Endocrine Abstracts

Objective: Transsphenoidal surgery is the treatment of choice for Cushing’s disease (CD). Surgery is challenging due to the often very small adenomas. In experienced pituitary centers a high remission rate is reported. Nevertheless, endocrinologists and neurosurgeons face cases with persistent or recurrent CD. These patients must be referred to an experienced pituitary center. In addition to medical treatment, radiation therapy and bilateral adrenalectomy, repeat TSS must also be evaluated. The aim of this study is to analyse the outcome of repeat surgery and to compare persistent and recurrent CD.

Methods: We retrospectively analysed 52 patients with confirmed CD, who underwent repeat TSS in our department. Both persistence of CD after unsuccessful first surgery (n=24) and recurrence of CD (n=28) were the indications for repeat TSS. Thirty-two patients underwent their first surgery externally, 20 patients had both TSS in our pituitary center. All surgeries were performed by a single experienced pituitary surgeon through a microscopic transsphenoidal approach.

Results: The time range between the first and the repeat TSS was between 0 – 93 months (median 7.5 months) in the case of persistent CD, and between 3 – 219 months (median 64.5 months) in the cases of recurrent CD (P< .0001). A high-quality MRI was performed preoperatively in all cases. A clear adenoma was found in 65.4% of cases (66.7% persistent CD, 64.3% recurrent CD). A remission rate of 71% (n=17/24) was achieved in the group with persistent CD, and of 82% (n=23/28) with recurrent CD. The complication rate was 5.7% (8.3% in persistent CD, 3.6% in recurrent CD). There was no mortality rate in either group.

Conclusion: Persistent and recurrent CD pose a greater challenge for further treatment. If repeat surgery is an option, it should be offered to the patient at an experienced pituitary center. A higher remission rate is achieved in recurrent CD compare to persistent CD. With high surgical experience, there is still a low complication rate of repeat TSS with a satisfactory probability of remission.