Indicazioni e timing della surrenectomia nella sindrome di Cushing (Adrenalectomy in Cushing syndrome)

From 1974 to 1993 we performed 261 unilateral or bilateral adrenalectomies. In 101 patients a clinical picture of primary hypercortisolism was present, caused in 50 by a cortisol-secreting neoplasm and in 51 by bilateral ACTH-dependent adrenal hyperplasia. There were 18 males and 83 females, with a mean age of 38 years (range 12-65). The perioperative mortality out of a total of 117 operations, was 1.9%. Only one patient died from causes connected with the operation: 4 years later she developed a Nelson's syndrome due to a malignant pituitary neoplasm. Intra- or postoperative complications occurred in 1.7% and 2.9% of cases respectively. Only in 5 patients, all of whom had a cortisol-secreting carcinoma, was a recurrence of the huperfunctional disease observed. In particular we have never observed any recurrences after bilateral adrenalectomy. Treatment for pituitary-dependent Cushing's syndrome is generally directed initially at the pituitary, but neither transsphenoidal hypophysectomy nor external irradiation of the gland gives a long-term cure rate of more than 50-60%. The only important sequela after bilateral andrenalectomy is Nelson's syndrome which, however, occurs in only 10-15% of patients who have undergone adrenal surgery. In conclusion, unless it is a question of malignancy, unilateral or bilateral adrenalectomy always cures the patient, with a mortality risk which is now almost nil and moderate morbidity. Furthermore, in our opinion, considering the results and the complications of treatment of the pituitary, the question arises whether it might be better to select a greater number of patients for bilateral adrenalectomy in the first instance on the basis of a more precise preoperative diagnosis.