Stroud Anna, Dhaliwal Pearl, Harvey Richard J, Alvarado Raquel, Jonker Benjamin P, Winder Mark J, Grayson Jessica W, McCormack Ann
Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, Sydney, Australia.
St Vincent's Hospital Clinical School, Faculty of Medicine, UNSW Sydney, Sydney, Australia.
Endocr Oncol. 2022 Apr 7;2(1):19-31. doi: 10.1530/EO-21-0026. eCollection 2022 Jan.
Transsphenoidal surgery (TSS) is the first-line treatment for Cushing's disease. The objectives of the study were to determine remission and recurrence rates after TSS for Cushing's disease, identify factors that predict these outcomes, and define the threshold for postoperative morning serum cortisol (MSeC) that most accurately predicts sustained remission.
Records were retrospectively reviewed for consecutive adults undergoing TSS for Cushing's disease at a tertiary centre (1990-2019). Remission was defined as MSeC <138 nmol/L by 6 weeks postoperatively. Recurrence was defined as elevated 24-h urine free cortisol, lack of suppression after dexamethasone or elevated midnight salivary cortisol.
In this study, 42 patients (age 47 ± 13 years, 83% female) were assessed with 55 ± 56 months of follow-up. Remission occurred after 77% of primary ( = 30) and 42% of revision operations ( = 12). After primary surgery, remission was associated with lower MSeC nadir (26 ± 36 nmol/L vs 347 ± 220 nmol/L, < 0.01) and lower adrenocorticotropin nadir (2 ± 3 pmol/L vs 6 ± 3 pmol/L, = 0.01). Sustained remission 5 years after surgery was predicted by MSeC <92 nmol/L within 2 weeks postoperatively (sensitivity 100% and specificity 100%). After revision surgery, remission was predicted by lower MSeC nadir (70 ± 45 nmol/L vs 408 ± 305 nmol/L, = 0.03), smaller tumour diameter (3 ± 2 mm vs 15 ± 13 mm, = 0.05) and absence of cavernous sinus invasion (0% vs 71%, = 0.03). Recurrence after primary and revision surgery occurred in 17% and 20% of patients respectively.
Lower postoperative MSeC nadir strongly predicted remission after both primary and revision surgery. Following primary surgery, an MSeC <92 nmol/L within 2 weeks predicted sustained remission at 5 years. MSeC nadir was the most important prognostic marker following TSS for Cushing's disease.
经蝶窦手术（TSS）是库欣病的一线治疗方法。本研究的目的是确定库欣病经蝶窦手术后的缓解率和复发率，识别预测这些结果的因素，并确定最准确预测持续缓解的术后早晨血清皮质醇（MSeC）阈值。
回顾性分析一家三级中心（1990 - 2019年）连续接受库欣病经蝶窦手术的成年患者的记录。缓解定义为术后6周时MSeC <138 nmol/L。复发定义为24小时尿游离皮质醇升高、地塞米松后未被抑制或午夜唾液皮质醇升高。
本研究共评估了42例患者（年龄47±13岁，83%为女性），随访时间为55±56个月。77%的初次手术（n = 30）和42%的再次手术（n = 12）后实现了缓解。初次手术后，缓解与较低的MSeC最低点（26±36 nmol/L对347±220 nmol/L，P < 0.01）和较低的促肾上腺皮质激素最低点（2±3 pmol/L对6±3 pmol/L，P = 0.01）相关。术后2周内MSeC <92 nmol/L可预测术后5年的持续缓解（敏感性100%，特异性100%）。再次手术后，缓解可通过较低的MSeC最低点（70±45 nmol/L对408±305 nmol/L，P = 0.03）、较小的肿瘤直径（3±2 mm对15±13 mm，P = 0.05）和无海绵窦侵犯（0%对71%，P = 0.03）来预测。初次手术和再次手术后分别有17%和20%的患者复发。
较低的术后MSeC最低点强烈预测初次手术和再次手术后的缓解。初次手术后，术后2周内MSeC <92 nmol/L可预测5年的持续缓解。MSeC最低点是库欣病经蝶窦手术后最重要的预后标志物。
