A critical evaluation of transsphenoidal pituitary surgery in the treatment of Cushing's disease: Prediction of outcome

Arnott, R. D.; Pestell, Richard G.; McKelvie, Penelope; Henderson, J. K.; McNeill, Peter; Alford, F. P.

doi:10.1530/acta.0.1230423

Cited by 58 publications

(31 citation statements)

References 19 publications

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“…A comprehensive review of large clinical studies reveals a recurrence rate of 20-25% 10 years after surgery (4). It is well established that the longer the period of follow-up, the higher the incidence of recurrence (short-term recurrence rates 0-13%, long-term recurrence rates of 5-27%) (26,27,28,29). In our study, we documented an overall recurrence rate of CD of 34% after first TSS, which falls at the higher end of the published range so far, supporting our study hypothesis.…”

Section: First Tsssupporting

confidence: 89%

Long-term remission and recurrence rates after first and second transsphenoidal surgery for Cushing's disease: care reality in the Munich Metropolitan Region

Dimopoulou

Schopohl²,

Rachinger³

et al. 2014

European Journal of Endocrinology

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Objective: Transsphenoidal surgery (TSS) presents the treatment of choice for Cushing's disease (CD). Remission and recurrence rates vary dependent on tumor size, extension, adenoma visibility on magnetic resonance imaging, and neurosurgical expertise. Other than published from single-surgeon neurosurgical series so far, we have aimed to describe long-term remission and recurrence rates of CD in a series incorporating different neurosurgeons, trying to reflect care reality in the Munich Metropolitan Region, which is accommodated by three tertiary university and multiple, smaller neurosurgical centers. Design: We conducted a retrospective analysis of 120 patients who underwent first and 36 patients who underwent second TSS as treatment for CD between 1990 and 2012. Methods: Patients were divided into three groups according to remission status. Potential risk factors for recurrence, pituitary function, and strategy in persistent disease were assessed. Results: Three outcome groups were identified according to remission status after first TSS (mean follow-up 79 months): remission, 71% (85/120), disease persistence, 29% (35/120), and disease recurrence, 34% (29/85) (mean time to recurrence 54 months). After second TSS (nZ36, mean follow-up 62 months), we documented remission in 42% (15/36), disease persistence in 58% (21/36), and disease recurrence in 40% (6/15) (mean time to recurrence 42 months). Postoperative hypocortisolism after first, though not after second, TSS was associated with a lower risk of suffering disease recurrence (riskZ0.72; 95% CI 0.60-0.88; exact significance (two-sided) PZ0.035). Conclusions: Our study shows higher recurrence rates of CD after first TSS than previously reported. Second TSS leads an additional 8% of the patients to long-term CD remission.

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Section: First Tsssupporting

confidence: 89%

Long-term remission and recurrence rates after first and second transsphenoidal surgery for Cushing's disease: care reality in the Munich Metropolitan Region

Dimopoulou

Schopohl²,

Rachinger³

et al. 2014

European Journal of Endocrinology

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“…Several authors have been using 24-h urinary cortisol measurement to assess immediate and long-term postoperative results in CD treatment (18,20,22,25,30,38,41,50,54,57,58,60,63,(67)(68)(69). Some of them considered normal urinary cortisol values enough to establish cure.…”

Section: -Hour Urinary Cortisolmentioning

confidence: 99%

“…By definition, almost complete overlap in levels is seen in various causes of pseudo-Cushing's states, emphasizing the potential for diagnostic confusion (7). The problem of crossreactivity becomes a particular issue if the possibility of exogenous glucocorticoid administration exists (57). HPLC has recently been compared with RIA for the measurement of cortisol and cortisone in the assessment of endogenous Cushing's syndrome and Cushing's syndrome due to exogenous glucocorticoid ingestion.…”

Section: -Hour Urinary Cortisolmentioning

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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“…Despite immediate remission, CD recurs with different reported rates primarily dependent on the duration of follow-up. Published short-term recurrence rates vary from 0 to 13%, with a median follow-up of !2 years (21)(22)(23). Studies with longer follow-up have reported overall recurrence rates of 5-27%, with median times to recurrence of 34-84 months (9-11, 16, 20, 24-29).…”

Section: Introductionmentioning

confidence: 99%

Sequential hormonal changes in 21 patients with recurrent Cushing's disease after successful pituitary surgery

Khalil

Baudry

Guignat

et al. 2011

European Journal of Endocrinology

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Objective: To describe the sequence of hormonal changes during recurrence of Cushing's disease (CD) after successful transsphenoidal surgery (TSS). Design: Retrospective study in a single center. Patients and methods: We studied 101 of the 127 patients treated by TSS for CD between 1996 and 2009, who had hypocortisolism or eucortisolism for at least 3 months post-TSS. We arbitrarily defined 'overt recurrence', as presence of two classical parameters of excess cortisol (increased midnight -either serum or salivary -and 24 h urinary cortisol (UC)), leading to further specific therapeutic action, and 'mild recurrence', as presence of a single classical parameter, leading to simple surveillance. Results: Of the 101 patients, 21 (20.8%) presented with recurrence, 'mild' or 'overt', during long-term follow-up (median 50.4 months, range 7-99). Recurrence occurred less frequently (16.8 vs 50%, PZ0.02), and later (mean 44.7 months, median 43, range 7-94 vs mean 21.5 months, median 17, range 3-61, PZ0.05), in patients with early post-TSS hypocortisolism compared with those with eucortisolism. Increase in midnight cortisol occurred in a mean time of 38.2 months, while UC elevation was observed at 50.6 months. Vasopressin analogs and CRH tests were eventually positive in 85 and 93% of all patients respectively; a positive response to one of the two dynamic tests preceded the increase in midnight cortisol or UC in 71 and 64% of the patients respectively. Conclusion: A positive response to vasopressin analogs and/or CRH tests occurs early in recurrence, followed by an increase in midnight cortisol, while UC elevation is at a later stage.

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A critical evaluation of transsphenoidal pituitary surgery in the treatment of Cushing's disease: Prediction of outcome

Cited by 58 publications

References 19 publications

Long-term remission and recurrence rates after first and second transsphenoidal surgery for Cushing's disease: care reality in the Munich Metropolitan Region

Long-term remission and recurrence rates after first and second transsphenoidal surgery for Cushing's disease: care reality in the Munich Metropolitan Region

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

Sequential hormonal changes in 21 patients with recurrent Cushing's disease after successful pituitary surgery

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