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Evaluation of Cushing's disease remission after transsphenoidal surgery based on early serum cortisol dynamics

Authors

  • Fabíola Costenaro,

    1. Post Graduate Program in Medical Sciences – Endocrinology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
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  • Ticiana C. Rodrigues,

    1. Post Graduate Program in Medical Sciences – Endocrinology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
    2. Division of Endocrinology, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
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  • Guilherme A. F. Rollin,

    1. Division of Endocrinology, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
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  • Nelson P. Ferreira,

    1. Division of Neurosurgery, Hospital São José, Irmandade da Santa Casa de Misericórdia, Porto Alegre, Brazil
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  • Mauro A. Czepielewski

    Corresponding author
    1. Post Graduate Program in Medical Sciences – Endocrinology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
    2. Division of Endocrinology, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
    • Correspondence: Mauro A. Czepielewski, Endocrinology Service, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos, 2350/12, 4 andar, Porto Alegre, RS 90035-003, Brazil. Tel.: + 5551 3359 8127; Fax: + 5551 3359 8777; E-mail: maurocze@terra.com.br

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Abstract

Objective

To evaluate the ability of post-transsphenoidal pituitary surgery (TSS) serum cortisol levels (s-cortisol) to predict surgical remission and recurrence of Cushing's disease (CD).

Design

One hundred and three patients with CD from a tertiary referral centre were prospectively analysed over 6·0 ± 4·8 years of follow-up. Twenty patients received perioperative glucocorticoids as routine care and had s-cortisol measured 10–12 days after TSS (Protocol I). Eighty-six patients (91 surgeries) had s-cortisol measured at 6, 12, 18, 24, 48 h, and 10–12 days after TSS, and received glucocorticoids only in case of adrenal insufficiency (Protocol II).

Main outcomes

Remission [clinical signs and symptoms of adrenal insufficiency (or hypocortisolism) plus cortisol <3 μg/dl on the 1-mg overnight test (OT) and/or normal free urinary cortisol] during follow-up. Recurrence was defined as loss of remission criteria at least 1 year after TSS.

Results

The remission rate after first TSS was 80%; 8% had recurrence. An s-cortisol nadir ≤3·5 μg/dl within 48 h after TSS had sensitivity of 73%, specificity and positive predictive value (PPV) of 100% and negative predictive value (NPV) of 60% and an s-cortisol nadir ≤5·7 μg/dl within 10–12 days of TSS had specificity and PPV of 100% and sensitivity of 91% NPV of 78% for CD remission.

Conclusion

At hospital discharge, the s-cortisol nadir within 48 h after TSS was already able to predict surgical remission for some patients, and the s-cortisol nadir within 10–12 days of TSS was able to predict cohort-wide surgical remission.

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