gms | German Medical Science

To evaluate the place of microneurosurgical treatment of Cushing’s disease (C.D.) with regard to therapeutical options like conventional radiotherapy or shaped beam radiosurgery and adrenalectomy.

From January 1998 to October 2004, a total of 127 patients suffering from C.D. were operated on by a single surgeon. In 34 cases, a re-operation was performed and 3 patients were operated three times. In the remaining 90 patients, primary operation was performed.

In 38 patients, preoperative MRI was negative. In 15 out of these 38 cases, no clearly defined adenoma was found during surgery. Among these 15 patients, partial hypophysectomy according to petrosal sinus sampling was performed in 7 cases. In 3 of these patients, early and long-term remission was achieved. In 13 of the remaining 75 cases, invasion of the cavernous sinus was already diagnosed preoperatively, so that total adenomectomy could not be expected. Mass reduction was declared as goal of the surgery and further radiotherapy was scheduled. In 50 out of the remaining 62 patients (80.6%) who were potential candidates for selective adenomectomy, early remission was found. Consecutively, a long-term control of 96% was achieved if an adenoma was found during surgery. The remaining 12 out of 62 patients (19.4%), in whom hypercortisolism persisted, were treated as follows: in 2 of them no further treatment was necessary due to mild clinical symptoms and in 3 cases only biochemical persistence of the disease was observed. In 3 patients, hypercortisolism was abolished by adrenalectomy, 2 patients underwent shaped beam radiosurgery and clinical symptoms improved. Among operative procedures, there was no significant morbidity or mortality. Medical treatment (n=4 cases) using Rosiglitazone showed no significant decline in cortisol levels. In the total series, 2 recurrences were observed (2/50=4%). In these patients, either recurrent surgery or radiotherapy was performed.

In C.D., surgery is still the treatment of choice. Remission can be observed in 80% of the cases without significant morbidity or mortality. In case of persistence or recurrence, eucortisolism is achieved by adrenalectomy or radiotherapy. Using advanced radiation treatment options like shaped beam radiosurgery, remission can be achieved earlier and with a minor risk of pituitary insufficiency. Even modern pharmacological treatment is of temporary use.