Pituitary Society Delphi Survey: An international perspective on endocrine management of patients undergoing transsphenoidal surgery for pituitary adenomas

Abstract

Purpose In adults and children, transsphenoidal surgery (TSS) represents the cornerstone of management for most large or functioning sellar lesions with the exception of prolactinomas. Endocrine evaluation and management are an essential part of perioperative care. However, the details of endocrine assessment and care are not universally agreed upon. Methods To build consensus on the endocrine evaluation and management of adults undergoing TSS, a Delphi process was used. Thirty-five statements were developed by the Pituitary Society’s Education Committee. Fifty-five pituitary endocrinologists, all members of the Pituitary Society, were invited to participate in two Delphi rounds and rate their extent of agreement with statements pertaining to perioperative endocrine evaluation and management, using a Likert-type scale. Anonymized data on the proportion of panelists’ agreeing with each item were summarized. A list of items that achieved consensus, based on predefined criteria, was tabulated. Results Strong consensus (≥ 80% of panelists rating their agreement as 6–7 on a scale from 1 to 7) was achieved for 68.6% (24/35) items. If less strict agreement criteria were applied (ratings 5–7 on the Likert-type scale), consensus was achieved for 88% (31/35) items. Conclusions We achieved consensus on a large majority of items pertaining to perioperative endocrine evaluation and management using a Delphi process. This provides an international real-world clinical perspective from an expert group and facilitates a framework for future guideline development. Some of the items for which consensus was not reached, including the assessment of immediate postoperative remission in acromegaly or Cushing’s disease, represent areas where further research is needed.

Pitfalls in the Diagnosis and Management of Hypercortisolism (Cushing Syndrome) in Humans; A Review of the Laboratory Medicine Perspective

“…These features mean that midnight salivary cortisol assessment is recommended as one of the initial tests that can be used in assessing possible Cushing syndrome [ 1 , 34 , 44 , 59 ]. It may also be a suitable tool for assessment during pregnancy and of remission of Cushing syndrome post surgical treatment [ 44 , 60 , 61 , 62 ].…”

“…The comparative diagnostic accuracy of cortisol measured in urine recommends it to be used as one of the possible first line tests to confirm hypercortisolaemia [ 1 , 30 ]. Urinary free cortisol (UFC) can also be used to assess remission, for example, surgical success [ 1 , 61 , 62 ]. As the cortisol is ‘free’, it is useful for the assessment of pregnant individuals (and others, see Section 2 ) in whom the CBG is elevated, which would cause a higher total cortisol result independently of the biologically active free fraction [ 1 ].…”

“…Combining early morning and later night total cortisol measurements to demonstrate the loss of diurnal variation (and thus detect hypercortisolism) has been studied, but it is not currently standard practice [ 86 ]. Sampling in the morning, e.g., 8 am, is therefore mainly reserved for monitoring management success [ 61 , 62 , 87 ]. For example, an early morning plasma cortisol concentration <55 nmol/L is associated with a high chance of remission, post pituitary surgery, for Cushing disease [ 88 ].…”

“…If ACTH concentration is inappropriately high, e.g., above 20 pg/mL, or an intermediate concentration, then an ACTH-dependent cause is indicated [ 62 ]. ACTH measurement may also be considered to assess remission post-surgery [ 61 ].…”

Perioperative Management of a Patient With Cushing Disease

“…Late-night salivary cortisol may be more useful in patients with normal 24-hour UFC preoperatively, cyclic CS, and those pretreated medically as their morning serum cortisol may not fall drastically after TSS [ 95 ]; the DST is considered less reliable in the assessment of remission especially because cortisol cutoff is not agreed on [ 96 ]. While some of these tests are not routinely used in the immediate postoperative period in the United States, differences in local practice exist worldwide as reflected in the International Pituitary Society Delphi Survey [ 97 ].…”