Corticotroph tumor progression after adrenalectomy in Cushing's Disease: A reappraisal of Nelson's Syndrome.
BACKGROUND
Adrenalectomy is a radical treatment for hypercortisolism in Cushing's disease. However, it may lead to Nelson's syndrome, originally defined by the association of a pituitary macroadenoma and high plasma ACTH concentrations, a much feared complication.


OBJECTIVE
The objective of the study was to reconsider Nelson's syndrome by investigating corticotroph tumor progression based on pituitary magnetic resonance imaging scan and search for predictive factors.


METHODS
This was a retrospective cohort study.


METHODS
The complete medical records of Cushing's disease patients at Cochin Hospital were studied.


METHODS
Patients included 53 Cushing's disease patients treated by adrenalectomy between 1991 and 2002, without previous pituitary irradiation.


METHODS
Clinical data, pituitary magnetic resonance imaging data, and plasma ACTH concentrations for all patients and pituitary gland pathology data for 25 patients were recorded. Corticotroph tumor progression-free survival was studied by Kaplan-Meier, and the influence of recorded parameters was studied by Cox regression.


METHODS
There was no intervention.


RESULTS
Corticotroph tumor progression ultimately occurred in half the patients, generally within 3 yr after adrenalectomy. A shorter duration of Cushing's disease (adjusted hazard ratio: 0.884/yr), and a high plasma ACTH concentration in the year after adrenalectomy [adjusted hazard ratio per 100 pg/ml (22 pmol/liter): 1.069] were predictive of corticotroph tumor progression. In one case, corticotroph tumor progression was complicated by transitory oculomotor nerve palsy. During follow-up, corticotroph tumor progression was associated with the increase of corresponding ACTH concentrations (odds ratio per 100 pg/ml of ACTH variation: 1.055).


CONCLUSIONS
After adrenalectomy in Cushing's disease, one should no longer wait for the occurrence of Nelson's syndrome: modern imaging allows early detection and management of corticotroph tumor progression.
Assié
Guillaume
G
Department of Endocrinology, Cochin Hospital, Faculté René Descartes, 27, rue du Fg St. Jacques, 75014 Paris, France.
Bahurel
Hélène
H
Coste
Joël
J
Silvera
Stéphane
S
Kujas
Michèle
M
Dugué
Marie-Annick
MA
Karray
Foued
F
Dousset
Bertrand
B
Bertherat
Jérôme
J
Legmann
Paul
P
Bertagna
Xavier
X
D000293:Adolescent; D000315:Adrenalectomy / Q000009:adverse effects*; D000324:Adrenocorticotropic Hormone / Q000097:blood; D000328:Adult; D000368:Aged; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D009347:Nelson Syndrome / Q000209:etiology*; D047748:Pituitary ACTH Hypersecretion / Q000601:surgery*; D012189:Retrospective Studies
D000324:Adrenocorticotropic Hormone