Transsphenoidal Microsurgery for Cushing’s Disease: Initial Outcome and Long-Term Results

Abstract

Untreated Cushing's disease and the resultant chronically elevated glucocorticoid levels lead to severe metabolic disturbances, including diabetes mellitus, obesity, hypertension, muscle wasting, and osteoporosis. Although transsphenoidal resection has become the standard of care for Cushing's disease with high initial success rates, little information is available on the long-term morbidity and mortality of patients in remission compared with patients with recurrent or persistent Cushing's disease after such treatment. We therefore conducted a retrospective study of 289 patients with Cushing's disease who underwent transsphenoidal microsurgery for an ACTH-secreting adenoma at a tertiary care center exclusively by one surgeon (C.B.W.). Postoperative remission was achieved in 82% (n = 236) of patients, with best initial remission rates observed in patients with grade I (86%) and II (83%) or stage 0 (88%), A (94%), and B (100%) tumors. Male gender, larger tumor size, and higher stage predicted poorer initial outcome. Long-term follow-up was obtained on 178 patients, with a median follow-up time of 11.1 yr (range, 0.6-24.1 yr). Thirteen of 150 (9%) of patients in initial remission developed recurrent disease, and 12 patients underwent additional treatment. At last follow-up, only two of these patients had active disease. However, of the 28 patients with initial persistent disease who had follow-up greater than 6 months, 10 patients continued to have active disease at last follow-up. Although overall survival rates in patients with initial remission did not differ significantly from expected compared with the general population based on age and sex distribution, patients with initial persistent disease had a significant increase in mortality compared with the expected mortality. Thus, successful treatment of Cushing's disease is associated with normal long-term survival. These results suggest that patients with persistent Cushing's disease require early and aggressive intervention to attempt to prevent this excess mortality.

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

“…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.…”

THERAPY OF ENDOCRINE DISEASE: Outcomes in patients with Cushing's disease undergoing transsphenoidal surgery: systematic review assessing criteria used to define remission and recurrence

“…Higher remission rates are generally reported in patients with discrete, easily operated tumors, with improved outcomes achieved with microadenomas vs macroadenomas (6,13,15,16,17,18) and with adenomas identified at surgery or by radiology or histopathology vs no adenomas identified (19,20). Other factors suggested to increase the success of initial TSS include extensive surgical experience and younger patient age (!25 years) (6).…”

Measurement of late-night salivary cortisol with an automated immunoassay system

“…Very similar presentations are common in insulin resistance syndrome and in polycystic ovary syndrome. It is not uncommon that Cushing's syndrome is diagnosed only in advanced disease states several years after the onset of symptoms, and so the disease is typically associated with substantial morbidity and mortality (1,2). Mild forms of Cushing's syndrome, however, probably often remain undiagnosed in obese diabetic patients (3,4).…”