Cushing's disease with pituitary apoplexy leading to hypopituitarism, empty sella, and spontaneous fracture of the dorsum sellae

1979 ◽  
Vol 51 (6) ◽  
pp. 866-869 ◽  
Author(s):  
Philip H. Gutin ◽  
William G. Cushard ◽  
Charles B. Wilson
Keyword(s):  
Pituitary Adenoma ◽  
Cushing’S Disease ◽  
Plasma Cortisol ◽  
Pituitary Apoplexy ◽  
Empty Sella ◽  
Cushing's Disease ◽  
Content Type ◽  
Urinary Levels ◽  
Fine Print ◽  
Transsphenoidal Resection

✓ A patient with a pituitary adenoma secreting adrenocorticotropin hormone manifested panhypopituitarism after an episode of pituitary apoplexy. The previously elevated urinary levels of 17-ketogenic steroids dropped sharply, and plasma cortisol became undetectable. The apoplexy also resulted in a partially empty sella on which the dorsum sellae collapsed. Recurrent Cushing's disease developed and was cured by transsphenoidal resection of a microadenoma.

Radiosurgery for Cushing's disease after failed transsphenoidal surgery

2000 ◽  
Vol 93 (5) ◽  
pp. 738-742 ◽  
Author(s):  
Jonas M. Sheehan ◽  
Mary L. Vance ◽  
Jason P. Sheehan ◽  
Dilantha B. Ellegala ◽  
Edward R. Laws
Keyword(s):  
Gamma Knife ◽  
Cushing’S Disease ◽  
Tumor Size ◽  
Transsphenoidal Surgery ◽  
Gamma Knife Radiosurgery ◽  
Magnetic Resonance Images ◽  
Cushing's Disease ◽  
Content Type ◽  
Fine Print

Object. Although transsphenoidal surgery has become the standard of care for Cushing's disease, it is often unsuccessful in normalizing cortisol production. In this study the authors investigate the safety and efficacy of gamma knife radiosurgery (GKRS) for Cushing's disease after failed transsphenoidal surgery.Methods. The records of all patients who underwent GKRS at the authors' institution after unsuccessful transsphenoidal surgery for Cushing's disease were retrospectively reviewed. Successful treatment was considered a normal or below-normal 24-hour urinary free cortisol (UFC) level. Records were also evaluated for relapse, new-onset endocrine deficiencies, interval change in tumor size, and visual complications.Forty-three patients underwent 44 gamma knife procedures with follow up ranging from 18 to 113 months (mean 39.1, median 44 months). Normal 24-hour UFC levels were achieved in 27 patients (63%) at an average time from treatment of 12.1 months (range 3–48 months). Three patients had a recurrence of Cushing's disease at 19, 37, and 38 months, respectively, after radiosurgery. New endocrine deficiencies were noted in seven patients (16%). Follow-up magnetic resonance images obtained in 33 patients revealed a decrease in tumor size in 24, no change in nine, and an increase in size in none of the patients. One patient developed a quadrantanopsia 14 months after radiosurgery despite having received a dose of only 0.7 Gy to the optic tract.Conclusions. Gamma knife radiosurgery appears to be safe and effective for the treatment of Cushing's disease refractory to pituitary surgery. Delayed recurrences and new hormone deficiencies may occur, indicating the necessity for regular long-term follow up.

Multiple pituitary adenomas in Cushing's disease

2000 ◽  
Vol 93 (5) ◽  
pp. 753-761 ◽  
Author(s):  
John K. Ratliff ◽  
Edward H. Oldfield
Keyword(s):  
Cushing’S Disease ◽  
Medical Records ◽  
Pituitary Adenomas ◽  
Cushing's Disease ◽  
Clinical Database ◽  
Null Cell ◽  
Content Type ◽  
Initial Surgery ◽  
Repeated Surgery ◽  
Fine Print

Object. Clinically evident multiple pituitary adenomas rarely occur. The authors assess the incidence and clinical relevance of multiple adenomas in Cushing's disease.Methods. A prospective clinical database of 660 pituitary surgeries was analyzed to assess the incidence of multiple pituitary adenomas in Cushing's disease. Relevant radiographic scans, medical records, and histopathological reports were reviewed.Thirteen patients with at least two separate histopathologically confirmed pituitary adenomas were identified. Prolactinomas (nine patients) were the most common incidental tumors. Other incidental tumors included secretors of growth hormone ([GH], one patient) and GH and prolactin (two patients), and a null-cell tumor (one patient). In two patients, early repeated surgery was performed because the initial operation failed to correct hypercortisolism, in one instance because the tumor excised at the initial surgery was a prolactinoma, not an adrenocorticotropic hormone—secreting tumor. One patient had three distinct tumors.Conclusions. Multiple pituitary adenomas are rare, but may complicate management of patients with pituitary disease.

Localization of pituitary adenomas by using intraoperative ultrasoound pituitary in patients with Cushing's disease and no demonstrable tumor on magnetic resonance imaging

1998 ◽  
Vol 89 (6) ◽  
pp. 927-932 ◽  
Author(s):  
Joe C. Watson ◽  
Thomas H. Shawker ◽  
Lynnette K. Nieman ◽  
Hetty L. DeVroom ◽  
John L. Doppman ◽  
...  
Keyword(s):  
Magnetic Resonance ◽  
Mr Imaging ◽  
Cushing’S Disease ◽  
Pituitary Adenomas ◽  
Pituitary Surgery ◽  
Intraoperative Ultrasonography ◽  
Cushing's Disease ◽  
Content Type ◽  
Negative Findings ◽  
Fine Print

Object. Pituitary surgery has been reported to produce remission of Cushing's disease with preservation of pituitary function in only 60 to 70% of patients. The inability to identify an adenoma accounts for most failed sellar explorations. Most negative surgical explorations occur in patients in whom magnetic resonance (MR) imaging of the pituitary demonstrates normal findings, which happens in at least 35 to 45% of patients with Cushing's disease. Methods. To examine the usefulness of intraoperative ultrasonography (IOUS) for identifying an adenoma in patients with no demonstrable tumor (negative findings) on pituitary MR imaging, we prospectively assessed the results of IOUS in 68 patients with a negative (59 patients) or equivocal (nine patients) MR image from a consecutive series of 107 patients with Cushing's disease (64%). We compared surgical findings and outcomes in these 68 patients with a group of 68 patients with Cushing's disease and negative findings on MR imaging in whom IOUS was not available. Intraoperative ultrasonography localized a tumor in 47 (69%) of 68 patients with negative findings on MR imaging. Surprisingly, the size of the adenomas that were detected with IOUS compared with the size of those not detected did not differ (6.8 ± 3.4 mm compared with 6.1 ± 2.8 mm [mean ± standard deviation], respectively [p = 0.5]). In four patients, no adenoma was found at surgery or in the pathological specimen (“true negative”). In eight patients, nine abnormalities detected by IOUS that were suspected adenomas were negative on exploration (“false positive”). Thus, IOUS has a sensitivity of 73% and a positive predictive value of 84% for detecting pituitary adenomas in patients with Cushing's disease and negative findings on MR imaging. Compared with the 68 patients who did not undergo IOUS, remission after surgery was improved (61 patients [90%] compared with 57 patients [84%]), the number of tumors found on exploration was increased (61 tumors compared with 51 tumors; p = 0.02), and the number of hemihypophysectomies was decreased (five compared with 15; p = 0.02) with IOUS. When the groups were compared after excluding patients with prior pituitary surgery, tumors were found in 91% versus 72% (p = 0.008), and remission occurred in 95% versus 87% of patients, respectively, in the groups that had or did not have IOUS. Conclusions. The IOUS is a sensitive imaging modality when used in patients with Cushing's disease in whom findings on pituitary MR imaging are negative. The improved ability to detect and localize these tumors by using IOUS positively affects surgical outcome.

Intrasellar persistent trigeminal artery associated with a pituitary adenoma

1989 ◽  
Vol 70 (2) ◽  
pp. 271-273 ◽  
Author(s):  
K. Stuart Lee ◽  
David L. Kelly
Keyword(s):  
Pituitary Adenoma ◽  
Sella Turcica ◽  
Preoperative Imaging ◽  
Persistent Trigeminal Artery ◽  
Pituitary Macroadenoma ◽  
Trigeminal Artery ◽  
Imaging Studies ◽  
Content Type ◽  
Fine Print ◽  
Transsphenoidal Resection

✓ The case of a patient with Cushing's disease and a pituitary macroadenoma, who also had a persistent trigeminal artery coursing through the sella turcica on preoperative imaging studies, is presented. The patient was treated by transsphenoidal resection of the tumor.

Intraoperative ultrasound-directed resection of pituitary tumors

1995 ◽  
Vol 83 (2) ◽  
pp. 225-230 ◽  
Author(s):  
Zvi Ram ◽  
Thomas H. Shawker ◽  
Mary H. Bradford ◽  
John L. Doppman ◽  
Edward H. Oldfield
Keyword(s):  
Mr Imaging ◽  
Cushing’S Disease ◽  
Intraoperative Ultrasound ◽  
Pituitary Tumors ◽  
Thyroid Stimulating Hormone ◽  
Cushing's Disease ◽  
Content Type ◽  
Normal Pituitary Gland ◽  
Intraoperative Localization ◽  
Fine Print

✓ Microadenomas of the pituitary vary in size, particularly those related to Cushing's disease. They are often not visualized on preoperative magnetic resonance (MR) imaging and may be difficult to find during surgical exploration of the pituitary. To enhance intraoperative localization of pituitary adenomas, we assessed the feasibility of using ultrasound to detect and localize pituitary tumors. Intraoperative ultrasound (IS) in the axial and sagittal planes was performed with an Intrascan system using a 12-MHz mechanically oscillating, end-firing transducer. Interpretation of the scans was performed by two individuals, who were usually blinded to the results of preoperative MR imaging or petrosal sinus sampling. Twenty-eight patients were examined. Eighteen of these patients had microadenomas (1.5–7 mm), all with Cushing's disease; nine had macroadenomas (10–20 mm), three of which were adrenocorticotropic hormone—secreting, three growth hormone—secreting, two thyroid-stimulating hormone—secreting, and one nonfunctioning; and one patient had an intrasellar craniopharyngioma. Normal sellar and parasellar structures, such as intrapituitary cysts, the intracavernous carotid arteries, and the diaphragma sella were easily visualized. Twenty-three of the 28 tumors, including 13 of the 18 microadenomas, were detected on IS (82% sensitivity). Tumors were seen as hyperechoic masses in 19 patients, mixed echogenicity in three, and isoechoic in one. In most macroadenomas IS allowed visualization of the interface between the tumor and the normal pituitary gland. These results indicate the potential of IS to aid the intraoperative localization and definition of pituitary tumors.

Surgical treatment of Cushing's disease

1987 ◽  
Vol 66 (2) ◽  
pp. 204-212 ◽  
Author(s):  
William F. Chandler ◽  
David E. Schteingart ◽  
Ricardo V. Lloyd ◽  
Paul E. McKeever ◽  
Gloria Ibarra-Perez
Keyword(s):  
Cushing’S Disease ◽  
Immunohistochemical Staining ◽  
Adrenocorticotropic Hormone ◽  
Cushing's Disease ◽  
Content Type ◽  
Acth Secreting ◽  
Endocrine Symptoms ◽  
Lung Carcinoid ◽  
Fine Print ◽  
Pharyngeal Pituitary

✓ The endocrinological, radiological, surgical, and pathological experience with 34 consecutive patients operated on for Cushing's disease is presented. Preoperative endocrine evaluation demonstrated that 19 patients had “typical” endocrine patterns for pituitary adrenocorticotropic hormone (ACTH)-dependent hypercortisolism and 11 had “atypical” testing. Pituitary pathology was found in 95% of the patients with typical preoperative endocrine testing but in only 55% of those with atypical testing. Eight of 34 preoperative computerized tomography scans demonstrated tumors, which correlated in all instances with the surgical findings. Microadenomas were removed from 25 patients, 22 of whom achieved postoperative remission of endocrine symptoms. Macroadenomas were found in three patients, only one of whom achieved remission after surgery. One patient had removal of an adenoma in the pharyngeal pituitary, and in another an ectopic lung carcinoid was excised; both of these patients were in postoperative remission. Four patients underwent transsphenoidal exploration but no definitive explanation was found for their hypercortisolism; these patients were not in remission. Immunohistochemical staining was performed on every specimen and all tumors showed excessive ACTH-secreting cells. A new rapid stain of the fibrovascular stroma is described.

Selective excision of adenomas originating in or extending into the pituitary stalk with preservation of pituitary function

1997 ◽  
Vol 87 (3) ◽  
pp. 343-351 ◽  
Author(s):  
R. Bryan Mason ◽  
Lynnette K. Nieman ◽  
John L. Doppman ◽  
Edward H. Oldfield
Keyword(s):  
Cushing’S Disease ◽  
Pituitary Tumors ◽  
Optic Chiasm ◽  
Anterior Lobe ◽  
Pituitary Function ◽  
Pituitary Stalk ◽  
Cushing's Disease ◽  
Content Type ◽  
Suprasellar Cistern ◽  
Fine Print

✓ When the surgeon identifies an adenoma within the gland and selectively excises it, endocrine-active pituitary tumors are usually cured and pituitary function is preserved. Occasionally ectopic adenomas arise primarily in the pituitary stalk or arise superiorly in the midportion of the anterior lobe and extend upward within the stalk. To determine if these tumors can be selectively excised with preservation of pituitary function, the authors examined the outcome of selective adenomectomy in 10 patients with Cushing's disease with an ectopic adenoma originating in, and confined to, the stalk (four microadenomas) or an adenoma extending superiorly through the diaphragma sella and into the stalk (five microadenomas and one macroadenoma) from an operative series of 516 patients with Cushing's disease. To reach the adenoma transsphenoidally in these patients, the diaphragma sella was incised anteroposteriorly in the midline to the anterior edge of the stalk, the suprasellar cistern was entered, and the adenoma was selectively excised using care to limit injury to the infundibulum. After selective adenomectomy, Cushing's disease remitted in all patients. All patients were hypocortisolemic immediately after surgery and required hydrocortisone for up to 21 months. Apart from the adrenal axis, pituitary function was normal in five patients in the immediate postoperative period, including two patients with tumors confined to the stalk and three patients with preoperative hypothyroidism (one patient) and/or hypogonadism (three patients). Three others with transient postoperative hypothyroidism (one patient) or diabetes insipidus (two patients) had normal pituitary function within 7 months of surgery. One patient with hypothyroidism and one with hypogonadism before surgery had panhypopituitarism postoperatively. A patient with a microadenoma located high in the stalk next to the optic chiasm had bitemporal hemianopsia postoperatively. These results demonstrate the feasibility of achieving curative transsphenoidal resection and preservation of pituitary function in cases of pituitary adenomas that are confined to the pituitary stalk or tumors that extend superiorly within the stalk from an intrasellar origin.

Repeat transsphenoidal surgery for Cushing's disease

1989 ◽  
Vol 71 (4) ◽  
pp. 520-527 ◽  
Author(s):  
Robert B. Friedman ◽  
Edward H. Oldfield ◽  
Lynnette K. Nieman ◽  
George P. Chrousos ◽  
John L. Doppman ◽  
...  
Keyword(s):  
Cushing’S Disease ◽  
Transsphenoidal Surgery ◽  
Ct Scanning ◽  
Pituitary Surgery ◽  
Cushing's Disease ◽  
Repeat Surgery ◽  
Content Type ◽  
Preoperative Ct ◽  
Pituitary Irradiation ◽  
Fine Print

✓ Transsphenoidal resection of adrenocorticotrophic hormone (ACTH)-producing pituitary adenomas has the potential of curing most patients with Cushing's disease. However, transsphenoidal exploration of the pituitary is not always curative, and patients who have remission of hypercortisolism following surgery occasionally develop a recurrence. Whether repeat pituitary surgery should be performed for recurrent or persistent Cushing's disease has not been evaluated previously. To determine the efficacy of transsphenoidal surgery in recurrent or persistent Cushing's disease, we performed transsphenoidal surgery in 31 patients (22 women and nine men) who had previously undergone a transsphenoidal operation and two female patients who had had previous pituitary irradiation only. In 24 (73%) of the 33 patients, remission of hypercortisolism was achieved by surgery. Although preoperative computerized tomography (CT) scanning identified an adenoma in only three of the 33 patients, in 20 patients a discrete adenoma was identified at pituitary exploration. The incidence of remission of hypercortisolism was greatest if an adenoma was identified at surgery and the patient received selective adenomectomy (19, or 95% of 20 patients), if there was evidence at surgery or by preoperative CT scanning that the previous surgical exposure of the pituitary was incomplete (seven, or 78% of nine patients), if an adenoma was seen on preoperative CT scanning (three of three patients), or if the patient had had prior pituitary irradiation without surgery (two of two patients). In contrast, only five (42%) of 12 patients who received subtotal or total hypophysectomy had remission of hypercortisolism. Surgically induced hypopituitarism occurred in six (50%) of these 12 patients, but in only one (5%) of the 20 patients who underwent selective adenomectomy. Three (13%) of the 24 patients who were in remission from hypercortisolism following repeat surgery developed recurrent hypercortisolism 10 to 47 months postoperatively. Repeat transsphenoidal exploration of the pituitary and treatment limited to selective adenomectomy should be considered in patients with hypercortisolism despite previous pituitary treatment. If an adenoma is identified during surgery, the chance of remission of Cushing's disease is high and the risk of hypopituitarism is low; however, if no adenoma can be found and partial or complete hypophysectomy is performed, remission of hypercortisolism is less likely and the risk of hypopituitarism is about 50%.

Usefulness of inferior petrosal sinus venous endocrine markers in Cushing's disease

1988 ◽  
Vol 68 (2) ◽  
pp. 205-210 ◽  
Author(s):  
John Zovickian ◽  
Edward H. Oldfield ◽  
John L. Doppman ◽  
Gordon B. Cutler ◽  
D. Lynn Loriaux
Keyword(s):  
Cushing’S Disease ◽  
Venous Blood ◽  
Pituitary Hormones ◽  
Cushing's Disease ◽  
Ectopic Acth Syndrome ◽  
Inferior Petrosal Sinus ◽  
Ectopic Acth ◽  
Content Type ◽  
Acth Secreting ◽  
Fine Print

✓ Bilateral and simultaneous sampling of the inferior petrosal sinuses in patients with Cushing's disease has been used to establish the presence and laterality of adrenocorticotropic hormone (ACTH)-producing microad-enomas prior to transsphenoidal surgery. Successful preoperative lateralization depends upon equivalent dilution of pituitary venous blood on the two sides since samples which are diluted by unequal amounts of non-pituitary blood may lead to erroneous results. To assure valid sampling results, the use of other pituitary hormones, measured simultaneously, has been proposed to correct the ACTH concentrations from the inferior petrosal sinuses against unequal dilution by non-pituitary venous blood. This proposal presumes that ACTH-secreting microadenomas will not cause unequal delivery of the other pituitary hormones into the two inferior petrosal sinuses. The inferior petrosal sinus concentrations of prolactin (PRL), thyrotropin (TSH), and the alpha subunit of human chorionic gonadotropin (α-HCG) were evaluated as indicators of pituitary venous blood dilution in 11 patients with Cushing's disease. Four patients with ectopic ACTH syndrome served as controls. Blood was withdrawn simultaneously from catheters in both inferior petrosal sinuses and from a peripheral vein for measurement of ACTH, PRL, TSH, and α-HCG. The ACTH concentrations were then corrected for dilution by non-pituitary blood by dividing the ACTH concentration from each side by the ratio of the inferior petrosal sinus to peripheral blood concentrations of PRL, TSH, and α-HCG for that side. At surgery, all 11 patients had ACTH-secreting microadenomas on the side predicted by the uncorrected ACTH concentrations. However, in three patients the corrected ACTH values would have led to erroneous results. Among the 18 sets of corrected inferior petrosal sinus measurements in these three patients, the corrected ACTH values failed to show an inferior petrosal sinus gradient in six and localized the tumor to the side opposite the adenoma in four. Incorrect lateralization was obtained with each of the hormones (PRL, TSH, and α-HCG) used for correction. Furthermore, the ipsilateral (side of tumor)-to-contralateral inferior petrosal sinus gradient of ACTH in patients with Cushing's disease was generally paralleled by a significant inferior petrosal sinus gradient of PRL, TSH, and α-HCG to the side of the tumor, whereas patients with the ectopic ACTH syndrome tended not to exhibit lateralizing (side-to-side) gradients. These findings indicate that the simultaneous measurement of inferior petrosal sinus concentrations of PRL or TSH or of the glycoprotein hormone α subunit does not improve preoperative localization of ACTH-secreting microadenomas and may lead to incorrect lateralization of the tumor. The results also suggest that ACTH-secreting microadenomas cause enhanced delivery of PRL, TSH, and α subunit into the inferior petrosal sinus ipsilateral to the tumor which, in turn, may reflect paracrine stimulation of hormone secretion in the anterior pituitary gland surrounding ACTH-secreting microadenomas.

scholarly journals Fluconazole for Hypercortisolism in Cushing’s Disease: A Case Report and Literature Review

2020 ◽  
Vol 11 ◽  
Author(s):  
Yiming Zhao ◽  
Weiwei Liang ◽  
Feng Cai ◽  
Qun Wu ◽  
Yongjian Wang
Keyword(s):  
Case Report ◽  
Pituitary Adenoma ◽  
Literature Review ◽  
Cushing’S Disease ◽  
Pituitary Surgery ◽  
Cortisol Concentration ◽  
Cushing's Disease ◽  
Radiological Findings ◽  
Increased Risk ◽  
Transsphenoidal Resection

BackgroundCushing’s disease is associated with an increased risk of pulmonary fungal infection, which could be a relative contraindication for pituitary adenoma excision surgery.CaseWe report a case of a patient with Cushing’s disease and pulmonary Cryptococcus neoformans. A 48-year-old woman was admitted to our hospital because of moon face and edema. Laboratory and radiological findings suggested a diagnosis of Cushing’s disease and pulmonary cryptococcus infection. Fluconazole 400 mg per day was administered intravenously and continued orally for 3 months. Both cryptococcus infection and hypercortisolism relieved and transsphenoidal resection was performed.ConclusionCushing’s disease can be effectively treated with fluconazole to normalize cortisol concentration prior to pituitary surgery. Fluconazole is an alternative treatment especially in Cushing’s disease patients with cryptococcal pneumonia.

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