Le Marc'hadour Pauline, Muller Marie, Albarel Frederique, Coulon Anne-Laure, Morange Isabelle, Martinie Monique, Gay Emmanuel, Graillon Thomas, Dufour Henri, Conte-Devolx Bernard, Chabre Olivier, Brue Thierry, Castinetti Frederic
Department of Endocrinology, CHU La Timone, APHM and CRN2M-UMR 7286- Faculte de Medecine Secteur Nord, Aix Marseille Université, Marseille, France.
Department of Endocrinology, Diabetology and Nutrition, CHU de Grenoble - Hôpital Albert Michallon, Grenoble, France.
Clin Endocrinol (Oxf). 2015 Aug;83(2):216-22. doi: 10.1111/cen.12739. Epub 2015 Mar 20.
Predicting the outcome of patients operated on for Cushing's disease (CD) is a challenging task. Our objective was to assess the accuracy of immediate postsurgical plasma cortisol, desmopressin test and the coupled dexamethasone-desmopressin test (CDDT) as predictors of outcome.
Sixty-seven patients with initial remission and a minimal postsurgical follow-up greater than 18 months were included in this retrospective bicentre study.
Follow-up included 3-6 months followed by yearly 24-h urinary-free cortisol, ACTH and cortisol plasmatic levels, a 1-mg overnight dexamethasone suppression test (1-mg DST), desmopressin test and the CDDT. ROC curves were performed to define the optimal threshold of immediate postsurgical cortisol level and 3- to 6-month desmopressin test and CDDT, as predictors of final outcome in comparison with classical biological markers of recurrence.
Eleven patients presented recurrence. The patient's median follow-up was 52 months (range, 18-180). As early predictors of outcome, immediate postsurgical plasma cortisol level <35 nmol/l predicted the lack of recurrence with 93% negative predictive value (NPV), whereas predictive positive value (PPV) was 25%. During the follow-up, the CDDT was more precise than the desmopressin test in predicting the lack of recurrence (100% NPV) when performed in the first 3 years after surgery. Positivity of the CDDT was defined based on ROC curves by ACTH and cortisol increments >50%. The CDDT was highly reproducible, as the same response was observed every year in 91% of the patients.
Adding the CDDT the first 3 years after surgery to immediate postsurgical cortisol evaluation should allow obtaining an optimal follow-up management of patients operated for Cushing's disease.
预测接受库欣病（CD）手术治疗患者的预后是一项具有挑战性的任务。我们的目的是评估术后即刻血浆皮质醇、去氨加压素试验以及联合地塞米松 - 去氨加压素试验（CDDT）作为预后预测指标的准确性。
本回顾性双中心研究纳入了67例初始缓解且术后最短随访时间超过18个月的患者。
随访包括术后3 - 6个月，随后每年进行24小时尿游离皮质醇、促肾上腺皮质激素（ACTH）和血浆皮质醇水平检测、1毫克过夜地塞米松抑制试验（1 - mg DST）、去氨加压素试验和CDDT。绘制ROC曲线以确定术后即刻皮质醇水平以及术后3至6个月去氨加压素试验和CDDT的最佳阈值，作为与复发的经典生物学标志物相比的最终预后预测指标。
11例患者出现复发。患者的中位随访时间为52个月（范围18 - 180个月）。作为预后的早期预测指标，术后即刻血浆皮质醇水平<35 nmol/L预测无复发的阴性预测值（NPV）为93%，而阳性预测值（PPV）为25%。在随访期间，术后前3年进行CDDT时，其在预测无复发方面比去氨加压素试验更精确（NPV为100%）。CDDT的阳性定义基于ROC曲线，即ACTH和皮质醇增量>50%。CDDT具有高度可重复性，因为每年91%的患者观察到相同的反应。
术后前3年在术后即刻皮质醇评估基础上增加CDDT，应能实现对库欣病手术患者的最佳随访管理。
