Endocrine Abstracts

When pituitary MRI show a typical imaging of adenoma, it is agreed that transsphenoidal surgery is the reference treatment with remission achieved in about 80% of patients. If MRI is negative or inconclusive, some authors consider that the results of surgery are less successful, and propose medical treatment as a first line therapy, despite a disease control rate between 30 and 70%. Since 1990, our center chose to systematically explore patients with ACTH dependent hypercorticism by a Bilateral Inferior Petrosal Sinus Sampling (BIPSS) when MRI is negative or inconclusive, and to perform transphenoidal neurosurgery when BIPSS demonstrates that ACTH is of pituitary origin. The remission data and the characteristics of the adenomas were retrospectively collected from the computerized medical file of all our patients operated for Cushing’s disease between 1992 and 2016. Our main objective was to evaluate the performance of neurosurgery in Cushing’s disease in patients with normal or inconclusive MRI versus MRI with a typical adenoma image. 184 patients were operated: 82 microadenomas, 16 macroadenomas, 43 with inconclusive MRI and 43 negative MRI. The postoperative remission rates were not statistically different, 85.4%, 93.7%, 72.1% and 74.4% (P=0.119) respectively. A crude cost analysis comparison between expert neurosurgery and medical treatment shows that in our country the cost of drugs to treat only one patient for Cushing’s disease for 30 years is equivalent to the cost of exploration and treatment of 30 to 60 patients in an expert center for pituitary surgery and neuroradiology. We conclude that even at the age of medical treatment neurosurgery in an expert center should be the first line therapy of patients with Cushing’s disease and a negative or inconclusive MRI.