Department of Endocrinology, Diabetes and Metabolism, Cleveland Clinic, 9500 Euclid Avenue Desk F20, Cleveland, OH, 44195, USA.
Regional Center for Endocrinology and Diabetes, Royal Victoria Hospital, Grosvenor Road, Belfast, UK.
Pituitary. 2017 Aug;20(4):430-440. doi: 10.1007/s11102-017-0802-1.
Transsphenoidal surgery (TSS) to resect a pituitary adenoma is considered first-line treatment for patients with Cushing's disease (CD). Early, post-operative remission rates >80% are expected for patients with a microadenoma (≤ 10 mm) visible on magnetic resonance (MR) imaging.
To report surgical outcomes and predictors of remission in a specialist center for patients with CD.
Clinical data was obtained from a prospective CD database in addition to review of all electronic medical, laboratory and surgical patient records. Patients who underwent their first TSS by one neurosurgeon between 2004 and 2013, and had a minimum 1 year follow up, were evaluated.
One hundred and one consecutive patients with CD (73F, 28M) underwent TSS. Median (range) age and follow-up were 47 (15-87) and 4.33 (1-9.8) years, respectively. At surgery, 74 (73.2%) patients had a microadenoma, 27 a macroadenoma; six of the latter patients had a planned, subtotal resection to control neurological signs due to mass effect. Initial remission rates were: microadenoma, 89% (66/74); macroadenoma, 63% (17/27); and 81% (17/21) in those macroadenomas where complete surgical removal was anticipated. Initial non-remission occurred in 18 patients, ten macro- and eight microadenoma; six of 18 had residual disease on most recent follow up. Six (2 macro, 4 micro) of the 83 patients with initial remission have had late (>12 months) recurrence of hypercortisolism that required either repeat TSS or adjunctive therapy, three of whom have persistent hypercortisolism. Macroadenoma (p = 0.003) and tumor invasion beyond the pituitary and sella (p < 0.001) were associated with failure to obtain remission with the initial TSS and greater likelihood of late recurrence. Patients in whom no lesion was seen on neuroimaging had rates of initial remission (21/25 or 84%) and a similar late recurrence rate of 4% (1/25) in comparison with those with MR-visible microadenomas (3/49, or 6%).
A team-based approach, in a specialized pituitary center, can lead to initial and durable, long-term remission in patients with CD. The presence of a macroadenoma and tumor extension beyond the pituitary and sella were predictive of initial non-remission as well as risk of late recurrence.
经蝶窦手术（TSS）切除垂体腺瘤被认为是库欣病（CD）患者的一线治疗方法。对于磁共振成像（MR）可见的微腺瘤（≤10mm）患者，术后早期缓解率预期超过 80%。
报告在库欣病患者的专科中心的手术结果和缓解的预测因素。
除了回顾所有电子病历、实验室和手术患者记录外，还从前瞻性 CD 数据库中获得了临床数据。评估了 2004 年至 2013 年间由同一位神经外科医生进行首次 TSS 且至少随访 1 年的 CD 患者。
101 例连续 CD 患者（73 例女性，28 例男性）接受了 TSS。中位（范围）年龄和随访时间分别为 47（15-87）和 4.33（1-9.8）年。在手术时，74 例（73.2%）患者为微腺瘤，27 例为大腺瘤；其中 6 例大腺瘤患者由于肿块效应引起的神经体征而计划行部分切除术以控制病情。初始缓解率为：微腺瘤 89%（66/74）；大腺瘤 63%（17/27）；预计完全切除的大腺瘤中为 81%（17/21）。18 例患者初始缓解后未缓解，其中 10 例为大腺瘤，8 例为微腺瘤；18 例中有 6 例在最近的随访中仍有残留疾病。83 例初始缓解的患者中，有 6 例（2 例大腺瘤，4 例微腺瘤）在术后>12 个月时出现皮质醇增多症复发，需要再次行 TSS 或辅助治疗，其中 3 例仍有皮质醇增多症。初次 TSS 未缓解与大腺瘤（p=0.003）和肿瘤侵犯垂体和鞍上（p<0.001）有关，且与晚期复发的可能性更大有关。在神经影像学上未见病灶的患者，其初始缓解率（25 例中有 21 例或 84%）与在磁共振上可见微腺瘤（49 例中有 3 例或 6%）的患者相似，且晚期复发率也相似（4%，25 例中有 1 例）。
在专门的垂体中心，基于团队的方法可以使 CD 患者获得初始和持久的长期缓解。大腺瘤和肿瘤向垂体和鞍上延伸是初始缓解不佳和晚期复发的预测因素。
