The role of bilateral adrenalectomy in the treatment of refractory Cushing's disease

Abstract

<jats:p>Cushing's syndrome (CS) results from sustained exposure to excessive levels of free glucocorticoids. One of the main causes of CS is excessive adrenocorticotropic hormone (ACTH) secretion by tumors in the pituitary gland (Cushing's disease [CD]). Cushing's disease and its associated hypercortisolism have a breadth of debilitating symptoms associated with an increased mortality rate, warranting urgent treatment. Currently, the first line of treatment for CD is transsphenoidal surgery (TSS), with excellent long-term results. Transsphenoidal resections performed by experienced surgeons have shown remission rates ranging from 70% to 90%. However, some patients do not achieve normalization of their hypercortisolemic state after TSS and continue to have persistent or recurrent CD. For these patients, various therapeutic options after failed TSS include repeat TSS, radiotherapy, medical therapy, and bilateral adrenalectomy (BLA). Bilateral adrenalectomy has been shown to be a safe and effective treatment modality for persistent or recurrent CD with an immediate and definitive cure of the hypercortisolemic state. BLA was traditionally performed through an open approach, but since the advent of laparoscopic adrenalectomy, the laparoscopic approach has become the surgical method of choice. Advances in technology, refinement in surgical skills, competency in adrenopathology, and emphasis on multidisciplinary collaborations have greatly reduced morbidity and mortality associated with adrenalectomy surgery in a high-risk patient population. In this article, the authors review the role of BLA in the treatment of refractory CD. The clinical indications, current surgical and endocrinological results reported in the literature, surgical technique (open vs laparoscopic), drawbacks, and complications of BLA are discussed.</jats:p>

Bilateral adrenalectomy: a review of 10 years’ experience

“…Postoperative complications were graded according to the Clavien-Dindo classification. 8 Data were collected retrospectively and analyzed using a specifically designed spreadsheet (Microsoft Excel, Microsoft Corporation, Redmond, WA). Statistical analysis was performed on parametric data using the student's t-test.…”

The Novel Use of Stereotactic Radiotherapy for Remnant Adrenal Tissue in Nelson Syndrome

“…The advantage of BLA is that it offers prompt and reliable relief of hypercortisolemia. However, the disadvantage of BLA is that it mandates lifelong glucocorticoid and mineralocorticoid replacement (4). With a few exceptions, it is generally considered a last resort therapy after repeat TSS, RT, and medical therapy have failed.…”

Bilateral adrenalectomy in the 21st century: when to use it for hypercortisolism?

“…Recent reviews have summarized the merits and pitfalls of BA. However, these reviews were usually not comparing BA with other therapeutic options, especially in the setting of acute severe hypercortisolism, or as a final option in patients treated long-term (Bertagna & Guignat 2013, Ritzel et al 2013, Osswald et al 2014, Katznelson 2015, Neychev et al 2015, Reincke et al 2015, Wong et al 2015. We will focus our discussion on these specific points.…”