Citation: European Journal of Endocrinology. 178(3):255-263, 2018 Mar.Journal: European journal of endocrinology.Published: 2018ISSN: 0804-4643.Full author list: Ironside N; Chatain G; Asuzu D; Benzo S; Lodish M; Sharma S; Nieman L; Stratakis C; Lonser R; Chittiboina P.UI/PMID: 29330227.Subject(s): *ACTH-Secreting Pituitary Adenoma/su [Surgery] | *Adenoma/su [Surgery] | Area Under Curve | Humans | *Hydrocortisone/bl [Blood] | Kaplan-Meier Estimate | Logistic Models | Neoplasm Recurrence, Local/bl [Blood] | *Neoplasm Recurrence, Local/ep [Epidemiology] | *Neurosurgical Procedures | *Pituitary ACTH Hypersecretion/su [Surgery] | Postoperative Period | ROC Curve | Remission Induction | Time FactorsInstitution(s): MedStar Washington Hospital CenterDepartment(s): Medicine/EndocrinologyActivity type: Journal Article.Medline article type(s): Journal ArticleDigital Object Identifier: https://dx.doi.org/10.1530/EJE-17-0873 (Click here)Abbreviated citation: EUR. J. ENDOCRINOL.. 178(3):255-263, 2018 Mar.Abstract: CONTEXT: Achievement of hypocortisolemia following transsphenoidal surgery (TSS) for Cushing's disease (CD) is associated with successful adenoma resection. However, up to one third of these patients recur.Abstract: OBJECTIVE: We assessed whether delay in reaching post-operative cortisol nadir may delineate those at risk of recurrence for CD following TSS.Abstract: METHODS: A retrospective review of of 257 patients who received 291 TSS procedures for CD at NIH, between 2003 and 2016. Early biochemical remission (serum cortisol nadir < 5 mug/dL), was confirmed with endocrinological and clinical follow up. Recurrence was detected by laboratory testing, clinical stigmata or medication-dependence during a median follow-up of 11 months.Abstract: RESULTS: Of the 268 unique admissions, remission was recorded in 241 instances. Recurrence was observed in 9% of these cases with cortisol nadir <= 5 mug/dL and 6% of cases with cortisol nadir <= 2 mug/dL. The timing of hypocortisolemia was critical in detecting late recurrences. Morning POD-1 cortisol < 3.3mug/dL was 100% sensitive in predicting durable remission and morning POD-3 cortisol >= 18.5mug/dL was 98.6% specific in predicting remote recurrence. AUROC analysis revealed that hypocortisolemia <= 5 micro g/dL before 15 hours (post-operative) had 95% sensitivity and an NPV of 0.98 for durable remission. Serum cortisol level <= 2 micro g/dL, when achieved before 21 hours, improved sensitivity to 100%.Abstract: CONCLUSIONS: In our cohort, early, profound hypocortisolemia could be used as a clinical prediction tool for durable remission. Achievement of hypocortisolemia <= 2 micro g/dL before 21 post-operative hours appeared accurately predict durable remission.