Cushing's Disease in Older Patients

Presentation and Outcome

Nidan Qiao; Brooke Swearingen; Nicholas A. Tritos

Disclosures

Clin Endocrinol. 2018;89(4):444-453. 

In This Article

Abstract and Introduction

Abstract

Background: To define the symptoms, signs and treatment outcomes in a population of older patients with Cushing's disease (CD).

Methods: We analysed the clinical presentation and treatment outcomes in 45 CD patients older than 60 years, in comparison with 90 CD patients younger than 60, and a control group of 45 older patients with nonfunctioning pituitary adenomas. We reviewed preoperative clinical characteristics, medical comorbidities, imaging findings and endocrine testing as well as surgical and endocrine outcomes.

Results: Older CD patients had significantly lower body mass index (BMI) (P = 0.031), were more likely to have muscle wasting (P = 0.006) and women were less likely to have hirsutism (P = 0.033). Older patients with CD had more medical comorbidities than younger patients, which correlated with a higher ASA grade (P < 0.001), but the surgical complication rates were similar in both groups. Surgical remission was achieved in 38/45 (84.4%) older patients and 78/90 (86.7%) younger patients (P = NS). Recurrent disease was more frequent in younger patients (19.2%) in comparison with older patients (2.6%, P = 0.019).

Conclusions: Older patients with CD appear to have a distinct phenotype with a more catabolic picture, including a lower BMI and greater prevalence of muscle wasting. Surgical outcomes are similar without a significant age-related increase in complications.

Introduction

Pituitary adenomas are one of the most common types of brain tumours, accounting for 15% of all intracranial neoplasms.[1,2] Cushing's disease (CD) is caused by a corticotroph pituitary adenoma that secretes excess adrenocorticotrophic hormone (ACTH). Common clinical symptoms and signs of CD include weight gain, centripetal fat deposition, cutaneous striae, skin thinning, muscle wasting and fatigue, among others. Hypercortisolism-related comorbidities (diabetes mellitus, hypertension, cardiovascular disease and deep venous thrombosis) may result in serious complications and a high mortality rate.[3,4] In a retrospective study of patients with CD, multivariate analysis indicated that older age at diagnosis was associated with an elevated mortality risk even after surgical treatment.[5]

Cushing's disease typically presents in young women. It is less common in paediatric patients, but its presentation in this population is well described. In the older population, previous studies have reported individual cases of older patients with CD[6–8] as well as older patients in surgical cohorts,[9–12] but these studies did not focus on the differences between presentation and outcome as a function of age in older patient groups.

We hypothesized that the clinical phenotype and outcomes of older patients with CD may be substantially different from those of younger patients with this condition. To characterize the clinical presentation, laboratory and imaging findings, and treatment outcomes of older patients with CD, we retrospectively analysed the case records of patients with CD who underwent pituitary surgery in our institution. We compared older patients with CD with two control groups: younger patients with CD, and older patients with clinically nonfunctioning pituitary adenomas, in an attempt to distinguish age- as opposed to disease-related effects.

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