Morning Serum Cortisol Level After Transsphenoidal Surgery for Pituitary Adenoma Predicts Hypothalamic-Pituitary-Adrenal Function Despite Intraoperative Dexamethasone Use

Manuylova, Ekaterina; Calvi, Laura M.; Vates, G. Edward; Hastings, Catherine; Shafiq, Ismat

doi:10.4158/ep15652.or

Cited by 14 publications

(7 citation statements)

References 31 publications

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“…A single morning cortisol has been shown to be diagnostic of adrenal insufficiency if the level is below 100 nmol/L [12]. Our results indicate that S-cortisol < 200 nmol/L seems to be an acceptable level to identify patients who need continuous hydrocortisone replacement in accordance with previous publications [9, 14, 16–18]. However, the diversity of S-cortisol at day 4 in our study indicates that, to predict long-term HPA-axis dysfunction at this point, the cutoff level must be significantly increased (Fig.…”

Section: Discussionsupporting

confidence: 89%

Evaluation of different hydrocortisone treatment strategies in transsphenoidal pituitary surgery

et al. 2019

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Background Hydrocortisone treatment in transsphenoidal pituitary surgery has been debated. Although several publications advocate restrictive treatment, centers around the world administer stress doses of hydrocortisone in patients with presumed intact cortisol production. Our aim with this analysis was to compare postoperative hypocortisolism in patients who received three different protocols of hydrocortisone therapy during and after surgery. Method This was a retrospective observational study. Based on perioperative hydrocortisone dose given, patients were divided in three groups: high dose (HD), intermediate dose (ID), and low dose (LD). Postoperative evaluation of the pituitary function was performed using S-cortisol at day 4 and short Synacthen test (SST) at 6–8 weeks. Patients with ACTH-producing adenomas or preoperative hydrocortisone treatment were excluded. Result There was no difference between the groups regarding failure rate of SST. The rate of failed SST (all groups) was 51/186 (27%), 24/74 (32%) in the HD group and 26/74 (35%) and 11/38 (29%) in the ID and LD groups respectively. There was no significant difference between the ID and LD groups regarding S-cortisol at postoperative day 4 regarding serum cortisol level below 200 nmol/L. There was a significant but weak correlation, r s 0.330 ( P < 0.01) between S-cortisol day 4 and SST at 4–6 weeks. Conclusions Peri and postoperative hydrocortisone treatment did not affect SST response 6–8 weeks postoperatively, whereas the rate of patients with S-cortisol below 200 nmol/L at postoperative day 4 did. LD hydrocortisone therapy seems to favor a better endogenous production in the early postoperative phase.

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Section: Discussionsupporting

confidence: 89%

Evaluation of different hydrocortisone treatment strategies in transsphenoidal pituitary surgery

et al. 2019

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“…The status of the hypothalamic-pituitary-adrenal axis (HPAA) before pituitary surgery accounts for differences in the management of central AI perioperatively and in the long term (Table 2). [10][11][12][13][14][15][16][17] One of the gray areas in the management of non-CD patients with normal preoperative HPAA is whether to give empiric GC coverage after surgery or to apply a steroid-sparing method, giving GC only if AI develops. To date, existing evidence has not demonstrated the superiority of one of the two strategies, and they are both used successfully in clinical practice.…”

Section: Management Of Aimentioning

confidence: 99%

Current best practice in the management of patients after pituitary surgery

Prete

Corsello

Salvatori

2017

Therapeutic Advances in Endocrinology

111

107

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Sellar and parasellar masses are a common finding, and most of them are treated surgically via transsphenoidal approach. This type of surgery has revolutionized the approach to several hypothalamic-pituitary diseases and is usually effective, and well-tolerated by the patient. However, given the complex anatomy and high density of glandular, neurological and vascular structures in a confined space, transsphenoidal surgery harbors a substantial risk of complications. Hypopituitarism is one of the most frequent sequelae, with central adrenal insufficiency being the deficit that requires a timely diagnosis and treatment. The perioperative management of AI is influenced by the preoperative status of the hypothalamic-pituitary-adrenal axis. Disorders of water metabolism are another common complication, and they can span from diabetes insipidus, to the syndrome of inappropriate antidiuretic hormone secretion, up to the rare cerebral salt-wasting syndrome. These abnormalities are often transient, but require careful monitoring and management in order to avoid abrupt variations of blood sodium levels. Cerebrospinal fluid leaks, damage to neurological structures such as the optic chiasm, and vascular complications can worsen the postoperative course after transsphenoidal surgery as well. Finally, long-term follow up after surgery varies depending on the underlying pathology, and is most challenging in patients with acromegaly and Cushing disease, in whom failure of primary pituitary surgery is a major concern. When these pituitary functioning adenomas persist or relapse after neurosurgery other treatment options are considered, including repeated surgery, radiotherapy, and medical therapy.

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“…In their series, 9 of 32 (28%) patients with an initial POD 1 cortisol ≥14 ug/dl went onto have POD 6 cortisol <14 ug/dl. [10] Their protocol was similar to ours in that all patients received intraoperative steroid coverage. However, clinical evaluation used a single cutoff value for serum cortisol (14 ug/dl) and CST was not consistently performed in their series.…”

Section: Discussionmentioning

confidence: 96%

“…A variety of protocols have been proposed to assess function in the early postoperative period, but controversy persists in key aspects of each protocol. [1,3,4,7,10-13] This includes both cutoff values and the timing of testing using morning serum cortisol. In general, it is agreed that there is a lower limit for a morning serum cortisol value that correlates with adrenal insufficiency as well as an upper limit indicating a functional HPA.…”

Section: Discussionmentioning

confidence: 99%

Postoperative day 1 versus postoperative day 5 morning cortisol for predicting an intact hypothalamic-pituitary axis: A cohort analysis

Dupépé

Patel

Miller

et al. 2019

Surgical Neurology International

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Background: A reliable standard for evaluating postoperative hypothalamic-pituitary-axis (HPA) function following transsphenoidal pituitary surgery (TSS) could reduce hospital stays and unnecessary prolonged steroid therapy. We retrospectively examined the predictive role of morning cortisol levels on long-term HPA function to develop an institutional protocol. Here, we report the results of this analysis, which is the first to report the predictive strength of multiple variables (i.e., timing of measurement and values of serum cortisol cutoffs) within the same cohort. Methods: A retrospective chart review was performed in 183 patients at a single institution from 2007 to 2012. 67 patients met inclusion criteria. The predictive value of postoperative day (POD) 1 and POD 5 morning cortisol for HPA function as determined by 1 ug cosyntropin stimulation test was evaluated using standard confusion matrix calculations and receiver-operator control curve analysis. Results: In our cohort, an early POD 5 serum morning cortisol 15 ug/dl predicted an intact HPA axis with 100% specificity, 51% sensitivity, and a positive predictive value (PPV) of 100%. A POD 1 serum cortisol 25 ug/dl was needed to achieve a specificity of 100% and PPV of 100% to predict an intact HPA axis with a sensitivity of 30%. A POD 1 serum cortisol 18 ug/dl predicted an intact HPA axis with 33.3% specificity, PPV of 90.9%, and a sensitivity of 51.3%. Conclusion: A POD 5 morning cortisol level 15 ug/dl is an excellent predictor of normal postoperative HPA function in patients undergoing TSS for pituitary adenoma.

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Morning Serum Cortisol Level After Transsphenoidal Surgery for Pituitary Adenoma Predicts Hypothalamic-Pituitary-Adrenal Function Despite Intraoperative Dexamethasone Use

Cited by 14 publications

References 31 publications

Evaluation of different hydrocortisone treatment strategies in transsphenoidal pituitary surgery

Evaluation of different hydrocortisone treatment strategies in transsphenoidal pituitary surgery

Current best practice in the management of patients after pituitary surgery

Postoperative day 1 versus postoperative day 5 morning cortisol for predicting an intact hypothalamic-pituitary axis: A cohort analysis

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