Outcomes and management of patients with Cushing's disease without pathological confirmation of tumor resection after transsphenoidal surgery.
BACKGROUND
Despite the success of transsphenoidal surgery (TSS) for the treatment of Cushing's disease, in a number of cases, an ACTH-staining pituitary adenoma is not identified histologically. The clinical significance of lack of histological confirmation remains unclear.


METHODS
This was a retrospective review of patients treated at the University of Virginia Medical Center.


METHODS
Of 490 TSS procedures for Cushing's disease between 1993 and 2004, we identified 111 cases without histological adenoma confirmation.


METHODS
Remission and recurrence of Cushing's disease were measured.


RESULTS
Overall, 50% of these patients achieved remission, a figure lower than for our entire series (79%) and for patients with histological confirmation of an ACTH-staining adenoma (88%) (P < 0.001). Patients with a history of two prior TSS achieved remission less often than patients with a history of fewer TSS (P = 0.026). No other factors influenced remission rates. Although the overall recurrence rate (21%, seven of 33 evaluated) was not different from previously published long-term studies, in three of seven cases of recurrence, early recurrences were noted between 2 and 4 months after remission. In patients who did not achieve remission, the most common and effective treatment options were repeat TSS, gamma-knife radiosurgery, and bilateral adrenalectomy.


CONCLUSIONS
The lower remission rate in patients without histological evidence of an adenoma is most likely a result of a decreased rate of adenoma extirpation. The incidence of early recurrence may be a unique feature of this patient population; patients without histological confirmation of tumor resection therefore require close and consistent monitoring postoperatively.
Pouratian
Nader
N
Department of Neurological Surgery, University of Virginia, Box 800212, Charlottesville, Virginia 22903, USA. np5k@virginia.edu
Prevedello
Daniel M
DM
Jagannathan
Jay
J
Lopes
M Beatriz
MB
Vance
Mary Lee
ML
Laws
Edward R
ER
D049913:ACTH-Secreting Pituitary Adenoma / Q000175:diagnosis / Q000473:pathology / Q000601:surgery*; D000236:Adenoma / Q000175:diagnosis / Q000473:pathology / Q000601:surgery; D000293:Adolescent; D000328:Adult; D000368:Aged; D002648:Child; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000175:diagnosis / Q000473:pathology; D018365:Neoplasm, Residual; D047748:Pituitary ACTH Hypersecretion / Q000175:diagnosis* / Q000473:pathology / Q000601:surgery*; D011379:Prognosis; D012074:Remission Induction; D012189:Retrospective Studies; D017211:Treatment Failure; D016896:Treatment Outcome