Long-term results after microsurgery for Cushing disease: experience with 426 primary operations over 35 years

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  • 1 Department of Neurosurgery, University of Erlangen-Nuremberg, Erlangen; and
  • 2 Department of Internal Medicine, Rotkreuzkrankenhaus, Munich, Germany
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Object

The aim of this paper was to demonstrate the long-term results following microsurgery in a single surgeon's continuous series of patients with Cushing disease (CD), to assess the influence of changes in surgical procedures, and to compare the results with those of other treatment modalities. In particular, preoperative diagnosis, tumor size, results of histological examination, and complications were considered.

Methods

Between 1971 and 2004, 426 patients suffering from newly diagnosed CD underwent primary surgery. Pre-operative measures included clinical examination, endocrinological workup (testing of the hypothalamic-pituitary-adrenal axis, and 2- and 8-mg dexamethasone overnight suppression tests), sellar imaging (polytomography, computed tomography, and magnetic resonance [MR] imaging), and in patients with negative results on imaging studies, inferior petrosal sinus sampling. Follow-up examinations consisting of endocrinological workup, and imaging took place 1 week and 3 months after surgery and then at yearly intervals.

Results

During microsurgery as first treatment, the adenoma finding rate was 86.6%. After selective adenomectomy, the remission rate was 75.9%, and this rate showed no improvement over the years. The best results were achieved in microadenomas confirmed on MR imaging or histopathological investigation. The recurrence rate (15%) and the complication rate (5.9%) declined over the years. If no adenoma was found, exploration of the sella turcica was performed in 45.6%, hypophysectomy in 3.5%, and hemihypophysectomy in 50.9% of these patients, leading to an early remission in 37.9%. In case of persistence or recurrence, further treatment (repeated operation, adrenalectomy, radio-therapy, or medical treatment) was used to control the disease.

Conclusions

Microsurgery remains the treatment of first choice in CD, even though no improvement in remission rates was observed over the years, because complication or remission rates for other treatment options are comparable or worse.

Abbreviations used in this paper:ACTH = adrenocorticotropic hormone; CD = Cushing disease; CRH = corticotropin-releasing hormone; CS = cavernous sinus; CT = computed tomography; DEXA = dexamethasone overnight test; IPS = inferior petrosal sinus; MR = magnetic resonance.

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Contributor Notes

Address correspondence to: Rudolf Fahlbusch, M.D., Ph.D., International Neuroscience Institute, Rudolf Pichlmayrstrasse 4, 30625 Hannover, Germany. email: fahlbusch@ini-hannover.de.
  • 1

    Bakiri F, , Tatai S, , Aouli R, , Semrouni M, , Derome PJ, & Chitour F, : Treatment of Cushing's disease by transsphenoidal, pituitary microsurgery: prognosis factors and long-term follow-up. J Endocrinol Invest 19:572580, 1996

    • Search Google Scholar
    • Export Citation
  • 2

    Batista DL, , Zhang X, , Gejman R, , Ansell PJ, , Zhou Y, & Johnson SA, : The effect of SOM230 on cell proliferation and adrenocorticotropin secretion in human corticotroph pituitary adenomas. J Clin Endocrinol Metab 91:44824488, 2006

    • Search Google Scholar
    • Export Citation
  • 3

    Bax TW, , Marcus DR, , Galloway GQ, , Swanstrom LL, & Sheppard BC: Laparoscopic bilateral adrenalectomy following failed hypophysectomy. Surg Endosc 10:11501153, 1996

    • Search Google Scholar
    • Export Citation
  • 4

    Blevins LS Jr, , Christy JH, , Khajavi M, & Tindall GT: Outcomes of therapy for Cushing's disease due to adrenocorticotropin-secreting pituitary macroadenomas. J Clin Endocrinol Metab 83:6367, 1998

    • Search Google Scholar
    • Export Citation
  • 5

    Bochicchio D, , Losa M, & Buchfelder M: Factors influencing the immediate and late outcome of Cushing's disease treated by transsphenoidal surgery: a retrospective study by the European Cushing's Disease Survey Group. J Clin Endocrinol Metab 80:31143120, 1995

    • Search Google Scholar
    • Export Citation
  • 6

    Bonelli FS, , Huston J III, , Carpenter PC, , Erickson D, , Young WF Jr, & Meyer FB: Adrenocorticotropic hormone-dependent Cushing's syndrome: sensitivity and specifity of inferior petrosal sinus sampling. AJNR Am J Neuroradiol 21:690696, 2000

    • Search Google Scholar
    • Export Citation
  • 7

    Brunt LM, , Moley JF, , Doherty GM, , Lairmore TC, , DeBenedetti MK, & Quasebarth MA: Outcome analysis in patients undergoing laparoscopic adrenalectomy for hormonally active adrenal tumors. Surgery 130:629635, 2001

    • Search Google Scholar
    • Export Citation
  • 8

    Buchfelder M, & Fahlbusch R: Neurosurgical treatment of Cushing's disease in children and adolescents. Acta Neurochir Suppl (Wien) 35:101105, 1985

    • Search Google Scholar
    • Export Citation
  • 9

    Cannavò S, , Almoto B, , Dall'asta C, , Corsello S, , Lovicu RM, & DeMenis E, : Long term results of treatment in patients with ACTH-secreting pituitary macroadenomas. Eur J Endocrinol 149:195200, 2003

    • Search Google Scholar
    • Export Citation
  • 10

    Chandler WF, , Schteingart DE, , Lloyd RV, , McKeever PE, & Ibarra-Perrez G: Surgical treatment of Cushing's disease. J Neurosurg 66:204212, 1987

    • Search Google Scholar
    • Export Citation
  • 11

    Chee GH, , Mathias DB, , James RA, & Kendall-Taylor P: Transsphenoidal pituitary surgery in Cushing's disease: can we predict outcome?. Clin Endocrinol (Oxf) 54:617626, 2001

    • Search Google Scholar
    • Export Citation
  • 12

    Chen JCT, , Amar AP, , Choi SH, , Singer P, , Couldwell WT, & Weiss MH: Transsphenoidal microsurgical treatment of Cushing disease: postoperative assessment of surgical efficacy by application of an overnight low-dose dexamethasone suppression test. J Neurosurg 98:967973, 2003

    • Search Google Scholar
    • Export Citation
  • 13

    Colao A, , Faggiano A, , Pivonello R, , Giraldi FP, , Cavagnini F, & Lombardi G: Inferior petrosal sinus sampling in the differential diagnosis of Cushing's syndrome: results of an Italian multicenter study. Eur J Endocrinol 144:499507, 2001

    • Search Google Scholar
    • Export Citation
  • 14

    Devoe DJ, , Miller WL, , Conte FA, , Kaplan SL, , Grumbach MM, & Rosenthal SM, : Long-term outcome in children and adolescents after transsphenoidal surgery for Cushing's disease. J Clin Endocrinol Metab 82:31963202, 1997

    • Search Google Scholar
    • Export Citation
  • 15

    Dickerman RD, & Oldfield EH: Basis of persistent and recurrent Cushing disease: an analysis of findings and repeated surgery. J Neurosurg 97:13431349, 2002

    • Search Google Scholar
    • Export Citation
  • 16

    Dyer EH, , Civit T, , Visot A, , Delalande O, & Derome PJ: Transsphenoidal surgery for pituitary adenomas in children. Neurosurgery 34:207212, 1994

    • Search Google Scholar
    • Export Citation
  • 17

    Erem C, , Algun E, , Ozbey N, , Azezli A, , Aral F, & Orhan Y, : Clinical laboratory findings and results of therapy in 55 patients with Cushing's syndrome. J Endocrinol Invest 26:6572, 2003

    • Search Google Scholar
    • Export Citation
  • 18

    Estrada J, , Boronat M, , Mielgo M, , Magallon R, , Millan I, & Diez S, : The long-term outcome of pituitary irradiation after unsuccessful transsphenoidal surgery in Cushing's disease. N Engl J Med 336:172177, 1997

    • Search Google Scholar
    • Export Citation
  • 19

    Fahlbusch R, , Buchfelder M, & Müller OA: Transsphenoidal surgery for Cushing's disease. J R Soc Med 79:262269, 1986

  • 20

    Flitsch J, , Knappe UJ, & Lüdecke DK: Direct intraoperative micro-method for hormone measurements of pituitary tissue in Cushing's disease. Surg Neurol 52:585591, 1999

    • Search Google Scholar
    • Export Citation
  • 21

    Flitsch J, , Knappe UJ, & Lüdecke DK: The use of postoperative ACTH levels as a marker for successful transsphenoidal microsurgery in Cushing's disease. Zentralbl Neurochir 64:611, 2003

    • Search Google Scholar
    • Export Citation
  • 22

    Grabner P, , Hauer-Jensen M, , Jervell J, & Flatmark A: Long-term results of treatment of Cushing's disease by adrenalectomy. Eur J Surg 157:461464, 1991

    • Search Google Scholar
    • Export Citation
  • 23

    Guilhaume B, , Bertagna X, , Thomsen M, , Bricaire C, , Vila-Porcile E, & Olivier L, : Transsphenoidal pituitary surgery for the treatment of Cushing's disease: results in 64 patients and long-term follow-up studies. J Clin Endocrinol Metab 66:10561064, 1988

    • Search Google Scholar
    • Export Citation
  • 24

    Hofmann BM, & Fahlbusch R: Treatment of Cushing's disease: a retrospective clinical study of the latest 100 cases. Front Horm Res 34:158184, 2006

    • Search Google Scholar
    • Export Citation
  • 25

    Hofmann BM, , Hlavac M, , Kreutzer J, , Grabenbauer G, & Fahlbusch R: Surgical treatment of recurrent Cushing's disease. Neurosurgery 58:11081118, 2006

    • Search Google Scholar
    • Export Citation
  • 26

    Howlett TA, , Plowman PN, , Wass JA, , Rees LH, , Jones AE, & Besser GM: Megavoltage pituitary irradiation in the management of Cushing's disease and Nelson's syndrome: long-term follow-up. Clin Endocrinol (Oxf) 31:309323, 1989

    • Search Google Scholar
    • Export Citation
  • 27

    Hoybye C, , Grenback E, , Rahn T, , Degerblad M, , Thorén M, & Hulting AL: Adrenocorticotropic hormone-producing pituitary tumors: 12- to 22-year follow-up after treatment with stereotactic radiosurgery. Neurosurgery 49:284292, 2001

    • Search Google Scholar
    • Export Citation
  • 28

    Hoybye C, , Grenback E, , Thorén M, , Hulting AL, , Lundblad L, & von Holst H, : Transsphenoidal surgery in Cushing's disease: 10 years of experience in 34 consecutive cases. J Neurosurg 100:634638, 2004

    • Search Google Scholar
    • Export Citation
  • 29

    Inoue HK, , Kohga H, , Hirato M, , Sasaki T, , Ishihara J, & Shibazaki T, : Pituitary adenomas treated by microsurgery with or without gamma knife surgery: experience in 122 cases. Stereotact Funct Neurosurg 72:1 Suppl 125131, 1999

    • Search Google Scholar
    • Export Citation
  • 30

    Izawa M, , Hayashi M, , Nakaya K, , Satoh H, , Ochiai T, & Hori T, : Gamma knife radiosurgery for pituitary adenomas. J Neurosurg 93:3 Suppl 1922, 2000

    • Search Google Scholar
    • Export Citation
  • 31

    Jennings AS, , Liddle GW, & Orth DN: Results of treating childhood Cushing's disease with pituitary irradiation. N Engl J Med 297:957962, 1977

    • Search Google Scholar
    • Export Citation
  • 32

    Joshi SM, , Hewitt RJD, , Storr HL, , Rezajooi K, , Ellamushi H, & Grossman AB, : Cushing's disease in children and adolescents: 20 years of experience in a single neurosurgical center. Neurosurgery 57:281285, 2005

    • Search Google Scholar
    • Export Citation
  • 33

    Kaltsas GA, , Giannulis MG, , Newell-Price JDC, , Dacie JE, , Thakkar C, & Afshar F, : A critical analysis of the value of simultaneous inferior petrosal sinus sampling in Cushing's disease and the occult ectopic adrenocorticotropin syndrome. J Clin Endocrinol Metab 84:487492, 1999

    • Search Google Scholar
    • Export Citation
  • 34

    Kim SH, , Huh R, , Chang JW, , Park YG, & Chung SS: Gamma knife radiosurgery for functioning pituitary adenomas. Stereotact Funct Neurosurg 72:1 Suppl 101110, 1999

    • Search Google Scholar
    • Export Citation
  • 35

    Knappe UJ, & Lüdecke DK: Persistent and recurrent hypercortisolism after transsphenoidal surgery for Cushing's disease. Acta Neurochir Suppl 65:3134, 1996

    • Search Google Scholar
    • Export Citation
  • 36

    Knappe UJ, & Lüdecke DK: Transnasal microsurgery in children and adolescents with Cushing's disease. Neurosurgery 39:484493, 1996

  • 37

    Lefournier V, , Martinie M, , Vasdev A, , Bessou P, , Passagia JG, & Labat-Moleur F, : Accuracy of bilateral inferior petrosal or cavernous sinuses sampling in predicting the lateralization of Cushing's disease pituitary microadenoma: influence of catheter position and anatomy of venous drainage. J Clin Endocrinol Metab 88:196203, 2003

    • Search Google Scholar
    • Export Citation
  • 38

    Leinung MC, , Kane LA, , Scheithauer BW, , Carpenter PC, , Laws ER Jr, & Zimmermann D: Long term follow-up of transsphenoidal surgery for the treatment of Cushing's disease in childhood. J Clin Endocrinol Metab 80:24752479, 1995

    • Search Google Scholar
    • Export Citation
  • 39

    Liddle GW: Tests of pituitary-adrenal suppressibility in the diagnosis of Cushing's syndrome. J Clin Endocrinol Metab 20:15391560, 1960

    • Search Google Scholar
    • Export Citation
  • 40

    Lim YL, , Leem W, , Kim TS, , Rhee BA, & Kim GK: Four years' experiences in the treatment of pituitary adenomas with gamma knife radiosurgery. Stereotact Funct Neurosurg 70:1 Suppl 95109, 1998

    • Search Google Scholar
    • Export Citation
  • 41

    Littley MD, , Shalet SM, , Beardwell CG, , Ahmed SR, & Sutton ML: Long-term follow-up of low-dose external pituitary irradiation for Cushing's disease. Clin Endocrinol (Oxf) 33:445455, 1990

    • Search Google Scholar
    • Export Citation
  • 42

    Liu C, , Lo JC, , Dowd CF, , Wilson CB, , Kunwar S, & Aron DC, : Cavernous and inferior petrosal sinus sampling in the evaluation of ACTH-dependent Cushing's syndrome. Clin Endocrinol (Oxf) 61:478486, 2004

    • Search Google Scholar
    • Export Citation
  • 43

    Mampalam TJ, , Tyrrell JB, & Wilson CB: Transsphenoidal microsurgery for Cushing's disease. A report of 216 cases. Ann Intern Med 109:487493, 1988

    • Search Google Scholar
    • Export Citation
  • 44

    Martinez R, , Bravo G, , Burzaco J, & Rey G: Pituitary tumors and gamma knife surgery. Clinical experience with more than two years of follow-up. Stereotact Funct Neurosurg 70:Suppl 1 110118, 1998

    • Search Google Scholar
    • Export Citation
  • 45

    McCance DR, , Russell CFJ, , Kennedy TL, , Hadden DR, , Kennedy L, & Atkinson AB: Bilateral adrenalectomy: low mortality and morbidity in Cushing's disease. Clin Endocrinol (Oxf) 39:315321, 1993

    • Search Google Scholar
    • Export Citation
  • 46

    Morange-Ramos I, , Regis J, , Dufour H, , Andrieu JM, , Grisoli F, & Jaquet P, : Short-term endocrinological results after gamma knife surgery of pituitary adenomas. Stereotact Funct Neurosurg 70:1 Suppl 127138, 1998

    • Search Google Scholar
    • Export Citation
  • 47

    Nagesser SK, , van Seters AP, , Kievit J, , Hermans J, , Krans HM, & van de Velde CJ: Long-term results of total adrenalectomy for Cushing's disease. World J Surg 24:108113, 2000

    • Search Google Scholar
    • Export Citation
  • 48

    Nagesser SK, , van Seters AP, , Kievit J, , Hermans J, , van Dulken H, & Krans HM, : Treatment of pituitary-dependent Cushing's syndrome: long-term results of unilateral adrenalectomy followed by external pituitary irradiation compared to transsphenoidal pituitary surgery. Clin Endocrinol (Oxf) 52:427435, 2000

    • Search Google Scholar
    • Export Citation
  • 49

    Nakane T, , Kuwayama A, , Watanabe M, , Takahashi T, , Kato T, & Ichihara K, : Long term results of transsphenoidal adenomectomy in patients with Cushing's disease. Neurosurgery 21:218222, 1987

    • Search Google Scholar
    • Export Citation
  • 50

    Nomikos P, , Buchfelder M, & Fahlbusch R: Current management of prolactinomas. J Neurooncol 54:139150, 2001

  • 51

    Nomikos P, , Buchfelder M, & Fahlbusch R: The outcome of surgery in 668 patients with acromegaly using current criteria of biochemical “cure”. Eur J Endocrinol 152:379387, 2005

    • Search Google Scholar
    • Export Citation
  • 52

    Nomikos P, , Fahlbusch R, & Buchfelder M: Recent developments in transsphenoidal surgery of pituitary tumors. Hormones (Athens, Greece) 3:8591, 2004

    • Search Google Scholar
    • Export Citation
  • 53

    O'Riordain DS, , Farley DR, , Young WF Jr, , Grant CS, & van Herden JA: Long-term outcome of bilateral adrenalectomy in patients with Cushing's syndrome. Surgery 116:10881094, 1994

    • Search Google Scholar
    • Export Citation
  • 54

    Oldfield EH, , Chrousos GP, , Schulte HM, , Schaaf M, , McKeever PE, & Krudy AG, : Preoperative lateralization of ACTH-secreting pituitary microadenomas by bilateral and simultaneous inferior petrosal venous sinus sampling. N Engl J Med 312:100103, 1985

    • Search Google Scholar
    • Export Citation
  • 55

    Pan L, , Zhang N, , Wang B, & Xu W: Pituitary adenomas: the effect of gamma knife radiosurgery on tumor growth and endocrinopathies. Stereotact Funct Neurosurg 70:1 Suppl 119126, 1998

    • Search Google Scholar
    • Export Citation
  • 56

    Pollock BE, & Young WF Jr: Stereotactic radiosurgery for patients with ACTH-producing pituitary adenomas after prior adrenalectomy. Int J Radiat Oncol Biol Phys 54:839841, 2002

    • Search Google Scholar
    • Export Citation
  • 57

    Rahn T, , Thorén M, , Hall K, & Backlund EO: Stereotactic radiosurgery in Cushing's syndrome: acute radiation effects. Surg Neurol 14:8592, 1980

    • Search Google Scholar
    • Export Citation
  • 58

    Ram Z, , Nieman LK, , Cutler GB Jr, , Chrousos GP, , Doppman JL, & Oldfield EH: Early repeat surgery for persistent Cushing's disease. J Neurosurg 80:3745, 1994

    • Search Google Scholar
    • Export Citation
  • 59

    Ross WM, , Evered DC, , Hunter P, , Benaim M, , Cook D, & Hall R: Treatment of Cushing's disease with adrenal blocking drugs and megavoltage therapy of the pituitary. Clin Radiol 30:149153, 1979

    • Search Google Scholar
    • Export Citation
  • 60

    Saeger W, & Lüdecke DK: Pituitary hyperplasia. Definition, light and electron microscopical structures and significance in surgical specimens. Virchows Arch A Pathol Anat Histopathol 399:277287, 1983

    • Search Google Scholar
    • Export Citation
  • 61

    Savage MO, , Lienhardt A, , Lebrethon MC, , Johnston LB, , Huebner A, & Grossman AB, : Cushing's disease in childhood: presentation, investigation, treatment and long-term outcome. Horm Res 55:1 Suppl 2430, 2001

    • Search Google Scholar
    • Export Citation
  • 62

    Semple PL, & Laws ER Jr: Complications in a contemporary series of patients who underwent transsphenoidal surgery for Cushing's disease. J Neurosurg 91:175179, 1999

    • Search Google Scholar
    • Export Citation
  • 63

    Semple PL, , Vance ML, , Findling J, & Laws ER Jr: Transsphenoidal surgery for Cushing's disease: outcome in patients with a normal magnetic resonance imaging scan. Neurosurgery 46:553559, 2000

    • Search Google Scholar
    • Export Citation
  • 64

    Sheehan JM, , Lopes MB, , Sheehan JP, , Ellegala DB, , Webb KM, & Laws ER Jr: Results of transsphenoidal surgery for Cushing's disease in patients with no histologically confirmed tumor. Neurosurgery 47:3339, 2000

    • Search Google Scholar
    • Export Citation
  • 65

    Sheehan JM, , Vance ML, , Sheehan JP, , Ellegala DB, & Laws ER Jr: Radiosurgery for Cushing's disease after failed transsphenoidal surgery. J Neurosurg 93:738742, 2000

    • Search Google Scholar
    • Export Citation
  • 66

    Shimon I, , Ram Z, , Cohen ZR, & Hadani M: Transsphenoidal surgery for Cushing's disease: endocrinological follow-up monitoring of 82 patients. Neurosurgery 51:5762, 2002

    • Search Google Scholar
    • Export Citation
  • 67

    Sonino N, , Zielezny M, , Fava GA, , Fallo F, & Boscaro M: Risk factors and long-term outcome in pituitary-dependent Cushing's disease. J Clin Endocrinol Metab 81:26472652, 1996

    • Search Google Scholar
    • Export Citation
  • 68

    Stévenaert A, , Perrin G, , Martin D, & Beckers A: [Cushing's disease and corticotrophic adenoma: results of pituitary microsurgery.]. Neurochirurgie 48:234265, 2002. (Fr)

    • Search Google Scholar
    • Export Citation
  • 69

    Storr HL, , Plowman PN, , Caroll PV, , Francois I, , Krassas GE, & Afsahr F, : Clinical and endocrine responses to pituitary radio-therapy in pediatric Cushing's disease: an effective second-line treatment. J Clin Endocrinol Metab 88:3437, 2003

    • Search Google Scholar
    • Export Citation
  • 70

    Tagliaferri M, , Berselli ME, & Loli P: Transsphenoidal microsurgery for Cushing's disease. Acta Endocrinol (Copenh) 113:511, 1986

  • 71

    Tindall GT, , Herring CJ, , Clark RV, , Adams DA, & Watts NB: Cushing's disease: results of transsphenoidal microsurgery with emphasis on surgical failures. J Neurosurg 72:363369, 1990

    • Search Google Scholar
    • Export Citation
  • 72

    Trainer PJ, , Lawrie HS, , Verhelst J, , Howlett TA, , Lowe DG, & Grossman AB, : Transsphenoidal resection in Cushing's disease: undetectable serum cortisol as the definition of successful treatment. Clin Endocrinol (Oxf) 38:7378, 1993

    • Search Google Scholar
    • Export Citation
  • 73

    Trecan GV, , Laudat MH, , Thomopoulos P, , Luton JP, & Bricaire H: Urinary free corticoids: an evaluation of their usefulness in the diagnosis of Cushing's syndrome. Acta Endocrinol (Copenh) 103:110115, 1983

    • Search Google Scholar
    • Export Citation
  • 74

    Tyrrell JB, , Findling JW, , Aaron DC, , Fitzgerald PA, & Forsham PH: An overnight high-dose dexamethasone suppression test for rapid differential diagnosis of Cushing's syndrome. Ann Intern Med 104:180186, 1986

    • Search Google Scholar
    • Export Citation
  • 75

    Vicente A, , Estrada J, , de la Cuerda C, , Astigarra B, , Marazuela M, & Blanco C, : Results of external pituitary irradiation after unsuccessful transsphenoidal surgery in Cushing's disease. Acta Endocrinol (Copenh) 125:470474, 1991

    • Search Google Scholar
    • Export Citation
  • 76

    Vladyka V, , Liscak R, , Simonova G, , Chytka T, , Novotny J Jr, & Vymaza J, : Radiosurgical treatment of hypophyseal adenomas with gamma knife: results in a group of 163 patients during a 5-year period. Cas Lek Cesk 139:757766, 2000

    • Search Google Scholar
    • Export Citation
  • 77

    Walz MK, , Peitgen K, , Hoermann R, , Giebler RM, , Mann K, & Eigler FW: Posterior retroperitoneoscopy as a new minimally invasive approach for adrenalectomy: results of 30 adrenalectomies in 27 patients. World J Surg 20:769774, 1996

    • Search Google Scholar
    • Export Citation
  • 78

    Weber A, , Trainer PJ, , Grossman AB, , Afsahr F, , Medbak S, & Perry LA, : Investigation, management and therapeutic outcome in 12 cases of childhood and adolescent Cushing's syndrome. Clin Endocrinol (Oxf) 43:1928, 1995

    • Search Google Scholar
    • Export Citation
  • 79

    Yoon SC, , Suh TS, , Jang HS, , Chung SM, , Kim YS, & Ryu MR, : Clinical results of 24 pituitary macroadenomas with LINAC-based stereotactic radiosurgery. Int J Radiat Oncol Biol Phys 41:849853, 1998

    • Search Google Scholar
    • Export Citation

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