Outcomes of Patients with Nelson's Syndrome after Primary Treatment: A Multicenter Study from 13 UK Pituitary Centers

• Published in: The journal of clinical endocrinology and metabolism 2020-05, Vol.105 (5), p.1527-1537
• Main Authors: Fountas, Athanasios, Lim, Eugenie S, Drake, William M, Powlson, Andrew S, Gurnell, Mark, Martin, Niamh M, Seejore, Khyatisha, Murray, Robert D, MacFarlane, James, Ahluwalia, Rupa, Swords, Francesca, Ashraf, Muhammad, Pal, Aparna, Chong, Zhuomin, Freel, Marie, Balafshan, Tala, Purewal, Tejpal S, Speak, Rowena G, Newell-Price, John, Higham, Claire E, Hussein, Ziad, Baldeweg, Stephanie E, Dales, Jolyon, Reddy, Narendra, Levy, Miles J, Karavitaki, Niki
• Format: Article
• Language: English
• Subjects: ACTH-Secreting Pituitary Adenoma - diagnosis; ACTH-Secreting Pituitary Adenoma - epidemiology; ACTH-Secreting Pituitary Adenoma - therapy; Adenoma; Adenoma - diagnosis; Adenoma - epidemiology; Adenoma - therapy; Adolescent; Adrenalectomy; Adrenocorticotropic hormone; Adult; Aged; Biomarkers, Tumor - analysis; Brain tumors; Child; Cohort Studies; Cushing syndrome; Cushing's disease; Development and progression; Diagnosis; Disease management; Female; Follow-Up Studies; Humans; Male; Medical prognosis; Metastases; Middle Aged; Nelson Syndrome - diagnosis; Nelson Syndrome - epidemiology; Nelson Syndrome - therapy; Neoadjuvant Therapy; Nervous system diseases; Patient outcomes; Patients; Pituitary; Pituitary gland; Pituitary gland tumors; Prognosis; Radiation therapy; Retrospective Studies; Surgery; Treatment Outcome; Tumors; United Kingdom - epidemiology; Young Adult
• ISSN: 0021-972X; 1945-7197
• DOI: 10.1210/clinem/dgz200

Long-term outcomes of patients with Nelson's syndrome (NS) have been poorly explored, especially in the modern era. To elucidate tumor control rates, effectiveness of various treatments, and markers of prognostic relevance in patients with NS. Retrospective cohort study of 68 patients from 13 UK pituitary centers with median imaging follow-up of 13 years (range 1-45) since NS diagnosis. Management of Cushing's disease (CD) prior to NS diagnosis included surgery+adrenalectomy (n = 30; eight patients had 2 and one had 3 pituitary operations), surgery+radiotherapy+adrenalectomy (n = 17; two received >1 courses of irradiation, two had ≥2 pituitary surgeries), radiotherapy+adrenalectomy (n = 2), and adrenalectomy (n = 19). Primary management of NS mainly included surgery, radiotherapy, surgery+radiotherapy, and observation; 10-year tumor progression-free survival was 62% (surgery 80%, radiotherapy 52%, surgery+radiotherapy 81%, observation 51%). Sex, age at CD or NS diagnosis, size of adenoma (micro-/macroadenoma) at CD diagnosis, presence of pituitary tumor on imaging prior adrenalectomy, and mode of NS primary management were not predictors of tumor progression. Mode of management of CD before NS diagnosis was a significant factor predicting progression, with the group treated by surgery+radiotherapy+adrenalectomy for their CD showing the highest risk (hazard ratio 4.6; 95% confidence interval, 1.6-13.5). During follow-up, 3% of patients had malignant transformation with spinal metastases and 4% died of aggressively enlarging tumor. At 10 years follow-up, 38% of the patients diagnosed with NS showed progression of their corticotroph tumor. Complexity of treatments for the CD prior to NS diagnosis, possibly reflecting corticotroph adenoma aggressiveness, predicts long-term tumor prognosis.