Preoperative Medical Treatment in Cushing's Syndrome: Frequency of Use and Its Impact on Postoperative Assessment: Data From ERCUSYN

Eur J Endocrinol. 2018 Apr;178(4):399-409. doi: 10.1530/EJE-17-0997. Epub 2018 Feb 12.

Abstract

Background: Surgery is the definitive treatment of Cushing's syndrome (CS) but medications may also be used as a first-line therapy. Whether preoperative medical treatment (PMT) affects postoperative outcome remains controversial.

Objective: (1) Evaluate how frequently PMT is given to CS patients across Europe; (2) examine differences in preoperative characteristics of patients who receive PMT and those who undergo primary surgery and (3) determine if PMT influences postoperative outcome in pituitary-dependent CS (PIT-CS).

Patients and methods: 1143 CS patients entered into the ERCUSYN database from 57 centers in 26 countries. Sixty-nine percent had PIT-CS, 25% adrenal-dependent CS (ADR-CS), 5% CS from an ectopic source (ECT-CS) and 1% were classified as having CS from other causes (OTH-CS).

Results: Twenty per cent of patients took PMT. ECT-CS and PIT-CS were more likely to receive PMT compared to ADR-CS (P < 0.001). Most commonly used drugs were ketoconazole (62%), metyrapone (16%) and a combination of both (12%). Median (interquartile range) duration of PMT was 109 (98) days. PIT-CS patients treated with PMT had more severe clinical features at diagnosis and poorer quality of life compared to those undergoing primary surgery (SX) (P < 0.05). Within 7 days of surgery, PIT-CS patients treated with PMT were more likely to have normal cortisol (P < 0.01) and a lower remission rate (P < 0.01). Within 6 months of surgery, no differences in morbidity or remission rates were observed between SX and PMT groups.

Conclusions: PMT may confound the interpretation of immediate postoperative outcome. Follow-up is recommended to definitely evaluate surgical results.

MeSH terms

  • Adrenal Glands / physiopathology
  • Adult
  • Aged
  • Cushing Syndrome / drug therapy*
  • Cushing Syndrome / physiopathology
  • Cushing Syndrome / surgery*
  • Databases, Factual
  • Europe
  • Female
  • Humans
  • Ketoconazole / therapeutic use
  • Male
  • Metyrapone / therapeutic use
  • Middle Aged
  • Paraneoplastic Endocrine Syndromes
  • Pituitary Gland / physiopathology
  • Postoperative Care
  • Postoperative Period
  • Quality of Life
  • Treatment Outcome

Substances

  • Ketoconazole
  • Metyrapone