title: Pure endoscopic transsphenoidal surgery for functional pituitary adenomas: outcomes with Cushing's disease.
abstract: BACKGROUND
  This study was performed to examine patient outcomes following pure endoscopic transsphenoidal surgery (ETS) for Cushing's disease (CD).
  
  
  METHODS
  We studied 64 consecutive patients who underwent 69 endoscopic transsphenoidal procedures. Radiological evaluation comprised detailed examination of preoperative magnetic resonance images (MRI), including positron emission tomography (PET) for select cases. Inferior petrosal sinus sampling (IPSS) was not performed for any patient. Remission was defined by the presence of hypocortisolemia with requirement for steroid replacement therapy or eucortisolemia with suppression to <1.8 μg/dl after 1 mg dexamethasone on evaluation at least 3 months after surgery.
  
  
  RESULTS
  Preoperative MRI was abnormal in 87.5 % of cases and included 11 macroadenomas (17.2 %). PET was used to localize the adenoma in four cases. For microadenomas, operative procedures executed were as follows: selective adenomectomy (n = 15), enlarged adenomectomy (n = 21) and subtotal/hemihypophysectomy (n = 17). Overall, pathological confirmation of an adenoma was possible in 58 patients (90.6 %). Forty-nine patients (76.6 %) developed hypocortisolemia (<5 μg/dl) in the early postoperative period. Mean follow-up was 20 months (range 6-18 months). Remission was confirmed in 79.7 % of the 59 cases followed up for >3 months and was superior for microadenomas (86.4 %) versus macroadenomas (55.6 %) and equivocal MRI adenomas (66.7 %). Postoperative CSF rhinorrhea occurred in five patients, and new endocrine deficits were noted in 17.1 % patients. A nadir postoperative cortisol <2 μg/dl in the 1st week after surgery was highly predictive of remission (p = 0.001).
  
  
  CONCLUSIONS
  ETS allows for enhanced intrasellar identification of adenomatous tissue, providing remission rates that are comparable to traditional microsurgery for CD. The best predictor of remission remains induction of profound hypocortisolemia in the early postoperative period.
authors.affiliation: Sections of Neurosurgery Department of Neurological Sciences, Christian Medical College, Vellore, India.
authors.forename: Sauradeep
authors.initials: S
authors.lastname: Sarkar
authors.affiliation: Department of Endocrinology, Diabetes & Metabolism, Christian Medical College, Vellore, India.
authors.forename: Simon
authors.initials: S
authors.lastname: Rajaratnam
authors.affiliation: Neuropathology, Department of Neurological Sciences, Christian Medical College, Vellore, India.
authors.forename: Geeta
authors.initials: G
authors.lastname: Chacko
authors.affiliation: Department of Radiodiagnosis, Christian Medical College, Vellore, India.
authors.forename: Sunithi
authors.initials: S
authors.lastname: Mani
authors.affiliation: Department of Endocrinology, Diabetes & Metabolism, Christian Medical College, Vellore, India.
authors.forename: Asha S
authors.initials: AS
authors.lastname: Hesargatta
authors.affiliation: Sections of Neurosurgery Department of Neurological Sciences, Christian Medical College, Vellore, India. agchacko@cmcvellore.ac.in.
authors.forename: Ari George
authors.initials: AG
authors.lastname: Chacko
mesh_terms: D000328:Adult; D000368:Aged; D065634:Cerebrospinal Fluid Leak / Q000453:epidemiology / Q000209:etiology; D003907:Dexamethasone / Q000494:pharmacology; D004724:Endoscopy / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D006854:Hydrocortisone / Q000097:blood; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000453:epidemiology; D019635:Neurosurgical Procedures / Q000379:methods*; D047748:Pituitary ACTH Hypersecretion / Q000601:surgery*; D010911:Pituitary Neoplasms / Q000473:pathology / Q000601:surgery*; D049268:Positron-Emission Tomography; D011183:Postoperative Complications / Q000453:epidemiology; D013100:Sphenoid Bone / Q000601:surgery*; D016896:Treatment Outcome
chemical_list: D003907:Dexamethasone; D006854:Hydrocortisone
keywords: Cushing’s disease; Endoscopic Transsphenoidal Surgery; Pituitary adenoma; Remission