Radiosurgical management of patients with persistent or recurrent cushing disease after prior transsphenoidal surgery: A management algorithm based on a 25-year experience

Joshua D. Hughes, William F. Young, Alice Y. Chang, Michael J. Link, Yolanda I. Garces, Nadia N. Laack, Geoffrey B. Thompson, Bruce E. Pollock

Research output: Contribution to journalArticlepeer-review

9 Scopus citations

Abstract

BACKGROUND: Patients with persistent or recurrent Cushing disease (CD) after prior transsphenoidal surgery require further treatment to reduce the disease's metabolic consequences. OBJECTIVE: To assess patient outcomes after stereotactic radiosurgery (SRS) for persistent or recurrent CD from adrenocorticotropin hormone (ACTH)-secreting pituitary adenomas and propose a management algorithm. METHODS: Retrospective review of 38 patients without prior radiation treatment having SRS for ACTH-secreting pituitary adenomas from 1990 to 2015. Favorable outcome was defined as biochemical remission and tumor growth control. Patients were evaluated separately if they underwent bilateral adrenalectomy (Adx). RESULTS: Twenty patients (53%) were treated with Adx and SRS (median margin dose, 25 Gy) and 18 patients (47%) received SRS alone (median margin dose, 22.5 Gy). Median follow-up after SRS was 76 mo. Of patients undergoing Adx, 18/20 (90%) had a favorable outcome. Two patients (10%) had tumor growth requiring additional treatment. A favorable outcome was achieved in 13/18 patients (72%) having SRS alone (median, 14 mo; interquartile range, 8-23). Five patients (28%) required additional treatment due to persistent hypercortisolemia (n = 4) or hypercortisolemia and tumor growth (n = 1). Favorable outcomes were more frequent in the Adx and SRS group at 1 yr (100% vs 33%; P <. 001) and 3 yr (100% vs 62%; P <. 01), but no different at 5 yr (88% vs 77%; P =. 63). CONCLUSION: SRS was effective for patients with persistent or recurrent CD. Patients with mild to moderate CD can be safely managed with SRS alone; patients with severe CD should be considered for Adx with either concurrent SRS or SRS performed at a later date if tumor growth occurs.

Original languageEnglish (US)
Pages (from-to)557-564
Number of pages8
JournalNeurosurgery
Volume86
Issue number4
DOIs
StatePublished - Apr 1 2020

Keywords

  • Adrenalectomy
  • Corticotropin
  • Cushing disease
  • Nelson-Salassa syndrome
  • Pituitary adenoma
  • Stereotactic radiosurgery

ASJC Scopus subject areas

  • Surgery
  • Clinical Neurology

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