In gratitude of the loyal support of our members, the CNS is offering complimentary 2021 Annual Meeting registration to all members! Learn more.

  • Surgical Management of MRI Negative Cushing Disease

    Final Number:
    1088

    Authors:
    Rupa Juthani MD; Phillip C Johnston MD; Amir Hamrahian; Lawrence Kennedy MD; Robert J Weil

    Study Design:
    Other

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2017 Annual Meeting

    Introduction: Management of patients with MRI-negative Cushing’s disease (CD) can be challenging; factors predicting tumor localization remain imperfect. Reported remission rates in the literature vary widely (~60 to 86%), further complicating decision-making. We examined our experience in 52 patients, over 7.5 years, operated upon by a single surgeon.

    Methods: Prospectively-collected data of 52 patients with MRI-negative CD were reviewed retrospectively. All patients who underwent transphenoidal surgery by a single surgeon from March 2006 to September 2013 were analyzed. Of these, nine (17.3%) had prior surgery elsewhere, without remission or tumor identification.

    Results: A tumor was identified at surgery in 47/52 (90%) patients; an ACTH-staining pituitary adenoma was confirmed in 38/47 (81%) of these tumors. Initial remission was achieved in 44/52 (84.6%) cases, with recurrence in 4/44 (9.0%) patients (mean time to recurrence 40.5 months, range 6-87). Excluding prior surgery patients, remission was achieved in 38/43(88%) patients with a mean follow-up of 34 months (range 1-118); there were three recurrences (3/38 or 7.8%). IPSS was performed in all patients; in 28/52 (53.8%) patients tumors lateralized; in 19 (67.8%), IPSS lateralization correlated with the location of the adenoma. Prolactin-adjusted ACTH ratios were more predictive of laterality than the unadjusted ACTH ratio (p=.044). Excluding four cases of hemi- or complete hypophysectomy, new postoperative hormone deficits were noted in 4/48 (8.3%) patients. Mean follow-up time was 37.5 months (range 1-118).

    Conclusions: Transphenoidal exploration and resection of radiographically negative CD can result in a high rate of tumor identification and durable remission with a low rate of new postoperative deficits. 88% of Cushing’s patients undergoing their first surgery achieved remission at a mean follow-up of 34 months. While IPSS may assist in guiding resection in MRI-negative cases, it remains an imperfect indicator of tumor laterality. The use of prolactin-adjusted levels may enhance the predictive value of IPSS.

    Patient Care: This research serves to augment our understanding of MRI-negative Cushing's disease and guide our surgical treatment algorithm. Specifically, the use of IPSS data should be tempered with the results of this paper that suggest that using alternative prolactin-adjusted rations can improve the prediction of laterality and subsequently guide surgical resection. This aims to improve remission rates for patients undergoing surgery for MRI-negative Cushing's disease.

    Learning Objectives: 1) IPSS data must be interpreted with an understanding of its limitations 2) Prolactin-adjusted ACTH levels can improve the predictive value of IPSS in laterality prediction

    References:

We use cookies to improve the performance of our site, to analyze the traffic to our site, and to personalize your experience of the site. You can control cookies through your browser settings. Please find more information on the cookies used on our site. Privacy Policy