Early Basal Cortisol Level as a Predictor of Hypothalamic-Pituitary-Adrenal (HPA) Axis Function After Pituitary Tumor Surgery

Abstract

Purpose The purpose of this study was to evaluate the clinical relevance of the early postoperative basal cortisol level in assessing the postoperative hypothalamic-pituitary-adrenal (HPA) axis function after pituitary tumor surgery. Methods We performed a prospective observational study that enrolled 83 patients operated for pituitary adenoma or other sellar lesions at the University Hospital Center Zagreb between December 2013 and April 2017 (44 nonfunctioning pituitary adenomas, 28 somatotropinomas, 5 craniopharyngiomas, 2 prolactinomas resistant to medical therapy and 4 other lesions - Rathke's cleft cyst, arachnoid cyst, chondroma and gangliocytoma). Exclusion criteria were Cushing's disease, chronic therapy with glucocorticoids prior to surgery and preoperative adrenal insufficiency. Early postoperative basal cortisol levels (measured on the second postoperative day) and the Synacthen stimulation test (performed 3 months after the surgery with the peak cortisol level of>500 nmol/L considered as a normal response) were analyzed to assess HPA axis function during follow-up. Results ROC analysis showed a cut-off of the basal cortisol level of ≥300 nmol/L measured on the second postoperative day to predict normal postoperative HPA axis function with the sensitivity of 92.31%, specificity of 87.14% and positive predictive value of 57.14%. Conclusion The basal cortisol level on the second postoperative day is a valuable tool to predict integrity of the HPA axis after pituitary tumor surgery. Our data suggest that the cortisol level of ≥300 nmol/L accurately predicts adrenal sufficiency and that in these patients glucocorticoid therapy can be withdrawn.

Transsphenoidal pituitary adenoma resection: do early post-operative cortisol levels predict permanent long-term hypocortisolism?

“…The exact cut-off value of cortisol serum levels to determine hypocortisolism and its appropriate timing of testing (laboratory value measured in µg/dl in morning serum) is still matter of debate [ 6 , 24 , 38 ]. Published cut-off values range between 4 µg/dl [ 21 ], 8 µg/dl [ 6 ], and 14 µg/dl [ 21 ].…”

Pituitary Stalk Morphology as a Predictor of New-Onset Adrenocortical Insufficiency and Arginine Vasopressin Deficiency after Transsphenoidal Resections of Pituitary Macroadenomas: A Retrospective Single-Center Study with a Focus on iMRI

“…Polovina et al performed early-morning cortisol testing on the second day after TSS by validating NAI via Synacthen ® testing three months post-surgery. Morning cortisol below an optimum cut-off of 300 nmol/L (10.9 µg/dL) was defined as NAI, with a sensitivity of 92% and a specificity of 87% [23]. In a comparative approach, Staby et al found a basal cortisol cut-off concentration of 300 nmol/L (10.9 µg/dL) within 48 h of TSS to have a sensitivity of 100% and a specificity of 81% in their work-up on 143 cases who underwent TSS on PA. To validate NAI, a Synacthen ® test six months post-surgery was used [24].…”

“…In summary, the peer-reviewed literature shows that early postoperative morning cortisol achieves a comparatively high sensitivity between 82 and 100% and a specificity between 56 and 87% for predicting NAI after TSS for PA. However, differing optimal cut-off values of 6.9, 10.9, and 12.4 µg/dL on differing postoperative days are presented [2,[22][23][24]. Furthermore, different therapy regimens have been used, with some centers establishing hydrocortisone substitution and some centers not beginning substitution unless basal cortisol levels show NAI.…”

Transsphenoidal Pituitary Adenoma Resection: Do Early Post-Operative Cortisol Levels Predict Permanent Long-Term Hormone Deficiency?

“…The exact cut-off value of cortisol serum levels to determine corticotropic de ciency and its appropriate timing of testing (laboratory value measured in µg/dl in morning serum) is still matter of debate [20,6,32]. Usual published cut-off values range between 4µg/dl [18] to 8µg/dl [6] to 14µg/dl [18].…”