Faut-il opérer les patients porteurs d’une maladie de Cushing avec IRM hypophysaire normale ou douteuse ? Étude rétrospective de 196 patients dont 88 sans image d’adénome

Abstract : Context. In patients with Cushing’s disease showing an image of pituitary adenoma at MRI, trans-sphenoidal surgery is the reference treatment. If, however, MRI is negative or inconclusive some authors propose medical treatment as an alternative, with the assumption that modern MRI misses only very small microadenomas that would be impossible to identify at surgery. Objective. To compare the outcomes of surgery in CD patients with either a typical image of adenoma at MRI or a negative/inconclusive MRI, including patients with a recent MRI. Methods and patients. Data were retrospectively collected for all 196 CD patients operated between 1992 and 2018 in our tertiary reference center, in which trans-sphenoidal surgery by an expert neurosurgeon is proposed to all CD patients with negative/inconclusive MRI and a pituitary ACTH gradient at Bilateral Inferior Petrosal Sinus Sampling (BIPSS). Results. This MRI was normal (n=44) or inconclusive (n=44) in 88 patients and showed an adenoma in 108 patients (microadenoma n=90 ; macroadenoma n=18). The proportion of negative/inconclusive MRI decreased with time from 60% (1992-96) to 27.5% (2012-2018), (p=0.015). Per-operatory visualization rates of the adenoma were only slightly lower in the patients with negative MRI (74% ; 85%; 93%; 100%; p=0.03) whereas post-operative remission rates were not significantly different (75%; 72%; 85%; 94%; p=0.09). Conclusion. Despite progress, MRI still misses 27.5% of corticotroph microadenoma, which can be visualized and removed by an expert neurosurgeon. Patients with CD and a normal or inconclusive MRI should still be referred to such neurosurgeons rather than treated medically.
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Master Thesis
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Justine Cristante. Faut-il opérer les patients porteurs d’une maladie de Cushing avec IRM hypophysaire normale ou douteuse ? Étude rétrospective de 196 patients dont 88 sans image d’adénome. Médecine humaine et pathologie. 2018. ⟨dumas-02053132⟩

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