title: Primary Endoscopic Transnasal Transsphenoidal Surgery for Magnetic Resonance Image-Positive Cushing Disease: Outcomes of a Series over 14 Years.
abstract: BACKGROUND
  There are scant data of endoscopic transsphenoidal surgery (ETS) with adjuvant therapies of Cushing disease (CD).
  
  
  OBJECTIVE
  To report the remission rate, secondary management, and outcomes of a series of CD patients.
  
  
  METHODS
  Patients with CD with magnetic resonance imaging (MRI)-positive adenoma who underwent ETS as the first and primary treatment were included. The diagnostic criteria were a combination of 24-hour urine-free cortisol, elevated serum cortisol levels, or other tests (e.g., inferior petrosal sinus sampling). All clinical and laboratory evaluations and radiological examinations were reviewed.
  
  
  RESULTS
  Forty consecutive CD patients, with an average age of 41.0 years, were analyzed with a mean follow-up of 40.2 ± 29.6 months. These included 22 patients with microadenoma and 18 with macroadenoma, including 9 cavernous invasions. The overall remission rate of CD after ETS was 72.5% throughout the entire follow-up. Patients with microadenoma or noninvasive macroadenoma had a higher remission rate than those who had macroadenoma with cavernous sinus invasion (81.8% or 77.8% vs. 44.4%, P = 0.02). After ETS, the patients who had adrenocorticotropic hormone-positive adenoma had a higher remission rate than those who had not (76.5% vs. 50%, P = 0.03). In the 11 patients who had persistent/recurrent CD after the first ETS, 1 underwent secondary ETS, 8 received gamma-knife radiosurgery (GKRS), and 2 underwent both. At the study end point, two (5%) of these CD patients had persistent CD and were under the medication of ketoconazole.
  
  
  CONCLUSIONS
  For MRI-positive CD patients, primary (i.e., the first) ETS yielded an overall remission rate of 72.5%. Adjuvant therapies, including secondary ETS, GKRS, or both, yielded an ultimate remission rate of 95%.
authors.affiliation: Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taiwan.
authors.forename: Chao-Hung
authors.initials: CH
authors.lastname: Kuo
authors.affiliation: Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taiwan; School of Medicine, National Yang-Ming University, Taiwan.
authors.forename: Yu-Shu
authors.initials: YS
authors.lastname: Yen
authors.affiliation: Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taiwan; School of Medicine, National Yang-Ming University, Taiwan. Electronic address: jauching@gmail.com.
authors.forename: Jau-Ching
authors.initials: JC
authors.lastname: Wu
authors.affiliation: School of Medicine, National Yang-Ming University, Taiwan; Department of Medical Research and Education, National Yang-Ming University Hospital, I-Lan, Taiwan; Institute of Hospital and Health Care Administration, National Yang-Ming University School of Medicine, Taipei, Taiwan.
authors.forename: Yu-Chun
authors.initials: YC
authors.lastname: Chen
authors.affiliation: Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taiwan; School of Medicine, National Yang-Ming University, Taiwan.
authors.forename: Wen-Cheng
authors.initials: WC
authors.lastname: Huang
authors.affiliation: Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taiwan; School of Medicine, National Yang-Ming University, Taiwan; Institute of Pharmacology, National Yang-Ming University School of Medicine, Taipei, Taiwan.
authors.forename: Henrich
authors.initials: H
authors.lastname: Cheng
mesh_terms: D000236:Adenoma / Q000473:pathology / Q000601:surgery*; D000328:Adult; D002426:Cavernous Sinus / Q000473:pathology / Q000601:surgery; D004724:Endoscopy / Q000009:adverse effects / Q000379:methods*; D005260:Female; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D009296:Nasal Cavity / Q000601:surgery; D009364:Neoplasm Recurrence, Local / Q000601:surgery; D019635:Neurosurgical Procedures / Q000009:adverse effects / Q000379:methods*; D047748:Pituitary ACTH Hypersecretion / Q000473:pathology / Q000601:surgery*; D016634:Radiosurgery; D016896:Treatment Outcome
keywords: Cushing disease; Endoscopic transsphenoidal surgery; Macroadenoma