cerrahpaşa Faculty of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Türkiye
| | - Bumin Dündar
- Department of Pediatric Endocrinology, Faculty of Medicine, Izmir Katip Çelebi University, İzmir, Türkiye
| | - Oya Ercan
- Department of Pediatric Endocrinology, Cerrahpaşa Faculty of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Türkiye
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Habib T, Abu-Abaa M, Redjal N. Cushing's Disease Associated With Partially Empty Sella Turcica Syndrome: A Case Report. Cureus 2023; 15:e40115. [PMID: 37425515 PMCID: PMC10329283 DOI: 10.7759/cureus.40115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2023] [Indexed: 07/11/2023] Open
Abstract
The association between empty sella turcica (EST) syndrome and Cushing's disease has been rarely reported. It is plausible to hypothesize that EST syndrome in association with Cushing's disease can be attributed to intracranial hypertension. In this case report, we present a 47-year-old male patient who presented with weight loss, fatigue, easy bruising, acanthosis nigricans, and skin creases hyperpigmentation. Investigations revealed hypokalemia and confirmed the diagnosis of Cushing's disease. Magnetic resonance imaging (MRI) brain showed a partial EST syndrome and a new pituitary nodule as compared with previous brain imaging. Transsphenoidal surgery was pursued and was complicated by cerebrospinal fluid leakage. This case reflects the rare association of EST syndrome and Cushing's disease, suggesting the increased risk of postoperative complications in this setting and the diagnostic challenge that EST syndrome imposes. We review the literature for a possible mechanism of this association.
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Affiliation(s)
- Tehmina Habib
- Internal Medicine, Capital Health Regional Medical Center, Trenton, USA
| | - Mohammad Abu-Abaa
- Internal Medicine, Capital Health Regional Medical Center, Trenton, USA
| | - Navid Redjal
- Neurosurgery, Capital Health Regional Medical Center, Trenton, USA
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Castle-Kirszbaum M, Amukotuwa S, Fuller P, Goldschlager T, Gonzalvo A, Kam J, Kow CY, Shi MD, Stuckey S. MRI for Cushing Disease: A Systematic Review. AJNR Am J Neuroradiol 2023; 44:311-316. [PMID: 36759141 PMCID: PMC10187804 DOI: 10.3174/ajnr.a7789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 10/11/2022] [Indexed: 02/11/2023]
Abstract
BACKGROUND MR imaging is key in the diagnostic work-up of Cushing disease. The sensitivity of MR imaging in Cushing disease is not known nor is the prognostic significance of "MR imaging-negative" disease. PURPOSE Our aim was to determine the overall sensitivity and prognostic significance of MR imaging localization of Cushing disease. DATA SOURCES We performed a systematic review of the MEDLINE and PubMed databases for cohort studies reporting the sensitivity of MR imaging for the detection of adenomas in Cushing disease. STUDY SELECTION This study included 57 studies, comprising 5651 patients. DATA ANALYSIS Risk of bias was assessed using the methodological index for non-randomized studies criteria. Meta-analysis of proportions and pooled subgroup analysis were performed. DATA SYNTHESIS Overall sensitivity was 73.4% (95% CI, 68.8%-77.7%), and the sensitivity for microadenomas was 70.6% (66.2%-74.6%). There was a trend toward greater sensitivity in more recent studies and with the use of higher-field-strength scanners. Thinner-section acquisitions and gadolinium-enhanced imaging, particularly dynamic sequences, also increased the sensitivity. The use of FLAIR and newer 3D spoiled gradient-echo and FSE sequences, such as spoiled gradient-echo sequences and sampling perfection with application-optimized contrasts by using different flip angle evolutions, may further increase the sensitivity but appear complementary to standard 2D spin-echo sequences. MR imaging detection conferred a 2.63-fold (95% CI, 2.06-3.35-fold) increase in remission for microadenomas compared with MR imaging-negative Cushing disease. LIMITATIONS Pooled analysis is limited by heterogeneity among studies. We could not account for variation in image interpretation and tumor characteristics. CONCLUSIONS Detection on MR imaging improves the chances of curative resection of adenomas in Cushing disease. The evolution of MR imaging technology has improved the sensitivity for adenoma detection. Given the prognostic importance of MR imaging localization, further effort should be made to improve MR imaging protocols for Cushing disease.
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Affiliation(s)
- M Castle-Kirszbaum
- From the Departments of Neurosurgery (M.C.-K., T.G., J.K., C.Y.K.)
- Surgery (M.C.-K., T.G.), Monash Health, Melbourne, Australia
| | | | - P Fuller
- Endocrinology (P.F.)
- Hudson Institute (P.F.), Melbourne, Australia
| | - T Goldschlager
- From the Departments of Neurosurgery (M.C.-K., T.G., J.K., C.Y.K.)
- Surgery (M.C.-K., T.G.), Monash Health, Melbourne, Australia
| | - A Gonzalvo
- Department of Neurosurgery (A.G., J.K.), Austin Hospital, Melbourne, Australia
| | - J Kam
- From the Departments of Neurosurgery (M.C.-K., T.G., J.K., C.Y.K.)
- Department of Neurosurgery (A.G., J.K.), Austin Hospital, Melbourne, Australia
| | - C Y Kow
- From the Departments of Neurosurgery (M.C.-K., T.G., J.K., C.Y.K.)
| | - M D Shi
- Barwon Health (M.D.S.), Geelong, Australia
| | - S Stuckey
- Department of Radiology (S.S.), Peter MacCallum Cancer Centre, Melbourne, Australia
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Yang AB, Henderson F, Schwartz TH. Surgical strategies in the treatment of MR-negative Cushing's Disease: a systematic review and treatment algorithm. Pituitary 2022; 25:551-562. [PMID: 35710682 DOI: 10.1007/s11102-022-01239-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/31/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE Several surgical strategies have been proposed to treat MRI-negative Cushing's Disease. These include tumor removal, if identified, and if a tumor is not identified, resection of varying degrees of the pituitary gland, often guided by inferior petrosal sinus sampling (IPSS). The relative risks and benefits of each strategy have never been compared. METHODS This systematic review of the literature included only studies on the results of surgery for MRI-negative patients with Cushing's Disease in which the surgical strategy was clearly described and associated remission and/or hypopituitarism rates detailed for each strategy. RESULTS We identified 12 studies that met inclusion criteria for remission rates and 5 studies for hypopituitarism rates. We divided cases into 6 resection strategies. Remission and hypopituitarism rates for each strategy were: (1) tumor identified, resect tumor only (68%, 0%); (2) resect tumor and surrounding capsule (85%, 0%); and if the tumor was not identified (3) resect inferior 1/3 of gland (78%, no data); (4) resect 30-50% of gland based on IPSS (68%, 13%); (5) resect > 50% but < 100% of gland (65%, 9%); (6) resect entire gland (66%, 67%). Strategy 3 only contained 9 patients. CONCLUSION Remission rates for MRI-negative Cushing's Disease support surgery as a reasonable approach. Results are best if a tumor is found. If a tumor is not identified, one can either remove one-third of the gland guided by IPSS lateralization, or remove both lateral portions along with the inferior portion leaving sufficient central gland to preserve function. Our recommendations are limited by the lack of rigorous and objective data.
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Affiliation(s)
| | - Fraser Henderson
- Department of Neurological Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, 525 East 68th St., Box #99, New York, NY, 10065, USA
| | - Theodore H Schwartz
- Department of Neurological Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, 525 East 68th St., Box #99, New York, NY, 10065, USA.
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Castle-Kirszbaum M, Uren B, Goldschlager T. Anatomic Variation for the Endoscopic Endonasal Transsphenoidal Approach. World Neurosurg 2021; 156:111-119. [PMID: 34610448 DOI: 10.1016/j.wneu.2021.09.103] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 09/23/2021] [Accepted: 09/24/2021] [Indexed: 10/20/2022]
Abstract
Knowledge of anatomy and its variations is the key to safe and efficient surgery. The endoscopic endonasal route to the sella has evolved to become the preferred route to access a wide variety of diseases. We describe the skeletal, vascular, and neural anatomic variations that could be encountered from the nasal phase, through the sphenoid phase, to the sellar phase of the operative exposure. A preoperative checklist is also provided.
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Affiliation(s)
| | - Brent Uren
- Department of Ear, Nose and Throat Surgery, Monash Health, Melbourne, Australia
| | - Tony Goldschlager
- Department of Neurosurgery, Monash Health, Melbourne, Australia; Department of Surgery, Monash University, Melbourne, Australia
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