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The diagnostic utility of late night salivary cortisol (LNSF) and cortisone (LNSE) in Cushing's syndrome. Ir J Med Sci 2020; 190:615-623. [PMID: 32803648 DOI: 10.1007/s11845-020-02334-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 08/01/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Measurement of late night salivary cortisol (LNSF) is useful in the identification of cyclical Cushing's syndrome (CS); the usefulness of its metabolite cortisone (late night salivary cortisone, LNSE) is less well described. AIM The aim of this study was to determine the utility of measuring LNSE in patients with confirmed CS compared with other diagnostic tests and to analyse serial LNSF measurements for evidence of variable hormonogenesis. METHODS This was a retrospective observational study including patients with confirmed CS in whom LNSF and LNSE were measured. RESULTS Twenty-three patients with confirmed CS were included, 21 with Cushing's disease. LNSF had a sensitivity of 92%, LNSE 87% and combined LNSF/LNSE 94% per sample. Four patients had cyclical hormonogenesis, when the definition of one trough and two peaks was applied to LNSF measurements, and a fifth patient fell just outside the criteria. Six patients had evidence of variable hormonogenesis, defined as doubling of LNSF concentration on serial measurements. Sensitivity of 24-h urinary free cortisol (UFC) was 89% per collection. Sixteen patients had simultaneous measurements of LNSF and UFC; in three patients, they provided discordant results. CONCLUSION LNSF appears more sensitive than LNSE and UFC in the diagnosis of CS, combining LNSF and LNSE results leads to superior sensitivity. Half of our cohort had evidence of cyclical or variable hormonogenesis. Fluctuations in LNSF did not always correlate with changes in UFC concentration, emphasising the importance of performing more than one screening test, particularly if pretest clinical suspicion is high.
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Voss M, Batarfi A, Steidl E, Wagner M, Forster MT, Steinbach JP, Rödel CM, Bojunga J, Ronellenfitsch MW. Adrenal Insufficiency in Patients with Corticosteroid-Refractory Cerebral Radiation Necrosis Treated with Bevacizumab. J Clin Med 2019; 8:jcm8101608. [PMID: 31623403 PMCID: PMC6832264 DOI: 10.3390/jcm8101608] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 09/26/2019] [Accepted: 09/27/2019] [Indexed: 11/16/2022] Open
Abstract
Cerebral radiation necrosis is a common complication of the radiotherapy of brain tumours that can cause significant mortality. Corticosteroids are the standard of care, but their efficacy is limited and the consequences of long-term steroid therapy are problematic, including the risk of adrenal insufficiency (AI). Off-label treatment with the vascular endothelial growth factor A antibody bevacizumab is highly effective in steroid-resistant radiation necrosis. Both the preservation of neural tissue integrity and the cessation of steroid therapy are key goals of bevacizumab treatment. However, the withdrawal of steroids may be impossible in patients who develop AI. In order to elucidate the frequency of AI in patients with cerebral radiation necrosis after treatment with corticosteroids and bevacizumab, we performed a retrospective study at our institution's brain tumour centre. We obtained data on the tumour histology, age, duration and maximum dose of dexamethasone, radiologic response to bevacizumab, serum cortisol, and the need for hydrocortisone substitution for AI. We identified 17 patients with cerebral radiation necrosis who had received treatment with bevacizumab and had at least one available cortisol analysis. Fifteen patients (88%) had a radiologic response to bevacizumab. Five of the 17 patients (29%) fulfilled criteria for AI and required hormone substitution. Age, duration of dexamethasone treatment, and time since radiation were not statistically associated with the development of AI. In summary, despite the highly effective treatment of cerebral radiation necrosis with bevacizumab, steroids could yet not be discontinued due to the development of AI in roughly one-third of patients. Vigilance to spot the clinical and laboratory signs of AI and appropriate testing and management are, therefore, mandated.
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Affiliation(s)
- Martin Voss
- Dr. Senckenberg Institute of Neurooncology, University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany.
- University Cancer Center (UCT) Frankfurt, University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany.
- German Cancer Consortium (DKTK), 60590 Frankfurt am Main, Germany.
- Frankfurt Cancer Institute (FCI), University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany.
| | - AbdulAziz Batarfi
- Department of Neurology, University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany.
| | - Eike Steidl
- Institute of Neuroradiology, University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany.
| | - Marlies Wagner
- Institute of Neuroradiology, University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany.
| | - Marie-Thérèse Forster
- Department of Neurosurgery, University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany.
| | - Joachim P Steinbach
- Dr. Senckenberg Institute of Neurooncology, University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany.
- University Cancer Center (UCT) Frankfurt, University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany.
- German Cancer Consortium (DKTK), 60590 Frankfurt am Main, Germany.
- Frankfurt Cancer Institute (FCI), University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany.
| | - Claus M Rödel
- Department of Radiotherapy and Oncology, University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany.
| | - Jörg Bojunga
- Department of Internal Medicine 1, University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany.
| | - Michael W Ronellenfitsch
- Dr. Senckenberg Institute of Neurooncology, University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany.
- University Cancer Center (UCT) Frankfurt, University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany.
- German Cancer Consortium (DKTK), 60590 Frankfurt am Main, Germany.
- Frankfurt Cancer Institute (FCI), University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany.
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