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Contemporary microsurgical concept for the treatment of Cushing’s disease: endocrine outcome in 83 consecutive patients

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Background  Evidence suggests that occult adenoma remnants are responsible for persistent Cushing’s disease (CD) following transsphenoidal surgery (TSS). To optimize the outcome, we have adapted our microsurgical concept. The influence of our surgical strategy on remission rate and pituitary function is presented.

Design and patients  83 patients undergoing TSS for newly diagnosed CD. An enlarged resection was performed in 36 patients. A modified exploration technique with radial incisions was performed in 19 patients in whom an adenoma was not readily detectable.

Results  The overall remission rate of primary surgery was 84·3% (70/83). A remission rate of 87·5% (63/72) was achieved in microadenomas. Six patients with microadenomas were re‐operated for persistence, and hypercortisolism was corrected in five of them. With re‐operation included, the overall remission rate for microadenomas was 94·4%. No procedure‐related complications occurred in primary surgery. Of the patients in remission, 72·5% had early postoperative random cortisol levels below 2 μg/dl, 17·4% had cortisol levels between 2 and 5 μg/dl, and 10·1% had cortisol levels >5 μg/dl. 15·2% of the patients with microadenomas developed postoperative partial hypopituitarism and 3% diabetes insipidus. No increased rate of hypopituitarism was found with enlarged adenomectomy compared to selective adenomectomy. Only a slightly higher rate of partial hypopituitarism (23·1%) was found if extensive exploration was required.

Conclusion  With our microsurgical concept, a high initial cure rate is achievable with minimal surgical morbidity. Enlarged adenomectomy has no adverse effect on the rate of postoperative hypopituitarism. Early repeat surgery is a successful option if CD persists.
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Document Type: Research Article

Affiliations: 1: Department of Neurosurgery, University of Tuebingen, Tuebingen 2: Department of Internal Medicine, University of Munich (Campus Innenstadt), Munich 3: Department of Internal Medicine 1, Hospital of Karlsruhe, Karlsruhe 4: Department of Internal Medicine (Endocrinology and Metabolism), University of Tuebingen 5: Department of Neuroradiology, University of Tuebingen, Tuebingen, Germany

Publication date: April 1, 2012

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