Transsphenoidal Surgery for Cushing Disease

Abstract

BACKGROUND This is a retrospective study of 136 patients with Cushing disease treated with transsphenoidal microsurgery. OBJECTIVE To evaluate factors influencing immediate postoperative results and long-term outcomes. METHODS Data regarding clinical presentation, endocrine evaluation, imaging studies, surgical technique, immediate postoperative biochemical remission (IPBR), and long-term results were entered into a database and analyzed statistically. IPBR was based on biochemical evidence of adrenal cortical insufficiency and clinical evidence of such insufficiency. RESULTS IPBR for the entire series was 83.4%. In microadenomas, IPBR was 89.8% with a mean immediate postoperative plasma cortisol (IPPC) of 2.1 μg/dL (range, <0.5–5.3). Positive magnetic resonance imaging (MRI) was associated with 18 times greater odds of finding microadenoma at surgery (P < .001) and with 4.1 times greater odds of IPBR (P = .07). In patients with a negative MRI, a positive inferior petrosal sinus sampling (IPSS) test was associated with 93% of IPBR (P = .004). IPBR in macroadenomas was 30.7%. Of patients followed for 12 months or longer, 34.8% required glucocorticoid replacement for the duration of follow-up. The mean follow-up in microadenomas was 68.4 months with a 9.67% incidence of recurrences. The estimated actuarial incidence of recurrences increased with the passage of time and IPPC of greater than 2 μg/dL was associated with higher incidence of recurrences, although without statistical significance (P = .08). CONCLUSION In microadenomas, a positive MRI and positive IPSS test were associated with a higher incidence of IPBR. Recurrences increased with the passage of time, and an IPPC of greater than 2 μg/dL may be associated with higher incidence of recurrences.

Long-term remission and recurrence rates in Cushing's disease: predictive factors in a single-centre study

“…Thus, regarding factors predictive of a good outcome, the presence of a microadenoma and subsequent positive histology are strong indicators of successful surgery, in accord with other studies (46), but this is in contrast to positive imaging (14) and is unrelated to the cyclic presence of hypercortisolaemia. As expected, the remission rate was higher in microadenomas compared with macroadenomas, as previously reported (12,20,21,47,48,49).…”

“…Subgroups studied in accord with another recent study (21). In contrast to previous studies, age, the presence of a macroadenoma and pre-operative tumour visualisation were not predictive of recurrence (20,25,28,50,53,54).…”

“…Transsphenoidal surgery (TSS) remains the procedure of choice with immediate post-operative remission rates ranging between 59 and 94% in major centres (6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21). The reason for this wide range is the variability in defining remission in each study, the inclusion or not of macroadenomas, and the number of the patients studied, rendering the interpretation of results problematic.…”

“…Furthermore, despite the fact that a number of studies argue against the use of the strictest criterion of remission (7,12,19,21,32), we have used both strict and less strict criteria of remission to explore whether this would help predict recurrence in the long-term. We particularly concentrated on the early and late outcomes of patients with CD submitted to a TSS as first-line treatment and on the recurrence rates with a minimum follow-up of 6 years, in order to obtain a clearer perspective on recurrence rates.…”

Cushing's disease: pathobiology, diagnosis, and management

“…46,58 However, the small adenoma size and a reduced signal-to-noise imaging ratio at the sella-sphenoid bone-air interface contribute to the 40%-60% lack of detection of CD-associated adenomas on MR imaging at time of clinical and biochemical diagnosis. 20,46 To best inferior Petrosal sinus sampling…”