Assessment of cure and recurrence after pituitary surgery for Cushing's disease.
BACKGROUND
The treatment of choice in Cushing's disease is transsphenoidal adenomectomy with a recurrence rate ranging 9-23%. We investigated whether abnormal hormonal responses may predict the relapse in "operated" patients followed-up for a long period.


METHODS
Sixty-eight surgically treated patients with Cushing's disease were followed-up for 12-252 months. Forty-eight patients underwent selective adenomectomy, 17 enlarged adenomectomy and 3 underwent total hypophysectomy. After surgery ACTH and cortisol levels were measured after stimulatory (desmopressin and CRH) and inhibitory tests (dexamethasone and loperamide).


RESULTS
After operation 46 patients were cured (group A), 15 patients only normalized cortisol levels (group B), 7 patients were surgical failures. During the follow-up, a disease-free condition was maintained in 48 of 61 cases (79%), while a recurrence occurred in 13 patients (21%, 5 of group A and 8 of group B). In 5/13 patients who relapsed an absent inhibition after dexamethasone and an exaggerated response to CRH test preceded the recurrence. In 5 other patients the relapse was suspected by loperamide test. In the 3 remaining cases, positive responses to desmopressin preceded the recurrence. In 7/13 patients who relapsed the pituitary tumour was visualized by MRI/CT imaging.


CONCLUSIONS
During the follow-up a careful assessment of ACTH dynamics is needed. Although no single test can reliably predict the late outcome, individual patients at risk for relapse may be identified by abnormal responses to desmopressin, CRH and loperamide tests; particularly, the persistent responsiveness to desmopressin may be a criterion of risk for recurrence in patients who only normalized cortisol levels after surgery.
Barbetta
L
L
Institute of Endocrine Sciences, Ospedale Maggiore IRCCS, University of Milano, Italy.
Dall'Asta
C
C
Tomei
G
G
Locatelli
M
M
Giovanelli
M
M
Ambrosi
B
B
D000236:Adenoma / Q000150:complications / Q000175:diagnosis / Q000601:surgery* / Q000652:urine; D000293:Adolescent; D000324:Adrenocorticotropic Hormone / Q000097:blood; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003480:Cushing Syndrome / Q000209:etiology* / Q000652:urine; D003894:Deamino Arginine Vasopressin; D005260:Female; D006801:Humans; D006854:Hydrocortisone / Q000097:blood / Q000652:urine*; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000175:diagnosis* / Q000517:prevention & control; D010911:Pituitary Neoplasms / Q000150:complications / Q000175:diagnosis / Q000601:surgery* / Q000652:urine; D012189:Retrospective Studies; D012307:Risk Factors; D016019:Survival Analysis; D016896:Treatment Outcome
D000324:Adrenocorticotropic Hormone; D003894:Deamino Arginine Vasopressin; D006854:Hydrocortisone