title: Localization of pituitary adenomas by using intraoperative ultrasound in patients with Cushing's disease and no demonstrable pituitary tumor on magnetic resonance imaging.
abstract: OBJECTIVE
  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=0.51). 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.
authors.affiliation: Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland 20892-1414, USA.
authors.forename: J C
authors.initials: JC
authors.lastname: Watson
authors.forename: T H
authors.initials: TH
authors.lastname: Shawker
authors.forename: L K
authors.initials: LK
authors.lastname: Nieman
authors.forename: H L
authors.initials: HL
authors.lastname: DeVroom
authors.forename: J L
authors.initials: JL
authors.lastname: Doppman
authors.forename: E H
authors.initials: EH
authors.lastname: Oldfield
mesh_terms: D000236:Adenoma / Q000097:blood / Q000150:complications / Q000175:diagnosis / Q000000981:diagnostic imaging* / Q000601:surgery*; D003480:Cushing Syndrome / Q000097:blood / Q000209:etiology*; D003937:Diagnosis, Differential; D006801:Humans; D008279:Magnetic Resonance Imaging; D016343:Monitoring, Intraoperative / Q000379:methods*; D010911:Pituitary Neoplasms / Q000097:blood / Q000150:complications / Q000175:diagnosis / Q000000981:diagnostic imaging* / Q000601:surgery*; D011237:Predictive Value of Tests; D011446:Prospective Studies; D016896:Treatment Outcome; D014463:Ultrasonography