Professor Li Quanmin: From diagnosis to treatment, in-depth interpretation of "International Consensus on the Diagnosis and Management of Cushing's Disease"

This article is published under the authorization of Professor Li Quanmin, please do not reprint without permission
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Introduction: On December 18, 2021, the "2021 Beijing Medical Doctor Association Endocrinology Specialist Branch Annual Meeting and Difficult Case Symposium" co-sponsored by the Beijing Medical Doctor Association and the Beijing Medical Doctor Association Endocrinology Specialist Branch will be held online
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Professor Li Quanmin from the Endocrinology Department of the Rocket Army Special Medical Center gave a wonderful academic lecture on the topic of "Interpretation of the International Consensus on the Diagnosis and Management of Cushing's Disease"
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Professor Li Quanmin gave an in-depth interpretation of the latest expert consensus on Cushing’s disease issued by the American Pituitary Association, covering various aspects of Cushing’s disease such as "screening, diagnosis, and treatment (surgery/drugs)
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 Professor Li Quanmin, Chief Expert of Endocrinology Department of Rocket Army Special Medical Center; Chief Physician, Professor, Doctoral Candidate, and Postdoctoral Supervisor; Member of Diabetes Branch of Chinese Medical Association; Vice Chairman of All-Army Endocrinology Specialty Committee; Vice Chairman of Diabetes Branch of Beijing Medical Association ; Vice President of Endocrinologist Branch of Beijing Medical Doctor Association; Vice President of Obesity Group of Chinese Diabetes Association; Chinese Journal of Diabetes, International Journal of Endocrinology and Metabolism, Diabetes Care Chinese Edition, Journal of Clinical Internal Medicine, Journal of Clinical Medicine ", "Medical Review" magazine editorial board; won one second prize for military medical achievement, nine military medical achievement third prize, edited or participated in the editing of 6 books, and published more than 180 academic papers in academic journals at home and abroad Promoting the update of the guidelines Regarding the origin of the disease, Professor Li Quanmin mentioned that Cushing’s syndrome is a general term for the symptoms caused by the excessive secretion of glucocorticoids (mainly cortisol) in the adrenal glands due to various causes.
It was first reported by Harvey Cushing in 1912, so it was Called Cushing syndrome (CS)
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Among them, the clinical type caused by hypersecretion of pituitary adrenocorticotropic hormone (ACTH) is the most common, also known as Cushing's disease
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In terms of morbidity, relevant data show that it is 2-3/1 million in Europe and 10-15/1 million in the United States.
China still lacks large-scale epidemiological data
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 Cushing’s disease is the most common cause of Cushing’s syndrome.
Accurate diagnosis, selection of appropriate treatment and optimal management of the disease are closely related to the prognosis of patients
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At the same time, compared with patients with Cushing’s syndrome caused by the adrenal glands, patients with Cushing’s disease have a worse long-term quality of life
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In the past five years, the academic community has made many progress in disease diagnosis and treatment, which has promoted the update of clinical guidelines
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Diagnosis of Cushing's Syndrome-the overall idea of ​​diagnosis and evaluation The overall diagnosis idea of ​​CS is shown in Figure 1
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Figure 1 Cushing’s syndrome diagnosis process 1.
Screening for suspected CS ➤ First choose urinary free cortisol (UFC), nocturnal salivary cortisol (LNSC), or both; if LNSC is not feasible, dexamethasone Suppression testing (DST) may also be an option
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➤LNSC multiple test specimens may be easier to collect
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 2.
The diagnosis of CS can use any of the following criteria; ➤24-hour UFC (two to three times)
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➤LNSC (two or more determinations)
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➤DST is not applicable to women and night shifts taking estrogen-containing oral contraceptives
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 Note: In order to improve the reliability of DST results and exclude false negatives and false positives, the concentration of cortisol and dexamethasone can be measured at the same time in the morning after taking 1 mg of dexamethasone at night
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 3.
If CS is suspected to be caused by adrenal tumors ➤The examination should start from DST
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➤LNSC has low specificity in these patients
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 4.
Assessment of disease recurrence status ➤Consider which tests are abnormal at the earliest
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➤LNSC is the most sensitive and should be done once a year
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➤DST and UFC often appear abnormal after LNSC
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➤UFC is usually the last to be abnormal
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 Diagnosis of Cushing’s Syndrome—Laboratory testing methods to evaluate Laboratory testing methods include midnight salivary cortisol (LNSC) testing, 2.
1 mg dexamethasone suppression test (DST) or low-dose 2-day dexamethasone suppression test (LDDT) and 24 Hourly urine free cortisol (UFC) test
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Among them, the sensitivity of all tests is higher than 90% (DST and LNSC have the highest sensitivity, UFC has the lowest sensitivity); the specificity is slightly lower than the sensitivity (LNSC has the greatest specificity, and DST and UFC has the least specificity)
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 1.
Midnight saliva cortisol test ➤The diagnostic utility of LNSC is based on the assumption that patients with Cushing’s syndrome lose the lowest point of normal cortisol secretion in the day and night.
It is recommended to perform at least two or three LNSC tests
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➤Sampling before going to bed instead of midnight can reduce false positive results because the lowest point of cortisol is closely related to the onset of sleep
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➤Liquid chromatography tandem mass spectrometry has high specificity, and immunoassay has high sensitivity to Cushing syndrome
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➤Multiple, periodic, and continuous LNSC tests are particularly useful for distinguishing patients with periodic Cushing’s syndrome.
These patients show normal cortisol secretion for several weeks to several months, interspersed with cortisol overdose episodes
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On the contrary, LNSC should not be performed on patients whose normal circadian cycle is interrupted, such as night shift workers
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 2.
Night 1mg dexamethasone suppression test In healthy individuals, super-physiological doses of dexamethasone can inhibit the secretion of adrenergic corticosteroids, thereby reducing the concentration of cortisol
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Therefore, after administering 1 mg of dexamethasone between 23:00 and midnight, at 08:00 in the morning, serum cortisol concentration lower than 50nmol/L (1.
8μg/dL) is considered a negative result
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[Such as increasing the cut point, such as 138nmol/L (5μg/dL), the sensitivity of DST decreases and the specificity increases
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The cortisol concentration lower than 50nmol/L can also exclude incidental adrenal tumors that secrete cortisol
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 False positive results may occur in the following situations: ➤Due to increased intestinal transit time, chronic diarrhea or celiac disease, rapid absorption or malabsorption of dexamethasone
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➤Receive CYP3A4 inducer therapy at the same time (such as phenobarbital, carbamazepine)
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➤And the increase in the concentration of corticosteroid binding globulin (CBG) caused by oral estrogen, pregnancy or chronic active hepatitis, thereby increasing the total cortisol concentration
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 Key points: Simultaneous measurement of dexamethasone and cortisol concentrations can reduce the risk of false positive results
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 False negative results may occur in the following situations: ➤ False negative results are not common, usually due to the simultaneous application of fluoxetine, cimetidine, or diltiazem to inhibit the metabolism of dexamethasone
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➤The concentration of CBG and albumin that can be found in patients with complicated nephrotic syndrome is reduced, and false negative results may also occur
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 3.
Urine free cortisol ➤It is recommended to perform at least two or three 24-hour urine UFC tests
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➤Compared with DST, the advantage of UFC is that UFC levels are not affected by changes in CBG and the speed of dexamethasone metabolism
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➤Gender, body mass index (BMI), age, too much or too little urine, and sodium intake all affect UFC concentration
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➤Because urine output and glomerular filtration rate significantly affect UFC, other screening tests, such as LNSC, may be the first choice for patients with renal impairment (eGFR<60mL/min) or clinically significant polyuria (>5L/24h)
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 4.
Identification of pseudo-Cushing syndrome (non-tumor high cortisol) ➤Depression and other mental illnesses, alcoholism, polycystic ovary syndrome, and obesity can activate the hypothalamus-pituitary-adrenal (HPA) axis.
Such people Features of Cushing’s syndrome (such as weight gain) often appear, and biochemical screening is required
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➤DST, LNSC and UFC can all be positive in these patients with pseudo-Cushing syndrome
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It is generally mildly elevated, and UFC is almost always within 3 times of normal
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➤Combined with LDDT-corticotropin releasing hormone (CRH) test, LDDT or desmopressin test may be able to distinguish ACTH-dependent Cushing syndrome from pseudo-Cushing syndrome
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 Identification of other situations: ➤Alcoholism: The similarity is that the symptoms are similar, blood and urine cortisol is elevated, and small doses of DXM cannot be suppressed; the identification point is that the biochemical abnormalities disappear after one week of abstinence from alcohol
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➤Depression: The similar point is that urinary cortisol is elevated, which cannot be suppressed by small doses of DXM; the distinguishing point is that there is no manifestation of Cushing syndrome
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 Diagnosis of Cushing's syndrome-imaging examination and tumor localization "Consensus" suggests that MRI is still the preferred imaging method for ACTH secreting pituitary adenomas (high quality, highly recommended), and 3T imaging is recommended instead of 1.
5T MRI imaging ( Low quality, can be recommended as appropriate)
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 Other points: ➤7TMRI has not been widely used.
If the tumor is not detected by 1.
5T or 3TMRI, there is currently no reason to perform 7TMRI reimaging
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Functional imaging may ultimately be a better method than MRI
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➤MRI is the preferred imaging method for detecting ACTH secretory pituitary adenomas
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Because most lesions are small, only about 50% of microadenomas are diagnosed when 1.
5TMRI is used
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➤Tumor size is not necessarily related to the degree of hypercortisolism in Cushing's disease
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In fact, patients with larger adenomas can show milder hypercortisolemia
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➤The neuroendocrine tumor tissues that secrete ACTH highly express somatostatin receptors.
The radionuclide-labeled octreotide is introduced into the body, which can bind to the receptors on the surface of tumor cells with specificity and high affinity, allowing ectopic tumors to be imaged
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➤Ga or Tc-SPECT imaging has a certain value for finding the lesions of ectopic ACTH syndrome, but the sensitivity is low
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Differential diagnosis-Differentiation of Cushing's disease and ectopic ACTH-dependent Cushing's syndrome 1.
Laboratory examination "Consensus" points out: in patients with Cushing's disease, pituitary tumors highly express vasopressin receptor and CRH receptor , Desmopressin stimulation test was positive
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Large doses of dexamethasone can inhibit ACTH secretion
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Most ectopic ACTH-secreting tumors do not express glucocorticoid receptor and vasopressin receptor
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Therefore, desmopressin and CRH stimulation tests are negative, and stimulation tests can help distinguish pituitary and ectopic tumors
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Elevated plasma ACTH and elevated cortisol concentration after CRH or desmopressin stimulation usually indicate Cushing’s disease
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 Related recommendations: ➤No laboratory test or a combination of laboratory tests can absolutely distinguish pituitary and ectopic ACTH-secreting tumors
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(High quality, highly recommended) ➤Consensus recommendation is to guide management based on clinical manifestations and trial results
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(High quality, highly recommended) ➤If ectopic ACTH syndrome is suspected (such as a male patient with very high UFC, severe hypokalemia, or both), when the pituitary MRI is not available, the trunk thin-slice CT scan is Useful
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(Low quality, recommended as appropriate) 2.
Inferior petrosal sinus venous blood sampling ACTH measurement and MRI ➤ Inferior petrosal sinus venous blood sampling ACTH (IPSS): IPSS measures ACTH in the pituitary gland and peripheral venous drainage, which is the gold for distinguishing ectopic ACTH dependent Cushing syndrome Standard, the ACTH ratio of the blood around the pituitary gland is greater than 2 or greater than 3 after stimulation, which indicates Cushing's disease
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Due to the potential risks, it is best to perform clinical, biochemical, and imaging examination results in a professional center when the results are inconsistent or it is difficult to identify the cause
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 ➤MRI: If the pituitary MRI shows that the tumor is larger than 10mm or more, and the results of the stimulation test are consistent with Cushing's disease, the diagnosis does not require IPSS (medium quality, highly recommended)
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Since the pituitary lesions found on MRI may be non-functional adenomas or other masses, and the source of ACTH may be ectopic, it is necessary to always consider whether the clinical manifestations, biochemical and other test results are consistent
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 Other points: ➤Pituitary lesions> 10 mm do not require IPSS, and patients with lesions less than 6 mm should undergo IPSS
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(Medium quality, highly recommended) ➤For tumors 6-9mm, expert opinions are different, but most recommend IPSS to confirm the diagnosis in this case
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(Medium quality, can be recommended as appropriate) ➤The measurement of prolactin helps to rule out the false negative of IPSS
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(Medium quality, recommended as appropriate) ➤High-dose DST and vasopressin stimulation tests are all positive, supporting the diagnosis of Cushing’s disease
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However, if they are inconsistent, IPSS is required
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(The quality is low, and recommendations can be made as appropriate) Cushing’s disease treatment-surgical treatment recommendations 1.
Pituitary surgery ➤Recommended transsphenoidal surgery is the first-line treatment for Cushing’s disease
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➤Remission is usually defined as a postoperative serum cortisol concentration of less than 55nmol/L (<2μg/dL).
If the operation is performed by an experienced surgeon, it will affect approximately 80% of microadenoma patients and 60% of patients with microadenoma.
Patients with adenoma can get relief
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➤The incidence of surgical complications is very low, the most common are hypopituitarism (about 10% of patients), permanent diabetes insipidus, cerebrospinal fluid leakage and venous thromboembolism (VTE <5% of patients), and perioperative mortality It is <1%
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 2.
Recurrence monitoring ➤The feature of recurrence after pituitary surgery is the clinical and biochemical features of recurrence of hypercortisolemia
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Low or undetectable cortisol concentration immediately after surgery is the standard for remission, and does not predict non-recurrence; patients with very low cortisol concentration (<2-5μg/dL) may relapse
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➤Compared with the diagnosis of Cushing’s syndrome, LNSC, 1-mgDST, UFC and desmopressin tests are less sensitive to recurrence, but have higher specificity
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LNSC can detect elevated cortisol levels before 1mg DST is positive, and UFC is often the latest item in patients with relapsed abnormalities
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As the results vary greatly, a series of monitoring is recommended
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 3.
Clinical recommendations for re-pituitary surgery The "Consensus" recommends: Patients with tumors on MRI examination, if there are no contraindications to surgery, especially those whose first surgery was not completed at the pituitary tumor center, can undergo repeated transsphenoidal surgery
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Even if the MRI examination does not show the presence of a tumor, if an experienced surgeon at a large pituitary treatment center considers it feasible, or if there is a central peripheral gradient in the IPSS before the first operation, then reoperation may be appropriate
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(Low quality, recommended as appropriate) Cushing's disease treatment-drug treatment recommendations "Consensus" pointed out: the treatment of Cushing's disease drugs mainly for adrenal steroid production, pituitary tumors somatostatin and dopamine receptors, glucocorticoid receptors
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The drug can be used to treat hypercortisol in patients with persistent or recurrent Cushing's disease, patients who are not suitable for or refuse surgery, and to control the cortisol concentration in patients undergoing radiotherapy
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 1.
Adrenal steroid production targeted therapy drugs include ketoconazole, methyltirone, mitotane and etomidate, as well as the recently approved Osilodrostat (Osidrostat), which can block one or more adrenal enzymes and reduce or Controls the production of cortisol, but does not directly act on the ACTH secreting adenoma of the pituitary gland, nor can it restore the circadian rhythm of the HPA axis
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 Factors affecting the selection of adrenal steroid production inhibitors: ➤When initial treatment, the speed of drug action, tolerability, convenience, degree of biochemical normalization, improvement of clinical symptoms, and availability and cost of drugs should be considered
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(Medium quality, highly recommended) ➤Ketoconazole is convenient for dose titration
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Concerns about induced liver toxicity and the need to monitor liver enzymes may lead to under-dose (medium quality, highly recommended)
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Men may experience hypogonadism
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➤Oxizopristat can achieve a higher normalization rate of cortisol
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It may be more convenient than methyltirone, but neither methyltirone nor oxizrostat cause sexual dysfunction
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(High quality, highly recommended) ➤In most centers, mitotane is rarely used as a single treatment for Cushing's disease
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(Low quality, can be recommended as appropriate) 2.
Pituitary somatostatin and dopamine receptor targeted therapy.
Dopamine agonist cabergoline and somatostatin receptor ligand Pasireotide are both used for persistent or recurrent hypercortisolism , Although only Pasireotide is approved for use in this population
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It has the effect of controlling tumors (shrinking and preventing growth), and has important clinical significance for patients with large residual tumors and corticotropin tumor progression or Nelson syndrome
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 3.
Factors affecting the choice of drugs for Cushing’s disease ➤ If cortisol concentration is required to be normalized quickly, consensus recommends adrenal steroid production inhibitors; Cezrestat and methyltirone have the fastest effect and can be taken orally, while etomidate can be used in severe cases In case of intravenous use
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(High quality, highly recommended) ➤For mild patients, if there is a residual tumor and hope that the tumor shrinks, consider using Pasirutide or Cabergoline
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(Medium quality, highly recommended) ➤If you have a history of bipolar disorder or impulse control disorder, avoid using cabergoline
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(Medium quality, highly recommended) ➤If there is no endocrinologist to monitor treatment response, use mifepristone with caution
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(Low quality, recommended as appropriate) ➤ Patients need to be informed that cortisol cannot be used to monitor treatment response or adrenal deficiency
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(High quality, highly recommended) ➤For pregnant women or women who want to become pregnant, consider cabergoline or methyltirone (low quality, recommended as appropriate), although no Cushing’s disease drug is approved for pregnancy
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➤Drug tolerance, side effects and concomitant diseases (such as type 2 diabetes, hypertension) can affect the choice of drugs
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(Medium quality, highly recommended) Table 1 The characteristics of Cushing's disease treatment drugs Figure 2 Adrenal targeted drug treatment of the site of action 4.
When using adrenal steroid production inhibitors or glucocorticoid receptor blockers, how to monitor tumors Grow? ➤MRI is usually performed 6-12 months after the start of treatment, and is repeated every few years according to the clinical situation
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(Medium quality, highly recommended) ➤It is difficult to determine whether the progression of the tumor is due to the loss of cortisol feedback or an aggressive and recurrent disease response
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(Low quality, recommended as appropriate) ➤We recommend monitoring ACTH concentration, because the progressive increase in ACTH may be a sign of tumor growth and requires MRI
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Although ACTH has a short half-life, fluctuations in concentration do not necessarily reflect tumor growth
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(Low quality, can be recommended at will) ➤If the tumor is found to grow progressively, the drug treatment should be suspended and the management plan should be reassessed
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(Medium quality, highly recommended) 5.
About preoperative medication ➤There is no good evidence to support preoperative medication
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(Medium quality, highly recommended) ➤Whether it is due to schedule or external factors, if the operation is delayed, most experts will consider using adrenal steroid production inhibitors
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(The quality of the operation is low, it can be recommended as appropriate) ➤Severe Cushing’s disease patients may have complications such as life-threatening infections, cardiovascular or thromboembolism, and preoperative drug treatment may be beneficial (low quality, recommended as appropriate) 6.
How to monitor the treatment response? Factors influencing the choice of combination therapy? ➤Therapeutic response should be combined with clinical manifestations and biochemical assessments, and only clinical endpoints should be used to define when glucocorticoid receptor blockers are used
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(Medium quality, highly recommended) ➤Cortisol concentration is usually measured with urinary free cortisol (except for mifepristone); in patients with adrenal insufficiency, urinary free cortisol cannot be measured, and early morning serum cortisol is preferred
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(High quality, highly recommended) ➤If cortisol levels continue to rise after 2-3 months of treatment with the maximum tolerated dose, you should consider changing the treatment method
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(Medium quality, highly recommended) ➤If cortisol does not return to normal, but can improve clinical symptoms, consider combined treatment
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(Low quality, recommended as appropriate) ➤If the dose is increased but the treatment has obvious drug resistance, consensus recommends switching to another treatment
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(Low quality, can be recommended as appropriate) 7.
Recommendations for combination therapy ➤There is little evidence-based evidence for combination therapy
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(High quality, highly recommended) ➤When most experts believe that single-agent therapy is ineffective, "ketoconazole combined with meticonazole" or "ketoconazole combined with osilodrostat" can improve adrenal blockade
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Low-dose combination of the two drugs is allowed
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(Low quality, can be recommended as appropriate) ➤If there is visible tumor, "ketoconazole combined with cabergoline or pasireotide" and "pasireotide combined with cabergoline" may be a reasonable combination
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(Low quality, can be recommended as appropriate) ➤Other combinations that can be used include triple "caergoline + pasiotide + ketoconazole" or "ketoconazole + mettyrone + mitotane"
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(Low quality, can be recommended at will) Cushing's disease treatment-radiotherapy recommendations Radiotherapy is mainly used for patients with persistent or recurrence after transsphenoidal surgery or adjuvant treatment of aggressive tumor growth
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Approximately two-thirds of patients receive biochemical remission within a few years after receiving conventional radiotherapy
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Recent stereotactic radiotherapy, including whole saddle radiotherapy, has shown a higher rate of biochemical remission
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Tumor control rates are usually higher
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 The “Consensus” recommends: ➤Radiotherapy is most commonly used for persistent hypercortisolism after incomplete pituitary tumor resection, especially if the tumor is aggressive or considered unresectable
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(High quality, highly recommended) ➤Stereotactic radiotherapy may be more feasible because it requires very few treatment sessions
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(High quality, highly recommended) ➤All patients receiving radiotherapy need to continuously monitor pituitary hormones and whether they relapse
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(High quality, highly recommended) Cushing's disease treatment-adrenalectomy Bilateral adrenalectomy can control the excessive secretion of cortisol in patients with persistent or recurrent Cushing's disease and ineffective drug therapy
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However, the choice of patients needs to be considered, because it may lead to adrenal insufficiency and the need for lifelong corticosteroid replacement therapy
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 Clinical recommendations for adrenalectomy: ➤For patients with Cushing’s disease, bilateral adrenalectomy is usually considered the last resort, and is chosen after other treatments have failed
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(Medium quality, strong recommendation) ➤For patients with severe hypercortisolemia, bilateral adrenalectomy can be performed early to avoid adverse effects caused by uncontrolled disease (medium quality, highly recommended)
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➤Many experts recommend early bilateral adrenalectomy for women who wish to become pregnant
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(Medium quality, highly recommended) ➤After bilateral adrenalectomy, according to the clinical situation, regularly monitor plasma ACTH and pituitary imaging, usually starting from 6 months after surgery
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(High quality, highly recommended) If corticotropin tumor progression is suspected, more frequent evaluations may be required
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(High quality, highly recommended) Management points for complications of Cushing's disease 1.
Hypercoagulability ➤There is no standard recommendation for the prevention of thrombosis before or after the operation of Cushing's disease
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In clinical practice, some experts have suspended estrogen therapy for female patients before surgery, but if it is used as a contraceptive measure, you should be careful, because pregnancy is also associated with an increased risk of thrombosis
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(Low quality, recommended as appropriate) ➤Patients with a history of thromboembolism or abnormal coagulation indicators, severe hypercortisolemia before surgery, using estrogen or oral contraceptives, poor mobility, long hospital stay before or after surgery Patients with high risk of venous thrombosis, such as high cortisol concentration or excessive replacement of cortisol after surgery, should consider preventive anticoagulation therapy
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(Medium quality is moderate, highly recommended) ➤Encourage all patients to get out of bed early after surgery and use elastic stockings
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(High quality, highly recommended) ➤If preventive anticoagulation is used, it is strongly recommended to give priority to low molecular weight heparin instead of oral anticoagulants, and more attention should be paid to preoperative treatment
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(Low quality, recommended as appropriate) ➤Although it is not clear when to stop and when to restart after surgery, anticoagulant drugs can be stopped before surgery to reduce the risk of intraoperative bleeding
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(Low quality, recommended as appropriate) 2.
Cardiovascular disease ➤Evaluate, monitor and treat according to the guidelines for patients at high risk of cardiovascular disease
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(High quality, strongly recommended) ➤Management strategies should be individualized according to the complications (such as hypertension or hyperlipidemia)
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(High quality, highly recommended) ➤Nursing should be coordinated with primary care and cardiologists as needed
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(The quality is very low and can be recommended as appropriate) 3.
Bone disease ➤It is recommended to conduct a risk assessment of bone loss and fracture for all patients
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(High quality, highly recommended) ➤Considering that even patients without osteoporosis are at risk of fractures, dual-energy X-ray bone densitometer alone cannot provide enough information, it is recommended to conduct bone quality or vertebral body morphology assessment (high quality, Strongly recommended); the above examinations are also useful for finding subclinical fractures (high quality, highly recommended), but may not be suitable for all patients
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The FRAX tool for assessing the risk of fractures in Cushing's disease has not been proven to be suitable for Cushing's disease
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➤Monitoring and follow-up of all adult high-risk groups
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(High quality, highly recommended) ➤Because excessive cortisol can increase the risk of fracture, patients with Cushing’s syndrome should consider routine anti-osteoporosis treatments (such as bisphosphonates) even if the bone density is normal
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(High quality, highly recommended) 4.
Growth hormone deficiency ➤Currently, there is no standard practice on whether, when and how to detect growth hormone deficiency in adults with Cushing’s disease
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Because the recovery of the hypothalamic-pituitary-adrenal (HPA) axis is often delayed after surgery, consensus recommends that you wait at least 6-12 months after surgery before considering growth hormone deficiency assessment
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(Medium quality, highly recommended) ➤Large adenomas and patients who are actively undergoing surgical resection are at increased risk of anterior pituitary hypofunction; patients with three or more pituitary hormone deficiencies are more likely to develop growth hormone deficiency
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(High quality, highly recommended) ➤For children, evaluate growth hormone deficiency 3-6 months after surgery, and start growth hormone therapy immediately when needed to ensure normal growth
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➤During remission, Cushing’s syndrome-related myopathy will not resolve spontaneously.
It is recommended that all patients undergo physical rehabilitation
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(Low quality, recommended as appropriate) Article summary Finally, Professor Li Quanmin concluded that Cushing’s disease is the most common cause of endogenous Cushing’s syndrome, caused by a pituitary tumor that secretes ACTH
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Compared with patients with adrenal causes of Cushing’s syndrome, patients with Cushing’s disease have a poorer long-term quality of life
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In clinical practice, accurate diagnosis, careful selection of treatment options and long-term management are required to optimize patient outcomes
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