Reoperation of Cushing’s Disease for Recurrence and Persistence without Visible MRI Finding

Abstract

Purpose: Transsphenoidal surgery (TSS) is the first-line treatment for Cushing’s disease (CD), even with negative preoperative MRI results. It is not rare that patients experiencing hypercortisolism persistence or recurrence have negative MRI after the initial surgery. We aim to analyze the efficacy of repeat surgery in these two groups of patients and assess if there is association of the positive MRI finding with early remission.Patients and methods: Clinical, imaging and biochemical information from 42 patients who underwent repeat surgery by a single neurosurgeon between 2002 and 2021 were retrospectively analyzed. The endocrinological, histopathological and surgical outcomes before and after the repeat surgery of 14 CD patients with negative MRI findings were compared with 28 patients with positive findings.Results: Immediate remission was achieved in 29 patients (69.0%) underwent repeat surgery. Of all patients, 28 (66.7%) had MRI findings consistent with solid lesion. There was no difference of remission rate between the recurrence group and the persistence group (77.8% vs. 57.1%, Odds Ratio = 2.625, 95% Confidence Interval =0.651 to 10.586). In patients with remission after the repeat surgery was not associated with the positive MRI finding (Odds Ratio = 3.667, 95% Confidence Interval = 0.920 to 14.622).Conclusions: In terms of recurrence, the repeat surgery with either positive or negative MRI showed a reasonable remission rate. For persistent disease with positive MRI finding, repeat surgery is still an option, while more solid evidence is needed to define if the negative MRI is predictor for failure reoperation of persistent hypercortisolism.