Delayed remission after transsphenoidal surgery in patients with Cushing's disease.
BACKGROUND
Transsphenoidal surgery (TSS) is the treatment of choice for Cushing's disease (CD). Postoperative hypercortisolemia mandates further therapy.


OBJECTIVE
The aim of the study was to characterize patients without immediate postoperative remission who have a delayed decrease to normal or low cortisol levels without further therapy.


METHODS
A retrospective case series was conducted at three tertiary care centers.


METHODS
We reviewed the records of 620 patients (512 females, 108 males; mean age, 38 +/- 13 yr) who underwent transsphenoidal pituitary surgery for CD between 1982 and 2007.


RESULTS
Outcomes were classified into the following three groups based upon the postoperative pattern of cortisol testing: group IC (immediate control) included 437 of the 620 patients (70.5%) with hypocortisolism and/or cortisol normalization throughout the postoperative follow-up; group NC (no control) included 148 of 620 patients (23.9%) with persistent hypercortisolism; and group DC (delayed control) included 35 of 620 patients (5.6%) who had early elevated or normal UFC levels and developed a delayed and persistent cortisol decrease after an average of 38 +/- 50 postoperative days. The total rate of recurrence was 13% at a median follow-up time of 66 months after TSS; the cumulative rate of recurrence at 4.5 yr was significantly higher in group DC vs. group IC (43 vs. 14%; P = 0.02).


CONCLUSIONS
Hormonal assessment in the immediate postoperative period after TSS for CD may be misleading because delayed remission can occur in a subset of patients. Expectant management and retesting may spare some patients from unnecessary further treatment. Optimal timing to determine the need for further therapy after TSS remains to be determined.
Valassi
Elena
E
Neuroendocrine Unit, Massachusetts General Hospital, 55 Fruit Street, Bulfinch 457B, Boston, Massachusetts 02114, USA.
Biller
Beverly M K
BM
Swearingen
Brooke
B
Pecori Giraldi
Francesca
F
Losa
Marco
M
Mortini
Pietro
P
Hayden
Douglas
D
Cavagnini
Francesco
F
Klibanski
Anne
A
D000324:Adrenocorticotropic Hormone / Q000097:blood; D000328:Adult; D005260:Female; D006801:Humans; D006854:Hydrocortisone / Q000652:urine; D008297:Male; D008875:Middle Aged; D047748:Pituitary ACTH Hypersecretion / Q000378:metabolism / Q000601:surgery*; D012189:Retrospective Studies; D013997:Time Factors
D000324:Adrenocorticotropic Hormone; D006854:Hydrocortisone