Outcomes and Management of Patients with Cushing’s Disease without Pathological Confirmation of Tumor Resection after Transsphenoidal Surgery

• Published in: The journal of clinical endocrinology and metabolism 2007-09, Vol.92 (9), p.3383-3388
• Main Authors: Pouratian, Nader, Prevedello, Daniel M., Jagannathan, Jay, Lopes, M. Beatriz, Vance, Mary Lee, Laws, Edward R.
• Format: Article
• Language: English
• Subjects: ACTH-Secreting Pituitary Adenoma - diagnosis; ACTH-Secreting Pituitary Adenoma - pathology; ACTH-Secreting Pituitary Adenoma - surgery; Adenoma - diagnosis; Adenoma - pathology; Adenoma - surgery; Adolescent; Adrenals. Adrenal axis. Renin-angiotensin system (diseases); Adult; Aged; Biological and medical sciences; Child; Endocrinopathies; Feeding. Feeding behavior; Female; Fundamental and applied biological sciences. Psychology; Humans; Male; Medical sciences; Middle Aged; Neoplasm Recurrence, Local - diagnosis; Neoplasm Recurrence, Local - pathology; Neoplasm, Residual; Non tumoral diseases. Target tissue resistance. Benign neoplasms; Pituitary ACTH Hypersecretion - diagnosis; Pituitary ACTH Hypersecretion - pathology; Pituitary ACTH Hypersecretion - surgery; Prognosis; Remission Induction; Retrospective Studies; Treatment Failure; Treatment Outcome; Vertebrates: anatomy and physiology, studies on body, several organs or systems; Vertebrates: endocrinology
• ISSN: 0021-972X; 1945-7197
• DOI: 10.1210/jc.2007-0208

Context: Despite the success of transsphenoidal surgery (TSS) for the treatment of Cushing’s disease, in a number of cases, an ACTH-staining pituitary adenoma is not identified histologically. The clinical significance of lack of histological confirmation remains unclear. Setting: This was a retrospective review of patients treated at the University of Virginia Medical Center. Patients: Of 490 TSS procedures for Cushing’s disease between 1993 and 2004, we identified 111 cases without histological adenoma confirmation. Main Outcome Measure: Remission and recurrence of Cushing’s disease were measured. Results: Overall, 50% of these patients achieved remission, a figure lower than for our entire series (79%) and for patients with histological confirmation of an ACTH-staining adenoma (88%) (P < 0.001). Patients with a history of two prior TSS achieved remission less often than patients with a history of fewer TSS (P = 0.026). No other factors influenced remission rates. Although the overall recurrence rate (21%, seven of 33 evaluated) was not different from previously published long-term studies, in three of seven cases of recurrence, early recurrences were noted between 2 and 4 months after remission. In patients who did not achieve remission, the most common and effective treatment options were repeat TSS, γ-knife radiosurgery, and bilateral adrenalectomy. Conclusion: The lower remission rate in patients without histological evidence of an adenoma is most likely a result of a decreased rate of adenoma extirpation. The incidence of early recurrence may be a unique feature of this patient population; patients without histological confirmation of tumor resection therefore require close and consistent monitoring postoperatively.