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Primary therapy of Cushing's disease: Transsphenoidal surgery and pituitary irradiation

INTRODUCTION

Cushing's disease is caused by pituitary corticotropin-(ACTH)-secreting tumors. These tumors are almost always benign and are usually microadenomas (ie, <10 mm in diameter). Treatment is aimed first at the anterior pituitary gland.

The progressive stages of treatment that may be required to cure a patient of Cushing's disease are shown in the figure (algorithm 1). Primary therapy consists of transsphenoidal surgery or pituitary irradiation; their efficacy will be reviewed here. Patients who fail this approach are usually treated by surgical or medical adrenalectomy. (See "Treatment of Cushing's syndrome: Diminishing adrenal cortisol synthesis".)

TRANSSPHENOIDAL SURGERY

Transsphenoidal microadenomectomy is currently the most popular, and probably the most rational, treatment for Cushing's disease. When successful, the patient is cured and is eventually left with normal hypothalamic-pituitary-adrenal function [1].

The operative approach varies. Traditionally the procedure involved transsphenoidal exploration through either a sublabial or endonasal approach, followed by use of a high powered microscope that allows for binocular vision. More recently, use of an endoscope, which does not provide binocular vision, has been advocated.

  • One study compared 42 patients with Cushing's disease and a visible microadenoma on MRI, who had received one or the other approach. The cure rate (76 percent) was similar in each group, but patients with the endoscopic approach had shorter hospital stays [2].
  • Another study using microscopy reported a higher cure rate (87 percent) in 136 patients with unrevealing MRI results [3].
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