scholarly journals Outcome of using the histological pseudocapsule as a surgical capsule in Cushing disease

2009 ◽  
Vol 111 (3) ◽  
pp. 531-539 ◽  
Author(s):  
Jay Jagannathan ◽  
Rene Smith ◽  
Hetty L. DeVroom ◽  
Alexander O. Vortmeyer ◽  
Constantine A. Stratakis ◽  
...  
Keyword(s):  
Mr Imaging ◽  
Remission Rate ◽  
Pituitary Surgery ◽  
Anterior Lobe ◽  
Accurate Identification ◽  
Cushing Disease ◽  
Complete Excision ◽  
Imaging Results ◽  
Prospective Database

Object Many patients with Cushing disease still have active or recurrent disease after pituitary surgery. The histological pseudocapsule of a pituitary adenoma is a layer of compressed normal anterior lobe that surrounds the adenoma and can be used during surgery to identify and guide removal of the tumor. In this study the authors examined the results of using the pseudocapsule as a surgical capsule in the resection of adenomas in patients with Cushing disease. Methods The authors reviewed a prospective database of data obtained in patients with Cushing disease who underwent surgery. The analysis included all cases in which a lesion was identified during surgery and in which the lesion was believed to be confined to the pituitary gland in patients with Cushing disease between January 1990 and March 2007. Since the objective was to determine the success of using the pseudocapsule as a surgical capsule, patients with invasive tumors and patients in whom no lesion was identified during surgery—challenging cases for surgical success—were excluded from analysis. Results In 261 patients an encapsulated adenoma was identified at surgery. Tumor was visible on MR imaging in 135 patients (52%); in 126 patients (48%) MR imaging detected no tumor. The range of tumor size overlapped considerably in the groups with positive and negative MR imaging results, indicating that in addition to size other features of the adenoma influence the results of MR imaging. In 252 patients hypercortisolism resolved after the first operation, whereas in 9 patients (3 with positive MR imaging and 6 with negative MR imaging) early reoperation was required. Hypercortisolism resolved in all 261 patients (256 with hypocortisolism and 5 with eucortisolism) before hospital discharge. Forty-six patients (18%) had postoperative electrolyte abnormalities (30 with hyponatremia and 16 with diabetes insipidus), but only 2 patients required treatment at discharge. The mean clinical follow-up duration was 84 months (range 12–215 months). Six patients (2%) had recurrence of hypercortisolism, all of whom were treated successfully with reoperation. Conclusions Because of their small size, adenomas can be challenging to identify in patients with Cushing disease. Use of the histological pseudocapsule of an adenoma allows accurate identification of the tumor and helps guide its complete excision. With this approach the overall remission rate is high and the rate of complications is low.

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

2021 ◽  
Vol 12 ◽  
Author(s):  
Amit Akirov ◽  
Vincent Larouche ◽  
Ilan Shimon ◽  
Sylvia L. Asa ◽  
Ozgur Mete ◽  
...  
Keyword(s):  
Remission Rate ◽  
Retrospective Chart Review ◽  
Pituitary Surgery ◽  
Serum Cortisol ◽  
Outcome Data ◽  
Cushing Disease ◽  
Persistent Disease ◽  
Feedback Suppression ◽  
Biochemical Testing

BackgroundGlucocorticoid 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.MethodsThe 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.ResultsOf 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.ConclusionsCC 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.

scholarly journals Endoscopic transsphenoidal pituitary surgery: a good and safe primary treatment option for Cushing's disease, even in case of macroadenomas or invasive adenomas

2013 ◽  
Vol 169 (3) ◽  
pp. 329-337 ◽  
Author(s):  
M A E M Wagenmakers ◽  
H D Boogaarts ◽  
S H P P Roerink ◽  
H J L M Timmers ◽  
N M M L Stikkelbroeck ◽  
...  
Keyword(s):  
Treatment Option ◽  
Cushing’S Disease ◽  
Remission Rate ◽  
Pituitary Surgery ◽  
Primary Treatment ◽  
Endoscopic Technique ◽  
Cushing's Disease ◽  
Recurrence Rates ◽  
Transsphenoidal Pituitary Surgery

ContextAlthough the endoscopic technique of transsphenoidal pituitary surgery (TS) has been widely adopted, reports on its results in Cushing's disease (CD) are still scarce and no studies have investigated long-term recurrence rates. This is the largest endoscopic series published till now.ObjectiveTo gain insight into the role of endoscopic TS as a primary treatment option for CD, especially in patients with magnetic resonance imaging (MRI)-negative CD and (invasive) macroadenomas.DesignRetrospective cohort study.Patients and methodsThe medical records of 86 patients with CD who underwent endoscopic TS were examined. Data on preoperative and postoperative evaluation, perioperative complications, and follow-up were collected. Remission was defined as disappearance of clinical symptoms with a fasting plasma cortisol level ≤50 nmol/l either basal or after 1 mg dexamethasone.ResultsThe remission rate in different adenoma subclasses varied significantly: 60% in MRI-negative CD (n=20), 83% in microadenomas (n=35), 94% in noninvasive macroadenomas (n=16), and 40% in macroadenomas that invaded the cavernous sinus (n=15). The recurrence rate was 16% after 71±39 months of follow-up (mean±s.d., range 10–165 months).ConclusionsEndoscopic TS is a safe and effective treatment for all patients with CD. Recurrence rates after endoscopic TS are comparable with those reported for microscopic TS. Our data suggest that in patients with noninvasive and invasive macroadenomas, the endoscopic technique of TS should be the treatment of choice as remission rates seem to be higher than those reported for microscopic TS, although no comparative study has been performed.

scholarly journals Current state of the art in the diagnosis and surgical treatment of Cushing disease: early experience with a purely endoscopic endonasal technique

2007 ◽  
Vol 23 (3) ◽  
pp. 1-8 ◽  
Author(s):  
Amir R. Dehdashti ◽  
Fred Gentili
Keyword(s):  
Surgical Treatment ◽  
Cavernous Sinus ◽  
Pituitary Surgery ◽  
Magnetic Resonance Images ◽  
Primary Therapy ◽  
Cushing Disease ◽  
Endoscopic Endonasal ◽  
Number Of Patients ◽  
Free Cortisol

Object Transsphenoidal pituitary surgery is the primary therapy for Cushing disease because of its potential to produce lasting remission without the need for long-term drug or hormone replacement therapy. The authors evaluated the current role of pure endoscopic endonasal pituitary surgery in the treatment of Cushing disease. Methods Twenty-five patients underwent pure endoscopic surgery for confirmed Cushing disease. Thirteen patients had microadenomas and seven had macroadenomas; magnetic resonance images obtained in five patients were only suspicious or nondiagnostic, and thus they underwent inferior petrosal sinus sampling. Two patients had evidence of cavernous sinus involvement. Final histological results were consistent with adrenocorticotropin hormone (ACTH)–secreting adenoma in 20 patients. Results Twenty patients (80%) had clinical remission and laboratory confirmation of hypocortisolemia (serum cortisol < 100 nmol/L requiring substitution therapy), suppression to low-dose dexamethasone, and normal 24-hour urinary free cortisol. The median follow-up period was 17 months (range 3–32 months). There was no recurrence at the time of the last follow-up. Three patients presented with new anterior pituitary deficiency, but no one had permanent diabetes insipidus. In one patient a cerebrospinal fluid leak developed but later resolved following lumbar drainage. Treatment failure was attributable to involvement of the cavernous sinus in two patients, incomplete tumor removal in one, negative exploration in one, and nodular corticotroph hyperplasia of the pituitary gland in one. Conclusions Early results indicated that endoscopic endonasal surgery is a safe and effective treatment for ACTH-producing adenomas. The rate of remission in this study is comparable to those in previous series, and the rate of major postoperative complications is extremely low. Further studies with a larger number of patients and longer follow-ups are required to determine whether this more minimally invasive pure endoscopic approach should become the standard of care for the surgical treatment of Cushing disease.

Characteristics of thoracolumbar intramedullary subependymomas

2009 ◽  
Vol 10 (1) ◽  
pp. 54-59 ◽  
Author(s):  
Berk Orakcioglu ◽  
Peter Schramm ◽  
Patricia Kohlhof ◽  
Alfred Aschoff ◽  
Andreas Unterberg ◽  
...  
Keyword(s):  
Adjuvant Therapy ◽  
Mr Imaging ◽  
Neurological Outcome ◽  
Tumor Recurrence ◽  
Medial Septum ◽  
Low Grade ◽  
Complete Excision ◽  
Spinal Cord Dysfunction ◽  
Favorable Neurological Outcome

Object Thoracolumbar intraspinal subependymomas are very rare intramedullary low-grade tumors. The authors report on the clinical and morphological features of 2 cases of thoracolumbar intraspinal subependymomas and provide midterm follow-up data. Methods The clinical and radiological profiles of 2 patients with progressive spinal cord dysfunction due to thoracolumbar intraspinal subependymomas were retrospectively studied and compared with previously reported cases. Results Patients with intraspinal subependymomas initially presented with back pain and long-tract signs. The tumors were hyperintense on T2-weighted MR imaging, isointense on T1-weighted imaging, and noncontrast enhancing. Within 1 of the tumors, a medial septum was present on axial T2-weighted imaging. The tumors were intramedullary but grew exophytically and were amenable to gentle surgical separation from normal neural structures. Therefore, gross-total resection was feasible, and neurological outcome was good. No further adjuvant therapy was conducted. On follow-up (at 58 and 18 months, respectively), no tumor recurrence was observed. Conclusions Symptomatic thoracolumbar intraspinal subependymomas with a distinct appearance on MR imaging are amenable to complete excision with favorable neurological outcome. In this study no tumor recurrence was observed at midterm follow-up in either patient, neither of whom underwent adjuvant therapy.

scholarly journals Intraoperative magnetic resonance imaging–assisted transsphenoidal pituitary surgery in patients with acromegaly

2010 ◽  
Vol 29 (4) ◽  
pp. E9 ◽  
Author(s):  
David Bellut ◽  
Martin Hlavica ◽  
Christoph Schmid ◽  
René L. Bernays
Keyword(s):  
Pituitary Adenomas ◽  
High Field ◽  
Remission Rate ◽  
Tumor Resection ◽  
Surgical Techniques ◽  
Length Of Hospital Stay ◽  
Residual Tumor ◽  
Imaging Results ◽  
Duration Of Surgery

Object Acromegaly is a rare disease, usually caused by a growth hormone (GH)–producing pituitary adenoma. If untreated, severe cardiovascular, metabolic, cosmetic, and orthopedic disturbances will result. Surgery is generally recommended as the first-line treatment. Transsphenoidal surgical techniques were recently extended by the introduction of intraoperative MR (iMR) imaging. In the present study, the contribution of ultra-low-field (0.15-T) iMR imaging to tumor resection, complication avoidance, and endocrinological and neurological outcome was analyzed. Methods A series of 39 consecutive transsphenoidal iMR imaging–guided (using the PoleStar N20 device) surgical procedures performed between September 2005 and August 2009 for GH-producing pituitary adenomas was retrospectively analyzed. In addition to the patients' clinical data, the following criteria were evaluated independently: duration of surgery; length of hospital stay; endocrinological parameters; results of neurological examinations; and pre-, post-, and intraoperative MR imaging results. Results Thirty-seven patients with acromegaly underwent 39 transsphenoidal surgeries for pituitary adenomas. During a median follow-up period of 30 months (range 9–56 months), the remission rate was 73.5% in 34 patients with primary surgery and 20% in 5 cases with previous surgery; overall the remission rate was 66.7%. There were no serious postoperative complications. Detection of tumor remnant on iMR imaging led to a 5.1% increase in remission rate. Conclusions In this largest study to date of GH-producing pituitary adenomas in which iMR imaging–guided transsphenoidal surgery was analyzed, the results suggest that this method is a highly effective and safe treatment modality, even compared with previously published surgical series in which high-field iMR imaging was used. Limitations of iMR imaging are the detection of small residual tumor in the cavernous sinus and persisting disease that could not be observed, even on diagnostic high-field follow-up MR images. This points to a general limitation regarding remission rates that can be achieved using iMR imaging. Nevertheless, iMR imaging led to an increase of the remission rate in this study.

Whole-Sellar Stereotactic Radiosurgery for Functioning Pituitary Adenomas

Neurosurgery ◽  
2014 ◽  
Vol 75 (3) ◽  
pp. 227-237 ◽  
Author(s):  
Cheng-Chia Lee ◽  
Ching-Jen Chen ◽  
Chun-Po Yen ◽  
Zhiyuan Xu ◽  
David Schlesinger ◽  
...  
Keyword(s):  
Stereotactic Radiosurgery ◽  
Pituitary Adenomas ◽  
Maximum Dose ◽  
Remission Rate ◽  
Inclusion Criteria ◽  
Cushing Disease ◽  
Radiation Delivery ◽  
Median Margin ◽  
New Onset

Abstract BACKGROUND: Functioning pituitary adenomas (FPAs) can be difficult to delineate on postoperative magnetic resonance imaging, making them difficult targets for stereotactic radiosurgery (SRS). In such cases, radiation delivery to the entire sella has been utilized as a radiosurgical equivalent of a total hypophysectomy. OBJECTIVE: To evaluate the outcomes of a cohort of patients with FPA who underwent SRS to the whole-sellar region. METHODS: This is a retrospective review of patients who underwent whole-sellar SRS for FPA between 1989 and 2012. Sixty-four patients met the inclusion criteria: they were treated with whole-sellar SRS following surgical resection for persistently elevated hormone levels, and (1) no visible lesions on imaging studies and/or (2) tumor infiltration of dura or adjacent venous sinuses observed at the time of a prior resection. The median radiosurgical volume covering sellar structures was 3.2 mL, with a median margin dose of 25 Gy. RESULTS: The median endocrine follow-up was 41 months; 22 (68.8%) patients with acromegaly, 20 (71.4%) patients with Cushing disease, and 2 (50.0%) patients with prolactinoma achieved endocrine remission. The 2-, 4-, and 6-year actuarial remission rates were 54%, 78%, and 87%, respectively. New-onset neurological deficit was found in 4 (6.3%) patients following treatment. New-onset hypopituitarism was observed in 27 (43.5%) patients, with panhypopituitarism in 2 (3.2%). Higher margin/maximum dose were significantly associated with a higher remission rate and development of post-SRS hypopituitarism. CONCLUSION: Whole-sellar SRS for invasive or imaging-negative FPA following failed resection can offer reasonable rates of endocrine remission. Hypopituitarism following whole-sellar SRS is the most common complication.

scholarly journals Recovery of Adrenal Function after Pituitary Surgery in Patients with Cushing Disease: Persistent Remission or Recurrence?

2019 ◽  
Vol 108 (3) ◽  
pp. 211-218 ◽  
Author(s):  
Andreea Liliana Serban ◽  
Elisa Sala ◽  
Giulia Carosi ◽  
Giulia Del Sindaco ◽  
Claudia Giavoli ◽  
...  
Keyword(s):  
Surgical Intervention ◽  
Pituitary Surgery ◽  
Disease Recurrence ◽  
Adrenal Function ◽  
Surgical Removal ◽  
Cushing Disease ◽  
Adult Age ◽  
First Line Therapy ◽  
Acth Secreting

Background: Cushing disease (CD) represents the principal cause of endogenous hypercortisolism. The first-line therapy of CD is surgical removal of the ACTH-secreting pituitary adenoma, which is generally followed by adrenal insufficiency (AI). Objective: To analyze the recovery of AI in patients with CD after pituitary surgery in relation with recurrence and persistent remission of CD. Patients and Methods: We performed a retrospective analysis of patients with CD who met the following inclusion criteria: adult age, presence of AI 2 months after the surgical intervention, and a minimum follow-up of 3 years after the surgical intervention. Results: Sixty-one patients were followed for a median of 6 years. Ten (16.4%) patients recurred during follow-up. The patients who restored adrenal function did so after a median time of 19 months, with a significantly shorter time in the recurrence group (12.5 vs. 25 months, p = 0.008). All 10 patients who recurred recovered their adrenal function within 22 months. The recovery rate of AI in the persistent remission group was 37.3% (19/51) at 3 years and 55.8% (24/43) at 5 years. In all patients the duration of AI was negatively associated with disease recurrence. Conclusion: The duration of postsurgical AI in patients with recurrent CD is significantly shorter than that in patients with persistently remitted CD, and this parameter may be a useful predictor of recurrence. Patients showing a normal pituitary-adrenal axis within 2 years after surgery should be strictly monitored as they are at higher risk of disease relapse.

Evolving criteria for post-operative biochemical remission of acromegaly: can we achieve a definitive cure? An audit of surgical results on a large series and a review of the literature.

2003 ◽  
pp. 611-619 ◽  
Author(s):  
G Minniti ◽  
M-L Jaffrain-Rea ◽  
V Esposito ◽  
A Santoro ◽  
G Tamburrano ◽  
...  
Keyword(s):  
Remission Rate ◽  
Univariate Analysis ◽  
Pituitary Surgery ◽  
Large Series ◽  
Pituitary Function ◽  
Oral Glucose ◽  
Surgical Results ◽  
Age Related ◽  
Biochemical Remission

Criteria to define the biochemical remission of acromegaly following surgery have changed over the years, and the current use of stringent criteria needs a critical re-evaluation of the surgical results. On the other hand, few data are currently available concerning the possible impact of pituitary surgery on the quality of life of operated acromegalic patients. In this prospective study, we wished to evaluate the initial outcome and long-term recurrence rate in a large series of acromegalic patients operated on by transsphenoidal surgery (TSS), to carefully analyse predictive factors for surgical outcome and to point out possible additional effects of surgery in these patients. Ninety-two out of 98 operated patients could be considered for follow-up. Biochemical remission was strictly defined as plasma GH levels <1 ng/ml during an oral glucose tolerance test (OGTT) and normalisation of age-related IGF-I levels. Hormonal assessment, including an OGTT, was performed 6 months following surgery and then annually to evaluate pituitary function. Fifty-five per cent of patients achieved a biochemical remission of acromegaly. The remission rate at 6 months was 80% for patients with microadenoma and 50% for macroadenoma. Univariate analysis showed that a large extrasellar extension, preoperative high GH levels and dural invasion were correlated with a poor outcome of surgery while, according to multivariate analysis, only invasion of cavernous sinus and preoperative GH levels > 10 ng/ml were independent negative predictors. Mortality was 0% and the overall complication rate was about 10%. Pituitary function worsened in five patients but improved in 16 out of 30 patients with preoperative pituitary defects. No recurrence was observed during a median follow-up of about 8 years. We conclude that TSS is able to achieve a biochemical remission in more than half of acromegalic patients, and that the current criteria for remission seem to indicate a cure in most cases.

scholarly journals Surgical outcomes and multidisciplinary management strategy of Cushing’s disease: a single-center experience in China

2020 ◽  
Vol 48 (6) ◽  
pp. E7 ◽  
Author(s):  
Keyi Zhang ◽  
Ming Shen ◽  
Nidan Qiao ◽  
Zhengyuan Chen ◽  
Wenqiang He ◽  
...  
Keyword(s):  
Cushing’S Disease ◽  
Surgical Outcomes ◽  
Management Strategy ◽  
Remission Rate ◽  
Pituitary Surgery ◽  
Multivariate Regression Analysis ◽  
Cushing's Disease ◽  
Endoscopic Endonasal ◽  
Remission Rates

OBJECTIVEThe primary aim of this study was to investigate the value of multidisciplinary team (MDT) management in treating patients with Cushing’s disease (CD). The secondary aim was to assess the concordance of bilateral inferior petrosal sinus sampling (BIPSS) lateralization with intraoperative observations.METHODSThe authors recruited 124 consecutive patients (128 procedures) who had undergone endoscopic endonasal resection of adrenocorticotropic hormone–secreting pituitary adenomas from May 2014 to April 2018 and assessed their clinical characteristics, surgical outcomes, and adjuvant therapies. The criteria for surgical remission were normalized serum and urinary cortisol levels, which could be suppressed by a low-dose dexamethasone suppression test at 3-months’ follow-up without adjuvant treatment.RESULTSThe remission rates of the 113 patients with long-term follow-up (20.3 ± 12.2 months) were 83.2% after surgery alone and 91.2% after adjuvant therapy. The surgical remission rates of macroadenomas, MRI-visible microadenomas, and MRI-negative tumors were 66.7% (12/18), 89.3% (67/75), and 75% (15/20), respectively (p = 0.039). The surgical remission rates had a trend of improvement during the study period (87.5% in 2017–2018 vs 76.5% in 2014, p = 0.517). Multivariate regression analysis showed that a history of previous pituitary surgery (OR 0.300, 95% CI 0.100–0.903; p = 0.032) and MRI-visible microadenoma (OR 3.048, 95% CI 1.030–9.019; p = 0.044) were independent factors influencing surgical remission. The recurrence rate was 3.2% after a mean of 18 months after surgery. The remission rate of postoperative MDT management in patients with persistent disease was higher than non-MDT management (66.7% vs 0%, p = 0.033). In cases with preoperative BIPSS lateralization, 84.6% (44/52) were concordant with intraoperative findings.CONCLUSIONSMRI-visible microadenoma and primary surgery were independent predictors of surgical remission in CD. The MDT management strategy helps to achieve a better overall outcome. BIPSS may help to lateralize the tumor in MRI-negative/equivocal microadenomas.

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