title: Outcomes and management of patients with Cushing's disease without pathological confirmation of tumor resection after transsphenoidal surgery.
abstract: 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.
authors.affiliation: Department of Neurological Surgery, University of Virginia, Box 800212, Charlottesville, Virginia 22903, USA. np5k@virginia.edu
authors.forename: Nader
authors.initials: N
authors.lastname: Pouratian
authors.forename: Daniel M
authors.initials: DM
authors.lastname: Prevedello
authors.forename: Jay
authors.initials: J
authors.lastname: Jagannathan
authors.forename: M Beatriz
authors.initials: MB
authors.lastname: Lopes
authors.forename: Mary Lee
authors.initials: ML
authors.lastname: Vance
authors.forename: Edward R
authors.initials: ER
authors.lastname: Laws
mesh_terms: 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