Cushing's disease today. Late follow-up of 17 adrenalectomy patients with emphasis on eight with adrenal autotransplants.

Cushing's disease has come full cycle. As originally asserted more than 50 years ago, modern diagnostic techniques now demonstrate an adrenocorticotropic hormone (ACTH) secreting pituitary adenoma in approximately 80% of such patients. At this historical juncture, we report a long-term follow-up of our 17 patients who underwent adrenalectomy (8) or later adrenalectomy plus adrenal autotransplantation (9) between 1955 and 1976. Two patients died soon after surgery and five others died later of "natural" causes. Four others moved away but were stable when last contacted. Of the six patients who remain available for current follow-up, three have undergone hypophyseal surgery. Another patient has evidence of pituitary enlargement, and the remaining two are yet to undergo computerized tomography (CT) scan. Four illustrative cases are reviewed in some detail. One case presented with Nelson's syndrome and acute onset blindness. The second represented multiple endocrine adenomatosis with hyperparathyroidism in addition to Cushing's disease. The third exhibited Cushing's syndrome from the autotransplants, finally cured by hypophysectomy. The fourth exhibited huge ACTH levels from a large pituitary adenoma that could not be totally resected and recurrent Cushing's syndrome associated with large autotransplant "adenomas." The initial surgical treatment of choice is pituitary adenectomy. Bilateral adrenalectomy will remain useful where curative pituitary surgery is not feasible. Neither pituitary irradiation nor medical therapy has been truly effective in our patients. Adrenal autotransplants survive, to some extent, in virtually all patients. However, the degree of function is variable, and the full function may not be achieved for many months or even years. Functioning autotransplants have not prevented Nelson's syndrome, and they would appear to offer little practical benefit at this time.

The Anger camera and the pertechnetate ion in the routine evaluation of thyroid uptake and imaging.

The thyroid traps the pertechnetate ion and iodine in a similar manner. Thus, 99mTc-pertechnetate may be used for thyroid uptake studies (including stimulation and suppression tests)8 as well as imaging. Images are obtained after an intravenous administration of 2--4 mCi of 99mTc-pertechnetate, and the scan is preceded by a trapping index at 20 minutes, measured as the neck to thigh ratio. In 1973, we compared 99mTc-pertechnetate with 131I in diagnostic uptake and imaging studies of the thyroid gland in 100 patients. We have had experience with an additional 100 patients, and modified our procedure so that the Anger camera with pinhole collimator will adequately replace the standard scintillation probe. Using the camera alone, with the 99mTc-pertechnetate makes the study less expensive and briefer, with no loss of information. Routine use of the scan aids in distinguishing diffuse from localized diseases.