Prospective evaluation of a protocol for reduced glucocorticoid replacement in transsphenoidal pituitary adenomectomy: prophylactic glucocorticoid replacement is seldom necessary.

BACKGROUND: Most pituitary surgery centres prescribe perioperative glucocorticoids to subjects undergoing transsphenoidal pituitary adenomectomy (TSA), despite reports suggesting this may be unnecessary. Evidence-based guidelines for glucocorticoid use in TSA have recently been published but there are no prospective studies of their utility. OBJECTIVE: To implement and assess a protocol for reduced glucocorticoid replacement for subjects undergoing TSA. DESIGN: Prospective and retrospective cohort study in an Australian pituitary surgery centre. PATIENTS AND MEASUREMENTS: Clinical and biochemical data for 56 TSAs performed for non-ACTH-secreting tumours between March 2004 and April 2006 were prospectively collected and compared with data for 47 TSAs performed between October 2001 and November 2003, before implementation of the protocol. In the prospective cohort, a postoperative days 1-3 morning serum cortisol threshold of 250 nmol/l (91 microg/dl) was used to guide long-term glucocorticoid requirement. RESULTS: Implementation of the protocol was associated with significant reductions in dose and duration of glucocorticoid treatment post TSA in 44 'low-risk' cases (no preoperative glucocorticoid use or evidence of pituitary apoplexy). In two low-risk cases, long-term glucocorticoid replacement was required despite postoperative cortisol greater than 250 nmol/l. Following the remaining 42 low-risk operations, glucocorticoid was not prescribed on hospital discharge on the basis of morning serum cortisol > 250 nmol/l and no clinical evidence of hypocortisolism. None of these 42 cases required glucocorticoid treatment for hypocortisolism following surgery. Short synacthen tests were performed in 35 of these subjects a minimum of 6 months after surgery and were normal. Use of the protocol was not associated with differences in postoperative complications. CONCLUSIONS: Reduced glucocorticoid replacement in TSA is safe and reduces patient exposure to glucocorticoids and their potential adverse events. The occurrence of hypocortisolism in two low-risk subjects with serum cortisol > 250 nmol/l highlights the importance of daily clinical assessment when using this protocol.

Cushing's case XLV: Minnie G.

A 23-year-old patient who was examined in 1910 by Harvey Cushing triggered his lifelong interest in the syndrome that bears his name. "Minnie G.," as she became historically known, presented with a "...syndrome of painful obesity, hypertrichosis, and amenorrhea with overdevelopment of secondary sexual characteristics accompanying a low grade of hydrocephalus and increased cerebral tension." This case stimulated Harvey Cushing's inquisitive mind and sparked an interest that 20 years later culminated in his seminal report, "The basophil adenomas of the pituitary gland and their clinical manifestations (pituitary basophilism)." In this classic work, Cushing reported in detail the cases of two patients encountered from his own practice and 10 similar cases collected from the literature. Minnie G. was the first case that Cushing reported. The clinical course of that case is briefly reviewed in this article.