Treatment Strategy Against Recurrent/Persistent Cushing’s Disease After Transsphenoidal Surgery

Objectives:Recurrent/Persistent Cushing disease requires extensive medical treatments for an optimal result. In this retrospective study, we will investigate the efficacy of all possible treatments for recurrent/persistent Cushing’s disease after initial transsphenoidal surgery.Methods:Among530Cushing patients diagnosed in Peking Union Medical College Hospital (PUMCH) Beijing from2000to2012, we retrospectively reviewed55records of Cushing’s disease who underwent primary surgical treatment to investigate the efficacy of TSS, radiotherapy and radiosurgery. Surgical treatment, radiotherapy, radiosurgery and bilateral adrenalectomy were all separately reviewed in our study.Result:43patients reached remission after multi-treatments scenario (TSS, radiotherapy and/or radiosurgery)(78%),11patients remained recurrent/persisted (20%), and1patient has died of without forensic analysis (2%). Overall, the recurrence rate for each successive treatment were36.4%(initial),27.3%(second),23.6%(third),21.8%(forth) and20%(fifth). The average time required for recurrence after initial treatment and repeated treatment was43.25±10.3and5.13±4.7months respectively (p=0.006),23.6%of patients tends of recur between within the first year, and51%patients between1-5years. As for secondary treatment, surgical treatment was more effective in biochemical remission in serum cortisol and ACTH when compared with radiotherapy. Radiosurgery was difficult to reach remission alone and required surgical intervention for remission. Bilateral adrenalectomy resulted2patients to Nelson’s syndrome, with intensive treatment, one patient reached biochemical remission.Conclusion:Under the analysis of all possible treatments in RCD, TSS remains as a recommended choice when adenoma can be identified under MRI review; radiotherapy is suggested as an alternative adjunctive treatment. As CD patients with serum cortisol level <2ug/dl or undetectable24hr UFC level can also recur after surgical treatment.5years or above follow up is strongly recommended.