Sunday, March 3, 2013

Reoccurrence: A Cushie's Worst Nightmare

Hooray. You somehow heard the word
Cushing's. Someone finally ran the right tests at the right time. You finally got some highs in cortisol and low ACTH (adrenal tumor) or high ACTH (pituitary tumor). A little spot doesn't light up on your mri ("hypointensity") and it is suspicious for a tumor. Ah ha. This is your surgical target.You finally found a genius neurosurgeon but s/he is three states away from you. You organize coverage for the house and kids while your parents and spouse go off to surgery with you. You are finally getting a surgery. You can believe it is finally happening. You wonder if you will every make it out alive and in what condition, what cortisol condition. 

Within a week or a few months, you start suspecting a reoccurrence. This is so unfair. You had surgery yet you still have Cushing's. Returning symptoms don't lie. Lab values don't lie. Doctors even neurosurgeons don't often know what to do with you-- they said they got all the tumor out, so... ?  They don't understand why the labwork shows high cortisol and high ACTH, I mean, they removed pituitary tumor out of your head!

This is one of many moments of true despair in a Cushie's life.

Every Cushing's patient worries about it, and most doctors deny it even is possible. "One surgery will remove the tumor and you'll be back to normal. No problem."  

Yeah, we wish.

This article gives some parameters for
post op ACTH levels - not just cortisol -  that may indicate a cure versus the dreaded reoccurrence. 

All Cushies study articles like this, hoping that their post op numbers fall within the magical range of cured Cushies. We are looking for hope even when there is none to be found.

Note: this is a small study with only 55 patients. Not a large sample size, but hey. Maybe they are on to something.

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Recurrences of ACTH-Secreting Adenomas After Pituitary Adenomectomy Can Be Accurately Predicted by Perioperative Measurements of Plasma ACTH Levels


  • Received November 15, 2012.
  • Accepted February 4, 2013.
 Authors
  1. Baha M. Arafah
  1. Division of Clinical and Molecular Endocrinology, Department of Neurological Surgery, University Hospitals Case Medical Center, Louis Stokes Cleveland Veterans Medical Center And Case Western Reserve University, Cleveland, Ohio 44106
  1. Address all correspondence and requests for reprints to: Baha M. Arafah, MD, Division of Clinical and Molecular Endocrinology, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, Ohio 44106. E-mail:baha.arafah@case.edu.

Abstract

Background: Adenomectomy is the treatment of choice for ACTH-secreting adenomas. Although the development of ACTH deficiency immediately after adenomectomy suggests surgical success, disease recurrence was reported in patients who developed hypocortisolism postoperatively. In the current study, we examined the value of measuring perioperative plasma ACTH and cortisol levels in predicting disease recurrence of patients with ACTH-secreting adenomas.

Methods: Consecutive patients (n = 55; 41 females, 14 males) with clinical, biochemical, and histological documentation of ACTH-secreting adenomas were investigated after pituitary adenomectomy. All patients were followed with clinical monitoring and frequent measurements of plasma ACTH and serum cortisol levels, and none received glucocorticoids unless or until they developed symptoms of adrenal insufficiency or when their serum cortisol levels were ≤3 μg/dL.

Results: Postoperative serum cortisol levels reached ≤3 μg/dL in 46 of 55 and were ≥4 μg/dL in the remaining 9. Simultaneously measured plasma ACTH levels in the latter 9 patients were >40 ng/L when the serum cortisol reached its nadir. In contrast, among the 46 patients who had serum cortisol levels of ≤3 μg/dL, plasma ACTH levels measured simultaneously were ≤20 ng/L in 38 of 46 and >20 ng/L in the remaining 8. During a mean follow-up period of nearly 7 years, patients who had a nadir plasma ACTH of >20 ng/L developed recurrences even though their postoperative serum cortisol levels were ≤3 μg/dL.

Conclusions: Despite profound hypocortisolemia after adenomectomy, a simultaneously measured plasma ACTH level of >20 ng/L in the perioperative period is highly predictive of future recurrence of ACTH-secreting adenomas.

  • Received November 15, 2012.
  • Accepted February 4, 2013.