Surgical outcomes in patients with Cushing’s disease: the Cleveland clinic experience

Philip C. Johnston, Laurence Kennedy, Amir Hamrahian, Zahrae Sandouk, James Bena, Betul Hatipoglu, Robert J. Weil

Research output: Contribution to journalArticle

Abstract

Context: Transsphenoidal surgery (TSS) to resect a pituitary adenoma is considered first-line treatment for patients with Cushing’s disease (CD). Early, post-operative remission rates >80% are expected for patients with a microadenoma (≤ 10 mm) visible on magnetic resonance (MR) imaging. Objective: To report surgical outcomes and predictors of remission in a specialist center for patients with CD. Patients and methods: Clinical data was obtained from a prospective CD database in addition to review of all electronic medical, laboratory and surgical patient records. Patients who underwent their first TSS by one neurosurgeon between 2004 and 2013, and had a minimum 1 year follow up, were evaluated. Results: One hundred and one consecutive patients with CD (73F, 28M) underwent TSS. Median (range) age and follow-up were 47 (15–87) and 4.33 (1–9.8) years, respectively. At surgery, 74 (73.2%) patients had a microadenoma, 27 a macroadenoma; six of the latter patients had a planned, subtotal resection to control neurological signs due to mass effect. Initial remission rates were: microadenoma, 89% (66/74); macroadenoma, 63% (17/27); and 81% (17/21) in those macroadenomas where complete surgical removal was anticipated. Initial non-remission occurred in 18 patients, ten macro- and eight microadenoma; six of 18 had residual disease on most recent follow up. Six (2 macro, 4 micro) of the 83 patients with initial remission have had late (>12 months) recurrence of hypercortisolism that required either repeat TSS or adjunctive therapy, three of whom have persistent hypercortisolism. Macroadenoma (p = 0.003) and tumor invasion beyond the pituitary and sella (p < 0.001) were associated with failure to obtain remission with the initial TSS and greater likelihood of late recurrence. Patients in whom no lesion was seen on neuroimaging had rates of initial remission (21/25 or 84%) and a similar late recurrence rate of 4% (1/25) in comparison with those with MR-visible microadenomas (3/49, or 6%). Conclusions: A team-based approach, in a specialized pituitary center, can lead to initial and durable, long-term remission in patients with CD. The presence of a macroadenoma and tumor extension beyond the pituitary and sella were predictive of initial non-remission as well as risk of late recurrence.

Original languageEnglish (US)
Pages (from-to)430-440
Number of pages11
JournalPituitary
Volume20
Issue number4
DOIs
StatePublished - Aug 1 2017
Externally publishedYes

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Pituitary ACTH Hypersecretion
Recurrence
Cushing Syndrome
Medical Electronics
Pituitary Neoplasms
Reoperation
Neuroimaging
Neoplasms

Keywords

  • Cushing’s syndrome
  • Remission
  • Single center experience
  • Transsphenoidal surgery

ASJC Scopus subject areas

  • Endocrinology, Diabetes and Metabolism
  • Endocrinology

Cite this

Johnston, P. C., Kennedy, L., Hamrahian, A., Sandouk, Z., Bena, J., Hatipoglu, B., & Weil, R. J. (2017). Surgical outcomes in patients with Cushing’s disease: the Cleveland clinic experience. Pituitary, 20(4), 430-440. https://doi.org/10.1007/s11102-017-0802-1

Surgical outcomes in patients with Cushing’s disease : the Cleveland clinic experience. / Johnston, Philip C.; Kennedy, Laurence; Hamrahian, Amir; Sandouk, Zahrae; Bena, James; Hatipoglu, Betul; Weil, Robert J.

In: Pituitary, Vol. 20, No. 4, 01.08.2017, p. 430-440.

Research output: Contribution to journalArticle

Johnston, PC, Kennedy, L, Hamrahian, A, Sandouk, Z, Bena, J, Hatipoglu, B & Weil, RJ 2017, 'Surgical outcomes in patients with Cushing’s disease: the Cleveland clinic experience', Pituitary, vol. 20, no. 4, pp. 430-440. https://doi.org/10.1007/s11102-017-0802-1
Johnston, Philip C. ; Kennedy, Laurence ; Hamrahian, Amir ; Sandouk, Zahrae ; Bena, James ; Hatipoglu, Betul ; Weil, Robert J. / Surgical outcomes in patients with Cushing’s disease : the Cleveland clinic experience. In: Pituitary. 2017 ; Vol. 20, No. 4. pp. 430-440.
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N2 - Context: Transsphenoidal surgery (TSS) to resect a pituitary adenoma is considered first-line treatment for patients with Cushing’s disease (CD). Early, post-operative remission rates >80% are expected for patients with a microadenoma (≤ 10 mm) visible on magnetic resonance (MR) imaging. Objective: To report surgical outcomes and predictors of remission in a specialist center for patients with CD. Patients and methods: Clinical data was obtained from a prospective CD database in addition to review of all electronic medical, laboratory and surgical patient records. Patients who underwent their first TSS by one neurosurgeon between 2004 and 2013, and had a minimum 1 year follow up, were evaluated. Results: One hundred and one consecutive patients with CD (73F, 28M) underwent TSS. Median (range) age and follow-up were 47 (15–87) and 4.33 (1–9.8) years, respectively. At surgery, 74 (73.2%) patients had a microadenoma, 27 a macroadenoma; six of the latter patients had a planned, subtotal resection to control neurological signs due to mass effect. Initial remission rates were: microadenoma, 89% (66/74); macroadenoma, 63% (17/27); and 81% (17/21) in those macroadenomas where complete surgical removal was anticipated. Initial non-remission occurred in 18 patients, ten macro- and eight microadenoma; six of 18 had residual disease on most recent follow up. Six (2 macro, 4 micro) of the 83 patients with initial remission have had late (>12 months) recurrence of hypercortisolism that required either repeat TSS or adjunctive therapy, three of whom have persistent hypercortisolism. Macroadenoma (p = 0.003) and tumor invasion beyond the pituitary and sella (p < 0.001) were associated with failure to obtain remission with the initial TSS and greater likelihood of late recurrence. Patients in whom no lesion was seen on neuroimaging had rates of initial remission (21/25 or 84%) and a similar late recurrence rate of 4% (1/25) in comparison with those with MR-visible microadenomas (3/49, or 6%). Conclusions: A team-based approach, in a specialized pituitary center, can lead to initial and durable, long-term remission in patients with CD. The presence of a macroadenoma and tumor extension beyond the pituitary and sella were predictive of initial non-remission as well as risk of late recurrence.

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