Repeat transsphenoidal surgery for Cushing's disease

Abstract

Transsphenoidal resection of adrenocorticotrophic hormone (ACTH)-producing pituitary adenomas has the potential of curing most patients with Cushing's disease. However, transsphenoidal exploration of the pituitary is not always curative, and patients who have remission of hypercortisolism following surgery occasionally develop a recurrence. Whether repeat pituitary surgery should be performed for recurrent or persistent Cushing's disease has not been evaluated previously. To determine the efficacy of transsphenoidal surgery in recurrent or persistent Cushing's disease, we performed transsphenoidal surgery in 31 patients (22 women and nine men) who had previously undergone a transsphenoidal operation and two female patients who had had previous pituitary irradiation only. In 24 (73%) of the 33 patients, remission of hypercortisolism was achieved by surgery. Although preoperative computerized tomography (CT) scanning identified an adenoma in only three of the 33 patients, in 20 patients a discrete adenoma was identified at pituitary exploration. The incidence of hypercortisolism was greatest if an adenoma was identified at surgery and the patient received selective adenomectomy (19, or 95% of 20 patients), if there was evidence at surgery or by preoperative CT scanning that the previous surgical exposure of the pituitary was incomplete (seven, or 78% of nine patients), if an adenoma was seen on preoperative CT scanning (three of three patients), or if the patient had had prior pituitary irradiation without surgery (two of two patients). In contrast, only five (42%) of 12 patients who received subtotal or total hypophysectomy had remission of hypercortisolim. Surgically induced hypopituitarism occurred in six (50%) of these 12 patients, but in only one (5%) of the 20 patients who underwent selective adenomectomy. Three (13%) of the 24 patients who were in remission from hypercortisolims following repeat surgery developed recurrent hypercortisolism 10 to 47 months postoperatively. Repeat transsphenoidal exploration of the pituitary and treatment limited to selective adenomectomy should be considered in patients with hypercortisolism despite previous pituitary treatment. If an adenoma is identified during surgery, the chance of remission of Cushing's disease is high and the risk of hypopituitarism is low; however, if no adenoma can be found and partial or complete hypophysectomy is performed, remission of hypercortisolism is less likely and the risk of hypopituitarism is about 50%.

Repeated transsphenoidal pituitary surgery (TS) via the endoscopic technique: a good therapeutic option for recurrent or persistent Cushing's disease (CD)

“…The remission rate of 71% achieved in this study compares favourably with the remission rates previously reported after repeated TS via the conventional microscopic technique, which vary between 37% and 73%, with a 0-25% relapse rate [19][20][21][22][23][24] (Table 3). When comparing the reported remission rates, it is important to note that the studies were carried out in different patient groups.…”

“…The studies on repeated TS in patients with persistent or recurrent CD report complication rates varying between 0% and 91%. [19][20][21][22][23][24] Although complication rates are influenced substantially by differences in definitions, the complication rate of repeated TS seems to be higher than the complication rate of primary TS.…”

“…When comparing the reported remission rates, it is important to note that the studies were carried out in different patient groups. Three studies included patients with both persistent and recurrent CD, [19][20][21] whereas other studies reported on patients with either persistent 22,23 or recurrent 24 CD. Criteria for remission also differed.…”

“…However, few investigators have addressed the results of repeated TS and the reported risk of hypopituitarism and other complications is higher than after the first TS. [19][20][21][22][23][24][25][26] Furthermore all previous studies operated upon patients via the conventional microscopic technique of TS. Cappabianca et al .…”

Gamma knife surgery in management of secretory pituitary adenoma preliminary evaluation of role, efficacy and safety

“…The persistence or recurrence of secretory pituitary diseases due to tumour invasion into surrounding structures or incomplete tumour resection is quite common and long term tumour control rates after transsphenoidal excision alone vary from 50 to 80% [5]. For residual or recurrent tumours fractionated radiation therapy has been the traditional treatment.…”