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Vega-Beyhart A, Araujo-Castro M, Hanzu FA, Casals G. Cortisol: Analytical and clinical determinants. Adv Clin Chem 2023; 113:235-271. [PMID: 36858647 DOI: 10.1016/bs.acc.2022.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Cortisol, the main human glucocorticoid, is synthesized from cholesterol in the adrenal cortex and predominantly metabolized by the liver. Interpretation of quantitative results from the analysis of serum, urine and saliva is complicated by variation in circadian rhythm, response to stress as well as the presence of protein-bound and free forms. Interestingly, cortisol is the only hormone routinely measured in serum, urine, and saliva. Preanalytical and analytical challenges arise in each matrix and are further compounded by the use of various stimulation and suppression tests commonly employed in clinical practice. Although not yet included in clinical guidelines, measurement of cortisol in hair may be of interest in specific situations. Immunoassays are the most widely used methods in clinical laboratories to measure cortisol, but they are susceptible to interference from synthetic and endogenous steroids, generally producing a variable overestimation of true cortisol results, especially in urine. Analysis by mass spectrometry provides higher specificity and allows simultaneous measurement of multiple steroids including synthetic steroids, thus reducing diagnostic uncertainty. An integrated review of cortisol in various disease states is also addressed.
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Affiliation(s)
- Arturo Vega-Beyhart
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Department of Endocrinology and Nutrition, Hospital Clinic, Barcelona, Spain
| | - Marta Araujo-Castro
- Department of Endocrinology and Metabolism, Hospital Universitario Ramón y Cajal, Madrid, Spain; Instituto de Investigación Biomédica Ramón y Cajal (IRYCIS), Madrid, Spain
| | - Felicia A Hanzu
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Department of Endocrinology and Nutrition, Hospital Clinic, Barcelona, Spain; Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Madrid, Spain; Department of Medicine, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain
| | - Gregori Casals
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Service of Biochemistry and Molecular Genetics, Hospital Clinic, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III (ISCIII), Madrid, Spain; Department of Fundamental Care and Medical-Surgical Nursing, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain.
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Casals G, Hanzu FA. Cortisol Measurements in Cushing's Syndrome: Immunoassay or Mass Spectrometry? Ann Lab Med 2020; 40:285-296. [PMID: 32067427 PMCID: PMC7054699 DOI: 10.3343/alm.2020.40.4.285] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 12/20/2019] [Accepted: 02/07/2020] [Indexed: 11/19/2022] Open
Abstract
Determination of cortisol levels in the urine (24 hours urine free cortisol), saliva (late-night), or serum (total cortisol after dexamethasone suppression) is recommended to screen for Cushing's syndrome (CS). This review focuses on the differences between the frequently used cortisol-antibody immunoassay-based methods and the highly specific mass-spectrometry-based methods that are progressively being employed in clinical laboratories for CS screening. The particular characteristics of cortisol metabolism and the lack of specificity of the immunoassays cause marked differences between both methods that are in turn highly dependent on the biological matrix, in which the cortisol is measured. Understanding the origin of these differences is essential for the interpretation of these results. Although cross-reactivity with endogenous steroids leads to grossly inaccurate results of immunoassay measurements of cortisol in the saliva and urine, preliminary evidence suggests that the clinical sensitivity of CS screening using immunoassays may be similar to CS screening using mass spectrometry. However, mass spectrometry offers more accurate results and considerably reduced variation across laboratories, while avoiding false-positive results. Moreover, mass spectrometry can overcome some common diagnostic challenges, such as identification of exogenous corticosteroids or simultaneous assessment of appropriate dexamethasone levels in suppression tests. Further, comprehensive mass spectrometry-based profiling of several steroid metabolites may be useful for discriminating among different subtypes of CS. Finally, this review discusses the main preanalytical factors that could cause variations in cortisol measurements and their influence on the reliability of the results.
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Affiliation(s)
- Gregori Casals
- Department of Biochemistry and Molecular Genetics, Hospital Clínic, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centrode Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), ISCIII, Madrid, Spain.
| | - Felicia Alexandra Hanzu
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Department of Endocrinology and Nutrition, Hospital Clínic, Barcelona, Spain.,Department of Medicine, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain
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Honour JW, Conway E, Hodkinson R, Lam F. The evolution of methods for urinary steroid metabolomics in clinical investigations particularly in childhood. J Steroid Biochem Mol Biol 2018; 181:28-51. [PMID: 29481855 DOI: 10.1016/j.jsbmb.2018.02.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 02/21/2018] [Accepted: 02/21/2018] [Indexed: 12/15/2022]
Abstract
The metabolites of cortisol, and the intermediates in the pathways from cholesterol to cortisol and the adrenal sex steroids can be analysed in a single separation of steroids by gas chromatography (GC) coupled to MS to give a urinary steroid profile (USP). Steroids individually and in profile are now commonly measured in plasma by liquid chromatography (LC) coupled with MS/MS. The steroid conjugates in urine can be determined after hydrolysis and derivative formation and for the first time without hydrolysis using GC-MS, GC-MS/MS and liquid chromatography with mass spectrometry (LC-MS/MS). The evolution of the technology, practicalities and clinical applications are examined in this review. The patterns and quantities of steroids changes through childhood. Information can be obtained on production rates, from which children with steroid excess and deficiency states can be recognised when presenting with obesity, adrenarche, adrenal suppression, hypertension, adrenal tumours, intersex condition and early puberty, as examples. Genetic defects in steroid production and action can be detected by abnormalities from the GC-MS of steroids in urine. New mechanisms of steroid synthesis and metabolism have been recognised through steroid profiling. GC with tandem mass spectrometry (GC-MS/MS) has been used for the tentative identification of unknown steroids in urine from newborn infants with congenital adrenal hyperplasia. Suggestions are made as to areas for future research and for future applications of steroid profiling. As routine hospital laboratories become more familiar with the problems of chromatographic and MS analysis they can consider steroid profiling in their test repertoire although with LC-MS/MS of urinary steroids this is unlikely to become a routine test because of the availability, cost and purity of the internal standards and the complexity of data interpretation. Steroid profiling with quantitative analysis by mass spectrometry (MS) after chromatography now provides the most versatile of tests of adrenal function in childhood.
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Affiliation(s)
- John W Honour
- Institute for Women's Health, University College London, 74 Huntley Street, London, WC1E 6AU, UK.
| | - E Conway
- Clinical Biochemistry, HSL Analytics LLP, Floor 2, 1 Mabledon Place, London, WC1H 9AX, UK
| | - R Hodkinson
- Clinical Biochemistry, HSL Analytics LLP, Floor 2, 1 Mabledon Place, London, WC1H 9AX, UK
| | - F Lam
- Clinical Biochemistry, HSL Analytics LLP, Floor 2, 1 Mabledon Place, London, WC1H 9AX, UK
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Sasaki Y, Katabami T, Asai S, Fukuda H, Tanaka Y. In the overnight dexamethasone suppression test, 1.0 mg loading is superior to 0.5 mg loading for diagnosing subclinical adrenal Cushing's syndrome based on plasma dexamethasone levels determined using liquid chromatography-tandem mass spectrometry. Endocr J 2017. [PMID: 28637948 DOI: 10.1507/endocrj.ej17-0083] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The low-dose dexamethasone suppression test (DST) is one of the commonly used initial tests for endogenous Cushing's syndrome (CS). However, there are two loading dose regimens (0.5-mg and 1-mg), which may cause some confusion in daily practice in Japan; furthermore, there are no reports regarding whether 0.5-mg DST is a better loading dose for detecting adrenal subclinical CS (SCS) based on the plasma dexamethasone (DEX) levels. Therefore, the aims of this study were (a) to develop a novel assay to measure DEX by using liquid chromatography tandem-mass spectrometry (LC-MS/MS) and (b) to compare between the 0.5-mg and 1-mg DST for SCS diagnosis based on the DEX levels. The study retrospectively analyzed 52 consecutive subjects hospitalized for diagnosis of adrenal incidentaloma but who did not exhibit an overt CS phenotype; eight (15.4%) patients were affected with adrenal SCS. Inter-individual variability of DEX levels after the DST was high, but intra-individual variability was low. DEX levels after 1-mg loading in each patient was around two times higher than those after 0.5-mg loading (ρ = 0.853 and p < 0.001). There were 45 (86.5%) and 17 (32.7%) subjects with DEX levels ≤2.2 ng/mL after the 0.5-mg and 1-mg DST, respectively (p < 0.001). Twenty-eight (93.3%) of 30 subjects and four (21.1%) of 19 subjects with detectable ACTH levels after the 0.5-mg and 1.0-mg DST, respectively, did not exhibit DEX levels >2.2 ng/mL. These results clearly indicate that the 1-mg DST is superior to 0.5-mg loading for the diagnosis of adrenal SCS.
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Affiliation(s)
- Yosuke Sasaki
- Division of Metabolism and Endocrinology, Department of Internal Medicine, St. Marianna University School of Medicine Yokohama City Seibu Hospital, Yokohama, Japan
- Division of Metabolism and Endocrinology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Takuyuki Katabami
- Division of Metabolism and Endocrinology, Department of Internal Medicine, St. Marianna University School of Medicine Yokohama City Seibu Hospital, Yokohama, Japan
| | - Shiko Asai
- Division of Metabolism and Endocrinology, Department of Internal Medicine, St. Marianna University School of Medicine Yokohama City Seibu Hospital, Yokohama, Japan
| | - Hisashi Fukuda
- Division of Metabolism and Endocrinology, Department of Internal Medicine, St. Marianna University School of Medicine Yokohama City Seibu Hospital, Yokohama, Japan
| | - Yasushi Tanaka
- Division of Metabolism and Endocrinology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
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Ceccato F, Antonelli G, Barbot M, Zilio M, Mazzai L, Gatti R, Zaninotto M, Mantero F, Boscaro M, Plebani M, Scaroni C. The diagnostic performance of urinary free cortisol is better than the cortisol:cortisone ratio in detecting de novo Cushing's syndrome: the use of a LC-MS/MS method in routine clinical practice. Eur J Endocrinol 2014; 171:1-7. [PMID: 24743401 DOI: 10.1530/eje-14-0061] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE The Endocrine Society Clinical Guidelines recommend measuring 24-h urinary free cortisol (UFF) levels using a highly accurate method as one of the first-line screening tests for the diagnosis of Cushing's Syndrome (CS). We evaluated the performance of UFF, urinary free cortisone (UFE), and the UFF:UFE ratio, measured using a liquid chromatography-tandem mass spectrometry (LC-MS/MS) method. SUBJECTS AND METHODS The LC-MS/MS was used to analyze UFF and UFE levels in 43 surgically confirmed CS patients: 26 with Cushing's disease (CD, 16 de novo and ten recurrences), 11 with adrenal CS and six with ectopic CS; 22 CD patients in remission; 14 eu-cortisolemic CD patients receiving medical therapy; 60 non-CS patients; and 70 healthy controls. Sensitivity and specificity were determined in the combined groups of non-CS patients, healthy controls, and CD in remission. RESULTS UFF>170 nmol/24 h showed 98.7% specificity and 100% sensitivity for de novo CS, while sensitivity was 80% for recurrent CD patients, who were characterized by lower UFF levels. The UFF:UFE and UFF+UFE showed lower sensitivity and specificity than UFF. Ectopic CS patients had the highest UFF and UFF:UFE levels, which were normal in the CD remission patients and in those receiving medical therapy. CONCLUSIONS Our data suggest high diagnostic performance of UFF excretion measured using LC-MS/MS, in detecting de novo CS. UFF:UFE and UFF+UFE assessments are not useful in the first step of CS diagnosis, although high levels were found to be indicative of ectopic CS.
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Affiliation(s)
- Filippo Ceccato
- Endocrinology UnitDepartment of Medicine DIMED, University-Hospital of Padova, via Ospedale Civile 105, 35128 Padova, ItalyLaboratory Medicine UnitDepartment of Medicine DIMED, University-Hospital of Padova, via Giustiniani 2, 35128, Padova, ItalyEndocrinology UnitUniversity-Hospital of Padova, via Ospedale Civile 105, 35128 Padova, ItalyDepartment of Laboratory Medicine,University-Hospital of Padovavia Giustiniani 2, 35128 Padova, Italy
| | - Giorgia Antonelli
- Endocrinology UnitDepartment of Medicine DIMED, University-Hospital of Padova, via Ospedale Civile 105, 35128 Padova, ItalyLaboratory Medicine UnitDepartment of Medicine DIMED, University-Hospital of Padova, via Giustiniani 2, 35128, Padova, ItalyEndocrinology UnitUniversity-Hospital of Padova, via Ospedale Civile 105, 35128 Padova, ItalyDepartment of Laboratory Medicine,University-Hospital of Padovavia Giustiniani 2, 35128 Padova, Italy
| | - Mattia Barbot
- Endocrinology UnitDepartment of Medicine DIMED, University-Hospital of Padova, via Ospedale Civile 105, 35128 Padova, ItalyLaboratory Medicine UnitDepartment of Medicine DIMED, University-Hospital of Padova, via Giustiniani 2, 35128, Padova, ItalyEndocrinology UnitUniversity-Hospital of Padova, via Ospedale Civile 105, 35128 Padova, ItalyDepartment of Laboratory Medicine,University-Hospital of Padovavia Giustiniani 2, 35128 Padova, Italy
| | - Marialuisa Zilio
- Endocrinology UnitDepartment of Medicine DIMED, University-Hospital of Padova, via Ospedale Civile 105, 35128 Padova, ItalyLaboratory Medicine UnitDepartment of Medicine DIMED, University-Hospital of Padova, via Giustiniani 2, 35128, Padova, ItalyEndocrinology UnitUniversity-Hospital of Padova, via Ospedale Civile 105, 35128 Padova, ItalyDepartment of Laboratory Medicine,University-Hospital of Padovavia Giustiniani 2, 35128 Padova, Italy
| | - Linda Mazzai
- Endocrinology UnitDepartment of Medicine DIMED, University-Hospital of Padova, via Ospedale Civile 105, 35128 Padova, ItalyLaboratory Medicine UnitDepartment of Medicine DIMED, University-Hospital of Padova, via Giustiniani 2, 35128, Padova, ItalyEndocrinology UnitUniversity-Hospital of Padova, via Ospedale Civile 105, 35128 Padova, ItalyDepartment of Laboratory Medicine,University-Hospital of Padovavia Giustiniani 2, 35128 Padova, Italy
| | - Rosalba Gatti
- Endocrinology UnitDepartment of Medicine DIMED, University-Hospital of Padova, via Ospedale Civile 105, 35128 Padova, ItalyLaboratory Medicine UnitDepartment of Medicine DIMED, University-Hospital of Padova, via Giustiniani 2, 35128, Padova, ItalyEndocrinology UnitUniversity-Hospital of Padova, via Ospedale Civile 105, 35128 Padova, ItalyDepartment of Laboratory Medicine,University-Hospital of Padovavia Giustiniani 2, 35128 Padova, Italy
| | - Martina Zaninotto
- Endocrinology UnitDepartment of Medicine DIMED, University-Hospital of Padova, via Ospedale Civile 105, 35128 Padova, ItalyLaboratory Medicine UnitDepartment of Medicine DIMED, University-Hospital of Padova, via Giustiniani 2, 35128, Padova, ItalyEndocrinology UnitUniversity-Hospital of Padova, via Ospedale Civile 105, 35128 Padova, ItalyDepartment of Laboratory Medicine,University-Hospital of Padovavia Giustiniani 2, 35128 Padova, Italy
| | - Franco Mantero
- Endocrinology UnitDepartment of Medicine DIMED, University-Hospital of Padova, via Ospedale Civile 105, 35128 Padova, ItalyLaboratory Medicine UnitDepartment of Medicine DIMED, University-Hospital of Padova, via Giustiniani 2, 35128, Padova, ItalyEndocrinology UnitUniversity-Hospital of Padova, via Ospedale Civile 105, 35128 Padova, ItalyDepartment of Laboratory Medicine,University-Hospital of Padovavia Giustiniani 2, 35128 Padova, Italy
| | - Marco Boscaro
- Endocrinology UnitDepartment of Medicine DIMED, University-Hospital of Padova, via Ospedale Civile 105, 35128 Padova, ItalyLaboratory Medicine UnitDepartment of Medicine DIMED, University-Hospital of Padova, via Giustiniani 2, 35128, Padova, ItalyEndocrinology UnitUniversity-Hospital of Padova, via Ospedale Civile 105, 35128 Padova, ItalyDepartment of Laboratory Medicine,University-Hospital of Padovavia Giustiniani 2, 35128 Padova, Italy
| | - Mario Plebani
- Endocrinology UnitDepartment of Medicine DIMED, University-Hospital of Padova, via Ospedale Civile 105, 35128 Padova, ItalyLaboratory Medicine UnitDepartment of Medicine DIMED, University-Hospital of Padova, via Giustiniani 2, 35128, Padova, ItalyEndocrinology UnitUniversity-Hospital of Padova, via Ospedale Civile 105, 35128 Padova, ItalyDepartment of Laboratory Medicine,University-Hospital of Padovavia Giustiniani 2, 35128 Padova, ItalyEndocrinology UnitDepartment of Medicine DIMED, University-Hospital of Padova, via Ospedale Civile 105, 35128 Padova, ItalyLaboratory Medicine UnitDepartment of Medicine DIMED, University-Hospital of Padova, via Giustiniani 2, 35128, Padova, ItalyEndocrinology UnitUniversity-Hospital of Padova, via Ospedale Civile 105, 35128 Padova, ItalyDepartment of Laboratory Medicine,University-Hospital of Padovavia Giustiniani 2, 35128 Padova, Italy
| | - Carla Scaroni
- Endocrinology UnitDepartment of Medicine DIMED, University-Hospital of Padova, via Ospedale Civile 105, 35128 Padova, ItalyLaboratory Medicine UnitDepartment of Medicine DIMED, University-Hospital of Padova, via Giustiniani 2, 35128, Padova, ItalyEndocrinology UnitUniversity-Hospital of Padova, via Ospedale Civile 105, 35128 Padova, ItalyDepartment of Laboratory Medicine,University-Hospital of Padovavia Giustiniani 2, 35128 Padova, Italy
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