Transsphenoidal Surgery for Cushing’s Disease

  • Kalmon D. Post
  • Margaret Pain
  • Hekmat Zarzour
  • Joshua Bederson
Chapter
First Online:

Abstract

The first line of treatment in Cushing’s disease is surgical resection. All patients with clinical evidence of Cushing’s disease should receive a full work-up to determine the source of the hypercortisolemia. Referral to a neurosurgeon is only necessary if the source of the endocrinopathy is suspected to be the pituitary gland. However, we believe that neurosurgeons operating on patients with Cushing’s disease must understand the preoperative work-up and be secure in the results along with the endocrine team. Mistakes in diagnosis are a frequent event when dealing with these patients. We will not review all the endocrine testing here.

Keywords

Transsphenoidal surgery Cushing’s disease Surgical resection Hypercortisolemia 
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References

  1. 1.
    Biller BM, Grossman AB, Stewart PM, Melmed S, Bertagna X, Bertherat J, Buchfelder M, Colao A, Hermus AR, Hofland LJ, Klibanski A, Lacroix A, Lindsay JR, Newell-Price J, Nieman LK, Petersenn S, Sonino N, Stalla GK, Swearingen B, Vance ML, Wass JA, Boscaro M. Treatment of adrenocorticotropin-dependent Cushing’s syndrome: a consensus statement. J Clin Endocrinol Metab. 2008;93:2454–62.CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Bonneville JF, Bonneville F, Cattin F. Magnetic resonance imaging of pituitary adenomas. Eur Radiol. 2005;15:543–8.CrossRefPubMedGoogle Scholar
  3. 3.
    Chandler WF, Barkan AL, Hollon T, Sakharova A, Sack J, Brahma B, Schteingart DE. Outcome of transsphenoidal surgery for Cushing disease: a single-center experience over 32 years. Neurosurgery. 2016;78:216–23.CrossRefPubMedGoogle Scholar
  4. 4.
    Chandler WF, Schteingart DE, Lloyd RV, Mckeever PE, Ibarra-Perez G. Surgical treatment of Cushing’s disease. J Neurosurg. 1987;66:204–12.CrossRefPubMedGoogle Scholar
  5. 5.
    Dallapiazza RF, Oldfield EH, Jane Jr JA. Surgical management of Cushing’s disease. Pituitary. 2015;18:211–6.CrossRefPubMedGoogle Scholar
  6. 6.
    De Tommasi C, Vance ML, Okonkwo DO, Diallo A, Laws Jr ER. Surgical management of adrenocorticotropic hormone-secreting macroadenomas: outcome and challenges in patients with Cushing’s disease or Nelson’s syndrome. J Neurosurg. 2005;103:825–30.CrossRefPubMedGoogle Scholar
  7. 7.
    Dickerman RD, Oldfield EH. Basis of persistent and recurrent Cushing disease: an analysis of findings at repeated pituitary surgery. J Neurosurg. 2002;97:1343–9.CrossRefPubMedGoogle Scholar
  8. 8.
    Erickson D, Erickson B, Watson R, Patton A, Atkinson J, Meyer F, Nippoldt T, Carpenter P, Natt N, Vella A, Thapa P. 3 Tesla magnetic resonance imaging with and without corticotropin releasing hormone stimulation for the detection of microadenomas in Cushing’s syndrome. Clin Endocrinol. 2010;72:793–9.CrossRefGoogle Scholar
  9. 9.
    Friedman RB, Oldfield EH, Nieman LK, Chrousos GP, Doppman JL, Cutler Jr GB, Loriaux DL. Repeat transsphenoidal surgery for Cushing’s disease. J Neurosurg. 1989;71:520–7.CrossRefPubMedGoogle Scholar
  10. 10.
    Gandhi CD, Meyer SA, Patel AB, Johnson DM, Post KD. Neurologic complications of inferior petrosal sinus sampling. AJNR Am J Neuroradiol. 2008;29:760–5.CrossRefPubMedGoogle Scholar
  11. 11.
    Gao Y, Zhong C, Wang Y, Xu S, Guo Y, Dai C, Zheng Y, Wang Y, Luo Q, Jiang J. Endoscopic versus microscopic transsphenoidal pituitary adenoma surgery: a meta-analysis. World J Surg Oncol. 2014;12:94.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Giraldi FP, Cavallo LM, Tortora F, Pivonello R, Colao A, Cappabianca P, Mantero F, Syndrome ABCS. The role of inferior petrosal sinus sampling in ACTH-dependent Cushing’s syndrome: review and joint opinion statement by members of the Italian Society for Endocrinology, Italian Society for Neurosurgery, and Italian Society for Neuroradiology. Neurosurg Focus. 2015;38:E5.CrossRefGoogle Scholar
  13. 13.
    Guilhaume B, Bertagna X, Thomsen M, Bricaire C, Vila-Porcile E, Olivier L, Racadot J, Derome P, Laudat MH, Girard F, et al. Transsphenoidal pituitary surgery for the treatment of Cushing’s disease: results in 64 patients and long term follow-up studies. J Clin Endocrinol Metab. 1988;66:1056–64.CrossRefPubMedGoogle Scholar
  14. 14.
    Higgins TS, Courtemanche C, Karakla D, Strasnick B, Singh RV, Koen JL, Han JK. Analysis of transnasal endoscopic versus transseptal microscopic approach for excision of pituitary tumors. Am J Rhinol. 2008;22:649–52.CrossRefPubMedGoogle Scholar
  15. 15.
    Hofmann BM, Hlavac M, Martinez R, Buchfelder M, Muller OA, Fahlbusch R. Long-term results after microsurgery for Cushing disease: experience with 426 primary operations over 35 years. J Neurosurg. 2008;108:9–18.CrossRefPubMedGoogle Scholar
  16. 16.
    Jagannathan J, Smith R, Devroom HL, Vortmeyer AO, Stratakis CA, Nieman LK, Oldfield EH. Outcome of using the histological pseudocapsule as a surgical capsule in Cushing disease clinical article. J Neurosurg. 2009;111:531–9.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Jehle S, Walsh JE, Freda PU, Post KD. Selective use of bilateral inferior petrosal sinus sampling in patients with adrenocorticotropin-dependent Cushing’s syndrome prior to transsphenoidal surgery. J Clin Endocrinol Metab. 2008;93:4624–32.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Kakade HR, Kasaliwal R, Khadilkar KS, Jadhav S, Bukan A, Khare S, Budyal SR, Goel A, Lila AR, Bandgar T, Shah NS. Clinical, biochemical and imaging characteristics of Cushing’s macroadenomas and their long-term treatment outcome. Clin Endocrinol. 2014;81:336–42.CrossRefGoogle Scholar
  19. 19.
    Kanter AS, Diallo AO, Jane Jr JA, Sheehan JP, Asthagiri AR, Oskouian RJ, Okonkwo DO, Sansur CA, Vance ML, Rogol AD, Laws Jr ER. Single-center experience with pediatric Cushing’s disease. J Neurosurg. 2005;103:413–20.PubMedGoogle Scholar
  20. 20.
    Kawamata T, Kubo O, Hori T. Surgical removal of growth hormone-secreting pituitary adenomas with intensive microsurgical pseudocapsule resection results in complete remission of acromegaly. Neurosurg Rev. 2005;28:201–8.CrossRefPubMedGoogle Scholar
  21. 21.
    Kelly DF. Transsphenoidal surgery for Cushing’s disease: a review of success rates, remission predictors, management of failed surgery, and Nelson’s syndrome. Neurosurg Focus. 2007;23:E5.CrossRefPubMedGoogle Scholar
  22. 22.
    Knappe UJ, Ludecke DK. Transnasal microsurgery in children and adolescents with Cushing’s disease. Neurosurgery. 1996;39:484–92; discussion 492–3.Google Scholar
  23. 23.
    Knosp E, Steiner E, Kitz K, Matula C. Pituitary adenomas with invasion of the cavernous sinus space: a magnetic resonance imaging classification compared with surgical findings. Neurosurgery. 1993;33:610–7; discussion 617–8.Google Scholar
  24. 24.
    Lambert JK, Goldberg L, Fayngold S, Kostadinov J, Post KD, Geer EB. Predictors of mortality and long-term outcomes in treated Cushing’s disease: a study of 346 patients. J Clin Endocrinol Metab. 2013;98:1022–30.CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Lonser RR, Ksendzovsky A, Wind JJ, Vortmeyer AO, Oldfield EH. Prospective evaluation of the characteristics and incidence of adenoma-associated dural invasion in Cushing disease. J Neurosurg. 2012;116:272–9.CrossRefPubMedGoogle Scholar
  26. 26.
    Lonser RR, Wind JJ, Nieman LK, Weil RJ, Devroom HL, Oldfield EH. Outcome of surgical treatment of 200 children with Cushing’s disease. J Clin Endocrinol Metab. 2013;98:892–901.CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Mampalam TJ, Tyrrell JB, Wilson CB. Transsphenoidal microsurgery for Cushing disease. A report of 216 cases. Ann Intern Med. 1988;109:487–93.CrossRefPubMedGoogle Scholar
  28. 28.
    Nishioka H, Fukuhara N, Horiguchi K, Yamada S. Aggressive transsphenoidal resection of tumors invading the cavernous sinus in patients with acromegaly: predictive factors, strategies, and outcomes. J Neurosurg. 2014;121:505–10.CrossRefPubMedGoogle Scholar
  29. 29.
    Oldfield EH. Surgical management of Cushing’s disease: a personal perspective. Clin Neurosurg. 2011;58:13–26.CrossRefPubMedGoogle Scholar
  30. 30.
    Oldfield EH. Editorial: management of invasion by pituitary adenomas. J Neurosurg. 2014;121:501–3.CrossRefPubMedGoogle Scholar
  31. 31.
    Oldfield EH, Vance ML. A cryptic cause of Cushing’s disease. J Clin Endocrinol Metab. 2013;98:4593–4.CrossRefPubMedGoogle Scholar
  32. 32.
    Oldfield EH, Vortmeyer AO. Development of a histological pseudocapsule and its use as a surgical capsule in the excision of pituitary tumors. J Neurosurg. 2006;104:7–19.CrossRefPubMedGoogle Scholar
  33. 33.
    Patil CG, Lad SP, Harsh GR, Laws Jr ER, Boakye M. National trends, complications, and outcomes following transsphenoidal surgery for Cushing’s disease from 1993 to 2002. Neurosurg Focus. 2007;23:E7.PubMedGoogle Scholar
  34. 34.
    Patil CG, Veeravagu A, Prevedello DM, Katznelson L, Vance ML, Laws Jr ER. Outcomes after repeat transsphenoidal surgery for recurrent Cushing’s disease. Neurosurgery. 2008;63:266–70; discussion 270–1.Google Scholar
  35. 35.
    Patronas N, Bulakbasi N, Stratakis CA, Lafferty A, Oldfield EH, Doppman J, Nieman LK. Spoiled gradient recalled acquisition in the steady state technique is superior to conventional postcontrast spin echo technique for magnetic resonance imaging detection of adrenocorticotropin-secreting pituitary tumors. J Clin Endocrinol Metab. 2003;88:1565–9.CrossRefPubMedGoogle Scholar
  36. 36.
    Peck WW, Dillon WP, Norman D, Newton TH, Wilson CB. High-resolution MR imaging of pituitary microadenomas at 1.5 T: experience with Cushing disease. AJR Am J Roentgenol. 1989;152:145–51.CrossRefPubMedGoogle Scholar
  37. 37.
    Pluta RM, Nieman L, Doppman JL, Watson JC, Tresser N, Katz DA, Oldfield EH. Extrapituitary parasellar microadenoma in Cushing’s disease. J Clin Endocrinol Metab. 1999a;84:2912–23.PubMedGoogle Scholar
  38. 38.
    Pouratian N, Prevedello DM, Jagannathan J, Lopes MB, Vance ML, Laws Jr ER. Outcomes and management of patients with Cushing’s disease without pathological confirmation of tumor resection after transsphenoidal surgery. J Clin Endocrinol Metab. 2007a;92:3383–8.CrossRefPubMedGoogle Scholar
  39. 39.
    Prevedello DM, Pouratian N, Sherman J, Jane Jr JA, Vance ML, Lopes MB, Laws Jr ER. Management of Cushing’s disease: outcome in patients with microadenoma detected on pituitary magnetic resonance imaging. J Neurosurg. 2008;109:751–9.CrossRefPubMedGoogle Scholar
  40. 40.
    Sheehan JM, Lopes MB, Sheehan JP, Ellegala D, Webb KM, Laws Jr ER. Results of transsphenoidal surgery for Cushing’s disease in patients with no histologically confirmed tumor. Neurosurgery. 2000;47:33–6; discussion 37–9.Google Scholar
  41. 41.
    Sol YL, Lee SK, Choi HS, Lee YH, Kim J, Kim SH. Evaluation of MRI criteria for cavernous sinus invasion in pituitary macroadenoma. J Neuroimaging. 2014;24:498–503.CrossRefPubMedGoogle Scholar
  42. 42.
    Starke RM, Reames DL, Chen CJ, Laws ER, Jane Jr JA. Endoscopic transsphenoidal surgery for Cushing disease: techniques, outcomes, and predictors of remission. Neurosurgery. 2013;72:240–7; discussion 247.Google Scholar
  43. 43.
    Tabarin A, Laurent F, Catargi B, Olivier-Puel F, Lescene R, Berge J, Galli FS, Drouillard J, Roger P, Guerin J. Comparative evaluation of conventional and dynamic magnetic resonance imaging of the pituitary gland for the diagnosis of Cushing’s disease. Clin Endocrinol. 1998;49:293–300.CrossRefGoogle Scholar
  44. 44.
    Valassi E, Biller BM, Swearingen B, Pecori Giraldi F, Losa M, Mortini P, Hayden D, Cavagnini F, Klibanski A. Delayed remission after transsphenoidal surgery in patients with Cushing’s disease. J Clin Endocrinol Metab. 2010;95:601–10.CrossRefPubMedPubMedCentralGoogle Scholar
  45. 45.
    Watson JC, Shawker TH, Nieman LK, Devroom HL, Doppman JL, Oldfield EH. Localization of pituitary adenomas by using intraoperative ultrasound in patients with Cushing’s disease and no demonstrable pituitary tumor on magnetic resonance imaging. J Neurosurg. 1998;89:927–32.CrossRefPubMedGoogle Scholar
  46. 46.
    Weil RJ, Vortmeyer AO, Nieman LK, Devroom HL, Wanebo J, Oldfield EH. Surgical remission of pituitary adenomas confined to the neurohypophysis in Cushing’s disease. J Clin Endocrinol Metab. 2006;91:2656–64.CrossRefPubMedGoogle Scholar
  47. 47.
    Wind JJ, Lonser RR, Nieman LK, Devroom HL, Chang R, Oldfield EH. The lateralization accuracy of inferior petrosal sinus sampling in 501 patients with Cushing’s disease. J Clin Endocrinol Metab. 2013;98:2285–93.CrossRefPubMedPubMedCentralGoogle Scholar
  48. 48.
    Woodworth GF, Patel KS, Shin B, Burkhardt JK, Tsiouris AJ, Mccoul ED, Anand VK, Schwartz TH. Surgical outcomes using a medial-to-lateral endonasal endoscopic approach to pituitary adenomas invading the cavernous sinus. J Neurosurg. 2014;120:1086–94.CrossRefPubMedPubMedCentralGoogle Scholar
  49. 49.
    Yamada S, Fukuhara N, Nishioka H, Takeshita A, Inoshita N, Ito J, Takeuchi Y. Surgical management and outcomes in patients with Cushing disease with negative pituitary magnetic resonance imaging. World Neurosurg. 2012;77:525–32.CrossRefPubMedGoogle Scholar
  50. 50.
    Zielinski G, Podgorski JK, Koziarski A, Warczynska A, Zgliczynski W, Makowska A. Surgical treatment of invasive pituitary adenomas (somatotropinoma or corticotropinoma). Neurol Neurochir Pol. 2003;37:1239–55.PubMedGoogle Scholar

Copyright information

© Springer International Publishing AG 2017

Authors and Affiliations

  • Kalmon D. Post
    • 1
  • Margaret Pain
    • 2
  • Hekmat Zarzour
    • 3
  • Joshua Bederson
    • 2
  1. 1.Department NeurosurgeryMount Sinai School of Medicine, Mount Sinai Health SystemNew YorkUSA
  2. 2.Department of NeurosurgeryMount Sinai School of MedicineNew YorkUSA
  3. 3.Department of NeurosurgeryJefferson University HospitalPhiladelphiaUSA

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