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J Clin Endocrinol Metab ; 105(5)2020 05 01.
Article in English | MEDLINE | ID: mdl-31735971

ABSTRACT

CONTEXT: Long-term outcomes of patients with Nelson's syndrome (NS) have been poorly explored, especially in the modern era. OBJECTIVE: To elucidate tumor control rates, effectiveness of various treatments, and markers of prognostic relevance in patients with NS. PATIENTS, DESIGN, AND SETTING: Retrospective cohort study of 68 patients from 13 UK pituitary centers with median imaging follow-up of 13 years (range 1-45) since NS diagnosis. RESULTS: Management of Cushing's disease (CD) prior to NS diagnosis included surgery+adrenalectomy (n = 30; eight patients had 2 and one had 3 pituitary operations), surgery+radiotherapy+adrenalectomy (n = 17; two received >1 courses of irradiation, two had ≥2 pituitary surgeries), radiotherapy+adrenalectomy (n = 2), and adrenalectomy (n = 19). Primary management of NS mainly included surgery, radiotherapy, surgery+radiotherapy, and observation; 10-year tumor progression-free survival was 62% (surgery 80%, radiotherapy 52%, surgery+radiotherapy 81%, observation 51%). Sex, age at CD or NS diagnosis, size of adenoma (micro-/macroadenoma) at CD diagnosis, presence of pituitary tumor on imaging prior adrenalectomy, and mode of NS primary management were not predictors of tumor progression. Mode of management of CD before NS diagnosis was a significant factor predicting progression, with the group treated by surgery+radiotherapy+adrenalectomy for their CD showing the highest risk (hazard ratio 4.6; 95% confidence interval, 1.6-13.5). During follow-up, 3% of patients had malignant transformation with spinal metastases and 4% died of aggressively enlarging tumor. CONCLUSIONS: At 10 years follow-up, 38% of the patients diagnosed with NS showed progression of their corticotroph tumor. Complexity of treatments for the CD prior to NS diagnosis, possibly reflecting corticotroph adenoma aggressiveness, predicts long-term tumor prognosis.


Subject(s)
Nelson Syndrome/diagnosis , Nelson Syndrome/therapy , ACTH-Secreting Pituitary Adenoma/diagnosis , ACTH-Secreting Pituitary Adenoma/epidemiology , ACTH-Secreting Pituitary Adenoma/therapy , Adenoma/diagnosis , Adenoma/epidemiology , Adenoma/therapy , Adolescent , Adult , Aged , Biomarkers, Tumor/analysis , Child , Cohort Studies , Female , Follow-Up Studies , Humans , Male , Middle Aged , Nelson Syndrome/epidemiology , Neoadjuvant Therapy , Prognosis , Retrospective Studies , Treatment Outcome , United Kingdom/epidemiology , Young Adult
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