Endoscopic Endonasal Approach in the Treatment of Cushing Disease: a Series of 18 Patients

Introduction: Endoscopic Endonasal Approach (EEA) has become the standard technique in the surgical treatment of pituitary tumors. Cushing Disease (CD) is a chronic and life-threatening condition caused by ACTH-secreting pituitary adenomas (PA). Despite some medical advances, PA surgical excision remains mainstay in the treatment of CD. Some particularities seem to make CD patients, also from the surgical standpoint, a peculiar subgroup among PA population.

Objective: To describe and discuss the EEA nuances and results in the treatment of a consecutive series of 18 patients with Cushing Disease.

Methods: A retrospective analysis of 18 consecutive CD patients surgically treated at a Brazilian hospital from April 2013 to October 2017. The standard EEA was employed, with lateral extension to the right Cavernous sinus (CS) in one case. Turbinectomies and/or posterior ethmoidectomies were eventually performed according to individual anatomic requirements.

Results: Mean follow-up was 25 months, ranging from 3 to 57 months. We found 5 macroadenomas, 12 microadenomas and 1 MRI-negative adenoma. Knosp grade ranged 0–1 for 35 cavernous sinus (CS), and was 4 in 1 CS. Total adenomectomy, confirmed by 3 months postoperative (PO) MRI in 16/18 patients, was achieved in all patients except one with total right CS ICA encasement, in which a small remnant was left lateral to the ICA. For one patient no postoperative MRI was performed due to a cascade of events beginning with an epistaxis on the PO day 4, aspiration pneumonia and shock leading to death on PO day 14. Other complications were: 1 CSF leak and meningitis (5.5%) requiring new EEA for leak repair, 5 cases of transitory DI (27%) and 1 permanent DI (5.5%). No other new endocrine deficiencies occurred. Endocrine control was achieved in 16/17 patients (94%), with one relapse (6.2%) after 23 months who was then lost to follow-up. The patient with cavernous sinus remnant was referred to radiosurgery.

Conclusion: EEA has become the gold-standard technique in the treatment of CD. It may render excellent results in disease control, with low morbidity, even for tumors extending laterally to the CS. Adjuvant radiosurgery should be reserved for cases where total resection is not possible.

No conflict of interest has been declared by the author(s).