Intermittent hypercortisolism: a disorder strikingly prevalent after hypophysial surgical procedures

To determine the frequency of intermittent hypercortisolism in a consecutive series of patients with Cushing's disease who underwent hypophysial surgical treatment.

Thirty-three patients with hypercortisolism of central origin underwent follow-up at approximately annual intervals for prolonged periods after a transsphenoidal pituitary surgical procedure. Clinical evaluation was done, and urinary steroid measurements, as well as dexamethasone suppression tests in some patients, were performed.

Frequently normal but intermittently increased urinary 17-hydroxycorticosteroid or cortisol excretion (or both) was found in six patients postoperatively, associated with intermittently severe hypertension, headaches, and weakness in only one patient. In a seventh patient, intermittently excessive cortisol excretion was clearly evident preoperatively.

Because corticoid excretion was variable preoperatively in three of the seven study patients, we conclude that intermittent hypercortisolism is commoner than previous evidence has shown, constitutes an extremely difficult diagnostic problem, and did not result from but failed to be cured by pituitary surgical treatment in 6 of 33 patients (18%). The findings emphasize the need for regular follow-up for several years in all patients with Cushing's syndrome who have undergone a hypophysial surgical procedure. Variable consistency of follow-up might partly explain the wide discrepancies between reports of 80 to 90% and 40 to 60% cure rates after a single hypophysial adenomectomy.