Transsphenoidal Surgery for Cushing's Disease

Fahlbusch, Rudolf; Buchfelder, Michael; Müller, Otto

doi:10.1177/014107688607900504

Cited by 168 publications

(84 citation statements)

References 29 publications

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“…the thromboembolic events were related to surgery, whereas VTE unrelated to surgery was reported in 44% of the patients with CS (9,14,15,32,36,38,39,40,47,48,49,50,51). VTE was reported as the cause of death in 11% (13/121) of the patients with CS.…”

Section: :4 M16mentioning

confidence: 99%

Adverse effects of glucocorticoids: coagulopathy

Coelho

Santos

Neto

et al. 2015

European Journal of Endocrinology

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Hypercortisolism is associated with various systemic manifestations, including central obesity, arterial hypertension, glucose intolerance/diabetes mellitus, dyslipidemia, nephrolithiasis, osteoporosis, gonadal dysfunction, susceptibility to infections, psychiatric disorders, and hypercoagulability. The activation of the hemostatic system contributes to the development of atherosclerosis and subsequent cardiovascular morbidity and mortality. Previous studies have identified an increased risk of both unprovoked and postoperative thromboembolic events in patients with endogenous and exogenous Cushing's syndrome (CS). The risk for postoperative venous thromboembolism in endogenous CS is comparable to the risk after total hip or knee replacement under short-term prophylaxis. The mechanisms that are involved in the thromboembolic complications in hypercortisolism include endothelial dysfunction, hypercoagulability, and stasis (Virchow's triad). It seems that at least two factors from Virchow's triad must be present for the occurrence of a thrombotic event in these patients. Most studies have demonstrated that this hypercoagulable state is explained by increased levels of procoagulant factors, mainly factors VIII, IX, and von Willebrand factor, and also by an impaired fibrinolytic capacity, which mainly results from an elevation in plasminogen activator inhibitor 1. Consequently, there is a shortening of activated partial thromboplastin time and increased thrombin generation. For these reasons, anticoagulant prophylaxis might be considered in patients with CS whenever they have concomitant prothrombotic risk factors. However, multicenter studies are needed to determine which patients will benefit from anticoagulant therapy and the dose and time of anticoagulation.

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Section: :4 M16mentioning

confidence: 99%

Adverse effects of glucocorticoids: coagulopathy

Coelho

Santos

Neto

et al. 2015

European Journal of Endocrinology

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“…Assie et al and Xing et al reported a lower incidence of cavernous sinus invasion [3,12]. Other authors have pointed out that the main factor influencing the effectiveness of surgical treatment, and highly important in terms of prognosis, is the degree of extrasellar expansion [3,25]. Suprasellar growth together with visual disturbances resulting from optic chiasm compression occurs quite frequently in NS [5,7].…”

Section: Prace Oryginalnementioning

confidence: 99%

Wyniki leczenia neurochirurgicznego gruczolaków kortykotropowych przysadki w zespole Nelsona — pułapki terapeutyczne

Zieliński

Witek

Maksymowicz

2015

Endokrynologia Polska

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Introduction: Nelson's syndrome (NS) is a rare clinical syndrome caused by an enlarging, aggressive corticotroph pituitary adenoma that can occur following bilateral adrenalectomy performed in the treatment of refractory Cushing's disease (CD). Such tumours respond poorly to currently available therapeutic options, which include surgery, radiotherapy, pharmacotherapy, and chemotherapy. They are a challenging problem in neurosurgical practice. The aim of this work was to evaluate the early and long-term results of microsurgery in a single surgeon's series of patients with NS.

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“…Bogan et al suggested that "normal cortisol levels" in a 2-mg overnight dexamethasone test should be considered criteria for cure (52). Similarly, Fahlbusch et al reported that levels less than 2 µg/dl are good predictors of cure (53). Other studies suggest that values of < 3 µg/dl (26), < 5 µg/dl (69), < 100 nmol/l (25), or < 8 µg/dl (70) could better identify those patients on CD remission.…”

Section: Low-dose Dexamethasone Cortisol Suppressionmentioning

confidence: 99%

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

Czepielewski

Rollin

Casagrande

et al. 2007

Arq Bras Endocrinol Metab

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We review the clinical and biochemical criteria used for evaluation of the transsphenoidal pituitary surgery results in the treatment of Cushing's disease (CD). Firstly, we discuss the pathophysiology of the hypothalamic-pituitary-adrenal axis in normal subjects and patients with CD. Considering the series published in the last 25 years, we observed a significant variation in the remission or cure criteria, including the choice of biochemical tests, timing, threshold values to define remission, and the interference of glucocorticoid replacement or previous treatment. In this context we emphasize serum cortisol levels obtained early (from hours to 12 days) in the postoperative period without any glucocorticoid replacement or treatment. Our experience demonstrates that: (i) early cortisol < 5 to 7 µg/dl, (ii) a period of glucocorticoid dependence > 6 mo, (iii) absence of response of cortisol/ACTH to CRH or DDAVP, (iv) return of dexamethasone suppression, and circadian rhythm of cortisol are appropriate indices of remission of CD. In patients with undetectable cortisol levels early after surgery, recurrence seems to be low. Finally, although certain biochemical patterns are more suggestive of remission or surgical failure, none has been proven to be completely accurate, with recurrence observed in approximately 10 to 15% of the patients in long-term follow-up. We recommended that patients with CD should have long-term monitoring of the CRH-ACTH-cortisol axis and associated co-morbidities, especially hypopituitarism, diabetes mellitus, hypertension, cardiovascular disturbances, and osteoporosis. RESUMOCritérios de Cura e Remissão na Doença de Cushing: Uma Atualização. Neste artigo, são revisados os principais critérios clínicos e hormonais utilizados para avaliação do tratamento cirúrgico da Doença de Cushing (DC). Inicialmente são comentados aspectos fisiopatológicos que orientam a avaliação hormonal e os principais fatores clínicos, laboratoriais, cirúrgicos e histológicos associados com melhores resultados, observados nas principais séries da literatura e em pacientes acompanhados prospectivamente pelos autores. Foram revisados, também, critérios adotados nas principais séries da literatura, nos últimos 25 anos, chamando-se atenção para as dosagens hormonais, o momento em que foram realizadas, a possibilidade de interferência de tratamentos prévios e da reposição glicocorticóide. À seguir, essas dosagens são discutidas salientando-se a importância do cortisol obtido seqüencialmente no pós-operatório e sem a interferência de reposição glicocorticóide. A experiência prospectiva dos autores, recentemente referendada na literatura, demonstra que valores de cortisol < 5 a 7 µg/dl associados com um período de dependência aos glicocorticóides > 6 meses, ausência de resposta do ACTH/cortisol ao DDAVP e/ou CRH, retorno da supressão à dexametasona e do ritmo circadiano, estão associados com remissão da DC. Em pacientes com cortisol indetectável após cirurgia transesfenoidal, a chance de recidiva parece ser menor d...

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Transsphenoidal Surgery for Cushing's Disease

Cited by 168 publications

References 29 publications

Adverse effects of glucocorticoids: coagulopathy

Adverse effects of glucocorticoids: coagulopathy

Wyniki leczenia neurochirurgicznego gruczolaków kortykotropowych przysadki w zespole Nelsona — pułapki terapeutyczne

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

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