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Impact of Technique on Cushing Disease Outcome Using Strict Remission Criteria

Published online by Cambridge University Press:  23 September 2014

Hussein Alahmadi ,
Michael D. Cusimano ,
Kenneth Woo ,
Ameen A. Mohammed ,
Jeannette Goguen ,
Harley S. Smyth ,
Robert L. Macdonald ,
Paul J. Muller ,
Eva Horvath  and
Kalman Kovacs
Hussein Alahmadi*
Affiliation:
Division of Neurosurgery, St. Michael Hospital, University of Toronto, Toronto, Ontario, Canada
Michael D. Cusimano
Affiliation:
Division of Neurosurgery, St. Michael Hospital, University of Toronto, Toronto, Ontario, Canada
Kenneth Woo
Affiliation:
Division of Neurosurgery, St. Michael Hospital, University of Toronto, Toronto, Ontario, Canada
Ameen A. Mohammed
Affiliation:
Division of Neurosurgery, St. Michael Hospital, University of Toronto, Toronto, Ontario, Canada
Jeannette Goguen
Affiliation:
Department of Internal Medicine, St. Michael Hospital, University of Toronto, Toronto, Ontario, Canada
Harley S. Smyth
Affiliation:
Division of Neurosurgery, St. Michael Hospital, University of Toronto, Toronto, Ontario, Canada
Robert L. Macdonald
Affiliation:
Division of Neurosurgery, St. Michael Hospital, University of Toronto, Toronto, Ontario, Canada
Paul J. Muller
Affiliation:
Division of Neurosurgery, St. Michael Hospital, University of Toronto, Toronto, Ontario, Canada
Eva Horvath
Affiliation:
Department of Laboratory Medicine & Pathobiology, St. Michael Hospital, University of Toronto, Toronto, Ontario, Canada
Kalman Kovacs
Affiliation:
Department of Laboratory Medicine & Pathobiology, St. Michael Hospital, University of Toronto, Toronto, Ontario, Canada
*
Division of Neurosurgery, St. Michael's Hospital, 30 Bond Street, Toronto, Ontario, M5B 1W8, Canada. Email: hussein_alahmadi@yahoo.com.
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Abstract

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Background:

Cushing disease (CD) constitutes a challenging condition for the pituitary surgeon. Given the variety of factors affecting outcomes in CD, it is uncertain whether the newer endoscopic technique improves the results of surgery.

Methods:

A review was conducted of CD cases at our institution between 2000 and 2010. Analysis was done to: determine if surgical technique had an effect on outcome, identify the predictors of outcome and provide details of failed cases. Remission was defined as normal postoperative 24-hour urinary free cortisol (24-h UFC), suppression of morning serum cortisol to <50 nmol/L after 1mg of dexamethasone or being dependent on steroid replacement.

Results:

Forty-two patients met our inclusion criteria. Average follow-up period was 33 months. There were 15 macroadenomas and 27 microadenomas. Seventeen patients had an endoscopic transsphenoidal surgery and twenty-five patients had a microscopic transsphenoidal procedure. Long-term overall remission was achieved in 26 (62%) patients. There was no significant difference in remission rates between the two techniques (p value 0.757). Patient's subjective symptomatic improvement and drop of morning serum cortisol in the postoperative period to less than 100 nmol/L correlated with long-term remission (p value 0.0031and 0.0101, respectively) while repeat surgery was the only predictor of the lack of postoperative remission (p value 0.0008).

Conclusions:

Revision surgery predicted poor remission rate for CD. Within the power of our study size, there was no difference in outcome between the endoscopic and microscopic approaches. Surgical outcomes should be reviewed in association with remission criteria used in a study.

Résumé:

Résumé:Contexte:

La maladie de Cushing (MC) présente des défis pour le chirurgien qui la traite. Compte tenu de la variété des facteurs qui influencent le résultat du traitement dans la MC, nous ne savons pas si la nouvelle technique endoscopique améliore le résultat de la chirurgie.

Méthode:

Nous avons revu les dossiers des patients atteints de la MC traités dans notre institution entre 2000 et 2010. Nous avons examiné si la technique chirurgicale influençait le résultat et identifié les facteurs de prédiction du résultat et nous fournissons également des détails sur les échecs. La rémission était définie comme étant un taux postopératoire normal de cortisol libre urinaire de 24 heures (24-h CLU), une suppression du cortisol sérique matinal à < 50nmol / L après administration de 1mg de dexaméthasone ou une dépendance à un remplacement stéroïdien.

Résultats:

Quarante-deux patients rencontraient nos critères d'inclusion. La durée moyenne du suivi était de 33 mois, 15 patients étaient porteurs de macroadénomes et 27 patients de microadénomes. Dix-sept patients ont eu une chirurgie transsphénoïdale endoscopique et 25 patients on eu une chirurgie transsphénoïdale microscopique. Une rémission à long terme a été observée chez 26 patients (62%). Il n'y avait pas de différence significative dans les taux de rémission entre les deux techniques (p = 0,757). L'amélioration symptomatique subjective des patients et l'abaissement du cortisol sérique matinal au cours de la période postopératoire à moins de 100 nmol / L était corrélée à une rémission à long terme (p = 0,0031 et 0,0101 respectivement), et une réintervention était le seul facteur de prédiction de l'absence de rémission après la chirurgie (p = 0,0008).

Conclusions:

Une réintervention était le facteur de prédiction d'une rémission incomplète dans la MC. Compte tenu de la puissance limitée d'une étude effectuée sur un échantillon de cette taille, nous n'avons pas constaté de différence entre le résultat de la chirurgie endoscopique et celui de la chirurgie microscopique. Les résultats chirurgicaux devraient être revus en parallèle avec les critères de rémission que nous avons utilisés.

Type
Research Article
Information
Canadian Journal of Neurological Sciences , Volume 40 , Issue 3 , May 2013 , pp. 334 - 341
Copyright
Copyright © The Canadian Journal of Neurological 2013

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