Many patients with Cushing disease still have active or recurrent disease after pituitary surgery. The histological pseudocapsule of a pituitary adenoma is a layer of compressed normal anterior lobe that surrounds the adenoma and can be used during surgery to identify and guide removal of the tumor. In this study the authors examined the results of using the pseudocapsule as a surgical capsule in the resection of adenomas in patients with Cushing disease.
The authors reviewed a prospective database of data obtained in patients with Cushing disease who underwent surgery. The analysis included all cases in which a lesion was identified during surgery and in which the lesion was believed to be confined to the pituitary gland in patients with Cushing disease between January 1990 and March 2007. Since the objective was to determine the success of using the pseudocapsule as a surgical capsule, patients with invasive tumors and patients in whom no lesion was identified during surgery—challenging cases for surgical success—were excluded from analysis.
In 261 patients an encapsulated adenoma was identified at surgery. Tumor was visible on MR imaging in 135 patients (52%); in 126 patients (48%) MR imaging detected no tumor. The range of tumor size overlapped considerably in the groups with positive and negative MR imaging results, indicating that in addition to size other features of the adenoma influence the results of MR imaging. In 252 patients hypercortisolism resolved after the first operation, whereas in 9 patients (3 with positive MR imaging and 6 with negative MR imaging) early reoperation was required. Hypercortisolism resolved in all 261 patients (256 with hypocortisolism and 5 with eucortisolism) before hospital discharge. Forty-six patients (18%) had postoperative electrolyte abnormalities (30 with hyponatremia and 16 with diabetes insipidus), but only 2 patients required treatment at discharge. The mean clinical follow-up duration was 84 months (range 12–215 months). Six patients (2%) had recurrence of hypercortisolism, all of whom were treated successfully with reoperation.
Because of their small size, adenomas can be challenging to identify in patients with Cushing disease. Use of the histological pseudocapsule of an adenoma allows accurate identification of the tumor and helps guide its complete excision. With this approach the overall remission rate is high and the rate of complications is low.
Please include this information when citing this paper: published online March 6, 2009; DOI: 10.3171/2008.8.JNS08339.
AtkinsonAB,,KennedyA,,WiggamMI,,McCanceDR,&SheridanB:Long-term remission rates after pituitary surgery for Cushing's disease: the need for long-term surveillance.Clin Endocrinol (Oxf)63:549–559,2005
BatistaD,,CourkoutsakisNA,,OldfieldEH,,GriffinKJ,,KeilM,&PatronasNJ,et al.:Detection of adrenocorticotropin-secreting pituitary adenomas by magnetic resonance imaging in children and adolescents with cushing disease.J Clin Endocrinol Metab90:5134–5140,2005
BlevinsLSJr,,ChristyJH,,KhajaviM,&TindallGT:Outcomes of therapy for Cushing's disease due to adrenocorticotropin-secreting pituitary macroadenomas.J Clin Endocrinol Metab83:63–67,1998
CheeGH,,MathiasDB,,JamesRA,&Kendall-TaylorP:Transsphenoidal pituitary surgery in Cushing's disease: can we predict outcome?.Clin Endocrinol (Oxf)54:617–626,2001
CiricI:垂体tumors.Neurol Clin3:751–768,1985
Cohen-GadolAA,,LiuJK,&LawsERJr:Cushing's first case of transsphenoidal surgery: the launch of the pituitary surgery era.J Neurosurg103:570–574,2005
CostelloR:Subclinical adenoma of the pituitary gland.Am J Pathol12:205–214,1936
DasK,,SpencerW,,NwagwuCI,,SchaefferS,,WenkE,&WeissMH,et al.:Approaches to the sellar and parasellar region: anatomic comparison of endonasal-transsphenoidal, sublabial-transsphenoidal, and transethmoidal approaches.Neurol Res23:51–54,2001
DavisWL,,LeeJN,,KingBD,&HarnsbergerHR:Dynamic contrast-enhanced MR imaging of the pituitary gland with fast spin-echo technique.J Magn Reson Imaging4:509–511,1994
DickermanRD,&OldfieldEH:Basis of persistent and recurrent Cushing disease: an analysis of findings at repeated pituitary surgery.J Neurosurg97:1343–1349,2002
GierachM,,PufalJ,,PileckiS,&JunikR:The case of Cushing's disease imaging by SPECT examination without manifestation of pituitary adenoma in MRI examination.Nucl Med Rev Cent East Eur8:137–139,2005
HammerGD,,TyrrellJB,,LambornKR,,AppleburyCB,,HanneganET,&BellS,et al.:Transsphenoidal microsurgery for Cushing's disease: initial outcome and long-term results.J Clin Endocrinol Metab89:6348–6357,2004
HardyJ:Transsphenoidal hypophysectomy.J Neurosurg34:582–594,1971
HardyJ:Transsphenoidal surgery.Surg Neurol5:160,1976.(Letter)
HardyJ,&VezinaJL:Transsphenoidal neurosurgery of intracranial neoplasm.Adv Neurol15:261–273,1976
HofmannBM,,HlavacM,,MartinezR,,BuchfelderM,,MullerOA,&FahlbuschR:Long-term results after microsurgery for Cushing disease: experience with 426 primary operations over 35 years.J Neurosurg108:9–18,2008
InvittiC,,Pecori GiraldiF,,de MartinM,&CavagniniF:Diagnosis and management of Cushing's syndrome: results of an Italian multicentre study. Study Group of the Italian Society of Endocrinology on the Pathophysiology of the Hypothalamic-Pituitary-Adrenal Axis.J Clin Endocrinol Metab84:440–448,1999
KanterAS,,DumontAS,,AsthagiriAR,,OskouianRJ,,JaneJAJr,&LawsERJr:The transsphenoidal approach. A historical perspective.Neurosurg Focus18:4E6,2005
LindsayJR,,NanselT,,BaidS,,GumowskiJ,&NiemanLK:库兴氏sy的长期不良的生活质量ndrome despite initial improvement after surgical remission.J Clin Endocrinol Metab91:447–453,2006
MampalamTJ,,TyrrellJB,&WilsonCB:Transsphenoidal microsurgery for Cushing disease. A report of 216 cases.Ann Intern Med109:487–493,1988
NakaneT,,KuwayamaA,,WatanabeM,,TakahashiT,,KatoT,&IchiharaK,et al.:Long term results of transsphenoidal adenomectomy in patients with Cushing's disease.开云体育app官方网站下载入口21:218–222,1987
NiemanLK:Medical therapy of Cushing's disease.垂体5:77–82,2002
OldfieldEH,&VortmeyerAO:Development of a histological pseudocapsule and its use as a surgical capsule in the excision of pituitary tumors.J Neurosurg104:7–19,2006
PatilCG,,PrevedelloDM,,LadSP,,VanceML,,ThornerMO,&KatznelsonL,et al.:Late recurrences of Cushing's disease after initial successful transsphenoidal surgery.J Clin Endocrinol Metab93:358–362,2008
PatronasN,,BulakbasiN,,StratakisCA,,LaffertyA,,OldfieldEH,&DoppmanJ,et al.:Spoiled gradient recalled acquisition in the steady state technique is superior to conventional post-contrast spin echo technique for magnetic resonance imaging detection of adrenocorticotropin-secreting pituitary tumors.J Clin Endocrinol Metab88:1565–1569,2003
RamZ,,NiemanLK,,CutlerGBJr,,ChrousosGP,,DoppmanJL,&OldfieldEH:Early repeat surgery for persistent Cushing's disease.J Neurosurg80:37–45,1994
SalenaveS,,GattaB,,PecheurS,,San-GalliF,,VisotA,&LasjauniasP,et al.:垂体magnetic resonance imaging findings do not influence surgical outcome in adrenocorticotropin-secreting microadenomas.J Clin Endocrinol Metab89:3371–3376,2004
SheehanJM,,LopesMB,,SheehanJP,,EllegalaD,,WebbKM,&LawsERJr:Results of transsphenoidal surgery for Cushing's disease in patients with no histologically confirmed tumor.开云体育app官方网站下载入口47:33–39,2000
TestaRM,,AlbigerN,,OcchiG,,SanguinF,,ScanariniM,&BerlucchiS,et al.:The usefulness of combined biochemical tests in the diagnosis of Cushing's disease with negative pituitary magnetic resonance imaging.Eur J Endocrinol156:241–248,2007
ThaparK,&LawsERJr,垂体tumors.KayeAH,&LawsERJr:Brain TumorsLondon,Churchill Livingstone,2001.803–854
WatsonJC,,ShawkerTH,,NiemanLK,,DeVroomHL,,DoppmanJL,&OldfieldEH:Localization of pituitary adenomas by using intraoperative ultrasound in patients with Cushing's disease and no demonstrable pituitary tumor on magnetic resonance imaging.J Neurosurg89:927–932,1998
WeilRJ,,VortmeyerAO,,NiemanLK,,DevroomHL,,WaneboJ,&OldfieldEH:Surgical remission of pituitary adenomas confined to the neurohypophysis in Cushing's disease.J Clin Endocrinol Metab91:2656–2664,2006
YapLB,,TurnerHE,,AdamsCB,&WassJA:Undetectable postoperative cortisol does not always predict long-term remission in Cushing's disease: a single centre audit.Clin Endocrinol (Oxf)56:25–31,2002
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