Treatment of Cushing's disease by transsphenoidal, pituitary microsurgery: prognosis factors and long-term follow-up.

Transsphenoidal pituitary microsurgery is considered as the best treatment of Cushing's disease. However, some recent studies reported disappointing results, leading their authors to suggest the possibility of returning to a first line adrenalectomy treatment. The aim of this study was to evaluate long-term results of transsphenoidal surgery in Cushing's disease, with special interest in factors that could affect the surgical outcome on the one hand and particular attention to surgical endocrine effects on the other. Fifty consecutive patients (34 females, 16 males, mean age 29.64 +/- 1.52 yr) were studied. The median post-operative follow-up was 71.5 months (range 25-219). Clinical, biological, surgical and pathological data between the success and failure groups were compared. Criteria of cure were: normal urinary free cortisol excretion, circadian cortisol rhythm and low dose dexamethasone test. Recovery of corticotroph and somatotroph functions were followed using the insulin test. Particular attention is given to clinical evolution in evaluating other pituitary functions. T4 or FT4, prolactin, E2 in women, testosterone in men, were measured. TRH and LHRH tests were not systematically performed. Only two parameters differed significantly between the cured and failure groups: the size of the adenomas was smaller and the pathological confirmation of the adenoma more frequent in the cured group. One patient had permanent corticotropic failure while two other had impaired response to hypoglycemia with normal cortisol basal levels. No acquired hypothyroidism nor hypogonadism were observed except in a patient who underwent two operations and radiotherapy. Recovery of GH function was slow. Definitive short stature was observed in all the patients whose disease began before the age of 16. Two patients had permanent diabetes insipidus. In conclusion, the most favorable prognosis in transsphenoidal surgery for Cushing's disease is observed in case of microadenoma confirmed by pathological examination. With this treatment, we obtained satisfactory results in Cushing's disease with minimal complications and no necessity of life-long endocrine substitutive therapy.

Enzymatic androgen assay: some properties of human placental microsomal aromatase.

The androgen content of biological fluids can be determined after their conversion into estrogens using human placental microsomal aromatase (HPMA). The purpose of this paper is to report some physico-chemical properties of HPMA. Using an accurate, specific and sensitive assay for HPMA, Km values for dehydroepiandrosterone (DHEA), androstenedione and testosterone were found to increase with increasing amount of the detergent (Triton X-100) added. Analysis at substrate concentrations 5-10 times above and below the Km values did not indicate any anomalous kinetic behaviour. Triton X-100, used for enzyme solubilization, significantly decreased the rate of aromatization of the three substrates by increasing their Km values. This effect was more important for testosterone than for androstenedione or DHEA. Using a new protocol for the determination of aromatase activity, kinetic properties of aromatase before and after solubilization are described.

[Thyrotropic reserve in Sheehan's syndrome. Study in 36 patients (author's transl)]. / La réserve thyréotrope au cours syndrome de Sheehan. Etude chez 36 malades.

Thyrotropic involvement is considered to be constant in Sheehan's syndrome. In this study, plasma thyroid stimulating hormone (TSH) levels were similar to those of normal women (respectively: 1.01 +/- 0.54 ng/ml and 0.54 +/- 0.27 ng/ml). The pituitary response to the administration of TRH was nul in 63.8% of cases. In one patient, thyrotrophic function was normal. Twelve patients had a minimal or moderate reserve of TRH. By order of prevalence, thyrotrophic involvement succeeds that of the somatotrophic and lactotrophic axes. There is no correlation with involvement of other axes which would make it possible to define a sequential course of pituitary lesions. These results are discussed in the light of the existing literature. The TRH test does not offer certain evidence of hypothalamic involvement.