Clinical review: Early morning cortisol levels as a predictor of remission after transsphenoidal surgery for Cushing's disease.
BACKGROUND
We describe the use of serum cortisol and ACTH levels on postoperative d 1 and 2 as remission predictors after transsphenoidal surgery for Cushing's disease (CD).


METHODS
Morning cortisol and ACTH levels were drawn daily after surgery; glucocorticoids were withheld until evidence of hypocortisolemia. Early remission was defined retrospectively as a subnormal morning cortisol level [< or =140 nmol/liter (< or =5 microg/dl)] on postoperative d 1 or 2 and sustained remission as subsequent eucortisolemia.


RESULTS
Of 40 consecutive adults with CD (mean age 39 yr), 80% achieved early remission. Of 39 patients with a minimum follow-up of 14 months (mean 33 months), 31 (79.5%) achieved sustained remission at a mean follow-up of 32 months, including 30 of 31 (97%) with early remission and one of eight (12%) without early remission (P < 0.0001). Sustained remission was achieved in 26 of 28 (93%) patients having their first operation, compared with five of 11 (45%) with a prior unsuccessful operation (P < 0.001). For the 32 patients in early remission vs. the eight in nonremission, mean nadir cortisol levels were 57.6 +/- 33.0 (2.05 +/- 1.2 microg/dl) vs. 631.1 +/- 352.2 nmol/liter (22.9 +/- 12.8 microg/dl) (P < 0.0001), and nadir ACTH levels were 11.9 +/- 6.5 vs. 64.1 +/- 54.6 ng/liter (P < 0.001). Of 31 patients with sustained remission, 100% had subnormal morning cortisol levels, whereas 31% had subnormal ACTH levels (P < 0.0001).


CONCLUSIONS
Serum morning cortisol levels on postoperative d 1 and 2 without glucocorticoid replacement provide a safe, simple, and reliable measure of early remission for CD and are predictive of sustained remission. This method allows for consideration of a repeat operation during the same hospitalization in patients with persistent hypercortisolemia.
Esposito
Felice
F
Division of Neurosurgery , University of Los Angeles California Medical Plaza, Los Angeles, California 90095-7182, USA.
Dusick
Joshua R
JR
Cohan
Pejman
P
Moftakhar
Parham
P
McArthur
David
D
Wang
Christina
C
Swerdloff
Ronald S
RS
Kelly
Daniel F
DF
D000324:Adrenocorticotropic Hormone / Q000097:blood; D000328:Adult; D000368:Aged; D015331:Cohort Studies; D003480:Cushing Syndrome / Q000097:blood* / Q000473:pathology / Q000601:surgery*; D017352:Echo-Planar Imaging; D005260:Female; D006801:Humans; D006854:Hydrocortisone / Q000097:blood*; D007016:Hypophysectomy; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D019635:Neurosurgical Procedures; D010901:Pituitary Function Tests; D010902:Pituitary Gland / Q000473:pathology; D011182:Postoperative Care; D011237:Predictive Value of Tests; D012008:Recurrence; D012074:Remission Induction; D013100:Sphenoid Bone / Q000601:surgery*
D000324:Adrenocorticotropic Hormone; D006854:Hydrocortisone