Use of morning serum cortisol level after transsphenoidal resection of pituitary adenoma to predict the need for long-term glucocorticoid supplementation

Clinical article

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  • 1 Department of Neurosurgery,
  • | 2 Brain Tumor and Neuro-Oncology Center,
  • | 3 Department of Endocrinology, and
  • | 4 Department of Hospital Medicine, Cleveland Clinic, Cleveland, Ohio; and
  • | 5 Swedish Neurosciences Institute, Swedish Medical Center, Seattle, Washington
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Object

Accurate assessment of the hypothalamic-pituitary-adrenal (HPA) axis is critical for appropriate management of the disease in patients with pituitary adenoma after transsphenoidal resection. The authors examine the role of the morning total serum cortisol level in the early postoperative period as a predictor of long-term HPA function.

Methods

Morning total serum cortisol was measured in 83 patients on postoperative Day 1 (or Day 2 if the patient received glucocorticoids during surgery) after transsphenoidal surgery for pituitary adenoma. These results were compared with those of definitive assays of HPA function performed at 1–3 months postoperatively, including cortrosyn/synacthen stimulation test (CST), insulin tolerance test (ITT), and metyrapone test (MTT). The ability of the early-postoperative morning cortisol level to predict HPA function was determined using standard confusion matrix calculations and receiver-operator control curve analysis.

Results

The authors found that an early postoperative morning total cortisol level ≥ 15 μg/dl is a sensitive and accurate predictor of normal HPA function in the postoperative period (sensitivity 80.5%, specificity 66.7%, positive predictive value 96.9%).

Conclusions

A morning total cortisol level ≥ 15 μg/dl in the early postoperative period after transsphenoidal surgery for pituitary adenomas is a good predictor of normal HPA function. This test has good sensitivity and accuracy and correlates well with the results of additional, definitive assays of HPA function (CST, ITT, and MTT) performed at 1–3 months postoperatively. Accordingly, it is the authors' practice to avoid exogenous perioperative glucocorticoid supplementation in patients with normal preoperative HPA function and postoperative morning total cortisol levels ≥ 15 μg/dl 1–2 days after transsphenoidal pituitary adenomectomy.

Abbreviations used in this paper:

CST = cortrosyn/synacthen stimulation test; HPA = hypothalamic-pituitary-adrenal; ITT = insulin tolerance test; MTT = metyrapone test; x30, x60 = mean value at 30 and 60 minutes.

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