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J Clin Endocrinol Metab. 2007 Sep;92(9):3383-8. Epub 2007 Jun 26.

Outcomes and management of patients with Cushing's disease without pathological confirmation of tumor resection after transsphenoidal surgery.

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1
Department of Neurological Surgery, University of Virginia, Box 800212, Charlottesville, Virginia 22903, USA. np5k@virginia.edu

Abstract

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, gamma-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.

PMID:
17595252
DOI:
10.1210/jc.2007-0208
[Indexed for MEDLINE]
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