Neuroendocrine Unit, Massachusetts General Hospital, 55 Fruit Street, Bulfinch 457B, Boston, Massachusetts 02114, USA.
J Clin Endocrinol Metab. 2010 Feb;95(2):601-10. doi: 10.1210/jc.2009-1672. Epub 2010 Jan 15.
Transsphenoidal surgery (TSS) is the treatment of choice for Cushing's disease (CD). Postoperative hypercortisolemia mandates further therapy.
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.
A retrospective case series was conducted at three tertiary care centers.
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.
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).
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.
经蝶窦手术（TSS）是治疗库欣病（CD）的首选方法。术后皮质醇过多症需要进一步治疗。
本研究的目的是描述那些没有立即术后缓解但随后皮质醇水平逐渐降低至正常或低值而无需进一步治疗的患者。
在三个三级保健中心进行了回顾性病例系列研究。
我们回顾了 1982 年至 2007 年间接受经蝶窦垂体手术治疗 CD 的 620 例患者（512 例女性，108 例男性；平均年龄 38 +/- 13 岁）的记录。
根据术后皮质醇检测结果，将结果分为以下三组：IC 组（即刻控制组）包括 620 例患者中的 437 例（70.5%），术后随访期间皮质醇水平降低或正常；NC 组（无控制组）包括 620 例患者中的 148 例（23.9%），持续皮质醇过多；DC 组（延迟控制组）包括 35 例患者（5.6%），他们在术后平均 38 +/- 50 天出现早期升高或正常 UFC 水平，并在延迟和持续皮质醇下降。TSS 后中位随访 66 个月时总复发率为 13%；在 4.5 年时，DC 组的累积复发率明显高于 IC 组（43%比 14%；P = 0.02）。
TSS 治疗 CD 后即刻的激素评估可能具有误导性，因为在一部分患者中可能会出现延迟缓解。期待治疗和重复检测可能使一些患者免于不必要的进一步治疗。TSS 后确定进一步治疗需求的最佳时机仍有待确定。
