Transsphenoidal Pituitary Surgery for the Treatment of Cushing' s Disease: Results in 64 Patients and Long Term Follow-Up Studies*

Abstract

Transsphenoidal pituitary surgery was performed in 64 patients with Cushing's disease in search of a corticotroph adenoma. In 4 patients, profuse local bleeding prevented completion of the exploration. Of the 60 patients who had an adequate exploration, 4 could not be followed after surgery. Short term assessment of the surgical outcome (3-6 months postoperatively) was performed on 60 patients, including the 4 who had incomplete pituitary exploration. Forty-two patients (70%) were judged as immediate successes [urinary cortisol excretion, less than 90 micrograms (less than 248 nmol)/day]; the mean urinary cortisol excretion and plasma ACTH level fell from 463 +/- 70 (+/- SE) to 26.7 +/- 3.6 micrograms/day (1277 +/- 193 to 74 +/- 10 nmol/day; n = 33) and from 111 +/- 33 to 36 +/- 14 pg/mL (24 +/- 7 to 8 +/- 3 pmol/L; n = 23) in patients who had both measurements pre- and postoperatively. Eighteen patients (30%) were judged as immediate failures; neither urinary cortisol excretion nor plasma ACTH levels changed significantly in patients who had both measurements pre- and postoperatively. The preoperative epidemiological, clinical, hormonal, and radiological characteristics of the 2 groups were similar. Histological examination of pituitary fragments removed in 58 of the 60 patients evaluated postoperatively revealed the presence of tumoral tissue in a higher percentage of patients in the immediate success group (72%) than in the immediate failure group (24%; P less than 0.01). The 42 patients in the immediate success group were followed from 6 months to 7 yr (median, 2 yr); 6 patients had recurrences from 2-3 yr after operation. Actuarial analysis indicates that the probability of a patient remaining well 6 yr after surgery is 72 +/- 20% (95% confidence limit). Most of the patients in the immediate success group had transient ACTH deficiency preceding a progressive return to normal pituitary-adrenal function.

Criteria of cure and remission in Cushing's disease: an update

“…Among experienced neurosurgeons, cure rate in the first surgery in CD is about 83 to 91% in microadenomas and 25 to 73% in macroadenomas (1,2,6,10,22,31,32). Tumor identification in the surgery together with histological adenoma confirmation are associated with better results (1,30,31). Guilhaume et al showed that patients with histological adenoma confirmation have better remission rates than those with negative histology (72% vs. 24%) (30).…”

Combined Reserpine and Pituitary Irradiation Therapy for Cushing's Disease Patients Following Unsuccessful Transsphenoidal Microsurgery.

“…Burch (1983) reported that the cure rate was below 60% in over a third of the responders he had surveyed. Guilhaume et al(1988) observed that out of 64 patients who underwent TPM, about 30% were judged as immediate falures. Boggan et al(1983) also reported that in 25% of patients who had extrasellar extension of the tumor, the cure rate by TPM was only 48%.…”

“…In general, in the cases successfully operated on, hypoadrenocortical phenomenon followed by a rapid decrease in plasma ACTH and serum F is commonly observed within a few days (Kuwayama et al, 1981;Tagliaferri et al, 1986;Guilhaume et al, 1988).…”

Adrenal Insufficiency after Incomplete Resection of Pituitary Macrocorticotropinoma of Cushing's Disease. Role of High Molecular Weight ACTH.

“…The reference range was 2.0-11.5 pmol/l. Cross reactivity with j3-LPH was 0.01%, and was far less than 0.01% with other POMC-related peptides, [11][12][13][14][15][16][17][18][19][20][21][22][23][24][1][2][3][4][5][6][7][8][9][10]. Plasma cortisol was measured by a Gammacoat cortisol kitTM (Incstar Co., Stillwater, MN, USA), and the reference range was 110-505 nmol/1.…”

“…According to the numerous reports on large populations of patients with Cushing's disease [1][2][3][4][5][6][7][8][9][10][11] including children and adolescents [10,11 ], pituitary macroadenomas larger than 10 mm in diameter could be found in 261 of a total of 1621 patients (16.1%). However, among children and adolescents, the percentage of macroadenoma was found to be much less than this series for adults [10][11][12].…”