The dynamics of post-operative plasma ACTH values following transsphenoidal surgery for Cushing’s disease

Srinivasan, Lakshmi; Laws, Edward R.; Dodd, Robert; Monita, Monique; Tannenbaum, Christyn E.; Kirkeby, Kjersti; Chu, Olivia; Harsh, Griffith R.; Katznelson, Laurence

doi:10.1007/s11102-011-0295-2

Cited by 25 publications

(15 citation statements)

References 22 publications

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“…However, in two other studies, the changes in plasma ACTH level failed to predict surgical success (152,153). In a few studies, an early decline in ACTH levels was shown to differentiate subjects in surgical remission from those with persistent disease (103,124,149,(152)(153)(154)(155). Furthermore, it has been reported that only 50% of patients with a clinical remission showed suppressed plasma ACTH levels (114).…”

Section: Morning Plasma Acthmentioning

confidence: 99%

The Treatment of Cushing's Disease

et al. 2015

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Cushing's disease (CD), or pituitary-dependent Cushing's syndrome, is a severe endocrine disease caused by a corticotroph pituitary tumor and associated with increased morbidity and mortality. The first-line treatment for CD is pituitary surgery, which is followed by disease remission in around 78% and relapse in around 13% of patients during the 10-year period after surgery, so that nearly one third of patients experience in the long-term a failure of surgery and require an additional second-line treatment. Patients with persistent or recurrent CD require additional treatments, including pituitary radiotherapy, adrenal surgery, and/or medical therapy. Pituitary radiotherapy is effective in controlling cortisol excess in a large percentage of patients, but it is associated with a considerable risk of hypopituitarism. Adrenal surgery is followed by a rapid and definitive control of cortisol excess in nearly all patients, but it induces adrenal insufficiency. Medical therapy has recently acquired a more important role compared to the past, due to the recent employment of novel compounds able to control cortisol secretion or action. Currently, medical therapy is used as a presurgical treatment, particularly for severe disease; or as postsurgical treatment, in cases of failure or incomplete surgical tumor resection; or as bridging therapy before, during, and after radiotherapy while waiting for disease control; or, in selected cases, as primary therapy, mainly when surgery is not an option. The adrenal-directed drug ketoconazole is the most commonly used drug, mainly because of its rapid action, whereas the glucocorticoid receptor antagonist, mifepristone, is highly effective in controlling clinical comorbidities, mainly glucose intolerance, thus being a useful treatment for CD when it is associated with diabetes mellitus. Pituitary-directed drugs have the advantage of acting at the site responsible for CD, the pituitary tumor. Among this group of drugs, the dopamine agonist cabergoline and the somatostatin analog pasireotide result in disease remission in a consistent subgroup of patients with CD. Recently, pasireotide has been approved for the treatment of CD when surgery has failed or when surgery is not an option, and mifepristone has been approved for the treatment of Cushing's syndrome when associated with impairment of glucose metabolism in case of the lack of a surgical indication. Recent experience suggests that the combination of different drugs may be able to control cortisol excess in a great majority of patients with CD.

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Section: Morning Plasma Acthmentioning

confidence: 99%

The Treatment of Cushing's Disease

et al. 2015

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“…In addition to serum cortisol, other laboratory criteria have been used, albeit infrequently, to define short-term remission (40). Among these criteria are lower than normal UFC (47), lower than normal plasma ACTH (52) and cortisol suppression after a low dose of dexamethasone (15).…”

Section: Criteria For Remission Glucocorticoid Replacement Therapy mentioning

confidence: 99%

A review of Cushing's disease treatment by the Department of Neuroendocrinology of the Brazilian Society of Endocrinology and Metabolism

Machado¹,

Fragoso²,

Moreira³

et al. 2018

Archives of Endocrinology and Metabolism

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The treatment objectives for a patient with Cushing's disease (CD) are remission of hypercortisolism, adequate management of co-morbidities, restoration of the hypothalamic-pituitary-adrenal axis, preservation of fertility and pituitary function, and improvement of visual defects in cases of macroadenomas with suprasellar extension. Transsphenoidal pituitary surgery is the main treatment option for the majority of cases, even in macroadenomas with low probability of remission. In cases of surgical failure, another subsequent pituitary surgery might be indicated in cases with persistent tumor imaging at post surgical magnetic resonance imaging (MRI) and/or pathology analysis of adrenocorticotropic hormone-positive (ACTH+) positive pituitary adenoma in the first procedure. Medical treatment, radiotherapy and adrenalectomy are the other options when transsphenoidal pituitary surgery fails. There are several options of medical treatment, although cabergoline and ketoconazole are the most commonly used alone or in combination. Novel treatments are also addressed in this review. Different therapeutic approaches are frequently needed on an individual basis, both before and, particularly, after surgery, and they should be individualized. The objective of the present review is to provide the necessary information to achieve a more effective treatment for CD. It is recommended that patients with CD be followed at tertiary care centers with experience in treating this condition.

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“…5 Once a diagnosis of ACTH secreting pituitary adenoma is confirmed, the first-line treatment is transsphenoidal surgery (TSS). 1,[6][7][8][9][10] An ability to predict intrapituitary corticotroph adenoma location indicative of CD is important for surgical planning and clinical outcome. [11][12][13][14] Identification of the precise tumor location has the potential to allow for a greater chance of disease remission while reducing the incidence of postoperative hypopituitarism.…”

Section: Introductionmentioning

confidence: 99%

Preoperative Lateralization Modalities for Cushing Disease: Is Dynamic Magnetic Resonance Imaging or Cavernous Sinus Sampling More Predictive of Intraoperative Findings?

et al. 2015

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Objective To analyze whether cavernous sinus sampling (CSS) and dynamic magnetic resonance imaging (dMRI) are consistent with intraoperative findings in Cushing disease (CD) patients. Design Retrospective outcomes study. Setting Oregon Health & Science University; 2006 and 2013. Participants A total of 37 CD patients with preoperative dMRI and CSS to confirm central adrenocorticotropic hormone (ACTH) hypersecretion. Patients were 78% female; mean age was 41 years (at diagnosis), and all had a minimum of 6 months of follow-up. Main Outcome Measures Correlations among patient characteristics, dMRI measurements, CSS results, and intraoperative findings. Results All CSS indicated presence of CD. Eight of 37 patients had no identifiable tumor on dMRI. Three of 37 patients had no tumor at surgery. dMRI tumor size was inversely correlated with age (rs ¼ À 0.4; p ¼ 0.01) and directly correlated to intraoperative lateralization (rs ¼ 0.3; p < 0.05). Preoperative dMRI was directly correlated to intraoperative lateralization (rs ¼ 0.5; p < 0.002). CSS lateralization showed no correlation with intraoperative findings (rs ¼ 0.145; p ¼ 0.40) or lateralization observed on preoperative dMRI (rs ¼ 0.17; p ¼ 0.29). Postoperative remission rate was 68%. Conclusion dMRI localization was most consistent with intraoperative findings; CSS results were less reliable. Results suggest that small ACTH-secreting tumors continue to pose a challenge to reliable preoperative localization.

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The dynamics of post-operative plasma ACTH values following transsphenoidal surgery for Cushing’s disease

Cited by 25 publications

References 22 publications

The Treatment of Cushing's Disease

The Treatment of Cushing's Disease

A review of Cushing's disease treatment by the Department of Neuroendocrinology of the Brazilian Society of Endocrinology and Metabolism

Preoperative Lateralization Modalities for Cushing Disease: Is Dynamic Magnetic Resonance Imaging or Cavernous Sinus Sampling More Predictive of Intraoperative Findings?

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