Early versus late Gamma Knife radiosurgery for Cushing's disease after prior resection: results of an international, multicenter study

J Neurosurg. 2020 Feb 21;134(3):807-815. doi: 10.3171/2019.12.JNS192836.

Abstract

Objective: The optimal time to perform stereotactic radiosurgery after incomplete resection of adrenocorticotropic hormone (ACTH)-producing pituitary adenoma in patients with Cushing's disease (CD) remains unclear. In patients with persistent CD after resection of ACTH-producing pituitary adenoma, the authors evaluated the association of the interval between resection and Gamma Knife radiosurgery (GKRS) with outcomes.

Methods: Pooled data from 10 institutions participating in the International Radiosurgery Research Foundation were used in this study.

Results: Data from 255 patients with a mean follow-up of 65.59 ± 49.01 months (mean ± SD) were analyzed. Seventy-seven patients (30%) underwent GKRS within 3 months; 46 (18%) from 4 to 6 months; 34 (13%) from 7 to 12 months; and 98 (38%) at > 12 months after the resection. Actuarial endocrine remission rates were higher in patients who underwent GKRS ≤ 3 months than when treatment was > 3 months after the resection (78% and 65%, respectively; p = 0.017). Endocrine remission rates were lower in patients who underwent GKRS at > 12 months versus ≤ 12 months after the resection (57% vs 76%, respectively; p = 0.006). In multivariate Cox regression analyses adjusted for clinical and treatment characteristics, early GKRS was associated with increased probability of endocrine remission (hazard ratio [HR] 1.518, 95% CI 1.039-2.218; p = 0.031), whereas late GKRS (HR 0.641, 95% CI 0.448-0.919; p = 0.015) was associated with reduced probability of endocrine remission. The incidence of some degree of new pituitary deficiency (p = 0.922), new visual deficits (p = 0.740), and other cranial nerve deficits (p = 0.610) was not significantly related to time from resection to GKRS.

Conclusions: Early GKRS is associated with an improved endocrine remission rate, whereas later GKRS is associated with a lower rate of endocrine remission after pituitary adenoma resection. Early GKRS should be considered for patients with CD after incomplete pituitary adenoma resection.

Keywords: Cushing’s disease; pituitary surgery; remission; stereotactic radiosurgery.

Publication types

  • Multicenter Study

MeSH terms

  • Adenoma / surgery
  • Adolescent
  • Adrenocorticotropic Hormone / metabolism
  • Adult
  • Aged
  • Aged, 80 and over
  • Child
  • Female
  • Follow-Up Studies
  • Humans
  • Male
  • Middle Aged
  • Pituitary ACTH Hypersecretion / diagnostic imaging
  • Pituitary ACTH Hypersecretion / surgery*
  • Pituitary Neoplasms / surgery
  • Postoperative Complications / epidemiology
  • Radiosurgery / methods*
  • Reoperation / statistics & numerical data
  • Retrospective Studies
  • Treatment Outcome
  • Young Adult

Substances

  • Adrenocorticotropic Hormone