Hostname: page-component-7bb8b95d7b-qxsvm Total loading time: 0 Render date: 2024-09-23T20:38:22.907Z Has data issue: false hasContentIssue false
  • English
  • Français

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.
Rights & Permissions [Opens in a new window]

Abstract

Core share and HTML view are not available for this content. However, as you have access to this content, a full PDF is available via the ‘Save PDF’ action button.
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

References

1. Nieman, LK, Ilias, I. Evaluation and treatment of Cushing's syndrome. Am J Med. 2005;118(12):1340–6.Google Scholar
2. Clayton, RN. Mortality in Cushing's disease. Neuroendocrinology. 2010;92 Suppl 1:71–6.Google Scholar
3. Clayton, RN, Raskauskiene, D, Reulen, RC, Jones, PW. Mortality and morbidity in Cushing's disease over 50 years in Stoke-on-Trent, UK: audit and meta-analysis of literature. J Clin Endocrinol Metab. 2011;96(3):632–42.Google Scholar
4. Kaltsas, G, Makras, P. Skeletal diseases in Cushing's syndrome: osteoporosis versus arthropathy. Neuroendocrinology. 2010;92 Suppl 1:60–4.CrossRefGoogle ScholarPubMed
5. Acebes, JJ, Martino, J, Masuet, C, Montanya, E, Soler, J. Early postoperative ACTH and cortisol as predictors of remission in Cushing's disease. Acta Neurochir (Wien). 2007;149(5):471–7.CrossRefGoogle ScholarPubMed
6. Alwani, RA, de Herder, WW, van Aken, MO, et al. Biochemical predictors of outcome of pituitary surgery for Cushing's disease. Neuroendocrinology. 2010;91(2):169–78.Google Scholar
7. Atkinson, JL, Young, WF Jr, Meyer, FB, et al. Sublabial transseptal vs transnasal combined endoscopic microsurgery in patients with Cushing disease and MRI-depicted microadenomas. Mayo Clin Proc. 2008;83(5):550–3.CrossRefGoogle ScholarPubMed
8. Bochicchio, D, Losa, M, Buchfelder, M. Factors influencing the immediate and late outcome of Cushing's disease treated by transsphenoidal surgery: a retrospective study by the European Cushing's Disease Survey Group. J Clin Endocrinol Metab. 1995;80(11):3114–20.Google Scholar
9. Esposito, F, Dusick, JR, Cohan, P, et al. Clinical review: Early morning cortisol levels as a predictor of remission after transsphenoidal surgery for Cushing's disease. J Clin Endocrinol Metab. 2006;91(1):7–13.CrossRefGoogle ScholarPubMed
10. Fomekong, E, Maiter, D, Grandin, C, Raftopoulos, C. Outcome of transsphenoidal surgery for Cushing's disease: a high remission rate in ACTH-secreting macroadenomas. Clin Neurol Neurosurg. 2009;111(5):442–9.Google Scholar
11. Gondim, JA, Schops, M, de Almeida, JP, et al. Endoscopic endonasal transsphenoidal surgery: surgical results of 228 pituitary adenomas treated in a pituitary center. Pituitary. 2010;13(1):68–77.Google Scholar
12. Hammer, GD, Tyrrell, JB, Lamborn, KR, et al. Transsphenoidal microsurgery for Cushing's disease: initial outcome and long-term results. J Clin Endocrinol Metab. 2004;89(12):6348–57.Google Scholar
13. Hofmann, BM, Hlavac, M, Martinez, R, Buchfelder, M, Müller, OA, Fahlbusch, R. Long-term results after microsurgery for Cushing disease: experience with 426 primary operations over 35 years. J Neurosurg. 2008;109(4):751–9.Google Scholar
14. Kabil, MS, Eby, JB, Shahinian, HK. Fully endoscopic endonasal vs. transseptal transsphenoidal pituitary surgery. Minim Invasive Neurosurg. 2005;48(6):348–54.Google Scholar
15. Kelly, DF. Transsphenoidal surgery for Cushing's disease: a review of success rates, remission predictors, management of failed surgery, and Nelson's Syndrome. Neurosurg Focus. 2007;23(3):E5.Google Scholar
16. Netea-Maier, RT, van Lindert, EJ, den Heijer, M, et al. Transsphenoidal pituitary surgery via the endoscopic technique: results in 35 consecutive patients with Cushing's disease. Eur J Endocrinol. 2006;154(5):675–84.Google Scholar
17. Patil, CG, Veeravagu, A, Prevedello, DM, Katznelson, L, Vance, ML, Laws, ER Jr. Outcomes after repeat transsphenoidal surgery for recurrent Cushing's disease. Neurosurgery. 2008;63(2):266–70.Google Scholar
18. Pouratian, N, Prevedello, DM, Jagannathan, J, Lopes, MB, Vance, ML, Laws, ER Jr, Outcomes and management of patients with Cushing's disease without pathological confirmation of tumor resection after transsphenoidal surgery. J Clin Endocrinol Metab. 2007;92(9):3383–8.Google Scholar
19. Santoro, A, Minniti, G, Ruggeri, A, Esposito, V, Jaffrain-Rea, ML, Delfini, R. Biochemical remission and recurrence rate of secreting pituitary adenomas after transsphenoidal adenomectomy: long-term endocrinologic follow-up results. Surg Neurol. 2007;68(5):513–18.Google Scholar
20. Jane, JA Jr, Laws, ER Jr. The surgical management of pituitary adenomas in a series of 3,093 patients. J Am Coll Surg. 2001;193(6):651–9.CrossRefGoogle Scholar
21. Cusimano, MD, Fenton, RS. The technique for endoscopic pituitary tumor removal. Neurosurg Focus. 1996;15;1(1):e1.Google Scholar
22. Arnaldi, G, Angeli, A, Atkinson, AB, et al. Diagnosis and complications of Cushing's syndrome: a consensus statement. J Clin Endocrinol Metab. 2003;88:5593–602.Google Scholar
23. Papanicolaou, DA, Mullen, N, Kyrou, I, Nieman, LK. Nighttime salivary cortisol: a useful test for the diagnosis of Cushing's syndrome. J Clin Endocrinol Metab. 2002;87(10):4515–21.Google Scholar
24. Tyrrell, JB, Findling, JW, Aron, DC, Fitzgerald, PA, Forsham, PH. An overnight high-dose dexamethasone suppression test for rapid differential diagnosis of Cushing's syndrome. Ann Intern Med. 1986;104(2):180–6.Google Scholar
25. de Herder, WW, Uitterlinden, P, Pieterman, H, et al. Pituitary tumour localization in patients with Cushing's disease by magnetic resonance imaging. Is there a place for petrosal sinus sampling? Clin Endocrinol (Oxf). 1994;40(1):87–92.Google Scholar
26. Findling, JW, Kehoe, ME, Shaker, JL, Raff, H. Routine inferior petrosal sinus sampling in the differential diagnosis of adrenocorticotropin (ACTH)-dependent Cushing's syndrome: early recognition of the occult ectopic ACTH syndrome. J Clin Endocrinol Metab. 1991;73(2):408–13.Google Scholar
27. Oldfield, EH, Chrousos, GP, Schulte, HM, et al. Preoperative lateralization of ACTH-secreting pituitary microadenomas by bilateral and simultaneous inferior petrosal venous sinus sampling. N Engl J Med. 1985;10;312(2):100–3.Google Scholar
28. Blevins, LS Jr, Christy, JH, Khajavi, M, Tindall, GT. Outcomes of therapy for Cushing's disease due to adrenocorticotropin-secreting pituitary macroadenomas. J Clin Endocrinol Metab. 1998;83(1):63–7.Google Scholar
29. Hardy, J. Transsphenoidal hypophysectomy. J Neurosurg. 1971;34:582–94.Google Scholar
30. Santos, A, Resmini, E, Martínez, MA, Martí, C, Ybarra, J, Webb, SM. Quality of life in patients with pituitary tumors. Curr Opin Endocrinol Diabetes Obes. 2009;16(4):299–303.Google Scholar
31. van Aken, MO, Pereira, AM, Biermasz, NR, et al. Quality of life in patients after long-term biochemical cure of Cushing's disease. J Clin Endocrinol Metab. 2005;90(6):3279–86.Google Scholar
32. Dehdashti, AR, Ganna, A, Karabatsou, K, Gentili, F. Pure endoscopic endonasal approach for pituitary adenomas: early surgical results in 200 patients and comparison with previous microsurgical series. Neurosurgery. 2008;62(5):1006–15.Google Scholar
33. Prevedello, DM, Pouratian, N, Sherman, J, et al. Management of Cushing's disease: outcome in patients with microadenoma detected on pituitary magnetic resonance imaging. J Neurosurg. 2008;108(1):9–18.Google Scholar
34. D’Haens, J, Van Rompaey, K, Stadnik, T, Haentjens, P, Poppe, K, Velkeniers, B. Fully endoscopic transsphenoidal surgery for functioning pituitary adenomas: a retrospective comparison with traditional transsphenoidal microsurgery in the same institution. Surg Neurol. 2009;72(4):336–40.Google Scholar
35. Hofstetter, CP, Shin, BJ, Mubita, L, et al. Endoscopic endonasal transsphenoidal surgery for functional pituitary adenomas. Neurosurg Focus. 2011;30(4):E10.Google Scholar
36. Tabaee, A, Anand, VK, Barrón, Y, et al. Endoscopic pituitary surgery: a systematic review and meta-analysis. J Neurosurg. 2009;111(3):545–54.Google Scholar
37. Cavagnini, F, Pecori Giraldi, F. Epidemiology and follow-up of Cushing's disease. Ann Endocrinol (Paris). 2001;62(2):168–72.Google Scholar
38. Shimon, I, Ram, Z, Cohen, ZR, Hadani, M. Transsphenoidal surgery for Cushing's disease: endocrinological follow-up monitoring of 82 patients. Neurosurgery. 2002;51(1):57–61.Google Scholar
39. McLaughlin, N, Kassam, AB, Prevedello, DM, Kelly, DF. Management of Cushing's disease after failed surgery-a review. Can J Neurol Sci. 2011;38(1):12–21.Google Scholar
40. Krikorian, A, Abdelmannan, D, Selman, WR, Arafah, BM. Cushing disease: use of perioperative serum cortisol measurements in early determination of success following pituitary surgery. Neurosurg Focus. 2007;23(3): E6.CrossRefGoogle ScholarPubMed
41. Lindsay, JR, Oldfield, EH, Stratakis, CA, Nieman, LK. The postoperative basal cortisol and CRH tests for prediction of long-term remission from Cushing's disease after transsphenoidal surgery. J Clin Endocrinol Metab. 2011;96(7):2057–64.Google Scholar