1. Earlier post-operative hypocortisolemia may predict durable remission from Cushing's disease.
- Author
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Ironside N, Chatain G, Asuzu D, Benzo S, Lodish M, Sharma S, Nieman L, Stratakis CA, Lonser RR, and Chittiboina P
- Subjects
- Area Under Curve, Humans, Kaplan-Meier Estimate, Logistic Models, Neoplasm Recurrence, Local blood, Postoperative Period, ROC Curve, Remission Induction, Time Factors, ACTH-Secreting Pituitary Adenoma surgery, Adenoma surgery, Hydrocortisone blood, Neoplasm Recurrence, Local epidemiology, Neurosurgical Procedures, Pituitary ACTH Hypersecretion surgery
- Abstract
Context: Achievement of hypocortisolemia following transsphenoidal surgery (TSS) for Cushing's disease (CD) is associated with successful adenoma resection. However, up to one-third of these patients recur., Objective: We assessed whether delay in reaching post-operative cortisol nadir may delineate patients at risk of recurrence for CD following TSS., Methods: A retrospective review of 257 patients who received 291 TSS procedures for CD at NIH, between 2003 and 2016. Early biochemical remission (serum cortisol nadir <5 μg/dL) was confirmed with endocrinological and clinical follow-up. Recurrence was detected by laboratory testing, clinical stigmata or medication dependence during a median follow-up of 11 months., Results: Of the 268 unique admissions, remission was recorded in 241 instances. Recurrence was observed in 9% of these cases with cortisol nadir ≤5 μg/dL and 6% of cases with cortisol nadir ≤2 μg/dL. The timing of hypocortisolemia was critical in detecting late recurrences. Morning POD-1 cortisol <3.3 μg/dL was 100% sensitive in predicting durable remission and morning POD-3 cortisol ≥18.5 μg/dL was 98.6% specific in predicting remote recurrence. AUROC analysis revealed that hypocortisolemia ≤5 µg/dL before 15 h (post-operative) had 95% sensitivity and an NPV of 0.98 for durable remission. Serum cortisol level ≤2 µg/dL, when achieved before 21 h, improved sensitivity to 100%., Conclusions: In our cohort, early, profound hypocortisolemia could be used as a clinical prediction tool for durable remission. Achievement of hypocortisolemia ≤2 µg/dL before 21 post-operative hours appeared to accurately predict durable remission in the intermediate term., (© 2018 European Society of Endocrinology.)
- Published
- 2018
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