title: Outcome of Cushing's disease following transsphenoidal surgery in a single center over 20 years.
abstract: BACKGROUND
  Historically, Cushing's disease (CD) was associated with a 5-yr survival of just 50%. Although advances in CD management have seen mortality rates improve, outcome from transsphenoidal surgery (TSS), the current first-line treatment, varies significantly between centers.
  
  
  OBJECTIVE
  The aim of the study was to define outcome including mortality in a cohort of CD patients treated with TSS over 20 yr.
  
  
  METHODS
  We conducted a retrospective cohort study of 80 patients who underwent TSS to treat CD between 1988 and 2009. In 72 cases, data on clinical features and outcomes were collected from medical records. In eight patients, records were unavailable, but in all cases mortality data were obtained from National Health Service (NHS) registries and recorded as standardized mortality ratio.
  
  
  METHODS
  The study was conducted in a United Kingdom tertiary referral center.
  
  
  METHODS
  Adult patients confirmed to have CD participated in the study.
  
  
  METHODS
  All patients underwent TSS.
  
  
  METHODS
  Patients were subdivided into groups based on disease response after initial treatment. Mortality according to subgroup was also assessed.
  
  
  RESULTS
  Median follow-up for clinical data was 4.6 yr. Three outcome groups were identified: cure, 72% (52 of 72); persistent disease, 17% (12 of 72); and disease recurrence, 11% (eight of 72). Median time to recurrence after initial remission was 2.1 yr (interquartile range, 1.3-3.1 yr). Mean follow-up for mortality was 10.9 yr. Thirteen of 80 patients had died: five of 52 in the cure group, two of eight in the disease recurrence group, two of 12 with persistent disease, and four of eight of those followed up by NHS registry search only. Overall, the standardized mortality ratio was 3.17 [95% confidence interval (CI), 1.70-5.43], whereas in the cure group it was 2.47 (95% CI, 0.80-5.77), and it was 4.12 (95% CI, 1.12-10.54) for disease recurrence/persistent disease groups.
  
  
  CONCLUSIONS
  We report long-term cure rates in excess of 70%. Mortality is increased in CD and may be higher in patients with persistent/recurrent disease compared to patients cured after initial treatment.
authors.affiliation: Centre for Endocrinology, Diabetes, and Metabolism, Institute for Biomedical Research, School of Clinical and Experimental Medicine, University of Birmingham, Birmingham B15 2TT, United Kingdom.
authors.forename: Zaki K
authors.initials: ZK
authors.lastname: Hassan-Smith
authors.forename: Mark
authors.initials: M
authors.lastname: Sherlock
authors.forename: Raoul C
authors.initials: RC
authors.lastname: Reulen
authors.forename: Wiebke
authors.initials: W
authors.lastname: Arlt
authors.forename: John
authors.initials: J
authors.lastname: Ayuk
authors.forename: Andrew A
authors.initials: AA
authors.lastname: Toogood
authors.forename: Mark S
authors.initials: MS
authors.lastname: Cooper
authors.forename: Alan P
authors.initials: AP
authors.lastname: Johnson
authors.forename: Paul M
authors.initials: PM
authors.lastname: Stewart
mesh_terms: D000328:Adult; D015331:Cohort Studies; D004739:England / Q000453:epidemiology; D005260:Female; D005500:Follow-Up Studies; D006785:Hospitals, University; D006801:Humans; D006973:Hypertension / Q000209:etiology / Q000517:prevention & control*; D008297:Male; D008499:Medical Records; D008866:Microsurgery; D008875:Middle Aged; D009296:Nasal Cavity; D057605:Natural Orifice Endoscopic Surgery; D009765:Obesity / Q000209:etiology / Q000517:prevention & control*; D047748:Pituitary ACTH Hypersecretion / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D010902:Pituitary Gland / Q000601:surgery*; D011183:Postoperative Complications / Q000453:epidemiology; D012008:Recurrence; D012042:Registries; D012074:Remission Induction; D012189:Retrospective Studies