Surgical Treatment of Cushing Disease: Experience of 123 Cases

Objective: Cushing’s disease (CD) comprises a spectrum of clinical manifestations secondary to hypercortisolism due to ACTH-secreting pituitary adenoma. Transsphenoidal adenomectomy remains the standard treatment with a recent surge in endoscopic approaches.

Methods: Data of all patients undergoing surgery for CD from 2009 to 2016 were analyzed retrospectively. Postoperative cortisol level of < 2 μg/dL was taken as remission and value between 2 and 5 μg/dL as possible remission. Remission during follow-up was defined as morning cortisol < 5.0 µg/dL or suppression of serum cortisol (<2 µg/dL) after overnight dexamethasone test.

Results: A total of 123 patients of CD were included for analysis and were divided into two groups; group A comprising 98 patients who underwent primary pituitary surgery and group B of 25 patients who underwent pituitary surgery for nonremission. In group A, 47 (47.9%) patients underwent microscopic surgery, 49 (50%) endoscopic surgery and two (2%) were operated transcranially; in group B, the numbers are 15 (60%), 8 (13.3%), and 2 (3.3%), respectively. Remission was achieved in 75.9% patients in group A and in 53.3% patients in group B. In statistical analysis, factors significantly associated with remission were type of surgery (p = 0.01), postoperative day 1 morning cortisol (p = 0.004 and postoperative day 1 morning ACTH (p = 0.015). The chance of remission was significantly more with endoscopic approach (40/45 = 88.9%) than microscopic (59.3%) or transcranial surgery (0/1 = 0%). ROC curve showed a cut-off value of 10.5 µg/dL (p < 0.001 with 87% sensitivity and 80% specificity). The chance of intraoperative CSF leak increased with macroadenoma (p = 0.07) and in redo surgery (p = 0.03).

Conclusion: Postoperative plasma cortisol level is a strong independent predictor of remission and value less than 10.5 µg/dL can be taken as cut-off for predicting remission, though it does not positively predict long-term recurrence. So, all patients with CD cured by surgery require long-term follow-up. Endoscopic TSS has taken over microscopic approach in the recent past and remission provided by endoscopy appears to be significantly better than microscopic approach.

No conflict of interest has been declared by the author(s).