Diagnosis and surgical management in patients with Cushing disease with negative magnetic resonance imaging

To analyze the outcome in patients who underwent transsphenoidal surgery (TSS) with Cushing's disease (CD) with no visible adenoma on magnetic resonance imaging (MRI).Between 2012 and 2014, 118 patients with CD underwent TSS at PUMCH. We retrospectively analyzed data in 43 patients without visible adenomas on MRI and compared them with 75 patients with MRI-visible microadenomas.Of 75 patients with MRI-visible microadenomas, postoperative remission was achieved in 64 patients (85.3%), and no recurrence or persistent of CD was observed during 2-year follow-up, and pituitary adenoma confirmed by pathology examination in 71 cases.Of 43 patients with negative MRI, postoperative remission was achieved in 32 patients (74.4%), and pituitary adenoma confirmed by pathology examination in 38 cases. No statistic difference was found between MRI-negative group and MRI-visible group after χ2 test (P value>0.05). BIPSS was performed in 32 cases, and 27 cases were positive. Pituitary adenoma was confirmed in 28 cases.There is no difference in remission rate of CD in MRI-visible and MRI-negative group. BIPSS should be performed in normal MRI cases. We recommend transsphenoidal surgery as the first-line treatment for CD. Selective adenomectomy was recommended when an adenoma was found during surgery, and partial or hemihypophysectomy when no adenoma was found.