Document Detail


The postoperative basal cortisol and CRH tests for prediction of long-term remission from Cushing's disease after transsphenoidal surgery.
MedLine Citation:
PMID:  21508126     Owner:  NLM     Status:  MEDLINE    
Abstract/OtherAbstract:
CONTEXT: Selective adenomectomy via transsphenoidal surgery induces remission of Cushing's disease (CD) in most patients. Although an undetectable postoperative serum cortisol (<2 μg/dl) has been advocated as an index of remission, there is no consensus on predictors of recurrence.
OBJECTIVE: We hypothesized that patients with subnormal cortisol (2-4.9 μg/dl) might achieve long-term remission and that postoperative responses to CRH might predict recurrence.
DESIGN, SETTING, AND PARTICIPANTS: We prospectively studied CD patients with initial remission after adenomectomy or hemihypophysectomy (n = 14). Long-term recurrence (n = 39) or remission (n = 293) was assigned by laboratory results, glucocorticoid dependence, or patient survey at a mean of 10.6 yr after surgery.
INTERVENTION AND MAIN OUTCOME MEASURES: Postoperatively, morning cortisol was measured on d 3-5, and cortisol and ACTH responses to ovine CRH were assessed around d 10.
RESULTS: Follow-up duration was median 11 yr (range 1-22.8 yr). Fewer patients achieved a cortisol nadir below 2 μg/dl (87%) than below 5 μg/dl (98%), yet recurrence rates were similar (<2 μg/dl, 9.5%; <5 μg/dl, 10.4%; 2-4.9 μg/dl, 20%; not significant). CRH-stimulated cortisol (P < 0.002) and ACTH (P = 0.04) values were higher for the recurrence than the remission group. However, no basal or stimulated ACTH or serum or urine cortisol cutoff value predicted all who later recurred.
CONCLUSIONS: A postoperative cortisol below 2 μg/dl predicts long-term remission after transsphenoidal surgery in CD. Remission in those with intermediate d 3-5 postoperative cortisol values (2-4.9 μg/dl) suggests that these patients do not require immediate reoperation. However, because no single cortisol cutoff value excludes all patients with recurrence, all require long-term clinical follow-up.
Authors:
John R Lindsay; Edward H Oldfield; Constantine A Stratakis; Lynnette K Nieman
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Publication Detail:
Type:  Journal Article; Research Support, N.I.H., Extramural; Research Support, N.I.H., Intramural     Date:  2011-04-20
Journal Detail:
Title:  The Journal of clinical endocrinology and metabolism     Volume:  96     ISSN:  1945-7197     ISO Abbreviation:  J. Clin. Endocrinol. Metab.     Publication Date:  2011 Jul 
Date Detail:
Created Date:  2011-07-07     Completed Date:  2011-09-12     Revised Date:  2013-06-30    
Medline Journal Info:
Nlm Unique ID:  0375362     Medline TA:  J Clin Endocrinol Metab     Country:  United States    
Other Details:
Languages:  eng     Pagination:  2057-64     Citation Subset:  AIM; IM    
Affiliation:
National Institute of Neurologic Disorders and Stroke, National Institutes of Health, Bethesda, Maryland 20892, USA.
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MeSH Terms
Descriptor/Qualifier:
Adolescent
Adult
Aged
Child
Child, Preschool
Corticotropin-Releasing Hormone / blood*
Female
Follow-Up Studies
Humans
Hydrocortisone / blood*
Hypophysectomy / methods
Male
Middle Aged
Pituitary ACTH Hypersecretion / blood*,  surgery
Pituitary Gland / surgery*
Postoperative Period
Predictive Value of Tests
Prospective Studies
Remission Induction
Treatment Outcome
Chemical
Reg. No./Substance:
50-23-7/Hydrocortisone; 9015-71-8/Corticotropin-Releasing Hormone
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