Contemporary microsurgical concept for the treatment of Cushing’s disease: endocrine outcome in 83 consecutive patients

Honegger, Juergen; Schmalisch, Kathrin; Beuschlein, Felix; Kaufmann, Sarah; Schnauder, Günter; Nägele, Thomas; Psaras, Tsambika

doi:10.1111/j.1365-2265.2011.04268.x

Cited by 55 publications

(41 citation statements)

References 39 publications

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“…This compares favorably with previously reported remission rates after microscopic TS in patients with ACTH-secreting macroadenomas which are on average 60%, despite the fact that most studies used less strict criteria for remission than we used (Table 2) (5,7,8,9,10,13,14,15,16,34,35,36). In line with our results, Starke et al recently reported a high remission rate of 87% in patients with ACTH-secreting macroadenomas (nZ15, of which six were invasive), achieved with endoscopic TS.…”

Section: Discussionsupporting

confidence: 81%

“…These reports show that, in experienced hands, excellent remission rates of over 80% can be achieved if a microadenoma is visualized on preoperative imaging (5,6,7,8,9,10,11,12,13,14,15,16). However, if no adenoma is visualized on preoperative imaging (magnetic resonance imaging (MRI)-negative CD), or if a macroadenoma is the cause of CD, remission rates are substantially lower (5,6,7,8,9,10,13,14,15,16). Furthermore, CD relapses in up to 25% of the patients.…”

Section: Introductionmentioning

confidence: 99%

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Endoscopic transsphenoidal pituitary surgery: a good and safe primary treatment option for Cushing's disease, even in case of macroadenomas or invasive adenomas

Wagenmakers

Boogaarts

Roerink

et al. 2013

European Journal of Endocrinology

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Context: Although the endoscopic technique of transsphenoidal pituitary surgery (TS) has been widely adopted, reports on its results in Cushing's disease (CD) are still scarce and no studies have investigated long-term recurrence rates. This is the largest endoscopic series published till now. Objective: To gain insight into the role of endoscopic TS as a primary treatment option for CD, especially in patients with magnetic resonance imaging (MRI)-negative CD and (invasive) macroadenomas. Design: Retrospective cohort study. Patients and methods: The medical records of 86 patients with CD who underwent endoscopic TS were examined. Data on preoperative and postoperative evaluation, perioperative complications, and followup were collected. Remission was defined as disappearance of clinical symptoms with a fasting plasma cortisol level %50 nmol/l either basal or after 1 mg dexamethasone. Results: The remission rate in different adenoma subclasses varied significantly: 60% in MRI-negative CD (nZ20), 83% in microadenomas (nZ35), 94% in noninvasive macroadenomas (nZ16), and 40% in macroadenomas that invaded the cavernous sinus (nZ15). The recurrence rate was 16% after 71G39 months of follow-up (meanGS.D., range 10-165 months). Conclusions: Endoscopic TS is a safe and effective treatment for all patients with CD. Recurrence rates after endoscopic TS are comparable with those reported for microscopic TS. Our data suggest that in patients with noninvasive and invasive macroadenomas, the endoscopic technique of TS should be the treatment of choice as remission rates seem to be higher than those reported for microscopic TS, although no comparative study has been performed.

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Section: Discussionsupporting

confidence: 81%

Section: Introductionmentioning

confidence: 99%

Endoscopic transsphenoidal pituitary surgery: a good and safe primary treatment option for Cushing's disease, even in case of macroadenomas or invasive adenomas

Wagenmakers

Boogaarts

Roerink

et al. 2013

European Journal of Endocrinology

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“…Our results were again in accordance with published series, as patients with macroadenomas experienced after first TSS lower remission rates compared with those with microadenomas (69 vs 79%). Of course, we have to concede that our cohort harbored a high prevalence of macroadenomas (27%) when compared with other series (20,21,25); this might be due to the fact that our endocrinology departments serve as referral centers for difficult, complicated cases.…”

Section: First Tssmentioning

confidence: 99%

“…Lack of consensus regarding remission criteria of CD has led to a broad range of recurrence rates reported (25). A comprehensive review of large clinical studies reveals a recurrence rate of 20-25% 10 years after surgery (4).…”

Section: First Tssmentioning

confidence: 99%

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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“…Since 2010, surgical series generally show remission rates between 65% and 85% and recurrence rates of 10%-35% (Table 1). [1][2][3]5,8,20,24,25,27,41,44,53,86,97,99,101,107 Surgical success and recurrence rates depend on surgeon experience, as well as the criteria used to define cure and length of follow-up.…”

mentioning

confidence: 99%

Cushing's disease: pathobiology, diagnosis, and management

Lonser

Nieman

Oldfield

2017

JNS

151

114

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Cushing's syndrome (CS) is caused by prolonged supraphysiological levels of circulating cortisol. Cushing's disease (CD) is the most common etiology (70%-80% of CS cases) of endogenous CS. It is caused by a pituitary adenoma that secretes adrenocorticotropic hormone (ACTH), which stimulates secretion of cortisol by the adrenal glands. If not effectively treated, CD is associated with hypertension, diabetes, obesity, osteoporosis, vascular disease, and shortened life span. Successful resection of a CD-associated ACTH-secreting pituitary adenoma results in immediate biochemical remission and preservation of pituitary function. Early identification of CD by clinical findings, endocrinological evaluation, and imaging studies is critical for diagnosis and effective surgical management. endocrinological and Clinical Features endocrinological Features Normal PhysiologyInsight into the normal and pathophysiological mechanisms of control of the hypothalamic-anterior pituitaryadrenal axis is critical to understanding the pathologic, diagnostic, and therapeutic features of CD (Fig. 1). 52 Under normal physiological conditions (circadian rhythm, where cortisol levels peak in early morning and nadir late at night), systemic inflammation (cytokine), or stress (physiological or psychological), corticotropin-releasing hormone (CRH; a 41-amino acid peptide) is released from the paraventricular hypothalamic nucleus via the median eminence. From the median eminence, CRH is transported in the hypophyseal portal venous system to the pituitary gland, where it binds to the CRH receptor-1 (CRH-R1) on pituitary corticotroph cells. CRH binding to CRH-R1 receptors activates adenylate cyclase and stimulates proopiomelanocortin (POMC) gene expression in the corticotroph cells.17,66 Proopiomelanocortin preprohormone is processed into ACTH (a 39-amino acid peptide) and b-lipotropin (a 93-amino acid peptide). Products of b-lipotropin include b-endorphin and a-lipotropin. ACTH is secreted into the systemic circulation and binds to receptors in the adrenal cortex, where it stimulates production and secretion of glucocorticoids, including cortisol. 83 Under normal conditions, circulating cortisol provides physiological control of this endocrine axis by its negative feedback inhibition on hypothalamic CRH and pituitary ACTH secretion. Cushing's disease (CD) is the result of excess secretion of adrenocorticotropic hormone (ACTH) by a benign monoclonal pituitary adenoma. The excessive secretion of ACTH stimulates secretion of cortisol by the adrenal glands, resulting in supraphysiological levels of circulating cortisol. The pathophysiological levels of cortisol are associated with hypertension, diabetes, obesity, and early death. Successful resection of the CD-associated ACTH-secreting pituitary adenoma is the treatment of choice and results in immediate biochemical remission with preservation of pituitary function. Accurate and early identification of CD is critical for effective surgical management and optimal prognosis. The authors review the cu...

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Contemporary microsurgical concept for the treatment of Cushing’s disease: endocrine outcome in 83 consecutive patients

Abstract: With our microsurgical concept, a high initial cure rate is achievable with minimal surgical morbidity. Enlarged adenomectomy has no adverse effect on the rate of postoperative hypopituitarism. Early repeat surgery is a successful option if CD persists.

Cited by 55 publications

References 39 publications

Endoscopic transsphenoidal pituitary surgery: a good and safe primary treatment option for Cushing's disease, even in case of macroadenomas or invasive adenomas

Endoscopic transsphenoidal pituitary surgery: a good and safe primary treatment option for Cushing's disease, even in case of macroadenomas or invasive adenomas

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

Cushing's disease: pathobiology, diagnosis, and management

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