Serum cortisol response to transsphenoidal surgery for Cushing disease

Postoperative Serum Cortisol and Cushing Disease Recurrence in Patients With Corticotroph Adenomas

CONTEXT

In Cushing disease, the association between the rate of serum cortisol decline and recurrent disease after corticotroph adenoma removal has not been adequately characterized.

OBJECTIVE

To analyze postoperative serum cortisol and recurrence rates in Cushing disease.

METHODS

Patients with Cushing disease and pathology-confirmed corticotroph adenoma were retrospectively studied. Cortisol halving time was estimated using exponential decay modeling. Halving time, first postoperative cortisol, and nadir cortisol values were collected using immediate postoperative inpatient laboratory data. Recurrence and time-to-recurrence were estimated and compared among cortisol variables.

RESULTS

A total of 320 patients met inclusion/exclusion criteria for final analysis, and 26 of those patients developed recurrent disease. Median follow-up time was 25 months (95% CI, 19-28 months), and 62 patients had ≥ 5 years follow-up time. Higher first postoperative cortisol and higher nadir were associated with increased risk of recurrence. Patients who had a first postoperative cortisol ≥ 50 µg/dL were 4.1 times more likely to recur than those with a first postoperative cortisol < 50 µg/dL (HR 4.1, 1.8-9.2; P = .0003). Halving time was not associated with recurrence (HR 1.7, 0.8-3.8, P = .18). Patients with a nadir cortisol ≥2 µg/dL were 6.6 times more likely to recur than those with a nadir cortisol of < 2 µg/dL (HR 6.6, 2.6-16.6, P < .0001).

CONCLUSION

Postoperative nadir serum cortisol is the most important cortisol variable associated with recurrence and time-to-recurrence. Compared to first postoperative cortisol and cortisol halving time, a nadir < 2 µg/dL showed the strongest association with long-term remission and typically occurs within the first 24 to 48 hours after surgery.

Characterization of a paradoxical post-operative increase in serum cortisol in Cushing disease

PURPOSE

In Cushing disease, early post-operative serum cortisol fluctuations have not been adequately characterized, and their association with initial remission and recurrence is unclear.

METHODS

A retrospective cohort study of patients with Cushing disease was conducted at two institutions. A "riser" was defined a priori as a paradoxical increase in serum cortisol with an immediate incremental increase in serum cortisol over three consecutive cortisol draws separated by roughly 6-h (definition 1). Post hoc analyses used a definition of two consecutive increases (definition 2). Risers were compared to non-risers for initial remission and time-to-recurrence.

RESULTS

A total of 505 patients with Cushing disease were screened, and 469 had adequate data for group assignment. Analysis of post-operative cortisol showed a subgroup of "risers" with a frequency of 3.6% for definition 1 and 42.6% for definition 2. In these patients, cortisol levels were significantly higher until approximately 36 h post-operatively, and cortisol had a significantly longer mean serum half-life. In the post hoc analysis, definition 2 risers had a lower remission rate compared to non-risers (162/196, 82.7%, versus 243/264, 92.0%) with an odds ratio of 0.41 (0.23-0.73; p = 0.003). For both definitions, recurrence was similar between groups.

CONCLUSIONS

We found that almost half of Cushing disease patients experienced a temporary increase in serum cortisol level during the early post-operative period. Serum cortisol half-life was longer, and the remission rates were lower, however, recurrence rates were similar to non-risers.

Corticotroph hyperplasia and Cushing disease: diagnostic features and surgical management

OBJECTIVE

This study was done to compare corticotroph hyperplasia and histopathologically proven adenomas in patients with Cushing disease by analyzing diagnostic features, surgical management, and clinical outcomes.

METHODS

Patients with suspected pituitary Cushing disease were included in a retrospective cohort study and were excluded if results of pathological analysis of the surgical specimen were nondiagnostic or normal. Cases were reviewed by two experienced neuropathologists. Total lesion removal was used as a dichotomized surgical variable; it was defined as an extracapsular resection (including a rim of normal gland) in patients with an adenoma, and for hyperplasia patients it was defined as removal of the presumed lesion plus a rim of surrounding normal gland. Bivariate and multivariate analyses were performed. Recurrence-free survival was compared between the two groups.

RESULTS

The final cohort consisted of 63 patients (15 with hyperplasia and 48 with adenoma). Normal pituitary acinar architecture was highly variable. Corticotroph hyperplasia was diagnosed based on the presence of expanded acini showing retained reticulin architecture and predominant staining for adrenocorticotropic hormone. Crooke's hyaline change was seen in 46.7% of specimens, and its frequency was equal in nonlesional tissue of both groups. The two groups differed only by MRI findings (equivocal/diffuse lesion in 46% of hyperplasia and 17% of adenoma; p = 0.03). Diagnostic uncertainty in the hyperplasia group resulted in additional confirmatory testing by 24-hour urinary free cortisol. Total lesion removal was infrequent in patients with hyperplasia compared to those with adenoma (33% vs 65%; p = 0.03). Initial biochemical remission was similar (67% in hyperplasia and 85% in adenoma; p = 0.11). There was no difference in hypothalamic-pituitary-adrenal axis recovery or disease recurrence. The median follow-up was 1.9 years (IQR 0.7-7.6 years) for the hyperplasia group and 1.2 years (IQR 0.4-2.4 years) for the adenoma group. Lack of a discrete lesion and diagnostic uncertainty were the only significant predictors of hyperplasia (sensitivity 53.3%, specificity 97.7%, positive predictive value 88.9%, negative predictive value 85.7%). An adjusted Cox proportional hazards model showed similar recurrence-free survival in the two groups.

CONCLUSIONS

This study suggests an association between biochemically proven Cushing disease and histopathologically proven corticotroph hyperplasia. Imaging and operative findings can be ambiguous, and, compared to typical adenomas with a pseudocapsule, the surgical approach is more nuanced. Nevertheless, if treated appropriately, biochemical outcomes may be similar.

Significance of Crooke's Hyaline Change in Nontumorous Corticotrophs of Patients With Cushing Disease

BACKGROUND

Glucocorticoid excess in Cushing disease (CD) leads to negative feedback suppression, resulting in Crooke's hyaline change (CC) of nontumorous pituitary corticotrophs. We aimed to determine the predictive value of CC of nontumorous corticotrophs in CD.

METHODS

The retrospective chart review study included patients with clinical, biochemical, radiologic and outcome data and evaluable histopathology specimens from pituitary surgery for CD. The main outcome was remission of CD, defined by clinical features, biochemical testing, and corticosteroid dependency.

RESULTS

Of 144 CD patients, 60 (50 women, mean age 43.6±14) had clinical follow-up, biochemical data and histopathology specimens that included evaluable nontumorous adenohypophysis. Specimens from 50 patients (83.3%) demonstrated CC in nontumorous corticotrophs, and 10 (16.7%) had no CC (including 3 with corticotroph hyperplasia). One patient with CC was lost to follow-up and one without CC had equivocal outcome results. During a mean (SD) follow-up period of 74.9 months (61.0), recurrent or persistent disease was documented in 18 patients (31.0%), while 40 (69.0%) were in remission. In patients with CC, the remission rate was 73.5% (95% CI, 59.7%-83.7%) (36/49), whereas it was 44.4% (95% CI, 18.9%-73.3%) (4/9) in patients with no CC. The combination of serum cortisol >138 nmol/L within a week of surgery coupled with absence of nontumorous CC greatly improved the prediction of recurrent or persistent disease.

CONCLUSIONS

CC of nontumorous corticotrophs was observed in 83% of patients with CD, and most patients with CC experienced remission. Absence of CC in nontumorous corticotrophs may serve as a predictor of reduced remission in patients with CD.

Cushing's Disease

In patients with Cushing's disease (CD), prompt diagnosis and treatment are essential for favorable long-term outcomes, although this remains a challenging task. The differential diagnosis of CD is still difficult in some patients, even with an organized stepwise diagnostic approach. Moreover, despite the use of high-resolution magnetic resonance imaging (MRI) combined with advanced fine sequences, some tumors remain invisible. Surgery, using various surgical approaches for safe maximum tumor removal, still remains the first-line treatment for most patients with CD. Persistent or recurrent CD after unsuccessful surgery requires further treatment, including repeat surgery, medical therapy, radiotherapy, or sometimes, bilateral adrenalectomy. These treatments have their own advantages and disadvantages. However, the most important thing is that this complex disease should be managed by a multidisciplinary team with collaborating experts. In addition, a personalized and individual-based approach is paramount to achieve high success rates while minimizing the occurrence of adverse events and improving the patients' quality of life. Finally, the recent new insights into the pathophysiology of CD at the molecular level are highly anticipated to lead to the introduction of more accurate diagnostic tests and efficacious therapies for this devastating disease in the near future.

Prognostic usefulness of ACTH in the postoperative period of Cushing's disease

OBJECTIVES

To analyze the usefulness of plasma ACTH in predicting CD remission after surgery and to evaluate the prognostic usefulness of ACTH measurement after the cortisol and ACTH nadir (48 h prior to discharge).

DESIGN

A prospective study was made of 65 patients with CD operated upon between 2005 and 2016.

METHODS

Postsurgery plasma ACTH and cortisol were measured every 6 h, in the absence of corticosteroid coverage. Hydrocortisone was started in the presence of adrenal insufficiency or cortisol <55.2 nmol/L. Plasma ACTH was again determined before discharge.

MAIN OUTCOME MEASURE

Usefulness of plasma ACTH in predicting CD remission.

RESULTS

Remission at 3 months of CD was achieved in 56 of 65 cases, with late recurrence in 18 of 58 cases. Following resection, the ACTH nadir was significantly lower referred to late remission (2.8 vs 6.5 pmol/L; P = 0.031) and higher for recurrence (2.1 vs 4.8 pmol/L; P < 0.001), and identical results were obtained for the ACTH values before discharge. In the analysis of the ROC curves, nadir and before discharge ACTH values <1.9 pmol/L and <2.6 pmol/L were respectively indicative of early remission (AUC 0.827; P < 0.001); <6.2 pmol/L of remission at 3 months (AUC 0.847; P = 0.001) and >3.2 pmol/L of recurrence (AUC 0.810; P < 0.001) in both ACTH values. A time to ACTH nadir <46 h was indicative of early remission (AUC 0.751; P = 0.001), while a time >39 h was indicative of recurrence (AUC 0.773; P = 0.001).

CONCLUSIONS

We propose an ACTH value <3.3 pmol/L as a good long-term prognostic marker in the postoperative period of CD. Reaching the ACTH nadir in less time is associated to a lesser recurrence rate.

Long-term outcome of trans-sphenoidal surgery for Cushing's disease in Indian patients

BACKGROUND

The results of trans-sphenoidal surgery (TSS) in Cushing's disease (CD) vary widely depending upon patient characteristics as well as surgical experience. Patients in India are often referred late to referral centers. We studied the rates of remission and endocrine deficiencies after TSS in patients with CD presenting to a referral hospital in India.

METHODS

Sixty consecutive patients (45 females, median age 24.5 years) who underwent TSS between 2000 and 2015 were studied. The median (range) duration of follow-up was 40 (3-138) months. Initial and long-term remission and relapse rates and pituitary hypofunction post-TSS were evaluated.

RESULTS

Eighteen (30%) patients harbored macroadenomas. Twenty-eight (47%) patients achieved remission in the immediate post-operative period (8 AM serum cortisol < 140 nmol/l), while a higher remission rate was noted at 6 months (39/54 patients, 72%). At 1 year 70% patients and at final follow-up [median duration 40 (range 3-138) months], 58% of patients were in remission. No pre- or post-surgical variables were consistently associated with remission, except for the 8-AM serum cortisol level on the fifth day after surgery. Seven (18%) patients relapsed on follow-up, including five patients who had fifth post-operative day 8 AM serum cortisol < 140 nmol/l. Twelve (25%) patients newly developed hypothyroidism and one (1.6%) patient developed amenorrhoea after TSS.

CONCLUSION

Remission rate at 6 months was higher than immediately after TSS. A significant proportion of patients relapsed, thus necessitating life-long follow-up. New-onset hypothyroidism was frequent after TSS.

An early post-operative ACTH suppression test can safely predict short- and long-term remission after surgery of Cushing's disease

PURPOSE

The present study evaluates the usefulness of an ACTH suppression test shortly after surgery, and to determine optimal cut-off values of included laboratory analyses, in predicting short- and long-term remission after surgery of Cushing's disease.

METHODS

A 48 h suppression test with betamethasone 2 mg/day applied after 45 transphenoidal adenomectomies in 28 patients was evaluated. Receiver operating characteristic (ROC)-curves were created for the included assays: plasma cortisol, plasma adrenocorticotropic hormone (ACTH) and urinary free cortisol (UFC). Plasma levels of cortisol and ACTH were measured both at 24 and 48 h. Youden's index was used to determine cut-off with the highest sensitivity and specificity in predicting short- (3 months) and long-term (5 years or longer) remission. The area under curve (AUC) illustrated the clinical accuracy of the different assays.

RESULTS

Plasma cortisol after 24 h with betamethasone was most accurate in predicting both short- and long-term remission. 3 months remission with cut-off 107 nmol/L: sensitivity 0.85, specificity 0.94, positive predictive value (PPV) 0.96 and AUC 0.92 (95% CI 0.85-1). 5 years remission with cut-off 49 nmol/L: sensitivity: 0.94, specificity 0.93, PPV 0.88, AUC 0.98 (95% CI 0.95-1). Analyses of ACTH or UFC did not improve diagnostic accuracy.

CONCLUSIONS

A 48 h, 2 mg/day betamethasone suppression test after transphenoidal surgery of Cushing's disease could predict short- and long-term remission with a high accuracy. Suppression of plasma cortisol after 24 h with betamethasone to values excluding Cushings disease in the diagnostic setting yielded the highest accuracy in predicting long-term remission.

Management of Cushing's Disease After Failed Surgery - A Review

Selective transsphenoidal adenomectomy is generally recommended for initial treatment of Cushing's disease (CD) because it achieves a high (70-85%) rate of remission. However, if initial surgery is not successful, the approach to persistent or recurrent CD is more complex. Because residual or recurrent adenoma is typically found at the site of the original adenoma, repeat transsphenoidal surgery is recommended including selective adenomectomy, hemihypophysectomy or total hypophysectomy. If repeat pituitary surgery does not achieve remission, then possible adjuvant therapies include radiosurgery or stereotactic radiotherapy, bilateral adrenalectomy, and/or medical therapy. In all cases of persistent or recurrent CD, successful treatment requires close collaboration of endocrinologists, radiation oncologists and neurosurgeons.

Prognostic Factors of Long-Term Remission After Surgical Treatment of Cushing's Disease

Transsphenoidal surgery is the main treatment of patients with adrenocorticotropic hormone (ACTH)-secreting pituitary adenomas. Although biochemical remission occurs in most patients undergoing operations at specialized centers, the recurrence risk is significant. Visualization of microadenomas on preoperative imaging and confirmation of ACTH-positive adenomas have been associated with higher remission rates. Low cortisol levels in the first 2 weeks postoperatively have been associated with durable remission; however, recurrence cannot be excluded by any cortisol threshold. The decision to perform a pituitary reoperation is based on this parameter; the protocols are institution specific. Patients with Cushing's disease warrant lifelong endocrinologic surveillance.

Efficacy of endoscopic endonasal transsphenoidal surgery for Cushing's disease in 230 patients with positive and negative MRI

OBJECT

The primary objective was to assess the remission rate, and the secondary objectives were to evaluate the early complications and recurrence rate and to define the predictive factors for the remission and recurrence rates.

PATIENTS AND METHODS

This prospective single-center study included 230 consecutive patients, operated on by a single surgeon for Cushing's disease via a transsphenoidal endoscopic endonasal approach, over a 6-year period (2008-2013). The patients included in this series were all adults (>18 years of age), who presented with clinical and biological characteristics of Cushing's disease confirmed based on dedicated MRI pituitary imaging. Biochemical remission was defined as a postoperative serum cortisol level <5 μg/dl on the 2nd day following surgery that required glucocorticoid replacement therapy.

RESULTS

The remission rate for the global population (n = 230) with a follow-up of 21 ± 19.2 months concerned 182 patients (79.1%) divided into 132 patients (82.5%) with positive MRI and 50 patients (71.4%) with negative MRI with no statistically significant difference (p = 0.077). Complications occurred in 77 patients with no deaths. A total of 22% of patients had transient diabetes insipidus and 6.4% long-term diabetes insipidus, and no postoperatively CSF leakage was observed. The recurrence rate was 9.8% with a mean time of 32.7 ± 15.2 months. The predictive factors for the remission rate were the presence of pituitary microadenoma and a positive histology. No risk factors were involved regarding the recurrence rate.

CONCLUSION

Whatever the MRI results, the transsphenoidal endonasal endoscopic approach remains the gold standard treatment for Cushing's disease. It was maximally effective with a remission rate of 79.1% and lower morbidity.

Current best practice in the management of patients after pituitary surgery

Sellar and parasellar masses are a common finding, and most of them are treated surgically via transsphenoidal approach. This type of surgery has revolutionized the approach to several hypothalamic-pituitary diseases and is usually effective, and well-tolerated by the patient. However, given the complex anatomy and high density of glandular, neurological and vascular structures in a confined space, transsphenoidal surgery harbors a substantial risk of complications. Hypopituitarism is one of the most frequent sequelae, with central adrenal insufficiency being the deficit that requires a timely diagnosis and treatment. The perioperative management of AI is influenced by the preoperative status of the hypothalamic-pituitary-adrenal axis. Disorders of water metabolism are another common complication, and they can span from diabetes insipidus, to the syndrome of inappropriate antidiuretic hormone secretion, up to the rare cerebral salt-wasting syndrome. These abnormalities are often transient, but require careful monitoring and management in order to avoid abrupt variations of blood sodium levels. Cerebrospinal fluid leaks, damage to neurological structures such as the optic chiasm, and vascular complications can worsen the postoperative course after transsphenoidal surgery as well. Finally, long-term follow up after surgery varies depending on the underlying pathology, and is most challenging in patients with acromegaly and Cushing disease, in whom failure of primary pituitary surgery is a major concern. When these pituitary functioning adenomas persist or relapse after neurosurgery other treatment options are considered, including repeated surgery, radiotherapy, and medical therapy.

Factors predicting the outcomes of removal of corticotropinom in Cushing's disease

Обоснование. Болезнь Иценко–Кушинга (БИК) – тяжелое многосимптомное заболевание гипоталамо-гипофизарно-надпочечниковой системы. Причиной заболевания является наличие аденомы гипофиза (кортикотропиномы). Увеличение секреции адренокортикотропного гормона (АКТГ) аденомой гипофиза приводит к повышенной секреции кортизола корой надпочечников и развитию тотального эндогенного гиперкортицизма. Золотым стандартом лечения данного заболевания является хирургическое удаление кортикотропиномы. Однако аденомэктомия не во всех случаях бывает эффективной, и примерно в 20% случаев после проведенного радикального лечения не удается достичь ремиссии заболевания и возникает рецидив. Цель. Целью нашей работы являлась оценка факторов, оказывающих влияние на результат аденомэктомии у пациентов с болезнью Иценко–Кушинга, и выявление предикторов рецидива. Методы. В исследование было включено 84 пациента (80 женщин и 4 мужчин) в возрасте от 18 до 58 лет с БИК до и после трансназальной аденомэктомии. Период наблюдения от 3 до 15 лет, начиная с 2001 г. (в среднем 9,0 лет). Была проведена ретроспективная оценка клинических и гормональных факторов (АКТГ и кортизола) до операции и через 1–3 и 8–13 дней после операции. Результаты. У 54 (64,3%) из 84 пациентов с БИК после проведенной трансназальной аденомэктомии развилась ремиссия заболевания. Оперативное лечение было неэффективно у 30 (35,7%) пациентов, и им была проведена повторная аденомэктомия. По данным МРТ головного мозга, среди пациентов с ремиссией заболевания чаще встречались микроаденомы гипофиза (54%) по сравнению с пациентами, у которых операция оказалась неэффективна, а на МРТ чаще встречались макроаденомы (63%). У всех больных с БИК независимо от исхода нейрохирургической операции наблюдалось достоверное снижение уровня кортизола и АКТГ в раннем послеоперационном периоде. Заключение. Показателями эффективности аденомэктомии и длительной ремиссии у пациентов с БИК являются уровень утреннего кортизола менее 100 нмоль/л и уровень АКТГ менее 10,0 пг/мл на ранних сроках после операции (1–13-й дни). Наличие надпочечниковой недостаточности после аденомэктомии является предиктором эффективности операции, но не исключает вероятности развития рецидива.

Postoperative Care Following Pituitary Surgery

Patients undergoing surgery for pituitary tumors represent a heterogeneous population each with unique clinical, biochemical, radiologic, pathologic, neurologic, and/or ophthalmologic considerations. The postoperative management of patients following pituitary surgery often occurs in the context of a dynamic state of the hypothalamic-pituitary-end organ axis. Consequently, a significant component of the postoperative care of these patients focuses on vigilant screening and observation for neuroendocrinologic perturbations such as varying degrees of hypopituitarism and disorders of water balance (diabetes insipidus and the syndrome of inappropriate antidiuretic hormone). Additionally, one must be cognizant of other potential complications specific to the transsphenoidal approach for tumor removal including cerebrospinal fluid leakage and meningitis. This review addresses the postoperative management of patients undergoing pituitary surgery with an emphasis on careful screening and recognition of complications.

Pure endoscopic transsphenoidal surgery for functional pituitary adenomas: outcomes with Cushing's disease

BACKGROUND

This study was performed to examine patient outcomes following pure endoscopic transsphenoidal surgery (ETS) for Cushing's disease (CD).

METHOD

We studied 64 consecutive patients who underwent 69 endoscopic transsphenoidal procedures. Radiological evaluation comprised detailed examination of preoperative magnetic resonance images (MRI), including positron emission tomography (PET) for select cases. Inferior petrosal sinus sampling (IPSS) was not performed for any patient. Remission was defined by the presence of hypocortisolemia with requirement for steroid replacement therapy or eucortisolemia with suppression to <1.8 μg/dl after 1 mg dexamethasone on evaluation at least 3 months after surgery.

RESULTS

Preoperative MRI was abnormal in 87.5 % of cases and included 11 macroadenomas (17.2 %). PET was used to localize the adenoma in four cases. For microadenomas, operative procedures executed were as follows: selective adenomectomy (n = 15), enlarged adenomectomy (n = 21) and subtotal/hemihypophysectomy (n = 17). Overall, pathological confirmation of an adenoma was possible in 58 patients (90.6 %). Forty-nine patients (76.6 %) developed hypocortisolemia (<5 μg/dl) in the early postoperative period. Mean follow-up was 20 months (range 6-18 months). Remission was confirmed in 79.7 % of the 59 cases followed up for >3 months and was superior for microadenomas (86.4 %) versus macroadenomas (55.6 %) and equivocal MRI adenomas (66.7 %). Postoperative CSF rhinorrhea occurred in five patients, and new endocrine deficits were noted in 17.1 % patients. A nadir postoperative cortisol <2 μg/dl in the 1st week after surgery was highly predictive of remission (p = 0.001).

CONCLUSION

ETS allows for enhanced intrasellar identification of adenomatous tissue, providing remission rates that are comparable to traditional microsurgery for CD. The best predictor of remission remains induction of profound hypocortisolemia in the early postoperative period.

Low immediate postoperative serum-cortisol nadir predicts the short-term, but not long-term, remission after pituitary surgery for Cushing's disease

BACKGROUND

Cushing's disease is an ACTH-producing pituitary adenoma, and the primary treatment is microscopic or endoscopic transsphenoidal selective adenectomy. The aims of the present study were to evaluate whether the early postoperative S-cortisol level can serve as a prognostic marker for short- and long-term remission, and retrospectively review our own short and long term results after surgery for Cushing's disease.

METHODS

This single centre, retrospective study consists of 19 consecutive patients with Cushing's disease who underwent transsphenoidal surgery. S-cortisol was measured every 6 h after the operation without any glucocorticoid replacement. We have follow-up on all patients, with a mean follow-up of 68 months.

RESULTS

At the three-month follow-up, 16 patients (84 %) were in remission; at 12 months, 18 (95 %) were in remission and at the final follow-up (mean 68 months), 13 (68 %) were in remission. Five-years recurrence rate was 26 %. The mean postoperative S-cortisol nadir was significantly lower in the group of patients in remission than in the non-remission group at 3 months, but there was no difference between those in long-term remission compared to those in long-term non-remission. The optimal cut-off value for classifying 3-month remission was 74 nmol/l.

CONCLUSION

We achieved a 95 % 1-year remission rate with transsphenoidal surgery for Cushing's disease in this series of consecutive patients. However, the 5-year recurrence rate was 26 %, showing the need for regular clinical and biochemical controls in this patient group. The mean postoperative serum-cortisol nadir was significantly lower in patients in remission at 3 months compared to patients not in remission at 3 months, but a low postoperative S-cortisol did not predict long-term remission.

The Treatment of Cushing's Disease

Cushing's disease (CD), or pituitary-dependent Cushing's syndrome, is a severe endocrine disease caused by a corticotroph pituitary tumor and associated with increased morbidity and mortality. The first-line treatment for CD is pituitary surgery, which is followed by disease remission in around 78% and relapse in around 13% of patients during the 10-year period after surgery, so that nearly one third of patients experience in the long-term a failure of surgery and require an additional second-line treatment. Patients with persistent or recurrent CD require additional treatments, including pituitary radiotherapy, adrenal surgery, and/or medical therapy. Pituitary radiotherapy is effective in controlling cortisol excess in a large percentage of patients, but it is associated with a considerable risk of hypopituitarism. Adrenal surgery is followed by a rapid and definitive control of cortisol excess in nearly all patients, but it induces adrenal insufficiency. Medical therapy has recently acquired a more important role compared to the past, due to the recent employment of novel compounds able to control cortisol secretion or action. Currently, medical therapy is used as a presurgical treatment, particularly for severe disease; or as postsurgical treatment, in cases of failure or incomplete surgical tumor resection; or as bridging therapy before, during, and after radiotherapy while waiting for disease control; or, in selected cases, as primary therapy, mainly when surgery is not an option. The adrenal-directed drug ketoconazole is the most commonly used drug, mainly because of its rapid action, whereas the glucocorticoid receptor antagonist, mifepristone, is highly effective in controlling clinical comorbidities, mainly glucose intolerance, thus being a useful treatment for CD when it is associated with diabetes mellitus. Pituitary-directed drugs have the advantage of acting at the site responsible for CD, the pituitary tumor. Among this group of drugs, the dopamine agonist cabergoline and the somatostatin analog pasireotide result in disease remission in a consistent subgroup of patients with CD. Recently, pasireotide has been approved for the treatment of CD when surgery has failed or when surgery is not an option, and mifepristone has been approved for the treatment of Cushing's syndrome when associated with impairment of glucose metabolism in case of the lack of a surgical indication. Recent experience suggests that the combination of different drugs may be able to control cortisol excess in a great majority of patients with CD.

Therapy of endocrine disease: outcomes in patients with Cushing's disease undergoing transsphenoidal surgery: systematic review assessing criteria used to define remission and recurrence

OBJECTIVE

A number of factors can influence the reported outcomes of transsphenoidal surgery (TSS) for Cushing's disease - including different remission and recurrence criteria, for which there is no consensus. Therefore, a comparative analysis of the best treatment options and patient management strategies is difficult. In this review, we investigated the clinical outcomes of initial TSS in patients with Cushing's disease based on definitions of and assessments for remission and recurrence.

METHODS

We systematically searched PubMed and identified 44 studies with clear definitions of remission and recurrence. When data were available, additional analyses by time of remission, tumor size, duration of follow-up, surgical experience, year of study publication and adverse events related to surgery were performed.

RESULTS

Data from a total of 6400 patients who received microscopic TSS were extracted and analyzed. A variety of definitions of remission and recurrence of Cushing's disease after initial microscopic TSS was used, giving broad ranges of remission (42.0-96.6%; median, 77.9%) and recurrence (0-47.4%; median, 11.5%). Better remission and recurrence outcomes were achieved for microadenomas vs macroadenomas; however, no correlations were found with other parameters, other than improved safety with longer surgical experience.

CONCLUSIONS

The variety of methodologies used in clinical evaluation of TSS for Cushing's disease strongly support the call for standardization and optimization of studies to inform clinical practice and maximize patient outcomes. Clinically significant rates of failure of initial TSS highlight the need for effective second-line treatments.

The prognostic value of perioperative profiles of ACTH and cortisol for recurrence after transsphenoidal hypophysectomy in dogs with corticotroph adenomas

BACKGROUND

Transsphenoidal hypophysectomy is an effective treatment for dogs with pituitary-dependent hypercortisolism (PDH). However, long-term recurrence of hypercortisolism is a well-recognized problem, indicating the need for reliable prognostic indicators.

OBJECTIVES

The aim of this study was to evaluate the prognostic value of perioperative plasma ACTH and cortisol concentrations for identifying recurrence of hypercortisolism after transsphenoidal hypophysectomy.

ANIMALS

A total of 112 dogs with PDH that underwent transsphenoidal hypophysectomy met the inclusion criteria of the study.

METHODS

Hormone concentrations were measured preoperatively and 1-5 hours after surgery. Both absolute hormone concentrations and postoperative concentrations normalized to preoperative concentrations were included in analyses. The prognostic value of hormone concentrations was studied with Cox's proportional hazard analysis.

RESULTS

Median follow-up and disease-free period were 1096 days and 896 days, respectively. Twenty-eight percent of patients had recurrence, with a median disease-free period of 588 days. Both absolute and normalized postoperative cortisol concentrations were significantly higher in dogs with recurrence than in dogs without recurrence. High ACTH 5 hours after surgery, high cortisol 1 and 4 hours after surgery, high normalized ACTH 3 hours after surgery, high normalized cortisol 4 hours after surgery and the random slope of cortisol were associated with a shorter disease-free period.

CONCLUSIONS AND CLINICAL IMPORTANCE

Individual perioperative hormone curves provide valuable information about the risk of recurrence after hypophysectomy. However, because no single cutoff point could be identified, combination with other variables, such as the pituitary height/brain area (P/B) ratio, is still needed to obtain a good estimate of the risk for recurrence of hypercortisolism after hypophysectomy.

Primary Endoscopic Transnasal Transsphenoidal Surgery for Magnetic Resonance Image-Positive Cushing Disease: Outcomes of a Series over 14 Years

BACKGROUND

There are scant data of endoscopic transsphenoidal surgery (ETS) with adjuvant therapies of Cushing disease (CD).

OBJECTIVE

To report the remission rate, secondary management, and outcomes of a series of CD patients.

METHODS

Patients with CD with magnetic resonance imaging (MRI)-positive adenoma who underwent ETS as the first and primary treatment were included. The diagnostic criteria were a combination of 24-hour urine-free cortisol, elevated serum cortisol levels, or other tests (e.g., inferior petrosal sinus sampling). All clinical and laboratory evaluations and radiological examinations were reviewed.

RESULTS

Forty consecutive CD patients, with an average age of 41.0 years, were analyzed with a mean follow-up of 40.2 ± 29.6 months. These included 22 patients with microadenoma and 18 with macroadenoma, including 9 cavernous invasions. The overall remission rate of CD after ETS was 72.5% throughout the entire follow-up. Patients with microadenoma or noninvasive macroadenoma had a higher remission rate than those who had macroadenoma with cavernous sinus invasion (81.8% or 77.8% vs. 44.4%, P = 0.02). After ETS, the patients who had adrenocorticotropic hormone-positive adenoma had a higher remission rate than those who had not (76.5% vs. 50%, P = 0.03). In the 11 patients who had persistent/recurrent CD after the first ETS, 1 underwent secondary ETS, 8 received gamma-knife radiosurgery (GKRS), and 2 underwent both. At the study end point, two (5%) of these CD patients had persistent CD and were under the medication of ketoconazole.

CONCLUSION

For MRI-positive CD patients, primary (i.e., the first) ETS yielded an overall remission rate of 72.5%. Adjuvant therapies, including secondary ETS, GKRS, or both, yielded an ultimate remission rate of 95%.

Cushing's disease: predicting long-term remission after surgical treatment

Cushing's disease (CD) is a state of excess glucocorticoid production resulting from an adrenocorticotropic hormone (ACTH)–secreting pituitary adenoma. The gold-standard treatment for CD is transsphenoidal adenomectomy. In the hands of an experienced neurosurgeon, gross-total resection is possible in the majority of ACTH-secreting pituitary adenomas, with early postoperative remission rates ranging from 67% to 95%. In contrast to the strong data in support of resection, the clinical course of postsurgical persistent or recurrent disease remains unclear. There is significant variability in recurrence rates, with reports as high as 36% with a mean time to recurrence of 15–50 months. It is therefore important to develop biochemical criteria that define postsurgical remission and that may provide prognosis for long-term recurrence. Despite the use of a number of biochemical assessments, there is debate regarding the accuracy of these tests in predicting recurrence. Here, the authors review the various biochemical criteria and assess their utility in predicting CD recurrence after resection.

Evaluation of Cushing's disease remission after transsphenoidal surgery based on early serum cortisol dynamics

OBJECTIVE

To evaluate the ability of post-transsphenoidal pituitary surgery (TSS) serum cortisol levels (s-cortisol) to predict surgical remission and recurrence of Cushing's disease (CD).

DESIGN

One hundred and three patients with CD from a tertiary referral centre were prospectively analysed over 6·0 ± 4·8 years of follow-up. Twenty patients received perioperative glucocorticoids as routine care and had s-cortisol measured 10-12 days after TSS (Protocol I). Eighty-six patients (91 surgeries) had s-cortisol measured at 6, 12, 18, 24, 48 h, and 10-12 days after TSS, and received glucocorticoids only in case of adrenal insufficiency (Protocol II).

MAIN OUTCOMES

Remission [clinical signs and symptoms of adrenal insufficiency (or hypocortisolism) plus cortisol <3 μg/dl on the 1-mg overnight test (OT) and/or normal free urinary cortisol] during follow-up. Recurrence was defined as loss of remission criteria at least 1 year after TSS.

RESULTS

The remission rate after first TSS was 80%; 8% had recurrence. An s-cortisol nadir ≤3·5 μg/dl within 48 h after TSS had sensitivity of 73%, specificity and positive predictive value (PPV) of 100% and negative predictive value (NPV) of 60% and an s-cortisol nadir ≤5·7 μg/dl within 10-12 days of TSS had specificity and PPV of 100% and sensitivity of 91% NPV of 78% for CD remission.

CONCLUSION

At hospital discharge, the s-cortisol nadir within 48 h after TSS was already able to predict surgical remission for some patients, and the s-cortisol nadir within 10-12 days of TSS was able to predict cohort-wide surgical remission.

An approach to the evaluation and treatment of Cushing’s disease

Cushing's syndrome is an uncommon disorder involving dysregulation of the hypothalamic-pituitary-adrenal axis resulting in endogenous hypercortisolemia. It has multiple causes, but most commonly is due to hypersecretion of corticotropin from the pituitary gland, called Cushing's disease. The diagnosis of Cushing's syndrome remains a challenge to clinicians because routine hormonal assays can have significant overlap in pathological and normal states. We will review an approach to evaluating patients with suspected cortisol excess. We will also discuss treatment options and post-surgical assessment for those diagnosed with Cushing's disease.

Surgical approach to pituitary tumors

Pituitary surgery is a continuously evolving specialty of neurosurgery that requires precise anatomical knowledge, technical skills, and an integrated appreciation of pituitary pathophysiology. It involves close cooperation between different specialists, i.e., the endocrinologist, neurosurgeon, neuroradiologist, pathologist, ophthalmologist, and others. It is currently possible to manage many of the different pituitary syndromes with more than one option, including medical, surgical, and radiotherapeutic options, either alone or in various combinations. In recent decades, the transsphenoidal midline route became the standard approach to the pituitary area, this being a less traumatic direct route to the sella, avoiding brain retraction and providing excellent visualization, with a lower morbidity and mortality rate as compared to transcranial procedures. Most pituitary adenomas can be managed and removed through a standard transsphenoidal approach, either microscopic or endoscopic. More recently, the introduction of the endoscope in the extended endoscopic endonasal approach has become more widespread. Here we report current indications and give a step-by-step account of the surgical techniques used in pituitary surgery, focusing on the "dangerous keypoints". We also describe possible complications of each kind of procedure.

Cushing's disease in 2012

The aim of this study was to review the literature published and the most important papers presented to meetings on Cushing's disease from October 2011 to September 2012. The selection has been performed according to the authors' criteria. Articles have been classified into five groups: quality of life and perception of the disease, clinical features and pathophysiology, comorbidity conditions, diagnosis, and treatment. The results and conclusions of each publication are discussed.

Endoscopic Transsphenoidal Surgery for Cushing Disease

BACKGROUND:

The efficacy of endoscopic transsphenoidal surgery (ETS) for Cushing disease has not been clearly established.

OBJECTIVE:

To assess efficacy of a pure endoscopic approach for treatment of Cushing disease and determine predictors of remission.

METHODS:

A prospectively acquired database of 61 patients undergoing ETS was reviewed. Remission was defined as postoperative morning serum cortisol of &lt;5 μg/dL or normal or decreased 24-hour urine-free cortisol level in follow-up.

RESULTS:

Overall, hypercortisolemia resolved in 58 of 61 patients (95%) by discharge. Tumor size did not predict resolution of hypercortisolemia at discharge (microadenomas [97%], magnetic resonance imaging-negative Cushing [100%], macroadenomas [87%]). At 2- to 3-month evaluations, 45 of 49 patients (91.8%) were in remission. Fifty patients were followed for at least 12 months (mean, 28 months; range, 12–72). Forty-two (84%) achieved remission from a single ETS. In these patients, there was no significant difference in remission rates between microadenomas (93%), magnetic resonance imaging-negative (70%), and macroadenomas (77%). Patients with history of previous surgery (n = 14, 23%) were 9 times less likely to achieve follow-up remission (P = .021). In-house cortisol level of &lt;5.7 μg/dL provided the best prediction of follow-up remission (sensitivity 88.6%, specificity 83.3%). Postoperative diabetes insipidus occurred transiently in 7 patients (9%) and permanently in 3 (5%). One patient experienced postoperative cerebrospinal fluid leak that resolved with further surgery.

CONCLUSION:

ETS for Cushing disease provides high rates of remission with low rates of complications regardless of size. Although patients with a history of previous surgery are less likely to achieve remission, the majority can still achieve remission following treatment.

Enhancing synaptic plasticity and cellular resilience to develop novel, improved treatments for mood disorders

There is mounting evidence that recurrent mood disorders - once considered “good prognosis diseases”- are, in fact, often very severe and life-threatening illnesses. Furthermore, although mood disorders have traditionally been conceptualized as neurochemical disorders, there is now evidence from a variety of sources demonstrating regional reductions in central nervous system (CNS) volume, as well as reductions in the numbers and/or sizes ofglia and neurons in discrete brain areas. Although the precise cellular mechanisms underlying these morphometric changes remain to be fully elucidated, the data suggest that mood disorders are associated with impairments of synaptic plasticity and cellular resilience. In this context, it is noteworthy that there is increasing preclinical evidence that antidepressants regulate the function of the glutamatergic system. Moreover, although clearly preliminary, the available clinical data suggest that attenuation of N-methyl-D-aspartate (NMDA) function has antidepressant effects. Recent preclinical and clinical studies have shown that signaling pathways involved in regulating cell survival and cell death are long-term targets for the actions of antidepressant agents. Antidepressants and mood stabilizers indirectly regulate a number of factors involved in cell survival pathways, including cyclic adenosine monophosphate (cAMP) response element binding protein (CREB), brain-derived neurotrophic factor (BDNF), the antiapoptotic protein bcl-2, and mitogen-activated protein (MAP) kinases, and may thus bring about some of their delayed long-term beneficial effects via underappreciated neurotrophic effects. There is much promise for the future development of treatments that more directly target molecules in critical CNS signaling pathways regulating synaptic plasticity and cellular resilience. These will represent improved long-term treatments for mood disorders.

Cellular plasticity and resilience and the pathophysiology of severe mood disorders

Recent advances in the identification of the neural circuits, neurochemicals, and signal transduction mechanisms involved in the pathophysiology and treatment of mood disorders have led to much progress toward understanding the roles of genetic factors and psychosocial stressors. The monoaminergic neurotransmitter systems have received the most attention, partly because of the observation that effective antidepressant drugs exert their primary biochemical effects by regulating intrasynaptic concentrations of serotonin and norepinephrine. Furthermore, the monoaminergic systems are extensively distributed throughout the network of limbic, striatal, and prefrontal cortical neuronal circuits thought to support the behavioral and visceral manifestations of mood disorders. Increasing numbers of neuroimaging, neuropathological, and biochemical studies indicate impairments in cellular plasticity and resilience in patients who suffer from severe, recurrent mood disorders. In this paper, we describe studies identifying possible structural, functional, and cellular abnormalities associated with depressive disorders, which are potentially the cellular underpinnings of these diseases. We suggest that drugs designed to enhance cellular plasticity and resilience, and attenuate the activity of maladaptive stress-responsive systems, may be useful for the treatment of severe mood disorders.

Use of the histological pseudocapsule in surgery for Cushing disease: rapid postoperative cortisol decline predicting complete tumor resection

Object

Subnormal postoperative serum cortisol levels indicate successful surgery and predict long-term remission of Cushing disease. Given the short serum half-lives of adrenocorticotropic hormone (ACTH) and cortisol, it is unclear why the decline in cortisol postoperatively is delayed for 18–36 hours. Furthermore, the relevance of the rate of cortisol drop immediately after surgery has not been investigated.

Methods

Patient data were analyzed from a prospectively accrued database. After surgery, cortisol replacement was withheld and serum cortisol measurements were obtained every 6 hours until values of 1.0–2.0 μg/dl or less were reached. The authors selected patients in whom serum cortisol dropped to 2 μg/dl or less after surgery (101 patients). Tumor resection was categorized as follows: 1) complete resection using the histological pseudocapsule as a surgical capsule, 2) complete piecemeal resection), 3) known incomplete resection, and 4) total hypophysectomy.

Results

The median time to reach a cortisol level of less than or equal to 2.0 μg/dl was 9.9, 19.4, 25.3, and 29.5 hours with hypophysectomy, pseudocapsule, incomplete resection, and piecemeal techniques, respectively. Pseudocapsule resection produced a faster decline in cortisol than piecemeal techniques (p = 0.0001), but not as rapid a decline as hypophysectomy (p = 0.033).

Conclusions

Complete resection by other techniques is associated with delayed cortisol decline compared with pseudocapsule surgery, which may represent the product of residual tumor cells and therefore may explain the higher rate of recurrent disease associated with piecemeal techniques. The prompt drop in cortisol after hypophysectomy compared with patients with pseudocapsule surgery suggests that the corticotrophs of the normal gland can secrete ACTH for 10–36 hours after surgery despite prolonged and severe hypercortisolism.

The dynamics of post-operative plasma ACTH values following transsphenoidal surgery for Cushing's disease

Rapid assessment of adrenal function is critical following transsphenoidal surgery (TSS) for Cushing's disease (CD) in order to determine surgical efficacy. We hypothesize that there may be a role for ACTH measurement as a rapid indicator of adrenal function. Following surgery for CD, glucocorticoids were withheld and paired plasma ACTH and serum cortisol levels were measured every 6 h. Post-operative hypocortisolemia was defined as serum cortisol <2 mcg/dl or a serum cortisol <5 mcg/dl with the onset of symptoms of adrenal insufficiency within 72 h. We studied 12 subjects, all female, mean age 44.6 years (range 25-55), including 13 surgeries: nine subjects attained hypocortisolemia. Plasma ACTH levels decreased more in subjects with hypocortisolemia (0.9 pg/ml/hr, P = 0.0028) versus those with persistent disease (0 0.2 pg/ml/hr, P = 0.26) within the first 48 h after surgery. In contrast to subjects with persistent disease, all subjects with hypocortisolemia achieved a plasma ACTH <20 pg/ml by 19 h (range 1-19 h). Four of the nine subjects with hypocortisolemia achieved plasma ACTH <20 pg/ml by 13 h and the remaining five subjects by 19 h. Hypocortisolemia occurred between 3-36 h following achievement of a plasma ACTH <20 pg/ml. In CD, a reduction in postoperative plasma ACTH levels differentiates subjects with surgical remission versus subjects with persistent disease. The utility of plasma ACTH measurements in the postoperative management of CD remains to be determined.

Stand-alone cage for posterior lumbar interbody fusion in the treatment of high-degree degenerative disc disease: design of a new device for an "old" technique. A prospective study on a series of 116 patients

Chronic lumbar pain due to degenerative disc disease affects a large number of people, including those of fully active age. The usual self-repair system observed in nature is a spontaneous attempt at arthrodesis, which in most cases leads to pseudoarthrosis. In recent years, many possible surgical fusion techniques have been introduced; PLIF is one of these. Because of the growing interest in minimally invasive surgery and the unsatisfactory results reported in the literature (mainly due to the high incidence of morbidity and complications), a new titanium lumbar interbody cage (I-FLY) has been developed to achieve solid bone fusion by means of a stand-alone posterior device. The head of the cage is blunt and tapered so that it can be used as a blunt spreader, and the core is small, which facilitates self-positioning. From 2003 to 2007, 119 patients were treated for chronic lumbar discopathy (Modic grade III and Pfirrmann grade V) with I-FLY cages used as stand-alone devices. All patients were clinically evaluated preoperatively and after 1 and 2 years by means of a neurological examination, visual analogue score (VAS) and Prolo Economic and Functional Scale. Radiological results were evaluated by polyaxial computed tomography (CT) scan and flexion-extension radiography. Fusion was defined as the absence of segmental instability on flexion-extension radiography and Bridwell grade I or II on CT scan. Patients were considered clinical "responders" if VAS evaluation showed any improvement over baseline values and a Prolo value >7 was recorded. At the last follow-up examination, clinical success was deemed to have been achieved in 90.5% of patients; the rate of bone fusion was 99.1%, as evaluated by flexion-extension radiography, and 92.2%, as evaluated by CT scan. Morbidity (nerve root injury, dural lesions) and complications (subsidence and pseudoarthrosis) were minimal. PLIF by means of the stand-alone I-FLY cage can be regarded as a possible surgical treatment for chronic low-back pain due to high-degree DDD. This technique is not demanding and can be considered safe and effective, as shown by the excellent clinical and radiological success rates.

Increased incidence of cage migration and nonunion in instrumented transforaminal lumbar interbody fusion with bioabsorbable cages

OBJECT

Recent advances in the field of spinal implants have led to the development of the bioabsorbable interbody cage. Although much has been written about their advantageous characteristics, little has been reported regarding complications associated with these cages. The authors conducted this prospective cohort study to compare fusion and complication rates in patients undergoing transforaminal lumbar interbody fusion (TLIF) with carbon fiber cages versus biodegradable cages made from 70/30 poly(l-lactide-co-d,l-lactide) (PLDLA).

METHODS

Between January 2005 and May 2006, 81 patients with various degenerative and/or structural pathologies affecting the lumbar spine underwent single- or multilevel TLIF with posterior segmental pedicle screw fixation using implants made of carbon fiber (37 patients) or 70/30 PLDLA (44 patients). Clinical and radiological follow-up was performed at 6 weeks, 3 months, 6 months, and 1 year, and is ongoing. The incidence of nonunion, screw breakage, and cage migration were compared between the 2 groups.

RESULTS

There was no significant difference in demographic data between the 2 groups, the mean number of lumbar levels operated, or distribution of the levels operated. There was a significantly increased incidence of nonunion (8 patients, 18.2%) and cage migrations (8 patients, 18.2%) in patients receiving the PLDLA implants compared with carbon fiber implants (no patients) (p = 0.006 and 0.007, respectively). There was no significant difference in demographic data between patients with cage migration and the rest of the patient population. Five of the 8 cases of migration occurred at the L5-S1 level while the remaining 3 occurred at the L4-5 level. The mean time to implant failure was 9.3 months.

CONCLUSIONS

This study showed an increased incidence of nonunion (18.2%) and postsurgical cage migration (18.2%) in patients undergoing TLIF with biodegradable cages versus carbon fiber implants (0%) (p = 0.006 and 0.007, respectively).

Peri-operative management of Cushing's disease

Management of patients with ACTH producing pituitary adenoma remains to be challenging. Removal of the pituitary adenoma through transsphenoidal surgery is the main stay of treatment. Complete resection of the adenoma is followed by the development of ACTH deficiency since the normal corticotrophs are suppressed by the pre-existing hypercortisolemia. The concern for ACTH deficiency has led many centers to advocate the use glucocorticoids before, during and after surgery. We provide evidence that such coverage with glucocorticoids is unnecessary until clinical or biochemical documentation of need is established. Given that patients are closely monitored, they are immediately treated with glucocorticoids once they exhibit any clinical and/or biochemical evidence of adrenal insufficiency. Defining remission in the immediate postoperative period has been rather difficult despite using different biochemical markers. Serum cortisol continues to be the best determinant of disease activity after surgical adenomectomy. However it needs to be interpreted with caution as a biochemical marker of remission in patients given glucocorticoids during and after surgery. Other biochemical markers are also used in the peri-operative period to determine the possibility of remission. These include the dexamethasone suppression test, CRH stimulation without dexamethasone, urinary free cortisol measurements, desmopressin stimulation test, the determination of salivary cortisol and / or plasma ACTH concentrations. Each test has its own advantages and limitations. The simplest and most informative approach is to measure serum cortisol levels repeatedly after surgery without the administration of exogenous glucocorticoids. Low serum cortisol levels (less than 2 μg/dL) in the peri-operative period are highly indicative of surgical success and a high likelihood for clinical remission. Higher serum cortisol levels require careful interpretation and further planning and discussions between the patient and the management team.

Corticotroph adenoma in the dog: pathogenesis and new therapeutic possibilities

The corticotrophinoma, causing pituitary dependent hypercortisolism, represents the highest percentage of pituitary tumours in the dog. The mechanism by which it develops is currently unknown and two theories are postulated: the hypothalamic and the monoclonal. It is not clear either what factors are involved in the tumour genesis; nevertheless, firm candidates are the Rb1 gene, proteins p27, p21 and p16, as are also defects in the glucocorticoid receptor and Nur77/Nurr1. The role of BMPs remains to be evaluated in greater depth. Although at present the chosen treatment in human is surgical, there are various pharmacological treatments already in use that have favourable results and others, still under research, also showing promising results.

Persistent adrenocorticotropin response to desmopressin in the early postoperative period predicts recurrence of Cushing's disease

CONTEXT

Patients with Cushing's disease (CD) often show an ACTH and cortisol response to desmopressin (DDAVP).

OBJECTIVE

We tested whether persistence of a positive response to DDAVP after successful surgery identifies patients at risk of CD recurrence.

DESIGN

We prospectively included all CD patients who had a positive response to DDAVP before successful surgery from 1995 through 2007.

SETTING

The study was performed at a university hospital.

PATIENTS

One hundred seventy-four patients with CD, 148 women and 26 men, mean age 36.1 +/- 0.8 yr, were studied. The median follow-up after surgery was 58 months (interquartile range 22-93 months).

INTERVENTION

DDAVP test was performed immediately before and after surgery.

MAIN OUTCOME MEASURE

An ACTH and cortisol increment of at least 30 and 20% above baseline, respectively, were considered as a positive response to DDAVP. The risk of CD recurrence was analyzed according to the postoperative hormonal response to DDAVP.

RESULTS

Recurrence of CD occurred in 19 patients (10.9%). The recurrence-free survival at 5 yr was 89.8% [95% confidence interval (CI) 84.2-95.4]. Patients with a positive ACTH response had a 5-yr recurrence-free survival of 82.6% (95% CI 70.6-94.6%) as compared with 94.0% (95% CI 88.2-99.8%; P < 0.01) in patients without it. Multivariate analysis showed that persistence of a positive ACTH response to DDAVP was significantly associated with CD recurrence.

CONCLUSION

Positive ACTH response to DDAVP after surgery is associated with an increased risk of CD recurrence. However, the specificity and predictive value of this finding are low.

Outcome of transsphenoidal surgery for Cushing's disease: a high remission rate in ACTH-secreting macroadenomas

OBJECTIVE

Although numerous studies have shown that transsphenoidal surgery is the best initial treatment for Cushing disease offering 59-95% of success, fewer information is available on the long-term outcome in the subgroup of patients harboring ACTH-secreting macroadenomas. The aims of this study were to analyze our 10-year experience with transsphenoidal surgery in Cushing's disease and to examine whether remission rates were different between micro- and macroadenomas.

PATIENTS AND METHODS

Forty consecutive patients with proven Cushing's disease (28 microadenomas, 12 macroadenomas [diameter: 10-25 mm], 3 patients with no visible adenoma at MRI) underwent transsphenoidal surgery (TSS) assisted by neuronavigation in our center between 1996 and 2007. The diagnosis was made using standard endocrinological criteria including bilateral inferior petrosal sinus sampling (BIPSS) with CRH stimulation in all patients with discordant or equivocal biochemical and radiological testing. Morning serum cortisol was measured during the first week postoperatively, and a complete endocrine evaluation was made in all patients at 6-8 weeks. Remission at follow-up was defined as a normal postoperative 24-h urinary free cortisol (UFC) or continued need for glucocorticoid hormone replacement after TSS.

RESULTS

Overall, 32/40 patients (80%) were in remission after one or more TSS. Interestingly, a very good remission rate (92%) was observed in the subset of macroadenomas, similar to that found in the group of microadenomas (84%, NS), while no post-surgical remission was observed in the 3 patients with no visible adenoma at MRI (p<0.01). Of the 8 patients not in remission after repeated TSS surgery, 3 underwent radiation therapy and three had bilateral adrenalectomy, allowing remission of their hypercortisolism. There was minor morbidity and no death.

CONCLUSION

While our overall results are in accordance with other published series, we show here that ACTH-secreting pituitary macroadenomas are usually not associated with a bad outcome, in contrast with patients with no visible adenoma at preoperative MRI.

Prospective evaluation of transsphenoidal pituitary surgery in 108 patients with Cushing's disease

Transsphenoidal pituitary surgery (TSS) remains the treatment of choice for Cushing's disease (CD). Despite the widespread acceptance of this procedure as the first line treatment in CD, the indication of a second TSS in not cured or relapsed DC patients is not consensus. We report the results of TSS in 108 patients with CD (a total of 117 surgeries). The mean postoperative follow-up period was 6 years. Remission was defined as clinical and laboratorial signs of adrenal insufficiency, period of glucocorticoid dependence, serum cortisol suppression on oral 1-mg dexamethasone overnight suppression test and clinical remission of hypercortisolism. We evaluated 103 patients with CD by the time of the first TSS. Fourteen patients underwent second TSS (5 had already been operated in others centers; in 5 patients the first surgery was not curative; in 4 patients CD relapsed). Remission rates were 85.4% and 28.6% (p < 0.001) after first and second TSS, respectively. In microadenomas, remission rates were higher than macroadenomas (94.9% vs. 73.9%; p = 0.006). In patients with negative pituitary imaging remission rates were 71.4% (p = 0.003; vs. microadenomas). Postoperative complications were: transient diabetes insipidus, definitive diabetes insipidus, hypopituitarism, stroke and one death. Only hypopituitarism was more frequent after second TSS (p = 0.015). In conclusion, TSS for CD is an effective and safe treatment. The best remission rates were observed at the first surgery and in microadenomas. The low remission rates after a second TSS suggest that this approach could not be a good therapeutic choice when the first one was not curative.

Midnight salivary cortisol determination for assessing the outcome of transsphenoidal surgery in Cushing's disease

CONTEXT

Midnight salivary cortisol (MSC) is now recognized as a reliable index for Cushing's syndrome diagnosis but has to be validated for the follow-up of treated patients.

OBJECTIVE

Our objective was to evaluate MSC for assessing the outcome of transsphenoidal surgery (TSS) in patients with Cushing's disease (CD).

DESIGN

We conducted a retrospective cohort study in a single center.

PATIENTS AND METHODS

Sixty-eight patients treated by TSS between 1996 and 2006 and followed for at least 6 months with postoperative MSC were included. Mean follow-up (+/- sd) was 45 +/- 31 months. Morning plasma cortisol was determined 5 d after TSS, and MSC and urinary cortisol (UC) were determined 6-12 months after surgery. The remission group included hypocortisolic (morning plasma cortisol < 50 ng/ml and/or insufficient response to cosyntropin) and eucortisolic (midnight plasma cortisol < 75 ng/ml and normal UC) patients. Patients in the treatment failure group had high midnight plasma cortisol and UC concentrations.

RESULTS

Fifty patients (74%) were in remission. Mean MSC was 0.7 +/- 0.4 ng/ml (range, 0.4-2.1 ng/ml) and 6.5 +/- 6.5 ng/ml (range, 2.1-27.2 ng/ml) for the remission and treatment failure groups, respectively (P = 0.001). A cutoff of 2 ng/ml for MSC gave a sensitivity of 100% and a specificity of 98% for treatment failure diagnosis, whereas UC less than 90 microg/d had a sensitivity of 71% and specificity of 98%. Postsurgical morning plasma cortisol less than or equal to 18 ng/ml had a sensitivity of 93% and specificity of 74%.

CONCLUSIONS

MSC is a simple, robust marker of remission after TSS for CD.

Treatment of haematogenous pyogenic vertebral osteomyelitis by single-stage anterior debridement, grafting of the defect and posterior instrumentation

Anterior debridement, grafting of the defect and posterior instrumentation as a single-stage procedure is a controversial method of managing pyogenic vertebral osteomyelitis. Between 1994 and 2005, 37 patients underwent this procedure at our hospital, of which two died and three had inadequate follow-up. The remaining 32 were reviewed for a mean of 36 months (12 to 66). Their mean age was 48 years (17 to 68). A significant pre-operative neurological deficit was present in 13 patients (41%). The mean duration of surgery was 285 minutes (240 to 360) and the mean blood loss was 900 ml (300 to 1600). Pyogenic organisms were isolated in 21 patients (66%). All patients began to mobilise on the second post-operative day. The mean hospital stay was 13.6 days (10 to 20). Appropriate antibiotics were administered for 10 to 12 weeks. Early wound infection occurred in four patients (12.5%), and late infection in two (6.3%). At final follow-up, the infection had resolved in all patients, neurological recovery was seen in ten of 13 (76.9%) and interbody fusion had occurred in 30 (94%). The clinical outcome was excellent or good in 30 patients according to Macnab's criteria. This surgical protocol can be used to good effect in patients with pyogenic vertebral osteomyelitis when combined with appropriate antibiotic therapy.

Transsphenoidal surgery for Cushing's disease: a review of success rates, remission predictors, management of failed surgery, and Nelson's Syndrome

Cushing's disease is a serious endocrinopathy that, if left untreated, is associated with significant morbidity and mortality rates. After diagnostic confirmation of Cushing's disease has been made, transsphenoidal adenomectomy is the treatment of choice. When a transsphenoidal adenomectomy is performed at experienced transsphenoidal surgery centers, long-term remission rates average 80% overall, surgical morbidity is low, and the mortality rate is typically less than 1%. In patients with well-defined noninvasive microadenomas, the long-term remission rate averages 90%. For patients in whom primary surgery fails, treatment options such as bilateral adrenalectomy, stereotactic radiotherapy or radiosurgery, total hypophysectomy, or adrenolytic medical therapy need to be carefully considered, ideally in a multidisciplinary setting. The management of Nelson's Syndrome often requires both transsphenoidal surgery and radio-therapy to gain disease control.

Stereotactic radiosurgery for Cushing disease: a review

✓ A contemporary review of the use of stereotactic radiosurgery in the treatment of Cushing disease (CD) is presented with information drawn from a literature review and from the author's experience. Stereotactic radiosurgery is an effective and safe therapeutic alternative for treating CD in carefully selected cases. Improvements in imaging, dose planning, and general understanding of radiobiology are likely to yield better results in the future.

Criteria of cure and remission in Cushing's disease: an update

We review the clinical and biochemical criteria used for evaluation of the transsphenoidal pituitary surgery results in the treatment of Cushing's disease (CD). Firstly, we discuss the pathophysiology of the hypothalamic-pituitary-adrenal axis in normal subjects and patients with CD. Considering the series published in the last 25 years, we observed a significant variation in the remission or cure criteria, including the choice of biochemical tests, timing, threshold values to define remission, and the interference of glucocorticoid replacement or previous treatment. In this context we emphasize serum cortisol levels obtained early (from hours to 12 days) in the postoperative period without any glucocorticoid replacement or treatment. Our experience demonstrates that: (i) early cortisol < 5 to 7 µg/dl, (ii) a period of glucocorticoid dependence > 6 mo, (iii) absence of response of cortisol/ACTH to CRH or DDAVP, (iv) return of dexamethasone suppression, and circadian rhythm of cortisol are appropriate indices of remission of CD. In patients with undetectable cortisol levels early after surgery, recurrence seems to be low. Finally, although certain biochemical patterns are more suggestive of remission or surgical failure, none has been proven to be completely accurate, with recurrence observed in approximately 10 to 15% of the patients in long-term follow-up. We recommended that patients with CD should have long-term monitoring of the CRH-ACTH-cortisol axis and associated co-morbidities, especially hypopituitarism, diabetes mellitus, hypertension, cardiovascular disturbances, and osteoporosis.

Prognostic factors for outcome after transsphenoidal hypophysectomy in dogs with pituitary-dependent hyperadrenocorticism

Object

The aim of this study was to determine prognostic factors for outcome after transsphenoidal hypophysectomy in dogs with pituitary-dependent hyperadrenocorticism (PDH).

Methods

One veterinary neurosurgeon performed transsphenoidal hypophysectomies in 181 dogs with PDH over a 12-year period. Survival analysis was performed with the Kaplan–Meier method. Prognostic factors were analyzed with the univariate Cox proportional hazard analysis followed by stepwise multivariate analysis. The log-rank test was used to assess disease-free fractions in three groups categorized according to early postoperative urinary corticoid/creatinine (C/C) ratios.

Results

Multivariate analysis revealed that old age, large pituitary size, and high preoperative concentrations of plasma adrenocorticotropic hormone were associated with an increased risk of PDH-related death. In addition, large pituitary size, thick sphenoid bone, high C/C ratio, and high concentration of plasma α-melanocyte–stimulating hormone (α-MSH) before surgery were associated with an increased risk of disease recurrence in the dogs that went into remission after hypophysectomy. Disease-free fractions were significantly higher in dogs with postoperative urinary C/C ratios in the lower normal range (< 5 × 10−6) than in dogs with postoperative C/C ratios in the upper normal range (5–10 × 10−6).

Conclusions

The results of this study indicate that pituitary size, sphenoid bone thickness, plasma α-MSH concentration, and preoperative level of urinary cortisol excretion are predictors of long-term remission after transsphenoidal hypophysectomy for PDH in dogs. Urinary C/C ratios measured 6 to 10 weeks after surgery can be used as a guide for predicting the risk of tumor recurrence.

Cushing disease: use of perioperative serum cortisol measurements in early determination of success following pituitary surgery

✓Despite many recent advances, management of cases of Cushing disease continues to be challenging. After complete resection of ACTH-secreting adenomas, patients develop transient ACTH deficiency requiring glucocorticoid replacement for several months. The current recommendation by many centers, including ours, for patients with ACTH-secreting adenomas is to withhold glucocorticoid therapy during and immediately after adenomectomy until there is clinical or biochemical evidence of ACTH deficiency. A serum cortisol level of less than 2 μg/dl within the first 48 hours after adenomectomy is a reliable biochemical marker of ACTH deficiency and is associated with clinical remission of Cushing disease. Higher serum cortisol levels in the immediate postoperative period should be interpreted with caution. The decision to immediately reexplore the sella turcica should be individualized, taking into account the findings at surgery, the histopathological findings, and the changes in serum cortisol levels as well as the patient's wishes and concerns. Optimal diagnosis and therapy for patients with Cushing disease require thorough and close coordination and involvement of all members of the management team.

National trends, complications, and outcomes following transsphenoidal surgery for Cushing's disease from 1993 to 2002

Object

Information about complications, patient outcomes, and mortality rate after transsphenoidal surgery (TSS) for Cushing's disease has been derived largely from single-institution series. In this study the authors report on inpatient death, morbidity, and outcomes following TSS for Cushing's disease on a national level.

Methods

All patients in the Nationwide Inpatient Sample (NIS) database who had undergone transsphenoidal resection of a pituitary tumor for Cushing's disease between 1993 and 2002 were included in the study. The number of cases per year, length of stay (LOS), and rates of inpatient complications, death, and adverse outcomes (death or discharge to institution other than home) were abstracted. Univariate and multivariate analyses were performed to determine the effects of patient and hospital characteristics on outcome measures.

Results

According to the NIS, there were an estimated 3525 cases of TSS for Cushing's disease in the US between 1993 and 2002. During this period, there was a trend toward a small increase in the number of TSSs for Cushing's disease. The in-hospital mortality rate was 0.7%, and the complication rate was 42.1%. Diabetes insipidus (15%), fluid and electrolyte abnormalities (12.5%), and neurological deficits (5.6%) were the most common complications reported. Multivariate analysis showed that complications were more likely in patients with pre-operative comorbidities. Patients older than 64 years were much more likely to have an adverse outcome (odds ratio [OR] 20.8) and a prolonged hospital stay (OR 2.2). Women were less likely than men to have an adverse outcome (OR 0.3). A single postoperative complication increased the mean LOS by 3 days, more than tripled the odds of an adverse outcome, and increased the hospital charges by more than US $7000.

Conclusions

The authors provided a national perspective on trends, inpatient complications, and outcomes after TSS for Cushing's disease in the US. Postoperative complications had a significantly negative effect on LOS, adverse outcome, and resource utilization. Advanced age and multiple preoperative comorbidities were identified as important risk factors, and their effects on patient outcomes were quantified.

Pitfalls in the management of Cushing’s disease

Cushing's disease is caused by functional corticotroph adenomas of the pituitary gland, most commonly noninvasive microadenomas. Transsphenoidal microsurgery is an effective means of control for patients with adrenocorticotrophic hormone-producing microadenomas. However, a wide variation of clinical outcomes and recurrence rates has been reported. The major causes of surgical failure in the treatment of Cushing's disease lies in inadequate preoperative evaluation, unsuccessful identification of the adenoma and inexperience of the surgeon. Furthermore, appropriate use of combination therapy, including surgery, radiotherapy, radiosurgery and adrenalectomy can improve the outcome. For optimal results in this rare disease, endocrinological, radiological and surgical procedures should be co-ordinated in a specialized center. In this review, factors affecting preoperative evaluation, surgical success and outcome are outlined in the light of current knowledge.

Early post-operative ACTH and cortisol as predictors of remission in Cushing's disease

AIM

To study the value of early (24 h) post-operative ACTH and serum cortisol as predictors of remission after transsphenoidal surgery in Cushing's disease.

METHODS

We prospectively studied 44 patients who underwent transsphenoidal surgery for Cushing's disease between 1997 and 2005. The mean follow-up period of patients after surgery was 49 months (19-102 months). The predictive value of clinical characteristics, pre-operative hormonal studies, radiological, surgical and histological findings, and post-operative hormonal studies were analysed. For the post-operative hormonal study plasma ACTH and serum cortisol were determined at 8.00 a.m. the day after surgery.

RESULTS

After surgery, Cushing's disease remitted in 39 patients (89%) and persisted in 5 patients (11%). Three patients relapsed during the follow-up period. Only three study variables were predictive of persistence of Cushing's disease after surgery: the non identification of the adenoma in histology (an adenoma was found in 87% of the patients in remission, and in 20% of treatment failures, p = 0.01), the early post-operative plasma ACTH (patients in remission: 2 pmol/L (1.1-10.8 pmol/L), treatment failures: 8.2 pmol/L (1.1-12 pmol/L), p = 0.019), and the early post-operative serum cortisol (patients in remission: 128.4 nmol/L (27.6-4644 nmol/L), treatment failures: 797 nmol/L (606-1037 nmol/L), p = 0.003). ROC curves indicated that plasma ACTH < or = 7.55 pmol/L distinguished patients in remission from treatment failures with 80% sensitivity and 97.4% specificity, and serum cortisol < or = 585 nmol/L with 100% sensitivity and 90% specificity.

CONCLUSIONS

Twenty-four hours after transsesphenoidal surgery for Cushing's disease, and without glucocorticoids replacement, patients with serum cortisol concentrations higher than 585 nmol/L, and/or plasma ACTH higher than 7.55 pmol/L, and/or those in which an adenoma is not identified in the histological study, have a high risk of treatment failure.