Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom.
Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, United Kingdom.
Front Endocrinol (Lausanne). 2023 Jan 13;13:1090144. doi: 10.3389/fendo.2022.1090144. eCollection 2022.
Cushing's disease presents major diagnostic and management challenges. Although numerous preoperative and intraoperative imaging modalities have been deployed, it is unclear whether these investigations have improved surgical outcomes. Our objective was to investigate whether advances in imaging improved outcomes for Cushing's disease.
Searches of PubMed and EMBASE were conducted. Studies reporting on imaging modalities and clinical outcomes after surgical management of Cushing's disease were included. Multilevel multivariable meta-regressions identified predictors of outcomes, adjusting for confounders and heterogeneity prior to investigating the effects of imaging.
166 non-controlled single-arm studies were included, comprising 13181 patients over 44 years.The overall remission rate was 77.0% [CI: 74.9%-79.0%]. Cavernous sinus invasion (OR: 0.21 [CI: 0.07-0.66]; p=0.010), radiologically undetectable lesions (OR: 0.50 [CI: 0.37-0.69]; p<0.0001), previous surgery (OR=0.48 [CI: 0.28-0.81]; p=0.008), and lesions ≥10mm (OR: 0.63 [CI: 0.35-1.14]; p=0.12) were associated with lower remission. Less stringent thresholds for remission was associated with higher reported remission (OR: 1.37 [CI: 1.1-1.72]; p=0.007). After adjusting for this heterogeneity, no imaging modality showed significant differences in remission compared to standard preoperative MRI.The overall recurrence rate was 14.5% [CI: 12.1%-17.1%]. Lesion ≥10mm was associated with greater recurrence (OR: 1.83 [CI: 1.13-2.96]; p=0.015), as was greater duration of follow-up (OR: 1.53 (CI: 1.17-2.01); p=0.002). No imaging modality was associated with significant differences in recurrence.Despite significant improvements in detection rates over four decades, there were no significant changes in the reported remission or recurrence rates.
A lack of controlled comparative studies makes it difficult to draw definitive conclusions. Within this limitation, the results suggest that despite improvements in radiological detection rates of Cushing's disease over the last four decades, there were no changes in clinical outcomes. Advances in imaging alone may be insufficient to improve surgical outcomes.
https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42020187751.
库欣病的诊断和治疗极具挑战性。尽管已经使用了多种术前和术中影像学方法，但这些检查是否提高了手术效果仍不清楚。我们的目的是探讨影像学的进步是否改善了库欣病的治疗效果。
对 PubMed 和 EMBASE 进行了检索。纳入了报告库欣病手术治疗后影像学方法和临床结果的研究。多水平多变量荟萃回归确定了结果的预测因素，在研究影像学的影响之前，先对混杂因素和异质性进行了调整。
纳入了 166 项非对照的单臂研究，共包括 44 年以上的 13181 例患者。总体缓解率为 77.0% [95%置信区间：74.9%-79.0%]。海绵窦侵犯（OR：0.21 [95%置信区间：0.07-0.66]；p=0.010）、影像学上无法检测到的病变（OR：0.50 [95%置信区间：0.37-0.69]；p<0.0001）、既往手术（OR=0.48 [95%置信区间：0.28-0.81]；p=0.008）和病灶≥10mm（OR：0.63 [95%置信区间：0.35-1.14]；p=0.12）与较低的缓解率相关。更宽松的缓解标准与更高的缓解率相关（OR：1.37 [95%置信区间：1.1-1.72]；p=0.007）。在调整了这种异质性后，与标准术前 MRI 相比，没有一种影像学方法在缓解方面显示出显著差异。总体复发率为 14.5% [95%置信区间：12.1%-17.1%]。病灶≥10mm 与更高的复发率相关（OR：1.83 [95%置信区间：1.13-2.96]；p=0.015），随访时间更长也与更高的复发率相关（OR：1.53 [95%置信区间：1.17-2.01]；p=0.002）。没有一种影像学方法与复发率有显著差异。尽管四十年来检测率有了显著提高，但报告的缓解率和复发率并没有显著变化。
由于缺乏对照性的比较研究，很难得出明确的结论。在这个限制条件下，结果表明，尽管库欣病的放射检测率在过去四十年中有所提高，但临床结果并没有改变。影像学的进步本身可能不足以改善手术效果。
https://www.crd.york.ac.uk/PROSPERO/，注册号 CRD42020187751。
