Disease Remission and Surgical Outcomes of Endoscopic Transsphenoidal Surgery for Cushing Disease: A Single Center Experience

Posted on February 1, 2026 by MaryO

Introduction

Transsphenoidal surgery is the primary treatment for patients with Cushing disease (CD). This study assessed the surgical and endocrinologic outcomes of patients with CD following endoscopic pituitary surgery using strict biochemical criteria to guide surveillance in patients not achieving early remission.

Methods

The medical records of all patients with CD who underwent endoscopic transsphenoidal surgery at a single institution between 2004 and 2025 were reviewed. Remission was defined as a fasting serum cortisol level <50 nmol/L (1.8 μg/dL) either basal or after 1 mg dexamethasone.

Results

A total of 125 patients were diagnosed with CD and had a primary endoscopic transsphenoidal surgery during the study period (median age 48 years [range: 14–79 years; M:F 93:32). Fifty-seven patients (45.6%) had a microadenoma, 41 (32.8%) had a macroadenoma, and 26 (20.8%) had no demonstrable focal lesion on pituitary magnetic resonance imaging (MRI) (MRI-negative CD). The median length of follow-up was 3.1 years (range: 1 month to 16.7 years). Initial remission rates 3 months after surgery were: 72.0% for patients with MRI-negative CD, 77.2% for microadenomas, and 48.7% for macroadenomas. Age, male sex, MRI-negative, and single operation were predictors of remission. Patients who achieved remission at 3 months were significantly more likely to be in remission at last follow-up after accounting for patient and tumor characteristics. The 5-year recurrence rate following remission was 6.9%.

Conclusion

Endoscopic transsphenoidal surgery is an effective first-line treatment for patients with CD but a significant minority will relapse. Close biochemical surveillance of patients who fail to achieve remission may support the use of early adjuvant radiotherapy.

Key words

Cushing disease
Endoscopic transsphenoidal surgery
Remission

Abbreviations

CD

Cushing’s Disease
CSF

Cerebrospinal fluid
DI

Diabetes insipidus
MRI

Magnetic Resonance Imaging

Introduction

Cushing disease (CD) is a rare endocrine disease caused by the circulation of excess cortisol due to hypersecretion of adrenocorticotrophic hormone from a pituitary adenoma. The annual incidence of CD is estimated to be between 1.2 and 2.4 million cases per year1, 2, 3 although it may be higher in selected patient populations such as those with poorly controlled diabetes and young patients with osteoporosis or hypertension.4 Untreated CD is associated with a very poor prognosis and a significantly reduced 5-year survival mandating prompt and effective treatment.5 Nevertheless, long-term management of patients with CD remains challenging.
In most cases of CD, the pituitary adenoma is benign and excellent remission rates have been reported with surgical treatment.6, 7, 8 Comparable remission rates of around 80% have been reported with both microscopic and endoscopic transsphenoidal pituitary surgery,7,8 however the basal serum cortisol level used to define remission varies significantly in the literature (50–138 nmol/L). Several previous studies have also excluded macroadenomas and invasive tumors from longitudinal analysis. As such, there is a paucity of long-term clinical data for an unselected population undergoing endoscopic transsphenoidal pituitary surgery for CD. Furthermore, there is little evidence concerning the optimal management of patients who fail to enter complete biochemical remission (basal serum cortisol level <50 nmol/L [1.8 μg/dL]) following their initial surgical treatment.
The aim of this study was to assess the treatment pathway and long-term outcomes of consecutive patients treated at a regional treatment center over a 20-year period. All surgical cases were performed using a purely endoscopic approach and we evaluated the impact surgical experience on clinical outcomes. We assessed biochemical remission rates immediately following surgery (within 2 weeks of surgery), at 3 months and at the patient’s most recent follow-up appointment and analyzed predictors of successful remission in our patient group. For those who did not achieve biochemical remission, we detail the treatment course of patients placed under surveillance and those who underwent adjuvant therapy. In doing so, we illustrate a complete picture of the surgical outcomes and subsequent management of an unselected population that may be encountered during the treatment of patients with CD at a dedicated regional center.

Methods

Study Population

We analyzed the medical records of all patients diagnosed with CD who underwent primary surgical treatment at King’s College Hospital, London, between January 2004 and January 2025. Patients were identified from our prospective pituitary multidisciplinary database and cross-referenced with data from the hospital’s clinical coding department and operative database.

Preoperative Investigations

Serum cortisol was measured by chemiluminescent assay (Siemens ADVIA Centaur XP) with a sensitivity of 0.0362 nmol/L. A diagnosis of Cushing syndrome was confirmed by a serum cortisol measurement of >50 nmol/L after administering a 1-mg low-dose dexamethasone suppression test. Additional 24-hour urinary free cortisol measurements (>50 μg/24 hours), late night salivary cortisol measurements (>4 nmol/L), plasma adrenocorticotrophic hormone levels (pg/mL), and 48-hour 2-mg low-dose dexamethasone suppression tests were performed as required. All patients with confirmed Cushing syndrome underwent magnetic resonance imaging (MRI) of the pituitary gland and in equivocal cases patients also underwent corticotrophin-releasing hormone stimulation, high-dose dexamethasone suppression test, and/or inferior petrosal sinus sampling before proceeding to surgery.

Surgical Procedure

Surgery was performed via an endoscopic transnasal transsphenoidal approach in all study patients as described by Jho9 and Cappabianca.10 Image guidance was used in patients with complex or atypical sinus or vascular anatomy, those with very small microadenomas, and in patients undergoing repeat surgery. Complete hypophysectomy (sellar clearance) was performed for patients with MRI-negative Cushing disease. The histological pseudocapsular technique was employed to permit wide exposure of the sella, pituitary, and parasellar region.11,12 If a cerebrospinal fluid (CSF) leak was identified intraoperatively, an autologous adipose tissue graft was positioned in the pituitary fossa and sphenoid sinus and in selected cases a vascularized naso-septal flap was also positioned over the defect.

Postoperative Investigations and Follow-up

Our postoperative protocol included endocrinologic assessment in the early postoperative period, within 72 hours of surgery, and again within the first 2 weeks following surgery. The patient’s initial treatment strategy was defined as any surgical management within 30 days of the patient’s first surgical procedure. If a postoperative CSF leak was suspected, samples of fluid were sent for confirmatory testing of β-2-transferrin. Management of the CSF leak was determined by its severity and included observation alone, insertion of a lumbar drain and a period of bed rest, and surgical repair. Postoperative diabetes insipidus was defined as patients with polyuria requiring ongoing desmopressin therapy 6 months after surgery.
Long-term biochemical assessment of cortisol status was performed on an annual basis, or more frequently depending on the patient’s individual status. A routine postoperative MRI scan was also performed 3 months postoperatively. Remission was defined as an early morning serum cortisol of <50 nmol/L (1.8 μg/dL) requiring substitutive therapy at 3 months postoperatively. Patients who failed to enter remission were considered for further pituitary surgery, radiotherapy, medical treatment, and/or bilateral adrenalectomy. Recurrence was defined as the re-emergence of clinical features of cortisol excess supported by biochemical evidence of cortisol excess as described above. Persistent disease was defined as such was defined as a postoperative basal cortisol(s) > 50 nmol/.

Data Collection

We reviewed the biochemical, radiologic, medical, and surgical records of all study patients. The following data were collected: demographic features, preoperative endocrinologic measurements, radiologic MRI features of the tumor (including tumor visibility on MRI and size), procedural complications (including CSF leak, meningitis, diabetes insipidus [DI], hematoma, visual complications, or new cranial nerve deficits), postoperative endocrinologic assessments, and any further treatments performed.

Statistical Analysis

Categorical data are summarized using frequencies and percentages and continuous data are described using means, standard deviations, medians, and ranges. Associations between categorical variables were assessed using Fisher’s Exact test. Multivariable logistic regression models were performed in which remission statuses at (i) 3 months and (ii) last follow-up were used as outcome variables. The list of predictors of each outcome included patient characteristics (sex, age), tumor category, number of operations performed, and the presence of postoperational complications, which were decided a priori. Subgroup analyses were also performed based on tumor category—microadenomas, macroadenomas, and MRI-negative CD.
Data were collated in Microsoft Excel (Microsoft, Redmond, WA). All statistical analyses were performed using R software version 4.2.1 (R Foundation for Statistical Computing, 2022; r-project.org). P-values less than 0.05 were considered statistically significant.

Ethics Statement

This study was approved by King’s College Hospital’s research committee without the need for informed consent. The study was conducted in accordance with the ethics standards of the institution’s research committee and with the 1964 Helsinki declaration and its later amendments.

Results

Baseline Characteristics

A total of 125 patients including 93 (74.4%) female patients and 32 (25.6%) male patients were diagnosed with CD and had primary endoscopic transsphenoidal surgery during the study period. The median age was 48 years (range: 14–79 years). Fifty-seven patients (45.6%) had a microadenoma, 41 (32.8%) had a macroadenoma, and 26 (20.8%) had no demonstrable focal lesion on pituitary MRI (MRI-negative CD). The median length of follow-up was 3.1 years (range: 1 month to 16.7 years). Of the 125 patients included in our study, 88 patients (70.4%) had a single operation during their initial treatment strategy. Thirty-seven patients (29.6%) had more than 1 operation; 4 patients (3.2%) had 3 operations during the study period. A summary of the baseline characteristics of our patients can be found in Table 1.

Table 1. Baseline Characteristics of the Study Population

Number of Patients 125
Patient variables
 Age Median 48 (range: 14–79) years
 Male 32 (25.6%)
Pituitary characteristics
 Microadenoma 57 (45.6%)
 Macroadenoma 41 (32.8%)
 No focal lesion on pituitary MRI (MRI-negative Cushing’ disease) 26 (20.8%)
Operative variables
 Single operation 88 (70.4%)
 More than 1 operation 33 (26.4%)
 3 operations 4 (3.2%)

Perioperative Complications

Forty patients (32.0%) had a complication following their surgery (Table 2). The overall complication rate for patients undergoing a single procedure was 23.9% (21 of 88) and was significantly lower than the complication rate in patients who had multiple operations: 51.3% (19 of 37) (P = 0.002). The complication rates for different tumor types were not significantly different: microadenoma 33.3% (19 of 57), macroadenoma 36.6% (15 of 41), MRI-negative CD 23.1% (6 of 26) (P = 0.274). There was a significant difference between complications in the second period; Period 1: 8.7% (2 of 23) and Period 2: 37.3% (38 of 102) (P = 0.008).

Table 2. Procedural Complications Encountered in Our Series

Complication N (%)
Any complication 40 (32.0%)
Persistent diabetes insipidus 18 (14.4%)
Cerebrospinal fluid leak 17 (13.6%)
Meningitis 2 (1.6%)
Ventriculitis 1 (0.8%)
Bleeding/haematoma 4 (3.2%)
Visual deterioration 2 (1.6%)
Death 3 (2.4%)
Eighteen patients (14.4%) developed persistent DI following surgery (requiring treatment for more than 6 months which we considered as a complication). Separately, in 12 patients (9.6%) the DI was transient and resolved spontaneously within 6 months of surgery, and 34 patients (27.2%) recovered from transient DI before discharge.
A confirmed postoperative CSF leak occurred in 17 patients (13.6%) and was significantly higher in patients who had multiple procedures; the CSF leak rate was 16.2% (6 of 37) in patients who had multiple procedures versus 12.5% (11 of 88) in those who only had a single procedure (P = 0.004). The type of tumor did not affect the CSF leak rate (P = 0.737). In 3 (2.4%) patients, the leak settled with observation alone. Three (2.4%) patients were managed with only a lumbar drain and 11 (8.8%) patients underwent surgical repair either as an executive decision or after failed lumbar drain. There were 2 (1.6%) cases with new cranial nerve deficits following surgery presenting with visual deterioration and a partial sixth nerve palsy. Two patients developed meningitis (1.6%), 1 (0.8%) developed ventriculitis. Four patients (3.2%) developed postoperative bleeding or hematoma requiring surgical attention.
Three (2.4%) patients died in the immediate perioperative period. One (0.8%) patient developed acute respiratory failure and suffered a cardiac arrest. Significant intraoperative bleeding was encountered in the other 2 cases (1.6%); 1 (0.8%) subsequently died of acute cardiorespiratory instability and the other (0.8%) died because of multiorgan failure following a prolonged stay on the intensive care unit.

Disease Remission

The overall remission rate 2 weeks following surgery was 59.0% (72 of 122), increasing to 60.7% (74 of 122) at 3 months. The remission rate 3 months following surgery was 72.0% (18 of 25) for patients with MRI-negative CD, 77.2% (44 of 57) for microadenomas, and 48.7% (19/39) for macroadenomas. Following adjuvant treatment and further surgery, the overall remission rate at last follow up was 68.0% (85 of 125).
Age, patient sex, tumor category and the number of operations were significant predictors of remission at three months. Age (adjusted odds ratio [aOR]: 1.04, 95% CI: 1.01–1.07, P = 0.009), male sex (aOR: 4.15, 95% CI: 1.64–10.53, P = 0.003), MRI-negative CD (aOR: 2.25, 95% CI: 1.24–4.07, P = 0.008), and single operation (aOR: 3.87, 95% CI: 1.56–9.61, P = 0.004), were predictors of remission at 3 months (Table 3).

Table 3. Multivariable Logistic Regression for Predictors of Remission at Last Follow-up

Outcome Predictor Multivariable Analysis
Adjusted OR (95% CI) P Value
Remission at 3 months Age 1.04 (95%CI: 1.01–1.07) 0.009
Sex† 3.31 (95%CI: 1.31–8.40) 0.011
MRI-negative Cushing disease‡ 1.88 (95%CI: 1.06–3.35) 0.031
Single operation§ 3.87 (95%CI: 1.56–9.61) 0.004
Remission at last follow-up Age 1.00 (95%CI: 0.97–1.04) 0.904
Sex† 2.92 (95%CI: 0.89–9.62) 0.003
MRI-negative Cushing disease‡ 1.84 (95%CI: 0.89–3.79) 0.008
Single operation§ 1.24 (95%CI: 0.36–4.24) 0.730
Remission at 3 months∗ 27.0 (95%CI: 8.47–83.33) <0.001
∗
No remission is used as the reference group.
†
Female is used as the reference group.
‡
Microadenoma is used as the reference group.
§
Multiple operation is used as the reference group.
Additionally, patients were more likely to be in remission at last follow-up if they had achieved remission at 3 months, compared with those who had not (aOR: 31.25, 95% CI: 11.2–90.9, P < 0.001). On multivariable analysis, this remained significant (aOR: 27.0, 95% CI: 8.47–83.33, P < 0.001).
Of the 72 patients who entered remission following surgery, 5 patients (6.9%) had relapsed at their last follow-up. Further intervention was performed/planned in all patients exhibiting recurrence, including repeat surgery and radiotherapy. Four of the 5 recurrences (80.0%) happened within the first 5 years.

Growth Hormone Replacement Therapy

In total, 48.0% (60 of 125) and 40.8% (51 of 125) patients required growth hormone replacement therapy at three months and at last endocrine follow up. Nine (15.0%) patients who initially needed growth hormone replacement, no longer required it at last endocrine follow-up.

Secondary Intervention

Patients with persistent disease are very likely to require a secondary intervention within a short time after initial surgery. The rate of secondary endoscopic transsphenoidal surgery was more common in patients with persistent disease (22 of 53, 41.5%) than those in initial remission (15 of 72, 20.8%) (aOR: 3.52, 95% CI: 1.48–8.38, P = 0.004). The ongoing management of patients with active disease with was tailored to the patient and included medical therapy with metyrapone, chemotherapy (temozolamide), bilateral adrenalectomy, and radiotherapy; either alone or in combination.

DISCUSSION

In one of the largest modern series in the literature, we reviewed the treatment pathway and long-term outcomes of consecutive patients treated for CD at a single regional treatment center over a 20-year period. Several previous studies have examined the surgical outcomes of patients undergoing microscopic surgery and a recent meta-analysis compared the early clinical outcomes of patients undergoing endoscopic surgery.7 However, there remains little evidence concerning the optimal long-term management of CD patients who do not immediately enter remission following surgery. Given the potential complications of CD and the challenges in managing recurrent disease, our center considers treating any patient with a cortisol of >50 nmol/L (1.8 μg/dL).

Remission

A postoperative cortisol of <50nmol/L is a good predictor of remission but not a guarantee and patients should be advised accordingly. The most conclusive finding of our study was that patients who achieved remission at 3 months were 3 times as likely to still be in remission at their last follow-up, having accounted patient and tumor characteristics. The overall initial 3-month remission rate for patients in our series was 60.7% and is comparable to other studies that have used a similarly low early morning serum cortisol level of <50 nmol/L (1.8 μg/dL) to define remission.13, 14, 15 Despite this, patients achieving early remission remain at risk of relapse with a 5-year recurrence rate of 6.9%. In addition, those with persistent disease are very likely to require a secondary intervention within a short time after initial surgery.
Using an early morning serum cortisol level of 50 nmol/L(1.8 μg/dL). to define remission enabled us to label a subgroup of patients with moderately lowered cortisol levels (50–150 nmol/L [1.8–5.4 μg/dL]) that were placed under close surveillance. It has been demonstrated that patients with postoperative cortisol of 55–137nmol/L (equivalent to 2–5.4 μg/dL) have a higher risk of late recurrence.12 We considered patients with a cortisol of greater than 150 nmol/L to be candidates for early secondary intervention without delay.
Radiotherapy, delivered by conventional external beam radiotherapy or via stereotactic radiosurgery, is typically used as a second-line treatment in CD patients after failure of initial or repeat pituitary surgery.8 In other centers, patients with similar moderately lowered cortisol level would have been labeled as being in remission and would not have been offered adjuvant radiotherapy. However, by closely observing the biochemical trends of these patients in the months following surgery we were able to offer further intervention at an earlier stage, thus avoiding the potentially harmful sequelae of untreated CD. In future work, it would be helpful to compare the long-term clinical outcomes of patients with moderately lowered serum cortisol levels who received early adjuvant therapy with patients who had similar biochemical results but did not receive adjuvant treatment.
Finally, we observed a statistically and clinically significant association between patient sex and tumor type on remission—a finding not previously reported. The underlying reasons for this result are unclear but further work should examine if, and how, the biology and histologic characteristics of adenomas changes with sex and age.9,16, 17, 18

Complications

Previous studies elected not to report the overall complication rate, hence at first sight, our overall complication rate of 32.0% may appear high even though the rate of individual specific complications are similar to those previously reported (Table 2).7, 8,15, 19 Postoperative complications were significantly higher in patients who underwent more procedures.
The overall perioperative mortality rate of 2.4% (n = 3) observed in this series is comparable with other published studies.7,8 One patient developed acute respiratory failure in the early postoperative period and died on day 3 following surgery. In the other cases significant intracavernous and intracranial bleeding was encountered and controlled; one patient subsequently developed acute cardiorespiratory instability and died on day 5; the other developed multiorgan failure and died following a prolonged stay on the intensive care unit. Following an internal review of these deaths we lowered our threshold for giving preoperative medical treatment such as ketoconazole or metyrapone in potential high-risk cases, particularly in those patients presenting with more severe clinical features at diagnosis. Preoperative medical treatment improves the quality of the tissues and increases the patient’s physiological reserve in preparation for surgery.14 In the ERCUSYN study, patients with severe clinical features who were treated preoperatively experienced comparable outcomes to those patients with milder features who were not treated with medical treatment before surgery. This justifies our approach to treat the more severe cases medically in the first instance. Nevertheless, preoperative medical treatment may confound the interpretation of early postoperative serum cortisol levels so close monitoring of these patients is required in the first few months following surgery.14 Since this change in practice, no deaths have occurred in patients undergoing surgery for CD at our unit.

Limitations

CD is a rare disease, and this study offers one of the larger modern series with practical illustrations of multidisciplinary practice at a tertiary pituitary center. Despite its size, this study did confirm that patients who achieved remission at 3 months were more likely to be in remission at the last follow-up. Patient and tumor characteristics were also important factors to consider. This study is nonetheless limited by lack of data on residual tumors found in postoperative MRIs. As such, we were unable to investigate further on the subgroup of patients without biochemical remission who had residual tumors. Furthermore, we do not fully know the proportion of MRI-negative patients who harbored an adenoma on histopathology, which may have skewed our findings. Further multi-institutional research is required to determine if patients with moderately lowered serum cortisol levels who receive early adjuvant radiotherapy have improved long-term clinical outcomes.

Conclusions

Despite good initial remission rates following endoscopic transsphenoidal surgery, this study demonstrated significant recurrence of CD. Nevertheless, patients who achieved initial biochemical remission (serum cortisol <50 nmol/L [1.8 μg/dL]) at 3 months were significantly more likely to achieve long-term biochemical remission. Selected patients with moderately lowered serum cortisol (serum cortisol 50–150 nmol/L [1.8–5.4 μg/dL]) responded well to early adjuvant radiotherapy but further research is required to determine their long-term clinical outcomes.

CRediT authorship contribution statement

Jonathan Shapey: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Writing – original draft, Writing – review & editing. Keng Siang Lee: Data curation, Formal analysis, Visualization, Writing – original draft. Vanitha Karunakaran: Formal analysis, Visualization, Writing – review & editing. Mohamed Okasha: Data curation, Writing – review & editing. Proma Dey: Data curation. Sabina Pate: Data curation. Mariusz T. Grzeda: Formal analysis, Writing – review & editing. Jackie Gilbert: Data curation, Writing – review & editing. Paul V. Carroll: Data curation, Writing – review & editing. Benjamin Whitelaw: Data curation, Writing – review & editing. Konstantinos Barkas: Data

curation, Writing – review & editing. Eleni Maratos: Data curation, Writing – review & editing. Sinan Barazi: Data curation, Writing – review & editing. Simon Aylwin: Data curation, Methodology, Supervision, Writing – original draft, Writing – review & editing. Nick WM. Thomas: Conceptualization, Data curation, Methodology, Supervision, Writing – review & editing.

References

Filed under: Cushing's, pituitary, Treatments | Tagged: , , , , | Leave a comment »

COVID-19 May Be Severe in Cushing’s Patients

Posted on January 23, 2026 by MaryO

A young healthcare worker who contracted COVID-19 shortly after being diagnosed with Cushing’s disease was detailed in a case report from Japan.

While the woman was successfully treated for both conditions, Cushing’s may worsen a COVID-19 infection. Prompt treatment and multidisciplinary care is required for Cushing’s patients who get COVID-19, its researchers said.

The report, “Successful management of a patient with active Cushing’s disease complicated with coronavirus disease 2019 (COVID-19) pneumonia,” was published in Endocrine Journal.

Cushing’s disease is caused by a tumor on the pituitary gland, which results in abnormally high levels of the stress hormone cortisol (hypercortisolism). Since COVID-19 is still a fairly new disease, and Cushing’s is rare, there is scant data on how COVID-19 tends to affect Cushing’s patients.

In the report, researchers described the case of a 27-year-old Japanese female healthcare worker with active Cushing’s disease who contracted COVID-19.

The patient had a six-year-long history of amenorrhea (missed periods) and dyslipidemia (abnormal fat levels in the body). She had also experienced weight gain, a rounding face, and acne.

After transferring to a new workplace, the woman visited a new gynecologist, who checked her hormonal status. Abnormal findings prompted a visit to the endocrinology department.

Clinical examination revealed features indicative of Cushing’s syndrome, such as a round face with acne, central obesity, and buffalo hump. Laboratory testing confirmed hypercortisolism, and MRI revealed a tumor in the patient’s pituitary gland.

She was scheduled for surgery to remove the tumor, and treated with metyrapone, a medication that can decrease cortisol production in the body. Shortly thereafter, she had close contact with a patient she was helping to care for, who was infected with COVID-19 but not yet diagnosed.

A few days later, the woman experienced a fever, nausea, and headache. These persisted for a few days, and then she started having difficulty breathing. Imaging of her lungs revealed a fluid buildup (pneumonia), and a test for SARS-CoV-2 — the virus that causes COVID-19 — came back positive.

A week after symptoms developed, the patient required supplemental oxygen. Her condition worsened 10 days later, and laboratory tests were indicative of increased inflammation.

To control the patient’s Cushing’s disease, she was treated with increasing doses of metyrapone and similar medications to decrease cortisol production; she was also administered cortisol — this “block and replace” approach aims to maintain cortisol levels within the normal range.

The patient experienced metyrapone side effects that included stomach upset, nausea, dizziness, swelling, increased acne, and hypokalemia (low potassium levels).

She was given antiviral therapies (e.g., favipiravir) to help manage the COVID-19. Additional medications to prevent opportunistic fungal infections were also administered.

From the next day onward, her symptoms eased, and the woman was eventually discharged from the hospital. A month after being discharged, she tested negative for SARS-CoV-2.

Surgery for the pituitary tumor was then again possible. Appropriate safeguards were put in place to protect the medical team caring for her from infection, during and after the surgery.

The patient didn’t have any noteworthy complications from the surgery, and her cortisol levels soon dropped to within normal limits. She was considered to be in remission.

Although broad conclusions cannot be reliably drawn from a single case, the researchers suggested that the patient’s underlying Cushing’s disease may have made her more susceptible to severe pneumonia due to COVID-19.

“Since hypercortisolism due to active Cushing’s disease may enhance the severity of COVID-19 infection, it is necessary to provide appropriate, multidisciplinary and prompt treatment,” the researchers wrote.

From https://cushingsdiseasenews.com/2021/01/15/covid-19-may-be-severe-cushings-patients-case-report-suggests/?cn-reloaded=1

Filed under: Cushing's, symptoms, Treatments | Tagged: , , , , , , , , , , , , , , , , , , , , | Leave a comment »

Low Cortisol Levels Hours After Surgery Predict Long-term Remission in Cushing’s Patients

Posted on January 21, 2026 by MaryO

The level of decline in blood cortisol levels in the immediate period after transsphenoidal surgery for Cushing’s disease may help predict which patients will achieve long-term disease remission.

The study, “Earlier post-operative hypocortisolemia may predict durable remission from Cushing’s Disease” was published in the European Journal of Endocrinology.

Transsphenoidal surgery (TSS) is a minimally invasive procedure for removing pituitary adenomas and is the primary treatment for Cushing’s disease.

But, while 77 to 98 percent of patients achieve remission after TSS, a third of these patients eventually will see their disease returning.

The surgical removal of the pituitary adenoma often leads to a drop in the adrenocorticotropic hormone (ACTH) and cortisol levels (hypocortisolemia).

“In the post-operative setting, failure to achieve hypocortisolemia is thought to reflect the presence of residual tumor cells,” the researchers wrote in the study. “Therefore, serum cortisol has become a well-established biochemical marker of early surgical remission.”

In an attempt to identify patients with a complete tumor resection – and with lower risk of recurrence – researchers examined the rates of serum cortisol decline in the immediate period after surgery.

The study included 257 Cushing’s disease patients who underwent 291 TSS interventions at the National Institutes of Health (NIH), between 2003 and 2016.

After surgery, patients had their cortisol levels measured every six hours until the third day after surgery. Then, patients had their cortisol levels measured every morning until day 10 or were discharged.

Early remission was defined based on nadir serum cortisol levels – the lowest concentration of cortisol, that is usually reached during the night – below 5 μg/dL.

Of 268 unique admissions, 90 percent of patients (241) achieved remission with a post-operative cortisol nadir below 5 μg/dL within 10 postoperative days.

However, recurrence was seen in 9 percent of these patients. For those with a cortisol nadir below 2 μg/dL, the rates of recurrence dropped to 6 percent.

Interestingly, the team found that cortisol levels below 5 μg/dL by 15 hours after surgery or below 2 μg/dL in the first 21 hours may “accurately predict durable remission in the intermediate term.”

“In our cohort, early, profound hypocortisolemia could be used as a clinical prediction tool for durable remission,” the researchers wrote.

“Such a clinical prediction tool may have significant utility in the management of [Cushing’s disease]. Further validation of its accuracy in a multi-centre prospective study with longer-term follow up is warranted,” the study concluded.

From https://cushingsdiseasenews.com/2018/01/18/low-cortisol-levels-after-surgery-may-predict-remission-cushings-disease/

Filed under: Cushing's | Tagged: , , , | Leave a comment »

Transsphenoidal Surgery Leads to Remission in Children with Cushing’s Disease

Posted on January 19, 2026 by MaryO

Transsphenoidal surgery — a minimally invasive surgery for removing pituitary tumors in Cushing’s disease patients — is also effective in children and adolescents with the condition, leading to remission with a low rate of complications, a study reports.

The research, “Neurosurgical treatment of Cushing disease in pediatric patients: case series and review of literature,” was published in the journal Child’s Nervous System.

Transsphenoidal (through the nose) pituitary surgery is the main treatment option for children with Cushing’s disease. It allows the removal of pituitary adenomas without requiring long-term replacement therapy, but negative effects on growth and puberty have been reported.

In the study, a team from Turkey shared its findings on 10 children and adolescents (7 females) with the condition, who underwent microsurgery (TSMS) or endoscopic surgery (ETSS, which is less invasive) — the two types of transsphenoidal surgery.

At the time of surgery, the patients’ mean age was 14.8 years, and they had been experiencing symptoms for a mean average of 24.2 months. All but one had gained weight, with a mean body mass index of 29.97.

Their symptoms included excessive body hair, high blood pressure, stretch marks, headaches, acne, “moon face,” and the absence of menstruation.

The patients were diagnosed with Cushing’s after their plasma cortisol levels were measured, and there was a lack of cortical level suppression after they took a low-dose suppression treatment. Measurements of their adrenocorticotropic (ACTH) hormone levels then revealed the cause of their disease was likely pituitary tumors.

Magnetic resonance imaging (MRI) scans, however, only enabled tumor localization in seven patients: three with a microadenoma (a tumor smaller than 10 millimeters), and four showed a macroadenoma.

CD diagnosis was confirmed by surgery and the presence of characteristic pituitary changes. The three patients with no sign of adenoma on their MRIs showed evidence of ACTH-containing adenomas on tissue evaluation.

Eight patients underwent TSMS, and 2 patients had ETSS, with no surgical complications. The patients were considered in remission if they showed clinical adrenal insufficiency and serum cortisol levels under 2.5 μg/dl 48 hours after surgery, or a cortisol level lower than 1.8 μg/dl with a low-dose dexamethasone suppression test at three months post-surgery. Restoration of normal plasma cortisol variation, eased symptoms, and no sign of adenoma in MRI were also requirements for remission.

Eight patients (80%) achieved remission, 4 of them after TSMS. Two patients underwent additional TSMS for remission. Also, 1 patient had ETSS twice after TSMS to gain remission, while another met the criteria after the first endoscopic surgery.

The data further showed that clinical recovery and normalized biochemical parameters were achieved after the initial operation in 5 patients (50%). Three patients (30%) were considered cured after additional operations.

The mean cortisol level decreased to 8.71 μg/dl post-surgery from 23.435 μg/dl pre-surgery. All patients were regularly evaluated in an outpatient clinic, with a mean follow-up period of 11 years.

Two patients showed pituitary insufficiency. Also, 2 had persistent hypocortisolism — too little cortisol — one of whom also had diabetes insipidus, a disorder that causes an imbalance of water in the body. Radiotherapy was not considered in any case.

“Transsphenoidal surgery remains the mainstay therapy for CD [Cushing’s disease] in pediatric patients as well as adults,” the scientists wrote. “It is an effective treatment option with low rate of complications.”

 

From https://cushingsdiseasenews.com/2019/01/15/transsphenoidal-surgery-enables-cushings-disease-remission-pediatric-patients-study/

Filed under: Cushing's, pituitary, Treatments | Tagged: , , , , , , , , , , | Leave a comment »

Rapid Endocrine Remission After ZAP-X Gyroscopic Radiosurgery for Cushing’s Disease

Posted on November 19, 2025 by MaryO

Abstract

Cushing’s disease is a rare but potentially life-threatening disorder caused by excessive adrenocorticotropic hormone (ACTH) secretion from a pituitary adenoma. Although transsphenoidal surgery remains the first-line treatment, radiotherapy (RT) can provide effective local and hormonal control in patients with persistent or recurrent disease; however, endocrine remission typically occurs only after several months or even years. To our knowledge, we report the first documented case of an exceptionally rapid hormonal remission following gyroscopic stereotactic radiosurgery (SRS) using the self-shielding ZAP-X system (ZAP Surgical Inc., San Carlos, CA, USA) in a patient with recurrent Cushing’s disease. The patient received a single-fraction dose of 25 Gy prescribed to the 57% isodose line. Remarkably, ACTH and cortisol levels normalized within one month after SRS, accompanied by a striking improvement in clinical symptoms and no treatment-related toxicity. This case highlights the potential of the ZAP-X gyroscopic radiosurgery platform to achieve rapid biochemical control in ACTH-secreting pituitary adenomas and suggests that the unique dose distribution characteristics of this novel technology may contribute to accelerated endocrine responses.

Introduction

Cushing’s disease stems from an excess production of adrenocorticotropic hormone (ACTH) by a pituitary adenoma, leading to elevated cortisol levels and symptoms resembling Cushing’s syndrome [1]. Untreated or inadequately managed hypercortisolism is associated with substantial morbidity and elevated mortality rates for patients with Cushing’s syndrome. While transsphenoidal surgery is frequently considered the preferred initial treatment approach, radiotherapy (RT) can also be contemplated, either as a standalone option for patients ineligible for surgery or as part of a multidisciplinary approach in instances where an adequate response is not attained following surgery. Conventional fractionated RT (CFRT), fractionated stereotactic radiosurgery (F-SRS), and stereotactic radiosurgery (SRS) have all been employed in the treatment of Cushing’s disease, yielding comparable disease control rates ranging from 46% to 100% [2-4]. However, unlike surgery, the response to RT may require time to manifest, and in certain instances, this duration can extend over months or years [4]. Sheehan et al. [5] indicated that the cure rate after RT in patients with Cushing’s disease was 34% in the first year, increasing to 78% by the fifth year. Although CyberKnife (Accuray Inc., Sunnyvale, CA, USA), Gamma Knife (Elekta AB, Stockholm, Sweden), and Linear Accelerator (LINAC)-based systems are all available for F-SRS and SRS, technological advancements are increasing the options. We have integrated the relatively new vault-free, frameless, gyroscopic radiosurgery system, ZAP-X (ZAP Surgical Inc., San Carlos, CA, USA), into our department and have begun using it for cranial F-SRS and SRS treatments [6,7]. To our knowledge, this report introduces the initial case of a patient diagnosed with Cushing’s disease who underwent gyroscopic SRS with the ZAP-X system, experiencing an unexpectedly rapid endocrine response following SRS.

Case Presentation

A 48-year-old female with an unremarkable medical history except for hyperlipidemia underwent investigation in 2018 due to symptoms and findings consistent with Cushing’s syndrome, leading to the detection of hypercortisolism. Her 24-hour urinary free cortisol and ACTH levels were 75 µg/day and 32 pg/mL, respectively. Serum cortisol remained unsuppressed following the 1 mg dexamethasone suppression test (DST), measuring 15.7 mcg/dL. On the magnetic resonance imaging (MRI) of the pituitary gland, a 4.5×3 mm microadenoma was detected in the left half of the adenohypophysis. Following the referral to the neurosurgery department, the patient underwent tumor resection via transsphenoidal endoscopic surgery in December 2018. The pathology resulted in a corticotroph pituitary adenoma. All her symptoms and signs related to Cushing’s disease resolved after surgery, and postoperative MRI showed no residual tumor. The patient was placed under observation without additional treatment. During follow-up visits, the patient remained asymptomatic for approximately five years.

In September 2023, the patient presented with complaints of proximal muscle weakness, irregular menstruation, and Cushingoid appearance. Upon evaluation, hypercortisolism was detected once again. On the pituitary MRI, no residual or recurrent lesion was observed. Subsequently, the patient underwent a second transsphenoidal surgery, but the pathology result did not reveal tissue consistent with a pituitary adenoma. In January 2024, upon initial presentation to our center, the patient’s ACTH level was 29.8 pg/mL, 24-hour urinary free cortisol was 442 µg/day, and serum cortisol following a 1 mg DST was 19 mcg/dL. The levels of the remaining anterior pituitary hormones were within normal ranges. The patient, who continued to exhibit symptoms consistent with Cushing’s syndrome, underwent another pituitary MRI. At this point, it was discovered that there was a recurrent lesion measuring 2×1 mm on the left half of the adenohypophysis. Pasireotide (0.6 mg once daily) was initiated for persistent hypercortisolism but was discontinued due to frequent diarrhea and a widespread allergic skin reaction. The patient was then evaluated by the multidisciplinary neuro-oncology tumor board at our hospital, which recommended RT as the next step. SRS was selected as the RT technique due to the tumor’s small size and its lack of proximity to critical structures such as the optic chiasm. A simulation computed tomography (CT) scan with a 1 mm axial slice thickness was conducted with the patient in the supine position. Intravenous contrast and a thermoplastic mask were utilized to ensure better visualization and precise immobilization. Gross tumor volume (GTV) was delineated as the macroscopic tumor volume according to the MRI, which was performed a few days before SRS. A planning target volume (PTV) was not generated for this case. The prescription dose was 2500 cGy in a single fraction to the 57% isodose (Figure 1). Dose-volume histogram (DVH) was presented in Figure 2. The SRS plan was generated with the integrated ZAP-X treatment planning software (version 1.8.58.12369), and detailed parameters of the plan were presented in Table 1.

Dose-distribution-of-the-gyroscopic-stereotactic-radiosurgery-plan-for-pituitary-adenoma
Figure 1: Dose distribution of the gyroscopic stereotactic radiosurgery plan for pituitary adenoma

The image shows the three-dimensional dose distribution generated using the ZAP-X system (ZAP Surgical Inc., San Carlos, CA, USA). The prescription dose of 25 Gy to the 57% isodose line is illustrated. A: planning computed tomography (CT) scan showing the isodose distribution around the target; B: planning magnetic resonance imaging (MRI) fused with CT for target delineation.

Dose-volume-histogram-(DVH)-of-the-gyroscopic-stereotactic-radiosurgery-plan
Figure 2: Dose-volume histogram (DVH) of the gyroscopic stereotactic radiosurgery plan

The DVH demonstrates a steep dose fall-off beyond the target margins, with minimal exposure to the optic nerves, optic chiasm, and brainstem, confirming optimal dose conformity and effective sparing of organs at risk. Within the gross tumor volume (GTV), the dose distribution is intentionally inhomogeneous, with a hot spot centrally located to ensure adequate tumor coverage and biological effectiveness.

Parameters Values
Volume (GTV) 0.13 cm3
Prescription dose & isodose 2500 cGy & 57.6%
Coverage 95.68%
Homogeneity index 1.74
New conformity index 1.48
Gradient index 3.58
GTV Dmean 3249 cGy
GTV Dmax 4340 cGy
GTV Dmin 2364 cGy
Optic chiasm (Dmax) 452 cGy
Left optic nerve (Dmax) 480 cGy
Right optic nerve (Dmax) 212 cGy
Brainstem (Dmax) 233 cGy
Number of beams 128
Number of isocenters 3
Monitor units 16.121
Collimator thicknesses 4 & 4 & 5 mm
Treatment delivery time 33 min
Table 1: Detailed parameters of the gyroscopic radiosurgery plan

Dmax: maximum dose; Dmean: mean dose; Dmin: minimum dose; GTV: gross tumor volume; mm: millimeter; min: minute

The treatment was well tolerated, and a marked biochemical response was observed one month after SRS, with ACTH and 24-hour urinary free cortisol levels decreasing to 14.2 pg/mL and 116 µg/day, respectively. Serum cortisol following a 1 mg DST was suppressed to 1.6 µg/dL. Concurrently, there was a noticeable improvement in the clinical signs and symptoms of Cushing’s disease. The patient was subsequently followed with regular clinical assessments at three-month intervals for one year. Throughout the follow-up period, ACTH, 24-hour urinary free cortisol, and post-DST serum cortisol levels remained near-normal (Figure 3). Levels of other anterior pituitary hormones were within normal limits. The patient’s biochemical parameters, including ACTH, urinary free cortisol, and serum cortisol levels before and after SRS, are summarized in Table 2. At the three-month post-SRS MRI, the lesion was found to be radiologically stable. However, the patient reported a subjective improvement in proximal muscle weakness beginning one month after treatment. No SRS-related toxicity was observed during the follow-up period, and partial regression of the Cushingoid phenotype was documented (Figure 4).

Temporal-changes-in-hormonal-parameters-following-gyroscopic-stereotactic-radiosurgery
Figure 3: Temporal changes in hormonal parameters following gyroscopic stereotactic radiosurgery

A: adrenocorticotropic hormone (ACTH) levels showed a rapid decline within the first month after treatment, remaining suppressed throughout follow-up; B: twenty-four-hour urinary free cortisol (UFC) demonstrated a similar sharp reduction after radiosurgery, indicating early biochemical response; C: serum cortisol levels after dexamethasone suppression normalized by the first month and remained within the physiological range during subsequent evaluations, consistent with sustained hormonal remission.

Parameter Unit Reference Range At Initial Diagnosis (2018) Recurrence (Jan 2024, before SRS) 1 Month After SRS 3 Months After SRS 6 Months After SRS 12 Months After SRS
ACTH pg/mL 7.2 – 63.3 32 29.8 14.2 11.0 12.5 15.0
24-hour UFC µg/day 20 – 90 75 442 116 65 55 45
Serum cortisol after 1 mg DST µg/dL < 1.8 (suppressed) 15.7 19.0 1.6 9.0 2.5 3.0
Table 2: Summary of laboratory findings before and after gyroscopic stereotactic radiosurgery

ACTH: adrenocorticotropic hormone; UFC: urinary free cortisol; DST: dexamethasone suppression test; SRS: stereotactic radiosurgery

Facial-appearance-before-and-after-gyroscopic-stereotactic-radiosurgery-(SRS)
Figure 4: Facial appearance before and after gyroscopic stereotactic radiosurgery (SRS)

The images illustrate the patient’s appearance at the time of initial diagnosis (A), before SRS (B), and after the procedure (C).

Discussion

To our knowledge, we report a rapid endocrine response observed in the first patient with Cushing’s disease treated using the ZAP-X gyroscopic radiosurgery system. Despite the patient having a significantly high 24-hour urinary free cortisol level before SRS, there was a considerable decrease within a short period after SRS.

Both surgical and medical treatments, along with RT, are viable approaches for managing pituitary adenomas. Approximately 70% of pituitary adenomas are associated with syndromes characterized by excessive hormone secretion, with the most common types producing prolactin, growth hormone, and ACTH [8]. Unlike non-secreting adenomas, the treatment goal for secreting adenomas extends beyond local tumor control to include the management of endocrinopathies. Although transsphenoidal surgery is commonly regarded as the first-line treatment, RT may also be considered, either as a primary modality in patients who are not surgical candidates or as part of a multimodal strategy when surgical outcomes are suboptimal. CFRT, F-SRS, and SRS have all been employed in treating patients with Cushing’s disease, yielding comparable disease control rates [9]. CFRT may be preferred, particularly for larger tumors or those located near organs at risk (OAR). In appropriately selected cases, advanced techniques such as F-SRS and SRS can shorten treatment duration and enable dose escalation within the tumor while providing a rapid dose fall-off outside the target volume. While RT can effectively control local tumor growth, its success in addressing endocrinopathies is typically more limited. In a systematic review, the rates of local tumor control and endocrine control for Cushing’s disease were reported as 92% and 48%, respectively [9]. Additionally, the radiation doses required for tumor control and endocrine response vary from each other [10]. While SRS doses ranging from 12 to 20 Gy typically achieve adequate local tumor control, especially in non-secreting adenomas, it has been observed that endocrine response rates improve at marginal doses around 30 Gy [11,12]. However, administering high doses can be challenging due to the presence of OAR, such as the optic apparatus, which is located in close proximity to the target volumes. It is recommended that the volume of the OAR receiving a dose of 8 Gy for the optic apparatus in SRS plans should be <0.2 cm³, and the volume receiving a dose of 10 Gy should be <0.035 cm³ [13]. Therefore, modern SRS platforms, which enable the delivery of high doses within the target volume while ensuring steep dose fall-off beyond it, offer the potential to widen the therapeutic window. In our patient, the ZAP-X gyroscopic SRS system enabled the delivery of 2500 cGy to the GTV at the 57% isodose line, while maintaining doses to OAR below recommended thresholds. Additionally, intratumoral hotspots allowed for the desired dose inhomogeneity, aligning with the core principles of SRS.

It is important to note that many patients with secreting pituitary adenomas suffer from symptoms caused by excessive hormone secretion, significantly impacting their quality of life and requiring consideration in treatment decisions [14]. In cases where patients experience severe symptoms due to elevated hormone levels, surgery may be prioritized, although various medical treatments are also viable options to consider. Pasireotide, a somatostatin analogue with multireceptor targeting, serves as an effective treatment for patients with persistent or recurring hypercortisolism post-surgery or when surgery isn’t viable. However, its tolerability is debatable due to various adverse effects such as hyperglycemia and diarrhea [15]. In our patient, despite initiating pasireotide due to persistently elevated hormone levels post-surgery, it was discontinued within less than two weeks due to intolerable adverse effects.

The biological effect of SRS on hormonal hypersecretion is believed to unfold gradually, and in some cases, this process may span months or even years. Sheehan et al. [5] reported outcomes for patients with Cushing’s disease, revealing a response rate of 34% at one year, 54% at two years, 72% at three years, and 78% at five years following SRS. In our patient, a significant decrease in 24-hour urinary free cortisol level was observed within only one month after SRS. To the best of our knowledge, this represents the most rapid endocrine response after SRS reported to date. It is important to consider, however, that the rapid hormonal normalization observed in our case may have been influenced by prior medical and surgical interventions. The patient underwent two transsphenoidal surgeries and briefly received pasireotide before radiosurgery, which could have altered tumor biology or hormonal responsiveness. Nevertheless, the close temporal relationship between ZAP-X treatment and biochemical remission strongly suggests a causal association. Potential factors contributing to this rapid endocrine response may include the administration of an effective radiation dose, such as 2500 cGy, utilization of a precise SRS technique like gyroscopic radiosurgery, and the presence of hotspots within the tumor, reaching up to 4000 cGy in a single fraction. During RT, the presence of hotspots within target volumes has been shown to be associated with increased local control for various tumor types [16,17]. Therefore, while it may not be directly attributable to hotspots, it seems possible that the underlying mechanism of the rapid endocrine response observed in our patient could be related to them. However, the short follow-up duration is the main limitation of this report.

Conclusions

To our knowledge, we report the first case of a refractory ACTH-secreting pituitary adenoma successfully treated using the vault-free ZAP-X gyroscopic SRS system. This case demonstrates that the unique design of the ZAP-X platform enables the safe delivery of a highly effective dose to the target while minimizing exposure to surrounding structures. In patients with Cushing’s disease, SRS can achieve rapid endocrine remission, although prospective studies are warranted to define the optimal dose and treatment parameters.

References

  1. Lonser RR, Nieman L, Oldfield EH: Cushing’s disease: pathobiology, diagnosis, and management. J Neurosurg. 2017, 126:404-17. 10.3171/2016.1.JNS152119
  2. Estrada J, Boronat M, Mielgo M, et al.: The long-term outcome of pituitary irradiation after unsuccessful transsphenoidal surgery in Cushing’s disease. N Engl J Med. 1997, 336:172-7. 10.1056/NEJM199701163360303
  3. Minniti G, Osti M, Jaffrain-Rea ML, Esposito V, Cantore G, Maurizi Enrici R: Long-term follow-up results of postoperative radiation therapy for Cushing’s disease. J Neurooncol. 2007, 84:79-84. 10.1007/s11060-007-9344-0
  4. Hughes JD, Young WF, Chang AY, et al.: Radiosurgical management of patients with persistent or recurrent Cushing disease after prior transsphenoidal surgery: a management algorithm based on a 25-year experience. Neurosurgery. 2020, 86:557-64. 10.1093/neuros/nyz159
  5. Sheehan J, Kondziolka 😧 Results of gamma knife surgery for Cushing’s disease. J Neurosurg. 2013, 119:1642.
  6. Weidlich GA, Bodduluri M, Achkire Y, Lee C, Adler JR Jr: Characterization of a novel 3 megavolt linear accelerator for dedicated intracranial stereotactic radiosurgery. Cureus. 2019, 11:e4275. 10.7759/cureus.4275
  7. Ehret F, Kohlhase N, Eftimova D, et al.: Self-shielding gyroscopic radiosurgery: a prospective experience and analysis of the first 100 patients. Cureus. 2024, 16:e56035. 10.7759/cureus.56035
  8. Daly AF, Beckers A: The epidemiology of pituitary adenomas. Endocrinol Metab Clin North Am. 2020, 49:347-55. 10.1016/j.ecl.2020.04.002
  9. Mathieu D, Kotecha R, Sahgal A, et al.: Stereotactic radiosurgery for secretory pituitary adenomas: systematic review and International Stereotactic Radiosurgery Society practice recommendations. J Neurosurg. 2022, 136:801-12. 10.3171/2021.2.JNS204440
  10. Minniti G, Osti MF, Niyazi M: Target delineation and optimal radiosurgical dose for pituitary tumors. Radiat Oncol. 2016, 11:135. 10.1186/s13014-016-0710-y
  11. Kotecha R, Sahgal A, Rubens M, et al.: Stereotactic radiosurgery for non-functioning pituitary adenomas: meta-analysis and International Stereotactic Radiosurgery Society practice opinion. Neuro Oncol. 2020, 22:318-32. 10.1093/neuonc/noz225
  12. Paddick I: A simple scoring ratio to index the conformity of radiosurgical treatment plans. Technical note. J Neurosurg. 2000, 93 Suppl 3:219-22. 10.3171/jns.2000.93.supplement
  13. Timmerman R: A story of hypofractionation and the table on the wall. Int J Radiat Oncol Biol Phys. 2022, 112:4-21. 10.1016/j.ijrobp.2021.09.027
  14. Johnson MD, Woodburn CJ, Vance ML: Quality of life in patients with a pituitary adenoma. Pituitary. 2003, 6:81-7. 10.1023/b:pitu.0000004798.27230.ed
  15. Manetti L, Deutschbein T, Schopohl J, et al.: Long-term safety and efficacy of subcutaneous pasireotide in patients with Cushing’s disease: interim results from a long-term real-world evidence study. Pituitary. 2019, 22:542-51. 10.1007/s11102-019-00984-6
  16. Owen D, Siva S, Salama JK, Daly M, Kruser TJ, Giuliani M: Some like it hot: the value of dose and hot spots in lung stereotactic body radiation therapy. Int J Radiat Oncol Biol Phys. 2023, 117:1-5. 10.1016/j.ijrobp.2023.03.056
  17. Abraham C, Garsa A, Badiyan SN, et al.: Internal dose escalation is associated with increased local control for non-small cell lung cancer (NSCLC) brain metastases treated with stereotactic radiosurgery (SRS). Adv Radiat Oncol. 2018, 3:146-53. 10.1016/j.adro.2017.11.003

 

From https://www.cureus.com/articles/430830-rapid-endocrine-remission-after-zap-x-gyroscopic-radiosurgery-for-cushings-disease-a-case-report?score_article=true#!/

​

Filed under: Cushing's, pituitary, Treatments | Tagged: , , , , | Leave a comment »

Next Page »