Diagnosis And Surgical Treatment Of Cushing’s Disease

Objective:To analyze the diagnostic modalities and demonstrate the results following surgical treatment of Cushing’s disease (CD), assess the the factors that influence the treatment effect and the influence on the pituitary function exerted by the operation, summarize the experience of treating refractory CD and understand the condition of recurrence.Methods:we retrospectively analyze the chart records of89patients with CD between August,2004and December,2011, among them,14were male patients,75were female patients; the age is35.66±13.08years old; the course of the disease ranged between1month and22years;68were primarily diagnosed patients,21patients were recurrent or refractory cases once underwent surgical operation and radiotherapy; all the patients presented with typical signs of Cushing’s syndrome; the pre-operative MRI results were as follows:15were macro-adenomas;43were visible micro-adenomas;25were suspected micro-adenomas and6were unvisible adenomas (the latter31cases were diagnosed as CD according to clinical presentations, dexamethasone suppression test and/or bilateral inferior petrosal sinus sampling results).35cases underwent bilateral inferior petrosal sinus sampling (BIPSS), among them,24were performed DDAVP stimulating test.4macro-adenomas were resected via trans-cranial approach, other85were all operated via transsphenoidal approach. The criteria of remission were defined as the remission of clinical presentations; lower than5μg/dl morning cortisol level in the first2post-operative days; normal or lower-than-normal range morning serum cortisol level within6months after the operation and normal range24h-urinary free cortisol (24h-UFC) level.Results:34patients were correctedly diagnosed as CD preoperatively after BIPSS (34/35,97.1%),11patients who did not undergo DDAVP stimulating test were all correctly diagnosed as CD, among the24patients who undergo DDAVP stimulating test,19were correctly diagnosed in the baseline condition (19/24,79.2%),4of the remained5cases were diagnosed as CD after DDAVP stimulating test were performed, the accuracy of DDAVP stimulating test was95.8%(23/24). The accuracy rate of lateralization of BIPSS was54.3%(19/35). The pathological results of the89cases were as follows:ACTH-secreting adenomas in58cases,pituitary corticotroph hyperplasia in6cases, residual of pituitary gland tissue in10cases, pituitary adenoma but with no positive ACTH staining in15cases. No severe post-operative complications happened. The remission rate was86.5%(77/89).4cases of68primarily diagnosed patients recurrented in the follow-up period, the recurrence rate is5.9%, the interval between recurrence and operation were respectively16,26,36and60months,2of them underwent gamma knife therapy and achieved remission,2of them are under intimate follow-up.Conclusion:BIPSS is the gold standard of diagnosing CD; DDAVP stimulating test can improve the accuracy of diagnosing CD; BIPSS helps little in lateralizing the lesion preoperatively. Operation is the treatment of choice of CD, transsphenoidal surgery is suitable for the majority cases.for the cases with negative MRI results, explorative operation is an option to be considered. Reoperation should be considered for recurrent or refractory cases. Intimate follow up should be performed after the operation to prevent recurrence and assess the function of target glands of pituitary gland.