Endocrine Abstracts

JOINT3574

Introduction: Cushing’s disease, characterized by hypercortisolism due to ACTH-secreting pituitary adenoma, requires accurate diagnosis and effective management to optimize patients’ outcomes. Transsphenoidal surgery is the first-line treatment, but persistent or recurrent disease may need alternative therapies. Bilateral adrenalectomy is effective in controlling hypercortisolism. However, it carries the risk of corticotrophin tumor progression or Nelson’s syndrome, necessitating long-term monitoring.

Case Presentations: We present three cases of Cushing’s disease in male patients who underwent bilateral adrenalectomy after unsuccessful transsphenoidal surgeries with persistent hypercortisolism and severe comorbidities. Case 1:A 51-year-old male was diagnosed with Cushing’s disease at the age of 44, initially presenting with hypogonadotropic hypogonadism attributed to a 7 mm pituitary microadenoma. Bilateral adrenalectomy was performed because of the disabling impact of the disease with severe hypertension, stroke, coronary artery disease, proximal muscle weakness, and worsening of preexisting diabetes. Postoperatively, the patient’s comorbidities improved, ACTH levels remained elevated at 1544 pg/mL under 30 mg/day of hydrocortisone and MRI showed 3 mm microadenoma. Case 2: The diagnosis in a 37-year-old male was revealed by bilateral aseptic osteonecrosis of the femoral heads. The patient underwent two transsphenoidal surgeries for two different pituitary adenomas, but remission was not achieved. Persistent hypercortisolism led to disabling complications, including osteoporosis and a suspicious left adrenal mass. Afet bilateral adrenalectomy, ACTH levels were markedly elevated at 1692 pg/mL under 20 mg/day of hydrocortisone. MRI at 5 years, revealed a 3 mm pituitary microadenoma. Case 3:A 37-year-old male was diagnosed at the age of 20 by a 7 mm right-sided ACTH-secreting pituitary microadenoma. Over the years, the patient developed prediabetes, osteoporosis, and grade 2 hypertension. Despite undergoing two pituitary surgeries, Cushing’s disease persisted. Postoperative pituitary imaging was normal, but adrenal imaging revealed four bilateral adrenal nodules ranging from 8 to 25 mm. Due to the disabling nature of the disease and the presence of adrenal nodules, bilateral adrenalectomy was performed. Postoperatively, ACTH levels were elevated at 405 pg/mL under 30 mg/day of hydrocortisone, but follow-up pituitary MRI showed no abnormalities.

Conclusion: Bilateral adrenalectomy is an effective treatment for refractory Cushing’s disease, particularly in cases where transsphenoidal surgery fails to achieve remission. However, elevated ACTH levels and the potential for corticotrophin tumor progression underscore the importance of long-term monitoring with serial pituitary imaging and biochemical assessments. Early detection of tumor progression allows for timely intervention with surgery, radiotherapy, or medical therapy, optimizing patient outcomes.