Delayed remission after transsphenoidal surgery in patients with cushing's disease

Elena Valassi, B. M K Biller, Brooke Swearingen, Francesca Pecori Giraldi, Marco Losa, Pietro Mortini, Douglas Hayden, Francesco Cavagnini, Anne Klibanski

Research output: Contribution to journalArticle

Abstract

Background: Transsphenoidal surgery (TSS) is the treatment of choice for Cushing's disease (CD). Postoperative hypercortisolemia mandates further therapy. Objective: 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. Design and Setting: A retrospective case series was conducted at three tertiary care centers. Patients and Intervention:Wereviewed 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. Results: 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). Conclusions: 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.

Original languageEnglish
Pages (from-to)601-610
Number of pages10
JournalJournal of Clinical Endocrinology and Metabolism
Volume95
Issue number2
DOIs
Publication statusPublished - Feb 2010

Fingerprint

Pituitary ACTH Hypersecretion
Surgery
Hydrocortisone
Control Groups
Therapeutics
Recurrence
Cushing Syndrome
Postoperative Period
Tertiary Care Centers
Testing

ASJC Scopus subject areas

  • Biochemistry
  • Clinical Biochemistry
  • Endocrinology
  • Biochemistry, medical
  • Endocrinology, Diabetes and Metabolism

Cite this

Delayed remission after transsphenoidal surgery in patients with cushing's disease. / Valassi, Elena; Biller, B. M K; Swearingen, Brooke; Giraldi, Francesca Pecori; Losa, Marco; Mortini, Pietro; Hayden, Douglas; Cavagnini, Francesco; Klibanski, Anne.

In: Journal of Clinical Endocrinology and Metabolism, Vol. 95, No. 2, 02.2010, p. 601-610.

Research output: Contribution to journalArticle

@article{8ad2ca0b903f41c99ab6b7dd90ef4c58,
title = "Delayed remission after transsphenoidal surgery in patients with cushing's disease",
abstract = "Background: Transsphenoidal surgery (TSS) is the treatment of choice for Cushing's disease (CD). Postoperative hypercortisolemia mandates further therapy. Objective: 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. Design and Setting: A retrospective case series was conducted at three tertiary care centers. Patients and Intervention:Wereviewed 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. Results: 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). Conclusions: 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.",
author = "Elena Valassi and Biller, {B. M K} and Brooke Swearingen and Giraldi, {Francesca Pecori} and Marco Losa and Pietro Mortini and Douglas Hayden and Francesco Cavagnini and Anne Klibanski",
year = "2010",
month = "2",
doi = "10.1210/jc.2009-1672",
language = "English",
volume = "95",
pages = "601--610",
journal = "Journal of Clinical Endocrinology and Metabolism",
issn = "0021-972X",
publisher = "The Endocrine Society",
number = "2",

}

TY - JOUR

T1 - Delayed remission after transsphenoidal surgery in patients with cushing's disease

AU - Valassi, Elena

AU - Biller, B. M K

AU - Swearingen, Brooke

AU - Giraldi, Francesca Pecori

AU - Losa, Marco

AU - Mortini, Pietro

AU - Hayden, Douglas

AU - Cavagnini, Francesco

AU - Klibanski, Anne

PY - 2010/2

Y1 - 2010/2

N2 - Background: Transsphenoidal surgery (TSS) is the treatment of choice for Cushing's disease (CD). Postoperative hypercortisolemia mandates further therapy. Objective: 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. Design and Setting: A retrospective case series was conducted at three tertiary care centers. Patients and Intervention:Wereviewed 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. Results: 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). Conclusions: 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.

AB - Background: Transsphenoidal surgery (TSS) is the treatment of choice for Cushing's disease (CD). Postoperative hypercortisolemia mandates further therapy. Objective: 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. Design and Setting: A retrospective case series was conducted at three tertiary care centers. Patients and Intervention:Wereviewed 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. Results: 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). Conclusions: 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.

UR - http://www.scopus.com/inward/record.url?scp=76149118065&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=76149118065&partnerID=8YFLogxK

U2 - 10.1210/jc.2009-1672

DO - 10.1210/jc.2009-1672

M3 - Article

C2 - 20080848

AN - SCOPUS:76149118065

VL - 95

SP - 601

EP - 610

JO - Journal of Clinical Endocrinology and Metabolism

JF - Journal of Clinical Endocrinology and Metabolism

SN - 0021-972X

IS - 2

ER -