Therapeutic problems with transsphenoidal pituitary surgery for Cushing’s disease

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Safe, definitive treatment of Cushing’s disease is now possible via total hypophysectomy or selective removal of an adenoma with transsphenoidal surgery.1–5 The short-term efficacy of pituitary tumor resection has been well demonstrated, although long-term data are lacking. Tyrrell et al2 suggested that some of these tumors may be too small to detect by current neuroradiologic techniques. Reported complications have included hemorrhage at the operative site,2, 3 and prolonged postoperative need for glucocorticoid replacement (slow hypothalamic-pituitary-adrenal axis recovery).1–4

In our study, 18 patients underwent either selective adenoma removal or total hypophysectomy for Cushing’s disease. Our purpose was to evaluate postoperative results of transsphenoidal surgical therapy as well as to record the radiologic data and complications associated with the procedure. We confirmed that initial cure is possible in a large percentage of the patients undergoing this form of therapy. In our series, however, as in all previous studies, not all patients were cured. Our data demonstrated that the tumors responsible are often too small to detect, even with current neuroradiologic techniques. Thus, patients were often selected for surgical therapy on the basis of biochemical criteria. In the present series, operative mortality was zero. However, we have encountered some morbidity not emphasized in prior reports. A crucial and disturbing finding was the recurrence of active Cushing’s disease in 2 patients after initial cure.

Patient population: preoperative and postoperative studies

Eighteen patients (14 women, 4 men; age range, 17–65 years) with the diagnosis of pituitary Cushing’s disease underwent transsphenoidal pituitary exploration . . .



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