Friday, April 15, 2011

Random postoperative day 3 cortisol as a predictor of hypothalamic-pituitary-adrenal axis integrity after transsphenoidal surgery


Endocrine Practice


American Association of Clinical Endocrinologists


1530-891X (Print) 1934-2403 (Online)


Health Services, Medical Sciences and Endocrinology






Maryam I. Khan, MD1, 2, Mouhammed A. Habra, MD, FACE1, Ian E. McCutcheon, MD3, Graciela M. Nogueras-González, MPH4, Jessica K. Devin, MD1, Naifa L. Busaidy, MD1, Nicholas B. Levine, MD3, Wayne Lindstrom, MD1, David Kagan, MD1, Camilo Jimenez, MD1, Steven G. Waguespack, MD, FAAP, FACE1

1Department of Endocrine Neoplasia and Hormonal Disorders, University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
2Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine, Houston, Texas, USA
3Department of Neurosurgery, University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
4Division of Quantitative Sciences, University of Texas M.D. Anderson Cancer Center, Houston, TX, USA


Objective: To determine if a random postoperative day 3 (POD3) cortisol ≥10μg/dl is predictive of adrenal sufficiency (AS) at 3-10 weeks after transsphenoidal surgery (TSS) and during long-term clinical follow up.

Methods: We retrospectively reviewed the case records of 466 patients who underwent TSS at our institution between 1991 and 2008. Eighty-three patients met inclusion criteria for the study: random cortisol measured on the morning of POD3, adrenal dynamic testing performed 3-10 weeks after TSS, and clinical assessment of the hypothalamic-pituitary-adrenal (HPA) axis at least 6 months after TSS.

Results: The sensitivity of a random POD3 serum cortisol ≥10μg/dl for the prediction of AS at a median follow up of 42 days was 64.81% (95% CI: 50.6-77.32), with an odds ratio of 3.1 (95% CI: 1.08-8.58). The specificity was 62.1% (95% CI: 42.3-79.3). At a median follow up of 500 days, only 2 patients with a POD3 cortisol ≥10μg/dl required hydrocortisone replacement, both of whom had multiple anterior pituitary hormone deficiencies and evidence of pituitary dysfunction during the perioperative period.

Conclusions: In the appropriate clinical context, a POD3 cortisol ≥10μg/dl accurately predicts the integrity of the HPA axis. The final decision regarding corticosteroid replacement should be individualized, taking into consideration the POD3 cortisol level, the clinical context in which the measurement was obtained, and any evidence of concomitant pituitary dysfunction in the perioperative period.

transsphenoidal resection, adrenal insufficiency, pituitary adenoma, hydrocortisone replacement

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