Exp Clin Endocrinol Diabetes 2020; 128(11): 709-714
DOI: 10.1055/a-0885-1568
Article

Early Basal Cortisol Level as a Predictor of Hypothalamic-Pituitary-Adrenal (HPA) Axis Function After Pituitary Tumor Surgery

Tanja Skoric Polovina
1   Department of Endocrinology, University Hospital Center Zagreb, Coatia
,
Ivana Kraljevic
1   Department of Endocrinology, University Hospital Center Zagreb, Coatia
,
Mirsala Solak
1   Department of Endocrinology, University Hospital Center Zagreb, Coatia
,
Annemarie Balasko
1   Department of Endocrinology, University Hospital Center Zagreb, Coatia
,
Arta Haxhiu
1   Department of Endocrinology, University Hospital Center Zagreb, Coatia
,
Arita Haxhiu
1   Department of Endocrinology, University Hospital Center Zagreb, Coatia
,
Tina Dusek
1   Department of Endocrinology, University Hospital Center Zagreb, Coatia
2   School of Medicine University of Zagreb, Coatia
,
Tamara Poljicanin
3   Croatian Institute of Public Health, Zagreb, Croatia
,
Darko Kastelan
1   Department of Endocrinology, University Hospital Center Zagreb, Coatia
2   School of Medicine University of Zagreb, Coatia
› Author Affiliations

Abstract

Purpose The purpose of this study was to evaluate the clinical relevance of the early postoperative basal cortisol level in assessing the postoperative hypothalamic-pituitary-adrenal (HPA) axis function after pituitary tumor surgery.

Methods We performed a prospective observational study that enrolled 83 patients operated for pituitary adenoma or other sellar lesions at the University Hospital Center Zagreb between December 2013 and April 2017 (44 nonfunctioning pituitary adenomas, 28 somatotropinomas, 5 craniopharyngiomas, 2 prolactinomas resistant to medical therapy and 4 other lesions - Rathke's cleft cyst, arachnoid cyst, chondroma and gangliocytoma). Exclusion criteria were Cushing's disease, chronic therapy with glucocorticoids prior to surgery and preoperative adrenal insufficiency. Early postoperative basal cortisol levels (measured on the second postoperative day) and the Synacthen stimulation test (performed 3 months after the surgery with the peak cortisol level of>500 nmol/L considered as a normal response) were analyzed to assess HPA axis function during follow-up.

Results ROC analysis showed a cut-off of the basal cortisol level of ≥300 nmol/L measured on the second postoperative day to predict normal postoperative HPA axis function with the sensitivity of 92.31%, specificity of 87.14% and positive predictive value of 57.14%.

Conclusion The basal cortisol level on the second postoperative day is a valuable tool to predict integrity of the HPA axis after pituitary tumor surgery. Our data suggest that the cortisol level of ≥300 nmol/L accurately predicts adrenal sufficiency and that in these patients glucocorticoid therapy can be withdrawn.



Publication History

Received: 01 October 2018
Received: 21 March 2019

Accepted: 27 March 2019

Article published online:
15 May 2019

© 2020. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 
  • References

  • 1 Marko NF, Gonugunta VA, Hamrahian AH. et al. Use of morning serum cortisol level after transsphenoidal resection of pituitary adenoma to predict the need for long-term glucocorticoid supplementation. J Neurosurg 2009; 111: 540-544
  • 2 Hout WM, Arafah BM, Salazar R. et al. Evaluation of the hypothalamic-pituitary-adrenal axis immediately after pituitary adenomectomy: Is perioperative steroid therapy necessary?. J Clin Endocrinol Metab 1988; 66: 1208-1212
  • 3 Watts NB, Tindall GT. Rapid assessment of corticotropin reserve after pituitary surgery. JAMA 1988; 259: 708-711
  • 4 Zada G, Kelly DF, Cohan P. et al. Endonasal transsphenoidal approach for pituitary adenomas and other sellar lessions: An assessment of efficacy, safety, and patient impressions. J Neurosurg 2003; 98: 350-358
  • 5 Arafah BM, Kailani SH, Nekl KE. et al. Immediate recovery of pituitary function after transsphenoidal resection of pituitary macroadenomas. J Clin Endocrinol Metab 1994; 79: 348-354
  • 6 Nomikos P, Ladar C, Fahlbusch R. et al. Impact of primary surgery on pituitary function in patients with non-functioning pituitary adenomas - a study on 721 patients. Acta Neurochir (Wien) 2004; 146: 27-35
  • 7 Fleseriu M, (chair) Hashim IA, Karavitaki N et al. Hormonal replacement in hypopituitarism in adults: An endocrine society clinical practice guideline. J Clin Endocrinol Metab 2016; 101: 3888–3921
  • 8 Jones SL, Trainer PJ, Perry L. et al. An audit of the insulin tolerance test in adult subjects in an acute investigation unit over one year. Clin Endocrinol (Oxf) 1994; 41: 123-128
  • 9 Grinspoon SK, Biller BM. Clinical review 62: Laboratory assessment of adrenal insufficiency. J Clin Endocrinol Metab 1994; 79: 923-931
  • 10 Courtney CH, McAllister AS, McCance DR. et al. Comparison of one week 09.00 h serum cortisol, low and standard dose synacthen tests with a 4 to 6 weeks insulin hypoglicaemia test after pituitary surgery in assessing HPA axis. Clin Endocrinol 2000; 53: 431-436
  • 11 Klose M, Lange M, Kosteljanetz M. et al. Adrenocortical insufficiency after pituitary surgery: An audit of the reliability of the conventional short synacthen test. Clin Endocrinol 2005; 63: 499-505
  • 12 Lindholm J, Kehlet H. Re-evaluation of the clinical value of the 30 min ACTH test in assessing the hypothalamic-pituitary-adrenocortical function. Clin Endocrinol 1987; 26: 53-59
  • 13 English K, Inder WJ, Weedon Z. et al. Prospective evaluation of a week one overnight metyrapone test with subsequent dynamic assesments of hypothalamic-pituitary-adrenal axis function after pituitary surgery. Clin Endocrinol 2017; 87: 35-43
  • 14 Kokshoorn NE, Romijn JA, Roelfsema F. et al. The use of an early postoperative CRH test to assess adrenal function after transsphenoidal surgery for pituitary adenomas. Pituitary 2012; 15: 436-444
  • 15 Karaca Z, Tanriverdi F, Atmaca H. et al. Can basal cortisol measurement be an alternative to the insulin tolerance test in the assessment of the hypothalamic-pituitary-adrenal axis before and after pituitary surgery. European Journal of Endocrinology 2010; 163: 377-382
  • 16 Inder WJ, Hunt PJ. Glucocorticoid replacement in pituitary surgery guidlines for perioperative assessment and management. J Clin Endocrinol Metab 2002; 87: 2745-2750
  • 17 Garcia-Luna PP, Leal-Cerro A, Rocha JL. et al. Evaluation of the pituitary-adrenal axis before, during and after pituitary adenomectomy. Is perioperative glucocorticoid therapy necessary?. Acta Endocrinologica (Copenh) 1990; 122: 83-88
  • 18 Auchus RJ, Shewbridge RK, Shepherd MD. Which patients benefit from provocative adrenal testing after trassphenoidal pituitary surgery?. Clin Endocrinol 1997; 46: 21-27
  • 19 Jayasena CN, Gadhvi KA, Gohel B. et al. Day 5 morning serum cortisol predicts hypothalamic-pituitary-adrenal function after transsphenoidal surgery for pituitary tumors. Clinical Chemistry 2009; 55: 972-977
  • 20 Cozzi R, Lasio G, Cardia A. et al. Perioperative cortisol can predict hypothalamus-pituitary-adrenal status in clinically non-functioning pituitary adenomas. J Endocrinol Invest 2009; 32: 460-464
  • 21 Wentworth JM, Gao N, Sumithran KP. et al. Prospective evaluation of a protocol for reduced glucocorticoid replacement in trassphenoidal pituitary adenomectomy: Prophylactic glucocorticoid replacement is seldom necessary. Clin Endocrinol 2008; 68: 29-35
  • 22 Marko NF, Hamrahian AH, Weil RJ. Immediate postoperative cortisol levels accurately predict postoperative hypothalamic-pituitary-adrenal axis function after trassphenoidal surgery for pituitary tumors. Pituitary 2010; 13: 249-255
  • 23 Khan M, Habra M, McCutcheon I. et al. Random postoperative day-3 cortisol concentration as a predictor of hypothalamic-pituitary-adrenal axis integrity after transsphenoidal surgery. Endocrine Practice 2011; 17: 717-726
  • 24 DeTommasi C, Goguen J, Cusimano MD. Transsphenoidal surgery without steroid replacement in patients with morning serum corticol below 8 µg/dl (250 nmol/L). Acta Neurochir 2012; 154: 1903-1915
  • 25 Little AS, Oppenlander ME, Knecht L. et al. Early postoperative serum cortisol measurements guide management in a steroid-sparing protocol and predict need for long-term steroid replacement after resection of non-functioning pituitary adenomas. JBM 2013; 3: 18-22
  • 26 McLaughlin N, Cohan P, Barnett P. et al. Early morning cortisol levels as predictors of short-term and long-term adrenal function after endonasal trassphenoidal surgery for pituitary adenomas and Rathkeʼs cleft cysts. World Neurosurgery 2013; 80: 569-575
  • 27 Regan J, Watson J. Selective use of peri-operative steroids in pituitary tumor surgery: Escape from dogma. Frontiers in Endocrinology 2013; 4: 1-5
  • 28 Bondugulapati LNR, Campbell C, Chowdhury SR. et al. Use of day 1 early morning cortisol to predict the need for glucocorticoid replacement after pituitary surgery. British Journal of Neurosurgery 2016; 30: 76-79
  • 29 Carrasco C, Villanueva PG. Selective use of glucocorticoids during the perioperative period of transsphenoidal surgery for pituitary tumors. Rev Med Chile 2014; 142: 1113-1119
  • 30 Tohti M, Li J, Zhou Y. et al. Is peri-operative steroid replacement therapy necessary for the pituitary adenomas treated with surgery? A systematic review and meta analysis. Plos One 2015; 10 (03) e0119621
  • 31 Prete A, Corsello SM, Salvatori R. Current best practice in the management of patients after pituitary surgery. Ther Adv Endocrinol Metab 2017; 8: 33-48
  • 32 Kristof RA, Wichers M, Haun D. et al. Peri-operative glucocorticoid replacement therapy in trassphenoidal pituitary adenoma surgery: A prospective controlled study. Acta Neurochir (Wien) 2008; 150: 329-335
  • 33 Zada G, Tirosh A, Huang AP. et al. The postoperative cortisol stress response following transsphenoidal pituitary surgery: A potential screening method for assessing preserved pituitary function. Pituitary 2013; 16: 319-325
  • 34 Barker FG, Klibanski A, Swearingen B. Transsphenoidal surgery for pituitary tumors in United States, 1996-2000: Mortality, morbidity, and the effects of hospital and surgeon volume. J Clin Endocrinol Metab 2003; 88: 4709-4719
  • 35 Müller HL. Craniopharyngioma. Endocrine Reviews 2014; 35: 513-543
  • 36 Manuylova E, Calvi LM, Vates GE. et al. Morning serum cortisol level after transsphenoidal surgery for pituitary adenoma predicts hypothalamic-pituitary-adrenal function despite intraoperative dexamethason use. Endocrine Practice 2015; 21: 897-902
  • 37 El-Sibai K, Rajpal A, Al-Aridi R. et al. The impact of perioperative dexamethasone administration in the normal hypothalamic pituitary adrenal response to major surgical procedures. Endocrine 2017; 58: 134-142
  • 38 Ospina NS, Al Nofal A, Bancos I. et al. ACTH stimulation tests for the diagnosis of adrenal insufficiency: Systematic review and meta-analysis. J Clin Endocrinol Metab 2016; 101: 427-434
  • 39 Dorin RI, Qualls CR, Crapo LM. Diagnosis of adrenal insufficiency. Ann Intern Med 2003; 139: 194-204
  • 40 Klose M, Lange M, Rasmussen AK. et al. Factors influencing the adrenocorticotropin test: Role of contemporary corticol assays, body composition, and oral contraceptive agents. J Clin Endocrinol Metab 2007; 92: 1326-1333