Impact of Technique on Cushing Disease Outcome Using Strict Remission Criteria

Abstract

334Cushing's Disease (CD) is the commonest cause of endogenous hypercortisolemia 1 and is associated with significant morbidity and mortality. [2][3][4] Transsphenoidal pituitary surgery remains the first line treatment for this condition with reported remission rates of 52% to 89%. [5][6][7][8][9][10][11][12][13][14][15][16][17][18][19] Many attempts have been made to identify factors that would predict sustained remission after surgical intervention. Suggested factors include smaller adenomas and the confirmation of adenoma intraoperatively. 18,20 The question of whether the newer endoscopic surgical technique (endo TSS) 21 has improved results compared to the older microscopic technique (micro TSS) remains to be answered. The aim of this report is to study the outcomes of 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 longterm remission (p value 0.0031and 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. RÉSUMÉ: Évaluation de l'impact de la technique utilisée, au moyen de critères de rémission rigoureux, sur le résultat de la chirurgie dans le traitement de la maladie de Cushing. Contexte : La maladie de Cushing (MC) présente des défis pour le chirurgien qui la traite. Compte tenu de la variété des facteurs qui influencent le résultat du traitement dans la MC, nous ne savons pas si la nouvelle technique endoscopique améliore le résultat de la chirurgie. Méthode : Nous avons revu les dossiers des patients atteints de la MC traités dans notre instit...

Treatment of Cushing's Syndrome: An Endocrine Society Clinical Practice Guideline

“…Many centers have replaced the transnasal route with an endoscopic endonasal approach (37), but both methods can be effective (38). Successful resection is most likely when performed by an experienced neurosurgeon who has a high volume of these cases.…”

The Treatment of Cushing's Disease

“…However, no homogeneity in the type of LDDST, in terms of dexamethasone dose and time, was reported across different studies. Indeed, some authors performed a 1-mg overnight LDDST (14,120,126,134,139,140,145,165,166,169), whereas other authors performed a 2-mg overnight or 2-mg 2-day LDDST (102,103,109,160,161,164,167,170,171). However, only a few studies have used exclusively this parameter to evaluate disease remission (146,169,171).…”

Outcomes of Endoscopic Transsphenoidal Pituitary Surgery

“…One study compared microscopic and endoscopic surgery for CD and found no difference in the remission rate between these two methods. 16 Many of microscopic series for CD have long-term follow-up and report recurrence rates up to 14%. 17 Starke and colleagues report a recurrence rate of 11% at 1 year, and Wagenmakers and colleagues report a rate of 16% at an average follow-up of 71 months.…”