Diagnostic Pitfalls in Cushing Disease: Surgical Remission Rates, Test Thresholds, and Lessons Learned in 105 Patients

被引:8
作者
Mallari, Regin Jay [1 ]
Thakur, Jai Deep [1 ,2 ]
Barkhoudarian, Garni [1 ,3 ,4 ]
Eisenberg, Amy [1 ]
Rodriguez, Amanda [1 ]
Rettinger, Sarah [1 ]
Cohan, Pejman [1 ]
Nieman, Lynnette [5 ]
Kelly, Daniel F. [1 ,3 ,4 ]
机构
[1] Pacific Neurosci Inst, Pacific Pituitary Disorders Ctr, Santa Monica, CA 90404 USA
[2] Univ S Alabama, Mobile, AL 36604 USA
[3] St Johns Canc Inst, Santa Monica, CA 90404 USA
[4] St Johns Hlth Ctr, Santa Monica, CA 90404 USA
[5] Natl Inst Diabet & Digest & Kidney Dis NIDDK, Diabet Endocrine & Obes Branch, NIH, Bethesda, MD 20814 USA
基金
美国国家卫生研究院;
关键词
Cushing's disease; pituitary adenoma; transsphenoidal surgery; ACTH; salivary cortisol; 24-hour urinary free cortisol; TRANSSPHENOIDAL SURGERY; CORTISOL; MANAGEMENT; RESECTION; OUTCOMES; ADENOMA;
D O I
10.1210/clinem/dgab659
中图分类号
R5 [内科学];
学科分类号
1002 ; 100201 ;
摘要
Context Confirming a diagnosis of Cushing disease (CD) remains challenging, yet is critically important before recommending transsphenoidal surgery for adenoma resection. Objective To describe predictive performance of preoperative biochemical and imaging data relative to post-operative remission and clinical characteristics in patients with presumed CD. Design, Setting, Patients, Interventions Patients (n = 105; 86% female) who underwent surgery from 2007 through 2020 were classified into 3 groups: group A (n = 84) pathology-proven ACTH adenoma; group B (n = 6) pathology-unproven but with postoperative hypocortisolemia consistent with CD; and group C (n = 15) pathology-unproven, without postoperative hypocortisolemia. Group A + B were combined as confirmed CD and group C as unconfirmed CD. Main outcomes Group A + B was compared with group C regarding predictive performance of preoperative 24-hour urinary free cortisol (UFC), late night salivary cortisol (LNSC), 1-mg dexamethasone suppression test (DST), plasma ACTH, and pituitary magnetic resonance imaging (MRI). Results All groups had a similar clinical phenotype. Compared with group C, group A + B had higher mean UFC (P < 0.001), LNSC (P = 0.003), DST (P = 0.06), and ACTH (P = 0.03) and larger MRI-defined lesions (P < 0.001). The highest accuracy thresholds were: UFC 72 mu g/24 hours; LNSC 0.122 mu g/dL, DST 2.70 mu g/dL, and ACTH 39.1 pg/mL. Early (3-month) biochemical remission was achieved in 76/105 (72%) patients: 76/90(84%) and 0/15(0%) of group A + B vs group C, respectively, P < 0.0001. In group A + B, nonremission was strongly associated with adenoma cavernous sinus invasion. Conclusions Use of strict biochemical thresholds may help avoid offering transsphenoidal surgery to presumed CD patients with equivocal data and improve surgical remission rates. Patients with Cushingoid phenotype but equivocal biochemical data warrant additional rigorous testing.
引用
收藏
页码:205 / 218
页数:14
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