Specific focus on the basal dura for improving Cushing’s disease surgery: a cohort study
Background and objectives
In Cushing’s disease, the rate of endocrine remission after surgery reaches about 80% in expert centers. However, due to the tumor’s ability to invade surrounding dural structures, hypercortisolism persists in 20% of patients or recurs in 15%. To improve remission likelihood, tumor resection can be extended to the dura in patients with basal dura invasion. The aim of this study was to evaluate the benefit of a surgical strategy based on a systematic focus on the basal dura.
Methods
Endoscopic surgery was performed in 89 adult patients without obvious cavernous sinus invasion. The basal dura was systematically removed whenever macroscopic invasion was suspected. Three groups were defined: (i) resected but non-invaded dura (n=14); (ii) resected and invaded dura (n=16); and (iii) non-resected dura (n=59). The cohort was compared to a personal control series of Cushing’s patients operated without a systematic focus on the basal dura.
Results
The mean follow-up duration was 19.9 ± 9.4 months. Endocrine remission was achieved in 15/16 (94%) patients with invaded dura, 14/15 (93%) with resected non-invaded dura, and 50/59 (85%) with non-resected dura. Anterior pituitary deficits and diabetes insipidus occurred in 3% and 9% of patients, respectively. Compared to the control series, the remission rate was significantly higher (88% vs. 75%, p = .019).
Conclusion
Tumorectomy extended to the basal dura is a safe procedure that maximizes surgical resection. Despite dural invasion, endocrine remission remains high when the dura is removed. A systematic focus on the basal dura can thus optimize endocrine outcomes in Cushing’s disease surgery.
