Biochemical Predictors of Outcome of Pituitary Surgery for Cushing's Disease

R.A. Alwani^a, W.W. de Herder^a, M.O. van Aken^a, J.H. van den Berge^b, E.J. Delwel^b, A.H.G. Dallenga^b, F.H. De Jong^a, S.W.J. Lamberts^a, A.J. van der Lely^a, R.A. Feelders^a
aDepartment of Internal Medicine, Division of Endocrinology, and
^bDepartment of Neurosurgery, Erasmus Medical Centre, Rotterdam, The Netherlands

Address of Corresponding Author

Neuroendocrinology (DOI: 10.1159/000258677)

Key Words

• Cushing's disease
• Pituitary adenoma
• Pituitary surgery
• Cortisol
• Metyrapone
• Corticotropin-releasing hormone
  
  

Abstract

Objective: Transsphenoidal surgery (TS) is the primary therapy for Cushing's disease (CD). The aims of this retrospective study were twofold: (i) investigate early and late results of TS for CD, and (ii) evaluate various postoperative tests in order to predict the outcome of TS.

Methods: We reviewed the long-term outcome in 79 patients with CD who underwent TS (median follow-up 84 months, range 6-197). Within 2 weeks after surgery, morning serum cortisol concentrations were obtained (n = 78) and corticotropin-releasing hormone (CRH) (n = 53) and metyrapone tests (n = 72) were performed. Three groups of outcome were identified: sustained remission, early failure (persistent CD), and late relapse.

Results: Immediate postoperative remission was achieved in 51 patients (65%), whereas 28 patients (35%) had persistent CD after TS. Ten patients developed recurrent CD after initial remission (20%). Morning cortisol: all relapses but one recorded serum cortisol >50 nmol/l. A cortisol threshold value of 200 nmol/l has a positive predictive value of 79% for immediate surgical failure (negative predictive failure [NPV] 97%). CRH test: CRH-stimulated peak cortisol ge600 nmol/l predicted early failure in 78% (NPV 100%). All relapses recorded CRH-stimulated peak cortisol ge485 nmol/l. Metyrapone test: 11-deoxycortisol ge345 nmol/l predicted an early failure in 86% of cases (NPV 94%).

Conclusion: Predictive factors of surgical failure are morning cortisol ge200 nmol/l, 11-deoxycortisol ge345 nmol/l after metyrapone and CRH-stimulated cortisol ge600 nmol/l. CRH and/or metyrapone testing are not superior to morning cortisol concentration in the prediction of outcome of TS. Careful long-term follow-up remains necessary independent of the outcome of biochemical testing.

Copyright © 2009 S. Karger AG, Basel

Author Contacts

Rehmat A. Alwani, MD
Department of Internal Medicine, Division of Endocrinology
Erasmus Medical Centre, Room H555, PO Box 2040
NL-3000 CA Rotterdam (The Netherlands)
Tel. +31 107 040 704, Fax +31 104 63639, E-Mail r.alwani@erasmusmc.nl

Article Information

Received: April 2, 2009
Accepted after revision: June 18, 2009
Published online: November 12, 2009
Number of Print Pages : 10
Number of Figures : 5, Number of Tables : 2, Number of References : 39

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