4.2 Review

Role of radiosurgery in the treatment of Cushing's disease

Related references

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Glucose and lipid metabolism abnormalities in Cushing's syndrome

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Long-term effects of glucocorticoid excess on the brain

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Summary: The clinical manifestations of metabolism and cardiovascular system in patients with Cushing's syndrome are well-known. However, recent studies have shown that hypercortisolism, both endogenous and exogenous, affects brain functioning at different time scales. This review discusses the effects of hypercortisolism on the brain, the prevalence of cognitive and neuropsychological deficits, and their course after remission. Possible underlying neuronal changes are also proposed based on experimental models and in vitro studies. Recommendations for future studies are provided.

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Summary: In the context of ACTH-dependent Cushing's syndrome, ectopic ACTH secretion from a neuroendocrine tumour needs to be differentiated carefully from pituitary-dependent Cushing's syndrome, Cushing's disease, for optimal therapy. Diagnosis may be difficult as clinical and biochemical tests may overlap with Cushing's disease. Imaging is essential and should be interpreted considering both anatomical and functional imaging modalities.

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Summary: Endogenous Cushing's syndrome (CS) is rarely encountered during pregnancy and the diagnosis is challenging. Conclusive recommendations or a standardized management approach for all patients with CS in pregnancy cannot be made due to the lack of comprehensive literature. Management decisions, including surgery, medical control, or conservative approach, should be highly individualized and consider various factors such as stage of gestation, tumor localization, severity of CS, maternal comorbidity, and patient choice.

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Summary: Pituitary MRI is essential for the diagnosis of ACTH-dependent Cushing's syndrome, but its results can vary. The expertise of the neuroradiologist, the use of a Tesla 3.0 MRI, and the choice of sequences are important factors. T2 and 3D gradient echo sequences after gadolinium injection are the most informative and can detect most macro- and microadenomas. However, diagnosing picoadenomas (<3-4 mm) remains challenging.

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Summary: Transsphenoidal surgery is the first-line treatment for Cushing's disease, but medical treatment is also an option in certain cases, such as severe hypercortisolism, short-term treatment before surgery, long-term treatment after failed surgery, or while waiting for the full effect of radiation therapy. The approach to medical treatment varies depending on the severity of hypercortisolism, with a block and replace approach for severe cases and a titration approach for mild cases.

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The corticotroph cells from early development to tumorigenesis

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Long-term follow-up and predictors of recurrence of Cushing's disease

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I. Jonathan Pomeraniec et al.

Summary: Stereotactic radiosurgery (SRS) is an effective treatment for pituitary adenomas, but the mechanism of delayed endocrine deficits is not well understood. This multicenter study aimed to evaluate radiation tolerance and identify predictors of delayed hypopituitarism after SRS for these tumors. The study found that tumor control was achieved in a high percentage of patients, but a significant number developed new loss of pituitary function, with certain factors such as tumor type, age, and radiation dose playing a role.

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Summary: Stereotactic radiosurgery (SRS) provides effective tumor control for secretory pituitary adenomas, but has a lower rate of endocrine improvement or remission.

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