Abstract
BackgroundFirst-choice treatment for Cushing’s disease is transsphenoidal adenomectomy. Since its introduction in the 1970s, many centers have now switched from microscopic to endoscopic surgery. We compared both techniques for the treatment of Cushing’s disease at the Leiden University Medical Center, a European reference center for pituitary diseases.MethodsCohort study with inclusion and follow-up of consecutive Cushing’s disease patients primarily treated by transsphenoidal surgery at the Leiden University Medical Center between 1978 and 2016. We compared remission rates (primary endpoint), mortality, and complications between microscopic (performed up to 2005) and endoscopic (performed from 2003 onwards) surgery. Subgroup analyses were performed by tumor size, surgical experience, and preoperative imaging techniques. Additionally, surgeons’ intraoperative findings regarding presence and removal of the adenoma were related to surgical outcome.ResultsOf 137 included patients, 87 were treated microscopically and 50 endoscopically. Three months after microscopic surgery, 74 patients (86%) were in remission. Five-year recurrence-free survival was 89% (95% confidence interval [CI]: 82–96%), and ten-year recurrence free survival was 84% (95% CI: 75–93%). After endoscopic surgery, 39 patients (83%) were in remission. Both five-year and ten-year recurrence-free survival were 71% (95% CI: 55–87%). Hazard ratio for recurrence was 0.47 (95% CI: 0.19–1.14), and for mortality 2.79 (95% CI: 0.35–22.51), for microscopic versus endoscopic surgery. No learning curve was found for endoscopy, nor an influence of preoperative imaging technique for microscopy. In addition, we did not find a clear relation between the surgeons’ intraoperative findings and surgical outcomes.ConclusionsThis study did not identify a clear advantage of microscopic or endoscopic transsphenoidal surgery for the treatment of Cushing’s disease based on clinical outcome. The transition to endoscopic surgery at our center was not accompanied by transient worsening of outcomes, which may be reassuring for those considering transitioning.
Highlights
MethodsCohort study with inclusion and follow-up of consecutive Cushing’s disease patients primarily treated by transsphenoidal surgery at the Leiden University Medical Center between 1978 and 2016
First-choice treatment for Cushing’s disease is transsphenoidal adenomectomy
The transition to endoscopic surgery at our center was not accompanied by transient worsening of outcomes, which may be reassuring for those considering transitioning
Summary
Cohort study with inclusion and follow-up of consecutive Cushing’s disease patients primarily treated by transsphenoidal surgery at the Leiden University Medical Center between 1978 and 2016. We compared remission rates (primary endpoint), mortality, and complications between microscopic (performed up to 2005) and endoscopic (performed from 2003 onwards) surgery. Study population Consecutive Cushing’s disease patients primarily treated with transsphenoidal surgery at the tertiary referral center Leiden University Medical Center, the coordinating center of the newly established European Reference Network for rare Endocrine conditions, and a European reference center for pituitary diseases, were included in this cohort study. Inclusion started in 1978, when the first transsphenoidal operation in the Netherlands was performed in Leiden. Microscopic surgery was performed from 1978 to 2005, whereas endoscopic surgery has been performed since 2003. There were no restrictions in presurgical medical treatment with cortisol lowering agents or in adjuvant therapy in case of persistent disease or for recurrence of disease
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