Artikel
Localization of pituitary adenomas in patients with Cushing disease (CD) with negative or inconclusive MRI findings using cavernous sinus sampling (CSS)
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Veröffentlicht: | 28. April 2011 |
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Gliederung
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Objective: Cushing disease (CD) shows a non-suppressed plasma ACTH in hypercortisolism, sufficient suppression of cortisol in dexamethasone tests and stimulation of ACTH or cortisol in the CRH test. If ACTH-secreting adenomas are not seen in high standard MRI (recently 3-Tesla), cavernous sinus sampling (CSS) has been used as an additional diagnostic tool. Ten years of experience in transnasal microsurgery of CD allow us to validate the usefulness of CSS.
Methods: 66 patients (9 children) underwent CSS between 1/1999 and 2010 because of inconclusive endocrine testing, recurrent disease, and/or negative MRI findings according to the method of A.Teramoto et al. (1993).
Results: Due to anatomical reasons the catheterization of the cavernous sinus failed in 2 patients (3%), actual hypercortisolism was not confirmed in 6 patients (9%). In 7 patients CSS excluded pituitary dependent Cushing disease with confirmed hypercortisolism. Therefore, these patients did not undergo pituitary exploration. So far, 2 ectopic ACTH-secreting tumors have been histologically confirmed in these patients. In the remaining 50 patients with a central-peripheral gradient, 41 CSS procedures lateralized the ACTH-adenoma of the pituitary correctly (82%), as proven by surgery. Despite a central-peripheral gradient there was no lateralization gradient in 6 cases. Of these, four patients had either a midline tumor/stalk tumor or a tumor extension into both sides of the pituitary. Therefore, the correct gradient was found in a total 90%. There was no procedure-related severe morbidity.
Conclusions: In cases with unclear endocrine tests and for localizing minute ACTH-secreting adenomas in the pituitary, CSS prior to transsphenoidal surgery is a very useful tool. Ideally, a discussion between the endocrinologist and the pituitary surgeon is advisable in cases with complex findings before invasive techniques are performed.