gms | German Medical Science

Objective: The transsphenoidal approach to sellar tumors has evolved enormously since its first description in the early 20^th century. Despite neurosurgical developments in transsphenoidal surgery such as neuronavigation and endoscopic techniques with the possibility of using angled optics especially surgical management of Morbus Cushing is still difficult. Here we retrospectively analyze the outcome of patients with M. Cushing in an entirely endoscopic transsphenoidal series.

Method: Among 416 endoscopic transsphenoidal resections of different tumors of the sella, operated by a mononostril or binostril approach since 2003, 24 operations in 19 patients were performed in cases of M. Cushing. The subgroup includes 17 women and 2 men, average age is 40.2 years. Follow-up is 2 months to 9 years.

Results: In 17 patients treatment started at primary diagnosis. 12 patients were cured by first surgery (71%), in 2 patients no recurrence occurred after second resection (Follow-up 8 years) and in one patient after third transsphenoidal resection of a recurrent tumor (Follow-up 5 years). One patient after unsuccessful first surgery underwent a bilateral adrenalectomy (Follow-up 2 years). With progressive symptoms one patient required bilateral adrenalectomy and subsequently developed a Nelson tumor which was removed transsphenoidaly. Radiation is planned for residual tumor in the cavernous sinus. In one patient who presented with recurrent tumor we performed the second resection and no further tumor has recurred (Follow-up 6 years). Another patient was operated twice unsuccessfully using a microscopic transsphenoidal technique. With two further transsphenoidal endoscopic resections he was not cured. Pasireotid caused side effects, radiotherapy was rejected by the patient and bilateral adrenalectomy is now discussed.

Conclusions: Despite modern techniques in transsphenoidal surgery the cure rate of M. Cushing is still limited. However even with repeated endoscopic procedures required in some recurrent tumors long term control can be achieved. A successful treatment often involves the cooperation of neurosurgeon, endocrinologist, neuroradiologist, abdominal surgeon and radiation therapist.