Management of Cushing’s Disease: Transsphenoidal Surgery.

From Lewis S. Blevins Jr, MD  –  Transphenoidal pituitary surgery is the treatment of choice In the setting of Cushing’s disease due to a well-defined pituitary adenoma. Occasionally, patients with a suspected pituitary adenoma, but without tumor identifiable on MRI, yet highly suspected because of results of IPSS and other dynamic studies, are also candidates for surgery. Success rates vary from institution to institution, according to the experience of the operating neurosurgeon, Intraoperative findings, and depend on tumor size and invasiveness. In most experienced centers of excellence, approximately 90% of those patients harboring microadenoma’s can be rendered disease-free. The recurrence rate varies between 5 to 15%. Most recurrences occur in the first 2 to 5 years after surgery but I have seen one patient with a delay of up to 15 years from the time of her original surgery. Only approximately two-thirds of patients with macroadenomas are rendered disease-free after surgery.

The success rate drops precipitously when larger tumors invade the cavernous sinuses or extend into another bony regions of the sella. Recurrence rates range between 30 to 50%. Absence of a tumor identified at the time of surgery, and lack of a tumor in the tissue samples removed at surgery. are both associated with a higher risk of failed surgery. Repeat surgery for either residual or recurrent disease results in remission in approximately one half of patients. Repeat surgery to debulk and control tumor can be beneficial even when a cute is not expected. I have seen one patient who required six operations to successfully manage her pituitary tumor.

Of course, surgical success depends on an accurate diagnosis. Work with your endocrinologist to ensure that the diagnosis rendered is based on reliable tests. If not, undergo more tests until the diagnosis is certain. Also, travel to a center of excellence to undergo surgery by an experienced pituitary surgeon. It will be with your time and efforts to ensure that you are set to avail yourself of the best opportunity to achieve a disease-free state as a result of the very first operation.

Painting by Lewis Blevins.  See more paintings here

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