Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Turin, Italy.
Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Turin, Italy,
Neuroendocrinology. 2021;111(7):639-649. doi: 10.1159/000509092. Epub 2020 Jun 3.
Multiple studies tried to identify cortisol cut-offs after pituitary surgery that could accurately assess hypothalamic-pituitary-adrenal (HPA) axis function; however, there is no consensus nowadays. This study aimed to evaluate the accuracy of morning cortisol after transsphenoidal surgery in predicting long-term secondary adrenal insufficiency.
In our tertiary center, we prospectively determined first- and second-day cortisol after transsphenoidal surgery in 92 patients without preoperative adrenal -insufficiency and not treated with glucocorticoids perioperatively. Definitive diagnosis of secondary adrenal insufficiency was obtained with re-evaluation 3 months after trans-sphenoidal surgery and clinical follow-up of at least 1 year.
Ten patients (10.8%) developed long-term postoperative secondary adrenal insufficiency. The ROC curves demonstrated that first-day cortisol had a moderate diagnostic accuracy, while a second-day cortisol ≤9.3 µg/dL (257 nmol/L) showed the best performance in predicting adrenal insufficiency (sensitivity [Se] 88.9%, specificity [Sp] 86.9%, AUC 0.921). Moreover, a second-day cortisol ≤3.2 µg/dL (89 nmol/L) was able to diagnose adrenal insufficiency in 100% of cases (Se 22.2%, Sp 100%) and >14 µg/dL (386 nmol/L) was able to exclude ACTH deficiency (Se 100%, Sp 57.4%).
Adrenal function can be carefully studied on the second day after pituitary surgery, using cut-off values that international guidelines suggested for non-stressed conditions. In fact, second-day cortisol levels ≤3.2 μg/dL (89 nmol/L) and >14 μg/dL (386 nmol/L) are diagnostic of secondary adrenal insufficiency and normal function, respectively. We also suggest performing a definitive re-evaluation with an HPA axis stimulation test when second-day cortisol values are between 3.3 and 14 μg/dL (90-386 nmol/L).
多项研究试图确定垂体手术后能够准确评估下丘脑-垂体-肾上腺（HPA）轴功能的皮质醇截断值；然而，目前尚无共识。本研究旨在评估经蝶窦手术后清晨皮质醇评估预测长期继发性肾上腺功能不全的准确性。
在我们的三级中心，我们前瞻性地确定了 92 例无术前肾上腺功能不全且围手术期未接受糖皮质激素治疗的患者经蝶窦手术后第 1 天和第 2 天的皮质醇。继发性肾上腺功能不全的明确诊断是在经蝶窦手术后 3 个月重新评估以及至少 1 年的临床随访获得的。
10 例（10.8%）患者发生长期术后继发性肾上腺功能不全。ROC 曲线显示第 1 天皮质醇具有中等诊断准确性，而第 2 天皮质醇≤9.3μg/dL（257nmol/L）在预测肾上腺功能不全方面表现最佳（敏感性[Se]88.9%，特异性[Sp]86.9%，AUC 0.921）。此外，第 2 天皮质醇≤3.2μg/dL（89nmol/L）能够诊断 100%的病例（Se 22.2%，Sp 100%），而>14μg/dL（386nmol/L）能够排除 ACTH 缺乏（Se 100%，Sp 57.4%）。
可以使用国际指南建议的非应激状态下的临界值，在垂体手术后第 2 天仔细研究肾上腺功能。事实上，第 2 天皮质醇水平≤3.2μg/dL（89nmol/L）和>14μg/dL（386nmol/L）分别诊断为继发性肾上腺功能不全和正常功能。当第 2 天皮质醇值在 3.3 至 14μg/dL（90-386nmol/L）之间时，我们还建议进行 HPA 轴刺激试验的明确重新评估。
